Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK
Health care has three components, according to Michael LeFevre (University of Missouri) who gave the opening keynote address at #NAPCRG2015. They are: to relieve suffering, to prevent future illness and to prolong life. Most of his career focused on prevention through his work with the US Preventive Services Task Force which was at the cutting edge of using science to inform clinical decisions. His involvement came during period of evolution from traditional consensus guidelines developed by experts to creating of evidence based guidelines based on formal evaluation of the literature. Difficulties arose when the evidence didn’t fit with established clinical practice and he described vividly events in 2009 when recommendations against routine mammography screening came out. Despite huge resistance and nationwide media interest, they stuck with their evidence based conclusions although one of the lessons they learned was that “we may be good at what we do but not always good at what we say”. So, now they have communications experts and a designated spokesperson. As the discussion afterwards revealed, a future challenge will be how to incorporate patient views and shared decision making into guideline application.
Late-life depression is difficult to treat because it’s not just a psychological condition but there are also biological and central nervous system changes. Mario Amore on behalf of the UC Davis/ Genoa and Bologna team described their RCT of physical activity where older patients exercised on stationary bicycles three times each week for six months. Overall there was a twofold improvement in those who took antidepressants and were active. Those who responded best were older, had psychomotor retardation, higher aerobic capacity and more polypharmacy. And despite the mean age of 75 years old, there were just two minor incidents.
Stroke is another major clinical issue and Grace Moran (Birmingham) described work looking at modifiable risk factors in patients with a stroke (2009-2013) in the Health Improvement Network, a database covering 6% of the UK population. The modifiable risk factors were atrial fibrillation, high cholesterol and high Blood pressure and they found that, overall, about half of those who would have benefited from primary preventive treatment had not been prescribed medication. Interestingly, this was more likely if the patient was a smoker and obese (or underweight). There are many reasons why medications may not have been prescribed but, she brought up an interesting point- might someone take a medico-legal case if they had had a stroke while eligible for treatment but not prescribed appropriately.
Has the traditional role of the family doctor been pushed aside? I was rather taken by a description in a qualitative paper by Gina Agarwal (McMaster) of the paramedic in a community health program in a seniors building in Hamilton. He was “All the things you want in a doctor or a health care professional. It’s not the pills they give you, it’s the feeling they give you”.
The session on “Secrets of my research success” is always intriguing and Jane Gunn (Melbourne) didn’t disappoint with the aid of her Aussie acronym “QANTAS”: A Qualification is important so aim for a masters or PhD and ideally develop a particular skill- expertise in a particular method, for example. Ambition is what is it drives you and you will know you are a real researcher If you are starting to think about it in the shower. Develop Networks, record ideas in Notebooks (or the electronic equivalent) and Nurture links. Take Time to develop- be passionate and persistent. Apply, in both senses, apply yourself to the task and apply for grants and opportunities. Support is important and seek mentors. Find someone who looks like what you want to look like- “you can’t build a house if you don’t know what a house looks like”. And, in keeping with the spirit of the acronym- Get out of your comfort zone and travel away.
But the session on International perspectives on palliative care was, for me, the most important session of the conference so far, and you can read all about this session in previous blogs posted today. Two sound bites caught my attention. Marianne Dees (The Netherlands) said we are guilty of “curative over treatment and palliative under treatment”, and Tony Caprio began his talk by observing that end of life conversations are unpopular in the US because "people see death as optional, and not an attractive option".
My research highlight so far was a poster by Martin Dawes' team (UBC) who described the method and preliminary recruitment for his study of the integration of pharmacogenomics into primary care. Family doctors could request PCR testing for key genes involved in drug metabolism to help their prescribing decisions. This is ground breaking research potentially creating a new model of personalised care.
This blog is one of a series from the 43rd North American Primary Care Research Group (NAPCRG) Annual Meeting, which runs from October 24-28, 2015, in Mexico. CMAJ is one of the sponsors of the meeting.