organized curiosity

Improving health care through research


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Mobile Health Apps – A Cautious Boon?

Mobile Health (mHealth) Applications for your smartphone, tablets, phablets, etc. are the next best thing in healthcare. We have moved from a recent push on enormous amounts of $$ being spent on Electronic Health/Medical Records (EHR/EMR) to a new trend in the building of mHealth applications that are easily accessible to the consumer. In the US alone, a report  in 2011 indicated that spending was to surge to a massive $40B in Healthcare IT and at the time were focused solely on EHR/EMR’s.

Consider the attractiveness of lightweight Mobile Apps that are inexpensive, albeit less comprehensive but a lot more consumer friendly. The last Apple Worldwide Developers Conference was also indicative that Big Business believes there to be big money in mHealth. This isn’t news, as Microsoft, Google and others have been in this space for some time now.

With all the competitors in the mHealth space, how can you stand out from the crowd? Is there a strategic way to do so? mHealth Apps if done correctly can set the stage for a consumers to take ownership and control of their healthcare. This revolution has been a long time coming.

We need to first understand the landscape of mHealth Apps. The Institute for Healthcare Informatics, in Patient Apps for Improved Healthcare noted that there were close to 43,000 mHealth Apps available on iTunes in mid-2013.  Most provide only information and 16,275 deal with health and treatment. This number has since grown and with Apple’s recent announcement, is bound to grow further with their strategic partnerships with the Mayo Clinic, IBM and Epic Systems. Detailed statistics on Mobile Apps are available at Statistic Brain.

A few strategic steps to consider are:

1 – Evidence (Data) – Use evidence to drive the development of a mobile app, as the platform is only a delivery mechanism. Consider the recent article in The New England Journal of Medicine by Nathan Cortez that asks if apps need to be regulated by the FDA to ensure they are safe and effective to use. In addition, Eric Topol also warns us of apps not having any validated data compared to accepted reference standards.

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2 – Partner up – If you are a healthcare professional looking to develop an mHealth app, get the right development as well as design partner to help you. Conversely, if you are a designer or a developer and are looking to develop a novel mHealth App, get a health professional to partner up. To be clear it does not have to be a partnership of equity, just a partner that can help with the expertise of their subject matter be it through an equity position or through term contracts.

3 – Design for the Consumer – Healthcare professionals are tireless champions for health and I have the utmost respect for them. Designers know how to design for the consumer and their visual needs. The healthcare professional knows their consumers health needs. A group of potential users to help you through the design process will bring rigour to the final product.

4 – Marketing – If you build it, they may not come. If mHealth Apps need to reach the masses, they need to be marketed appropriately to the targeted audiences. This could take the form of partnerships with other healthcare professionals for their patients to media coverage through industry specific publications, mass media, newspapers, social media influencers, etc. to ensure a wider access and distribution medium.  Marketing takes resources and funding partners need to understand that without marketing, the app may not be used.

In the Maritimes we have seen the mobile space develop quite quickly in healthcare, with Dr. Dunbar, an Orthopedic Surgeon at Capital District Health Authority currently developing a Gait Monitoring System, hoping to reduce wait times for in-hospital appointments garnering the same information via the App, along with exercise videos, diets, etc. Dr. Kutcher, the Sun Life Financial Chair in Adolescent Mental Health and a Psychiatrist with the IWK Health Centre had the Transitions app (http://teenmentalhealth.org/transitions) developed for youth transitioning from the school system to post-secondary education providing for a free resource that has been widely used across Canada. You will also find Apps from all the major pharmacies and some from private first responders within the market. That said, there are a lot more in the pipeline that will be available soon.

-Ashwin Kutty

Full disclosure: I am the President & CEO of WeUsThem Inc. and we are in the business of designing & developing mobile applications including mHealth Apps. I will be at the Medicine 2.0 World Congress in Spain & Maui this year talking about Business in Healthcare if you would like to join me.

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A Good but not Perfect Solution for a Killer Disease

The Public Health Agency of Canada reports on diseases affecting Canadians, including the flu. As you can see in the graph below there are thousands of hospitalizations each year in Canada for influenza. In fact the data from the Public Health Agency is an underestimate because some provinces don’t report and some infections may be undetected.

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As well, hundreds of Canadians die each year from influenza, as can be seen in the second graph. It is important to note that this year’s data includes up to January 10th.  It is hard to predict what this year’s final numbers will be but there is potential it could be a bad year.

Several systematic reviews have shown that flu shots are effective. That does not mean that getting a flu shot is any sort of guarantee that you won’t get the flu. It does lower your chances, however, and may make flu a bit milder if you do catch it.   In truth many medical treatments are much less than 100% effective but we still use them.

There can be slight negative reactions to flu shots, such as arm soreness or a bit of a funky feeling.  What flu shots don’t do is give you the flu because the vaccine is made from a dead virus that cannot cause the flu.

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Recent reports in the media tell us that this year’s flu shot is not a great match for the virus that is currently making the rounds.  That means that it will not be quite as effective as if it were a good match. It does not mean that it is totally ineffective.

Let’s be clear on one thing. I am a psychologist, not an infectious disease specialist. So what is a psychologist doing writing about the flu?  Because behavior can be an important way to prevent the flu.

Flu spreads via droplets from coughing, sneezing or talking. It also spreads from the flu virus being on a surface and then being transferred on the hands to the mouth or nose.

People who have weak immune systems because of very advanced age or because of a disease or treatment of a disease, such as cancer, are particularly vulnerable. You never know if your co worker has a child or partner or aged parent at home who is immunocompromised.

Here are the behaviors that you can do to reduce the flu in yourself and others around you.

  1. Get the flu shot. It helps prevent the flu. If you don’t have the flu, you won’t spread it.
  2. If you are sick. Stay at home. Don’t spread the flu (or a cold).
  3. Cough and sneeze into your sleeve. Throw out tissues when you use them.
  4. Clean your hands every chance you can by washing with soap and water or using alcohol based hand sanitizers.

Don’t be responsible for infecting someone else.

~Dr. Patrick McGrath


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When I Am Ill Put Me in a Clinical Trial

Fortunately, I am now in excellent health. I try to keep it that way by moderation in everything (except I guess I work too much; this blog is being written at 7am on Sunday).  I keep moving in spite of my sedentary job, I eat well, I watch my weight, I don’t drink too much and I am happy most of the time. At my age, it is a bit unusual that I have no chronic health problems.  I did have a heart arrhythmia but it was cured at the QEII heart rhythm unit.

But I will develop some health problems and when I do, I will try to find a clinical trial to participate in.  Moreover, I will always encourage my family to find and participate in clinical trials. I even tried to sign up for the Ebola trial at the IWK but was too old for it. I sign up for as many studies as I can even if I am not sick.

Why do I want to participate in clinical trials?Research

  1. Clinical trials are a way to get new treatments before they are widely available. In addition, all study drugs are provided free of charge.
  2. Care in clinical trials is even more carefully monitored than in regular care. There are extra staff. Often times a special nurse is assigned to clinical trial participants. That means your condition is even more closely monitored.
  3. I always learn something and meet new people. This may not be a motivation for others but I think participating in research is fun and interesting. I meet the research staff and I have learned about things such as vaccines for shingles, new ways of measuring visual acuity and the benefits of blueberries.
  4. All clinical trials are voluntary. No one is ever required to be in a clinical trial and I can drop out any time without affecting future care.
  5. There is no cost to being in a clinical trials except time. In some trials where a lot of time is involved, there may be payment for participation.
  6. Clinical trials are safe. Before any clinical trial is done, many studies are completed on safety. Participants are monitored for any negative events. All trials are scrutinized by our Research Ethics Board which is made up of scientists, clinicians, ethicists and lawyers who have nothing to do with the trial.
  7. Clinical trials make a contribution to science and improve others treatments. Even if I don’t benefit from a new drug or process, I have the satisfaction of contributing important information to what we know.
  8. I never feel I am a “guinea pig” or am being denied care. In all cases, I am told exactly what will be done. In cases of important illnesses, most trials compare standard care with a new treatment that might be better. Sometimes the comparison is standard care plus a placebo versus standard care and another active drug.

~Dr. Patrick McGrath


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Reversing the trend of antimicrobial resistance

There are few medical discoveries that have changed the course of human history more than antibiotics.  Prior to the serendipitous discovery of penicillin in 1928 a pneumonia was fatal in over 35% of infections and a simple cut leading to a skin infection would kill over 10% of people.  Since the development of antibiotics, now less than 10% of people die from pneumonia and death from skin infections are uncommon.  These miracles of modern medicine have been so successful, that by the late 1960’s physicians and policy makers were declaring victory in the war against bacteria.

Yet nature hates a void and more importantly is more clever than we will ever be.  Within 3 years of its discovery, bacteria developed resistance to penicillin. Since 1928 we have seen the introduction of multiple different classes of antibiotics, each having had the promise of protecting us from even the nastiest of bacteria.  Yet not long after each antibiotic has been introduced, the bacteria have found ways to resist its killing potential.  And where has that left us?  We now have an antimicrobial resistance (AMR) problem that has been declared a global heath emergency. Antimicrobial resistant organisms (AROs) now cause over 2 million infections and kill 23,000 people in the US each year costing 20 billion dollars in excess health care costs and over 30 billion dollars in lost productivity.  Infections like gonorrhoea (one of the Center for Disease Control in Atlanta’s three most urgent threats) were once easily treated but have become so resistant that we soon may not have any treatment options.2 In addition, the overuse of antibiotics and the elimination of “good bacteria” from our bowels have left an opening (remember nature hates a void) for opportunistic pathogens like clostridium difficile diarrhoea (the second of the CDC’s top three urgent treats), leading to increased health care cost due to prolonged hospitalizations or more dramatically, loss of your colon or death.

So how did this happen? It is a complicated problem and we have a complicated relationship with antimicrobials.  There is no question antibiotics save lives.  As we advance our ability to prolong life through toxic combinations of drugs to kill cancer or suppressing our immune systems to allow a life saving transplant to flourish, we modify the human hosts ability to fight infection increasing our reliance on antibiotics. But it is the inappropriate use of antibiotics that is probably the biggest driver of resistance.

In medicine we want to help patients and as patients we often want a pill to make us feel better.  For example, the vast majority of sore throats (and most other upper respiratory tract infections) are due to viral infections.  Antibiotics have absolutely no activity on viruses, yet antibiotics are often requested and prescribed for sore throats.  However, taking these antibiotics pressures the bacteria that normally live in you body to evolve, and adapt to survive in the presence of a chemical designed to kill them. Just as important, many of the genetic changes behind resistance can be transmitted from one bacteria to another. Bacteria can collect many different resistance genes, so eventually they have a full set that protects them from all different types of antibiotics.  In Canada you need a prescription to get antibiotic.  However in other regions of the world, antibiotic are freely available over the counter which leads to indiscriminate and inappropriate use.todd-hatchette

AMR is also the result of antibiotic use outside medicine.    We use tons of antibiotics in agriculture which is added to the feed of animals to can keep them healthy and increase production.  However, this leads to the evolution of resistance in bacteria living in these animals, which can cause infections in humans or transfer their resistance genes to other bacteria that commonly infect humans.  In addition, AMR can be an unintended consequence of obsession to ensure everything we own is clean and sterile.  We impregnate our plastic toys with triclosan to reduce bacterial contamination with the goal of making them safer. However, this chemical can turn on antibiotic resistance genes in bacteria so rather than preventing infection we are creating the potential for infections that are harder to treat.

AMR also reflects the new global reality.  We live in a global village where you can travel halfway around the world in a day. We also have a form of medical tourism where people travel to places like India for surgical procedures they cannot get in North America. AROs that develop in one region can hitch a ride on returning travellers where they can be transmitted to people within local hospitals.

So how do we address this problem?  We need to do a better job of identifying these infections and ways to prevent transmission. In the hospital AROs are transmitted to patients on the hands of health care workers. In short we need to wash our hands.  Clearly it is not just that simple. Antimicrobial stewardship programs need to be instituted in all health care settings.  We need to track resistance and we need to change how we use antibiotics. We need to use the narrowest spectrum antibiotic needed for the shortest time necessary to cure the infection.  We also need to promote the development of new antibiotics to deal with these resistant infections.  This is a challenge because it takes 10 years and billions of dollars to bring a new drug to market and how can a business lobby their share holders to back a drug which has restricted use and therefore a restricted market.  However, we need them and as importantly we need to reserve these drugs for resistant infections and not use them indiscriminately.

What can you do?  Remember that not every sniffle, cough or sore throat requires an antibiotic. Similarly if your physician suggests you need it, question why to make sure you really do.  When you do make sure to take them as directed. Global consumption of antibiotics has increased 40% in the last year. Recent modeling suggests that if this disturbing trend is not reversed, by 2050 AMR infections will surpass cancer as the number one cause of death and cost the world economy 100 TRILLION dollars. But if we take action now and work together we can ensure we do not regress into a pre-antibiotic era of medicine where physicians watch helplessly as people die from infections that should be treatable.

~Dr. Todd Hatchette


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“Did you see this video on You Tube?”

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“Did you see this video on You Tube?” This is a question I over-hear or have had directed at me more times than I can count. Usually by one of my three children who want to keep me abreast of the latest post-wisdom-tooth-extraction-delirium or cute-puppies-sleeping videos. This trolling of You Tube and Instagram for entertainment is somewhat foreign to me – I’m getting old – I suppose it’s the digital age version of flipping through magazines and looking at glossy pictures. But the digital age is not going away, as a matter of fact, it is rapidly reinventing itself at a pace that I can’t keep up with. Remember podcasts? Well that was SO 10 YEARS AGO.

As much as my mind is boggled by all the social media out there, I’d like to think my learning curve has been quite steep. I’m not a You-Tuber or Instagrammer, however Twitter (as a professional tool) makes sense to me. It feels more like streaming headlines to keep me in the loop. At a recent Royal College of Physicians and Surgeons Conference http://icreblog.royalcollege.ca/ I spent a full day in a Social Media Summit where I was amazed to see the extent to which various forms of social media have planted themselves firmly in the research and medical education worlds as a tool for information exchange. Conference goers shared slides, opinions, commentaries on Twitter, Instagram and Facebook, some sessions were live-streamed, other sessions were live-Tweeted…yes, live-Tweeted…with such reach that an individual in the southern US was weighing in on topics and opinions being generated from a talk they weren’t even attending. I myself, a rather novice and slightly anti-social social media user, got caught up in the energy and tweeted points of interest and self-reflection in an effort to share with my academic and research followers. I also wanted to be as cool as all the other people who were so effortlessly and simultaneously soaking in information and Tweeting about it at the same time.

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Although the Tweeting and Instagramming activities in this particular context are likely more “social”, social media in general can serve as a very useful tool for what researchers call Knowledge Translation (knowledge dissemination, sharing, etc.). Podcasts and Tedx sessions are great sources for engaging and intellectual talks about a range of science and research topics. Want to know about a drug to slow down Parkinson’s disease? There’s a podcast for that. https://www.michaeljfox.org/foundation/news-detail.php?podcast-drug-that-may-slow-parkinson-progression-granted-23-million-from-nih-for-phase-iii

Want to know about ethical issues in HIV research? There’s a Tedx talk for that https://www.ted.com/talks/boghuma_kabisen_titanji_ethical_riddles_in_hiv_research

Social media such as You Tube can be an excellent resource for parents looking for information about a range of children’s health issues. The IWK’s Dr. Christine Chambers  http://pediatric-pain.ca/faculty/christine-chambers/ has had tremendous success with a You Tube video that has taken years of pediatric pain research and put it into a brief video designed to teach parents how to make needles less painful for their children.

In 142 characters or less, agencies like the National Institutes of Health https://twitter.com/nih and the Canadian Institute for Health Research https://twitter.com/cihr_irsc keep researchers informed about funding opportunities and the public informed about health research related topics of current relevance.

These are great, reputable sources for both health professionals and the lay person interested in hot topics related to health research in North America.

As curiosity driven beings, we are sponges for information. Social media in its various forms provides us access to a range of ground-breaking findings, trends, publications, videos and reports. A study published in the Journal of Medical Internet Research reported that 24.1% of 485 physicians surveyed used social media daily to “scan or explore medical information”. Moreover 57.5% of those physicians saw social media as beneficial, engaging, and useful for acquiring current, high-quality information. http://www.jmir.org/2012/5/e117/ . But with the sheer volume of information that’s out there, and the rapid fire speed with which we glance over that information, how can researchers and health care providers accurately assess what is “high quality information”?

In evidence-based settings (medicine, research) knowledge users engage in critical appraisal – an activity that involves a comprehensive assessment of various aspects of a research paper in order to weigh the overall pros and cons of that evidence. Criteria such as peer review, inclusion of detailed methodology, identification of limitation weigh heavily in the final assessment of overall merit. However in a digital age where knowledge is at our fingertips, there seems to be very little information about how we might critically appraise that information for validity and reliability. I can Google the most recent status of flu vaccine uptake, but is it correct?

Should scientific content distributed across social media as a form of knowledge exchange be subject to the same sort of critical appraisal as traditional forms of scholarly knowledge sharing? Journal publications are peer-reviewed. Conference presentations undergo a review process before accepted. However, as researchers we can Tweet our opinions about our (or others) research, Instagram a photo of a table or chart or You Tube a video of a lecture and there it is, out in the digital world to be consumed. And who’s to say any of this is accurate, reliable or valid? Can the retweet, the favorite and the like be considered a virtual form of peer review?

One side of the coin is that perhaps knowledge exchange on social media is nothing more than the new casual conversations around the proverbial water cooler. Brief snippets of information and videos can keep you up to date on the current issues in your research area.

The other side of the coin is that perhaps we should start considering critical appraisal tools – with either intuitive or formal processes – to apply to various forms of social media. Although I doubt very much that any good researcher would expect his or her audience to accept the “trust me” defense and accept a tweet, podcast or Instagram as gospel, I often wonder if the knowledge consumer doesn’t stop to assess the information. Even where links are provided to support posts with journal articles, charts and data, I would bet very few of us dig deeper when all we’re looking for is the digital version of a sound bite.

So where does this leave us as critical thinkers? I believe we should apply the same critical lens to knowledge that is disseminated through social media as we apply to traditional forms of knowledge dissemination. Perhaps the same rigor we apply to systematic critical appraisal is not required, but I would suggest the grain-of-salt approach. Is the source reputable? Does the source provide additional reputable links for more detailed information? Is the information based on evidence or opinion? These are just a few high level considerations.

There’s a lot of information out there and separating the good from the bad can be a cumbersome process. At least when things get overwhelming, there will always be cute-puppies-sleeping videos…guaranteed to be a valid and reliable source of stress relief.

~  Dr. Jill Hatchette


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10 Reasons Why I Hate Research

 

Why I Hate Research

I should tell you, there was a time when I hated research enough that I nearly quit. When I finished my PhD (in the last century), I hated research. I had become a psychologist because I wanted to help kids. Although I did well in my PhD, I was so fed up that I didn’t publish my PhD research which was a series of studies on the measurement of social skills. I felt it didn’t do any good and would only be read by a few other scientists.

I applied only for clinical jobs. Unfortunately, the clinical job I applied for required I do a bit of research. I started some research on children with recurrent abdominal pain because no one could figure out what to do with these patients. It related directly to my patients and within three years, I was hooked on research.  During my career, I have spent thousands of hours doing my research, supervising student research, and I have published hundreds of scientific papers.  Although my days are now spent as Vice President of Research and Innovation, I can’t imagine how I could live without doing research.

But I still hate research at times.  Here are 10 reasons why.

  1. Research crushes some of the best and the brightest young minds. Research funding is so tight that some outstanding young scientists don’t get funding. For example, in the regular Canadian Institute of Health Research competition, there was about an 85% failure rate. With low success rates for grants, it takes an almost insane devotion to science to continue in research.
  2. Research doesn’t get enough attention in the media. Maybe this is unseemly whining, but I wish that instead of the focus we have on celebrities and athletes we had a bit more focus on my brilliant colleagues who are scientists. Did you ever notice that the newspaper has a large section on sports but only a few columns on science and research. If you look up what is trending on Twitter, it is never science. Not that I think scientists should be pursued by papparazi, but more attention would be good.
  3. Research fails a lot of the time. Many of my research ideas and those of other researchers fail. It is necessary. In fact, if you don’t fail in your studies, you are not being adventuresome enough. Failure of a study, if designed right, is just another data point. My first study when I started my research career was a failure and it taught me a lot. But it can be miserable to spend months working on a project to see it fail.
  4. Sometimes partners you choose are not good collaborators. This is fortunately rare and most collaborators are outstanding. Because research often requires multiple investigators with different skills, collaborators who don’t deliver can devastate a study.
  5. Sometimes it takes longer than I think it should to do a study. The most common problem in clinical research is enrolling participants with most trials not meeting their planned level of participants.
  6. Research takes a lot of your personal time and is often done outside of regular work hours. I don’t know of any top flight researcher who does not spend many extra hours on research.
  7. Sometimes research doesn’t go anywhere – findings not used, papers not published.
  8. It is hard to keep up with the rapidly changing field – must stay current by reading a lot of journals, attending international conferences etc.
  9. Research is sometimes not valued.  Even though there is great research evidence for a decision, this may not be acted on by policy makers and others.  This can be frustrating.
  10. Grant reviewers sometimes just don’t get it and give poor ratings to my proposal. But it is probably not their fault.  It is likely that I have not done a good enough job explaining the research or the potential value of the research.

 

~Dr. Patrick McGrath


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10 Reasons Why I Love Research

Someone suggested that I write a blog on why I love research. You know “10 reasons to love science”. I found this interesting You Tube video and would recommend you take five minutes to watch it for fabulous visuals.

My reasons for loving research may be less exciting and I doubt I will get the 7 million plus views. Regardless, here are my 10 reasons for loving research:

  1. Research makes a difference. Nothing can be as rewarding as the satisfaction of knowing that something you discovered or developed is making a difference in people’s lives. One of my great joys is seeing the reports on specific children who have benefitted from our Strongest Families
  2. Research is challenging. Nature does not give up its secrets easily. Whether it is a basic biomedical secret about the action of a specific messenger in the brain or the best way to help a parent deal with a temper tantrum, the secret is often harder to discover and hard to prove.
  3. Research is competitive. I always tell my students that no one cares if you are the best researcher in a specific discipline in Nova Scotia. It only matters if you are among the best in Canada, or in the world. Getting a grant is competitive. The success rate in national competitions is now around 18% but sometimes much lower. It is hard when you don’t succeed, but great when you win by getting a grant, publishing a paper or spinning off a company.
  4. Research is fun. Science is a lot of work but when the work is complete, you have deserved some fun. Some people might think that researchers are boring nerds. Well some of us may be nerds, but we are certainly not boring. In fact, artistic and musical abilities seem to be more prevalent among scientists than in the general population. I have none of these artistic abilities but I do like to have a good time.
  5. Research stretches your mind. I often have the chance to chat with incredibly intelligent trainees and young scientists. It challenges me to understand what they are doing. Research is moving so fast that you have to work at it to keep up in your own area. It is only possible to get snapshots of what is happening outside your research area.
  6. Research introduces you to such interesting people. I have made friends around the world because of my research. Right now, I have projects underway in Finland and Spain, and collaborators and research-friends in many different countries. Sometimes we are able to connect at research conferences but I don’t get to see them very often.
  7. Research is the future. It is exciting to be part of an adventure that will change what happens next year or in 10 or 15 years’ time. I can see where research that I conducted 10 years ago has contributed to better care now. The study I design today may determine how healthcare is provided in the next few years.
  8. Research involves collaboration across disciplines. As a psychologist, I love working with and learning about new ways of doing things from my colleagues who are working in nursing, medicine and basic science. These interprofessional opportunities make the research experience richer and the outcomes much more valuable.
  9. Partnering with non-researchers is enlightening. While the image of a research scientist working alone in their lab may have been common 100 years ago, these days researchers work across sectors, often with community agencies, patients and government representatives. I love working with my research partners as I learn a lot from them and am able to share my ideas with those outside of my field.
  10. Research is highly regarded. Being a scientist is prestigious. It is easier to enjoy your job if it is thought highly of by others. I am vain enough to be at least a bit influenced by the positive regard of others about my profession.

 

It would be great to hear from you about why you love research.

~Dr. Patrick McGrath