Domhnall 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…