Training in the ethics of audit, quality improvement and research

I read McGuire and Dalton's account 1 of their experiences with trying to conduct a small-scale study and the resultant ethical conundrums that were thrown up, and fully agree with the accompanying editorials by Yentis 2, 3 analysing the issues that arose from this case report. However, I would also like to discuss a few issues, which the case highlighted to me that have not yet been mentioned. Trainees in anaesthesia are required to conduct one audit every year and present evidence of this in order to pass our Annual Review of Competencies and Progress (ARCP). From experience, the lines that separate audit, quality improvement and research are often indistinct. There may or may not be best practice guidelines to audit against in every area of anaesthesia, and often interventions may be introduced during the project cycle, which actually may not be what is regular practice at a particular institution because the aim is to change behaviours to achieve ‘quality improvement’. Therefore, due to the pressures to get these projects completed quickly, there is often little thought given to seeking ethical approval. Furthermore, due to the time it takes to take a proposed project through the whole Health Research Authority, and Research Ethics Committee process, which then leaves little time for the trainee to actually conduct the project before they have to rotate to another hospital again, trainees are disincentivised to do so. Additionally, despite an emphasis on getting projects completed, there is very little formal training offered to the trainees in audit, quality improvemnet and research methods, and the ethical issues surrounding these. In order for trainees to gain proper training in this area, they often have to take time out of their training programs to undertake formal research fellowships or embark on projects linked to higher research degrees. The majority of trainees cannot afford the time investment to do this. There needs to be more clarity and education for trainees doing projects. Case reports such as these serve as strong examples for learning ‘to do things right’. The educational value of these articles is immense.