Some interesting threads have been weaving through the Annals TRACK online discussion since the last issue.
The study of community-based participatory research (CBPR) in practice-based research networks1,2 raised questions about what constitutes community3,4 and how the many communities active in clinical research can be engaged in this “revolutionary challenge to how research is conceptualized, conducted and disseminated.”3 “Like Community Oriented Primary Care (COPC) before it, ... CPBR may be another compelling idealized model that is drastically altered by the ugly facts on the ground. And like COPC, and indeed like Family Medicine itself, CPBR maybe worth doing badly rather than not at all.”3
Comments on the series of studies of diabetes quality of care highlight the vital need for basic research on practice to guide development of quality improvement interventions amidst the complexity of primary care.5–9
A multifaceted challenge10 to the notion of shared decision making was raised in response to the study by Saba and colleagues of the experience of partnership in primary care.11 The study of the association of anger and injury12 elicited calls for additional analyses.13 The authors are working on these, and they may well be posted by the time this On TRACK is published.
Consistent with the theme of articles in the current issue, one reader found evidence for the future of family medicine New Model practice14 in a study of the effects of open-access scheduling on the quality of depression care.15
One essay in the last issue16 evoked recognition of the depth and beauty of narrative and of the important role of stories as part of the evidence for, as well as the day-to-day work of, medicine.17
The other essay provoked outcries about the shameful powerlessness that we sometimes allow to infect patients’ care and medical trainees’ roles.18–21 This story of the (over) treatment of an elderly man22 brought forth a sense of shame for the profession18 and reflections on “the difference between treatment and care.”19
Another reflection outlined the need for both “hunting” and “foraging” tools to support evidence-based patient care. Hunting tools help the clinician efficiently find evidence to answer particular clinical questions, whereas foraging tools update clinicians on the latest advances and setbacks.23
A senior researcher added his personal validation to the efforts by Glasgow and colleagues24 to help researchers make hard decisions in choosing measures of health behavior change.25 This researcher’s experience with the Robert Wood Johnson Diabetes Initiative corroborates the benefit of making compromises by reducing the number of items to decrease respondent burden and of enabling studying the broad range of variables needed to understand and improve primary care.
A challenge by a “concerned consumer”26 raised a sophisticated methodological concern about a previous study of the interaction between dietary intake of iron, serum transferrin saturation, and the risk of cancer.27
Finally, a graduate student28 discerned that not every statement in an evidence-based medicine article is evidence-based. She questions the generalization from an evidence review for the US Preventive Services Task Force,29 which states that women suffering from postpartum depression and experiencing major stress from breastfeeding should not breastfeed.
These reader observations and the research articles and essays that stimulated them illustrate the importance of including an on-the-ground perspective in the development and interpretation of information. It is beautiful for our models and ideals to be “altered by the ugly facts on the ground.”3
Please contribute your own insights to the discussion of the current issue at http://www.AnnFamMed.org.
- © 2006 Annals of Family Medicine, Inc.
