Carolyn Chew-Graham is a General Practitioner and Professor of General Practice Research at Keele University.
Her areas of interest and expertise include the primary care (including in prisons) management of people with mental health problems, multiple health conditions and unexplained symptoms, and the mental health and wellbeing of clinicians.Patient and Public Involvement is key to all her research. She chairs the RCGP ‘Research Paper of the Year’ panel. Carolyn was awarded an OBE for services to general practice and primary care research, including research into Long Covid, in the King’s Inaugural Birthday Honours List, June 2023. Carolyn is an NIHR Senior Investigator.
Chris Salisbury is Emeritus Professor of Primary Health Care at the University of Bristol. He describes himself as having had three overlapping careers: as a full time GP for more than 10 years, then as an academic doing research and teaching alongside general practice, and finally as a leader and manager. His academic work has focused on how to ‘do family practice better’
“…this was something I wanted to incorporate into my working life. I wanted to be an academic researcher. I wanted to do some research alongside being a doctor.”
Chris Salisbury. Hello, I’m Chris Salisbury, and today I’m talking to Carolyn Chew-Graham. Carolyn is Professor of General Practice at Keele University and she’s had a number of influential roles, including as chair of the Society of Academic Primary Care, and has chaired lots of other bodies, including the RCGP Research Funding Board and the RCGP Research Paper of the year competition. We’ll talk about some of those roles later. But, first, welcome to this MedicsVoices interview. Tell us your story, how did you come to be a primary care academic
Carolyn Chew-Graham: Interestingly, I was out for lunch with my cousin a couple of weeks ago and she reminded me that, when I was about 14, I said I wanted to be a doctor because I wanted to help people. That was in the context of my father dying. And I think that had a big influence on me because prior to that I wanted to be an archaeologist or a geography teacher. And I still look at “Time Team” and other archaeology television programmes and think – I wonder what my life would have been like if I’d gone on to do archaeology. So, from the age of 14, I had decided I was going to be a doctor.
I went to Manchester Medical School and I think I was quite driven. In the summer before I went to university, I read the prospectus where it talked about intercalation opportunities and I thought- oh, I’d like to do that. And that was before I’d even gone to medical school. I’ve always been driven, a bit of a perfectionist, a bit competitive. Looking back at my time as a student, perhaps my work-life balance wasn’t as interesting or as good as other people’s. I did an intercalated year in physiology and really enjoyed that. I really enjoyed developing a hypothesis and doing some not very good lab work. I didn’t have anything published but I still enjoyed the experience and thought that maybe this is something I’d like to do in the future. In my fourth year I was based at Leighton Hospital in Crewe, and during the public health component- it was called community medicine then- I developed a questionnaire to give to people with diabetes about their knowledge of diabetes and the sort of self-management techniques that they needed to adopt. I interviewed people and managed to get a presentation at a social medicine conference out of that work. Again, I think that made me feel that this was something I wanted to incorporate into my working life. I wanted to be an academic researcher. I wanted to do some research alongside being a doctor.
CS: That’s really interesting and chimes with quite common themes. When you talk to medical academics, you often hear that they went into medicine or nursing because of someone of their own being ill- as with your father dying when you were a teenager. And also this perfectionist trait, and the experience of doing research as a student and then getting the bug. Your big area of interest is mental health problems, why did that come about?
CC-G: I was fortunate to be a GP trainee at the Robert Darbishire Practice based at Rusholme Health Centre. My trainer was (Emeritus Professor) Carl Whitehouse, who is still a hero of mine. Because it was an academic practice I had the opportunity to get involved in research. At that time I was more interested in older adults and got some funding with David Wilkie and Carolyn Glendinning to look at a developing component of the GP contract, the over 75 health check. I led a qualitative research project interviewing commissioners of care and providers of care about the value of the over 75 health check-up, which was published. At that time we didn’t record interviews, we made verbatim notes in order to use the quotations. And, this was at a time where you’d send a number of typed copies of a manuscript by post to the journal hoping- please publish this. And, that was my first funded research
CS: Were you still a trainee when you did this?
CC-G: Yes. Because I happened to be in that practice and the academic unit was upstairs at Rusholme Health Centre, we mixed in the common room and I had that opportunity. And I also did a couple audits/ research, a questionnaire for women around the menopause. I was quite influenced by David Goldberg’s work. He was a psychiatrist who worked with Linda Gask, and we worked together subsequently and are friends. David Goldberg had done some work about how people come to the GP and depression is not identified. He did waiting room surveys. And he and Linda developed training for GPs with which I became involved. And, it occurred to me then when I was a GP trainee- and everybody knows this now- that people didn’t come with one problem, they came with multiple problems and that often it was the really tricky psychosocial problems that perhaps didn’t present, that underpinned all their other problems. I felt quite impotent when I first started as a GP trainee in a really deprived area of Moss Side, Rusholme, where people had multiple problems and I felt I couldn’t do much about it, and I felt it was the mental health difficulties that people had that were not identified in general practice. We didn’t have talking therapies in those days. If somebody had severe mental illness you could refer to psychiatry but otherwise you managed those problems yourself, and probably not very effectively. I think it was that feeling of impotence and wanting to make a difference to the care of people with mental health problems that led me to research into mental health.
But I did other work. I was involved in a trial in chronic fatigue syndrome, so I’m also interested in those unexplained persistent physical symptoms. And there is quite an overlap with mental health difficulties. It’s not that the primary problem is a mental health problem, but that people who have chronic fatigue or chronic pain will be anxious or depressed because of the symptoms that they have. And often because of the sort of gaslighting that they perceive from medical professionals and their families, friends, and employers.
Carolyn was awarded an OBE for services to general practice and primary care research, including research into Long Covid, in the King’s Inaugural Birthday Honours List, June 2023.
CS: There’s another really common theme in your story and that is the importance of key people that you met early in your career who were mentors but also you were in a research active environment so you saw things going on and you wanted to do them as well. What lessons are there for us in that?
CC-G: I now feel that I act as a mentor or role model, and I think that’s really important. I think people have to see somebody like you to be able to think that that they could do it. I would have looked at Linda Gask and Carl Whitehouse and thought I want to be like that, I want to do that. And David Metcalfe as he was the person who led the department in Manchester and managed to find funding to employ me as a lecturer. Without that step up and the opportunity to have protected time, it’s not sustainable to expect somebody who’s working full time as a GP to become a proficient researcher.
CS: I was thinking along similar lines, that there’s a huge gap between the kind of mental health problems that we see in primary care that are often difficult to fix, and the really seriously mental ill where secondary care get involved, and that’s fairly rare. It’s the sense that more needs to be done, it could be done better, more help is needed.
CC-G: It’s the bread and butter of general practice. Many people who come to primary care consultations have a mental health problem in addition to what they’re presenting. When I first started years ago, it was the hidden agenda. We now encourage trainees to ask about mental health, we’ve talked about the stigma associated with mental health difficulties and that people wouldn’t present, so I think patients are presenting now. But I think there’s still a gap in what GPs feel they can do. Part of me is a bit despairing about the fragmentation of general practice, the remote consulting, the signs “one problem per consultation” which you see displayed in general practice waiting rooms, which I just absolutely hate. People don’t just have a single problem. You need to get to the bottom of all their problems and disentangle them to then make a plan of how you can help and what needs to be tackled.
CS: I agree with you about everything you said about the problem with one problem per consultation. Just following on about depression and mental health, and your career has been over a similar time to me, there was a great campaign early in my career that GPs were not diagnosing depression, it was underdiagnosed, that they need to be doing more and should be screening for it and checking for it and treating people better and giving them more treatment. And there’s been a massive explosion in the use of antidepressants and also in CBT and now GPs are being criticized because they’re prescribing too many antidepressants or for too long. And yet I was taught that it’s a chronic disease and some people need to stay on them forever. Have you got a view about this criticism of GPs for prescribing too many antidepressants now?
CC-G: Twenty or 30 years ago when David Goldberg was talking about the need to identify depression and need to treat it, the only option really was depressants. I think we’ve got more options now as GPs. We can refer to NHS talking therapies or we can signpost people. People have to refer themselves, but that’s another story. And I think you are absolutely right that depression is considered by many people to be a recurrent problem and that some people do need to stay on them long term. But, fewer people than perhaps we are prescribing for. Reaching for the prescription pad, although obviously it’s on computer now, I think it is too easy to leave people on antidepressants. And, I reflect on the medication review tick box that we have on our systems and whether that medication review is done properly or not. I don’t think we have the time, or possibly the inclination, I think that the tick box is just too easy. Yes, I have done that. They’re on the telephone. That’s fine.
CS: Although there been a massive expansion in CBT. My experience is that it works brilliantly for some people. But my experience in working in quite a deprived area with often not very articulate people is that they often didn’t want to go to CBT, and when they did go, they might go just once and then not go again. Is that your experience as well?
CC-G: Again, I work in a fairly mixed area and the first barrier is you’ve got to refer yourself. I’ve had consultations where I’ve had to sit with people and go through the link on their phone to help them out. And then the link doesn’t work, and then I’m frustrated too because I’ve sent them this link. If they don’t have a smartphone, if they can’t manage the technology, if they don’t have English as a proficient language, that’s the initial barrier to getting into CBT. And it doesn’t suit everybody, it is quite protocolised. So even people who felt it’s been useful have said, that with the person who delivered it, it was very much by the book, there’s no flexibility. And there aren’t many other options on the NHS. We’ve got social prescribing now which may offer some people an alternative or an addition. But again, I think feedback from patients, and the research evidence base around social prescribing, is that it’s quite hit and miss. Social prescribers may not know what their remit is, they are getting burnt out, and the turnover is quite high. There’s been very little true evaluation of social prescribing. What’s been done locally is evaluating the process, the throughput of people rather than any outcomes. So we’re referring people to social prescribing but we don’t actually know what they’re delivering and whether it helps.
CS: So we need to avoid the idea that there’s one simple solution, whether it’s CBT or antidepressants or social prescribing, that’s going to solve the problem.
“With Long Covid, I’m convinced there’s underlying pathophysiology. We haven’t identified the problem with Chronic Fatigue Syndrome yet, but the evidence is emerging, I think, because of long Covid that there may be a genetic predisposition to Chronic Fatigue Syndrome, that there may be an underlying problems with the response to a virus.”
CS: Then during the pandemic, you became interested in the phenomenon of Long Covid, and you’ve been writing about that. Do you think that’s related to your experience of working with medically unexplained symptoms, or do you see this as different?
CC-G: So, I’ll tell you the story. Over five years ago when we were all working online remotely with telephone consultations, people said, I think I had Covid in March but obviously there was no testing so they didn’t know if they’d had Covid, but they had had a respiratory infection and they weren’t recovering. They felt fatigued and anxious and worried and didn’t feel that they were believed. They might have had other consultations or their families didn’t believe that they hadn’t recovered. The narrative I was hearing as a GP were just like the narratives of people with Chronic Fatigue Syndrome or Fibromyalgia- these persistent symptoms, they couldn’t quite explain them. And so I thought this needs something done about it. So this really was a question that came directly from the consulting room. And during that time there was quite a bit on social media. There were articles in The Guardian about this thing that came to be called Long Covid. It was about August or September in 2020, at which time I was working with a team analysing the interviews we had collected. We got that published and we’ve continued to work on that. We know from other research that’s coming out, together with bench science, that there are probably vascular or autoimmune features, or persistence of the virus in cells. So it is a condition that does have an underlying pathology. And I think it’s also making me reflect on work I did 15 years ago on chronic fatigue syndrome, being involved in a trial of pragmatic rehabilitation, and thinking is there some underlying pathophysiology of chronic fatigue syndrome or myalgic encephalomyelitis that means that activity management or rehabilitation is not a total solution and we should be looking at the pathologies. And it makes me feel a little bit uncomfortable that I went down that route based on the evidence that was available at the time. But, actually, was it dismissing peoples’ symptoms as something that could be addressed with a behavioural change?
CS: Isn’t this the temptation to fall into a kind of dualism between physical and mental health? You said earlier that people have physical problems, but they sometimes present with mental health manifestations of those physical problems. It’s as if, in the case of both medically unexplained symptoms and Long Covid, somehow we want to make it either mental or physical, whereas in many ways they are both. The physical problems manifest and affect your mental health, and the interface between them.
CC-G: And I’m very clear when I’m working with people with Long Covid that whilst I do mental health research and whilst what we’re talking about may be mental health, it’s not because I believe their symptoms are caused by mental illness. I believe the symptoms are real, but they may have had a reaction to that and living with those symptoms, which means that they may be anxious or depressed or may have changed their behaviour. Therefore, looking at things they do on a day to day basis, looking at improving their function, might improve things. With Long Covid, I’m convinced there’s underlying pathophysiology. We haven’t identified the problem with Chronic Fatigue Syndrome yet, but the evidence is emerging, I think, because of long Covid that there may be a genetic predisposition to Chronic Fatigue Syndrome, that there may be an underlying problems with the response to a virus. And I, probably shouldn’t chastise myself too much because the FINE trial that we conducted 15 years ago was based on the evidence that was available at the time.
CS: I think you describe yourself as mainly a qualitative researcher, and yet you’ve done trials, you’ve done systematic reviews. If you were advising early career academics, someone like yourself 20 years ago, would you encourage them to have the kind of breadth of expertise that you have or would you say to get a special area of methodology and do that?
Lester Resource (for Adults) 2023 Update
To cite: Perry BI, Holt RIG, Chew-Graham CA, Tiffin E, French P, Pratt P, Byrne P, Shiers DE. 2023 update (with acknowledgement to the late Helen Lester for her contribution to the original 2012 version) Positive Cardiometabolic Health Resource: an intervention framework for people experiencing psychosis
and schizophrenia. 2023 update. Royal College of Psychiatrists, London.
Edited By: Carolyn Chew-Graham
Health Expectations is an open access health and social care journal publishing new research and articles that promote critical thinking and informed debate about all aspects of patient and public involvement and engagement (PPIE) in health and social care, policy and practice, health and social care research and education of health and social care professionals.
CC-G: So I don’t think I’m a trialist at all. I work on trials, but often either because of my expertise in primary care or because I’m leading the process evaluation within a trial. Talk to me about power calculations and I glaze over, there’s a statistician who does that. I think the key messages is to work in a multidisciplinary team where everybody brings their expertise. I guess that I would say to somebody, an academic clinical fellow or clinical lecturer, try and get as much training as you can in lots of different methods, but you will develop an expertise in one area. That might be qualitative or mixed methods, process evaluations, in systematic reviews, realist reviews, or that might be in leading randomized controlled trials.
CS: Another part of your career is that you are Editor in Chief of the journal “Health Expectations”. That’s a lot of work. Why did you take that on and what would you learn from it?
CC-G: It’s my 6:00am morning work. The story behind that is I’ve always felt that the voices of people with the lived experience of illness are really important and from about 2006 the NIHR encourage this, so all my research has had lived experience advisory groups or patient co-investigators, before it got really trendy- although perhaps the word trendy is a bit pejorative. Health Expectations is a journal that wants to ensure that the patient voice is heard, whether that’s in research or in service development or in education. And so I think it’s a really important journal. The impact factor has gone up this year, which is good because it did dip a bit which was a bit sad. It’s a lot of work, but I think the value of doing any editorial work, as with all written peer review, and I always say this to early career researchers- do peer review work because you can have a look at what other people are publishing, the latest is in your area, and you can look at the writing styles. You can learn a lot from reviewing good manuscripts, but also for reading less good. It’s a lot of work, but I think it’s very worthwhile. And it’s encouraging people to publish their work around patient involvement. We have 200 manuscripts a month submitted and about a third of those are put through for review.
CS: And then finally, you’ve been chair of various academic professional bodies and in particular, the Society of Academic Primary Care. So you are well placed to think about the current status of primary care academia. How would you describe it?
CC-G: I think there are there are really good bits. I think it is thriving. Our recent scientific meeting in Cardiff was fantastic. It had a really good vibe. There were lots of young people presenting, getting awards, and two brilliant distinguished presentations. And that made me think that primary care academia is safe with the next generation.
But there are also the challenges that most departments face that are reflective of the state of universities. There are the difficulties in finance. You may have a post that needs filling but is that post going to be approved by the university because they’re cost-cutting? There’s a lot of uncertainty. I always feel for early career researchers on short term contracts. I think it’s really difficult, and they have to be really persistent to want to stay in the job where they’ve got funding for another nine months, and they’re not sure what’s going to happen then. And then I think it reflects on the standard of all our work. You may have a 2 million pound project and you get all this data, and then the researcher leaves and you’re scrambling around to try and write the paper up at weekends. And it could have been a much better paper if you’d had that researcher for perhaps another three months just to write the paper or the poster and some other form of dissemination, particularly to a lay audience. That dissemination always gets squeezed. I do hope that NIHR may have a look at this when funding projects. My experience is that they always come back and say, can you cut the cost? And the way you cut the cost is to not spend as much time writing it up, or one less conference, or take out six months of a research post. And, that’s to the detriment of projects. I’m positive because there are lots of people coming up through the ranks and doing really good work but I worry about the funding model, the short-term contracts for early career researchers and the state of our universities.
CS: Carolyn, thank you again for doing this interview. When I first asked you to do it, you were a bit hesitant because you weren’t sure that you’d have anything to say. But you’ve got lots to talk about.
CC-G: I think perhaps a lot of people, I was going to say a lot of women but I don’t think it is confined to women, struggle with ‘imposter syndrome’. When I first went to medical school, I was quite confident. And then of course, everybody’s got grade As at A-level and people have very different backgrounds. My background was working class and none of my family were doctors, and so I felt quite unconfident. I guess I’ve always had what we call ‘imposter syndrome’. I’ve always felt that perhaps I don’t deserve to be here, that people are going to find me out and I think that’s a struggle that a lot of people live with. And I think that’s one of the things that it leads me to be a mentor for RCGP and also for the Society for Academic Primary Care. And again, in those confidential conference conversations, that feeling of inadequacy, that imposter syndrome, does come out in other people. And I can share that that’s something that I struggle with. I think being open about it and honest about it, is really important.
CS: So many people describe that sense that everybody else is more competent than me, but many people feel that. Many people look at your career and see the amazing list of achievements and things you’ve been involved in. You’re a busy woman and you’ve done a lot of things. It’s a delight to talk to you. Thank you so much for giving up your time to do this interview. Thank you.
… and friends
