Venturing into the unknown
David Unwin FRCGP, The Norwood Surgery, Southport
Two years ago I believed that research in general practice was impossible for any overworked, full-time GP struggling with the pain of constant political meddling and under resourcing. I thought that getting something published belonged to the fantasy world of academia along with 20 minute appointments and having time to read journals. I am embarrassed now to admit how wrong I was, but also grateful for a journey that has been exiting, energising and a lot of fun. It has even changed my consulting style to be far more collaborative with my patients - a surprise for a 56 year old GP!
As so often is the case, my journey began with a question. Obesity, why was it getting out of hand? Also, why did I never seem able to help patients much with it? A sort of learned helplessness had crept in so that I stopped even commenting on it. I felt as if there was no point. If I didn't have something that worked, it just seemed rude.
The turning point was a book ‘Beat the Diet Trap’ by Dr John Biffa. I wouldn’t normally read a book like this, but my wife made me. It was full of heresy like ‘fat isn’t always bad’ and ‘some calories are more fattening than others’. Obviously nonsense! However, there were a worrying number of references - so just to prove him wrong I used Google to plough through them. The glycaemic index of bread is worse than table sugar? I double checked - it is! Not only that, but things have changed since I was a student. It is now so easy to look into any subject. No trip to the library needed, Google has it all! (Hint preface your Google enquiry with ‘scholarly articles for…) After a while of searching, I found ‘Pub Med’ provided better quality answers to my questions. Amazingly, I was having fun and I had found a huge world of people asking questions and then looking for answers. Medicine has few absolute truths - they are on the move, it’s the guidelines that are rather static.
I started keeping some of the articles to show the partners. My interest awakened, I bought a few copies of the book for patients and asked their opinion of Dr Briffa’s low carbohydrate diet (my first collaborative act). Amazingly, they came back thinner and claimed not to be hungry! By this time I was also on the low carb diet myself, no bread for weeks and never felt better. Thinking afresh about obesity with my putative tool in mind, who were the patients I most wanted to help? The internet to the rescue once again - becoming a type 2 diabetic brings the same cardiovascular risk as an untreated hypertensive with a systolic BP of over 200 (thank you Q risk).
So now we have the very basis of research; a problem (obesity and a raised HbA1c), and a possible solution (the low carb diet).
Ethics: I was very lucky at this point that a partner pointed out I should check out any possible interventions with the BMA ethics department. I resisted for a week suspecting my baby project would be strangled in red tape. In fact they were very helpful and have no wish to complicate matters unnecessarily, providing particularly useful advice on consent. So we were on, doing actual research – pinch me!
We recruited our patients, explaining what the diet involved and asking permission to share anonymised data. They were far more interested than I had expected, particularly liking the computer generated graphs of their progress handed out at each monthly measuring session. One of the bits I found most exciting was the blood results coming in –normally this is such a computer chore but when the evidence of better diabetic control started coming in I couldn’t wait to open that inbox. Nearly every day I was seeing patients who were proud of their weight loss achievements which subtly changed my consulting style to something more collaborative. It felt that I was working alongside my patients with shared goals rather than lecturing them.
The results and engagement with the academic community: Again Google to the rescue. Find the authors of work related to your interest and get chatting about your shared enthusiasm via the email addresses on their publications. It is possible they may give advice, comment and statistical help. I was lucky to find Professor Roy Taylor of Newcastle University who very kindly worked out the following; ‘Blood glucose control improved (HbA1c 51±14 to 40±4mmol/mol; p<0.001). By the end of the study period only 2 patients remained with an abnormal HbAic (>42mmol/mol), even these two had seen an average drop of 23.9mmol/mol. Weight fell from 100.2±16.4 to 91.0±17.1kg (p<0.0001) and waist circumference decreased from 120.2±9.6 to 105.6±11.5cm (p<0.0001)’ Check out those p values!
Help from an unusual quarter: In a sense the internet is democratising research, making it more accessible. Blogging ‘interest groups’ taught me such a lot, though it started rather badly. I tried to join diabetes.co.uk as they have a very active low-carb forum with thousands of members. Imagine my surprise to be removed from the site as a possible ‘troll’ (defined as ‘a person who sows discord on the Internet by starting arguments or upsetting people, by posting inflammatory, extraneous, or off-topic messages in an online community’). This occurred because it was difficult for the them to believe initially I was a bona fide doctor taking up their cause. After clearing up the misunderstanding, many on the site knew more than me about diabetes and helped search for references, also providing a lot of welcome encouragement (I got 19,000 hits). A word of caution – remember anything said online cannot be retrieved, make it clear you cannot ethically give any specific advice on medical problems.
Writing it up: I didn’t have the confidence to try for publication at the start so a useful step up was to enter for the Mersey RCGP deanery annual awards. This was daunting but friendly as I’m not sure how many applicants they actually get. Another low key idea would be to enter a poster presentation at a conference. It gives a sense of purpose and belonging at a conference that feels good.
The journals: Embarrassingly I didn’t know that the mark of respectability here is that all work is peer reviewed, so if it’s a publication you have never heard of, check. Each journal has a detailed ‘information for Authors’ section online. This gives useful facts about how they want your findings set out, including how many words you are allowed. In the end Practical Diabetes took pity on me and how proud I was when the paper copy came through the post. Even better how pleased my brilliant patients were, and thinner too!