20 January 2016

Part 2: The ‘four seasons’ of a clinical academic without borders

Franco Cappuccio, Professor of Cardiovascular Medicine & Epidemiology, continues his journey through the ‘four seasons’ of his career to date as a clinical academic which we hope will inspire and delight you and hopefully encourage some of you to follow suit in this challenging but fulfilling medical career path.

Part 2. The Season of Growth (1989-1999)

With Donald Singer and Graham MacGregor
at St. George's 
After a short spell of work back in Italy, in 1989 I accepted a five-year fixed term contract as a Clinical Lecturer in Medicine at St George’s Hospital Medical School in South London, where Graham MacGregor had moved as a Professor. I returned to my previous research group. I completed the training in General Internal Medicine (MRCP then FRCP), resumed clinical research, secured grant income, consolidated my publication record, and pursued my previous interests in epidemiology.

During the first part of this period, I published relentlessly and got myself involved in numerous clinical trials studying the mechanisms by which different drugs lower blood pressure in people with hypertension. I was rapidly absorbing a level of expertise in hypertension that later in  
my career would constitute an asset.

The passage to epidemiology and public health

Geoffrey Rose’s work on the principles of prevention has inspired generations of epidemiologists and clinicians worldwide, including me. His clear paradigm of Sick individuals and sick populations opened the vision of a physician like me (who had great expectations to make a difference) not to neglect the bigger picture of prevention: to amalgamate the dichotomy between ‘high-risk’ and ‘population’ strategies.

If we wish to find the causes of common diseases, we ought to study the determinants of the ‘normal’ levels of the risk factors as “the population mean predicts the number of deviant individuals. If we wish to find the causes of hypertension, obesity, alcoholism … then we need to study the determinants of average blood pressure, weight and alcohol intake …” (Br Med J 1990). When referring to the strategy of secondary prevention of cardiovascular disease, Jeremiah Stamler, another great cardiovascular epidemiologist of our time I had the pleasure to meet recurrently, used to say: “The strategy [of secondary prevention] is late, defensive, reactive, time consuming, associated with side effects, costly, only partially successful, and endless”.  These thoughts represented the most powerful encouragement of chronic disease prevention, through actions directed at avoiding the occurrence of the disease in the first place rather than focusing exclusively on the clinical approach of disease management.

Working at the LSHTM

I set off to pursue epidemiology by enrolling into a Master programme in Epidemiology and Public Health at the London School of Hygiene & Tropical Medicine where I completed an MSc and worked for a further three years. My training peaked with the MFPH (then FFPH) and the participation at the Advanced Ten-Day Seminar in Cardiovascular Epidemiology held in Singapore in 1993.

The winning team with the officers of the RCGP

established a personal line of research by succeeding in fully funding a research programme known as The Wandsworth Heart & Stroke Study (WHSS). I returned to practice cardiovascular medicine at St George’s as a Senior Lecturer (then Reader), in a highly ethnically mixed area of South London. I began to question whether and why some risk factors appeared more often in some groups than others. I established a population-based survey of three ethnic groups in South London, and studied them in all possible aspects, including the establishment of a biological and genetic databank for future exploitation. The study was published widely and in high impact journals, its results influenced future directions in the diagnosis and management of CVD risk factors in ethnic minority groups and led to the 2002 RCGP and Boots The Chemists Research Paper of the Year Award (Royal College of General Practitioners). The Research Paper of the Year Award had been running since 1996. Its purpose was to raise the profile of research in general practice and to give recognition to an individual, or group of researchers, who had undertaken and published an exceptional piece of research relating to general practice. The paper demonstrated the difficulties of applying the Framingham risk assessment for ten-year coronary risk across different ethnic populations and indicated the need for further inclusions of estimates of risk based on ethnic background (precursor of the QRISK-2 Score).

Next time: The Season of Ripening. If you have any questions or comments for Professor Cappuccio please post below. 

Career learning points:

  • Pursue your ideas, if you believe in them. 
  • Work hard and value other people, colleagues, your team. 

What did my research show about salt?

  • Salt intake is a determinant of the rise in blood pressure with age. 
  • Reducing salt intake reduces blood pressure in a dose-dependent manner in everyone. 
  • Salt intake is too high in populations, and a reduction across the entire population would reduce high blood pressure and cardiovascular events. 

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