AUTHORS: Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov
In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.
Today, the subject is professor Lucy Chappell, an NIHR research professor in obstetrics, and an honorary consultant obstetrician at Guy's and St. Thomas' in London. Professor Chappell was responsible for the development of a new diagnostic task for pre-eclampsia, which is now part of routine clinical practice. She has recently been appointed as the new chief scientific adviser to the Department of Health and Social Care.
A podcast of this interview is available here:
How did you get to where you are today?
My career path is a series of zig zags - it’s certainly not a straight line. There’s been a lot of unexpected opportunities. I’ve tried to make the most of what's been a very interesting career. Medical school was a ‘fork in the road’, where they changed the training.
This meant that I went to do a PhD, came back into clinical, chose to do sub-specialty training, and got another unexpected break and took a lecturer's post. I became a senior lecturer. Then I was put forward for an NIHR research professorship, which was really transformative.
Now, there’s the opportunity to become the next chief scientific adviser to the Department of Health and Social Care.
What attracted you to obs and gynae?
As with many of these events, it was because of an inspirational teacher. I initially trained at St Thomas' Hospital, and then went to Cambridge for my clinical. While I was there, I was taught by Mr Robinson - a consultant who taught in a different way, and talked about medicine in a different way, and about the ‘bigger picture’.
He made me see further than the medicine, the diagnoses, and isolated events in the consultation. I then went into trauma surgery in the States. When I came back I was thinking of being a trauma surgeon.
However, I loved the thought of working with women, particularly in pregnancy - so women who didn't have a disease, but who were well, and having a physiological event called ‘pregnancy’. It struck me as an amazing time in a person's life, and I am still absolutely passionate about providing care for pregnant women and their wider families.
How did you become involved in research?
My first involvement in research was as a BSc student. At medical school, about 10% of us had the opportunity to do an intercalated degree, and I chose physiology. I did a BSc, and some taught modules, and then typically it was a term of lab research.
This got me thinking: ‘Why couldn’t we not only provide the care and the guidelines, but go beyond that and make the guidelines?’
Then there was another opportunity, when they changed the training for me to undertake a PhD. I went ‘cold calling’ to a number of departments - obs and gynae, vascular physiology - and ended up doing a PhD with Professor Lucilla Poston, who's still here at King's and head of the School of Life Course Sciences.
It was about looking for those opportunities. I've enjoyed both the wet lab work and the clinical research, which I now do more of.
What was your PhD?
That was a trial of Vitamin C and E in women at increased risk of pre-eclampsia, and was one of my first Lancet papers.
Tell us about the work you’ve done with preeclampsia?
This is a really interesting example of a ‘red thread’ through my career, because while I undertook my PhD, I also measured some biomarkers, and one of them happened to be placental growth factor. It showed that it was discriminatory between those who went on to get pre-eclampsia and those who did not.
Fast forward a few years when I was a lecturer. I did a cohort study of women focussing on this promising biomarker, and showed that it outperformed all our other tests. This is a really good example of where we do lots of things in the NHS which don't have a good evidence base, but where there is an opportunity to evaluate, and then potentially implement a biomarker with a better evidence base.
After doing the cohort study, we went on to do a trial of a diagnostic test where you've got to consider both the diagnostic test performance, and also what clinicians and women do with the results.
In that trial, we showed that implementing, or revealing the result of this diagnostic test halves the time to make the diagnosis and reduces maternal complications.
That, together with other work by other colleagues in the field, has led to it being adopted widely by NHS England across the NHS. It's now gone into clinical practice.
What are your current research interests?
Broadly speaking I'm focussed mainly now on pregnancy hypertension. I’ve also done some work in cholestasis of pregnancy, and did a trial of ursodeoxycholic acid against placebo. I'm just starting a new trial of the two most commonly used antihypertensives - labetalol versus nifedipine.
That's an interesting one and a subject close to my heart, because drug trials in pregnancy are complex, often not picked up by the pharmaceutical companies because of concerns, but really important to women. A lot of my trials have had a strong public and patient involvement with engagement woven through them, because if you work in pregnancy, the women are very much at the centre of what we do - rightly so.
Typically, I look for research questions that are important to women, to my clinical practice, and to my colleagues, and then set about them. Hopefully we produce evidence that then makes a difference, because we can stop doing interventions that don't have a good evidence base. But also importantly, to improve our knowledge and our understanding, for example, of pregnancy antihypertensives.
How did you first get involved in trial design?
A bit fortuitously. When I did my BSc, I did some lab work. What I've done, slightly unintentionally, is to try and get experience in a number of areas, but I've ended up working mainly in the Phase 3 trials space.
That's at the interface between discovery science, and taking the most promising ideas and interventions forward from the discovery science through a really rigorous evaluation, so that it can be implemented into clinical practice. People have talked about the pipeline, but I see it more as a circle in that we need the ideas from discovery science, and it's so important that we fund work in that area.
It's also essential that we evaluate them in robust trials, but then, think: ‘How does my research make a difference in practice or policy or guidelines?’ And: ‘What do we learn from that Phase 3 trial space that makes us go back to the drawing board?’
So think about: ‘Who did that intervention work for?’ but more importantly: ‘Who did it not work for?’ and ‘Where do I need to go back round the circle to ask us what discovery science can tell us next?’ It's the pivotal point of that translational circle that I feel is very relevant to making a difference to outcomes.
What are the main unanswered questions?
There is still an unanswered question about how we prevent preeclampsia. We were always taught as medical students that there was one plaque remaining at the Chicago Lying-in Hospital for women for the person who discovered the cure for preeclampsia.
As we're done more and more research into the disease, we've also understood its complexities. I'm particularly interested in pre-eclampsia and other pregnancy disorders, not just being a disorder of pregnancy, but having lifelong implications. Women both enter pregnancy with risk factors - that's inevitable - but there is much more that we could be doing in the preconceptual space.
Also, these diseases of pregnancy have lifelong implications, and we have this window of opportunity that is underutilised, and where we could change a trajectory in the post-pregnancy space. I would love to see a cure for preeclampsia, but I don't think it's going to come in one huge leap.
I think it is going to carry on coming in incremental leaps, and that reminds us why team science is so much more important than individual egos. ‘Team Science’, and the diversity of ideas are most likely to tackle this problem.
How do students and doctors develop experience in trials and delivery?
There are a number of ways, and I would recommend a two-pronged approach. One is a theoretical basis, underpinning trial design. The other is practical experience. There are plenty of taught courses around trial design, and they are useful and can be helpful.
There's everything from doing good clinical practice - which is a free, online course, for example, through the NIHR learning portal - through to very popular MScs in clinical trials. But it's most useful when it's paired with real world experience.
There are opportunities, certainly for doctors, and also for students, to get involved in seeing recruitment to trial, by understanding how research is offered within an ethical framework in a positive way to as many people as possible - avoiding the gatekeeping, avoiding people saying: 'Well, I've decided that you're not suitable for this research’.
COVID has really changed this in that we've seen enormous awareness and interest in participation in research. I would really like to see how we capitalise on this, not in an exploitative or coercive way, but to say to patients that they have an opportunity to shape the future and how we evaluate these treatments.
They are not guinea pigs. They are part of it, and they should be part of it from the design phase, from the prioritisation phases, all the way through to the dissemination. If we make patients active partners in all these stages of research, then they can be part of that. Students and doctors likewise.
They can be part of this future. And it's not about a split between the NHS and academia. It is about everyone playing their part.
Can you tell us about your interest in improving women's health in low and mid-income countries?
I've just been on a phone call with the team about the timing of delivery in women with late, pre-term preeclampsia. Interestingly, in the United States, when you're over 34 weeks pregnant, if you get preeclampsia, it’s pretty standard just to get delivered. In the UK and Europe there is a different stance.
There is uncertainty as to the benefit for the woman and her baby. So we did a large trial called the PHOENIX trial, which was published in 2019. It showed that planned delivery reduces adverse outcomes for the woman, but increases neonatal unit admission for the baby, and we've got the two year follow-up results of that coming out later this year.
With settings like Zambia or India, which is where we're currently working, the risk of antenatal stillbirth is much higher than compared to say the UK setting with expectant management. But equally, if we go for planned delivery, what about the neonatal risks? The availability of neonatal care is different.
So you've got the same question, the same disease - preeclampsia - but the setting makes a difference. Rather than automatically extrapolating the results from a high-income setting into places like Zambia and India, we are doing a very similar research trial called CRADLE-4 in those settings. We've started recruiting.
A key part of that was working with the local partners in those places to understand what was important to them. They and the women played a really important role in designing that work, and they're very involved in answering it. We've got great engagement from the local teams.
How can someone excel in research?
Be curious. Do the research because you're interested and want to know, rather than just for ‘brownie points’ on your CV. It is so much easier to do what is hard work if you are genuinely curious.
‘Persevere’, which is a better word than, 'Be resilient.' 'Be resilient,' implies that the system batters and bruises you, whereas persevering implies that we all get knocked back. I get my grants and my manuscripts rejected, but I tend to persevere and pick myself up and try again if I think that the research question is important to women and to the community.
The third thing I care about is integrity. It is not enough to do research to clamber over others and get to the top, if you don't have the integrity woven through. So it is about ensuring integrity for the patients, integrity for the team, and making sure that we don't lose sight of what is important, which is improving the health and wealth of our patients. As the NIHR mission says: 'It's not about personal ambition’.
How do you feel about your new role as chief scientific adviser for the government?
It's a phenomenal role. I'm very excited to be taking it on. But I also recognise the considerable challenges that the health and social care landscape has as a result of COVID, how hard everyone in the health and social care community have worked, and what the toll has been on the country.
Whether it's directly through COVID, or indirectly through the waiting lists, and the impact on how we deliver care more broadly.
What will this role involve?
It's an interesting role because I didn't know much about how the Department of Health and Social Care worked until I got involved with some work over the last few years as an NIHR research professor.
The role has two main parts to it. One is as chief scientific adviser, where the role is to provide advice to ministers and to the politicians who make the decisions. That should be based on the science, the research, the evidence. That is what I can bring, given my track record. That is absolutely the right basis on which to provide the advice.
The other part of it is to head up the National Institute for Health Research, with a large budget, making a real difference to funding the research that is really changing patients' lives and patients' outcomes, and has now got a much broader remit to include social care.
There's a long track record of research in health, but the department has changed its name to the DHSC, and includes social care in a very welcome move. NIHR recognises that as well. It will be exciting to see further development in all of those areas.
What's important to you as a leader?
Two aspects of this matter to me. One is to be rigorous on the science. The other is to think about the relational aspects, and how I use a combination of the two to get the best results. Over the years I've enjoyed strong collaborations that are underpinned by trust.
Sometimes those are more straightforward than others and, in this role, I am sure that I will need to win both that trust from many people and many stakeholders, and to think about how we work collaboratively across many sectors.
I hope that I will bring a passion for finding and funding the best evidence. But I also hope to understand the personal aspects, and to try and be inspiring, using both from my personal qualities and my science background to inspire others, and to realise that my legacy is best summed up in those who come after me.
It's always been exciting to hire people who are bright, ambitious, and bring ideas, and then to allow them to fly and spread their wings. I hope to carry on doing that in this role.
What was your involvement with the RECOVERY trial?
The RECOVERY trial is an extraordinary example of where the UK has led and delivered on globally changing practice for patients with COVID. It was set-up rapidly, and I became aware that, really unusually, they had not excluded pregnant women from the trial.
I hoped that we could do more than not actively exclude them, by enabling inclusion. There are very few examples before the RECOVERY trial of where a platform has actively included adults with no upper age limit, and included children and pregnant and breastfeeding women.
It is a challenge in many regards. We set out to scope each of the treatments on the platform trial and, wherever possible, to include it, or to adapt it. We don't recommend ten days of dexamethasone, because dexamethasone crosses the placenta.
We use it to induce foetal lung maturity, but if you use it in prolonged doses then it can cause growth and neurodevelopmental problems, so we adapted it to prednisone or hydrocortisone. Equally important were the trials of the interventions that were not shown to be beneficial. Hydroxychloroquine, lopinavir–ritonavir and azithromycin - each of those three were suitable for pregnant women and pregnant women were included.
The other intervention that has been shown to be beneficial is tocilizumab, and we actively ensured that pregnant women were eligible for that and included. It's been a real example of how I've worked outside my specialty area, and really pushed on equity of access to the interventions for pregnant and breastfeeding women.
Although there have been challenges along the way, I hope that we've set the bar high for participation in trials like this going forward.
What flaws has COVID exposed?
It's easier to answer: ‘What have we done well?’ That is about the speed of getting research up and running. We showed that it was possible to conduct ethical research speedily, but without losing all the regulatory oversight.
We've seen where we've been able to pick and choose the really important aspects of that governance, but also where we don't necessarily have to make it as burdensome. That's a tight line to walk, because it is so important that patients know that they're well-being is safeguarded if they take part in research.
Looking forward, we say: 'What are the good bits that we should retain?' A lot of people are thinking about this post-COVID more widely. Research started to become better integrated into everyday NHS practice. For me, that's an absolute win. I don't think research is different from clinical practice.
It should be an integral part, and it would be my ambition to see that developed even further, so that there is not a ‘them’ and ‘us’ culture, but that: ‘These are the people who give clinical care. These are the people who do research’. I would like to see that seamlessly integrated. I think COVID has given us an opportunity to look at how we do that going forward.
How can we maintain the collaboration we’ve seen during COVID?
We should maintain this collaboration because it benefits the system. But if we do that, then we've got to look at how we reward and incentivise collaborations as opposed to individual benefits. That really comes down to the metrics by which we are judged, both within an institution or nationally.
So I think there will be real interest to say: 'How do we ensure that we don't have perverse disincentives to collaborate?’ ‘How do we ensure that we carry on seeing the big picture, and that there is reward for team effort and collaboration within the country and across countries?’
Maybe it needs a look again, and I think this is being planned - to ensure that we don't have overt or covert disincentives to collaboration.
What are your proudest achievements?
The team. I'm so proud when someone, or several of my team achieve something, because that, to me, is a much more tangible legacy than anything that I do. I never work in isolation. And I am also a representative of a much bigger team.
Whether it's a member achieving a PhD, or often, just seeing how they are flourishing, that’s what I’m most proud of. It is so heartening when you see people developing and growing, and not necessarily quite as they expected.
Sometimes there are twists and turns. There have been many twists and turns in my life.
Who are your role models?
I've had some key role models. And there’s also been ‘anti-role’ models. Both are very powerful in shaping us. Professor Andy Shennan is a professor at King's College, London, who has been inspirational because he's both shown me what integrity means, and because he's backed me through ‘thick and thin’. We all have rollercoaster times in our careers, and it's easy to back people when they're doing well, but it's even better when people back you through some thinner times.
My father was an inspiration to me before he died, when I was a very new doctor, because he taught me that I could aim high. We talk about ‘glass ceilings’ and ‘sticky feet’, and my mission is to address both of them, and to ensure that people are enabled to achieve their potential.
Both by not putting artificial barriers in the way going upwards, but also thinking about how we encourage people to move from where they're standing, and to think about how we ensure that we offer those opportunities to everyone regardless of gender, ethnicity or other characteristics.
I believe we need to do so much more to reduce both health inequalities, and inequalities across the research community.
My ‘anti-role models’, I won't be naming, but they're the people who I’ve looked at and thought: ‘I do not ever want to be treated as I have just been treated’. It’s shaped my behaviour - I hope - positively, because it reminds me of what it feels like to be at the other end of being treated like that.
I can think of several key points where I've had a bumpy ride, and I hope it has shaped me for the better by saying: 'Think carefully about what you give out, so that you don't have others experiencing some of what you’ve had’. Overall, I hope it's shaped me to be a positive person who can give, and give out, in a positive way.
What setbacks have you had?
I have had many setbacks. If you saw my CV, you wouldn't see the setbacks in it. Behind every CV is often a shadow CV, which has got the bumps in the road, which are ironed out on the piece of paper that is the formal CV.
The setback that came when they announced that we weren't going to get registrar training numbers meant that I was without the prospect of a job, but out of it came the opportunity to do a PhD. It needed some hard work by me to go and find a PhD, but with it came the opportunity for an academic career that has led to where I am today.
A posting in a unit where I perceived the culture to be fairly toxic led to an opportunity to both re-evaluate what we contribute to a culture, to take responsibility for my contributions to that culture, and to think about how I could influence the context, so that even in a midst of a very tough time, I survived and eventually moved on and thrived.
At times when I've wondered whether I can continue in a certain career path, I've taken the opportunity to seek colleagues and peers and mentors who I value, who have looked after me through tough times and supported me, which has reminded me to aim to do the same for others.
It's a virtuous circle of mentorship, support and encouragement, so I now have the opportunity to help others in their career because I was helped, particularly when I doubted whether I could continue. I still have setbacks. I do not have a shiny, straight line career and I'm sure I won't.
The failures and the setbacks are what shape us most positively, and make us who we are, and they make us able to deal with the upcoming bumps in the road as well. I'm sure the next five years are going to be interesting, and I will use everything I've learnt over the last 25 years to that end.
What lessons have you learnt?
It's about looking for the opportunities and taking them. I've been pondering: ‘Why have I ended up where I have?’ I think it's understanding that those forks in the road are what allow you to progress in lots of different ways.
Keep making the forks in the road, look for them and accept that you will go down a fair number and get to dead ends and need to retrace your steps. I liken it to doing ‘Go Ape’, the tree walk. There is no such thing as a ‘straight line’ career ladder.
It is much more like Go Ape, where you have to go over a number of obstacles and sometimes you have to take a zip wire into the unknown. I've taken a few zip wires, and sometimes you end up in a bog and have to get out of it, but sometimes you end up in an interesting place. So it’s about keeping your eyes open for those, and don't get disheartened if the first ones don't work out.
There will be others, and then there will be more opportunities. Sometimes you have to wait for the wind to change and then the opportunity presents itself. You have to be persistent and have that innate curiosity.
Find what fires you up. Find what you're passionate about and focus on that. It might be an academic career, but equally it might be that you want to make a difference in the clinical space, either as a manager or for providing good quality clinical care.
There is space for all of us in medicine, and there is an opportunity to shine and to make a difference, whichever of those paths someone chooses.
What's your favourite book?
I like reading fiction. I'm in a book club. The reason I'm in a book club is that I get to read six or twelve books a year and, most importantly, they're books that I would never pick up myself. Thank you to my fellow book club members who regularly put stuff across my bedside table Kindle that I would not otherwise come across.
There have been a good number of favourite books along the way. I really enjoyed The Orphan Master's Son, which is from a few years ago. But I also love reading new fiction by a whole range of authors, and to be pushed out of my comfort zone with reading.
On my bedside table at the moment, I've got a copy of Yes, Minister. It was given to me by a friend in preparation for this CSA role, because I'm about to go into a new environment, and I'm about to try and understand how it works. So we will see whether anything has changed since the days of Yes, Minister.
I hope that it will be good preparation. It's really exciting to be taking on this new challenge - just to have an opportunity to shape how our health and social care policy is made and disseminated. I would like to encourage all medical students and doctors to look for opportunities outside their comfort zone. I'm quite sure this one is outside of mine, and I really hope that I can do my best in the new role.
Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.