By David Tuller, DrPH
In early 2019, I wrote about an awful online training course for general practitioners on recognizing and caring for patients diagnosed with what was referred to as CFS/ME. The module, called METRIC, promised to provide â€œGPs and other primary care practitioners with an overview of the presentation, diagnosis, assessment and ongoing managementâ€ of the illness. It was based on the discredited PACE trial and a related effort called the FINE trial.
PACE was a methodological and ethical disaster, and FINE produced null results for its primary outcomes. (The FINE authors have made unwarranted claims of success in fatigue reduction because a post-hoc change in scoring methods made the results appear somewhat better. This post-hoc analysis does not alter the fact that the trial had null results for its pre-designated measures.) Given these failures, It is certainly problematic that this research should have been used for medical education. But that didnâ€™t stop the Royal College of General Practitioners from developing and hyping METRIC, which promotes the treatment paradigm focused on graded exercise therapy and cognitive behavior therapy.
But the GET/CBT treatment approach pushed by METRIC has been thrust into an existential crisis. Last month, the National Institute for Health and Care Excellence published a new draft of medical guidelines for what it now calls ME/CFS that reverses its previous advice and dumps the recommendations for GET and CBT. This NICE draft led to whines of protest from the usual suspects, who have apparently recognized, to their dismay, that they no longer control the disease narrative.
They also canâ€™t control the impact of the new draft on subsequent developments. Two weeks after the draft was published, the British Journal of General Practice posted an opinion piece about outdated medical practices that compared the GET/CBT approach to other â€œrubbishedâ€ treatments. Now the Royal College of General Practitioners has apparently thought better of its â€œevidence-basedâ€ METRiC program. The METRIC site currently includes this advisory:
â€œThe course is currently offline while being reviewed to be in accordance with new NICE guidelines.â€ [bold in the original]
Does Chew-Graham still believe in GET/CBT for ME/CFS, or not?
The main author of METRIC was Carolyn Chew-Graham, a professor of general practice research at Keele University in Staffordshire. I wrote an e-mail to her about the problems with METRIC in early 2019, and never heard back. Professor Chew-Graham is a long-time member of the GET/CBT ideological brigades and was in fact one of the co-authors of the FINE trial. That raises some interesting questions, such as: Does Professor Chew-Graham agree with the withdrawal of METRIC? Has she changed her views on the appropriateness of the GET/CBT approach for ME/CFS?
In fact, I have a sense that Professor Chew-Graham is no longer brandishing the GET/CBT paradigm as the answer. In a webinar on what is being called “long-Covid” held by the Royal Society of Medicine earlier this year, Professor Chew-Graham appeared to be a strong advocate of pacing, rather than pushing through symptoms, as a way to cope with the profound exhaustion some patients report after an acute bout of Covid-19. Interestingly, a fellow ideological brigadier, Liverpool physician Alastair Miller, pushed the GET/CBT approach and suggested that PACE suffered primarily from bad public relations rather than being marred by egregious methodological and ethical lapses.
Professor Chew-Graham is also a leader in the movement to push everyone with so-called â€œmedically unexplained symptoms,â€ or MUS, into CBT and related treatments. This is a core aspect of the metastasizing NHS program called Improving Access to Psychological Therapies, or IAPT. In IAPT, CFS/ME is considered an MUS. So is irritable bowel syndrome. So, it seems, are any symptoms or complex of symptoms that a primary care physician canâ€™t explain.
Many of the leading lights in this domainâ€”Professor Michael Sharpe, Professor Trudie Chalder, and on and onâ€”have played central roles in ensuring that the MUS category is framed as a primarily psychological construct. Interestingly, these investigators have demonstrated significant scientific illiteracy in misstating a core statistic about the cost of MUS from a seminal paper in their claimed field of expertise. The misstatement, which has been replicated in paper after paper, has had the effect of tripling the apparent cost of MUS to the NHSâ€”a factor that would certainly support the claimed need for expanding the IAPT program to these hard-to-treat conditions. (A smart observer first alerted me to this statistical misstatement and how the MUS “experts” repeated it throughout the MUS literature.)
Last year, Professor Chew-Graham was forced to correct this mistake in a paper she wrote for the British Journal of General Practice. She ignored my initial letter to her pointing out the error, and I had to engage in an extended e-mail exchange with the journal editor to ensure that the correction was made. Professor Chew-Grahamâ€™s unwillingness to engage or to correct her own paper after an indisputable mistake was pointed out does not speak to a high level of academic or intellectual integrity.
As I understand it, the goal of this ideological movement has been to train GPs to quickly identify people with MUS and shunt them off to psycho-behavioral rehabilitation rather than sending them for expensive and presumably pointless medical tests and specialist consultation. As now seems apparent, the PACE trial was meant to serve as sort of a â€œproof-of-conceptâ€ template for this approach, given that these clinicians have regarded CFS/ME as a poster-illness for MUS.
Now that NICE has seen fit to dump the GET/CBT approach, where does that leave the IAPT program expansion? How can the NHS continue to justify including MUS in the IAPT program when the theoretical foundations for this approach are disintegrating quickly?
And since, in the case of long-Covid, Professor Chew-Graham has publicly softened her stance on the appropriate treatment for non-specific symptoms following an acute viral illness, what is her current position on the expansion of IAPT to CFS/ME and other supposed MUS? Does she still back this approach? And if she no longer does, when does she plan to say so publicly and take responsibility for her past assertions?