Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK
Some sessions just stand out. Dee Mangin‘s stunning distinguished presentation of her research into whether iron deficiency without anaemia in infants affected their long term developmental outcomes. They had, incredibly, 100% recruitment with blood tests in infants, and they followed the kids meticulously for 6 years with validated outcomes for intellectual and psychomotor ability. There was no loss to follow up with only minimal data loss e.g. 5% missing blood data blood at age 6 years. Dee’s presentation kicked off a superb afternoon on Tuesday at NAPCRG 2015 of ground-breaking trials asking important clinical questions… Do steroids help in chronic cough? What’s the effectiveness of maintenance SSRI (and what happens with antidepressant withdrawal)? It would be unfair to release any of these findings in a blog and we all look forward to publication of the papers. Suffices to say, they will be practice-changing.
But, why not release them on social media? Our current model of research publication that blocks early dissemination seems completely out of step with the potential for social media to immediately disseminate research findings worldwide. This contradiction was highlighted by one speaker who began his presentation by explicitly asking the audience not to tweet or post his results on social media. Another speaker reminded her audience, busy photographing her slides with their cell phones, that the results had not yet been published. Doesn’t it seem wrong that the results of these studies will have to wait for the peer reviewed journals to crank into action before patients can benefit?
Further limitations of our knowledge dissemination model were explored in a session by Roger Jones, editor of BJGP, and Paul Little asking if we can measure the impact of research. The UK Research Excellence Framework is exploring new metrics of research impact and, while changes are already in place. It will take tome before researchers appreciate what impact means. At present, Impact Factor dominates everything. When inviting to authors to submit their research to CMAJ, their first question is almost invariably about our impact factor- when it should be about our audience and whether they are listening. On forums for journal editors, a frequent is how to improve impact factor. And, when listening to authors present work at primary care meetings like NAPCRG, I am increasingly intrigued when they say they have published their work in some obscure specialist journal, chasing impact factor with little likelihood of their primary care target audience ever reading it- particularly if behind access controls. The first step in communication and effecting change is to make sure your target audience reads it.
Multimorbidity and co-morbidity are at the core of general practice. We see our patients struggle with the burden of multiple illnesses and problems, and the research community has charted the range, nature and the implications of multimorbidity. One of the final sessions of the 2015 NAPCRG conference brought together some of the world leaders in multimorbidity research to look at the research agenda and, in particular, the key measurement metrics for future multimorbidity research. As we grappled as a group with the difficulties of establishing the research agenda, a few things stood out for me. The concept of the treatment burden resonates – patients’ difficulties coping with illness and medication. We think a lot less, though, about the system burden and, paradoxically, the better we are at managing the single disease burden, the greater the system burden on our patients with co-morbid disease as they attend multiple clinics, outpatient departments, and comply with multiple diagnostic and follow-up tests. Just meeting all their chronic disease monitoring requirements is a full time job. Moira Stewart, who had just attended the WONCA Europe meeting in Istanbul (two major meeting, two continents, in two days) summarised the important measurements: quality of life, functional status and patient engagement and identified three areas for further exploration, how patients weigh the constructs, how we measure wellbeing and, patients understanding of their conditions.
While we can hardly describe multimorbidity as a niche topic, it is a relatively uncharted. For authors publishing in less well known and understood areas, it is important to remember that while you may be an expert in the field and can carry out a conversation in the language of that research, not everyone else is as immersed in the topic. If a journal rejects your manuscript and you feel they don’t understand the importance of the topic, perhaps they don’t. So, before you submit your research for publication, in a complex topic like multi morbidity, test you message. Try presenting your work internally or ask your peers to comment. But, not to your own research group or friends in the department. Try it on your specialist colleagues with no knowledge in the field to ensure that your message is clear to those with little expertise. If you cannot explain it to them simply and clearly, you are unlikely to convince an editorial team. Don’t submit your manuscript in hope, submit it with clarity.
And, now for the grumble. “Secrets of my research career” is aimed at early career researchers, although a show of hands at one of the two sessions showed a wide range of researchers at different levels in their careers. These sessions should be encouraging and enabling but, sadly, I found them rather depressing overall. The panelists and audience seemed to wallow in the difficulties – how hard it is, how difficult it is to get on the research ladder, write grants, get funding, and publish research. A number of speakers emphasized the importance of saying no, protecting your time, avoiding teaching and administration responsibilities. I could have cheered when Kurt Stange asked from the floor that they tell us what gave them joy in their work. Jeannie Haggerty recommended that, early on, they say yes to every opportunity, and Martin Fortin said his team celebrated their successes with a great meal and good wine. Let’s enjoy the fun of a stimulating and exciting career. Please forget the “poor me”. Few looking at us through the windows of this luxury hotel in Cancun would have any sympathy. We have rewarding careers, stimulating research opportunities, and friendship and collegiality in a caring profession. Our discomfort is relative, brought into clear focus by the health disparities in Mexico highlighted in Wednesday’s keynote by Carmen García-Peña. Let’s get real.
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.
Get real indeed.
There is something about being primary care practitioners that promotes introspection and feeling hard done by, increasingly in clinical practice as well as research careers (as Domhnall reports on comments at NAPCRG). Such negativism, even if it has roots in reality, will blight attempts to improve selection of primary care as a career choice if we aren’t careful. I agree with Domhnall – whatever the challenges, and they are great presently, we have it good compared to most in the population and should be using our positions of influence to promote change for the better – for ourselves as well as our patients. Advocacy for junior career challenges shouldn’t obscure the opportunities that career presents, whether caring for others or presenting in the sun-drenched Yukutan.
Lets try not to end up like the glittering but now extinct Mayans (penned from the home of the marauding conquistadors).