Carolyn Chew-Graham is professor of general practice research at the School of Medicine, Keele University, Staffs, and Chair, RCGP Research Paper of the Year
Aghna Wasim is a medical student at the School of Medicine, Keele University, Staffs
The Research Paper of the Year (RPY), awarded by the Royal College of General Practitioners (RCGP), gives recognition to an individual or group of researchers who have undertaken and published an exceptional piece of research relating to general practice or primary care. The three categories are Clinical Research, Health Services Research (including Implementation and Public Health) and Medical Education with relevance to primary care. Papers are scored on the criteria of originality, impact, contribution to the reputation of general practice, scientific approach and presentation.
For RPY 2023, we received 52 eligible submissions – papers reporting research across the whole range of primary care research and education.
General Practitioners should offer low-dose amitriptyline to patients with IBS whose symptoms do not improve with first-line therapies…
Clinical research
The overall winner from Category 1 reported the ANTLANTIS trial: Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment in primary care (ATLANTIS) (https://doi.org/10.1016/S0140-6736(23)01523-4) which demonstrated that titrated low-dose amitriptyline was superior to placebo as a second-line treatment for IBS in primary care across multiple outcomes, and was safe and well tolerated. The authors recommend that General Practitioners should offer low-dose amitriptyline to patients with IBS whose symptoms do not improve with first-line therapies, with appropriate support to guide patient-led dose titration, such as the self-titration document developed for this trial (https://ctru.leeds.ac.uk/atlantis/). Professor Hazel Everitt, an academic GP in Bristol led this multi-centre trial and presented the findings at the RCGP Annual conference in 2023.
| Aghna reflects:
From a medical student perspective, this paper is a reminder to the importance of staying informed about latest evidence regarding the effectiveness of treatment options and ensuring that one’s practice is reflective of this. In the context of this trial, this would mean that an increasing number of clinicians are aware of the benefits of titrated low-dose amitriptyline as a second-line treatment for IBS and take it into consideration as a potential management option for their patient. This paper helps combat the uncertainty that currently exists about the therapeutic potential of tricyclic antidepressants in the management of IBS. Moreover, the findings from this study reinforce the significance of clear communication, specifically when providing information about treatments, as a factor that promotes their acceptability among patients, and the importance of including the patient in making treatment decisions. The patient-led titration guide looks particularly useful. |
Another trial was highly commended in Category 1: Clinical and cost-effectiveness of nurse-delivered sleep restriction therapy for insomnia in primary care (HABIT): a pragmatic, superiority, open-label, randomised controlled trial which showed that a brief nurse-delivered sleep restriction therapy in primary care reduces insomnia symptoms, is likely to be cost-effective, and has the potential to be widely implemented as a first-line treatment for insomnia disorder. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00683-9/fulltext):
As GPs, we are often faced by requests for help with poor sleep and we offer ‘sleep hygiene’ advice. This new intervention was more effective than sleep hygiene and also improved depressive symptoms. The trial showed that the intervention was cost-effective; however, until included in NICE guidance, it is unlikely to be commissioned or available for our patients.
| Aghna reflects:
This study provides an early indication to medical students of how guidelines surrounding insomnia management might be evolve over the coming years. Given the prevalence of poor sleep and the likelihood of medical practitioners being required to manage offer support to patients at some point in their careers, this trial potentially prompts medical students to start considering the possibly of offering sleep restriction therapy as an alternative to sleep hygiene advice and reflecting on the feasibility of training in the technique and delivering it themselves. |
Health services research
Winner of category 2 was Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis (https://qualitysafety.bmj.com/content/early/2023/11/26/bmjqs-2023-016674.long). This study aimed to understand why safety incidents occur in remote primary care encounters, and what can be done to minimise such incidents. The paper gives examples of safety incidents which we will all resonate will all of us, and the key message that clinical assessment provides less information when a physical examination (even just being in the same room as the patient) is not possible. Hence, the remote consultation has a higher degree of inherent uncertainty. The paper includes a helpful table with the authors’ recommendations to reduce safety incidents.
| Aghna reflects:
The growing use of remote encounters in primary care mandate that medical students be adequately trained in this manner of consultation during their education. Although medical students are exposed to the remote clinical environment to some extent, the sessions rarely, if at all, incorporate teaching regarding safety incidents and their prevention. Therefore, this study has important implications in relation to helping medical students learn how to identify patients at-risk of safety incidents and introduce them to measures that can be taken at an individual level to mitigate the risk. Furthermore, medical students that recognize the utility of these findings may communicate the need for additional training on safety in a remote encounters as a part of their curriculum to their school and tutors, possibly leading to consideration for its inclusion. |
Medical education with relevance to primary care
The Category 3 winner was Performance of ethnic minority versus White doctors in the MRCGP assessment 2016 -2021: a cross-sectional study (https://bjgp.org/content/bjgp/73/729/e284.full.pdf)
…ethnic background did not reduce the chance of passing GP licensing tests once [other factors] were accounted for.
This important paper showed that ethnic background did not reduce the chance of passing GP licensing tests once sex, place of primary medical qualification, declared disability, and Multi-Specialty Recruitment Assessment (MSRA) scores were accounted for. The reassuring finding that ethnic status had no significant effect on performance at licensing assessments once selection scores and other demographic factors were accounted for suggests that, rather than the explanation being related to ethnic group, the reason for these differences is owing to differences on entering GP training rather than examiner bias or racial discrimination.
| Aghna reflects:
Medical students from ethnic minority backgrounds are often concerned about the prevalence of discrimination and racial bias within examination and workplace settings, including worries that their efforts at licensing exams maybe tainted due to racism. The findings from this study provide much needed reassurance that hard work and commitment will not be wasted because of their association with a particular ethnic group, consequently encouraging them to progress through their careers with more confidence. |
Finally, a paper on continuity of care was highly commended in Category 2: A contemporary ontology of continuity in general practice: Capturing its multiple essences in the digital age (https://www.sciencedirect.com/science/article/abs/pii/S0277953623004690?via%3Dihub)
This paper reports a development of a framework of continuity: relational, clinical, distributed work and commitment to a community. We all talk about the importance of continuity and the evidence that it improves patient outcomes and clinicians’ satisfaction; this paper suggests that relational continuity has costs as well as benefits. For the patient there may be a trade-off between seeing one’s usual clinician and receiving continuity for a particular illness episode if the initial consultation was with (for example) someone other than the usual GP. There are also trade-offs between working as a full-time general practitioner and pursuing other professional or personal commitments, especially at a time when burnout in general practice is at an all-time high.
The authors also describe the challenges of the broader primary care team, with the aim of efficient division of labour (with every member of the team doing the component they are most suited for and nobody doing a task that could be delegated) and the near-absurdity (the authors’ term) of illness episodes that are split into multiple fragmented tasks each undertaken by a different member of staff. The patient has thus been divided into fragments of care and the burden placed on the patient in such a circumstance magnified.
| Ahgna reflects:
When medical students discuss continuity of care and its importance, they are often referring to continuity in the context of the therapeutic relationship. This study encourages more intertwined approach that combines relational continuity with continuity of illness; distributed work; and commitment to community in addition to acknowledging the downsides to it, expanding medical students’ perceptions of the term. This broadened perspective may be particularly useful for medical students when championing ideas to promote high quality care for patients as well as implementing continuity in their own practice as clinicians of the future. |
The winning papers reporting research utilising a range of methods, highlight a range of clinical problems (insomnia and IBS) and highlight important system phenomena (patient safety and continuity), providing learning for the next generation of doctors, including GPs.
If you read a paper that has particular relevance for your work, published in 2024, please consider submitting this for RPY 2024 – the call will be out soon.
Featured photo by Giorgio Trovato on Unsplash.
