Dr Grant Russell is a family physician, Head of School of Primary Health Care, and Professor of General Practice Research at Monash University in Melbourne Australia.
Every few months, someone writes about the parlous state of academic primary care. It was Domhnall MacAuley’s turn a few months ago, as he lamented that academic Family Medicine Departments lack direction, that there was no market for traditional GP research and the academic GP community is getting more and more distant from the patient and from their clinical colleagues. Domhnall’s concerns extended beyond the walls of the university – suggesting that, across general practice the “concept of personal, primary and continuing care exists only in memory”.
Anxiety about the future of the discipline of family medicine is not new. I remember 25 years ago telling an esteemed GP I was thinking about becoming a family physician, only for the celebrated old doctor to say, “I don't know why you want to – see, general practice is finished.” Others have written, and often, about the state of family medicine since the term first began to be used in the 1940s. Underlying all of this are questions of security – “Are we good enough?” “Do we fit?” “Does anyone listen to us?”
Those arguments never carried much weight with some of those who shaped the discipline. Gayle Stevens, Ian McWhinney, Barbara Starfield just got on with articulating what family practice is, why it matters and what sort of a difference it has made to the lives of those in need. My own country Australia, has added to the tradition - today’s Australian family practice owes much to Max Kamien’s work with indigenous populations, John Murtagh’s educational genius and Charles Bridges Webb’s methodical descriptions of patients and their problems.
Through the last 2 decades, the Australian government used its Primary Health Care Research, Evaluation and Development Strategy (PHCRED) to support academic primary care. PHCRED comprised the Australian Primary Health Care Research Institute, the Primary Health Care Research and Information Service and a network of Centres of Research Excellence. Each made major contributions to the quality of the primary care system and to the growing reputation of Australian academic primary care.
However over the last 6 months the PHCRED strategy has been dismantled. APHCRI was defunded from the end of 2015. PHCRIS has a 6 month stay of execution after a decision for it not to be funded beyond June 30, 2016. Only one of the Centres of Excellence will be functioning by mid-2017. As a last straw, in April this year, the government withdrew support for the world's longest running study of general practice. Operating since 1997, the Bettering the Evaluation and Care of Health (BEACH) program is the only continuous nationally representative study of general practice in the world.
So, in what seems like déjà vu, family doctors and the rest of the primary care community have spent the last couple of months scrabbling to make the case for primary care research. Many of them will be coming together tomorrow at Australia’s premier primary care research event the PHC-RED Conference. So, amid the plenaries, the presentations and the posters will be a community wondering where the next grant comes from - how the next generation of researchers will be trained and how can we generate the knowledge that the system needs for improvement.
It’s easy to respond to Australia’s primary care funding decisions with hand wringing and despair. And I can assure you that there has been more than a little of that in the last few weeks. I think there will always be those who fret about the security of a generalist discipline in a specialized world. And always governments that seek to put their own stamp on policy – sometimes with unanticipated consequences.
In responding I think we can take some advice from the late, and celebrated Canadian academic, Martin Bass. Bass cautioned family physicians against learned helplessness; he wanted us to acknowledge the importance of the discipline, and to recognize that we had more value and more influence than we gave ourselves credit for.
I am confident that those luminaries who have come before us have left a discipline with the maturity to deal with trends in policy and changing economic circumstances. Australian family practice needs to shape the future by harnessing the skills we have learned as family physicians – to understand context, acknowledge complexity, to be comfortable with uncertainty - and to be always on the lookout for the unexpected solutions.
For, as Martin Bass reminded us in 1987,
No-one but ourselves can fully know our needs and our patient’s needs.
No-one can better research our patients than ourselves.
No-one but ourselves will answer our questions exactly.