Optimizing clinical research in ophthalmology in Kerala: Expanding the clinician scientist pool and practitioner-researcher base

INTRODUCTION Evidence is the foundational basis for the practice of modern clinical and preventive ophthalmology. High-quality clinical care, preventive strategies and efficient service delivery systems must be built on robust evidence to sustain and improve gains in eye care delivery outcomes. The translation of discoveries into better diagnostics, therapies, and preventive strategies depends on technological advances and the capacity of clinicians to investigate, analyze, publish and practice high-quality evidence. However, evidence is a dynamic construct that can change depending on multiple stressors, including environmental, lifestyle, personal or group risk behaviors, patient expectations of acceptable care outcome endpoints, compliance and comfort, besides the usual tropes of availability, affordability, and accessibility. The dynamic nature of evidence naturally requires a regular loop of feedback and action to maintain its high quality and for refinements as appropriate. Kerala, often called the “health model of India,” offers a fertile ground for ophthalmic research, with high literacy, strong healthcare utilization, and a rapidly ageing population. Lifestyle diseases and metabolic disorders are high and can result in the earlier onset of adult-onset chronic diseases.[1-7] Yet, despite high patient volumes and access to advanced technology in several centers, the state’s ophthalmic research output in terms of inclusivity can be improved further to include individual clinician experiences (ICE).[8-12] In this editorial, we present that the future of ophthalmic research in Kerala rests on two parallel but complementary pathways: (1) nurturing a cadre of clinician-scientists who can lead high-impact, hypothesis-driven, and translational studies, and (2) expanding a broader base of individual practitioner-researchers who contribute practice-based evidence from diverse clinical settings. Both groups are essential for a sustainable research ecosystem. WHY DOES KERALA NEED A STRONGER OPHTHALMIC RESEARCH ECOSYSTEM? Kerala’s healthcare profile is unique due to several factors that include (but are not limited to), High life expectancy and ageing population, increasing the burden of cataract, glaucoma, lifestyle and metabolic disorder-related eye diseases, and age-related macular degeneration (AMD). An apparently strong health-seeking behavior, reflected in high rates of cataract surgery uptake and eye health care utilization. Robust private sector, with many ophthalmologists in solo or small-group practices across the state. Despite this, the translation of these advantages into world-class research output has been limited. Research output from Kerala in the form of case reports, retrospective series, cross-sectional studies, prospective studies or audits, randomized controlled trials, multicenter collaborations, population-based epidemiological studies, and translational studies can be further improved. The number of centers and practitioners contributing to research output can also be substantially increased from a primarily teaching hospitals and some academic private sector centers to include individual practitioners. A stronger research culture would not only improve local clinical practice but also provide globally relevant insights. THE DICHOTOMY OF RESEARCH AND CLINICAL PRACTICE A major limitation to integrating research into clinical practice is the dilemma of the scope of research and its impact on actual clinical practice. The term research can be broken down into two parts- re (signifying repeat) and search- or the repeated search for an answer. The repeated search emphasizes the dynamic nature of evidence and the need for constant appraisal of evidence. Research is therefore not limited to seeking answers to new questions but also includes reaffirming the validity, reliability, and relevance of existing information. New questions arise when existing information is found to be irrelevant or incomplete for optimal care. A fundamental requisite for research is, therefore, a curiosity to observe and understand the current care pathways, their impact at the individual and group levels, and factors that affect outcomes. There are no answers to be sought if there are no questions that are asked and questions do not arise unless one observes what is happening. Clinicians are concerned about the impact on the individual patient and are constantly exploring ways to improve patient outcomes. This is a natural process of curiosity that is embedded in clinical or preventative care and forms the foundational basis for research. The curiosity exists already. It just needs to be encouraged, nurtured, and made meaningful. If we carry this argument forward, research can be translated as an approach to satisfy one’s curiosity to understand some questions: What is happening Why is it happening Who is affected (example: Differences between different demographic groups) Where is it happening (example: multiple levels from the macro to the micro) How is it happening What is being done What are the outcomes What are the gaps. All these questions apply to every clinician irrespective of the setting of their practice. These are questions that are intuitively answered during the clinical and preventative care assessment and delivery process. The answers are assessed considering known knowledge, experience or evidence and appropriate care pathways are designed. All personnel involved in clinical care are thus engaging in some form of research daily in care delivery. The dichotomy between clinical care and research is an artificial box that does no justice to the innate exploratory curiosity of the clinician to improve themselves for optimal care delivery. THE DUAL STRATEGY: CLINICIAN-SCIENTISTS AND PRACTITIONER-RESEARCHERS The ophthalmic research ecosystem cannot rely solely on a small number of academic centers. It must be broadened in scope and inclusivity to include every clinician providing care. The individual clinician experience (ICE) is important in the ecosystem of clinical research; however, it is often ignored in the context of research results. The generation of evidence from the few may not always translate into optimal health benefits for the many. Generated evidence must be tested in a diverse range of settings and contexts to ensure appropriate care for different groups of people, and ICE is an important part of this process. Two groups need simultaneous development: Clinician-Scientists: Ophthalmologists with structured research training, dedicated time, and mentorship who can lead hypothesis-driven studies, clinical trials, and translational research. They can be part of teaching institutes and tertiary care centers, and centers of excellence. Practitioner-Researchers: Individual ophthalmologists in individual or group practice or district hospitals, or primary care who may not have extensive research training or advanced infrastructure but can contribute real-world data, clinical audits, multicenter studies on impact, and identify problems of relevance for clinical care at the ground level. Both groups serve complementary roles: [Table 1].Table 1: Comparison of clinician-scientists and practitioner-researchersClinician-scientists drive innovation and complex research, forge new pathways of care, improve understanding of pathophysiologic basis at multiple levels and provide evidence for translational care. Practitioner-researchers are equally important as they provide scale, diversity, and practice-based insights on what really works on the ground and is relevant for patients. Practice-based researchers actually provide and complete the evidence feedback loop essential to refining and optimizing patient care. DEVELOPING CLINICIAN-SCIENTISTS IN KERALA Early exposure and training pathways Integrate research methodology, critical appraisal, and statistics into MBBS and postgraduate ophthalmology curricula. These must include formal structured training as well as providing a clinical environment that encourages and nurtures the natural curiosity of the budding or transitioning clinician. The focus must be on practical, pragmatic application or translation into practice of theoretical concepts rather than a theory-heavy approach. Understanding the interpretations and translation of statistics for clinical and preventive care is important. Improve the focus on critical thinking, encouraging a questioning approach. Restructure the MS/MD thesis or dissertation system by including postgraduate and undergraduate students in departmental research studies. Expecting a post-graduate student to come up with an original question of their interest within the first few months of residency is quirky, to put it mildly. Expecting them to complete a high-quality study within a limited timeframe is also not pragmatic. The conversion rates of residency dissertations to high-quality peer-reviewed publications are testament to this difficulty. Instead, it might be better to engage residents (and undergraduates) as investigators in departmental research studies using the opportunity to practically train them in structured pathways to seek answers to questions. The learning can be hands-on training on measuring variables, understanding confounders, bias, data documentation, privacy and ethical considerations, basic analysis, interpretation and presentation of data, how it is implemented into care delivery and for policy development. The process also allows for the continued integration and expansion of teaching programs to include clinicians who completed residency as practitioner-based researchers who continue to be part of a multicenter team. Rapid advancements in technology translate to rapid shifts in the relevance of evidence. Skills to appraise evidence are of utmost importance for all care providers to differentiate appropriate information and misinformation. Replace the existing dissertation system with a more pragmatic skill-based appraisal that integrates making clinical decisions utilizing evidence appraisal as a foundation. Create MD-PhD/MS-PhD pathways in collaboration with universities to develop a pool of dedicated clinician-scientists. Formal mentorship networks linking young ophthalmologists with experienced researchers. State and university-level seed grants targeted at early-career ophthalmologists. Seed grants can be considered by the Ophthalmology Associations at the state and national level to answer questions of regional and national interest. Career advancement pathways that reward research productivity alongside clinical excellence. BUILDING THE PRACTITIONER-RESEARCHER BASE Simplifying entry into research Starting from the undergraduate and postgraduate levels, encouraging participation in research teams as co-investigators. Organize practice-based research workshops and hands-on mentoring through the Kerala Society of Ophthalmic Surgeons (KSOS) and district branches. Online courses and certification programs in clinical research and publication ethics. These must be integrated with pathways to join research teams on various care questions and develop their own locally relevant questions. Infrastructure and ecosystem support Low-cost electronic health records with research-ready data fields. Shared biostatistics and data analysis support units at medical colleges accessible to private practitioners on payment of a fee. The fee can be used to improve the clinical care and research infrastructure of the department. Creation of live dashboards that can show impact of evidence translation into clinical practice in real time. Such dashboards can illustrate how each individual practitioner is contributing to the reduction of ocular morbidity at the district and state level. Collaborative research networks Creation of a Kerala Ophthalmology Research Network (KORN) pooling data across practices in both the public and private sectors. Mentorship and guidance through KORN for all ophthalmologists in the state. Develop district-based subchapters of KORN. Encourage constant dialogues between clinician scientists and practitioners. Design multicenter studies on different eye conditions that can develop as long-term studies to inform practice and form a training ground for residents on acquiring and appraising evidence. Develop district-based data on various eye conditions and service gaps. Ethics and regulatory facilitation Regional ethics committees serving clusters of practices. Simplified guidance documents on the Indian Council of Medical Research (ICMR) regulations for practitioners. Challenges and solutions Create a roadmap with timelines to strengthen and broaden ophthalmic research in Kerala [Table 2]. Table 2: Proposed roadmap for strengthening ophthalmic research in Kerala Time Constraints: Simplify data collection and promote collaborative studies. Prioritize quality of clinical care and emphasize quality checks, audits and evidence integration and appraisal at all levels of care. Research Quality: Provide methodological mentorship and peer review at the protocol stage. Shift focus from theory to hands-on applications and pragmatic, practical learning. Identify locally relevant questions: Focus on questions that impact care at the local level, building from feedback and inputs from practitioners on the ground. Ethical Hurdles: Streamline IEC approvals via pooled committees. Sustainability: Celebrate success stories and highlight the impact of research on clinical practice. Provide clear links from questions to answers to translation to clinical practice. Nurture long-term multidisciplinary and multi-setting teams Reshape mindsets from exclusivity to inclusivity. Consider all streams of curiosity-driven questions as important. All levels of care have their own unique set of problems that need to be addressed. Consider societal, community and patient impact of research outcomes and not just publication metrics. Clinical and public health research must lead to improved health outcomes and population metrics of eye care, including functional aspects and patient-reported outcomes. CONCLUSION Kerala stands at a pivotal moment in ophthalmology research. With its high patient load, advanced clinical practice, and robust healthcare infrastructure, the state has all the ingredients to become a national and global leader in ophthalmic research. Realizing this potential requires parallel investments: cultivating a cadre of well-trained clinician-scientists and empowering a large network of practitioner-researchers. Together, they can generate high-quality, locally relevant, and globally significant evidence. The initiative to scale and transform the ophthalmology research landscape in Kerala can be led by the professional organization of Ophthalmologists in Kerala (KSOS). Ophthalmologists in Kerala have a readily available medium to discuss and disseminate their research through the Kerala Journal of Ophthalmology and annual scientific conferences. The vision for the next decade is clear: a Kerala where every ophthalmologist—whether in an academic institute or private clinic—sees research not as an optional extra, but as an integral part of improving patient care and advancing eye health. Are we willing to shift gears? Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.