Improving Health Care Globally: A Critical Review of the Necessity of Family Medicine Research and Recommendations to Build Research Capacity

Chris van Weel’s and Walter W. Rosser’s paper would have a profound impact to recommendations and practical guidelines how family physicians could develop and improve research in family medicine throughout the world. They also collected an impressive number of references which easily lead to additional investigations about topic. Following the article Improving Health Care Globally (1) I conduced some interviews with colleagues about their opinion about topic and did small research through some working and some not yet published documents. The results are amazing! Colleagues, clinical specialist, were astonished at the beginning. “Why is it needed? We have the very same principles. Research in medicine is already organized round the world.” were very often answers. They received brief information from the article and some examples from every day work, such as: “who really need clinical specialist for every medical complain”, and at the and of a dialogue there level of understanding and approval increased. All colleagues GPs supported the idea of global research network. Their most common answers were: 1. It is needed to support family medicine as scientific discipline. 2. If we don’t have solid evidence based research in family medicine, we would have problems to produce relevant recommendation and algorithms for every day work in practices. Recommendations from other medical specialities can’t be directly applicable in family medicine. That is very important in a court of law as well. 3. It is needed to harmonize family medicine globally, especially in context of free movement of medical professionals. But, local specific needs of patients must be identified and that is possibly only through solid research. 4. If it’s not developed systematically through prepared network, it is up to individual GP to be as inventive as possible to make some reserved time in practice to conduct a research, not mentioned to find resources for such work, what is much easier said then done. 5. It is an excellent opportunity for career development. Family physicians often feel isolated, and that is a great opportunity to step out of isolation.

Primary care contributed to improved public health, as expressed trough different health parameters, and a lower utilisation of medical care leading to lower costs. Physicians working in primary care in comparison with other specialists took care of many diseases without loss of quality and often at lower cost. The organisation of primary care was important in respect of reimbursement by capitation, more group practices, higher personal continuity, and having generalists as primary care physicians. There is an extensive need for future research in this area. (2) General practice / family medicine (GP/FM) is being recognised as an increasingly important element of modern health-care systems, being popular with patients able to retain a personal relationship with their doctor in the increasingly impersonal world of health-care delivery, and with politicians because of its inherent cost effectiveness. General Practice has developed with the breath taking progress in the medical sciences, the health care system expectations growing accordingly. (3) An international consultation includes an analysis of the potential effect of creating a primary health care delivery system based on the model of family medicine. The consultation culminated in the creation of the speciality of family medicine and in the establishment of the medical educational system to train family physicians. (4) But all this is often not relevant for young people to choice medicine as their carer, or family medicine at the and of their medical school. There are reports about serious problems to recruit young doctors to primary care. (5) Offering new opportunities on a field of research would also make Family Medicine more attractive choice for young colleagues and would build up self-esteem of already working doctors.

In order to make Family Medicine a real tool to improve health care globally further activities are needed to build research capacity in every country linked in global network.

Ref.: 1. 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; 2(Supp 2):S5-S16. 2. Engstrom S, Foldevi M, Borgquist L. Is general practice effective? A systematic literature review, Scan J Prim Health Care 2001;19:131-44. 3. UEMO 2004 POLICY DOCUMENT ON SPECIALIST TRAINING, UEMO 2004/034. www.uemo.org. Accessed September 24, 2004. 4. Montegut AJ, Cartwright CA, Schirmer JM. An international Consultation: The Development of Family Medicine in Vietnam. Fam Med 2004;35(5):325-6. 5. Minutes from Working Group Future GP Workforce. UEMO draft document 2004/025. www.uemo.org. Accessed September 24, 2004.

Competing interests:   None declared

Wonca, Walter W Rosser and Chris van Weel deserve many accolades for successfully organizing the 2003 Wonca research conference. This has resulted in seminal papers and practical recommendations to guide Wonca and family physicians in their vision to improve research in family medicine throughout the world.

As a conference participant, my overriding memory is of the strong fellowship of seventy-eight family physicians coming together from thirty- four countries to decide on the essentials of family medicine research, and how to build capacity to reach that vision. Previous Wonca meetings have shown that family physicians share common values of clinical care. This research conference demonstrated that family physicians, from both developed and underdeveloped countries, share the vision of strengthening research in our discipline.

One recommendation for capacity building encourages the use of participatory (action) research to involve family physicians in the research needs of their communities. Participatory (action) research supports family physicians and communities to form research partnerships, which combine expertise from researchers and expertise from communities, with the end goals of both answering questions relevant to the community and increasing scientific knowledge. The knowledge, expertise, and resources of the involved community are often key to successful research. The three primary features of participatory research are collaboration throughout the research process, mutual education, and action on the results that are relevant to the community. This partnership approach to research is a natural evolution for family physicians who have significant experience in developing partnerships with their patients for clinical care. It shares some goals of community oriented primary care, which also seeks to directly improve the health of the community [1]. Wonca also recommends the development of international ethical guidelines, in particular for participatory (action) research, to ensure additional protection of communities in addition to protection of the individual.

Reference 1.Nighswander T. Classic Evidenced Based Research is Unrealistic for Physicians Practicing in Sub Sahara Africa. Annals of Family Medicine. Track comments June 8 2004

Competing interests:   None declared

Walter Rosser, Chris van Weel and colleagues have done a creditable job in reviewing Primary Care Research from an international perspective. Developments such as the Brisbane Initiative are certainly steps in the right direction for building capacity and family medicine research. Family medicine still lags behind other disciplines in its academic base; until we can develop more coherent career structures and encourage our younger colleagues to choose careers in this field, our discipline will retain its undue focus on service without an appropriate evidence-base.

Building capacity in academic Primary Care can be a frustrating exercise and one which probably requires "eternal vigilance". In the UK, whilst Departments of Primary Care have generally expanded over the last decade, this has been largely through health service rather than education sector investment. Further, despite this expansion and the best efforts of initiatives such as the Scottish School of Primary Care, there is the sense that capacity building has stalled, particularly with the reduction in research and development funds for health services research and a general decline in clinical academic activities.

The paper by Rosser et al paints a lively picture; there is without doubt a mixed economy of activities around the world ranging from PhD programmes to "virtual schools". WONCA does seem to be well placed to take on a facilitative role in funding and co-ordination of research. Only then can academic family medicine assume its rightful place amongst other international academic communities.

Competing interests:   None declared

The article has an interesting and comprehensive content that need to be considered by many FP researchers, policy makers and academic institutions. It contains a rich material and describes many ways to establish and develop research capacities. I think the article (and the whole supplement) will be frequently quoted and also be an inspiration for many readers.

I want to add a few comments. The authors discuss the isolation of FP research in relation to other research areas (biomedical realms) and describe it as encouraging signs when FP researchers have broken out of the "loneliness". Partly I agree. But I think it is also important to balance this acceptance in the medical research society in relation to the danger of loosing the FP identity. The cornerstones of FP are difficult to analyze and describe within the traditional biomedical research paradigms. Thus being strictly loyal to the characteristics of the subject (see the person rather than disease; understand the context of illness; attach importance to subjective aspects of medicine etc) might imply a risk of research isolation with an intact identity. On the other hand a too close contact (and inclusion) with the traditional research ideas could mean a fading of important specific values. It is important to contemplate on this balancing between being out in the cold and be within the common medical research culture with less identity. Sometimes a choice is necessary and the guiding principle must be that the identity can not be too watered down.

Qualitative research methods are often very useful in studying our core concepts. Research cooperation with bodies experienced in theses methodologies (social and humanistic sciences) is important to support (1).

The authors also strongly support the necessity of evidence based facts and these are usually received from different types of systematic review studies. The qualitative research experiences are more seldom used in reviews however. Recently a report on integrating qualitative research with trials in systematic reviews has been published (2). That is very satisfactory and an extended use of such methods will include important FP experiences and understanding in the knowledge basis in the suggested clearinghouses.

References

1. Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. Lancet 2001;358:397-400.

2. Thomas J, Harden A, Oakley A et al. Integrating qualitative research with trials in systematic reviews. BMJ 2004;328:1010-12.

Competing interests:   None declared