DEVELOPING AND WRITING YOUR TRIOLOGICAL THESIS

1. DEVELOPING AND WRITING YOUR TRIOLOGICAL THESIS Maureen Hannley, PhD

2. SUCCESSFUL THESES2001 � 2010 (n = 242) Not necessarily representative of preferred topic areas, just the distribution last year.Not necessarily representative of preferred topic areas, just the distribution last year.

3. THE MYTHOLOGY OF THE TRIOLOGICAL THESIS(or more Urban Legends Debunked)

4. DON�T DISS MY THESIS Claim: The thesis has to be a production equivalent to a doctoral dissertation Status: False Origins: The Triological thesis guidelines describe a candidate�s thesis as a �carefully written, �comprehensive dissertation..� and in past years they were often vast productions several hundred pages long. But emphasis now is on timely publication Reality: According to the guidelines, the thesis should be no more than 40 pages (including text and figures) double-spaced, with no more than 50 references, in a format suitable for publication in The Laryngoscope. This is NOT equivalent to a doctoral dissertation!

6. HOW CAN I WRITE THEE? LET ME COUNT THE WAYS Claim: The thesis work cannot have been used for any other purpose Status: False Reality: Candidates may use work begun in their residency that, in part, has been previously published. It is permitted to use work that has been submitted as a Master�s thesis, as long as it meets the format, publication, and originality requirements.

7. (SOMETIMES) IT TAKES A VILLAGE Claim: The thesis cannot have multiple authors Status: False Reality: �Although the candidate may be assisted in his/her work, the candidate must state in writing at the time of submission that he/she is personally responsible for 70% or more of the text and 70% or more of the research.�

8. SOME EXCELLENT REFERENCES Troidl, H et al., Surgical Research: Basic Principles and Clinical Practice (3rd Ed.). New York: Springer, 1998 Stone, J., Conducting Clinical Research: A Practical Guide. Cumberland, MD: Mountainside MD Press, 2006 Belsher, J, Jacobsen, J, From Idea to Funded Project. Phoenix: Oryx Press, 1992 Spilker, B., Guide to Clinical Trials. New York: Raven Press, 1991 Norman, G, Streiner, D, PDQ Statistics (2d Ed.). St. Louis: B.C. Decker, Inc., 1999 Hulley et al., Designing Clinical Research (3rd Ed). Baltimore: Lippincott, Williams & Wilkins, 2007 These are books greatly useful for anyone involved in scientific writing and researchThese are books greatly useful for anyone involved in scientific writing and research

9. MOTIVATIONS FOR DOING RESEARCH Writing a thesis can help to achieve the loftiest goal, but at the very least will achieve the first two.Writing a thesis can help to achieve the loftiest goal, but at the very least will achieve the first two.

11. BUILDING A THESIS*

12. The general process, with very pragmatic origins.The general process, with very pragmatic origins.

13. First step is to identify a problem and formulate a question. Other steps will follow.First step is to identify a problem and formulate a question. Other steps will follow.

14. INTERESTS, TOPICS, QUESTIONS, & PROBLEMS Find an interest in a broad subject area �What am I interested/expert in?� Narrow the interest to a plausible topic �What are unsolved gaps or inconsistencies in this area?� Develop questions within the topic �What do I want to know?� Develop a rationale for the project �Why is it important to know this?�

15. DEVELOP AN IDEA Read the most authoritative sources until you come to a point where the sources disagree. This is where unsolved questions may reside. Talk with the leading figures in the area. Attend their lectures and be alert to problems they identify. Seek out and read strategic research plans of medical and research organizations. Contemplate your own experience. What are the problems or questions that frustrate you? Have you found a solution you think will benefit your peers and patients?

16. SIX STEPS TO DEVELOP A COMPELLING NOVEL IDEA Identify the niche area Collect and critically analyze background information related to the problem Develop a preliminary idea (don�t force it) Assess the idea�s potential for success and modify it, if necessary Seek constructive criticism from colleagues Refine the idea to maximize its potential for impact on your field

17. INVESTIGATIONAL CATEGORIES Descriptions of problems required for planning interventions �Transtympanic vs. Sustained Release Administration of Gentamicin: Kinetics, Morphology, and Function� �Carcinoma of the Oropharynx: Factors Affecting Outcomes� �Improving Surgical Wound Healing with Basic Fibroblast Growth Factor After Radiation� �A Standardized Regimen of Antibiotics Prevents Infectious Complications in Skull Base Surgery� �Clinical and Symptom Criteria for the Active Diagnosis of Chronic Rhinosinusitis� These are some titles of Candidates� theses from 2000 that fall into this category; note that they identify either novel interventions or factors that may lead to planning more effective interventions.These are some titles of Candidates� theses from 2000 that fall into this category; note that they identify either novel interventions or factors that may lead to planning more effective interventions.

18. INVESTIGATIONAL CATEGORIES Information required to evaluate ongoing interventions, assess progress �The Long-term Effect of Adenotonsillectomy on Quality of Life in Pediatric Patients� �Therapeutic Selective Neck Dissection: 25 Year Review� �Long-term Follow-up for Children Treated with Surgical Intervention for Chronic Sinusitis� �Intratympanic Dexamethasone for Sudden Sensorineural Hearing Loss Following Failure of Systemic Therapy� Therapeutic Efficacy of the Epley Canalith Repositioning Maneuver Endoscopic Percutaneous Dilational Tracheotomy: A Prospective Evaluation of 500 Consecutive Cases

19. INVESTIGATIONAL CATEGORIES Information required to define problems� �Direct Evidence of Bacterial Biofilms in Otitis Media� �Herpes Simplex Virus and Meniere�s Disease� Analyze possible causes� �Direct Nasopharyngeal Reflux of Gastric Acid is a Contributing Factor in Refractory Chronic Rhinosinusitis� �The Role of Nitric Oxide in the Development of Distant Metastases from Squamous Cell Carcinoma� or offer solutions �Regular Tracheostomy Tube Changes to Prevent Formulation of Granulation Tissue�

20. SELECT A TOPIC Relevance Avoidance of duplication; originality Feasibility Ethical acceptability Applicability of possible results and recommendations Urgency of data needed The �Big So-What�

21. FOUR TESTS OF THESIS TOPIC Is it new? Is it true? So what? Who cares?

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23. ASKING THE RIGHT QUESTION Ask a question with clinical relevance, not just clinical application Ask a question that interests you and will sustain your interest Ask the question in such a way that either a positive or negative answer will be interesting Be specific Make sure you have time, resources Subjects Database/access Collaborators if appropriate

24. REFINE YOUR RESEARCH QUESTION Define the population to be studied Define the period of time for the study Select the variables to be measured Change non-specific variables into variables that can be measured.

25. THE RESEARCH QUESTION Begin by asking the question as a general statement �In patients with recurrent acute sinusitis by accepted criteria is ESS the best treatment option to improve symptoms and disease-specific QOL?� Use PICO to help structure the question

26. PICO P = Population, Patient or Problem I = Intervention C = Control or Comparison O = Outcome

27. THE RESEARCH QUESTION P = (Pediatric, adult) patients with recurrent acute sinusitis I = Endoscopic sinus surgery C = Medical treatment O = Symptoms and disease-specific QOL �In (age) patients with recurrent acute sinusitis by accepted criteria does ESS compared to medical treatment improve symptoms and disease-specific QOL?�

28. STRUCTURE What you did Why you did it What you found What it means

29. DETERMINE WHAT YOU ARE GOING TO MEASURE Variables that you are going to need to measure Be parsimonious; if it won�t add to your answer, don�t do it Each additional variable complicates your statistics & increases your sample size requirement Recognize the value of independent converging measures Reliability and validity of instruments

30. VARIABLES

31. Having selected a question, the next steps are to design the project and select the method of data collection.Having selected a question, the next steps are to design the project and select the method of data collection.

32. ESSENTIAL PRELIMINARIES Consult a statistician Question design statistical treatment Sample size estimations Involve sponsor/mentor in planning process Careful, comprehensive literature review Consultation with an experienced biostatistician is a key step as he or she will help turn your question into a credible design and select the appropriate statistical or analytical method. DO NOT present yourself to a statistician after the fact with an armload of data.Consultation with an experienced biostatistician is a key step as he or she will help turn your question into a credible design and select the appropriate statistical or analytical method. DO NOT present yourself to a statistician after the fact with an armload of data.

33. SELECT A STUDY STRATEGY Basic vs. clinical Prospective vs. retrospective Efficacy vs. effectiveness Duration of study Cross-sectional vs. longitudinal Medical vs. patient outcome

34. THE EVIDENCE PYRAMID

35. TYPES OF STUDIES

36. TYPES OF STUDIES

37. FORMULATE PROJECT OBJECTIVES, HYPOTHESES Formulation of objectives will help: Focus the study, narrowing it to essentials Avoid collection of data not strictly necessary for solving defined problem Organize the study in clearly defined parts or phases Analogue is principle guiding selection of lab/radiology tests necessary to establish a diagnosis: �will it change the way you treat your patient?�Analogue is principle guiding selection of lab/radiology tests necessary to establish a diagnosis: �will it change the way you treat your patient?�

38. LINKAGE OF THREE KEY COMPONENTS Long-Term Goal: Broadest (the Forest) Projects your continuum of research Overall Objective: Narrower Step along the continuum Must be achieved regardless of how the hypothesis tests Central Hypothesis: Narrowest (the Tree) Best bet, but could be invalid (alternative presented later, therefore)

39. STATE OBJECTIVES Cover different aspects of problem and contributing factors in coherent way and logical sequence. Use specific action-oriented verbs (�to verify� �to compare� �to establish� etc.) that correspond with goals and methodology. Avoid weak verbs (�to find out�, �to characterize�, �to correlate�) that give the impression of a hypothesis � seeking project, a.k.a. a fishing expedition Objectives should be demonstrably achievable through selected methodology and subjects. State assumptions underlying your project.

40. WRITE THE HYPOTHESIS Write what you expect to find from your study. What are the general relationships implied by your hypothesis? Are there any specific alternative relationships or explanations that would serve as competing or rival hypothesis? State your hypothesis in a clear, concise sentence. Should be directional and quantifiable Should be simple, specific, and stated in advance

41. TYPES OF HYPOTHESES Null hypothesis (H0) �There is no difference in symptom resolution or disease-specific QOL in children with recurrent acute sinusitis treated with ESS and those treated medically.� Formal basis for testing statistical significance Alternative hypothesis �Children with recurrent acute sinusitis treated with ESS will have significantly better symptom resolution and better disease-specific QOL than those treated medically.�

42. NOTE (NB) An objective is NOT synonymous with an hypothesis. Objective: what you wanted to accomplish with your project; where you were going Hypothesis: best guess as to how the project would turn out, given the way you did it (subjects, methods, analysis) Both MUST be stated.

43. SELECT YOUR SAMPLE(S) Describe the characteristics of the subjects who will be eligible for participation in your study Describe the characteristics of the subjects who will be excluded from your study Describe the population (beyond your sample) to which you wish to generalize your conclusions Determine sample size necessary for desired statistical power

44. ELIMINATE OR CONTROL THE BIASES Effects of historical events Effects of maturation, gender, ethnicity Effects of repeated measurement Instrument �decay� Effects of statistical regression Subject selection Loss of subjects Patient recall Investigator bias

45. TO ENHANCE CREDIBILITY Appropriate controls Appropriate operational definitions Appropriate measurement tools Appropriate design and analysis Balanced perspective Cite others� work If there are 2 camps, make sure you cite both sides

46. Nothing improves the performance of an innovation more than the lack of controls. Bearman et al., 1974

47. CONDUCTING THE THESIS PROJECT

48. SCIENTIFIC INTEGRITY AND ETHICS Ethics in scientific design and conduct Ethical justifiability Clinical equipoise Informed, comprehending, voluntary consent Confidentiality Use of animals Scientific adequacy Conflict of interest

49. MANAGE THE DATA Collect the data Maintain quality control over the data Enter the data to a database Store the data Analyze the data

50. DATA ANALYSIS Descriptive Numbers, demographics: n, age, gender, ethnicity Central tendency: mean, median, mode Variation: range, standard deviation, percentile Inferential Process of inferring features of population from observations of a sample; confidence interval Likelihood that observed effect/differences could be due to chance: standard error of mean Many inferential tests depending on research design and whether data are normally distributed

51. �A difference to be a difference should make a difference.� Gertrude Stein

52. WRITING THE THESIS Larry McMurtry: You expect far too much of a first sentence. Think of it as analogous to a good country breakfast: what we want is something simple, but nourishing to the imagination. Hold the philosophy, hold the adjectives, just give us a plain subject and verb and perhaps a wholesome, nonfattening adverb or two.Larry McMurtry: You expect far too much of a first sentence. Think of it as analogous to a good country breakfast: what we want is something simple, but nourishing to the imagination. Hold the philosophy, hold the adjectives, just give us a plain subject and verb and perhaps a wholesome, nonfattening adverb or two.

53. THE MOST IMPORTANT RULE Read the guidelines for thesis format and submission Read them again Follow them to the letter

54. THE ABCs OF SCIENTIFIC WRITING Accuracy Brevity Clarity

55. APPROACH TO THESIS PREPARATION

56. THE BAIT AND THE PUNCHLINE Introduction Opening quotation or fact Context of past research Condition of ignorance Cost of that ignorance Gist of solution Conclusion Gist of solution Larger significance or application What is still not known Call for further research Closing quotation or fact

57. USE STRONG ACTION VERBS Analyze Assess Categorize Compare Contrast Demonstrate Establish Explain Illustrate Investigate Measure Organize Quantify Solve Summarize Test

58. BE CONCISE Wordy Due to the fact that It is clear that For the reason that Fewer in number In excess of In order to Furnish an explanation for During the time that Concise Because Clearly Because Fewer More than To Explain While

59. INTRODUCTION Clear and concise Justification for the study Establishes novelty and originality re: salient research Intriguing and inviting Last sentence: states study objective AND hypothesis

60. METHODS AND PROCEDURES Reveal how carefully you conducted your research Allow another researcher to replicate your study Sections Subjects or Participants Experimental design Equipment or measures Procedures Subject selection Measurement of dependent variables References to support choice of procedures

62. A USEFUL EXERCISE Convert pooled data to charts (bar, pie, scatter, etc.) Write 1-2 bullets/sentences about what chart tells you Write 1-2 bullets/sentences about any alternative explanations for the display This can serve as outline for Results and Discussion sections

63. RESULTS Report only results that bear on your question (not every analysis needs to be shown) A good Results section should tell a story Analyses that support the integrity of the study (internal consistency, variance, etc) Present analyses in logical sequence Use tables & figures to relieve clutter of numbers For key data, present in both table and figure

64. ILLUSTRATIONS To illustrate this: Process Logical relationships Object Parts of complex object Action, step in process Results Use this: Flow chart, decision tree Diagram, matrix Photo, drawing Microscopic view, drawing Schematic, photo, diagram Photo, graph, matrix

65. DISCUSSION Considers findings in light of other theories and past research; be objective! Begin with brief overview of problem and your findings � should not reiterate Results, but state whether Hypothesis accepted or rejected, with reference to statistical analysis Identify limitations of your research � why they aren�t fatal flaws and can represent opportunities for further research

66. THE BEST DEFENSE�.. The Questions What is your point? What is your claim�s scope? What evidence do you have? What links evidence to claim? But what about�.? But what if�.? No problems at all? Your Answers I claim that� I limit it to� I offer as evidence� I offer this principle� I can rebut that. First�. My claim stands as long as... Well, I have to admit that�

67. JUST DO IT!

68. SCIENTIFIC INTEGRITY Scientific dishonesty Fabrication of data or analysis Selective, undisclosed rejection of undesired results Erroneous use of statistical methods to achieve desired outcome Distorted interpretation of results or conclusions Plagiarism of results or writings of other authors Distorted representation of other researchers� results Wrongful or inappropriate attribution of authorship Omission of recognition of original observations made by other scientists

69. Contact Me! Maureen Hannley, PhD 520-638-5097 mhannley@gmail.com