From opera buffa to opera seria: anniversaries of Royal College of Surgeons of England research initiatives

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This year, 2023, is the anniversary of three initiatives of the Royal College of Surgeons of England: 30 years of the Research Fellowship Scheme, 25 years of the Clinical Effectiveness Unit, and 10 years of the Clinical Research Initiative. During the previous century it was argued that surgical clinical research was faltering, and 27 years have elapsed since Richard Horton’s now infamous editorial ‘Surgical research or comic opera: questions, but few answers’ was critical of surgical research1. The editorial went on to state ‘cynics might even claim the personal attributes that go to make a successful surgeon differ from those needed for collaborative multicentre research’. Furthermore, Horton quoted the words of medical statistician Major Greenwood from 1923, ‘I should like to shame (surgeons) out of the comic opera performances which they suppose are statistics of operations’. Horton stated that, in surgery journals, only 7% of papers reported data from RCTs and case series were the most common type of manuscript. Horton concluded that logic insists that a large proportion of the surgical literature is of questionable value and proposed that only when the quality of publications in the surgical literature has improved will surgeons reasonably be able to rebut the charge that as much as half of the research they undertake is misconceived. Richard Horton was certainly harsh, but were Horton’s statements fair? Perhaps an analysis of the literature would have shown that the same criticisms were applicable to other specialties. However, there were issues in terms of surgical research. It could be argued that, historically, surgeons focused on practical surgical competence, training, and management rather than research, and funding agencies focused on basic science and translational research. Spending on surgical research was less than 2% of the total research budget, yet 30% of National Health Service (NHS) patients received surgical care. However, 30 years ago, a number of research initiatives were introduced, which created change and has resulted in a substantial shift in surgical research culture2. The Royal College of Surgeons of England Research Fellowship Scheme commenced in 1993 and has trained a generation of surgeons with an interest in basic, translational, and clinical research. The Clinical Effectiveness Unit founded in 1998 has developed audit and research methodologies and has produced evidence on clinical effectiveness and cost-effectiveness. After the turn of the century, there has been an exponential growth in clinical research, including trials (specifically RCTs). The infrastructure underpinning this evolution has been three-fold. First, the birth of the National Institute for Health Research (now called the National Institute for Health and Care Research (NIHR)). The NIHR has played a fundamental role both in terms of access to funding and delivery of research via the Clinical Research Networks and through NIHR infrastructure within NHS trusts supporting the delivery of clinical research. Second, the formation of the Royal College of Surgeons of England Clinical Research Initiative, and, third, a growth in methods suitable for the design and delivery of surgical trials, much of which was funded by investment into the Medical Research Council (MRC) 2010 initiative ‘Hubs for Trials Methodology Research’. More recently, the Research Excellence Framework has accelerated the change, and created a greater emphasis towards impact, which the surgical research environment is well placed to deliver. A new surgical culture that places emphasis on conducting high-quality research to advance patient care is now firmly established in the UK. In turn, this has led to a growth in surgical research output. There is now a substantial cohort of surgeons determined to deliver high-quality research; importantly, this includes, not just academic consultants, but also NHS consultants, who form the majority of the surgical workforce in the UK. The role of trainees, particularly the major impact of trainee collaboratives, cannot be overstated. Moreover, collaboration with other specialties and methodologists has been crucial. Horton stated in the Lancet editorial that ‘to retain their academic reputation surgeons must find imaginative ways to collaborate with epidemiologists to improve the design of the case series and to plan randomised trials’; trial methodologists, statisticians, health economists, database programmers, qualitative researchers, research nurses, and patient representatives can now be added as integral members of surgical research. The role of the Clinical Trials Units and the NIHR Clinical Research Networks infrastructure have also been critical in the successful delivery of surgical research. This is reflected in the quality of surgical research output beyond the UK and across the world. See Box 1. Work with patients to define important surgical research questions Establish a research committee within the appropriate national surgical college Engage with funders: government funding streams, philanthropists, charitable trusts, and foundations Define a research strategy focusing on individuals (fellowships) and projects (e.g. specific trial funding), and the creation of a dynamic and collaborative community of researchers Support trainees to establish research collaboratives Utilize a model of collaborative authorship Focus on impact (using results to define guidelines and change practice) Work with patients to define important surgical research questions Establish a research committee within the appropriate national surgical college Engage with funders: government funding streams, philanthropists, charitable trusts, and foundations Define a research strategy focusing on individuals (fellowships) and projects (e.g. specific trial funding), and the creation of a dynamic and collaborative community of researchers Support trainees to establish research collaboratives Utilize a model of collaborative authorship Focus on impact (using results to define guidelines and change practice) Work with patients to define important surgical research questions Establish a research committee within the appropriate national surgical college Engage with funders: government funding streams, philanthropists, charitable trusts, and foundations Define a research strategy focusing on individuals (fellowships) and projects (e.g. specific trial funding), and the creation of a dynamic and collaborative community of researchers Support trainees to establish research collaboratives Utilize a model of collaborative authorship Focus on impact (using results to define guidelines and change practice) Work with patients to define important surgical research questions Establish a research committee within the appropriate national surgical college Engage with funders: government funding streams, philanthropists, charitable trusts, and foundations Define a research strategy focusing on individuals (fellowships) and projects (e.g. specific trial funding), and the creation of a dynamic and collaborative community of researchers Support trainees to establish research collaboratives Utilize a model of collaborative authorship Focus on impact (using results to define guidelines and change practice) The Royal College of Surgeons of England Research Fellowship Scheme gives trainees, and now also specialty and specialist doctors (SAS) surgeons, an opportunity to dedicate an interval of time solely to research. Founded in 1993, following a case to Council from then President Sir Norman Browse, with Sir Peter Morris as its first Chair, the aim of the scheme has been to facilitate new knowledge acquisition that will translate over time into improved surgical outcomes. In addition, and perhaps as importantly, it aims to encourage more surgical trainees to view research as an important part of their training. The scheme is designed to identify and encourage those who wish to pursue an a

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