Primary Care Research: Looking Back and Moving Forward With Reflections on NAPCRG’s First 50 Years

Honoring the Past

Every organization emerges in an environment that propels it into existence to fill needs and meet challenges. NAPCRG’s origin story is an international account involving the United Kingdom, Canada, and the United States in the early 1970s, at a time of great upheaval in society and rapid shifts toward sub-specialization in medicine.² The turmoil included people marching in the streets demanding an end to war, civil rights for people of all races, and equal rights for women. General practice was steeply declining in the United States and just finding its way in Canada and the United Kingdom.

Family medicine was not the result of a scientific breakthrough or technological advance. Instead, it was created to respond to the pleas of communities for good doctors to look after them regardless of their medical or health problems. Family medicine entered this chaotic environment as a new medical specialty aspiring to meet the needs of patients, communities, and national health care systems. The most urgent need was to train expert generalist physicians, and the demand for education took precedence over research and intellectual development of the emerging specialty.

A few exceptional general practitioners in the United Kingdom, Canada, the Netherlands, and the United States championed research in and about general practice. They recognized that the disease-oriented research done in hospitals and speciality clinics is not representative of primary care patients and cannot provide the knowledge needed for community-based practice. These radical visionaries recast the gaze of research from organs and hospitals to whole persons and the communities where they live, work, and play.²

In 1972, they gathered in Virginia to share ideas about establishing a research enterprise in family medicine. Convening the group was Dr Maurice Wood, who had left his practice in the United Kingdom to help build academic family medicine in Virginia and dramatically influenced the development of family medicine in North America.³

That first meeting exceeded expectations. Participants declared it an essential building block in the foundation of family medicine, the invention of primary care research, and the transformation needed in medical practice and health care. They looked to Dr Wood to create the structure to bring them together to do this important and exciting work.

With support from the fledgling Department of Family Medicine at Virginia Commonwealth University, they teamed with many others, including early researchers in general internal medicine, pediatrics, nursing, epidemiology, and behavioral sciences, to create a new organization devoted to research in primary care.² They strategically crafted the name to avoid the limits of family medicine, United States, or Canada. They called it “The North American Primary Care Research Group.” (Table 1)

The organization and members have been guided for over 50 years by enduring core values that characterize a culture in contrast to the academic establishment and traditional scientific and specialist societies.^1,2,6 (Table 2)

NAPCRG developed along 3 main paths: building partnerships, innovating research methods, and nurturing a diverse community of contributors.¹²

Building Partnerships

NAPCRG was built to span the longest undefended border in the world, welcoming primary care researchers across Canada and the United States. While maintaining this distinctive bi-national structure, NAPCRG reached out to embrace colleagues worldwide.^6,28 NAPCRG earned its position as a member of the “family of family medicine” organizations,^27,28 including the alphabet soup of organizations in the United States and the College of Family Physicians of Canada.^7,4,27 It quickly grew to include key organizations in colleague countries. WONCA, the World Organization of Family Doctors, brought a global community.^2,4,28 Each partner organization added essential connections to practitioners, patients, and governments.

To reflect is worldwide membership and mission, the ogranization now names itself simply NAPCRG.

NAPCRG helped birth and foster practice-based research networks (PBRNs) across North America and worldwide.^21,22 In 1979, it endorsed the Ambulatory Sentinel Practice Network (ASPN), supported by the Rockefeller and Kellogg Foundations and the University of Colorado Department of Family Medicine.^21,22 Since 2012, NAPCRG has hosted the Practice-Based Research Networks Conference and developed PBRN Research Good Practices,^31,32 with support from the Agency for Healthcare Research and Quality (AHRQ).² Many practicing clinicians connect with research through these networks.

NAPCRG has always held the patient and community close to its heart and embraces them as essential partners to inspire research and connect it to what matters most.^{1,2,4,12,13,17,24,25} NAPCRG pioneered participatory research^2,4,24 with landmark policy statements that respect the knowledge and honor the wisdom of patients and communities.^24,25,33,34

Through the Patient and Clinician Engagement (PaCE) program, NAPCRG brings together hundreds of patient-clinician dyads for advocacy, engagement, and research.^17,18

Following these commitments, NAPCRG has established positions for Canadian and US patients on its governing board and welcomed patients on committees.^1,17

Another powerful partnership created Annals of Family Medicine to publish primary care and family medicine research, sponsored by NAPCRG and joined 6 other organizations American Academy of Family Physicians (AAFP); Society of Teachers of Family Medicine (STFM); American Board of Family Medicine (ABFM); Association of Family Medicine Residency Directors (AFMRD); and the The College of Family Physicians of Canada (CFPC).³⁵ Annals quickly became a premier journal and celebrated its own 20th annivsary in 2023.

NAPCRG continues to build authentic partnerships. Colleagues in organizations across the family of family medicine look to NAPCRG for policy and advocacy on primary care research.^26,28 International membership continues to grow.^1,4-6

Advancing Research Methods

These partnerships empowered development of primary care research methods with depth and diversity that reflect the members, their interests, the problems they address, and the communities they serve.³⁶

The early need was for classification and coding systems to describe the problems seen and the services provided in primary care.^2,3 With WONCA and the World Health Organization (WHO), NAPCRG led the development of the International Classification of Health Problems in Primary Care (ICHPPC).^19,20

NAPCRG was an early champion of qualitative³⁷ and mixed methods research.²³ NAPCRG—largely led by Canadian colleagues devoted to responsible research with indigenous communities—pioneered community-based participatory research.^24,25,33,34

Other methods have grown along with the membership and the mission, including the sciences of complex adaptive systems, ethnography, geographic information systems, implementation, decision making, communication, education, and public health.³⁸

Working with these core values, key partners, and innovative methods over 50 years, NAPCRG has generated landmark documents that mark milestones along its path to the present (Table 3.)

NAPCRG’s current work emphasizes integration. Interprofessional clinical teams integrate fragmented services into coordinated systems of care. Interdisciplinary research teams integrate research traditions and techniques into programs of investigation that combine diverse research methods and study designs.

A major focus is the innovations that integrate and coordinate care to transform practice and health care systems.^2,30 Primary care addresses the whole, not splitting it into tiny parts. As clinicians, they care for the whole person; as researchers, they study the whole process of care. Primary care researchers examine care that integrates attention to multiple morbidities and medicines, simultaneously addresses mental and physical health, and considers the importance of family and community.⁴³ Such systems go by various names: in the United States, the patient-centered medical home and behavioral health integration into primary care; in Canada, the patient’s medical home, and the patient-centered clinical method; in the United Kingdom and Europe, patient-centered primary care.

Multimethod studies of these complex interventions show success—sometimes. Current research reveals at least 2 critical challenges: (1) lack of equity—these innovations do not always reach or work well for all patients or communities; and 2) lack of uptake—sometimes called implementation failure.⁴⁴ Disadvantages related to race, ethnicity, income, geography, and bias can contribute to both problems. These challenges may yield to further work in the NAPCRG tradition of co-creating new models of care.

NAPCRG helps advance diverse research methods, team science, and international collaboration.^2,5,6,11 Members develop connections, networks, colleagues, and friends.^6-8

Research is a team sport, and relationships are crucial to success. Teams take on scientific challenges that require the assembly of complementary strengths, expertise, and enthusiasm. NAPCRG helps researchers extend their networks and strengthen their skills, regardless of career stage or research experience. This synthesis of expertise, experience, and inspiration can help advance inquiry and improve care.

Nurturing a Community of Contributors

To members of the community, the N of NAPCRG has always stood for nurturing.^2,7,9

Member surveys consistently show that the top value members take home from meetings and membership is networking, meeting old friends, and connecting with new colleagues. They sense they belong, often sharing, “I feel at home at NAPCRG” and “I have found my people.”^4,6-8,10 See a sample of NAPCRG voices in Table 4.

In recognition of NAPCRG’s 50th anniversary, the leadership invited select authors to reflect on its history, contributions, and enduring spirit. Other authors added voices to the celebration.¹ (Table 5)

From its founding, the organization embraced community-based practitioners, learners at all levels, and patients and community representatives. NAPCRG invests in these relationships with positions on its Board of Directors.^1,8

NAPCRG supports new attendees, trainees, and international visitors with welcoming social events, custom learning programs, and opportunities for participation and leadership.^6,8,29 Experienced researchers value opportunities for teaching and mentoring.^7,8,10 Questions at posters or after presentations are kind, inquisitive, and often offer collaboration: “You can do it; I can help.”⁷

The Grant Generating Project and other programs have helped generations of early career researchers become successful investigators.^10,14,15 The Rising Stars preconference brings emerging researchers together with mentors and colleague networks.⁸

NAPCRG has grown from a binational group into a global organization that supports researchers worldwide to improve the care of all.^1,6,11,12,28 The annual meeting is a melting pot where ideas from different countries, health care systems, and settings of care mix with the secret sauce of multiple disciplines, methods, and generations.^6,11 The nurturing and inspiring atmosphere creates opportunities for all to share questions, ideas, and methods; to learn different ways of seeing primary care; and to explore how we can best develop and sustain primary care worldwide.^2,7,9

Moving Forward

Over these first 50 years, NAPCRG has evolved from a curious collection of pioneering general practitioners to a transnational, transdisciplinary, and transgenerational fellowship advancing primary care research.^11,12,28 NAPCRG culture and values have empowered the global primary care research enterprise and can help guide the future development and application of the new knowledge needed for brighter futures.^6,28

Primary care must continue to co-create a global family of researchers that is inclusive, equitable, and transformative.^2,8,30 Patients can be further embraced in primary care, quality improvement, and research. Clinicians and researchers need the experience, knowledge, and perspective they bring as whole persons. The primary care research community can nurture talent, build capacity, and respect all. As we grow together, such authentic partnerships can help patients, communities, and primary care all thrive.

Social turmoil still surrounds us. Politics is polarized, science is distrusted, and facts are dismissed.⁴⁵ The goal to provide quality health care to all still seems beyond reach. Disparities, inequities, and racism still dwell in the house of medicine. The limited views of specialists still dominate medicine.⁴⁵ Moreover, care is increasingly threatened by corporate interests of profit, depersonalization, and expense accounting.

The primary care workforce is still sorely inadequate to meet the obligation of taking care of the folks. The family medicine vision of comprehensive, relationship-oriented care is threatened by clinician burnout, commercial pressures, the shrinking scope of practice, bureaucratic burdens, and interruptions in continuity forced by payor contracts and interchangeable “providers.” The primary care research enterprise remains underfunded, undervalued, and vulnerable. It often requires creative investigators to wedge their whole-person questions into disease and organ funding priorities.²

Family medicine and primary care have led the fight and done the hard work, but much remains to be accomplished.¹ NAPCRG can help primary care move forward with foundational values, interdisciplinary teams, diverse voices, community partnerships, critical thinking, rigorous methods, clinical experience, and audacious imagination.^{1,2,4,11,36,45}

The future of medicine, primary care, and research offers exciting possibilities, new technologies, and innovations, including artificial intelligence (AI) and machine learning, robotics, genomics, continuous patient monitoring, and self-management.⁸

Empowered by these innovations, we can find complex patterns to help answer new and different types of research questions. We can speed the cycles from evidence to insight to care.⁴⁵ We can develop tools to predict risk and provide personalized care. These technologies can free clinicians and researchers from the burdens of data collection, record keeping, paperwork, and compliance. These tools can help mitigate primary care clinician shortages, address problems with equity, and refocus medical care on the health of persons, families, and communities.

This pursuit of promising innovations must supplement, not supplant, continued research to deepen our understanding of the natural history of illness, the dynamics of caring, how to attain and sustain health, and the most effective and equitable ways to implement what we already know works for our patients in our communities.²

The voices of primary care—including clinicians, researchers, patients, and caregivers—need to lead in envisioning and shaping this future. We must manage the risks. Data and tools can be biased. Poor deployment or scale-up of technology can increase inequities and worsen the digital divide. Results can be misinterpreted, devices can disrupt workflow, and humanistic care and critical thinking can be lost. Careful and critical development of technological innovations is essential; their ultimate impact depends on the people who choose if and how to use them.

Together, we must examine the best evidence before moving innovations into practice. We must ask what success looks like—and to whom.⁴⁵ We must continue to learn from the past—and each other, share failures, and celebrate accomplishments.

Scientists stand on the shoulders of giants. Primary care researchers understand they also stand shoulder-to-shoulder with giants, many unrecognized. Diversity is strength,⁴⁶ and research must make room for voices not speaking, amplify voices not heard, and echo voices too long ignored.^2,8

As we invite those historically underrepresented to our table, we humbly request seats at their tables, celebrating communities’ autonomy and wisdom.⁴⁵

Adventures lie ahead in care, research, and innovation. New questions, visions, and relationships will arise. Old problems will require new methods and partnerships. Like one-half a century ago, the times are still tumultuous in health care and the surrounding society. NAPCRG can help balance evolution with revolution. It can look for the need to make “good trouble” by disrupting dysfunctional systems and questioning assumptions held too long by the wrong people for the wrong reasons. Primary care still has solutions to offer, and primary care research will be needed to inform choices, enhance care, and improve health.^30,47

Fifty years of NAPCRG experience can help us navigate this high-risk, high-return future if we trust our fundamental values, invest in our human assets, and honor our commitments to patients and communities. As primary care researchers embarking on the journey of the next 50 years, we know that NAPCRG is our home, full of fellow adventurers.