Evolution and survival of the fittest

It is mid-June and it seems presumptuous to be writing this now as I do not actually take over from Kevin O’Brien until August. However, when it comes to publishing schedules, needs must, so here I am writing this with a fair degree of trepidation — this is after all the journal of the British Orthodontic Society. Whilst its name may have changed over the years, The Journal has a long and illustrious history — just looking at the names of previous editors reads like a Who’s Who of British orthodontics: Dick Mills, Bill Houston, Barry Leighton, Lawrence Usiskin, Ray Edler, Malcolm Jones and Kevin O’Brien. I am sure that each editor has necessarily changed the Journal in keeping with the times. Most recently, Kevin O’Brien brought in many changes to keep pace with the push towards using a fully evidence-based approach so far as is possible. It should therefore come as no surprise that I do not intend to reverse these changes — we are after all trying to provide the best patient care. ‘Best’ involves all manner of treatment aspects but it should mean we do something because we have good reason to do something rather than no reason. Consequently, my aim will be to strengthen and evolve the journal along the lines already in place, maintaining both the research and clinical practice aspects. This maybe easier said than done — it is clear that the research environment is becoming tougher and tougher.

The irony is however that whilst the need for good, research/evidence-based practice is clear to all and the pressure to provide such studies has probably never been greater, yet the constraints and pressures on researchers and clinicians have probably also never been greater. Let’s take one example: ethics approval. Recently, the whole process has gone electronic — all UK-based researchers involved in any form of clinical research will need to get to know the COREC website (Central Office for Research Ethics Committees). A process easier said than done. The procedure has effectively been unified across the UK and this in itself is no bad thing. However, that does not mean the process has been simplified. Far from it if you have already tried to navigate the COREC website.

Whilst changes have come in as a result of the European Clinical Trials Directive, UK medical crises which seem to hit the headlines so spectacularly and regularly (the Bristol cardiac surgeons; Alder Hey and Shipman to name but a few) have probably not helped prevent the situation we now have. Something like 60 electronic pages must be completed and submitted (and that doesn’t include all the information sheets, consent forms etc.) before we carry out even the simplest research project involving humans. Chairman’s action no longer exists (a big hit particularly for undergraduate elective projects for example). It doesn’t matter whether you propose heart transplant research or an investigation of orthodontic treatment outcome or a retrospective analysis of old cephs — the process is the same. It’s hardly a great invitation or stimulus ‘to do that research!’ The serious problems that such onerous approval processes can induce (including important research simply not being done), together with the lack of evidence for the use of such a ‘one size fits all’ approach being either necessary or useful — have recently been highlighted.¹ Our international colleagues may well be able to teach us some lessons as the irony extends even further: it has been suggested that UK researchers may be left out of international multi-centre research as the ethical approval process is so arduous and time consuming.² Not only that but student research (of which there is a huge volume) must now come through the same process (often it had been approved by chairman’s action), overwhelming the relatively small number of ethics panels. Such research also clashes with the ethical ethos as of course this research is done at least partly for training purposes. It may therefore not be the ultimate in ‘best’ research because novices are (by definition) not expert and are undertaking the work (albeit under supervision) to gain and improve their research strength; in addition, time-scales and other training commitments preclude attention being devoted exclusively to research. So, the dilemma is that if we want good research in the future, the ethics panels will have to be pragmatic and accept some reduction in scrutiny to some extent. If they do not, standards of patient care may suffer anyway —defeating the whole object of the ethical procedure!

Ultimately I have no quick fix but one (positive) side effect of these difficulties could be that if one has to put that much effort into doing research, one may as well try and do the biggest and best projects possible. Orthodontics needs research to progress and orthodontic research needs to be fit to survive — this will be one way of achieving this. Good luck!