Family Medicine Research: Implications for Wonca

INTRODUCTION

Several attempts have been made to define or describe the role of the general practitioner^1–,⁴ since Wonca was formed as a world organization for family doctors in 1972. A similar effort to write a policy document on family medicine research has not been done.

Research is seen by most family physicians as a specialist endeavor or a task necessary for the few family physicians who want to become academics. Research is not appreciated as a part of good primary care. This lack of understanding that research is an integral part of both intellectual and practical family medicine greatly influences the thinking of those who administer primary care—the politicians, practice managers, health economists, and primary care administrators—and the family physicians themselves. To change their attitude toward family medicine research, the notion that research is an integral to family medicine should be promoted.

The challenge for Wonca is how to describe family medicine research in terms that cause family physicians to regard it as a part of their specialty. Wonca must support and encourage family physicians to be active in family medicine research; promote high-quality research in family medicine; educate politicians, administrators, and managers so they understand the necessity of family medicine research; and encourage governments and donor organizations to fund international family medicine research.

RECRUITMENT AND TRAINING

RESEARCH THEMES

The important questions in family medicine depend on the “eyes that see,” but it is more likely that a curious family physician can formulate interesting research questions and find research methods that are applicable to primary care than a physician who has no experience in family medicine.

There are many relevant clinical questions that need answers. Some patients are seen only by a family physician, who both diagnoses and manages the patient’s health problem without referring to other physicians. Some patient care problems can be solved by using clinical controlled trials, but often these methods are not practical in a primary care setting, and other methods have to be used or developed.

Some problems encountered in family practice are related to patients who complain of vague symptoms from many parts of the body. The biomedical approach is insufficient to understand these patients’ conditions, and research methods from other sciences have to be applied. A considerable portion of the research in primary care should focus on health problems that most people have most of the time.⁵

Epidemiological studies are important because they form the basis for our knowledge of primary care. Epidemiological research requires data about patient’s disease episodes when the patient reports unspecified symptoms to when the symptoms become a defined pathological entity that can be labeled with a diagnosis. To do this research and compare results internationally, it is necessary to develop a comprehensive classification of patients’ reasons for the encounter, the process of care, and the family physician’s diagnostic terminology.⁶

Health care service research is another important topic in which family physicians should be involved. Teamwork and cooperation among the different health care workers and the different levels of health care are core issues for a health care system and for the optimal use of resources. The way we deliver health care to people has a great impact not only on their health but also on recruitment and sustainability of health care personnel, especially in rural and remote areas. We need to know more about how organizing health services affects both patients’ health-seeking behavior and the use of resources.

In societies where changes in organization and financing of health care services are frequent, there is a need for monitoring and documenting the effect of such changes. Although the changes are mainly administrative, they have a great impact on the working conditions of family physicians.

Other themes are prevention of major health problems, especially those related to a population’s lifestyle, such as smoking, excessive drinking and eating, and lack of physical exercise. Prevention of infectious diseases, such as measles, acquired immunodeficiency syndrome, and malaria, and early detection of treatable cancers, such as cervical uterine cancer and breast cancer, are additional large areas for primary care research.

Disease mongering has become a real threat to the balance of health care.⁷ Strong pharmaceutical and medical industries and special interest groups among patients, politicians, and physicians influence the demand for care by the general public. These influences can change the patient’s reason for encounter and move the family physician’s work away from detecting and treating specific diseases toward dealing with resourceful and demanding individuals whose main concern is fear of a disease they do not have. In a world where individualism and money play an increasing role, family physicians have to work for solidarity and fairness in the distribution of the health care resources.

The implications for Wonca are to (1) help define researchable questions, (2) help to prioritize family medicine research in developed as well as in developing countries, and (3) encourage the profession and societies to focus on the important aspects of medicine.

METHODS

To carry out research in a primary care setting, special methods and research design must be used. These methods have to be developed and described by the family physicians and other professionals working in primary care.

Wonca supports this development through the Wonca International Classification Committee (WICC) and other working parties and groups. Through the years WICC has been one of Wonca’s most productive committees. Its main task has been to develop a number of comprehensive classifications for primary care. The best known is the International Classification for Primary Care, now available in its second edition (ICPC-2)⁶ and in an electronic format ICPC-2-E.⁸ This classification must be able to communicate with such classifications as ICD-10, which is used in secondary and tertiary health care service. ICD-10 can be mapped to other major classifications, such as SNOMED CT, ICD-10-CM, and ICD-10-AM, which ensures a conversion between these classifications and ICPC-2.

A fruitful relationship between Wonca and the World Health Organization (WHO) has resulted in establishing a working group of the center heads of the WHO Collaborating Centres on Classifications and WICC. The task is to get WHO to adopt ICPC-2 as a member of the family of classifications. ICPC-2 is one of the missing links in the WHO family of classifications. It is the only comprehensive primary care classification that enables the coding of the patient’s reason for encounter and the physician’s classification of the patient’s health problems in diagnostic terms.

To facilitate international communication and understand the concepts relevant to family medicine, WICC has developed the Wonca Dictionary of General/Family Practice.⁹ This dictionary is the first attempt to provide a comprehensive source for understanding the words, terms, and concepts we use in family medicine. It is based on “An International Glossary for General/ Family Practice,”¹⁰ which mostly contains scientific terms related to family medicine.

Other tools have been adapted to the specific needs in family practice. Among these tools are the DUSOI/WONCA severity of illness charts⁸ and the Dartmouth COOP/WONCA functional assessment charts.¹¹ Both have been extensively tested internationally in family medicine and have been useful and valid for specific research purposes. To gain wider use, these tools must be developed further and tested in primary care settings in different parts of the world.

Other health outcome measures have been developed and modified for use in primary and ambulatory care,¹² and should be available to family physicians throughout the world. Methods for recording practice activity and software programs that can retrieve data from the electronic patient records are examples of tools that can help and promote research in family practice.

It is important to look for new research methods if we want to answer research questions about patients with many or vague symptoms and with health problems that do not represent defined clinical entities, or if we want to understand why patients behave in a strange way. To gain insight into such problems, qualitative research methods are needed, and these methods are relatively new to medicine. They are not yet integrated and approved by the dominant scientific bodies in most medical schools. These methods, adopted from such sciences as anthropology, psychology, and sociology, are often based on interviews, focus groups, and other observations that can help us to understand our patients rather than simply counting them.

To promote international communication and to develop international research programs, it is important that we harmonize data about family medicine and develop terminology, definitions, and classifications that we share. Standards of good primary care research and ethical considerations must be developed to prevent exploitation of populations in developing countries for commercial reasons or scientific merit. Only an international organization such as Wonca can do this and make these standards available for family physicians throughout the world.

The implications for Wonca are to (1) develop a comprehensive database of research tools relevant in family medicine research; (2) support development and tests of research tools and methods; (3) support adaptation of research methods and tools to suit the needs of family medicine research; (4) promote international communication by harmonizing data, terminology, classifications, standards, and definitions; and (5) describe ethical guidelines for international family medicine research that supplement national guidelines.

CONCLUSION

It is now time for Wonca to determine a policy for family medicine research by developing a long-term and comprehensive strategy to promote research in family medicine and primary care.

This policy should be made known to every member organization and every family physician. It should also be made known to WHO, governments, and other national and international bodies that want to have well-functioning comprehensive health care in which family medicine plays an important role. Through this effort, Wonca can help change the research culture among family physicians worldwide and in the medical scientific community at large.

The following are ways Wonca can promote family medicine research:

1. Write a Wonca policy statement on research in family medicine/primary care

2. Describe family medicine research in all parts of the medical curriculum

3. Arrange focused and high-quality research workshops, courses, and master classes

4. Influence journals and indexing bodies to include family medicine as a specialty heading

5. Create scholarships and fellowships for international family medicine researchers

6. Describe ethical guidelines for international primary care research and post research follow-up

7. Influence WHO and other international bodies, governments, and national colleges about the necessity of good family medicine research

Wonca can also create the following databases:

1. International research funding

2. Institutions with expertise in research and education

3. Mentors, supervisors, and other resource persons

4. Family medicine research tools, methods, and strategies

5. Family medicine research literature and bibliographies

6. International research networks, audits, and working groups

7. Models of successful family medicine research projects

8. Harmonized data, terminology, definitions, standards, and classifications