Victor Montori and France Légaré raised interesting points about guidelines. Victor pointed out that, although most guidelines are issued by specialist groups, the authors opt out of clinical decision-making by suggesting that GPs can apply guidelines flexibly in the context of an individual patient’s circumstances. But, when you introduce quality measures, people hold you to those quality measures, and all flexibility is lost. France described the lure of standardization, which also concerned Larry Green, who suggested we could handle this using a genome metaphor in accepting that, although we all have a standard double helix, it still allows for infinite variation.
Depression and culture
Weng Yee Chin gave some fascinating insights into depression in Hong Kong. Some features were unsurprising: a prevalence of 11%, a dissonance between the doctor-diagnosed and PHQ9-screened cases, and the association with multimorbidity. Surprisingly, however, patients sought more help from psychiatrists than from family doctors. But, for me, the cultural issues were most striking: Chinese people put much more emphasis on holistic medicine, so that depression may be seen as a stigma. Rather than describe depression as an illness, it is more acceptable to look upon it as a personality weakness or the result of the stress of coping with the high-pressure, 24-hour, Hong Kong lifestyle. Hence, depression may be described more in somatic terms. The system, too, militates against doctors treating depression as an illness. Because the average consultation in the public sector is five minutes, there is little incentive to talk about mental health; it is much easier to give a tablet than to talk about feelings.
General practice in Québec
Mylaine Breton painted an interesting picture of the extraordinary variation across different models of general practice provision. Her findings relating to solo practice were remarkable. Although opening hours seemed fewer, patients did not consider access to be a problem. Surprisingly, 25% of solo practices did not use computers. As we move towards larger practices and prioritize quality measures, Mylaine reflected that there is something about solo practice that we need to look at more closely — patient perceptions do not appear to be linked to organizational factors.
Secrets of success
In an “Ask the experts” interactive session, Frank Sullivan, David Katerndahl and Carol Herbert each discussed their three secrets of success. Frank identified humility, persistence and infrastructure. David suggested getting all the training you can, thinking outside the box and writing as much as you can. Carol identified irrepressible optimism, working with the resources available and loving your research question. The main problems identified by an audience mostly consisting of junior researchers were time management, writing skills and balancing their lives. But, as David pointed out, the key is to define what you mean by success, which may depend on where you are in your career. In general, the consensus was that it’s best to stick to the usual routes and recognize the accepted model in academic practice, which includes postgraduate degrees, publications and grant acquisition.
Primary care in the US
Carol Tran, from the Robert Graham Centre, gave an intriguing talk on the number of primary are doctors needed in the United States. With a projected retirement at age 66 years, and no change in team or panel size 33 000 more primary care doctors will be needed by 2035, which means 2200 new first year residents by 2020. Her colleague, Andrew Bazemore, looked at the brand “family medicine,” which defines itself as generalist; however, in his study involving 31 000 physicians, looking only at those physicians with a plurality of activity, he found evidence that comprehensive generalism is under pressure.
Ovarian cancer is very difficult to detect. In his systematic review, Mark Ebell found little benefit from screening via bimanual examination.
Jinping Xu found that men with prostate cancer consistently overrated treatment benefits. In the discussion around her paper, the audience explored the problems surrounding the term “watchful waiting,” which was considered too negative. As one patient had suggested, it sounded too much like “wait and watch me die.” There seemed to be consensus that “active surveillance” was preferable.
Paul Little described work from his trial of acetaminophen with or without ibuprofen. He found that, rather than benefiting patients with respiratory disease, ibuprofen, particularly with acetaminophen, may be unhelpful. It is difficult to know why, but as Dee Mangin suggested to me during the discussion, perhaps inhibition of the inflammatory response may not be such a good idea. Paul also commented that the more experienced he has become in undertaking trials, and he has done many, the longer his team spends in preparation (qualitative work, piloting, etc.). And, this was someone who had just described his recent web-based infection control trial involving 20,000 participants.
I particularly enjoyed a conversation with L.J. Fagnan and his perspective on the “Medical Home,” which he feels suggests a type of practice limited by walls. He suggested family medicine should be looking outwards with greater involvement of communities. Communities should, perhaps, have more influence on how their family doctors practise, and could even have a role in recruiting their family doctors.
The key message of the conference came from Google, via Joe Selby from the Patient Centred Outcomes Research Institute, who quoted the company’s number one principle, which should be central to family medicine. “Focus on the user and all else will follow.”
This blog adds to a series on global primary care research hosted on CMAJBlogs.com to coincide with NAPCRG’s Annual Meeting (2014)