Nick Knight

Nick Knight: podiatrist in independent practice

My research journey

Research has always been something that has interested me within podiatric practice. Working in both the NHS and private sector, I have noted first-hand the challenges involved in conducting and implementing research into clinical practice due to pressures such as appointment numbers, time, and resources.

'It has been exciting going on this journey of blending education, research, and enterprise to try to benefit clinical practice’

So why the interest?

In a nutshell, the use of research evidence supports my ability to provide care to patients that is contemporary and up-to-date with the latest technology and interventions. Through research, there is an opportunity for success, in terms of patient outcomes, which can lead to improved team morale and environment. The common phrase ‘success breeds success’ rings true. Research findings can provide evidence that podiatrists are clinically and cost-effective in delivering patient care.  Anecdotal evidence and single clinician/practice claims are no longer listened to when bidding for work as society today demands data and evidence to substantiate those claims. In providing evidence, the research data supports the narrative we are trying to tell and showcases the podiatric interventions or ideas and advice that we know will improve patient lives.

The journey

My journey started when I was doing my MSc. I will be completely honest; I was a numbers guy and I was fixed on quantitative data. However the research module on my MSc opened my eyes to qualitative methods and the importance of being able to show impact through understanding the experiences and opinions of my patients.

Whilst building my clinical caseload in the private sector I was also managing a growing family. Initially, I started to rent rooms from fellow practitioners and started to build a team around me. Consequently, I started to change my thinking and focused on trying to understand whether we deliver what we say we are going to deliver, how can I measure this and how can I be sure we are doing this well? My approach started to evolve, and I wanted to know what questions or patient reported outcome tools should I be using to identify how a patient’s treatment journey went. I also wanted to know about patient satisfaction scores, the  length of time the treatment plan takes to complete and how many appointments on average patients need.

As a result, through my practice, I created our clinical templates on the Cliniko system (a patient management programme), Microsoft Forms and CliniqApps using evidenced-informed practice. This allowed us to automatically send questionnaires to patients after the treatment had finished. This continued for around 9-12 months.

At the time, I thought things are going okay and the clinical team were doing well. I then received an email from Dr Charlotte Dando (Charlie) about participating in her PhD study as part of a consensus exercise on Morton’s Neuroma. Charlie was also keen to observe my clinical practice and by the end of the few days I offered her a job. She was a little surprised and thought I was joking!

Charlie and I started to review the clinical data specific to pathology. We realised we could be doing better and a solution to this would be for me to take the next step and have my own premises for the business (Peppermill Barn, Romsey). Although I had established links with surrounding Higher Education Institutes (HEIs), Charlie provided the equilibrium to allow both businesses to work together.

Once settled into the new clinic, we decided that we needed some help and guidance. Professor Cathy Bowen, Dr Lucy Gates, Charlie, and I over a few teas, formulated the clinical questions we wanted to ask. Those questions are still reviewed for relevancy and are still in use today. We now have over 350 completed patient journeys, in addition to the 6, 12 and 18-month follow-up data. It's lovely to hear from our patients and see what they have been up to.

Building the relationship

Over time I have built a good relationship with the University of Southampton and the academic podiatry team. The NK Active team host their students on clinical placement and supports the rehabilitation and clinical teaching on campus. In return, I hold a visiting lecturer status and receive mentorship from Professor Cathy Bowen.  This has led to me being involved with wider research projects within the University.

Needing each other

From the early days of working with the University of Southampton, it became clear that both parties need each other. As clinicians we can be guilty of being fearful of research by not fully understanding the implications and what is involved. On the other hand, researchers need to know what the key questions are that should be investigated as well as see the variety of care services available to have a clear vision of how to implement evidence into clinical practice. It has been exciting going on this journey of blending education, research, and enterprise to try to benefit clinical practice.  

Learning points

I do think that in healthcare we can be guilty of assuming that all research must be a double-blind randomised control trial (RCT) to be valid. However, an RCT may not be the correct methodology to help answer a question. Collecting your clinical data in the clinic is the start of a potential research journey.

I have found the use of data and regular audits helpful to assess what is working well, what needs improvement and where time should be wisely spent in my NKActive company. The audit data has also been useful to support my bids for work contracts.

Technology is your friend, with the rise and speed of technological advancements once you have set up your clinical data collection and audit process you can automate a lot of the data collection. You can also set up your electronic note templates to export the data that can be easily used for audit and research.

There will be errors along the way, and I made one in the early days which resulted in a large amount of my data not being useable.

It’s not just about the numbers, I started as someone who wanted to collect quantitative data but now, I look at my company and we have a pragmatic approach using both qualitative and quantitative data.  I get the feel-good factor when I see the NK Active team and our patients succeed.

My final thoughts

Reflecting on my journey so far with implementing research into private practice, I am a strong advocate that we should all be doing this for the good of the profession. It’s not as scary as you think. I do not believe that being in private practice is a barrier, because as clinicians we have something to offer to the researchers and the researchers have something to offer to us. There are collaborations to be made, you just need to start by having the conversations. 

My advice is to be open to change. Having an open mindset has been a strength that has allowed me to see the opportunities they have presented to me.  

I have been very fortunate to have Charlie as part of our team and her role as a clinical academic has been invaluable in helping to build the bridges between clinical practice, research, and academia.

I am excited for the future to be involved in some larger projects and to start seeing some of our work published. Building working relationships, starting conversations and teamwork has positively impacted my company. As a podiatrist, running a private practice we have lots to offer.

Final thoughts from Nick:

‘Research is not as scary as you think. I do not believe that being in private practice is a barrier, because as clinicians we have something to offer to the researchers and the researchers have something to offer to us’

‘I have found the use of data and regular audits helpful to assess what is working well, what needs improvement and where time should be wisely spent in my company. The audit data has also been useful to support my bids for work contracts.’