Prof. Dr. Goh is the Head and Senior Consultant Nephrologist in Serdang Hospital. He became a member of the Royal College of Physicians in United Kingdom MRCP(UK) in 1996. He obtained his further training as Renal Fellow at Monash Medical School, Melbourne, Australia. He was awarded the Fellowship of Royal College of Physicians and Surgeons in 2002 and Fellowship of Academy of Medicine of Malaysia in 2012.
Prof. Dr. Goh has published numerous original articles in international peer-reviewed journals in the field of general nephrology, dialysis and transplantation. He has special interest in peritoneal dialysis (PD) and has numerous publications in PD-related articles in Seminars in Dialysis and Peritoneal Dialysis International. Being an ardent speaker in his expertise, he is a frequently sought after invited speakers and has presented numerous scientific papers in international meetings and congresses. He is also involved in many Registries and Clinical Practice Guidelines and sits in many panels / committees / advisory boards as well as professional societies at both national and international levels. Currently, he is the President of the Malaysian Society of Nephrology (MSN), a member of ISPD Working Party on PD Access Guidelines and Asia Pacific Renal Advisory Board member. He is also the Editor of National Renal Registry and was appointed as an Adjunct Professor. He is a member of Asia Pacific Congress of Nephrology 2018, 23rdInternational Conference on AKI CRRT 2018, and International Society of Nephrology Global Health Summit.
- How did you first get into clinical research?
I was first involved in doing research many years ago since I was in Penang Hospital in the early days as a trainee, long before CRC was established. The first time I was properly exposed to the conduct of a clinical trial was in Melbourne, Australia when I was doing my fellowship training at the Monash University. It was in 1998 when my first abstract was accepted in international meeting and eventually published.
When I returned from Melbourne, it was actually the time when CRC had just started to grow. In fact, I was fortunate enough to be the first batch to attend the GCP course conducted by CRC.
My primary interest is still investigator-initiated research (IIR), as it can be seen in most of the works that I have published. When CRM was first conceptualized in 2010, I felt that there was a need to support it. After being involved in many years of research and publication, I find that whenever I encourage junior doctors to do research, they always say that there is not enough time, inadequate resources etc, hence, it is not possible. So, when CRM formally brought in industrial-sponsored research (ISR), I felt that it was a good direction because ISR would be able to bring in the know-how including resources and that the junior doctors can learn from it, and then be on their own to do the IIR later.
- How has clinical trials change your practice and management of patient care?
I always believe that a good investigator, a good researcher and a good scientist will always be a good clinician. The first thing is to be a good investigator as they are always very disciplined and paying attention to details. These are also the attributes and traits that are very important to be a good clinician.
The second thing is curiosity. A good researcher is usually the one that is very curious, very inquisitive and also very observant. These are all important attributes which also happen to be important traits of a good clinician.
As a good clinician, our job is mainly to solve patient’s problems. I always remind junior colleagues that same diseases can present differently, and different diseases can present the same way. It is very important for one to be aware of that. When one observes certain abnormally or what I call an outlier, to those good clinicians who are very observant, they will start to ask very simple questions. Why did the patient present in this way? Why now and not before? Or why is it that the patient is given the right diagnostic and despite appropriate treatment did not respond as expected? A clinician has to ask these questions which are equally important as a researcher. Therefore, a good researcher would usually become a good clinician.
For example, in my own field, I have many interest areas in research but sometimes due to circumstances, we have to focus in one key area. My niche is in peritoneal dialysis (PD) and I am a key opinion leader (KOL) in peritoneal dialysis in the Asia Pacific region. This is actually circumstantial. What happened was that many years ago, I observed that PD has always been perceived as second class, inferior technology for patients with end stage renal disease compared to haemodialysis. Based on that observation, I started to ask a very simple question. Why should it be this way?
PD in actual fact has many good scientific reasons to be at least equal, if not better than haemodialysis treatment, but still the pick-up rate is very low. Based on this observation, we started a series of soul searching, root cause analysis and audit, and started a series of research and investigation. And then we realized that the most important factor that hinders utilization of PD is related to the access for dialysis, which is called PD catheter. So, we embarked on a series of research and publication in this area.
Firstly, we demonstrated that if the PD catheter insertion is done by nephrologists with interest in PD, there would be many positive results, not only the outcome would be better, but the response time would also improve. As a result, this finding changed entirely the concept of PD perceived by patients.
Initially we started it in one centre, subsequently we were able to demonstrate that when this same process was replicated in other centres, it produced similar positive impacts of pick-up rate in PD. This was our second paper. The third paper was on how to train the operator and we introduced the concept of CUSUM.
The result of these series of publications has translated into the Clinical Practice Guideline (CPG) on PD catheter insertion by International Society of Peritoneal Dialysis. This has shown that results of research can influence our clinical practice and also translate into good patient care.
- What one word best describes your career as a clinical researcher/investigator? Why?
If I would have to choose just one word to describe a good researcher, I think sincerity is the key. Usually the person who is sincere in carrying out their work would also be a highly- disciplined and honest character. For a good researcher, research integrity is an aspect of moral character. It involves above all, a commitment to intellectual honesty and responsibility for a range of practices that characterise responsible research conduct.
These are all good attributes of a good researcher and these are also important attributes as a good clinician and professional.
However, sincerity is very difficult to measure. It is not measurable.
I always say that the one important attribute for a good worker, if I have to choose just one which is measurable will always be punctuality. When I say punctual, it just does not mean coming to work on time but also one who respects deadlines and not ask for extension. These are usually good and disciplined worker.
A person who is always punctual comes together with many other positive attributes. They are very organised, responsible, disciplined and always deliver what they promised on time which also means they are sincere in their work and are professional.
- What would be your advice to aspiring clinical researchers?
Research belongs to the field of creative industry. A lot of people think that by doing research, they could become an overnight expert or an overnight celebrity, but unfortunately, research is not like this. For a start, you must have a passion or at least an interest in it. As I mentioned before, a good researcher comes with certain good attributes, they are disciplined, inquisitive and observant. So, to be a good researcher, you should be motivated by your curiosity, as well as the urge and sincere need to find an explanation to your observation and curiosity. That should be the primary motivation of research, not because of anything else, not because of fame or money. I always say that if your aim is about fame and money, it is better to indulge yourself in the reality shows and competitions where you may become sensational overnight (LOL).
Research is a very long journey. Just for simple illustration, to come out with a research idea after a good observation, it would take probably no less than 6 months for you to get a protocol ready. If your protocol is so good without any amendment and you manage to get the necessary authorities’ approval, you then start the investigator’s meeting, start recruiting patients, collecting data, etcetera, the recruitment period itself would take no less than 12 months up to 18 months, or even longer. This will then be followed by data analysis and report which would also take no less than 6 months. So, in total, it would take you about 2½ years, and that is provided that your research is smooth, everything is top notch, and no questions asked. For you to produce your first manuscript which would probably take another 6 months down the line, or longer which comes to a total of no less than 3 years. If, let us say the manuscript is so well written and gets accepted immediately without any corrections by a peer-reviewed journal and accepted for publication which would require another 6 months, that makes up to 3½ years. This long process is not uncommon. In fact, most of the time, our manuscripts would be revised a couple of times, if not rejected by a few journals. It is not uncommon that from the manuscript stage until it is finally accepted for publication, it could take more than 12 months, or even longer. Therefore, for only one good research, it takes about 3 to 4 years to complete. And you will never become famous with just one publication, because once a paper is published, that paper will be evaluated by your fellow colleagues. They will approve or disapprove your observation, either by critically appraising your paper or repeat your observation. So, for them to cite your work or make reference to your work, it would need another couple of years.
So as a good researcher, you should be motivated by your sincere urge to find the truth. The fuel is your curiosity, the tool is your observation. Eventually, when your work gets recognised, that recognition should be the by-product, bonus, and should not be your primary motivation.
- What type of breakthroughs in nephrology do you wish to see in the next 5 to 10 years?
There are many breakthroughs in nephrology, and I will only discuss in 3 areas. For example, the understanding of acute insult to the kidney has evolved leaps and bounds in the last decade. There are definitely more markers as well as algorithms that enable us to predict an acute insult to the kidney which allows us to intervene much earlier to prevent it from permanent damage and give patients best chance to recover.
There are also several advancements in understanding of the final pathway of kidney injury, which is fibrosis. Fibrosis is associated with many disease processes, but the most important one is aging. With the understanding of those areas, we will be able to not only prevent but reverse fibrosis, therefore allow the injured kidney an opportunity to regenerate and recover itself. For example, studies had demonstrated that restoration of Nox4-Nrf2 redox balance may be a therapeutic strategy in age-associated fibrotic disorders, potentially able to resolve persistent fibrosis or even reverse its progression.
There are also advances in bio-artificial kidney, and the advancement in this field is so amazing that scientists already started experimenting on printing kidney, and found to function in the experimental model. This may sound like too incredible but would eventually replace the needs for organ donation. If we can start printing our own kidney, it would break through the need of organ donor, or xeno-transplantation, which the scientific communities in this field have been struggling for the past half century to look for the Holy Grail. That would entirely revolutionize the management of end stage renal disease by giving one another new organ.
So, these are some of the breakthroughs in nephrology that I wish to see, some are almost there, and some probably happening in next 5 to 10 years, some obviously will take much longer still.
- What changes would you like to see being made by the policy makers to create a more conducive ecosystem for the conduct of clinical trials in Malaysia?
To promote a culture of clinical trial, we need to understand the research ecosystem better. First, the most important link is to get the right people. Without the right people, no matter how good your policy is, no matter how developed your infrastructure is, no matter how advance your facility is, no matter how much grants received, human resource, etcetera, it would still not produce a favourable outcome.
So, rather than building more facilities or creating more good policies, I believe that the first approach is to get the right person, identify the key people. Again as I mentioned earlier, researchers belong to the creative industry. Not every single one is cut out to be a reseacher. For example, we have conducted quite a number of GCP courses. How many of them have really been involved in one single clinical trial? My impression is that the number is less than 10%. Worst still, how many of them have become a consistently repeated investigator? That would be probably less than 3%. What does this number mean? Does it mean that we fail in having good policy? Does it mean that we fail in giving them opportunity? I don’t think so. I think fundamentally they are probably just not interested to be a researcher or investigator. They probably have many other interest areas which they may excel, but not in this area. So, the support should be built around those who are interested. When you have KOL, usually through KOL, they can provide leadership, they can become a mentor to the junior doctors and over the years, they would build up the whole system together, and subsequently every single one of the team member would eventually become an accomplished researcher in their own right, and then branch out on their ownafter working so many years with the KOL, and become their own leader in research. The same process would be repeated, and then we would have the multiplying effects.
At the moment, we still do not have the critical mass of good KOL/researcher providing this type of leadership. What we need is to build the support around them, so when we are able to reach the critical mass, the research culture, process and ecosystem would be self-generating eventually.