SPEAKER_03 0:07

Welcome to this episode of the Thought Broadcast, the Australasian psychiatry podcast produced by trainees for trainees, where we try to demystify the scholarly project and humanize the research experience. So we've got a we've got a full compliment of the trainee editorial board and the deputy editor of the journal here on the on the episode today. And we're also joined by special guest uh Malcolm Forbes, who is the author of today's uh journal article that we will be discussing, and uh our our resident expert on on systematic reviews as a way of completing the scholarly project. So we'll do some quick introductions just to get everybody um get everybody online. Start with you, Brian. How are you today, Brian?

SPEAKER_00 0:51

Yeah, I'm good. Thanks, Ollie. I'm happy to be here. I'm Brian, one of the SOC trainee editor, and I work in Tuong in Queensland at the moment.

SPEAKER_03 0:59

Beautiful. And then you, Michael, how are you today?

SPEAKER_01 1:02

Yeah, good thanks, Ollie. Yeah, trying to keep out of the rain here in Adelaide. It's a bit of a wintry day. Um, I'm based here with the rural and remote service. Very good.

SPEAKER_03 1:10

And Andy, how are you?

unknown 1:12

I'm great.

SPEAKER_04 1:12

So thanks, Ollie. I'm director of training up in Townsville, and it's always lovely up here, mate.

SPEAKER_03 1:16

So very good. Uh my name's Ollie Robertson. I'm from um Bowen Health in Victoria. And uh we're joined today by Malcolm Forbes. Um Malcolm is currently completing his training uh at Bowen Health, and I think he's only maybe a week or two away from finishing, which is a fantastic achievement. But Malcolm, uh, can you introduce yourself to the audience and let us know what you're up to uh in work and life at the moment?

SPEAKER_02 1:42

Yeah, thanks very much, Ellie, and uh thanks to you and the team for having me on today. So I'm yeah, finally a registrar in my last uh fortnight of training, and uh I'm currently working at Barwyn Health in a research registrar role half the time and a clinical role the other half of the time. And uh yeah, so I'm happy to talk a bit about my project and uh and and answer any questions.

SPEAKER_03 2:09

So we've just snuck in, we've just got you as a trainee, so yeah, good timing from us. So the theme of today's discussion is is systematic reviews. Andy's had some thoughts on systematic reviews in the past, so I thought maybe we'd hand to him for a bit of introduction before we get to to Malcolm's story.

SPEAKER_04 2:26

So as a director of training, I get to see most of the systematic reviews in North Queensland, so Cairns, Townsville, Mackay. Systematic reviews do tend to be fairly popular. They're attractive for a number of reasons for registrars. There's a feeling that you have a lot more control over the timing and the scope of what you're doing. So you can have a very targeted uh set of questions, questions or set of questions that you want to answer. And people see that as a fairly time-limited sort of thing. Whereas if you do one of the other forms, like an audit or research, things can blow out in terms of time. So you have to go through ethics often, you might have to go through recruitment, those sorts of things. So I think there's a number of reasons they're attractive.

SPEAKER_03 3:07

The article that we'll be discussing today, and you know, to be honest, we're really talking about about Malcolm's story, but it's it's titled The Clinical Utility of Structural Neuroimaging in First Episode Psychoses, a systematic review. It was actually published in the Australian and New Zealand Journal of Psychiatry in 2019. And then Malcolm's um published a follow-up article in Australasian Psychiatry. Uh, so that was uh an article entitled When Should We Image Our Patients, Appropriate Use of Imaging in Impatient Psychiatry. So what would be really nice to hear, Malcolm, um, is what was going on for you at the time that you came up with the idea. How did you see a need for this study to take place and sort of how did it all get started?

SPEAKER_02 3:48

This idea came around uh when I was a first-year registrar. And what I'd noticed uh in the inpatient unit where I worked was that there was significant variation among consultants and among teams with respect to ordering investigations. And we had my boss who was uh pretty restrained um with uh the suite of investigations that we'd ordered for patients. Then there was another team who had spent, you know, myself and the other registrars calculated probably about three to four to four thousand dollars um for every patient coming through the door just on investigations. And as an example, for first episode psychosis, each patient would get an MRI, an EEG, uh ANA, ENA, anchor, anti-NMDA, and so forth. And I asked uh this consultant on this other team, I was working with them and I said, Look, why do you um you're very thorough and uh I'm just curious, you know, where does that come from? And um and they explained this this is in the guidelines. Um I'm just following the guidelines. And so I went and had a look at the origin first episode psychosis guidelines. And lo and behold, they had a huge number of investigations listed, and I went through all of those and I looked down the bottom and looked at the reference, and I thought, okay, I'll go and find out what the evidence for all of this is is about. And uh I I looked at that article that was referenced, and it was an opinion article. And so it was just three reasonably eminent uh psychiatrists from the US who had just argued that these are the investigations that seem about right. And so I thought there has to be a more robust way of finding what should be done. And I decided to focus in on neuroimaging and uh started this uh systematic review at that time and worked with uh a number of um number of experts in the area, some neuroradiologists and and uh neuropsychiatrists, and uh we put together a paper. Um it took me a couple of years to slowly plot along and get it all done, but I wasn't in a rush at the time.

SPEAKER_03 6:04

Was there something about your your background or what what you were doing before you came into psychiatry that you think kind of influenced how you saw the investigations being used?

SPEAKER_02 6:14

Yeah, so so I'm someone who's uh slowly found no way um into psychiatry. So I'm uh I'll be 10 years as a doctor at the end of my training. And so I was a medical registrar um beforehand and did some work in ED, um, some locum uh ED side uh ED registrar jobs and and uh flirted with a few different areas um before I settled down uh with psychiatry. And so I did come in uh, you know, with with um uh with that perspective. And so sometimes I did think, you know, are we really thinking when we're ordering these investigations? Are we are we using the investigations judiciously? Because when you're ordering any test, as we all know, you want to think about what is the pretest probability? Will this test change the management of this patient? Those are questions that should be asked. And is there any harm that could come from inadvertent harm that could come from ordering this test?

SPEAKER_01 7:17

Malcolm, one of the things I really like about your story is that even as a first-year registrar, you haven't been overawed by looking to the guidelines and doing some research that has the potential to challenge conventional wisdom. And I think as a trainee, that's uh a really good example and something that hopefully the listeners might be able to take out as well. That um there's no reason why as a trainee we can't do research that has impact. And um I suppose there's a potential for your research to potentially change the guidelines. Do you know if there's um been any uh movement in that area?

SPEAKER_02 7:47

Yeah, thanks, Michael. I mean, it is, it's it can be very empowering doing research. You can find interesting things, find novel things, and at the end of the day, we want to do research that does influence clinical practice. And so uh at the time when I uh did this review, there were there were five guidelines: the US guidelines, the UK guidelines, the ANZ guidelines, Australian-New Zealand ones, the origin ones, and um uh uh Canadian ones. And so at the time, the UK ones said don't order CT or MRI and first episode psychosis, the Americans and the group from Origin said definitely do it. Um, the Australian-New Zealand guidelines were sort of on the fence. And um, since publishing this paper, it's been cited by the American Psychiatric Association in their psycho uh schizophrenia treatment guidelines. And so it has had a role. Um, and and in their latest guidelines, they now recommend uh taking a case-by-case approach rather than ordering it for everyone. And so, you know, this this research, um, I'm not I'm not saying our paper was the one that changed the guidelines. There was obviously other things going on, but uh it could have had an impact. And I think that's um that's something that that you know it's important for trainees to remember. The work, the research we do um can be powerful and can be can be influential.

SPEAKER_04 9:15

Well, one of the things that struck me, uh Malcolm, is that you you do have a bit of a cast of thousands on the original paper, including some pretty heavy hitters. And I was wondering how you negotiated to get all these people involved in in the project. I imagine there were different roles for other people. So some people were helping you with the methodology of a systematic review, and some people were more involved with the technical side of the neuroimaging and so on.

SPEAKER_02 9:40

Yeah, yeah, that's right. So we did have eight as part of the team, and each person had a specific role. And so the the key, the core group was uh Dennis, who was a statistician and epidemiologist um from University College London, and Steve Kisley, who I think is the master of systematic reviews. He's he's published 50 at least. Um, and so I'd worked with both of them before, and so we had the idea, but there were certain things that we we needed done. So Dennis Feliculis is a neuropsychiatrist, and uh Steve Stuckey is director of uh diagnostic neuroradiology at Monash. And I needed experts to look at the specific findings and judge whether they could be causally related to psychosis. And so they had a very specific role and they did their job very well. And so they uh looked at the individual findings and then went through a process where there, if there was any disagreements and there was only a couple, they would then uh come to a consensus. And so uh yeah, it it was a doing a doing a project like this is a little bit different from a standard systematic review where you're just looking through the literature. We had a bit more of an involved process here because we were looking at specific neuroimaging findings and then making a judgment about whether they could or could not be causally related to psychosis. And so that's part of the reason we had a few extra folks on board. Um, but everyone was more than happy. Uh, some of them I knew, others I just sent an email uh and got in touch, and uh they were very keen to get involved. And um, I'm extremely grateful because it couldn't have happened without the uh without the team on board.

SPEAKER_04 11:24

I I get the feeling that you had a very good plan when you approach them. And that I think that's a key ingredient for other registrars. It it is really helpful for the people that you approach to know that you've done some background reading, you've got some ideas for the systematic review, rather than come with a topic area and just say, Well, what do you think I should do? You may not go with the original idea, but that will then let someone like Steve Keasley or or Dennis know that you're serious, you have background knowledge, and it'll be uh a much uh more smooth process then for developing the systematic review.

SPEAKER_02 12:02

Yeah, I I agree completely. I think if you're going to approach someone, uh especially if you're approaching them cold, it's best to get an introduction where possible from someone else. Um but I always send, you know, my approach with any research is to send a one-page research outline um and also outline to the uh folks I'm approaching who else is involved and my brief research experience.

SPEAKER_00 12:35

When you apply, was that in the ESU from the collection you had to clarify the role of the major authors and things like that?

SPEAKER_02 12:41

Uh so I did the retrospective approval to get it to get it accredited. Um because you know it's it's half the price if you do it that way. So if you get it approved retrospectively, it's only $400 or something, it's uh $900 for the application. And so I thought, well, financially it makes sense to publish a paper and then get it approved. And generally, if if something has gone through a peer review process and is in a decent journal, then um it's hard for them to knock it back. Um, you know, they'd be bold to do that. But I did when I re wrote the letter to the college and said, look, this is the situation, um, I did say, look, I came up with the idea, I did all the um all the analysis myself. I wrote the first draft of the paper, um, and I got Steve Kisley, who was my supervisor, to sign that. So um, yeah, there was there was a process. Just you do obviously need to do the lion's share of the work if you're, you know, um, but but this idea that you know research doesn't occur. Very few people, especially in biological science, do research by themselves. We all work in teams and you bring something to the the table.

SPEAKER_04 13:53

Just from the director of training perspective, uh, yeah, the college doesn't have any any issue with that. The one thing I would mention is it is for all of the different types of scholarly project, if you if you are going to go for exemption, you do need to look pretty closely at what the uh uh requirements are if you hadn't gone the exemption pathways because it's not just enough to get a peer review, you also have to get the other aspects. And um, people, for example, have done not enough uh case studies to get the case study um side through, even though it's been published, it's not enough. Um, and word limits and those sorts of things. So you you you can add to what you've published if you haven't quite met the word limit. You can then um uh package with what you've published some additional material that gets you over the line.

SPEAKER_03 14:38

Yeah, that was a that was a point that came up in our last episode. If anyone hasn't listened to that, they should go back and and have a listen. But um it's demonstrating scope, and the scope of the project has to fit the scope of the scholarly project, um, not just a published article, which might be a thousand words or 1,500 words. Not to say that there's any less work, it's more just how does the committee then know um that you've done that work if they can't see it? I'm just wondering, Malcolm, like very practical things. Did you use uh a particular guideline to get the systematic review done? Is that a is that an international guideline that everyone follows, or is there different ways of going about it? Like what can you share to the audience on that?

SPEAKER_02 15:17

Yeah, so so as uh Andy mentioned, the Prisma guidelines are the guidelines you have to follow for a systematic review. Um, I used uh if I was doing a systematic review now, I'd use a program called Covidence, C-O-V-I-D-E-N-C-E. And so that's quite a useful program. And anyone with access to a university should have access to that uh that program. And it can be really, really helpful um when you're going through the Prisma process. And so having a look or just Googling that program and having to read about it can be very helpful. Um, having shared EndNote files so everyone had the same references, um, that can be useful too. Um, but I won't I won't go through the specifics of how I completed this one because it's it's a bit dry. Um people can read it in the methodology, but um, but yeah, broadly followed the um the Prisma guidelines.

SPEAKER_03 16:14

And I mean, what about the human cost? You know, we sort of we see the we see the the title up in lights, and it's you know, the it's obviously a very impactful paper, and you've been working with some great people, but you know, there must have been some long hours put in, like after after hours work or weekend study. Like, how did you get it done?

SPEAKER_02 16:32

Yeah, uh I mean I've always been interested in in research and I've done a couple of systematic reviews before this one. And so it wasn't when I say it took me two years, that's because I was faffing about doing other things, you know, um, getting stuck into other projects. It does take time. Um, but I think I think if you're if you're interested in it, um, and if you start it early, it can be exciting, especially if it's clinically relevant stuff. Um and so, you know, one opportunity which I'd encourage all registrars to consider, especially if they're interested in clinical academic work down the track, um, is taking on a research registrar position. Um, one of the reasons I I came across to Bael was because uh there was an opportunity to work uh in a research registrar position with Professor Michael Burke, the Deacon, who's uh the highest sided psychiatry and neuroscience researcher in Australia. So he's a he's a serious heavy hitter, he's an incredible guy, very, very helpful, excellent mentor. And so um so, you know, something like that, I think that really uh helps you get excited about research and enjoy the process.

SPEAKER_01 17:49

Malcolm, is there anything else that um with the benefit of experience and hindsight that you might have done differently with your project or things that you've learned along the way that have made a real difference to your research career?

SPEAKER_02 18:00

Uh the things I've learned along the way, Michael, is is having a good mentor. And so um with any project, you want to have someone who's experienced. I know colleagues of mine and friends have started their scholarly project and have worked with a senior author, author or a psychiatrist who doesn't have a lot of research experience. And and I've certainly made that mistake in the past going well back, and I learned from that mistake, and I made sure I never did it again. Um, if you're publishing a systematic review, you want your senior author or supervising author to have published at least five of them. You know, if you're publishing a randomized control trial, you want them to have done RCTs. If you're publishing a case control study, you want them to have done case control studies. And so you want to do that, you want to have someone guiding the process who knows the system inside out. And the other bit of advice is liaising and and talking with statisticians early on, because I I I've done it myself and I know colleagues who've done it, have got halfway through a project and then realize, oh my goodness, we've totally stuffed the data collection up, and they've had to go back to square one. And so if you talk with a statistician early on, they'll advise you on what to do, and uh you can, you know, you can you can put in place the the steps to ensure the project's a success.

SPEAKER_01 19:22

Um that's good advice. How did you find your um mentor? You mentioned you've worked with um Steve in the past. How did that come about your um professional relationship with him?

SPEAKER_02 19:34

Uh that's a good question. I I actually can't remember how we first met, Steve and I, but we've published three systematic reviews together. Um I think we met through a through a friend, and um and I uh I think I I got in touch with him about a paper he wrote and I said I thought it was a great paper. And um and then yeah, we just got in touch down, you know, further on. And I uh when I had this idea, I sent I spoke with him about it. He says, yeah, sounds good. Well, you know, put together a research plan and let's see how it goes. Um so yeah, I mean it there's a kind of sometimes these relationships just start through a sort of organic, you know, process, you get to know someone or you hear about someone. But there's other research I've done where I've seen some work from from a you know a researcher and I just send them an email. I say, hey, I love the work that you did here. Um I've got this idea. What do you think about it? Um could we perhaps collaborate?

SPEAKER_03 20:32

Malcolm, we're just going back to the um to the systematic review process itself. I I mean, every every research question can't be answered with a with a systematic review. Um but I I mean I I'm I do think that maybe some some people listening might uh might not sort of see which questions are appropriate, what what are the necessary kind of requirements within the literature in order to use this um system in order to answer a question? And can you sort of can you give us some um more background on that or sort of enlighten us on that on that front?

SPEAKER_02 21:08

Yeah, sure. So you want to have a very clearly demarcated question, and there needs to be some studies done on it because obviously a systematic review is a review of the existing literature. You can add a meta-analysis if there's quantitative data. And so, if we, you know, talking about this uh review in particular, um, you know, we had a population we were looking at. We were looking at an intervention. Here was a test. Um, in some systematic reviews, you'll have a comparison group, and then you're looking at a specific outcome. So the PICL or Pico model is an easy way to sort of look at a research question. What population are you interested in? What is the intervention? What is the comparison if it if it might be there? And then what is the outcome of interest? And so for this one, we were looking at population was all people with first episode psychosis. The sort of intervention, I suppose, was neuroimaging. And the outcome we were looking at structural findings and so um findings on C tier MRI that may be causally related to psychosis. And that's what Dennis and Stephen may gave their judgment on whether they could or couldn't.

SPEAKER_03 22:20

And can you speak at all about um the quality of the of the studies that need to go into the to the systematic review in order to get good or or reliable um or draw reliable conclusions from it? I think one of the analogies I've heard is um, I think it's rubbish in, rubbish out, or some people have talked about baking a cake. If you bake a cake with terrible ingredients, you're not gonna get a very good cake. But if you bake a cake with beautiful, you know, free-range eggs and organic milk and lovely um, you know, high quality chocolate, then you're gonna get a really nice chocolate cake. So I mean, it is that something that you've experienced when you've done when you've done the reviews?

SPEAKER_02 22:59

Yeah, yeah, absolutely. Yeah, you want to have a you want to have the tasty tasty chocolate cake. That's what everyone's interested in. So, you know, it is it is the rubbish in, rubbish out, or garbage in, garbage out principle for sure. Um, and you know, and that's you you can still do a review. Like, for example, this paper, there was only, I think, two or three studies that were were reasonable, were considered high quality. Um, and that can be one of your limitations of the study. You can say, look, the evidence that we have um suggests this, and we're saying that neuroimogene isn't indicated in first-tip so psychosis and otherwise healthy young people with no focal neurology. Um, but we're relying on, you know, reasonably sort of low to middle quality studies, observational studies. And so you can, of course, include that as a limitation, but you do want to consider it. So before starting the systematic review, you want to do a quick look of the literature first. You want to make sure no one else has done it, and you want to make sure it's not underway at the moment. And there's a website you can check called Prospero, and so you can search the keywords. So for this one, I'd look at neuroimagine first episode psychosis, and someone might have already registered that they're they're undertaking this study. And then in that case, you just go hands off. This is already beginning getting done and you leave it. Um, but I I think beginning with just a Google Scholar search and or a PubMed search and just having a quick look, see what's out there, see the quality of the studies, and then you can um you can go through, you know, if if there's some decent studies there, more than more than a few three or four, you can no systematic reviews been done, uh, you can get on board. If you're just starting, um, probably a good starting point is um a paper, I forget the exact year, but it was published in Australasian Psychiatry and Steve Kisley was the senior author on how to do a systematic review. And it goes through a series of steps. And so having a read of that, um, and even just googling how do I do a systematic review and running through the process, um, that's that's sort of the starting point. Um, but having a really uh skilled team on board um is very important. Having a good question, a clear question is very important, and um and making sure it's registered on Prospero so someone else doesn't come in and do the review and publish it before you do, and you know, all your time and effort is wasted.

SPEAKER_04 25:32

What I really like about this uh is it really demonstrates the scientist practitioner model in action, really. When you start to think about research like this, you start to think about hypotheses that you would then test by looking at the research. And and that's actually a really good answer to the frustration that you might feel as a registrar working in an area where you just don't know what the best practice is. You now have the scientific method at your beck and call to go and investigate and find out either this is the best way to do it, or we actually don't know the best way to do it, and therefore you have to use your own clinical judgment. So there are some systematic reviews where where they don't actually find any really good solid evidence and they can still be published because often an absence of evidence is a useful thing to know, both to stimulate new research, but um so that you can fall back on your general principles and know that you have to make your own best judgment based on the information that you've got at hand.

SPEAKER_02 26:30

Yeah, I think that's that's spot on. And I think it adds a lot of excitement to the work we do because, you know, seeing patients is extremely rewarding, um, really, really interesting work. And and it can be, you know, you make a career out of it and it's great. But I think it's nice if you can progress science a little bit too and and and move psychiatry forward a little bit. It it all happens incrementally. And so having having some interest in research or some exposure to research, and the scholarly project is a is a good way for that to happen um or get people acquainted with it, I think it adds a lot of colour and uh and excitement to um our careers.

SPEAKER_04 27:09

And uh I'm wondering whether Malcolm that COVID has interfered with your international career of jumping around the world going to conferences and that sort of stuff. Were you planning to jet off to Geneva and and that sort of thing to present this sort of research?

SPEAKER_02 27:25

I I did uh I did actually present this uh this research. So it was a couple of years back. So this paper I presented um uh I think it was up in Cairns, uh the um the last Congress, uh maybe a couple of years back or something. And um, and I went over to New York and presented it at uh the APA conference um too. And so so I got in before, but yeah, normally um one of the other perks of having a little bit of you know a research uh job is that you get a huge amount of opportunity to travel and network. And so um and it's it's often uh paid for as well. So yeah, COVID's been hard. Uh there's a lot more Zoom meetings rather than catching up with people face to face and having a drink together. But um but alas, that's uh that's the the life we're all in at the moment.

SPEAKER_03 28:17

So I reckon we are getting to the point where we should say, Malcolm, thank you so much for coming on and sharing your experiences and your thoughts on how to get through and do a really successful scholarly project. Um, and also I think offering some inspiration to trainees that not only can they do a scholarly project, but they can produce some really impactful research that um can uh you know get them an opportunity to fly to New York and present overseas and do some fantastic stuff. So uh it's been it's been a pleasure. Thank you so much.

SPEAKER_02 28:50

I thank thank you so much. And um and and thanks thanks to you all for starting this this podcast. I think it's a fantastic idea and um I think it's an extremely useful resource for for registrars because this is a it's a tough area of training, and um uh yeah, to have some guidance um is is really really helpful. So good on you all.

SPEAKER_03 29:11

Excellent.

SPEAKER_02 29:11

Thanks very much, Malcolm.

SPEAKER_03 29:12

Thanks for having me. As always, we'd like to thank David Beal for helping us produce this podcast, Shadi Dave for our intro and exit music, and also Sidoni Apprentice for our logo design. Thank you.