22
The heAlTh | April, 2020
| Interview |
research. This topic has been highlighted
internationally, but in Malaysia no one
seems to have taken up this issue.”
An Histopathologist and Statistician by
training, Dr Manimalar talks to The Health
about enhancing the quality of research and
other issues close to her heart.
Some excerpts:
Dire need
for quality
medical
research
local universities should join forces
to enhance research quality due to a
shortage of resources
L
OCAL universities currently suff er
from a situation where academic
or university physicians need to
publish research papers to obtain
their promotions. Thus, they may
end up cutting corners which
results in publishing low-quality
research.
Dr Manimalar Selvi Naicker of Universiti
Malaya Medical Centre has been a strong
advocate of raising the quality of medical
research at local hospitals and universities.
“This is something the public often does
not understand. When the doctor gives you
an opinion, it is not entirely his opinion. It
is from a body of medical research. So, the
medical research must be of good quality
and doctors must be able to read it critically
and apply it to the individual patient in
front of them.” This is known as the practice
of Evidence-Based Medicine (EBM)
“Generally, our basic undergraduate and
specialist degrees do not train us to do or
understand this kind of research. That is
why I started my eff orts to highlight the
defi cient way in which we specialists have
been trained and the quality of our medical
Why is this poor quality of research
happening?
There are three main reasons in general and
one which is particular to Malaysia.
In general, good quality research needs
the money and infrastructure to train
researchers, to do large-scale clinical
research and a governance system to
prevent abuses by clinical researchers
(research misconduct). These systems are
not in place in Malaysia to any reliable
extent.
The Malaysia specifi c reasons are our
small 32 million population which is
distributed over numerous Government,
private and university hospitals, thus
making for ineff ective research.
I have been bringing this up in the media,
to the Malaysian Medical Council (MMC)
and the Ministry of Health (MOH) in the last
few years. Universities have got their own
ecosystem, which isn’t necessarily in the
patients’ best interest. For example, if I want
a promotion within a reasonable time frame,
I must be able to publish research papers very
fast irrespective of the quality of the article.
And unfortunately, these papers are used to
treat patients. Publishing articles in top-tier
medical journals too does not guarantee that
the research is of good quality. Doctors are
placed in an ethical dilemma.
Since there is a lack of funds, what can we
do?
Locally, no university seems to have enough
money or infrastructure to train doctors
to be clinical researchers. I’m telling the
government that it is a huge undertaking.
There are just not enough resources.
Therefore, we need to bring together our
universities to do this.
We also have to streamline the way
research grants are allocated. Currently,
research institutions receive small grants,
which is then distributed to small groups
of researchers to do small studies. So it
is better to consolidate them and work
together.
Everyone should be made to work under the
existing MOH research infrastructure known
as the National Institutes of Health (NIH).
Let’s take dengue research, for instance.
You cannot allow individual institutions
like universities to undertake the research.
You have to establish something like a
dengue national research committee,
under NIH. This committee will identify
gaps in our knowledge and design and
undertake large scale studies to answer
those questions. Why are our patients
dying? To answer this question, we need the
government to mobilise data from almost
every hospital and examine all the death
cases. Then we will know the trends of the
death in such cases so that in future we can
watch such patients before they turn bad.
With a solid research agenda, we may even
discover the cause of death and even new
treatments.
What are the consequences
of bad research?
When you allow bad research to happen, you
are going to treat a lot of people based on the
wrong analysis. The wrong drug may not
work on you, but you may still experience
the adverse eff ect of the drug nonetheless.
The delay in getting the right drug may
also worsen your original disease. And you
will also incur a cost of unnecessarily
purchasing a wrong drug. This will add
to patient suff ering and increase the cost
of treatment unnecessarily. Why should
patients be made to suff er this way? But if
you have proper research, all this can be
contained to a greater extent.
What are your views on some hospitals
being under the Ministry of Education
(MOE) and some under MOH?
This is not a good idea. For the research
part at least, all hospitals including
university and private hospitals should
come under the MOH. And all Medical
Research Ethics Committees (MREC)
should be external to the institutions.
Otherwise, they cannot be truly
independent.
For example in university hospitals,
the MREC is primarily composed of MOE
employees. This clearly is a confl ict of
interest situation because universities
profi t in other ways by publishing
research, such as university rankings.
MREC committee members profi t by being
promoted if they publish a large quantity
of research. Hence, both employer and
employee may have disincentives to keep
a strict watch on their MRECs as this may
slow down their research publication
pipeline. For example all clinical data
should be audited to ensure it is not
fabricated/falsifi ed as it is going to be used
to treat patients. Do university MREC’s
routinely audit data?
Further, it may be better to bring all
university hospitals under the MOH. For
example, as confusing as the UK NHS
structure is, university hospitals still come
under the NHS umbrella. In Malaysia,
university hospitals are stand-alone
institutions.
So why is that a problem here?
Universities and university hospitals
both have their agenda. Typically, to get
promoted in a university, some of the
main criteria one needs are a “certain”
number of research papers published
and a “certain” amount of research
grants secured. The problem with that
is clinical research does not lend itself to
this type of “mass production”. It is too
time-consuming and laborious. The only
way academic researchers will be able to
fulfi l that “quota” is by doing low-quality
research or fabricating / falsifying data or
engaging in other questionable practices
like self-publishing, extreme self-citations.
Malaysian universities are no strangers to
most of these undesirable scenarios. We
have been in the news!
However, though these low quality
papers may be good for university rankings,
they are dangerous for patient care.
Producing high quality research papers
is such a diffi cult task that even if I can
manage to do one or two, I can retire
happily. That’s because clinical research
has to be high-quality research. You can’t
just produce fi ve or 10 papers per year.
Universities are cutting down on
research grants. Your comments, please.
The problem with research grants is
two-fold. The fi rst is that each grant is too
small to be clinically useful. The second it
the lack of transparency in how each grant
is awarded. There is virtually no way of
knowing the qualifi cations of the people
who peer-review our grant applications.
And, given that Malaysia does not really
have many trained clinical researchers,
who then has been “peer-reviewing” our
grant submissions? This is a mystery that
needs to be solved.
Despite cutting the grants, universities