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Bidirectional Research Roundtable Summary

June 17, 2013

As a federally supported component of the National Institutes of Health (NIH), the National Institute of Dental and Craniofacial Research (NIDCR) aims to improve oral, dental and craniofacial health through research, research training, and the dissemination of health information. In keeping with its mission, the Institute continually defines, develops, and implements approaches that strengthen interactions between academicians and clinicians. Three key goals of doing so include: 

  • Defining approaches to enhance how clinicians inform the development of research questions
  • Developing strategies to increase research engagement and knowledge flow among academic and clinical communities
  • Engaging a broader community in NIDCR-supported research

Bidirectional Research: Goals and Means

Toward meeting these goals, and toward developing its next, 6-year Strategic Plan, NIDCR is currently considering the model of bidirectional research. This approach, broadly defined, is an iterative knowledge exchange between clinicians and basic scientists, in which insights into biological mechanisms and disease processes inform and spur new clinical interventions and, conversely; observations about the nature and progression of disease made in the course of patient care and clinical research stimulate new basic investigations — ultimately leading to improved clinical care outcomes.

In June 2013, NIDCR convened a multifaceted group representing the wide-ranging diversity of the Institute’s constituency (see Roster). The assembly included basic and clinical researchers, practitioners, and academicians from various NIDCR mission areas, as well as representatives from industry and professional organizations. This group was tasked with evaluating the potential of bidirectional research to identify new avenues of basic research investigations and advance evidence-based dental care. Among the issues under consideration included environment/infrastructure, process/models, information/data acquisition/processing, existing/emerging opportunities, partnerships, and outcome measures.

To prompt discussion, the group learned of examples and individual experiences with bidirectional research, as defined above, to provide some insights into the variables and factors that drive a successful research relationship between a basic researcher and a clinician providing a unique case or patient sample. In most scenarios, successful research efforts have resulted from a shared passion that accomplishes several goals: caring for a patient in need, solving a scientific mystery, and developing knowledge for the future.

In contrast, as explained by roundtable participants, less successful forays into bidirectional or other collaborative research have resulted from a lack of commitment from one or both partners, an uneven concern for the outcome of the effort, or the perception that the shared effort is tilted toward one partner’s agenda. Examples include: i) a basic researcher seeking samples for his or her own analysis and use without intellectual clinical consult and ii) a practitioner planning a project without adequate consideration of the research approach, available evidence base, and/or statistical tools needed to answer a given question.

The group considered several examples of research that involved a partnership between scientists at varied levels of the investigational spectrum — as well as practitioners in real-world settings — and reviewed aspects of each case scenario. Ensuing group discussion visited the merits and drawbacks of bidirectional research, as well as other research efforts that followed alternative models. A range of issues surfaced, which are presented below in a contextual summary.

Discussion: Key Themes

I. Human pathobiology is best understood by studying humans

Although research that employs murine and other preclinical animal and cellular models has proven valuable in building a foundation of knowledge about biomedicine, studying humans is an indispensable component of advancing human health through research. Further, “practical wisdom” gleaned by health care providers that work daily with patients can be a very effective guide toward generating research ideas and developing successful treatment approaches. The patient-centered care model emboldened by current trends in healthcare reform can be particularly conducive to research: As an active participant in his or her health, a patient can help guide and speed the discovery and translational process.

The NIDCR Practice-Based Research Network (PBRN) is one example of a collaborative research approach that has found success. This national assembly of research teams, stratified into regional groupings of dental practitioners and academic (mostly clinical) researchers, has defined problems encountered in clinical practice, then advanced those problems for further potential research study. Final selection of research projects occurs in a stepwise fashion. After research ideas “bubble up” from regional PBRN sub-groups, they are vetted first by the Executive committee that includes several practitioners and then ultimately by NIDCR staff that ensure the appropriate and balanced use of Institute funds.

As described by PBRN leadership, the effort is characterized by “remarkable” interactions among participants. Much of the program’s success and progress has been fueled by vigilance toward maintaining a culture of routine face-to-face interactions, a sense of humility that all participants are on an even footing, and a shared desire to advance clinical care for real people in real-world settings. Beyond these features is an engaged group of members that value management and intentionally choreograph interactions among researchers and practitioners.

In general, the PBRN approach has offered a convenient vehicle for assembling recurrent clinical observations and challenging, then strengthening and changing, the evidence base. To date, the group has not made substantial intentional outreach/engagement to the basic science community, but rather has concentrated its efforts on practice-derived questions. However, there may be untapped opportunities to connect these practitioners to basic researchers. Creative approaches may facilitate interactions such that these connections move past the current sense of “fitting a square peg into a round hole.”

Aside from the PBRN, various programs and strategies have been developed by NIH to encourage “multimodal” research that links academicians, community health providers, and patients. One notable example is the NIH-sponsored Clinical and Translational Science Award (CTSA) program launched in 2006. The CTSA program has developed several resources, including: 

  • ResearchMatch.org,1 a service that aims to improve clinical trial recruitment by providing a way to connect people who are trying to find research studies with researchers who are seeking people to participate in their studies
  • University of Alabama at Birmingham (UAB) Translational Investigator Exchange Service, which brings together complementary teams of basic and/or clinical investigators
  • University of California, San Francisco (UCSF) Profiles2 and UCSF Research Navigator3 tools 
    Harvard Catalyst Profiles4
  • Weill-Cornell Clinical and Translational Center website5

Patient advocates and their cognate societies have also been very helpful in making connections between patients and research studies.
 
Matching patients, providers, and academic researchers remains challenging for many, however. As noted by roundtable participants, engaging with CTSAs and other research programs, as well as acquiring relevant resources, is very difficult for people “not in the system” of biomedical research.

II. The oral health evidence base is dynamically built, consulted, and applied

In conducting and evaluating research, continuous learning is a requisite. A barrier to bidirectional, or any collaborative, cross-disciplinary research pursuit, is a perceived trade-off between studying problems sometimes viewed as arcane and the urgency of caring for patients waiting to have their health issues fixed.

Among busy clinicians, the incessant need to address patient care may cultivate and perpetuate a desire to acquire information quickly rather than look for it through iterative research. One approach welcomed by practitioners to help connect patient-derived observations and/or data is an online vehicle to “crowdsource” research or clinical questions. Potential approaches include the development and maintenance of listservs and question banks. Also desirable are access to i) shared research resources, such as biobanks for clinical biospecimens; ii) data collection tools and instructions; and iii) electronic health records. Because multi-site collection requires standardization that is difficult and costly, dental researchers could borrow tools and approaches from other clinical trial networks outside the realm of oral health. Forging such connections might also advance the ability to harness information, data, and samples from non-dental practitioners in other medical settings that also confront manifestations of oral disease.

III. Both scientific and practical priorities affect the success of research collaborations

All biomedical and behavioral research has value, yet choosing topics for research investigation is a complex process affected by a number of variables. Bidirectional research that involves different levels of investigation is affected by these variables that may appear to conflict. Whereas curiosity to explore the unknown may drive most basic research pursuits, burden of disease and quality-of-life issues often guide the selection of topics for clinical research investigation. Addressing common clinical problems through research offers the value of applying cutting-edge knowledge and tools toward the development of new, improved treatment paradigms for common and/or chronic dental and other oral health conditions. Also important is the issue of time: will the benefits of research be achieved in the near term, and help patients now? Or will knowledge acquisition add to the foundation of health information that will be realized later, through a less defined trajectory?

Rare diseases, for example, offer an “avenue of discovery” to connect a clinical observation with a biological mechanism, and this approach is a main intent of bidirectional research as defined earlier in this document. The NIH Undiagnosed Diseases Program6 is a good example of how such a research approach has been effective, leading to the definition of new conditions, as well as to the development of novel treatments for certain rare ailments. Along the way, those investigations have also deepened knowledge of basic human pathobiology, and they promise future, less tangible benefits toward fortifying the foundation of knowledge about science and health.

Despite the exploratory value of rare disease research, however, it remains a mystery to many would-be researchers outside well-funded academic centers. In addition, unusual patient cases that might qualify as “rare” may not surface in community clinics, or they may not be recognizable as such since individual dental practitioners that see clinical problems typically don’t have a voice that is heard outside their personal sphere of influence of friends and trusted colleagues. Nor do such individuals know how to pursue the time-consuming process of initiating research partnerships and acquiring the necessary resources. In addition, opportunities for collaboration and cross-discussion are fewer in dentistry compared to medicine.

Behavior change is a longstanding issue facing the NIH and other entities that support scientific research that interrogates human disease. Many clinical problems and chronic diseases of the mouth, and elsewhere in the body, have roots in unhealthy human behaviors. For many years, oral health has served as a prime example of the value of prevention in deterring disease, and much of this progress has come from fostering behaviors that promote and maintain oral health. However, a multitude of factors affect an individual’s behavior, and many of these factors are societally influenced. The availability of healthy food, safe exercise environments, and routine oral care is beyond the reach of many vulnerable populations. NIDCR and other NIH components whose missions encompass chronic diseases that are affected so strongly by societally influenced factors must collaborate with other sectors to more fully understand, and ultimately manipulate, disease-provoking behaviors. Bidirectional research or any other NIDCR-supported research approach cannot address those issues alone.

Because so many parameters define research need, it is likely that a variety of models should be designed and implemented to meet the needs of oral health researchers and the NIDCR stakeholder community that also includes patients and practitioners. The PBRN approach represents one model of successful research that engages practicing dentists, but other approaches are needed to spur connections between basic researchers and clinicians, as well as to ensure that those collaborations interrogate questions whose answers will positively affect human health outcomes.

IV. Engagement is a key aspect of successful research collaboration

Research collaborations rarely work when they are forced. Despite the genuine desire to advance human health among biomedical researchers who populate various positions along the research continuum from basic to clinic to community, performing collaborative research remains challenging. A substantial gulf separates basic and clinical scientists, and health providers often lie further still from either “end” of the spectrum. Several features establish and maintain this gulf: unclear communication resulting from specialized vocabularies, time pressures, inconsistent goals, financial disincentives, and education gaps.

Oft-heard phrases describing the chasm include, from basic scientists: “Clinical faculty don’t care about what I do,” and from clinicians, “Most basic scientists don’t have a clue about bringing a discovery to treatment.” Even at professional meetings, basic scientists and clinicians are so focused on improving their own specialized skill sets and knowledge base that they often each attend only their own sessions, prohibiting cross-learning and cross-talk. Examples of efforts or approaches that have enhanced cross-disciplinary interactions include i) institutional “tumor boards” that emulate patient-centered care, ii) electronic and social media interactions, iii) modest-sized grants that facilitate communication and coordination,7 and iv) institutional investigational new drug (IND) groups. Each of these examples has facilitated cross-learning, shared resources, and/or face-to-face interactions that have improved collaborative work.

Beyond the issues described above that limit or even prohibit collaboration, another key factor is drive: Successful research partnerships occur when both partners “want to know the answer” to a common problem and have a passion to solve it. In the case of biomedical research, that problem must have human clinical relevance. Both research partners must also be highly engaged and matched in their expectations to contribute equally to the partnership. Research collaborations doomed to fail include those in which one partner “services” the other without intellectual resonance. Moreover, many team science endeavors are plagued by issues of credit and review, and only succeed fully when the team holds more value than that of any individual player.

One barrier to the advancement of oral health through evidence-based practice is insufficient training in the knowledge and conduct of biomedical and behavioral research. Roundtable participants noted a general failure of dental school trainees and practicing dentists to recognize holes in the evidence base, stemming in part from the fact that much of what is taught in dental school “this is the way we’ve always done it,” as noted by one roundtable participant. Ideally, training would provide the necessary scientific vocabulary to communicated with researchers, as well as introduce cutting-edge tools and approaches that could be bought to bear on understanding the fundamental causes of confounding clinical issues that face the oral health community.

Conclusions


Biomedical and behavioral research efforts do not operate in a vacuum. Emerging areas of science and evolving healthcare practices continuously re-frame the research environment. These shifts open up opportunities in new areas of science. In addition, beyond specific scientific areas, continuously improving technologies may offer new lenses on old problems, thereby revealing new scientific “truths.”

Healthcare reform that widens general access to care may shift priorities toward preventive care and treatment, enabling a broader community of potential patients for study through clinics. At present, however, the dental insurance landscape is skewed toward well-off patient populations who can afford it, and children who are covered by Medicaid, complicating the acquisition of data from insurer pools and necessitating creative approaches to collecting, sharing, and storing patient-derived data of value to oral health researchers.

Inevitably, the current austere NIH funding climate exacerbates the problem of dental researchers not applying for federal research money, and financial concerns such as student debt deter dental school graduates from pursuing research. These realities compound efforts to encourage research among all types of biomedical scientists, not only those invested in oral health research and patient care, and cultural challenges and practical constraints will continue to frustrate progress toward bidirectional and other collaborative research on topics that affect oral health and that involve researchers within and outside dentistry. It remains unclear at this time whether a comprehensive bidirectional research program would suit the needs and goals of NIDCR, but the Institute will continue to consider options and additional models to foster basic-clinical research partnerships toward bettering the nation’s oral health. 

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References

1https://www.researchmatch.org/ 
2http://profiles.ucsf.edu/search/ 
3http://accelerate.ucsf.edu/navigation 
4http://connects.catalyst.harvard.edu/Profiles/search/ 
5http://weill.cornell.edu/ctsc/services_and_resources/crossinstitutional_collaborator_search.html 
6http://rarediseases.info.nih.gov/research/27/undiagnosed-diseases-program
7Examples include NIDCR collaborative research supplements, Stanford’s SPARK program  


PARTICIPANTS

Martha J. Somerman, DDS, PhD
Director
National Institute of Dental and Craniofacial Research
Bethesda, MD 20892

Isabel Garcia, DDS, MPH
Deputy Director
National Institute of Dental and Craniofacial Research
Bethesda, MD 20892

Robert J. Berendt
NIDCR Strategic Planning Advisor
Robert J. Berendt Associates
Organizational Planning and
Management Analysis
Washington, DC 20008

Paul Benjamin DMD, MAGD, FACD.
25 SE 2nd Avenue. Suite #336
Miami, FL 33131

Pamela K. Den Besten, DDS
Professor and Chair
Department of Orofacial Sciences
School of Dentistry
University of California, San Francisco
San Francisco, CA 94143

Gregg H. Gilbert, DDS, MBA, FAAHD, FICD
Professor and Chair
Department of Clinical & Community Sciences
School of Dentistry
University of Alabama at Birmingham
Birmingham, AL 35294-0007

Ann Griffen, DDS, MS
Professor
Division of Pediatric Dentistry
The Ohio State University
Columbus, OH 43210

Linda Hallman, DDS, PhD
Director of Orthodontics
Washington Hospital Center
Washington, DC 20010

Jose Luis Millan, PhD
Professor and Sanford Investigator
Sanford-Burnham Medical Research Institute
La Jolla, CA 92037

Sara Pai, MD, PhD, FACS
Associate Professor
Departments of Otolaryngology
Head and Neck Surgery and Oncology
Johns Hopkins Medical Institutions
Sidney Kimmel Comprehensive Cancer Center
Baltimore, MD 21287

Vincent Prestipino, DDS
7830 Old Georgetown Rd
Bethesda, MD 20814

Elizabeth Roberts, DDS, MBA
Director, Scientific & Professional Affairs
North America Oral Healthcare Research
Development & Engineering
Johnson & Johnson Consumer & Personal Products
Worldwide Division of Johnson & Johnson Consumer Companies, Inc.
Morris Plains, NJ 07950

Mark E. Sobel, MD, PhD
Executive Officer
American Society for Investigative Pathology
9650 Rockville Pike
Bethesda, MD 20814-3993

Clark M. Stanford DDS, Ph.D.
Associate Dean for Research
College of Dentistry
University of Iowa
Iowa City Iowa 52242

Jennifer Webster-Cyriaque DDS PhD
Associate Professor
Department of Dental Ecology, School of Dentistry
Department of Microbiology, School of Medicine
Oral HIV AIDS Research Alliance, Virology Unit PI
University of North Carolina Chapel Hill
Chapel Hill, NC 27599


AGENDA

8:30 AM Welcome and Background: NIDCR’s Interest in Bidirectional Research
Dr. Martha Somerman, Director, NIDCR

Bidirectional research is an iterative knowledge exchange between clinicians and basic scientists, in which insights into biological mechanisms and disease processes inform and spur new clinical interventions and, conversely, observations about the nature and progression of disease made in the course of patient care and clinical research stimulate new basic investigations – ultimately leading to improved clinical care outcomes.

Goals: a) defining approaches for enhancing the ways clinicians inform the development of research questions; b) developing strategies to increase the research engagement and flow of knowledge gained from research and clinical practice between academic communities and practitioners; and c) engaging a broader community in NIDCR research.

9:00 AM Discussion of Roundtable Format and Approach
Robert Berendt, NIDCR Strategic Planning Advisor 

  • Group introductions
  • General questions

9:15 AM Topic I: Drawing on Individual Experiences with Bidirectional Research 

  • What are your experiences with bidirectional research? Can you describe relevant success stories/case studies?
  • Have you made clinical observations that suggested a basic research question? Was there a researcher you could/did partner with to pursue this line of investigation?
  • What made those bidirectional research efforts successful? What allowed clinical observations to inform basic research design? What allowed basic research observations to inform clinical practice?
  • Do roadblocks exist to this flow of information? If yes, what are they and how can they be overcome?
  • Open discussion among the group
  • General summary and conclusions

10:30 AM Break

10:45 AM Topic II: Scientific Content and Outcomes

  • What areas of research are currently ripe for application of bidirectional approaches? Areas could run the gamut from rare cases featuring mysterious conditions or unique patient presentations, to areas of unmet clinical needs that impact many patients in an average practice 
  • What are some “provocative questions” that could be answered by bidirectional research – questions to challenge researchers to think about and elucidate specific problems in key areas of research that are deemed important but have not received sufficient attention?
  • How would we measure successful outcomes of bidirectional research? Are there short-term benchmarks that could be used to indicate our effort to encourage bidirectional research is on the right track?
  • Open discussion among the group
  • General summary and conclusions

12:00 PM Lunch

1:00 PM Topic III: Devising Models for Bidirectional Research 

  • Note: There could be a continuum of bidirectional research activity ranging from enhancing communication between clinicians and researchers to supporting the development and stability of collaborative research teams that include clinicians
  • How could we help clinicians identify and communicate research questions that emerge through clinical care to basic researchers? Reciprocally, how could we channel basic science discoveries of biological and behavioral mechanisms for clinical applications?
  • How could clinicians easily communicate case studies/patient samples to researchers? Reciprocally, how could basic science investigators explore these observations, e.g. possibly utilizing a biospecimen collection?
  • What would a framework for bringing the necessary players together into a collaborative team look like?
  • Open discussion among the group
  • General summary and conclusions

2:15 PM Break

2:30 PM Topic IV: NIDCR Facilitation of Bidirectional Research

  • What practical considerations could/should NIDCR address to facilitate bidirectional research?
  • What scientific considerations could/should NIDCR address to facilitate bidirectional research?
  • How would this new focus on bidirectional research relate to existing NIDCR investments – e.g. the NDPBRN, existing multi-disciplinary grants, CTSAs? For example, could the NDPBRN be tapped for generating potential research questions?
  • Should NIDCR partner with specialty organizations for input?
  • How do we get the dental community to utilize the research match tools available at several CTSA institutions?
  • Open discussion among the group
  • General summary and conclusions

3:30 PM Summary, General Conclusions, and Wrap-Up

  • Brief overview of key points raised
  • Closing comments and questions from the group
  • Next steps in strategic planning

4:00 PM Adjourn

Additional topics for discussion, if time permits:

o Should we incorporate bidirectional research in our training and career development program? If so, how? What should we prioritize? For example, are there enough basic and clinical researchers and practitioners to engage in this process? Is there a way to incorporate this approach into dental school curriculum, so that clinicians are more prepared to engage with basic scientists?

o How do we involve our broader community (including patients) in the process? Should we involve the community in developing research questions?

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This page last updated: October 24, 2014