Thinking the unthinkable: General Practice Research

DMacA_3Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK

 

Reading a recent robust critique of the achievements and challenges to academic general practice in the UK, and a plea by senior academics for increased capacity in clinical academic general practice, I began to wonder.... How might we design general practice research for the future, what direction should a department of general practice take, and where does general practice fit into the future of clinical research? As an intellectual exercise, I allowed myself to think the unthinkable. And, for a general practice academic, brought up in family medicine and immersed in the traditions of personal primary and continuing care, this felt like heresy. At the very least, however, perhaps we should begin to think creatively about the future. What do you think?

It is difficult to see a future for academic general practice. The initial great advances in general practice research were because general practitioner academics identified key research questions from patient contact and followed these ideas through. But, academic general practice has become less and less embedded in daily patient care and many academics now have considerably reduced clinical commitments. The leadership role is very different. As academics become distanced from their clinical colleagues, they lose credibility. Yet, the pressures on academia are such that it is increasingly difficult to maintain any meaningful relationship with patients. Is it realistic to ask academics to care for patients in the way traditionally expected of family doctors- personal, primary and continuing care and, if so, should we stop the charade?

Academic departments of general practice struggle in the current research environment. Medical science is increasingly about asking key research questions that require large sample frames with populations of sufficient size to meet statistical significance. This means large teams of academics with industrial level support. Small regional general practice research departments struggle to compete and larger central departments are required to create critical mass. There seems little future for the individual researcher with an idea trying to develop a research project in a small regional department – and difficult to see where the grants might come from. For a fledgling general practice academic, such a career path may not be as financially rewarding nor offer long term career prospects to compete with clinical practice. And, for a financially limited academic department, it is more cost effective to employ a non-doctor primary care researcher. By the time a doctor completes medical school and has the minimum necessary postgraduate clinical experience, a non-medical researcher who started university at the same time will have a Masters degree, a PhD and a string of publications. So, it is likely that research to guide the future of practice will increasingly be undertaken by non-doctors. Already the gap between research and practice is increasing- primary care research has its own research conferences, separate from general practice professional and clinical conferences and academic units have become departments of primary care reflecting a workforce that has more non-medical researchers than doctors. In this context, regional general practice academic departments, and prospective general practice researchers, may need to completely rethink their aims and objectives, and small regional departments may need to reinvent themselves.

Publishing research has become increasingly challenging. As journal editors, we too may be part of the problem because we prioritise robust studies with sufficient power to answer important clinical questions. Blue skies research, and studies exploring new ideas in small populations, simply don’t have the same impact and struggle to find a home in the high profile general medical journals. Few practices have sufficient patient numbers to attain the statistical power to answer complex research questions and small groups of geographically localised practices or even regional practice research networks may not interest editors of journals concerned with international generalizability. Journals prioritise research from representative samples where findings can be generalised across populations and between countries. Indeed, much of what we might loosely call general practice research is now taken from general practice databases and aggregated general practice electronic records but, that doesn’t make it general practice research- it is database research that could be undertaken by anyone.

General practice is no longer defined by the personal relationship with patients. Practices seldom provide direct clinical care for their patients beyond the standard working day. Continuity of care is now based on the electronic medical record rather than a person- and there are no theoretical reasons why that electronic record cannot be accessed by all health care professionals. Doctors offering twenty four hour access to patients, even for terminal care, are rare. Indeed, few doctors now work five days each week. Portfolio careers are common. So, the concept of personal, primary and continuing care exists only in memory.

Patients are no longer segregated into either hospital of the community. Hospital stays are much shorter with increasing day care, outpatient and ambulatory investigations, and greater outreach by nursing and paramedical staff. The sharp boundary definitions between hospital and general practice that may have existed in the past are long gone. Patients don’t exist in, and are not defined by a particular environment, hospital or the community. It is increasingly difficult to define patient care as either general practice or hospital based. Patients are identified by clinical conditions that know no boundaries and treatment is centred on clinical management rather than the location of the treatment. Conditions, other than related to acute or intensive care, don’t exist only in hospital nor are other diseases characterised as being only from general practice. Clinical care is a continuum, there are no boundaries, and no limits to general practice as previously defined. So, what is general practice research?

Let’s ask the difficult questions: where is the future in general practice research? Do we need any more research on the consultation, the doctor patient relationship, continuity of care? If we are to address key clinical questions we need large patient population with sufficient numbers of patients for statistical significance and these are no longer defined by location in hospital or the community. Perhaps it is time to abandon the concept of general practice research and create generic clinician researchers without any particular specialty label. Should we think more about applied health research and integrate research departments of general practice into larger generic clinical groups. Perhaps we need to think more creatively about patient benefit and abandon old models. Clinical teaching has evolved in response to more community involvement. It may be time to re think our current model of academic general practice.

I hope my general practice academic colleagues will forgive me for this deliberately provocative piece. But, let’s start a conversation…

9 thoughts on “Thinking the unthinkable: General Practice Research

  1. John Nichols

    I found this very interesting and very, very challenging – because I completely disagree. I do small pilot studies and I get them published. There can still be quite useful statistical analyses in these small studies and they point the way for larger studies. My last pilot study involved just four local GP practices and just 28 subjects with proven diverticulitis. Despite the small numbers, my results (benefits of taking a daily probiotic) looked statistically significant (but only just) and that does the job. The main conclusion is that a larger study IS justifiable. There must still be GPs who want to follow a hunch, which is how I started. Of course, the first bit of advice they need is to do a literature search. Next, pair up with an appropriate university colleague (I did a lot of work with a trace element scientist) and then, before they go any further, find a good statistician. If there was no longer any mileage in this approach, it would be a crying shame, but I am sure this is NOT true. The little thinking GP with a hunch is still part of the research scene and always will be.

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  2. Dr Liz Sturgiss

    As a ‘fledgling” GP academic in Australia, I find this piece very provocative!
    I have chosen this career path despite the lack of financial reward – as you rightly point out I could make a much higher wage in clinical practice. But I have chosen this path to contribute to my profession through teaching and research. There are many rewards in an academic career beyond the financial. (And in case you are wondering, yes I’m the primary breadwinner in my family).
    My colleagues and I all work in clinical practice and maintain a strong patient base. I’m not sure why you believe that general practice care is no longer relationship based? It certainly does not reflect my personal practice. Perhaps the Australian system is different to Ireland.
    It is interesting that you mention “the gap” between research and practice. Locally we have many examples of clinically relevant research that is changing practice internationally (see Dr Clare Heal https://research.jcu.edu.au/portfolio/clare.heal/) Surely an alternative option to your suggestion of leaving research to non-GPs, is to support more research to come from clinical practice? I can only see that “the gap” between research and practice will widen without GPs being involved in a research capacity.
    In reply to “where is the future of general practice research?” – personally my mind is full of questions and ideas. There is so much we don’t know about the why and how of general practice – it has been described as a “black box” (see Michael Kidd http://www.globalfamilydoctor.com/News/FromthePresidentTheWorldBankRomaniaICPCreadon.aspx) to those sitting outside the primary health care system.
    We need to improve our methods for measuring value and what constitutes good general practice. We need novel research methods and appropriate outcome measures to encompass true primary care of whole-people and communities.
    When I think of the future of general practice research, I feel slightly overwhelmed with how much more there is to discover and learn. I also feel excited and hopeful that research can bring better policies and practice to improve patient health and experience of the health system. I feel grateful to be part of the general practice academic community.
    Perhaps our difference of opinion is merely a reflection of our stages of career. Maybe one day I will be as cynical, but I hope not.

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    1. Dr Charlotte Hespe

      Here here Liz, I definitely could not have put it any better!!!!
      The joy of primary care research is that is at the point where things really happen and where we have an ability to measure and understand how to really implement “evidence based guidelines” and really have an impact on health!
      I too am a fledgling “researcher” but I have 20 years of clinical background that has guided me into taking this wonderfully challenging aspect of primary health care to try and make an even bigger impact on improving the health of the Australian population.

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  3. Domhnall MacAuley

    Thank you very much for responding. I very much appreciate your comments. And, of course this was written in a deliberately challenging way in order to create a conversation. I believe its important that we discuss the future of general practice research in the current environment….but, please don’t shoot the messenger. Asking difficult questions doesn’t necessarily mean cynicism. And, I am a great fan of Clare’s work.
    Domhnall

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    1. John Nichols

      Dear Domhnall,
      I understood that your blog was intended to be challenging, of course. When I was writing a column in a medical newspaper in the 1980s, I sometimes felt moved to write something challenging and controversial just to get a response. There is a serious issue underlying the discussion, as you have implied. The current drift, as you outlined, seems to be designed to silence the “little people” like myself. I have heard that there is indeed some truth in this and that government officials feel that supporting maverick GPs with strange ideas is a waste of money. The maverick GP should be encouraged to discuss his “strange idea” with someone like yourself but not simply told “forget it”?

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  4. Martin Marshall

    Thanks Domhnall, these are exactly the right challenges to make. My view is that we need a range of models of primary care research, all valued and supported. We need large scale studies done by traditional academic institutions with big infrastructures. We need practice- and small network-based research addressing grounded questions coming from the front line. We need both of these models to revisit empirically the core values of general practice. We need a stronger focus on participatory models of research, like the ‘researchers-in-residence’ programme that we are developing at UCL (http://qualitysafety.bmj.com/content/early/2014/06/03/bmjqs-2013-002779.full). And we need to develop the clinicians-as-scholars model, people driven by a spirit of inquiry with an understanding of research but no desire to make a career out of it.
    Essentially, we need what we’ve got but more of it and better. Am I asking for too much?

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  5. Pat Harrold

    There is a lot to consider in your piece Domhnall. I suppose the days when Fry et al. took a cool look at what we were doing ,and not what we thought we were doing ,may be over. But they may not be. You always need the person who will ask the question that nobody else has thought of, or sees what everybody else has seen but nobody thought was worth a second glance (Tourette’s and h .Pylori spring to mind).Will a in vitro researcher spot what a GP in the field sees? I doubt it.
    If a GP has to work at the coalface five days a week, with a dollop of out of hours thrown in ,there will be no place for reflection, research or that vital qualitative research which is teeming and evolving in plain sight. Many of us need an academic department in our lives to complement the day job .
    Academic General Practice is very new. It will find it’s niche. You have got the ball rolling nicely Domhnall,for some frank discussion. You are a modern day Fry.

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  6. Clare Heal

    Thank you very much for your interesting and provocative blog. I have had many similar thoughts about general practice research, and with my recent promotion to Professor I have been reflecting on my own career as a general practice academic.
    I agree that there are many barriers to a career as a general practice academic. Financially it may not be rewarding as other medical specialties, and the career pathway of first gaining a medical degree and clinical experience before embarking on a masters and PhD is a long one. Keeping up with clinical practice and trying to keep some credibility with colleagues, while working as a full time academic, can be exhausting. However it is also an extremely flexible career, and one that fits in well with childcare commitments. It allows for opportunities to travel, collaborate, and the rewards of helping to educate future doctors are tremendous.
    I think that we need to preserve general practice research as a separate and unique specialty, rather than allowing it to merge into the area of primary care research. I am continually frustrated that my specialist colleagues conduct research in areas which they consider to be clinically import, while primary care research often focuses around health resources and service delivery. There are so many important clinical problems that are unique to general practice and should be the focus of research.
    In my own research career, I have always used simple clinical questions generated by grass roots GPs. I also think it is important to look for research topics which are unique to your own particular practice, and try to exploit this. In my case, as a GP in rural Tropical North Queensland, the high GP case load of minor skin excisions, coupled with a high infection rate has meant that trials investigating surgical site infection have been highly feasible – in fact more so than for hospital based surgical departments. I would encourage GPs to look for areas of clinical research which are particularly feasible in their own practice – be it refugee health, h. pylori or diverticulitis.
    In Australia, we are currently struggling with the limited funding awarded from the National Health and Medical Research Council (NHMRC) for GP research. However with grass roots research projects that are relevant to local GPs, and therefore generate goodwill and enthusiasm in the GP workforce, I believe it is still possible to conduct high quality, relevant but low cost research.
    I am actually quite optimistic about the future of GP research. With bright young academics such as Dr Liz Sturgiss, and the enthusiastic medical students who I am currently supervising in GP based projects, I think the future lies in good hands.

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  7. Aline Ramond-Roquin

    Many thanks Domhnall for this interesting and provocative reading! After making us want to shoot the messenger :-), it really promoted further reflection… and it called for response!
    You pointed out a highly meaningful question: What is the future of general practice research and of academic general practice? As you rightly stated, general practice has much evolved and boundaries between general practice and other care settings are no longer as they were traditionally… However, does it justify simply abandoning general practice research and moving towards what could be labelled “generic clinical research”, with the only aim to meet journals sample size requirements?
    Fortunately there are alternatives to this quite unexciting scene.
    General practitioners are no longer single-handed clinicians that offer twenty four hours access to patients. One may regret (or not) this evolution but this has been justified (at least partly) by the increasing complexity of the patients’ needs (aging, multiple chronic conditions…) that the general practitioner cannot anymore fill alone. Aligned with the increasing need for interdisciplinary and integrated care for patients, academic general practice has already shifted from isolated departments to interdisciplinary collaborative teams. The force of such teams is not (essentially) to create critical mass. The main interest is to gather different perspectives from different clinical (and non-clinical) backgrounds, in order to co-create evidence that will ultimately benefit most to patients. General practice researchers, as much as other researchers, have their own role to play in these interdisciplinary teams.
    We will soon post a complementary comment on this so meaningful topic, with a specific focus on multimoribidity. We invite all researchers and other interested stakeholders to visit the IRCMo (International Research Community on Multimorbidity) blog in about ten days to read it.
    In conclusion, general practice research should and will certainly continue to evolve, because it has to remain grounded in the (rapidly evolving) general practice reality. We believe that it still has a bright future ahead. Lasting with a deliberately provocative question, we may ask to the messenger: “What is the future of journals not interested in publishing general practice research grounded in the real world and adapting designs to its complexity?”

    Reply

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