As a community-based family physician, Dr. Carrie Bernard examines research questions that are directly relevant to her patients and practice.

“All of my research has come out of the clinical world, and for me, that’s what makes research meaningful,” says Dr. Bernard, physician at William Osler Health Centre in Brampton. “I see myself as firmly planted in the community as a physician. That is my home, and that is what matters to me. I am most interested in research that is going to help my patients in the long run.”

Since she started to undertake research projects over the last decade, she has partnered with researchers to work on projects ranging from humanitarian health care ethics to advanced care planning. One of her most recent projects, funded by a PSI Foundation grant for Medical Education Research that the Post-MD Level, focused on how ethics curriculum is taught to postgraduate family medicine trainees.

Dr. Bernard says that PSI’s support of family physicians and their understanding of their unique research approach helped her feel valued as a researcher.

“PSI felt like the right place to go for this funding because it represents who I am as a physician first and a researcher,” she says. “They understand and expect that as an MD, you will need to partner with a PhD researcher on your project. You’re not viewed as a lesser researcher because of that.”

New ethics curriculum aimed to increase confidence with challenging situations

Dr. Bernard’s transition to doing research was a gradual one. She had been practising as a family physician for several years when she volunteered on a humanitarian trip to northern Uganda with Médicins Sans Frontières (Doctors Without Borders). The experience left her with many questions about how to do humanitarian medical work ethically, but she realized she needed a research-focused education to properly answer the questions.

So, while continuing to practice family medicine fulltime, she earned a master’s degree in public health at the University of Toronto, focusing on global health and ethics.

Her master’s degree opened up new opportunities in academia, and in 2014, she joined U of T’s Department of Family and Community Medicine as Associate Program Director, Curriculum and Remediation. As part of her role, she began working with a team of physicians, ethicists and education experts to re-design how ethics is taught during family medicine residencies.

“One of the main reasons doctors run afoul with regulatory bodies is because of unprofessional behaviour and understanding how to manage these fraught and ethically challenging situations. It’s incredibly important to make sure you have strong ethical judgment to build trusting relationships with patients,” she says. Yet, “Family medicine trainees and even many practising family physicians feel underprepared and unconfident when it comes to ethics.”

Dr. Bernard worked closely on the new curriculum with Dr. Mahan Kulasegaram, director in the Office of Education Scholarship in the Department of Family and Community Medicine and an expert in learning sciences. They, along with the rest of their team, spent more than a year developing a new ethics curriculum that relied on family physicians – not trained ethicists – to teach the curriculum, as well as deliberately integrated ethical principles with the day-to-day work of family medicine.

“You can do a lecture on the principles of ethics, but if it’s not integrated within a realistic case that learners can understand in a clinical way, it seems remote,” she explains. “Our whole interest was really on grounding it in integration in family medicine and basing it on learning principles.”

Dr. Bernard and Dr. Kulasegaram then applied to PSI Foundation to evaluate the new curriculum. They worked with physician teachers at four teaching sites to teach the new curriculum, interviewed residents before and after they completed the curriculum, and evaluated the residents’ performance in the objective structured clinical examination (OSCE).

Positive pilot results help curriculum become self-sustaining

Dr. Bernard says that she and the team were “blown away” by the results. Residents from the pilot sites performed significantly better in a five-station OSCE focused on ethical issues compared to their peers who learned from the standard curriculum. And in the interviews, residents said they had greater awareness of ethical principles and could use a formal ethical deliberation process in challenging situations, which gave them more confidence to act and incorporate patients’ values into ethical deliberations.

Dr. Bernard says she was most pleased with what happened next: based on these results, the pilot sites not only continued using the new curriculum, but also supported the other training sites in implementing it. Having the curriculum become self-sustaining at the training sites was exactly the kind of result that the curriculum redesign team had hoped for.

“Now every single training site in our department is teaching it, and the original sites are acting as helpers,” she says. “We had hoped this would become a ‘train the trainer’ mentorship community of practice, and it just happened naturally that as these teachers became empowered and confident, they started teaching others.”

Having demonstrated these positive results in one department, the team hopes to generate more awareness of the curriculum results among physician teachers and residency program directors at medical schools across the country. In the long-term, she hopes that the curriculum will help more family physicians be more confident in their ethical deliberations and build positive patient relationships.

“Funding good educational research means we’re going to have good doctors in the future,” she says. “PSI’s support of this project is amazing because it directly affects the people – that is, the medical residents – who are going to make a difference in the future.”

“PSI Foundation It is one of the few granting agencies that funds clinical research. Its reviewers understand good science and good methodological design, but as clinicians, they also see the clinical problems. I feel that, as a clinician, I can be competitive with PSI because they understand that type of work.” – Dr. Joel Fish, plastic surgeon and Medical Director of the Burn Program at the Hospital for Sick Children, Toronto

Hypertrophic scars – thick and stiff severe scars that are often the result of burns – can affect children’s lives in many ways, interfering with a child’s growth, mobility and even confidence. And children with these scars haven’t had many effective treatment options to reduce the scar’s appearance and size.

But a new laser therapy may help to treat these scars, whether they are new or even several years old.

Dr. Joel Fish, a plastic surgeon and Medical Director of the Burn Program at the Hospital for Sick Children (SickKids) in Toronto, led a PSI Foundation–funded clinical trial that has provided some of the strongest evidence so far supporting the use of a new laser therapy to treat hypertrophic scars in children.

Lasers have been used in medical treatment for many years, particularly for cosmetic procedures, but recent research had suggested that two specific kinds of lasers, pulsed dye laser (PDL) and carbon dioxide laser, could be particularly useful for treating burn scars – even scars that are more than 10 years old.

“It’s one of the few therapies to come along in many years that has real benefits, not just on new scars but on mature scars, so it’s quite unique,” says Dr. Fish.

But more definitive research about the effectiveness of laser therapy, especially in children, was needed. Dr. Fish and his research team designed a clinical trial to determine whether laser therapy could improve hypertrophic scars in children, and received PSI funding in 2016 to conduct the trial.

Approximately 25 children with hypertrophic scars were treated with three laser therapy sessions over the course of a year. To determine whether the scars improved over the course of treatment, between sessions Dr. Fish and his team measured the scar’s height and thickness, stiffness, vascularity and colour, using validated subjective scar assessment scales and objective tools, such as conventional ultrasound and ultrasound elastography.

After all of the laser therapy treatments, the team found that the height of the scars improved, the thickness and colour improved, and the scars were less itchy, demonstrating that the therapy was highly effective.

“It really did have measurable effects, and not only were they measurable, the scars don’t go back to the way they were,” says Dr. Fish. “Once you achieve the scar being a little bit flatter or softer or less red or less itchy, it doesn’t go back.”

With these positive results, the team now plans to do further work to understand when treatment should start and how many sessions are optimal, as well as examine how the treatment works, all of which will help to refine the therapy.

SickKids has the largest pediatric burn program in the country by a large margin, and children from across the country have been treated in Toronto instead of closer to home. In fact, it is one of the few centres in Canada to use laser therapy to treat scars in children.

But Dr. Fish’s study, along with a handful of other trials, is generating interest in the health care community about the potential for this treatment. Directors of burn programs from different countries have learned from Dr. Fish’s team how to treat children with laser therapy to implement their own programs, and more hospitals across the country are beginning to invest in the technology.

“To our knowledge, this is the most comprehensive study to date that demonstrates that laser treatment leads to significant improvements in children with burn scars,” says Dr. Fish. “We hope that our findings will encourage other providers to invest in this valuable therapy for their patients.”

A clinical study supported in part through PSI has examined one of the most common complications faced by patients in critical care – diarrhea. Dr. Joanna Dionne, who is leading the Diarrhea, Interventions, Consequences and Epidemiology in the Intensive Care Unit (DICE-ICU) study, says that PSI support was essential to the study, which aims to improve care for patients experiencing diarrhea while in the ICU.

“My Resident Research Grant from PSI was truly transformative. It provided not only financial support, but also encouragement that my physician community in Ontario believed in me and this research,” she says. “This topic may not be ‘flashy,’ but diarrhea certainly affects many critically ill Ontarians, and we could certainly change care and impact our patients if we understood it better.”

Dr. Dionne is a gastroenterologist, intensivist and internist at Hamilton Health Sciences and assistant professor at McMaster University. As a trainee in critical care with her mentor, Dr. Deborah Cook, she realized that not much information was available about the incidence of diarrhea in the ICU and its causes.

This realization eventually led to the DICE-ICU pilot study, a prospective cohort study to establish the prevalence of diarrhea in patients in critical care, identify risk factors and document its consequences on clinical decisions and outcomes. The pilot study began with four sites in Ontario, then added two sites in the US. In 2016, Dr. Dionne received a PSI Resident Research Grant to expand the study to another three Ontario sites, which mean that nearly 900 critical care patients in total participated in the study.

Residents are the principal investigators on PSI Resident Research Grants, helping them gain key research skills to help prepare them for careers as independent clinician scientists.

“Early support will make or break someone’s career and will lead them to becoming a researcher or not,” says Dr. Dionne. “It’s not just about the science, but also getting experience with the administrative work of leading a study that is so vital for your career development. It’s absolutely fundamental.”

DICE-ICU study will provide foundational information about understudied topic

The DICE-ICU pilot study used three different definitions of diarrhea to estimate the incidence in critical care patients, which ranged from 40% to 77% depending on the definition. It also identified the risk factors most strongly associated with diarrhea, which included the number of days a patient was prescribed antibiotics. And, importantly, the study suggested that Clostridium difficile, which has been thought to be major cause of diarrhea in critical care patients, is actually responsible for only a small proportion of cases.

Based on these pilot results, Dr. Dionne initiated a larger DICE-ICU study, which includes more than 1,000 patients at 12 centres in four countries – the largest study of its kind in the world. The results will provide foundational information on the cause and impact of diarrhea in the ICU and may influence treatments that increase risk of diarrhea, such as antibiotic prescribing and enteral feeding practices in ICU patients.

In 2019, Dr. Dionne received a PSI Research Trainee Award, a two-year award that provides support to protect 75% of her time for research and allowed her to further the DICE-ICU study.

“The funding I received from PSI has been the building blocks of a research program that otherwise may not have been funded,” she says. “And importantly, PSI is able to support you as you grow as an investigator. It supports junior and early career investigators and has different programs to support you over time. That longitudinal support is absolutely transformative.”

Dr. Dionne says that it was challenging to get the DICU-ICU study underway, in part because there hasn’t been much interest in studying diarrhea in critical care patients or recognition of its clinical importance. But mentorship from Dr. Cook and support from PSI encouraged her to continue pursuing this question. This support inspires her to give back to younger trainees now and in the future.

“It makes me want to give back to my province, to PSI which has been incredibly instrumental to my career, and to give those opportunities to the next generation of young investigators,” she says.

Despite the challenges young clinicians may face, especially when trying to undertake a new research program, she encourages them to persevere to examine important clinical questions that can change patient care.

“It’s a true honour to work with patients and serve my community and my province, but when you’re working at the bedside, there’s always a question you cannot answer. That curiosity always drives me back to research,” she says. “As a physician, I can do my best for my patients, but as a researcher I can help patients that I will never meet, and I think that’s pretty powerful.”

A recent clinical trial, supported in part by PSI Foundation, is challenging the dogma around antibiotic use to treat community-acquired pneumonia in children. 

Physicians have traditionally prescribed a 10-day course of antibiotics, but this has been based more on convention rather than evidence. Dr. Jeffrey Pernica, a pediatrician and infectious diseases specialist at McMaster Children’s Hospital, recently led a clinical trial to determine whether a five-day course of antibiotics is as effective as the longer course.

“As medicine has transitioned to relying more on evidence rather than convention, we’re all trying to be more rational with antibiotic courses in order to make patient management plans that carry the most potential benefit and the least potential harm,” says Dr. Pernica. “As physicians, we all have a responsibility to make sure that when we use antibiotics, the courses we select are based on the best evidence so that our patients receive just the amount of antibiotics that they require – and no more.”

Potential antibiotic-associated harms include increasing rates of circulating antibiotic-resistant bacteria, medication costs to the families, short-term side effects, as well as longer-term health effects from disrupting the microbiome, including obesity and allergic disease.

Dr. Pernica first led a pilot study comparing a 10-day course of amoxicillin to a five-day course of amoxicillin for community-acquired pneumonia as part of his master’s degree in health research methodology. Based on the pilot study’s results, he received a PSI Foundation Clinical Research Grant in 2015 to expand the study and launch the SAFER (Short-Course Antimicrobial Therapy for Pediatric Respiratory Infections) trial.

“PSI feels like a collegial organization, and the grant reviewers are really my peers,” says Dr. Pernica. “They have the best interests of Ontarians at heart and a good idea of what studies are actually going to be useful for Ontario citizens, academics and clinicians.”

With PSI support, Dr. Pernica and his team recruited 281 children from six months to 10 years old who were diagnosed with pneumonia in the emergency departments at McMaster Children’s Hospital and the Children’s Hospital of Eastern Ontario. The children received either the full 10-day course of antibiotics or five days of antibiotics and five days of placebo and were followed closely until they were assessed two to three weeks after diagnosis.

The trial results, published in JAMA Pediatrics in March 2021, demonstrate that the short course of antibiotics was comparable to the standard course in treating children with community-acquired pneumonia. At 14 to 21 days after enrollment, 85.7% of children on the short course of antibiotics were “clinically cured” based on the study’s strict definition, compared to 84.1% of children on the longer course. The researchers then did a post hoc analysis to examine how many of the children clinically improved without needing additional antibacterials: 93.5% of children on the short course and 90.4% on the longer course fit this criteria. Taken together, the results suggest that the short course of antibiotics is just as effective as the longer.

Dr. Pernica says the trial did not require any special tests for physicians to order or onerous follow-up for patients, reflecting real-world conditions of how pneumonia in children is diagnosed and treated, which should allow the results to be quickly integrated into practice. 

“The patients in this study are very similar to patients that doctors see every day in Canadian emergency departments and diagnose with pneumonia,” says Dr. Pernica. “For that reason, we think that this evidence is generalizable to the vast majority of children being diagnosed with pneumonia in Ontario emergency departments and will be of practical use for Ontario-based physicians.” 

Given the urgency and scale of the challenge of antibiotic resistance, Dr. Pernica and his team are now focused on knowledge translation to incorporate the results into prescribing practices. They are working with research groups such as Pediatric Emergency Research Canada to integrate the results into practice and reduce antibiotic use where possible.

“Antibiotic resistance has become so important, not just in other places in the world, but here in Canada as well. We all need to do our part to use antibiotics responsibly so that we are still able to control bacterial infections in our population,” says Dr. Pernica. “It’s going to be critical to make sure that clinicians in Canada use only as much antibiotics that are needed to cure a patient, but no more.”

“PSI’s Resident Research Grant gives you complete ownership over the project, and you gain important skills in grant writing, finances, and leading projects. For someone like me, who is interested in a career in research, these elements are going to be important in my future, and having a resident-focused grant gives you some of those skills that are important to any scientist.” – Dr. Fahima Dossa, general surgery resident, University of Toronto

Dr. Frances Yeung, a former pediatric resident at London Health Science Centre (LHSC), says her PSI Resident Research Grant was not only critical for her resident project, but also for putting her on the path of a research career.

“It piqued my interest in research. Prior to this, I didn’t know if I wanted to incorporate research into my future career,” says Dr. Yeung, now a clinical fellow at The Hospital for Sick Children. “Now I have more confidence and the knowledge to do so.”

Dr. Yeung led an ambitious, methodologically intense project for any resident – a clinical trial comparing two approaches to maintain a peripheral intravenous catheter (PIVC) in children.

PIVCs are essential for delivering fluids and treatments into a patient’s bloodstream, and because they can be painful and time-consuming to insert, health care providers try to make these devices last as long as possible. Two approaches are currently commonly used: “to keep vein open” (TKVO), which is a continuous low infusion of fluid through tubing, and a saline-lock, which “locks” a small amount of saline into the PIVC and requires no other tubing.

Dr. Yeung and her supervisor, Dr. Sepideh Taheri, saw that there was a lack of guidance around which method to use. Different countries, provinces and even centres differ in their preferred method.

For example, saline-lock is commonly used in Manitoba, where Dr. Yeung did her first-year residency, and in the United Kingdom, where Dr. Taheri worked prior to coming to Ontario. But at the Children’s Hospital at LHSC, where they worked together, TKVO was used most often.

In reviewing the literature, they found that very little research had been done to determine which approach should be used. Previous research had been based in the neonatal intensive care unit (NICU), but no studies had been done in the pediatric population.

The research in the NICU suggested that saline-lock made it easier for parents to care for their babies and reduced the risk of strangulation from tubing, reduced the burden on nurses to check the PIVC, and likely resulted in cost savings, but the big question – how long each approach maintains the PIVC in pediatric patients – was unclear.

Clinical trial is recognized nationally and changes practice locally

With a PSI Resident Research Grant, Dr. Yeung led a clinical trial comparing TKVO and saline-lock to determine how long each method maintained the PIVC in children from newborns to 17 years old. For three months, every child who was enrolled in the study received TKVO. This was followed by three months where every child who was enrolled had a saline-lock. The research team measured how long each PIVC remained patent, as well as collected data on complications and patient and caregiver satisfaction.

Importantly, they found that the two approaches were not significantly different in how long they maintained the PIVC, complications from PIVC, and patient and caregiver satisfaction.

“It was an important result that there was no difference between the two in the length of time that the IV lasted,” says Dr. Yeung. “And we know that saline-lock has those additional benefits, so hopefully other pediatric centres across Canada will consider moving toward using it.”

The study results have strong potential to help guide physicians’ decision-making, and Dr. Yeung and Dr. Taheri have presented the results at hospital rounds, conferences and national webinars to increase awareness. In LHSC, they noticed that practice is already starting to change, with more pediatricians and nurses choosing to use saline-lock for their patients.

In particular, Dr. Yeung presented at the National Pediatric Resident and Fellow Research Competition in 2019 and won the resident category. Her research stood out, in part, because of the more intense research methodology involved in a clinical trial.

Support from her supervisors in developing the trial and from PSI to fund the trial were key to her success. PSI Resident Research Grants are unique in that they require the trainee to be the principal investigator on the grant and perform the majority of the research, preparing them for future careers as clinician scientists.

“A clinical trial can be difficult to accomplish and requires so many resources, and many residents take on projects that are less intense in their methodology. The PSI grant definitely gave me more confidence in completing my own research and working through the methodology with my supervisors,” she says.  “Before this trial, I had never been involved in such a big study, and it has helped me develop stronger skills in research methodology and clinical trials. Now I have the confidence to move forward in this career.”