How to become an academic GP and the issues around research

I usually start my blog posts with how I meet my interviewees but, in absolute truth, I have no idea where and when Dipesh and I met. It must have been at an RCGP conference, but I do remember bumping into him later on at the RCGP HQ on Euston Road where we sat in the Members’ Lounge just chatting over coffee. Dipesh is an academic GP and is currently doing a pre-PhD In-Practice fellowship in research at Queen Mary, University of London (QMUL) funded by the NIHR. For the record, I do not have a research background and I can barely do a Pubmed search. However, I geek out on primary care and often read around it and write opinion pieces so only have a handful of publications. I’m also currently reading a Masters in Medical Anthropology where there is a lot of reading and writing. However, I’ve really had to ask Dipesh to simplify the lingo because the academic pathway can often feel opaque to an outsider. But, as I usually find in our conversations, we digress onto larger topics of social inequality and the like.

Becoming an academic GP

Dipesh knew that he wanted an academic career before finishing med school. He decided to google 'academia and GP' and came across a few BMJ articles including one by Professor Helen Stokes-Lampard. He emailed her and she emailed him back with a few pointers. Just goes to show that cold calling can work! Unfortunately, he missed out on an academic foundation year post (he says he was woefully underprepared) but he badgered a lecturer at the university near his Foundation year placement if he could do some research with him and they worked on a project on cardiovascular risk in ethnic minorities. He put together this systematic review around his weekends and night shifts which sounds super painful, but this obviously paid off when he applied for academic GP. In terms of the academic clinical fellowships, he also points out that they are looking for an all-rounder as they are investing in an academic leader of the future. He saw it as a mapping exercise, going through the white spaces and ensuring that every base on the application form was covered. I know I say this time and time again but look at the person spec on the advert and make sure you are prepared for an example for each specification. He recalls the classic questions in this interview - "What are your strengths?", "What are your weaknesses?" "What is your biggest achievement?" Then he had to analyse a paper and then he had to discuss a paper that he had recently read. It was hard and Dipesh regrets not doing enough interview prep. Having got through by the skin of his teeth, he recommends future applicants not to take it lightly and ideally practise with someone who has gone through the same application process before.

GP training is three years in the UK and, in academic GP, the last year is extended over two years so that the training is a full four years - two or three days of clinical and then the remainder in academia. He enjoyed the fact that it was very user-led: you had to find your own supervisor, have ad hoc conversations with people with similar interests. He took his academic career forward by applying for a research fellowship after completing academic GP training. He failed the first time, but like most eventually successful people, he picked himself up, got some feedback and came back bigger and better the next year. He reminds me that if someone is giving you money to do a project or PhD, you need to bring some sort of value. The advice for applying for a NIHR fellowship that he received that was invaluable was that it is important to look at the person (are they employable, academic with a good track record?), the place (is the institution good and is the supervision right for the methodology employed?), the project (is it a meaningful research question? Is it ambitious enough?) and patient and public involvement (PPI, have patients been involved from the start? Is the research question relevant to patients?)

Once you have academic days, you have paid time allocated to write applications and to read and write as well as institutional access to journals. Those not in academic roles are doing it in their free time with limited resources - it's not a level playing field. It is often very hard to get your foot on the ladder and it can be quite intimidating to an outsider. Dipesh agrees that it is so easy to feel insecure just because you don't have at least one paper in a journal with a high impact factor. His advice is to start small - try to write opinion pieces and letters to journals. He says that F3's are very popular at the moment so it can give applicants an extra year to stretch out your CV or negotiate a project at the local university academic general practice or primary care department.

The issues around research

Where do we start...?

Dipesh argues that there are two ways of seeing science. The first is as a single truth that is unearthed and is independent of the world around it. The second is that evidence is qualitative and that science has a different way of looking at the same data - none of them are invalid but shaped by the world around us. Interpreters are all biased and we all challenge the world view of how science is interpreted. Which begs the question, are they the right questions we are asking or funding? My medical anthropology Masters has me examining our notion of the universality of biology - an assumption of normality - that all bodies are cardboard cutouts of each other. Who chooses the arbitrary cutoff points that defines normal and abnormal? Invariably it will be a human being, or a group of human beings and we can only assume that they are not without biases based on their cultures, backgrounds and upbringing.

Furthermore, let's take the example of the prestige of institutions. If you come across a paper written by someone at Harvard or Oxford, it sounds pretty good already, right? You can argue that blinding should sort this out but, if you are peer-reviewing within this small community, it's pretty obvious who's written what. This disadvantages institutions from lower-income countries where the name might not carry as much prestige and status. Let's also look at who funds the research. When conducting international research, who's standards are we abiding by? You could argue that these should be international standards that meet everyone's criteria but ultimately, if funded by a European/North American institution, that is the lens you will be seeing the data. In an era where science is religion, we need to be clear that science and research is not as objective as we like to think it is. This is abundantly clear during this pandemic where there is public confusion on how scientists can argue you each other when, supposedly, there is only "one universal truth."

Finally, at the user end, access to the research can be a real issue. One of the things I respect about academia is the potential to impact real change. One good paper can change the practice of millions and improve patient care. But, in my opinion, it is so hard to have access to the right resources if you are not connected to an institution. Dipesh recommends using Google Scholar which can be added an extension into Google Chrome as a extension you can use to find PDFs of the paper. He also recommends ResearchGate but also just emailing the author directly as many are very happy to share their research. It turns out that there are ways of trying to circumnavigate the system. Furthermore, this pandemic has shown me the advantage that I am at for being a native English speaker in keeping up with new articles, not to mention those wanting to publish. When the evidence is changing every day, the fact that international journals are published in the international language of English disadvantages those who do not speak English. No one wants to feel that they have had life easier than others but some of us need to check our privileges.

The morality of health

Hilariously, Dipesh got into some hot water on social media recently . He had posted the findings of the a BJGP article critiquing lifestyle medicine movement on Twitter and the article received some backlash to the article itself, LinkedIn and on the British Society of Lifestyle Medicine. So, just to be clear, he is not against the principles behind the lifestyle medicine movement - to eat better, to exercise, to prioritise sleep, to reduce toxins like tobacco and alcohol, to minimise stress - but he has some issues about how it ignores the wider issues. There is a huge focus on individual choices on whether we choose to follow these principles or we don't. The by-product of this narrative is that if you are not healthy, it is your fault. What's my opinion of lifestyle medicine? I love it but I do strongly believe that it's a middle-class movement. Being able to afford to eat healthily and to go to the gym and to have time to unwind is a privilege of the financially comfortable in the UK and I cannot dismiss what Dipesh is saying. He feels that this can put a lot of pressure on patients who don't have these privileges and I agree that this can make us come across as the morality police. He feels that we're not tackling upstream social and political determinants of health - good education, good housing, stable minimum wages, - that give us the breathing space to pursue lifestyle medicine hacks. He argues that inequality isn't Instagrammable and doesn't quite have the positivity algorithm that lifestyle medicine can have to go viral.

So what's the alternative? In medicine, we're very good at fishing people out of the river but we're not so good at understanding how they fell in upstream. Capitalism has created a milieu of abundance but, within the neoliberal framework, it is now up to the individual to be the driver of their own destiny and absolves the powers that be of our wellbeing. Take burnout questionnaires and mental health days that are popular in private companies. This takes the onus away from the company because it is up to the employee to be aware of their mental health when we all know that reducing work pressure is the best way to avoid burnout. When market forces are placed to make you work harder and make you rest less because there is always more to be attained, I feel that placing the responsibility on the patient for burning out because they didn't take their mental health day a little bit precious. I don't know anyone who would cancel a day of work on the day because of their anxiety out of fear of letting everyone else down. Other examples? In the UK, there are more fast food shops clustered around schools in deprived areas than richer areas. Is it a surprise that children from lower-income families are twice as likely to be overweight than their richer counterparts? Is it really their fault? Can we truly lecture our patient about not going to the gym when having a gym membership implies financial and time security to do so?

Dipesh describes it as a double-edged sword of freedom - the freedom to change is also the freedom to blame. Dipesh feels that we need to concentrate our research more on issues that create good health (salutogenesis) - better housing, clean safe outdoor spaces, connected communities, walkable cities and consider universal basic income. I wholeheartedly agree on this and I encourage you to listen to 'Reasons to be cheerful' which is one of my most favourite podcasts which discusses these issues on how to build a better world.

Final words

As you all know, I love putting the world to rights and it was a pleasure to do this with someone on the other side of the research fence. We digressed hugely but ultimately the point of this blog post was to encourage anyone who was thinking of research to try it and try your best not to feel intimidated. I try to encourage younger generations to submit pieces into the BJGP or Innovait which are very open to a variety of articles and can be a way of gaining confidence in your writing skills. Also, don't be afraid to cold-call researchers or to strike up a conversation. The worst thing that could happen is that they don't respond and at least you're no worse off than before. If you've not been to a conference before, it's a great place to meet people and I love collecting email addresses and business cards. And if that is too much of a hurdle, you can private message me to find a way to get started

Dipesh in his clinical room.

Thanks to Dipesh for your time for the interview.

You can follow him on twitter @DipeshGopal or Instagram @drdipeshgopal

You can also listen to him here in an interview with Dr Aman Arora and in this podcast by my friend Shubs AKA 2 GPs in a pod.