Assessing Clinical Discoveries

This paper is really fascinating and intriguing, and I like underscore only a paramount statement:"Because every patient is different, we know them as individuals." WE, i.e., General Practitioners.For the first time, I communicated earlier to my colleagues, in a intentionally provocative way, the existence of Single Patient Based Medicine (SPBM) by an e-letter to BMJ.com, in May 2003, cited by website “Planning for the EU public Health Portal” at the URL:

http://europa.eu.int/comm/health/ph_information/documents/ev_20030710_co01_en.pdf, although in every my pubblication, in internet or in paper reviews, such as theory was implicitly present from both epistemological and practical utilization view-point (See in this website www.semeioticabiofisica.it).It appears clear that I do not intend absolutely to set SPBM against EBM.

On the contrary, in my opinion, the two theories must interact, since they complete and integrate each with the other, deriving certainly a great utility for physicians, patients, and National Health Services, as allows me to state 52-year-long clinical experience (1,2).

1. Stagnaro Sergio. Single Patient Based Medicine: its paramount role in Future Medicine. Public Library of Science. http://medicine.plosjournals.org/perlserv/?request=read-response 2005 2. Stagnaro S., Stagnaro-Neri M., Single Patient Based Medicine.La Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Ed.Travel Factory, Roma, 2005. http://www.travelfactory.it/

Competing interests:   None declared

Competing interests:   None declared

Several of us involved in the Family Physicians Inquiries Network have been asked to comment on Ian McWhinney's editorial. I'm hopeful that Bernard Ewigman will comment-his thoughts about this are much deeper than mine. I first heard the FPIN vision at a special research plenary session at an annulal STFM meeting several years ago. Basically, the vision was to be able to get answers to clinical questions at the point of care in near real time. This was the Google approach to sifting through massive amounts of medical data, but before Google was around. The vision was to have a community of practicing FP's who would work on analyzing and synthesizing available research, put it through an evidence and patient orientation sifter, and store it in an easily retrieveable way. The key factor was that it would be done in the context of how practicing physicians ask clinical questions when seeing patients. One of the truly innovative approaches Bernard had was to develop a web-based method for physicians to ask clinical questions and store them. These then were (and still are) collected and voted on by the FPIN community to prioritize which questions to tackle first. The FPIN community, made up of many medical school family medicine departments and community residency programs, then volunteers to work on trying to answer these questions, but in a structured way, with evidence grades. The most rigorous FPIN answers are Clinical Inquiries, published in the J of Family Practice and American Family Physician. Of course, there is often no good evidence based answer to many of these questions, and this in turn should be able to help drive research agendas.

What does this have to do with Dr. McWhinney's editorial? I believe approaching things from questions we have while seeing patients is another form of "clinical insights." As Dr. McWhinney hopes for, it begins with a relationship with a patient, or perhaps many patients with the same problem. By definition, it is patient-centered. I would argue that the first discovery we should pursue is seeing whether there already is an answer to our question. (And how more efficient and effective if we share our answer with the medical community!) And, as is very often the case, we find no good answer, we can synthesize our own observations, formulate hypotheses, and if we don't have the time or resources to test them ourselves, at least share them, and perhaps stimulate others to test them. But what a waste if there is no forum to share this. So the bottom line is that I would encourage the Annals to consider taking the risk on publishing "clinical insights" work.

Competing interests:   None declared

Dr. McWhinney makes several astute observations regarding the role of observation in the development of new medical knowledge. Dr. Whinney’s editorial encourages family medicine journals and reviewers to be more receptive to clinician observations and discoveries, and he uses as examples Alexander Fleming and James Fleming. Dr. McWhinney mentions that there are currently practitioners “who have made important discoveries but whose work has been rejected by family medicine journals.” Since Drs. Fleming and Mackensie lived and worked decades ago, a more contemporary example (or examples) might illustrate for family medicine journal editors and reviewers the type of insights that Dr. McWhitney believes deserve publication.

One aspect of contemporary medical publication that Dr. McWhinney does not mention is the proliferation of open-access journals that are available via the Internet. If a physician or medical scientist is willing to pay a fee, almost anything can be published nowadays. For many of these journals, there is little or no peer review involved. Consequently, it is difficult for the casual reader to discern what is meritous and what is not. While the open-access journals offer an outlet for physicians who are frustrated by the decision of peer-reviewed journals to reject an original idea, it is likely that almost no one is reading what is ultimately published in these journals.

I agree with Dr. McWhinney that it would be a welcome development if peer-reviewed family medicine journals took an interest in publishing observations and ideas that do not fit the conventional mold.

Robert P. Blankfield, MD, MS

Competing interests:   None declared

Dr McWhinnie argues for the value of insight during routine clinical practice, and the ability of front line clinicians to recognize, record and study what is new and important.

It is well known that we normally have more questions than answers during daily practice. As a front line clinician, I can attest to the fact that I am faced with new discoveries in my own practice on a routine basis, but I probably fail to recognize them or neglect to follow-up in the vast majority of cases. When I do have what I think is a valuable clinical insight, what do I then do with it?

Doing research takes time, knowledge and money. An insight remains an insight unless it leads to accurate knowledge that others can use. The value of front line physicians is in the questions that we raise (stemming directly from daily patient care); it may not necessarily be in the ability to conduct studies. The barriers to research (obtaining grants, difficult, bureaucratic and time consuming REB applications, time to write and publish) are now so high that they keep practicing physicians out. I may be able to recognize important problems in my own practice, but I can't study them in a form that is publishable as "research".

I don't think we need to throw "rigour" out; there are valuable aspects to methodology, such as the ability to replicate experiments, or a reliable estimate of how accurate a result is. What we do need to think about removing are the aspects of research that do not add value, but simply make studies frustrating and difficult to do (and there are now many of those).

I think collaborations between front-line clinicians and experienced researchers, such as practice-based networks, are likely to lead to fruitful projects. I would like to see more of those in Canada.

Competing interests:   None declared