What are trainee research networks?

Trainee research networks (TRNs) are a collaborative effort to conduct high-quality multicentre audits or research that is led, designed and delivered by trainees. The first UK Gastroenterology trainee network was created in 2015 in the Midlands and there are now at least 11 established networks with many successfully delivering regional and national projects, publishing in peer-reviewed journals and presenting their data at national and international conferences.1–8 TRNs offer the opportunity for trainees to work with and learn from peers at different stages of their training while also receiving support and guidance from senior investigators.9 More importantly, TRNs allow trainees to develop their own ideas and prioritise projects they feel will impact their clinical practice, rather than contributing to an established programme delivered by a clinical or educational supervisor.

What is ‘green gastroenterology’?

As a specialty, gastroenterology has been at the leading edge when it comes to understanding the impact of clinical practice on climate change, with the British Society of Gastroenterology (BSG) launching its climate change and sustainability strategy in November 2021.10 A survey led by the NHS Sustainable Development Unit reported that 98% NHS staff believe that healthcare systems should work in ways which support the environment,11 and 86% of leading international gastroenterologists believe that climate change represents a crisis.12 However, just over half of gastroenterologists surveyed reported having made climate-focused changes in their professional practice, suggesting that there are a number of barriers we face when it comes to putting ‘green Gastroenterology’ into practice.

What are the challenges to delivering ‘green gastroenterology’?

Barriers may be financial, systemic or behavioural in nature.12 In the current highly pressured NHS working environment, the competing demands of clinical work can consume the time and energy required to introduce changes in practice. It is easy to feel that change is the responsibility of the organisation rather than the individual, and with only 9% of international gastroenterology societies having a climate working group or committee,12 it is clear that leadership is required in setting standards to facilitate change. Unfortunately, the main limitation for publishing or setting guidelines on practising in a more sustainable manner is the lack of sufficient evidence. In 2023, the BSG, Joint Advisory Group on GI Endoscopy and Centre for Sustainable Health created working groups that assigned specific topics to address this issue. Systematic reviews were performed to assess the data available for each of the topics and a joint statement (see online supplemental table 1) published.1 Prior to this, the European Society for Gastrointestinal Endoscopy, published 10 statements pledging recommendations for the greener practice of gastroenterology and endoscopy (See online supplemental table 2).2

These statements provide a scaffolding of ideas and mission statements by which the gastroenterology and hepatology community can build their practice on. When analysed alongside other publications looking at the impact of gastroenterology and hepatology on the environment, it becomes clear that a shift in routine practice including improving education, clinical pathways and rationalising of procedures can have a marked reduction in carbon emissions. Alongside these changes, an increased adoption of digital information sharing with patients and virtual consultations can have a further positive impact on the environment.3

Financial constraints are significant in many global healthcare settings, particularly in the wake of the COVID-19 pandemic. In fact, there are often financial incentives to undertake activity, which causes harm to the climate. For example, many national societies derive income from annual meetings, but these meetings have a significant carbon impact.13 While the BSG has launched a ‘sustainability symposium’, making climate impact a key message at its meetings, we need to consider the use of technology to deliver meetings in a more climate sustainable manner. While some climate sustainable changes to clinical practice may appear costly and time-consuming in the short term, they are likely cost-effective in the long term. For example, ensuring that patients have been adequately prepared for an endoscopic procedure through rigorous preassessment and bowel preparation to reduce the chance of rebooking, and developing systems to safely recycling endoscopic equipment where possible would likely be cost-saving in the long-term.11

Furthermore, while there has been an understandable focus on endoscopy as a source of much visible wastage within gastroenterology practice,14 there is a need to consider other areas that are ripe for change. For example, lessons learnt from the COVID-19 pandemic in practicing telemedicine or patient-led follow-up to cut down on travel emissions for patients and staff.15 In fact, recent publications in gastroenterology and hepatology have shown that virtual appointments can reduce carbon emissions while providing safe patient outcomes and positive patient satisfaction scores.16–18 Similarly, a move towards subcutaneous biologics and novel oral therapies as first line in inflammatory bowel disease (IBD) could potentially reduce traffic in our infusion units. The British Association for the Study of the Liver has formalised their commitment to delivering sustainable care in hepatology, acknowledging that the incipient changes in climate are likely to increase the global burden of liver disease.19 Examples of sustainable practice include focusing efforts on prevention of liver disease, delivery of virtual transplant assessment pathways and identification of prognostication scores for screening of patients with stable compensated cirrhosis that could reduce hospital resource use.

Ultimately, any move towards greener practice requires collaboration between motivated individuals who have buy-in from stakeholders, and the time and agency to make changes at a local level—all of which can feel in short supply in our current clinical practice.

What is the current research and understanding of ‘green gastroenterology’?

Given that healthcare is responsible for 4.4% of the world’s carbon footprint and that endoscopy is a high-volume generator of carbon-based waste,20 there is a need to reduce the impact of gastrointestinal and hepatology services on the environment. We performed a scoping review (see online supplementary methods) to understand the current evidence base of what has been done to reduce waste and impact on the environment across services. A total of eight studies16–18 21–25 were highlighted (see online supplemental figure 1), which predominately focused on endoscopy waste management (5/8) with the remaining studies exploring the impact of virtual outpatient appointments (table 1). While no randomised controlled studies were conducted, a common finding between studies was no reports of patient harm where there was a change in approach to a more environmentally sustainable way of working. This would suggest that there is likely to be further scope for innovation to reduce the impact that our services have on the environment. Importantly, one study was conducted by a trainee network16 demonstrating that there is potential for trainees to lead development in this area.

As a gastroenterology and hepatology community, we have become increasingly aware of the impact lifestyle has on our risk of disease. However, we still have relatively limited understanding of the impact of the environment, climate change and pollution on our risk of developing gastrointestinal and liver disease. Establishing an evidence base would allow us to inform our patients and healthcare policymakers about the range of risk associated with ongoing pollution and climate change. We, therefore, performed a scoping review to further understand the current evidence base regarding this association (see online supplementary data for methodology).

A total of 48 studies were identified (See online supplemental figure 1) which predominately explored associations between pollution/climate change and gastrointestinal/liver cancer26–47 (22/48), followed by IBD48–58 (11/48), liver disease59–67 (9/48) and other gastrointestinal diseases49 55 68–73 (8/48) (table 2). All studies were observational with the majority retrospective in design (40/48). A commonality with the studies was the challenge of eliminating or adjusting for confounding factors for disease development with socioeconomic status a clear potential confounder in the studies examining occupational risk. This is a potential challenge in understanding the impact of the environment and climate change on the risk of developing disease. It is clear that further work is required to provide better quality evidence to better appreciate the impact of the environment, climate change and pollution on gastrointestinal and liver disease.

Unfortunately, while randomised control trials would allow us to understand causation rather than correlation, this type of study analysis is methodologically unfeasible to assist our understanding of these relationships. However, there are several approaches that can be used to reduce the impact of confounding factors. Mendelian randomisation, used in the study by Sun et al,26 could be employed to better understand the association of pollution and climate change with gastrointestinal and liver disease.26 The concept of Mendelian randomisation utilises genetic variants, which are determined at birth, which are associated with an exposure of interest, for example, increased circulating levels of pollutants such as carbon monoxide (CO), to understand if they are associated with an outcome, such as a disease of interest.74 75 Multiple gene targets are usually identified via genome-wide association studies and subsequently, analysis can be complex. While there has been increased funding and support for TRNs through charities and societies including GUTS UK and the BSG, this methodology is currently unlikely to be viable for most TRNs due to the cost and expertise required. However, using specific genetic variants can be used to increase outcome events and provide a better understanding of association between gastrointestinal and liver disease and pollution/climate change. Furthermore, this type of study analysis could allow trainees to collaborate on an international scale to compare different environmental policies used in managing the risk of climate change and pollution on the risk of developing gastrointestinal and liver disease.

What are the challenges to delivering research in an environmentally sustainable domain?

Ongoing research is integral to clinical practice but carries with it a significant burden to the environment. It is estimated that an average of 78.4 tonnes of CO₂ is generated per clinical trial, which is equivalent to the emissions produced by nine people in the UK for an entire year.76 The MRC CRASH trial had estimated total emissions equivalent to 126 tonnes of CO₂, which is roughly equal to that produced by 32 individuals over a year, or 525 round trip flights to New York from London.77 The trial centre produced the largest proportion of CO₂ (39%), followed by delivery of drugs and documents (28%) and travel (23%).77 While it can be challenging to deliver research in an environmentally sustainable domain given that a large proportion of emissions appear to be out of the control of individual researchers, they should still aim to reduce the environmental harm caused by their activities.

Targets for sustainable practice in laboratories have been outlined78 but a common barrier described is lack of knowledge and understanding among clinical laboratory staff.79 Cold storage in laboratories is one of the largest energy consumers with materials often kept in refrigerators and freezers for several years, if not decades.80 Lab research is also a high producer of plastic waste, accounting for nearly 2% of total plastic waste.80

The National Institute for Health and Care Research (NIHR) Carbon guidelines have key recommendations for conducting greener research.81 These include a focus on research questions that are most important to patients and ensuring rigorous systematic review prior to embarking on research that could be answered from existing evidence. Non-English-language publications present a challenge in this respect particularly as China now has the largest global share of academic publications, with output increasing by 51% between the years 2016 and 200282. It follows that a ‘green researcher’ should think two times before excluding them from literature searches, but translation is equally time-consuming and costly. Furthermore, regardless of the research question, there should be a focus on efficient study design and avoidance of unnecessary data collection.81 This can be challenging while not compromising the quality of research. Efficiency can be increased by answering several research questions in a single trial, but this is logistically challenging; as demonstrated by only a small percentage of ongoing NIHR trials being factorial trials.81 Remote data collection and utilisation of videoconferencing can help to deliver research in an environmentally sustainable way by reducing travel. However, this may not always be feasible and rather prove to be more challenging for certain demographic populations such as the elderly and/or low socioeconomic groups.

A significant barrier to conducting green research is the heavy influence of commercial activity and financial incentives, which often competes with the aim to provide significant long-term benefits to patients and the environment; a fact that is mostly unavoidable given the high cost of research. It is particularly relevant in the field of gastroenterology, with commercial research accounting for 41.8% of studies in the NIHR Clinical Research Network (CRN) portfolio.83 Working with over 90 industry sponsors from 2019 to 2020, it gives the specialty one of the largest commercial portfolios in the NIHR CRN.83

The pressure on researchers to achieve publications in the so-called ‘publish or perish’ phenomenon84 is in conflict with the green agenda. The focus on achieving publications rather than producing meaningful research has contributed to the rising number of publications year on year.82 It is estimated that just 45% of articles are cited within the first 5 years of publication,84 suggesting waste from low-quality or irrelevant research. Meanwhile high-impact journals tend to be biased towards large-scale studies with extensive data, rather than simple studies delivered in an environmentally sustainable way. The carbon cost of research remains whether it is published or not, but given duplication of work, it is increased further if it remains unreported.81 Every effort should be made to make all data publicly available, but this is in the hands of journals’ peer-review systems. It is estimated that at least 12 000 trials completed every year remain unpublished81 and a systematic review showed that only 53% of abstracts have full data available after 9 years.85 There are alternatives to the traditional peer review process, including postpublication peer review; however, a huge culture shift will be required for this to be recognised and respected among the academic community.

The ‘IBD Bioresource’ is an example of collaborative working in an environmentally sustainable domain. It is an open-access platform aimed at advancing research in Crohn’s and ulcerative colitis, including data from over 25 000 patients.86 Samples were largely collected as part of routine clinical care and so limiting its environmental impact. The use of the data is maximised as it is open to any researcher approved by an ethics committee. Hopefully, there will be an increase in such collaborative working and data sharing in the future.

Overall, the idea that it is the responsibility of the research facility rather than individuals is a key factor that needs to change in order to lead to organisation-wide improvements. Clinical researchers often have short-term contracts feeling like they have limited time to make any meaningful lasting changes; however, they should always consider the environmental impact of their research when formulating a research proposal and should aim to evaluate its carbon cost on completion.

How can TRNs help to deliver a ‘green gastroenterology’ research approach?

As part of a new generation of gastroenterologists, it is vital that we as trainees embed climate-focussed decision-making into our clinical practice. Trainees moving between trusts for their specialty training are required to demonstrate agility and flexibility in their practice, making them ideally placed to identify and adopt novel climate sustainable approaches. The interconnectedness of TRNs provides a forum in which to share examples of good practice and to audit between trusts. In aligning themselves with the BSG’s ‘green’ agenda,10 TRNs will be able to access the support and resources available through the society, ensuring that trainees are part of the driving force towards sustainability in our clinical practice.

Reducing waste is key to the delivery of sustainable research, whether that be carrying out systematic reviews to avoid duplicating existing research, or designing clinical trials to answer several questions through one study. Many of the NIHR’s ‘Carbon Guidelines’ are applicable to the work of TRNs.81 A key benefit of research delivered by TRNs is its collaborative nature. By having ready access to a group of engaged trainees from across a region, it is possible to conduct multicentre observational studies and access a large potential patient cohort, increasing the chances of generating a study, which is adequately powered to observe differences. While gastroenterology TRNs have yet to deliver a prospective clinical trial, international trainee-led surgical research networks have demonstrated that this is feasible.81 As trainees, we are likely to have had limited involvement in trial design, so engagement with the NIHR network and local methodologists is vital to ensure that study design is efficient, making good use of patient populations and patient time.

The NIHR Carbon Guidelines recommend measuring outcomes remotely wherever possible.7 Many TRNs are comfortable with remote monitoring, having engaged in data collection using secure online servers such as RedCAP. In connecting trainees across a geographic region or nation, TRNs are well accustomed to meeting virtually to discuss progress, reducing the impact of travelling to meetings. Although TRNs typically run on modest budgets, it is important for trainees to consider funding sources and to ensure that any industry partners are committed to green principles.

Finally, we cannot forget that environmental health is a global issue. Carbon emissions from one country affects people in another. For gastroenterology (or any medical or surgical department), to be truly ‘green’ international collaboration must coexist. Given the aforementioned benefits of TRNs such as remote collaboration, their regular use of remote monitoring tools and engaged trainees, TRNs are ideally placed to lead the way in international quality improvements in green gastroenterology and beyond. The Royal College of Physicians currently has 14 registered TRNs with an additional 27 TRNs registered in the UK for the surgical specialties. As such, the UK has vast experience in setting up and successfully running TRNs. Now is the right time for networks to expand not just beyond their deaneries but crossing national and international boundaries as well and green gastroenterology is the right reason to do so.

Moving forwards

Gold standards for endoscopic procedures clinical practice already exist, which are well known and well practised. Nationally there are also targets for clinical pathways and referral times. The same needs to be true for clinical practice that impacts on the environment. While societies have started to publish best practice statements on improving sustainability, more data are still required to consolidate the evidence in order to produce impactful guidance and gold standards.

To obtain more robust data and create change, a team of like-minded individuals needs to come together and supports change at both the management and grass root level, building a team of people who first acknowledge the problem; second, are interested in tackling the issue at hand; and, importantly, will be present at the time affected by the change.87 The TRN groups are the ideal team members who can initiate change by developing, disseminating and implementing best practice in green gastroenterology—perhaps even in an internationally coordinated fashion. As Segal et al wrote in 2022, ‘The potential of TRNs is clear. What comes next is in our hands’.9