Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK. He’s currently also Chair of the Jury for the National Research Award of the Swiss College of Primary Care Medicine
Swiss primary care research has a very bright future, from what I could see at the early career researchers meeting (TAN HAM) that I attended recently in Bern. Oliver Senn put together a superb programme but the key to its success was the commitment and contribution of the researchers. It was their programme and, not only did they present their work with skill and style, and almost exclusively in English, but each research presentation was chaired by one of their peers as the senior academics looked on from the side lines. The presentations were fantastic, covering a range of topics, as described below. But I thought the peer chaired sessions were an innovation worth replicating at other national and international meetings.
Many countries are struggling to recruit and retain a family medicine workforce and Switzerland is little different. Zsófia Rozsnyai investigated what type of training curriculum might be most attractive to medical students and young doctors. She surveyed 242 students of the five Swiss universities together with 312 young physicians. It was fascinating to see, not just their preferred specialty rotations, but the specific training courses that they would like to undertake: ultrasound, laboratory medicine, and manual medicine. Among the least attractive features of family medicine she identified were the long term commitment to practice, and the salary differential with hospital specialists. The subsequent discussion brought out a fascinating idea: wouldn’t it be interesting to borrow from economic theory and do a discrete choice experiment? How much would you be prepared to give up in your salary to become a family doctor? Like many countries Switzerland has undertaken a number of initiatives to get family physicians to work in under-doctored areas, including offering financial incentives, but not all wish to remain long term in the same Canton. Stated encouraging factors include mentoring and career guidance by family doctors, a broad curriculum, and increased training within primary care practices.
Stefan Gysin took a different approach to the workforce problem, the emerging shortage of family practitioners, a lack of young doctors, an ageing population and the shift from more acute to chronic care. He was interested in exploring new models of inter professional collaboration and his study looked at the role of nurse practitioners in an initiative in Bürglen, a community with a population of 4000. His work was more about economics and policy, trying to explore billing issues, and the conflict between feasibility and need, especially in rural practice, looking at costs and legal aspects, acceptance, satisfaction and, of course, medical outcomes.
Could pulse oximetry have a role in the clinical assessment of children with pneumonia in Papua New Guinea? Pneumonia is the leading cause of death in children under 5 and a major burden in developing countries. Radiology is seldom easily accessible so it seemed useful to ask if hypoxaemia could predict severity of illness and, in this study, Julien Blanc compared oximetry to clinical signs. The major limitation was the lack of specificity for pneumonia and while the discriminative power was moderate, it was easy to use and inexpensive. While it may useful addition to clinical assessment in coastal areas, it may be of limited value at altitude – remember, we were in Switzerland!
Many countries are concerned about polypharmacy and Catrina Waldegg described a randomised controlled trial of a deprescribing algorithm. A key concern was that reduction in medication should not reduce quality of life. There were changes, not unexpectedly, in both intervention and control groups and many drugs were stopped, but the audience was particularly interested in exploring the type of drugs that were stopped.
Developing a questionnaire study is seldom straightforward. Arun Senchyna’s proposed study was to look at barriers to depression care in family practice but, building on his preparatory work, he gave an in-depth explanation of the different stages in creating a useful questionnaire. Doctors may think they can easily develop a simple questionnaire but they often end up with incoherent and uninterpretable results. Arun elegantly described the importance of response process validation, cognitive interviews, construct validity, internal and external reliability, and all the other essential processes required to successfully develop a questionnaire. If you don’t have his expertise, the message is to get help – ask you psychology colleagues. And, I particularly enjoyed his Noah’s Ark analogy to explain content validity: “Are all the relevant animals aboard?”