I was put in touch with Sophie, a British GP trainee, whilst I was working in Japan, when she approached my then boss, Ryuki, about coming to Fukushima to do qualitative research. Her work, the patient voice project, studies the biopsychoscial model in communities in four different countries and whether that has an impact on mental health and presentations in the GP consultation room. It’s an incredibly broad topic and I’m excited about seeing the fruits of her labour. But the thing that struck me about Sophie was that she had thought of this project whilst in her consultation room in London and had transformed this fleeting thought, through hard graft, into an Out-of-Programme Experience (OOPE) with no personal research background nor institutional support. That’s pretty impressive in my books.
We spent a month together in a very small village, Tadami, as part of her Japan leg, where I acted as her translater. It was an intense month with lots of bizarre scenarios leading to some pretty hilarious anecdotes, and I have to say I am glad to say that we’ve stayed in touch since.
So how would Sophie explain her project in her own words?
“It is a research and film project exploring the impact of community on mental health and wellbeing. I began to develop the idea of exploring the topic as a qualitative study through talking to someone who had done similar research. Qualitative analysis appealed to me as I wanted to, rather than collect data through questionnaires, collect patients’ and doctors’ actual experiences or stories from around the world. Alongside designing the study I decided I wanted to capture the stories on film because I thought that it would be a powerful way of presenting the findings and also a way to record my own journey throughout the year.”
“I knew I wanted to have a year out and do something a bit different. Having just started GP training, I wanted it to be community-focused. During my last GP placement, I had become interested in the types of patients I was seeing and noted that I was consulting with a lot of patients with mild mental health or psychological issues. Mental health has always been of particular interest to me and, whilst I enjoyed these consultations, I also felt quite challenged by them. I wanted to look really at why I was seeing so many people with these kind of problems and think about how I could possibly optimise our time together as doctor and patient. The idea of doing a global project came about from talking to a friend who works in the States. We were comparing our experiences, the types of patients we saw and how we managed them, and it triggered the idea of visiting global communities and looking at how they do things differently.
So with a year of planning, she formulates a plan to visit remote Scotland, Norway, the U.S and Japan.
“I probably started planning it a year before my first flight. The real difficulty was finding out and knowing who to go to and who to ask for advice. Obviously the OOPE programme is very well-established but doing something on your own and not through an established scheme was a little bit unconventional. It was off my own back but I’d say, in the end, that was a positive thing because it allowed me the freedom to do what I wanted. However, it was also hard because I didn’t have very much support at the beginning”
An OOPE is traditionally taken between ST2 and ST3 in GP training. There are established programmes to work abroad (especially via the London deanery) but some trainees also use that time to do a MSc. Unfortunately, deaneries don’t always offer deanery-approved placements and not all are supportive in taking time out. It would be good to know if you do face any barriers trying to organise one so that the JIC can look into it. Click here for a quick guide to considerations written by the founder of the JIC, Dr Luisa Pettigrew.
“So at that point I started writing what I thought of as a proposal – what were my ideas, why I thought it was important and how I saw it going. I got advice from people who were in research along the way – people at Imperial College, a GP at the Royal Geographical Society, and my own mum who has a background in qualitative research. I then knew I had a deadline where I had to get things worked out by. I had to have supervisors in each of the countries I would visit and I had to prove that I was spending time in a medical setting learning something useful. I then started thinking about where I wanted to go, why I wanted to go there and trying to make connections.”
“The main person I dealt with in the UK in organising my OOPE was, Dr Patrick Kiernan, who runs the OOPE programme in London. He was very supportive in the end but I think he may have doubted at the beginning that I would be able to do it. Initially he was worried that I had taken on too much, that it was overwhelming and that I didn’t have experience in either of the elements, which was true in a way! But once I got going he was very complimentary and pleased, I think, that I’d managed to make it work. After working out most of the details I submitted the proposal to him and he submitted it to a board; when it got to that stage they okayed it pretty quickly.”
“I started by doing a trial of the study in London. Very kindly my ST3 training practice allowed me to be there for a month and use their patients [to trial my methodology]. My first proper stop was Hoy in the Orkney Islands: the most remote and rural community I could find within the UK, followed by California where I spent time in both a private practice and free clinic for people without insurance. Next I flew out to Norway, again to a rural practice just outside of Bergen, and ended in Japan.”
I can only imagine the skills that she has managed to acquire in the past year. I ask her what she would have done differently if she had to do it again.
“Quite soon into the process I came to realise that I needed some form of academic sponsorship if I wanted to apply for funding. I approached Imperial College and ended up talking with Professor Majeed in the General Practice department. He was very kind and agreed to sponsor the project but I sensed my topic and choice of study wasn’t really his area of interest , and I probably would have found more guidance through someone involved in a similar type of work already.”
“If I were to do it again I would start preparing earlier, particularly in terms of trying to find funding. One of the things I often struggled with was having the time to complete applications for deadlines; a problem exacerbated by the fact I was doing a rotation in acute medicine at the time! As a consequence, I ended up paying for most of it myself and that was an added pressure.”
“Part of me thinks it would have been easier to have done a Masters in a set topic – there would have been more academic support and that would have taken away a lot of the anxiety at the beginning, but honestly I don’t think I would have had the experiences that I had – I can’t think of anywhere that would have allowed me to go to four different countries and funded it.”
I can imagine the level of uncertainty faced by Sophie in the initial stages. It’s easy to look at her project now and congratulate her for pulling it off but I feel the credit should really go to her for picking herself up and pushing forward with it even when there must have been a lot of internal and external doubt. I can imagine there were many times where giving up would have been the easier option but thankfully she didn’t.
“I’ve seen positive impacts in terms of my own confidence and I’ve learnt and developed new skills in research and film-making but the highlights were definitely the huge diversity of people that I met along the way coupled with the experiences I know I wouldn’t otherwise have had exposure to . I just ended up in some crazy situations like interviewing opiate addicts in the sticks of America to learning how to cross-country ski to being embraced, like a family member, by a small Scottish community – it was just incredible. It was a huge privilege to meet such a variety of people from all walks of life and to have them open up to me about such a sensitive subject, especially in somewhere like Japan, where talking about mental health has traditionally been so taboo.”
For the record, even I had never seen that side of Japan. We managed to get a real candid insight into some very personal moments of the villagers and I hold some pretty precious memories from my time in Tadami. I have some real life-envy thinking about how incredible the other three-quarters of her project must have been.
Sometimes I wish she had found the JIC earlier as we would have offered her a lot of enthusiasm and validation for her work even if it was just to bounce a few ideas around. Organising your own projects can seem daunting and there can be a lot of anxiety around it especially when your peers seem puzzled by your lifestyle choice. With us, we love someone who’s got a project in mind and we love that buzz of the unconventional. And what I love about Sophie is that she’s taken every scrap of opportunity that has come her way.
“The main thing I would say to my two years ago self is ‘don’t be afraid’. I was so terrified of coming out of training and of what people would think and looking back now I really needn’t have been. I was desperate to get ‘permission’ in order to legitimise the work and it really took me the whole year to realise that whilst I needed support and whilst there were certain hoops I had to jump through, what I did was up to me and me alone and it was therefore up to me to make it work. So my advice to anyone else would be just do it. Worse case scenario is that you have a year out that doesn’t go that well. It’s really not the end of the world. As long as you have a roof over your head and can feed yourself, the rest will fall into place”
And did she feel that it has been positive for her clinical work?
“It’s definitely positively impacted my clinical work. I’m more aware of how I use that 10-15 minutes with patients having observed many differing consultation styles over the year. It’s made me doubly aware of how big a problem mental health is in London and how the environment and society structure here influences it. Most patients I see in my current practice will trigger a memory of someone I met abroad and it’s easy to draw comparisons. As an example one of my first patients after I came back to the UK was a 91 year-old man who was living completely isolated in an affluent area of London. I was able to make a direct comparison to a 91 year-old who lived in Orkney who had very similar health problems but, due to the setting, was cared for very differently by the community. Now on encountering different scenarios each day, I can’t help but think how would it would be managed elsewhere and how we could take note and potentially improve things here. Thinking about certain themes along these lines such as social isolation in the elderly over the past few months has triggered collaboration with the Campaign to End Loneliness and the Loneliness Commission in conjunction with the Jo Cox Foundation.”
“It’s channelled my focus and it’s made me less afraid of stepping out of the box. If I got a job doing research in California next year or anything else, I would jump at it. I know I want to travel and I don’t want to purely practice in London. I hope that things will come of it. So even if it’s a publication or something can happen with the film, it could really shape my career. Perhaps I will end up being a part-time film maker! Who knows?”
We’ve joked that this is the first step of a life-long project. There are so many off-shoots that can be generated from her ideas and there’s plenty of them!
“I’m still working through all of the interviews and writing it up. I’m doing an article for Innovait and am hoping to do some retrospective blogging for the BMJ. I’ve had to accept over the last few months that I have to take it one step at a time as it’s a lot of work.”
“I’m working with a small production company in the States who specialise in health films. They’re kindly looking through the gallons of footage I’ve collected in the hope that we can use it to put something together.”
The plan is to create something like a proof-of-concept that she can take to sponsors to show what her project is about, something commonly done in the film industry. Click here to see the initial fruits of her labour (it’s slightly tear-jerking – something both Ryuki, my old boss, and I commented on after watching it!)
And now? Now, she has slipped back into her ST3, and doing normal ST3 things like revising for her CSA. During this interview, I get a real sense that this was a journey in itself for Sophie – whether that was a journey of learning how to use the camera, how to run a focus group, how to analyse the qualitative data she collected and even just learning about herself.
“When I look at myself even a year ago, I genuinely feel quite different. I’m more confident in myself and I’m not afraid to stand up and talk about what I’m passionate about. Without wanting to sound corny, I’ve come to know myself a bit more and I’d recommend a seeking out a similar experience to anyone for that reason alone. I’m itching to build on what I’ve done so far and excited to see what the future might bring”
I know that I am preaching to the converted here on this blog but time out-of-programme or even time-out-of-daily-grind can be so empowering. Spending some time abroad in a work setting has been advocated by Lord Nigel Crisp as it gives new skills and insights to our NHS staff. We appreciate that planning your own project like Sophie is hard work and we are happy to triangulate your ideas (and anxieties) and support you through the process!
Sophie is currently an ST3 at the Riverside VTS in London. You can read her thoughts on her project via her blog https://www.thepatientsvoiceproject.com/blog