Carolyn A Chew-Graham is Professor of General Practice Research at Keele University and Chair of the Royal College of General Practitioners Research Paper of the Year. She is on Twitter: @CizCG0
Helen Leach is an Academic Clinical Fellow at the University of Warwick.
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.
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Overall winner: Clinical Research
For RPY 2021, we received 50 submissions — some truly excellent papers. The overall winner of the RPY award 2021 was from category 1 (Clinical Research): Antibiotics for lower respiratory tract infection in children presenting in primary care in England (ARTIC PC): a double-blind, randomised, placebo-controlled trial.1
This study was led by Paul Little from the University of Southampton, and demonstrated that amoxicillin for uncomplicated chest infections in children is unlikely to be clinically effective either overall or for key subgroups in whom antibiotics are commonly prescribed. The authors conclude that unless pneumonia is suspected, clinicians should not prescribe antibiotics for most children presenting with chest infections. The authors emphasise the need for safety-netting advice — encouraging parents to monitor their child and provide advice about when to consult again.
The reviewing panel reflected that not only was this a very well conducted trial, which will impact on clinicians’ behaviour, it linked with the key role primary care must play in antibiotic stewardship. GP trainees will need to learn to manage uncertainty and risk, and become confident in ‘safety netting’.2
We must encourage GP trainees to acquire and use current evidence, and that they can demonstrate this in their MRCGP.
Two highly commended papers
Two papers were highly commended by the panel judging category 1 papers: Risk of thrombocytopenia and thromboembolism after COVID-19 vaccination and SARS-CoV-2 positive testing: self-controlled case series study.3 This database study demonstrated increased risks of vascular and haematological events leading to hospital admission or death for a short time after first doses of the ChAdOx1, nCoV-19, and BNT162b2 mRNA vaccines.
The risks of such events were substantially higher after SARS-CoV-2 infection. This paper has a really important public health message that can be used as evidence by primary care clinicians in conversations with people who are vaccine-hesitant.
Maintenance or discontinuation of antidepressants in primary care.4 This trial demonstrated that among patients recruited from general practices who felt well enough to discontinue antidepressant therapy, those who were assigned to stop their medication had a higher risk of relapse of depression by 52 weeks than those who were assigned to maintain their current antidepressant prescription. The lesson from this trial is that people on antidepressants should be reviewed regularly by GPs with a discussion about whether to continue medication.
A GP needs to feel comfortable discussing the risk of relapse of depression with a patient when considering reducing and withdrawing an antidepressant. This study provides evidence to inform that discussion.
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Winner of category 2: Health Services Research (including implementation and public health)
The winner of category 2 was another trial: Non-speculum sampling approaches for cervical screening in older women, randomised controlled trial.5 The trial demonstrated that offering non-speculum clinician-taken sampling and self-sampling substantially increases uptake in older, lapsed attendee women.
Non-speculum clinician sampling appeals to women who dislike the speculum but still prefer a clinician to take their sample. Providing a choice of screening modality may be important for optimising cervical screening uptake.
GP trainees may have little contact with women attending for cervical smears, which are largely done by practice nurses, but they may speak to women opportunistically and in postnatal checks, so being aware of the choices available is key to offering advice to women.
It is vital to encourage GP trainees to engage with research … to support their development in areas such as managing risk, shared decision making, and dealing with uncertainty.
Winner of category 3: Medical Education with relevance to primary care
The winner of category 3 was the paper: Candidate perceptions of the UK Recorded Consultation Assessment: cross-sectional data linkage study.6 This study provided early evidence that the Recorded Consultation Assessment (RCA) was a feasible alternative to the Clinical Skills Assessment (CSA) during the COVID-19 pandemic, but also shows areas for improvement. This paper reflects the earliest modifications of the exam, and changes have certainly been made since then to reflect day-to-day practice.
The RCA is not without its criticism, but this paper demonstrates that it was a pragmatic replacement for the CSA at the height of the pandemic. The introduction of the RCA has arguably had the largest impact on GP trainees over the last 2 years.
Further work is required to establish whether there are any issues surrounding differential attainment, particularly for less-than-full-time (LTFT) ethnic minorities or international medical graduates.7 The RCA will need to evolve to reflect the rapidly changing face of delivering primary care and consider whether its current model reflects the ability of trainees to undertake the role of a qualified GP.
It is vital that GP trainees engage with research
For many trainees, keeping up with research in primary care may fall last on a list of priorities that is overwhelmingly populated by mandatory portfolio entries or exams. However, these winning and commended papers contain relevant learning for GP trainees of all stages as they cover the breadth of the curriculum for both competencies and clinical topics.
It is vital to encourage GP trainees to engage with research, not least for clinical updates, but also to support their development in areas such as managing risk, shared decision making, and dealing with uncertainty. Trainees can also use the emerging evidence from trials such as ARTIC PC1 to empower patients to make decisions within primary care consultations.
… these winning and commended papers contain relevant learning for GP trainees of all stages …
Equally, we should highlight research that, on face value, may not look as relevant. While trainees may not be directly involved in cervical smears, for example, they should opportunistically be participating in health promotion and demonstrating this within their portfolio.
We hope that you will (re-)read the winning papers and reflect on how research carried out in general practice informs our clinical decision making and supports us to deliver evidence-based care to our patients.
We must encourage GP trainees to acquire and use current evidence, and that they can demonstrate this in their MRCGP.
We can all support trainees by signposting them to WiseGP (https://www.wisegp.co.uk), an initiative supported by the RCGP, the Society for Academic Primary Care, and the National Institute for Health Research School for Primary Care Research. Winners of the RPY award are encouraged to submit GEMS (General practice Evidence for Modern day practice) to the WiseGP website, and you will find previous years’ winners at https://www.wisegp.co.uk/gem-library.
The call for RPY 2022 will be out in the summer — please do submit a paper you feel has impacted on your clinical practice.
Acknowledgements
The RPY award is well supported by RCGP staff in Policy, Research and Campaigns. Thank you to all panel members and chairs involved in the process for giving their time, particularly with all the competing demands on us.
References
1. Little P, Francis NA, Stuart B, et al. Antibiotics for lower respiratory tract infection in children presenting in primary care in England (ARTIC PC): a double-blind, randomised, placebo-controlled trial. Lancet 2021; 398(10309): 1417–1426.
2. Edwards PJ, Bennett-Britton I, Ridd MJ, et al. Factors affecting the documentation of spoken safety-netting advice in routine GP consultations: a cross-sectional study. Br J Gen Pract 2021; DOI: https://doi.org/10.3399/BJGP.2021.0195.
3. Hippersley-Cox J, Patone M, Mei XW, et al. Risk of thrombocytopenia and thromboembolism after covid-19 vaccination and SARS-CoV-2 positive testing: self-controlled case series study. BMJ 2021; 374: n1931.
4. Lewis G, Marston L, Duffy L, et al. Maintenance or discontinuation of antidepressants in primary care. N Engl J Med 2021; 385(14): 1257–1267.
5. Landy R, Hollingworth T, Waller J, et al. Non-speculum sampling approaches for cervical screening in older women: randomised controlled trial. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/BJGP.2021.0350.
6. Botan V, Laparidou D, Phung V-H, et al. Candidate perceptions of the UK Recorded Consultation Assessment: cross-sectional data linkage study. Educ Prim Care 2022; 33(1): 32–40.
7. Bostock N. ‘Perfectly good trainees’ lost as revamped GP exam deepens inequality, LMCs warn. GP Online 2021; 12 May: https://www.gponline.com/perfectly-good-trainees-lost-revamped-gp-exam-deepens-inequality-lmcs-warn/article/1715778 (accessed 5 Jul 2022).
Featured photo by Giorgio Trovato on Unsplash.
