A GP Registrar’s Role in Research, with Particular Reference to the CANDID Study

By Dr Karl Kotwal

Rother House Medical Centre

One of the most attractive features of general practice is the sheer scope and diversity of the work that it can involve. However, research in primary care isn’t something that is taught or indeed encouraged in the GPVTS programme. This to me is counter-intuitive when you think about the fact that around 90% of all NHS contacts take place in primary care and so really we should be at the very forefront of research.

At medical school and beyond it was understood that if you were going into a hospital position as a specialist, then research was a necessary requirement for the advancement of any position within that specialty. However, in general practice this was not the case. I find this a real shame that more GPs are not involved with research simply because good quality research underpins all of our decision-making.

This is especially important in general practice where we have time constraints with limited resources and need to make critically important decisions without the aid of instant imaging, pathology and specialist review which is so readily available in secondary care. In this respect it is the history taking that is so vitally important in our decision-making.

Take the CANDID study for example.

Abdominal complaints are amongst the most common in general practice.

How do you spot the cancers from the benign complaints?

What are the right questions to ask and how should the answers be interpreted?

How common is tenesmus, rectal bleeding, change in bowel habit etc.?

Only by looking back retrospectively can we answer these questions. This research study will lead to more sensitive and specific questioning that in turn will help clinicians make better diagnosis and decisions. It would be interesting to know how many of the 2WW GI referrals are confirmed cases of cancer and by changing our questioning, how we can improve on this. This is one example of exciting research that we as GPs can easily become involved with if we engage in research within our practices.

One of the things I was most concerned about was the idea of asking patients to participate in research, in this case the CANDID trial. Personally if I feel a two week wait is warranted then I will be open and honest and explain that I am concerned the symptoms may be caused by a possible cancer and that in order to exclude this as soon as possible I am referring the patient on what is called a two week wait appointment.

The reason I do this is because I feel the patient has a right to know what I’m thinking or concerned about and secondly when they arrive at the appointment, they are prepared for a possible discussion surrounding cancer and this is easier for the patient and the clinician involved. However, as soon as the “C”-word is mentioned, I’m sure that patients will find it difficult to take in any further information. This is where a GP can use good and clear communication skills, together with the correct timing to ask the patient to participate in research. I might say something like:

“ We are lucky at our practice to be involved in an important research study looking into the symptoms that you have described. It would be very useful for our research team to contact you to discuss this further. Is this okay with you and do you have any questions about that?”

I find that if you raise the issue at the right time in the right way, and with empathy and respect, then most patients will happily consent. Fortunately in my experience I have not had difficulty in recruiting people to the study.

The benefits are clear. General practice, our patients and our understanding of the disease process are changing all the time. Patients are becoming more aware of their symptoms and the factors that affect disease are also becoming more apparent, such as the role of diet in cancer. The general practitioner’s role is to correctly identify and interpret these symptoms and to reassure or investigate as appropriate. Without research how are we to keep up with this changes?

Being a research practice benefits not only the patients but also the GPs. Participation and affiliation with clinical research networks allow us to:

• contribute to the wider scientific community,

• stimulate debate within the practice and

• give us a further sense of worth /pride within the NHS.

The experience for myself has been a wholly positive one because it was made easy for us by having a research nurse on site to talk to and support us with clear and simple resources to work from which meant that it didn’t take too much time to implement.

My fear was that the study would become too time consuming and stressful and wouldn’t fit into a 10-minute consultation, but this has not been the case. We are lucky at my practice that we have had this opportunity to become involved in research and make a positive contribution. Depending upon the circumstances of the practice, I would recommend that more of them should become involved in research and GPs should try to incorporate this into their every-day practice.