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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Training for Public Health Preparedness
the generalizability question (again)
The Role of Family Physicians and Practice Based Research Networks in Early Detection of Bioterrorist Agents and Emerging Infections
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Jonathan L. Temte, Madison, WI Associate Professor, UW Dept. of Family Medicine
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To the Editor: As noted by Dr. Calmbach, family physicians need significantly more training in public health preparedness. Such training, ideally, would not only encompasses response to bioterrorism, but also to more likely events such as naturally emerging infections (e.g., SARS, pandemic influenza), natural disasters (e.g., hurricanes, tornados), and healthcare delivery problems (e.g., hospital closures, vaccine shortages). In all these realms, connectivity and ready access to information can be essential to individual and public health. Great progress is being made on the information technology front as applied to biodefense. For example, the National Electronic Data Surveillance System can provide early warning of health events based on geographical and temporal clusters of similar cases. As shown in our studies [1,2], however, information technology must be coupled with an understanding of the practice patterns and sensibilities of clinicians generating electronic medical data given the complexity of generating a diagnosis. Furthermore, electronic data is devoid of the richness of contextual information. Accordingly, there will continue to be needs for networks of sentinel clinicians. Practice-based research networks have a significant role in responding to new and emerging health threats. By virtue of exposure to and experience with systematic data collection, connectivity and cooperative effort, PBRNs provide ideal venues to conduct short-term surveillance, to rapidly test training and response protocols, and to assess the role of “just-in-time” sources of information. Jonathan L. Temte, MD/PhD Associate Professor of Family Medicine (1)Temte JL, Anderson AL. Rapid Assessment of Agents of Biological Terrorism: Defining the Differential Diagnosis of Inhalational Anthrax Using Electronic Communication in a Practice-Based Research Network. Ann Fam Med 2004;2:434-437. (2)Temte JL, Zinkel AR. The Primary Care Differential Diagnosis of Inhalational Anthrax. Ann Fam Med. 2004;2:438-444. Competing interests: None declared |
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Frederick M Chen, Seattle, Washington acting asst professor, Univ of Washington
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This article raises 2 issues about PBRN generazlizability for this timely topic of bioterrorism preparedness. On the one hand, I wonder whether we really need yet another study that demonstrates that PBRN physicians and data collected from them is as good, if not better, than random samples of practicing physicians. On the other hand, there will always be nagging questions that arise for any research methodologist who wonders if these PBRN physicians are really like 'regular' family doctors out there in practice. This study raises valid points that in the case of, say, bioterrorism research, where rapid response and timely answers to pressing questions are vital, the value of PBRN physicians answering email surveys outweighs concerns about validity. Using the same argument, though, you can see the need for the answers to these questions to be valid and representative for the population of primary care physicians who are on the front line. Policymakers will not be concerned much with details of study design and validity. Instead, answers that guide their decision-making, or even better, support the decisions they've already made, will be most useful. I don't doubt that these findings are valid and relevant. But researchers should continue to be wary of the trade-offs that occur when research is asked to answer timely, real world questions. Competing interests: None declared |
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Walter L. Calmbach, San Antonio, Texas, USA Univ. of Texas Health Science Center at San Antonio
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The article by Temte and Anderson in this month’s Annals makes an important contribution to our understanding of the role of family physicians in detecting and recognizing illnesses that may be due to chemical or biological bioterrorism (1). The terrorsist attack on September 11, 2001, and the subsequent unsolved anthrax attacks, made bioterrorism preparedness a national priority. As weapons, bacterial pathogens are relatively easily obtained, prepared, and dispersed. Unfortunately, most US physicians have never encountered most of these agents and the diseases they produce. To prepare for this threat, several issues must be addressed: physician training, greater use of information technology, and further PBRN research. Training: Family physicians will be the sentinel responders to any putative bioterrorist attack, However, a survey of family physicians found that only 27% believed that the US health care system was adequately prepared for such an attack (2). Twenty six percent felt that they knew what to do in the event of a bioterrorist attack, and only 18% had previous training in bioterrorism preparedness. Family physicians need more training in bioterrorism preparedness and better access to public health and medical information. Public health programs must be designed and implemented so that primary care physicians are prepared to recognize, diagnose, and treat illness caused by these agents (3) Information Technology: Great Britain has experimented with using their primary care offices as a sentinel practice network (4). They used computerized medical records to track working diagnoses and calculate weekly incidence rates for 13 targeted conditions. Greater use of EMR’s in this country could help track rare and emerging conditions as well. Likewise, the internet holds promise for disseminating valid information quickly and efficiently to patients and the public (5). PBRN’s need an electronic infrastructure that promotes enhanced communication, decision support for physicians and practices, data warehousing, and rapid integration of new findings into daily practice. Further PBRN Research: Future research projects will require greater cooperation among PBRN’s, as well as leadership from the AAFP National Network and the Federation of PBRN’s. Studies must be designed to train and test PBRN physicians on the most likely threats: smallpox, anthrax, plague, botulism, tularemia, viral hemorrhagic fever. An online clearinghouse of methods and resources should be made available to all PBRN’s. Family physicians and practice-based research networks must take the lead and prepare for the threat of bioterrorism and emerging infections. 1. Temte JL, Anderson AL. Rapid assessment of agents of biological terrorism: defining the differential diagnosis of inhalational anthrax using electronic communication in a practice- based research network. Ann Fam Med 2004;2: 434-437. 2. Chen FM, Hickner J, Fink KS, Galliher JM, Burstin H. On the front lines: family physicians' preparedness for bioterrorism. J Fam Pract 2002; 51(9): 745-50. 3. Hodgkin P, Perrett K. The role of primary care in bioterrorism, epidemics and other major emergencies: failing to plan is planning to fail. Brit J Gen Pract 2003; 53(486): 5-6. 4. Fleming DM, Barley MA, Chapman RS. Surveillance of the bioterrorist threat: a primary care response. Communicable Disease & Public Health 2004; 7(1): 68-72. 5. Kittler AF, Hobbs J, Volk LA, Kreps GL, Bates DW. The Internet as a vehicle to communicate health information during a public health emergency: a survey analysis involving the anthrax scare of 2001. J Med Internet Res 2004; 6(1): e8. *** Online Resources: AHRQ: http://www.bioterrorism-uab.ahrq.gov CDC: http://www.bt.cdc.gov FDA: http://www.fda.gov/cber/cntrbio/cntrbio.htm Competing interests: None declared |
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