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EditorialEditorials

Research in Family/General Practice is Essential for Improving Health Globally

Walter W. Rosser and Chris van Weel
The Annals of Family Medicine May 2004, 2 (suppl 2) S2-S4; DOI: https://doi.org/10.1370/afm.145
Walter W. Rosser
MD, CCFP, FCFP, MRCGP
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Chris van Weel
MD, PhD, FRCGP
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  • Re: Implementing the Kingston Recommendations
    Walter W Rosser
    Published on: 06 June 2004
  • Re: Academic primary care in the UK
    Walter W Rosser
    Published on: 06 June 2004
  • Primary Care and Family Medicine eHealth Research to Help Achieve the Millennium Development Goals
    Rodolfo J Stusser
    Published on: 05 June 2004
  • Implementing the Kingston Recommendations
    Lee Gan Goh
    Published on: 01 June 2004
  • Academic primary care in the UK
    Tony Kendrick
    Published on: 01 June 2004
  • Published on: (6 June 2004)
    Page navigation anchor for Re: Implementing the Kingston Recommendations
    Re: Implementing the Kingston Recommendations
    • Walter W Rosser, Kingston On Canada

    Go Lee Ghan: Thank you for your comments. One of my many new understandings that emerged from the conference was that the recommendations are universal and apply in similar ways in the most developed countries as well as the most underdeveloped countries. The concept of mentor ship being not only person to person but institution to institution and even country to country was another great idea. Thank you for your input...

    Show More

    Go Lee Ghan: Thank you for your comments. One of my many new understandings that emerged from the conference was that the recommendations are universal and apply in similar ways in the most developed countries as well as the most underdeveloped countries. The concept of mentor ship being not only person to person but institution to institution and even country to country was another great idea. Thank you for your input and best wishes. Walter and Chris.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (6 June 2004)
    Page navigation anchor for Re: Academic primary care in the UK
    Re: Academic primary care in the UK
    • Walter W Rosser, Kingston On Canada
    • Other Contributors:

    Tony: Thank you for this very helpful commentary. The advances in GP research in the UK are among the most impressive in the world. Yet we all experience similar challenges usually on a smaller scale. The greatest advance in the UK was the government committment of funding in proportion to the NHS budget for research. In your surveys can you show the impact of the research (not in the academc sense such as citation index...

    Show More

    Tony: Thank you for this very helpful commentary. The advances in GP research in the UK are among the most impressive in the world. Yet we all experience similar challenges usually on a smaller scale. The greatest advance in the UK was the government committment of funding in proportion to the NHS budget for research. In your surveys can you show the impact of the research (not in the academc sense such as citation index) on the population of the UK. This is where we can win out over the molecular researchers. I am unaware of effective measures of this type of impact, but would appreciate your thoughts. Thank you for your comments. walter

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (5 June 2004)
    Page navigation anchor for Primary Care and Family Medicine eHealth Research to Help Achieve the Millennium Development Goals
    Primary Care and Family Medicine eHealth Research to Help Achieve the Millennium Development Goals
    • Rodolfo J Stusser, Havana, Cuba
    • Other Contributors:

    Dear Distinguished Guest Editors Dr. Walter W. Rosser and Dr. Chris van Weel,

     

    Congra...

    Show More

    Dear Distinguished Guest Editors Dr. Walter W. Rosser and Dr. Chris van Weel,

     

    Congratulations for so significant results! To read this online set of so valuable papers has been a great pleasure and a happy surprise very expected by us since the late 1980s. We have enjoyed very much the reading of your editorial and paper as well as the other nine papers of this crucial international supplement of the Annals of Family Medicine dedicated to “Improving Health Globally and the Need for Primary Care Research: Report of the World Organization of FamilyDoctors (Wonca)Kingston, Ontario Conference”. We agree with all the thoughts and recommendations of the eleven papers, and would like to make some late reflections and suggestions, if possible.

     

    One of us who has made scientific research and research training of postgraduates in family medicine for 15 years is going to attend the Wonca 2004 Conference at Orlando this October 13-17. Maybe he could also attend previously the North American --and Caribbean-- Primary Care Research Group meeting, if he is invited as first Cuban international member of the AmericanAcademy of Family Physicians.

     

    We would like to share some personal points of view to complement your contributions as well as the contributions of the other nine distinguished authors. It is important to notice that we do not want to make a prescription for the low-income countries and lowest-income areas of high-income countries. Very far from that we only would like to encourage more meditations and discussions to help improve this so relevant scientific medical and health care matter of our times: Family Medicine Research.

     

    It is true that the increasing interest in theprovision of primary health care clinical service and educationhas not been accompanied by investment in researchefforts, as you well said in your editorial. However, family medicine researchers could take more advantage of the new ehealth research methods that began to appear in the medical methodological arsenal in the middle of the 1990s, which could be of great help.

     

    Our late but sincere comment on this set of important results of the Wonca meeting is as follows:

       

    Primary Care and Family Medicine eHealth Research to Help Achieve the Millennium Development Goals*

     

    In 1978, the World Health Organization (WHO) promoted a comprehensive and integral primary health care (PC) strategy to achieve the unfulfilled goal: “Health for All by the Year 2000”. Those efforts increased PC professionals and services, but results were insufficient due to scarce physicians, nurses, other resources, community participation, and deviation in low-income countries and areas to selective and vertical PC strategies in child survival.[1] PC research and development (R&D) to improve the quality of care was increased, although little useful results were obtained due to limited scientific and financial support.[2] In the 1990s, the WHO created the Council on Health Research for Development to strengthen the national health R&D strategies, and afterwards the Global Forum for Health Research Foundation (GFHR) to help correct a 10/90 funding gap on global health R&D problems. In 2000, the WHO and other international agencies established eight Millennium Development Goals (MDGs) to improve in new terms the health and life of humanity.[3] In 2004, the North American Primary Care Research Group (NAPCRG) and the World Organization of Family/General Doctors (Wonca) recognized that research in family medicine and other general specialties of primary care are essential and need to be increased to improve health globally.[2,4-5]

     

    Ten years ago, ehealth applications through the Internet and other information and communication technologies (ICTs) emerged as new tactics to assist all the levels of health care, education and R&D.[6] They are already integrating “at distance” researchers, research centers, and research designs, observations, experiments, analysis and results as never before in the whole world, through high speed communication channels that each time gives more possibility to a more comprehensive text, image and voice information exchange.[7-8]

     

    In our view the use of the ehealth R&D tactics per se in PC and family medicine (FM), and of the ehealth R&D collaboration in an integrated local, regional, and global health R&D strategy more reoriented to the PC/FM needs, can help strengthen the national R&D strategies, correct the 10/90 funding gap, and finally achieve the eight MDGs.

     

    The ehealth R&D in PC/FM per se made through personal computers, Internet, and other ICTs, could constitute some of the long time desired high-technologies that the general and family physicians have never had for PC/FM research in the last 60 years of biomedical technological boom. With all those ICTs, they are beginning to design and carry out their highly complex general research on their patients, families, and communities, as well as on their health services, even in the most remote areas with bad snail mail.[9] One interesting example of this is the Clinical Assessment of the Reliability of the Examination CARE Collaborative Multipractice Study.[10]  Nevertheless, ehealth R&D perspectives seem wider than to allow the web-based collection and analysis of international data. The ehealth R&D is begining to allow virtual team "hands on" design, conduction, analysis, publication, discussion, and assessment of observational and experimental studies and results online and practically in real time, so far through high-speed web-based exchange of text, images and voice.[7]

     

    The ehealth R&D could allow through automated data mining techniques (ICTs extension of the statistical data-dredging in paper) two types of integrated multiple bioclinical, epidemiological, and sociohealth research methods. 1) The classical hypothesis-driven research in universal scientific databases, as for example PubMed, by discovery support systems as for instance ArrowSmith;[11] and 2) the data-driven research in local, provincial, and national health care databases of electronic health records in PC settings with lab data, images, and text of also secondary and tertiary care settings, through new discovery support systems that could arise to research the multidimensional biological, psychological and social process of the patient, family and community health.[9]

     

    The ehealth research through the ICTs could allow the reintegration research in bigger clusters of scientific knowledge --with new kind of cause-effect relations-- of the atomized human being health issues in the enormous and marvelous amount of very differentiated little pieces of scientific knowledge produced so far by the other technologies of the biomedical and public health specialized sciences in the last 150 years, as well as could promote new kinds of integrated general clinical and health research and sciences.[9]

     

    Also, diverse comprehensive national and international health R&D collaboration networks and partnerships with an integrated policy and system through ehealth R&D tactics could be created.  In them, the secondary and tertiary more specialized care R&D, as well as the industrial R&D, could be more integrated with the PC/FM R&D of the patient and family health and its determinants at their community, nourished also by the world applied R&D results of the human genome and brain projects, within other global, regional and international projects.

     

    This integrated health R&D strategy could help PC/FM to continue addressing its corresponding standard R&D scientific targets to lower infant, maternal and infectious mortality, morbidity and disability, lengthening the life span with basic physical quality of health. But also, in these physical survivors the PC/FM ehealth R&D could help approach more effectively behavioral scientific targets not well achieved up to date. For example: How to encourage in the patient, family and community higher levels of civility, education, culture, and more positive life styles and health determinants to enjoy more healthier and prosperous lives in the material, spiritual and cultural senses taking them out of the vicious circle of poverty? How to promote in them higher quantitative health and life standards, but with basic quality of health and life too? 

     

    With the R&D methodological support of the investigators of the institutes, hospitals, clinics of the government, universities, industry, and private sector, as well as with international collaboration and external financing, it could be started the development of sentinel ehealth R&D community centers with practice-based R&D networks and partnerships in the capital and provinces creating a stronger PC/FM R&D subsystem integrated to the national health R&D system.[9]  Their main tasks could be among others as follows:

     

    The creation of areas or centers of PC/FM clinical and population trials to test assimilable technologies and procedures from institutes, hospitals and other PC settings as: natural products, alternative techniques, behavioral change programs, vaccines, drugs, medical equipment, and biotechnological products for the prevention, diagnosis, prognosis, therapeutics and rehabilitation of risks, deaths, injuries, diseases, and disabilities.

     

    The creation of areas or centers of PC/FM R&D to develop new own research spaces of the FM and other PC community specialties, as general internal medicine, pediatrics, obstetrics, epidemiology, health management, and different research spaces shared with other specialties,[12] as for instances: integrated and dynamic classification of health per se, health problems and disease, including positive health status and its determinants; direct PC, home care and integration of care of patients through new ehealth applications, and standardized electronic health records for PC or unique for all the national health system;[13] new methods for health status measurement and assessment in patients, families, communities and populations, and new methods to assess patients for multiple conditions or pathogens at point-of-care.[14]

     

    Some of these centers of excellence for PC/FM R&D could be made WHO collaborating centers for the low-income countries and lowest-income areas of high-income countries, conducting also bottom-up regional and global health R&D projects through ehealth R&D collaboration, beginning from the crucial PC/FM research problems and needs integrated with the ones of the institutes and hospitals, to increment the health results, social impacts, and cost-effectiveness of the national and international cooperation.

     

    Concluding, the PC/FM ehealth R&D national and international collaboration networks, public-private and civil-society partnerships, which could be also promoted by the NAPCRG and Wonca, can allow the WHO, GFHR, and other international agencies in the low-income countries and areas of high-income countries to strengthen and integrate their PC/FM and all levels of care, education, and R&D to achieve their MDGs goals.

     

    The brightest future of primary care and family medicine research depends of ehealth research too.

    Let’s continue openly to new reflections and discussions!

    Thank you.

     

    Rodolfo J. Stusser, MD

    Primary Care Research Unit, VedadoHealthCommunity Center, Havana, Cuba.

    http://familydoctor.org/myhavananpolyclinic/

    Richard A. Dickey, MD

    Clinical Endocrinology Section, WakeForestUniversitySchool of Medicine, Winston-Salem, NC, USA.mdrad@charter.net

    Alfredo Rodriguez, MSc

    Public Health Computerization Project, Center for Health Informatics Development,

    Havana, Cuba. alfredo@cedisap.sld.cu

     

    * We hope to discuss this paper in the GFHR/WHO/Mexican Health Secretary: “Forum 8 and World Summit in Health Research to Achieve the MDGs”. Mexico City, November 16-20, 2004.

     

    References


    1. Werner D, Sanders D, Weston J, Babb S, Rodriguez B. QuestioningtheSolution: ThePoliticsofPrimaryHealthCareandChildSurvival. Palo Alto CA: HealthWrights; 1997. Itwill be available online at: http://www.healthwrights.org/books/QTSonline.htmAccessed May 28, 2004.
    2. Rosser WW, van Weel C. Research in Family/General Practice is Essential for Improving Health Globally. AnnFamMed. 2004;2(suppl_2):S2 - S4. [Free Full Text][PDF]
    3. United Nations. Millennium Development Goals (MDGs).Division for Social Policy and Development.Department of Economic and Social Affairs.New York, 2000. Available at: http://www.un.org/millenniumgoals/  Accessed May 28, 2004.
    4. Green LA. News: Future of Family Medicine Recommendations Confirm Need for Increased Research from Family Physicians. From the NAPCRG.Ann Fam Med. 2004;2:282-283.[Free Full Text]
    5. van Weel C, Rosser WW. Improving Health Care Globally: A Critical Review of the Necessity of Family Medicine Research and Recommendations to Build Research Capacity.Ann Fam Med. 2004;(suppl_2):2:S5-S16. [Abstract][Free Full Text][PDF]  
    6. Stusser RJ, Kriel RL, Dickey RA, Krach LE.  Reviews. Personal view: How the internet could help Cuba more in health research. BMJ. 2004;328:1209 (15 May). [Free Full Text]
    7. Stusser RJ, Dickey RA, Kriel RL, Krach LE. International e-Health Research Collaboration Method for Global Health Research.Article under review in an Informatics Journal.
    8. Dickey RA, Stusser RJ, Kriel RL, Krach LE. Online Virtual Health Research via Cuban-US Collaboration. Abstract for Poster presentation, ENDO 2004, Endocrine Society Annual Meeting, New Orleans, June 2004.Availableat:

    http://www.abstracts2view.com/endo/sessionindex.php?p=2Accessed May 28, 2004.
    9. Stusser RJ. Rapid Response: IT will lead to radical redesign of health care, education and research. BMJ.2004 (17 May). [Free Full Text]
    10. Straus SE, McAlister F, Sackett DL.Clinical Assessment of the Reliability of the Examination (CARE) Collaborative Multinational Study, Mt. Sinai Hospital, University of Toronto, 2003.Available at: http://www.carestudy.com/CareStudy/Accessed May 28, 2004.
    11. Smalheisser NR. Informatics and hypothesis-driven research.EMBO Rep. 2002; 3:702. [F ree Full Text]
    12.  Stusser RJ. The creation of family medicine new research spaces.Integration Science Program.Plaza Community Polyclinic/Nuclear Clinical ResearchCenter, Havana, 1996. Available at: http://www.fortunecity.com /skyscraper/systems/1000/artfam2.html. Accessed May 28, 2004.
    13. Norris TE, Goldberg HI, Fuller S, Tarczy-Hornoch P, editors. Informatics in Primary Care.Strategies in Information Management for the Health Care Provider. 1st ed.New York: Springer Verlag; 2002.
    14. VarmusHE’s Scientific Board. Goals and Grand Challenges in Global Health.Foundation for the National Institutes of Health, Bethesda, MD, 2003. Available at: http://www.grandchallengesgh.org Accessed May 28, 2004.

     

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (1 June 2004)
    Page navigation anchor for Implementing the Kingston Recommendations
    Implementing the Kingston Recommendations
    • Lee Gan Goh, Singapore, Singapore

    The Kingston invitational conference in Family Medicine Research was a forum in which the major issues of family medicine research were scrutinised in the plenary sessions and also in the small group discussions. The Kingston Conference recommendations that came out of the processes represent a fine distillation of the contributions of the participants and indeed form a milestone in the development of family medicine re...

    Show More

    The Kingston invitational conference in Family Medicine Research was a forum in which the major issues of family medicine research were scrutinised in the plenary sessions and also in the small group discussions. The Kingston Conference recommendations that came out of the processes represent a fine distillation of the contributions of the participants and indeed form a milestone in the development of family medicine research as a global activity.

    Accolades must be given to the two convenors Chris van Weel and Walter W Rosser. Upon their shoulders lay the task of putting the recommendations together and the outcome in this issue of the Annals. Titled Improving Health Care Globally: A Critical Review of the Necessity of Family Medicine Research and Recommendations to Build Research Capacity, the output is their labour of love and a powerful roadmap to the family medicine fraternity worldwide.

    The Kingston recommendations together form a road map for organizational, national, and regional efforts at developing family medicine research infrastructure and processes. From the standpoint of implementing the family medicine recommendations, it is useful to group the recommendations into three big areas:

    Building dissemination mechanisms and clearinghouse. Family medicine research, like all research, need to be widely disseminated and applied at the various settings: in the practice, the classroom, and at meetings. Making family medicine findings easily available is therefore important. The possibilities for such activities are many: the classroom, conferences and meetings (recommendation 1), websites, journals, newsletters (recommendation 6) and also respositories and clearinghouses (recommendation 3). The Internet and websites like the GFD website form ideal repositories that can be accessed 24 hours a day. The use of some form of classifying family medicine research will be useful. The classification model of patient, doctors, disease, and services by Kurt Stange is worth considering.

    Building research infrastructure and processes. There are several infrastructure and processes that can be set up: the sentinel practice systems (recommendation 2); university departments and institutes (recommendation 4); and practice-based research networks (recommendation 5). Each of these could be linked into a local network and across countries as regional networks. The power of numbers can be realized in the collaborative studies that could be spawned. Into these infrastructure and processes must be included learning, training and mentoring. The cascade of learning and teaching where the more able and experienced (the research leaders) teach the next level (research principal investigators) in turn the next level (the neophytes), very much like the system of clinical teaching in the wards is the way to go.

    Building social capital. Social capital is important for research sustainability over the long haul. Funding of international collaborative research (recommendation 7); setting up of international ethical guidelines (recommendation 8); and meeting specific needs (recommendation 9) are important social capital building blocks.

    The forthcoming Wonca Asia Pacific workshop on research network development in Phuket will focus on some of these implementation areas.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (1 June 2004)
    Page navigation anchor for Academic primary care in the UK
    Academic primary care in the UK
    • Tony Kendrick, Southampton, England

    Commentary from:

    Tony Kendrick

    Professor of Primary Medical Care, University of Southampton, England. Director, Wessex Primary Care Research Network (WReN). Chair, UK Society for Academic Primary Care (SAPC) Heads of Departments Group.

    The UK Heads of Departments Group welcomes and endorses the call by Chris van Weel and Walt Rosser to display the research achievements of family medicine and...

    Show More

    Commentary from:

    Tony Kendrick

    Professor of Primary Medical Care, University of Southampton, England. Director, Wessex Primary Care Research Network (WReN). Chair, UK Society for Academic Primary Care (SAPC) Heads of Departments Group.

    The UK Heads of Departments Group welcomes and endorses the call by Chris van Weel and Walt Rosser to display the research achievements of family medicine and promote the development of greater research capacity.

    Three years ago we carried out a survey of all academic departments of general practice and primary care in the UK (the report, entitled New Century New Challenges, may be found on the SAPC website at http://www.sapc.ac.uk/Mackenzie2.doc ). This survey was a follow-up to the 1986 Mackenzie Report. We found that, between 1986 and 1998, there was a significant expansion in research capacity. By 2001 we numbered 31 university medical school departments, including 66 professors, 128 full- time equivalent senior clinical staff, and 41 fte senior non-clinical academic staff. However, this expansion had slowed between 1998 and 2001. We are currently repeating the census of staffing levels, as we suspect growth has not been maintained at the same rate over the last three years.

    Departments of academic general practice and primary care demonstrated that they could achieve the highest ratings in the UK universities research assessment exercise of 2001. Examples of high quality research cited in the SAPC report include major studies of health promotion and prevention, help-seeking behaviour, acute illness, chronic disease management, the organisation of primary care, and the primary- secondary care interface.

    Many primary care networks have been developed in the UK, and are most successful when working closely with university departments. My own department in Southampton runs the 294 member Wessex Research Network WReN. A series of highly successful and important trials have been carried out in WReN, as in other networks such as the Midlands Research Network MidReN, run from the department at Birmingham.

    However, we face a number of challenges to the maintenance and development of primary care research in the UK. We are still a small minority of clinical academics in the UK – around 5% only, despite the fact that 90% of health care contacts occur in our primary care system. The establishment of new departments has largely involved a redistribution of the existing pool of senior academic staff, and recruitment and retention of junior staff is difficult due to a lack of lecturer level posts compounded by significant disparity between the pay of academics and their service colleagues. Non-clinical researchers are often employed on short-term contracts tied to research grants, with little or no job security or professional development in post. We continue to lobby government and universities for more resources and better established career pathways.

    Research funding in the UK has become more top-down, with fewer opportunities to win response-mode project grants for good ideas, and a much greater emphasis on commissioning research from the centre. Laboratory based biomedical research has been funded at the expense of clinical and health services research. However, there will soon be new opportunities offered by the Medical Research Council, and the National Health Service Research and Development Directorate, which have both acknowledged the need for more funding of clinical research, through national networks related to particular topics such as cancer, diabetes, and mental health. It remains to be seen how primary care research, which often cuts across specific clinical topics (for example looking at continuity of care, whole person care, and the primary-secondary care interface) might benefit from the UK Clinical Research Collaboration which is being developed to take this forward. We are doing our best to influence that agenda.

    I recommend that colleagues seeking to develop research capacity in primary care in their countries look at the history of such developments in the UK. We should also continue to work together through WONCA, NAPCRG, the EPGRN, the International Federation of Research Networks and other international collaborations, to develop international studies which will demonstrate the excellence of primary care research and its potential to address some of the biggest problems facing health care systems.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 2 (suppl 2)
The Annals of Family Medicine: 2 (suppl 2)
Vol. 2, Issue suppl 2
1 May 2004
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Research in Family/General Practice is Essential for Improving Health Globally
Walter W. Rosser, Chris van Weel
The Annals of Family Medicine May 2004, 2 (suppl 2) S2-S4; DOI: 10.1370/afm.145

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Research in Family/General Practice is Essential for Improving Health Globally
Walter W. Rosser, Chris van Weel
The Annals of Family Medicine May 2004, 2 (suppl 2) S2-S4; DOI: 10.1370/afm.145
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