“…why had I been ignoring general practice? I want to be dealing with common problems that are important for public health…”
Paul Little is Professor of Primary Care Research at the University of Southampton. He is a Fellow of the Academy of Medial Sciences, a National Institute of Health Research (NIHR) Senior Investigator (emeritus), and winner of the Maurice Wood award (for Lifetime contribution to primary care research).
He led a wide range of studies in acute infections; diagnostic studies, prospective cohorts, placebo controlled trials, pragmatic trials of antibiotic prescribing strategies, and complex interventions to address antimicrobial stewardship and reduce the threat to public health of antibiotic resistance. His research has demonstrated reductions in antibiotic use in RTIs using: delayed antibiotic prescriptions; a clinical score for pharyngitis (FeverPAIN); communication skills training; C-reactive protein (CRP) point-of-care tests; and a digital intervention to support handwashing. This research has formed a key part of 9 national and 4 international guidelines, two UK 5-year AMR strategies and a successful intervention by the CMO for overprescribing GPs
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In conversation with Chris Salisbury
Emeritus Professor of Primary Health Care at the University of Bristol. He was a full time GP for more than 10 years and an academic doing research and teaching alongside general practice. His academic work focused on how to ‘do family practice better’ and the impact of new models of care.
Hello, I’m Chris Salisbury, and today I’m having a chat with Paul Little who is Professor of Primary Care Research at the University of Southampton and recognized as one of the leading primary care researchers in the world. Thank you for joining us. What we’d like to do is to understand a bit about your story. So let’s start at the beginning. How did you come to do medicine?
Paul Little: Well, that’s a story in itself. Very early, in my teens, I was thinking I quite like the idea of medicine. Then I got involved in music as a cellist. I’m very glad I did because I wouldn’t have met my lovely wife had I not got involved in music. But, you become a bigger fish in a smaller pond. Much as I enjoyed playing, I was a slightly nervy performer, and you have to be pretty robust about being able to perform music so I couldn’t see myself being a performer. I did academic music up to a point but I just didn’t enjoy dissecting music. So, having started with the idea that I’d be doing music, either as a performer or as an academic, I couldn’t see myself doing that. So, I swapped courses after my first lot of A-levels, I did physics in a year, and then took a year out after that. In effect I had the extra two years, applied for various medical schools, got into Oxford and was very happy there.
CS: Did come from an academic family?
PL: Both parents went to university. My father was in the Foreign Office, he got a First Class degree. They met in Ireland at Trinity College, Dublin. My mum did pursue an academic career for a while, but ran into the ground at the end with her PhD, not because of what she’d done but because of a not particularly fair examiner, and we all know what that can be like. She just couldn’t face the revamp that she needed to do. She enjoyed her academic work and produced some nice papers, some of which I’ve read. I think that’s partly what attracted me to thinking about being a clinical academic. I’d seen it as a satisfying thing to do. I’d seen my mum do it and enjoy it.
CS: Then you went to Oxford. But you didn’t go straight into general practice after medical school…
PL: I knew fairly early on that I wanted to have a research element to my job. There was a research job in Brighton, so I thought I might dip my toes to see what it’s like. I was interested in the larger questions about common illness. Part of the job was running a “me-too” blood pressure trial for my boss, and part of it allowed me to do what I wanted so I did a study on diet and hypertension. I knew nothing about research or research methods, and my boss certainly didn’t. He was a rather eccentric charismatic guy who ran the renal unit, but he wasn’t really a researcher. That was my first dip into research and I did enjoy it, but I realized that I was slightly at sea, went back into medicine, did a medical rotation, and at that stage thought I’d be aiming for public health with both a clinical and an academic component. My aim was to get the medical membership and then do the public health exams but I realized that I really did love seeing patients, and I didn’t want to be in a discipline where I couldn’t see patients, so I stopped public health. I hadn’t been thinking of general practice, I’d been thinking of a hospital or public health career but having got my postgraduate qualifications and ready to go on in hospital medicine, I couldn’t see any of the consultants around whose jobs I really wanted. They didn’t see much of their patients other than in outpatients after having seen them in the acute ward. I quite enjoyed acute medicine, but I didn’t see the interaction with patients over the medium to longer term. It just didn’t happen, as with most of the hospital specialties.
I then rethought – why had I been ignoring general practice? I want to be dealing with common problems that are important for public health – doing something that would make a difference to a lot of people rather than just for a smaller number in a particular specialty. I then looked at the possibilities for academic practice. I’m a country boy so I wanted to be outside London. I looked around for departments outside London, and Southampton it was. I came to Southampton and identified a practice, who were wonderful with me in terms of their flexibility. I went to see John Bain, then Head of the Academic Department and said, “ I’m interested in a clinical academic career, and I’m pretty sure it’s going to be in general practice but this is my plan: I’m going to start the training here in Romsey, then go abroad for probably a year or two – because I’d always had a passion to go and do something in a low to middle income country – then come back, finish my training and aim to pursue a clinical academic career in general practice.” Amazingly both my practice and John agreed.
I went off to Nepal, had a really interesting time, and came back after about two years. John Bain had left, and Ann Louise Kinmonth was now the new Professor. I went and explained the interaction I’d had with John who had told me to come back as soon as I returned. I said I was interested in an academic career. Ann Louise perhaps saw something in me and said “Yes, that’s fine, we’ll work together on an application.” In those days there were only two things you could apply for: One was an MRC fellowship and one was a Wellcome Training Fellowship. I applied for the Wellcome Training Fellowship and was lucky enough to get it, which was great as it gave the opportunity to do MSc training. So I did an MSc at the London School and started to develop an understanding of research methodology, That was a turning point, I guess.
“…why weren’t people very interested in this? I think it’s because, and I came across this in some colleagues, who said, “lt is just that it’s trivial, you know, it’s a quick consultation.” There was too little public health interest and I think people at that stage did not really understand the public health importance of antibiotic resistance although it was already recognised.
An interview on BJGPLife about a study looking at the effectiveness of antibiotics for chest infections in children. Antibiotic effectiveness for children with lower respiratory infections: prospective cohort and trial. Access the video on BJGPLife here and you can access the paper, published in BJGP here
CS: You were the first GP to get one of those Wellcome doctoral Fellowships. And then you went on to be the first person to get an MRC Clinician Scientist Fellowship. There are two interesting things about that story for me. One is that we’re about the same age and we started about the same time but it would never even have occurred to me that there was a possibility to do a Fellowship. It’s interesting that that you did, and that was probably because of Ann Louise?
PL: It was Ann Louise looking after me and suggesting that I applied.
CS: Let’s just go back to the common illness theme. I first became aware of you because of your studies on sore throat and coughs and the use of antibiotics. That’s been a theme throughout your career, hasn’t it? And, although common illnesses are common there was very little good research on what to do about sore throats or coughs or whatever. Why do you think people weren’t doing that research and why did you want to do it?
PL: How I got interested was through the study we did on ear disease in Nepal, which was just an opportunist thing. I knew that I wanted to go and do something, whether it was in the clinical context or as a research project, in a low or middle-income country.
My wife worked for an ENT surgeon, Neil Wier, a remarkable character who’d set up a charity in Nepal to do ‘Ear Camps’ for people with chronic suppurative ear disease. Neil is just a fantastic ‘can-do’ character. He managed to get 20,000 pounds to support us doing a survey of deafness and ear disease in Nepal. Basically what we found was that suppurative complications were relatively common as was deafness – its probably one of the biggest disabilities in developing countries and often people didn’t get adequate treatment in rural areas.
When I came back and did my training in general practice, in contrast I saw that antibiotics were being used for most infections, even in my practice which was a pretty good practice. So I did a bit of hunting around, looking at what evidence there was. There wasn’t very much evidence and what evidence there was suggested that we probably weren’t doing terribly much for symptoms anyway, which is what people were coming with. I wondered what the impact was of prescribing things for people with a short-lived illness where they may think that it’s the antibiotics allowing it to settle. So, during my training, I thought what we needed was an open trial to look at beliefs and behaviours following different prescribing strategies.
But, as you say, why weren’t people very interested in this? I think it’s because, and I came across this in some colleagues, who said, “lt is just that it’s trivial, you know, it’s a quick consultation.” There was too little public health interest and I think people at that stage did not really understand the public health importance of antibiotic resistance although it was already recognised. Also infections affects millions of people – most of us will get some kind of respiratory infection each year. So it’s of huge importance for the workplace, and for our consultations: in every surgery you’d see people with infections, and you needed to know what to do and what not to do. But, to be fair, we’re talking about the ‘80s, early ‘90s, and most of the things that we did had little research. So maybe infections were not that much different from anything else.
CS: The other thing that struck me when I looked at your CV and some of your earliest papers, was that you were doing randomized controlled trials right from the very beginning. Do you want to tell us about that?
PL: It’s not that that I don’t believe in observational studies, because I think they provide very useful evidence, and sometimes that evidence is more generalizable. But, confounding is a key problem. Confounding by indication is a really important problem and it’s very difficult to fully get around. You can try and find ways of doing it and we have done that in observational studies but ultimately you do want to try and get randomized evidence. The problem about randomized trials, particularly, is whether the people who agree to participate in trials are generalizable in terms of the people that you want to treat with the knowledge that you gain from those trials. That’s the big problem. But it’s quite interesting how we’ve managed to show over the years that even though trial populations might not seem to be generalizable, you often do get reasonably generalizable results from trials. For a quantitative paradigm I think it’s the strongest evidence, because you get around confounding by indication in a more robust way than you can do with an observational study.
CS: You’ve been a pioneer on research methods like trials and you’ve done incredibly influential research. But then in 2013, you took on a big managerial role by going off to be the director of one of the main UK research funding programs. I have to say that at the time I was surprised that you would do that because I thought you loved doing research, and this was going to take up a lot of your time. Do you want to just explain that?
PL: I really enjoyed it. I enjoyed bringing a sort of pragmatic GP perspective to funding decisions. And also I enjoyed being part of funding panels that are often a bit black and white, as opposed to my approach as a panel chair, and then subsequently as the funding board director, which was- this is a great idea, there might be some problems, but why not work with the applicants on this and see if we can get something that we all think is good and worthwhile. I enjoyed the creativity or potential creativity of being on the funding panel. I was then asked to apply for the director of this funding board. Although I’m not a natural administrator, strategically I can have good ideas and I can be involved in creative decisions about how to support good pragmatic research. I felt this was an opportunity to do some good, and if I didn’t turn out to like it, I could always resign – see how it goes for a year or so. But I thoroughly enjoyed it, actually. I wasn’t the administrator – it was mainly strategy, being on the panels, deciding which way we should be going, and trying to fund good research. I really enjoyed that and it was very interesting.
The problem for me then was that I was working six plus days a week, and it was a two day a week job. So I then had to make the difficult decision to give up clinical practice because I didn’t want to give up teaching completely and I didn’t want to give up research. I thought, and it turned out to be true, that as long as I was in very close contact with clinical colleagues, I wouldn’t become distanced, I would still understand the clinical context. And I always think as a clinician in my studies and in applying for grants. I’m still a clinician and it hasn’t altered my perspective at all.
“Trust. Trust the people that are running the project. You also want your team to be keen and to enjoy work so make research as fun as you can… I also try and take a caring approach to the people who work on my studies.”
CS: What you’ve just said about the six plus two days leads me to what I been dying to ask you which is, how do you do it? You’ve published over 500 papers. I thought you were cutting down but looking at your website you seem to have about four major research programs still on the go. What advice would you give somebody who wants to be equally productive? How can you do it? What tips have you got?
PL: Trust. Trust the people that are running the project. You also want your team to be keen and to enjoy work so make research as fun as you can. Universities aren’t terribly fun places in terms of bureaucracy, so make it fun and I think most of my management meetings have been fairly light touch. I also try and take a caring approach to the people who work on my studies. If they need time off, for whatever reason, they can have time off. I don’t micromanage their time. I don’t micromanage the studies. All of that, you get back ‘in spades’: any time you are generous to other people, you always get that back. That’s not a reason for doing it, but it turns out to be true. So, I think I’ve liberated myself from spending lots of time managing projects. Otherwise I wouldn’t be able to deliver the number of projects I have been lucky to be able to do.
Also, I think I’ve had trouble saying no to good ideas! Great people come along, and I try to encourage them and their ideas because we’re about ideas and trying to convert those ideas to something that might make a difference to patients. So, that’s partly how I’ve ended up doing such a lot.
The other thing is that I probably haven’t been as sensible as I should have been about balancing my work and home life. Certainly in the early years, I didn’t come home early enough, and that was a mistake. I probably would have ended up doing very similar things but, I think I didn’t get the balance right, particularly early on.
CS: You’ve won so many awards; Fellow of the Academy of Medical Sciences; the Maurice Wood Award at NAPCRG, and the Discovery Award from the Royal College of GPs, which are both for outstanding lifetime contribution. And then, of course, your CBE (Commander of the British Empire) from the Queen. But, what do you do when you’re not working?
PL: What do I do when I’m not working? Well, I like films and I love the streaming services – they provide really interesting variety. I also love walking – just getting out, being under the sky, near trees, which I find very therapeutic. I keep the music going as much as I can. That’s something that went a little bit and, if you don’t have time to practise, your skills do go. I’m getting the cello out a bit more now, which is great. My wife Alison and I are now in a local chamber orchestra which is great fun. I joined a choir recently because Alison dragged me along, and I think it’s very therapeutic. And physical activity. I’m a very bad tennis and badminton player but I play a few times a week.
CS: Whenever I’ve met you at conferences, you’ve always seemed to be on your way back from a run…
PL: Hmmm.. not really a run, I sort of jog and walk. I don’t know what it’s called these days.
“Make sure that you develop, as early as you can, a good work-life balance. I would have done that differently if I had my time again. It wasn’t bad, but it wasn’t good.”
The PRINCIPLE and PANORAMIC teams were awarded the Prix Galien, considered the equivalent of the Nobel Prize in biopharmaceutical research.
CS: You’ve talked a bit about your career but, looking back, is there anything you would do differently if you were starting your career again?
PL: Its difficult to say because so much of a career is serendipity, and something about life choices, and they all meld together. On my journey to being involved in research, I wish I’d joined a good unit early on rather than wasting time. Perhaps it wasn’t really a waste of time because, actually, I learned what bad research is, and that’s probably helpful. I’d advise getting involved with the good mentor and a good unit as early as you can possibly be, and get research training.
Doing more work at home was something I discovered only in the petrol crisis. I had to bring work home, and that was actually a jolly good thing. I was trying to completely separate work and home and I don’t think that’s helpful for home life. And I’m not sure it’s helpful for work life either. Be flexible, and find a career path that is flexible. Being a clinical academic is brilliant, particularly in general practice, because it’s just so flexible.
Make sure that you develop, as early as you can, a good work-life balance. I would have done that differently if I had my time again. It wasn’t bad, but it wasn’t good. My poor wife had to look after young children for too long in the day, and that wasn’t really necessary and it wasn’t kind.
CS: I suspect almost all successful academics would say the same thing; that looking back, they should have done their work life balance a bit differently. Paul, It’s a great pleasure to talk to you, and to find out a bit more about your story. Thank you very much.
