Is primary-care research a lost cause?

Abstract

“Primary care is in crisis … the field has failed to hold its own among medical specialties”. This is the conclusion of a group gathered under the auspices of the Robert Wood Johnson Foundation, the deliberations of which are summarised in a series of papers published in the Feb 4, 2003, issue of the Annals of Internal Medicine. The notion of primary care risks being swept away, argued Lewis Sandy and Steven Schroeder, respected commentators on internal medicine. “Would it make a difference if the field were to fail?”, ask the authors of another paper. On this shaky foundation rested an important conference this month on research in family medicine, organised by WONCA, the World Organisation of Family Doctors, and held in Kingston, Canada. This gathering of family practice leaders and investigators represented all continents of the world. They set out to produce a statement on the future prospects of primary-care research—and did so. But a series of commissioned papers intended to launch discussion at the conference also revealed the loss of direction— and confidence—that primary-care research is presently experiencing. Very few examples of good family practice research were presented. Instead, the language of theory prevailed. Wheels, quadrants, domains, boxes, interfaces, triangles, dimensions, structures, frameworks, and paradigms dominated not only the papers for discussion but also much of the discussion itself. The emphasis on reflection at the expense of action was telling—and disappointing. According to those in Kingston, primary-care researchers see themselves, their subject, and their task as being different from those of other specialists. They felt misunderstood by mainstream academia, funding bodies, and journal editors. Their interest in qualitative methods and endpoints that go beyond simply counting deaths were commonly pushed to the margins of biomedicine. They claimed a complexity for their subject not shared by other areas of clinical practice. The great challenge for those interested in studying family practice was to draw a boundary around their discipline, to stake out a unique knowledge base ideally with a distinctive set of methods. These arguments are quasi-mystical nonsense. Blaming others for failing to make an impact will do little to win the hearts and minds of sceptics, if sceptics exist. Moreover, primary care is not uniquely complex. Surgery is an immensely difficult field to investigate, and yet good progress is being made in tackling questions that were once considered impossible to answer. And the great strength of primary care is that it does not have a boundary. Family practice offers a perspective that should influence all other clinical specialties. In sum, if primary care has anything at all to do with improving a person's health, then its contribution to that end will be measurable. Or is primary care to be accepted as the homoeopathy of modern medicine—incontest-able, irreducible, and, ultimately, irredeemable? This painful introspection was no fault of WONCA. Efforts to develop primary-care research deserve strong support. In a review of the scope and application of clinical trials in family practice, published in the British Journal of General Practice last year, Aziz Sheikh and colleagues concluded that: “There is now widespread acknowledgement of the absence of a sound evidence base underpinning many of the decisions made in primary care.” The goal for investigators must be to formulate testable questions, the answers to which will make a difference to patients. A particular focus for inquiry should surely be the family. If general practice does have any claim to uniqueness, it comes closest when thinking about the family—the vital context of most personal illness in the community. That context has changed dramatically during the past decade—economically, socially, educationally, and sexually. There is now a diversity of family forms—single, one-parent, same-sex, double-income—which influences the way in which, for example, illness presents. Previously hidden epidemics of mental ill-health (see p 995) and domestic violence both have critical family contexts. And as peoples migrate across continents as well as nation-states, the impact of culture on medicine becomes ever more important. The Lancet enthusiastically welcomes research that links health and disease to the family, together with work that examines other aspects of the primary-care perspective. But let there be no more conferences asking, “Why research in family medicine?”