Bridging the Gap between Family Medicine Research and Practice A Renaissance in Family Practice Rese

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Bridging the Gap between Family Medicine Research
and PracticeA Renaissance in Family Practice
Research

• W.W. Rosser, Professor and Head
• Department of Family Medicine, Queens University
• Kingston, Ontario, Canada

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Presentation Outline

• Defining the terms
• Identifying some gaps
• Lack of a research culture
• A proposed Renaissance
• Is there a research base?
• Can we build capacity?
• Conclusion

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Definition

• The word Renaissance is derived from the Latin
  Nascentia to be born
• Renaissance is is defined as the revival of art
  and literature under the influence of classical
  models of the 14th to 16th century and any
  similar revival.1

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Out of the Dark Ages

• The generalist was dominant in medicine until the
  early 20th century.
• Major discoveries in medicine prior to the 20th
  century were made by generalist scientists.
• The generalists entered the dark ages in the
  mid 20th century and have undergone a revival in
  the late 20th and early 21st century.
• 25 years ago who would have imagined having 2500
  family physicians attend a meeting in Florence.

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A Renaissance

• We are now at the cusp of a renaissance-like
  revival of research in family practice, moving
  our discipline forward in the 21st century to
  improving the delivery of health care and the
  health outcomes of our patients and, our
  countries.
• Surrounded by the glory of the original
  Renaissance in Florence, provides an ideal
  environment in which to explore a potential
  renaissance in family practice research.

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Identifying Gaps

• Evidence of the strength of primary care/family
  practice.
• The gap between our current research base and
  practice
• The gap between evidence and its optimum
  application for patients.

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The Strength of Family Practice

• Barbra Starfield has provided very convincing
  evidence of what a strong primary care system has
  to offer to a country and its population.2
• There is a clear relationship between the quality
  of the primary care system in a country, the cost
  and the health outcomes of the population. 3
• She developed this evidence using an index
  measuring the strength of primary care in a
  country and then comparing health outcomes and
  costs in 15 countries including several in
  Europe.4,5,6

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The Strength of Family Practice

• More recently she has found that if specialist
  trained physicians are delivering primary care,
  the poor outcomes for the population rise in
  comparison with trained family physicians
  providing primary health care. 7
• Another finding is that people with co- morbidity
  have better outcomes when cared for by a family
  physician than a specialist, while specialists
  may provide better care for persons with a single
  problem.8

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The Strength of Family Practice

• A recent Harvard University survey of Canadian
  and U.S. citizens found that with ½ the amount
  of money per capita spent for health care in
  Canada compared to the US, every population
  health outcome including satisfaction with health
  care was better in Canada. Much of this finding
  can be attributed to the strength of Family
  Practice in Canada.9

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The Gap in Research Base

• Most of our clinical interventions that are
  evidence based are derived from the findings of
  large randomized controlled trials conducted in
  teaching hospitals using carefully selected
  patient populations.10
• Individuals in large trials often have a single
  problem, very unlike our elderly patients who
  usually have 3 to 6 co-morbid conditions.

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Gap in Research Base

• The conclusions, directives and guidelines
  produced from most of these studies are not
  easily applied to our patients.
• Application of guidelines must be in a patient
  centered way responding to the beliefs and values
  of the patient. 11
• Many therapeutic interventions offer our patients
  marginal benefit that may be exceeded by risks
  (cholesterol and lipid lowering). It is the
  Family Physicians responsibility to provide our
  patients with accurate information on which
  patient base therapeutic decisions.12

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Gap in Research Base

• We need much more research like that done by the
  Italian Collaborative group of The Primary
  Prevention Project. 13
• This trial on the value of low dose ASA in
  preventing heart attack was carried out in
  unselected Family Practices populations, making
  the results applicable in any family practice.
• Although this style of research is rare, it is
  the way all research that we use in our practice
  should be conducted.14

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The Gap Between Evidence and Practice

• Guidelines using data from trials that are not
  relevant to family practice, usually produced
  without family physicians input, become
  controversial. 15
• British General Practitioners have rebelled
  against the NHS producing and paying premiums on
  population based evidence that they question.
• Family physicians who resisted adoption of HRT
  guidelines that were strongly promoted in the
  1990s by gynecologists, now find that their
  intransigence has saved womens lives.16

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The Gap Between Evidence and Practice

• More trials in the context of Family Practice
  producing evidence relevant to our patients,
  would allow us to better serve our patients.
• A recommendation from the WONCA research
  conference in Kingston, Canada in 2003 was that
  evidence should be generated in the context of
  each country since different health beliefs and
  cultural practices can make trial results from
  one country less applicable in another. 17

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Lack of a Research Culture

• Family Medicine Research is defined by some as
  Research done in the context of Family
  Practice.
• Even with the breadth of this definition,
  relatively few of the estimated 6 million medical
  articles published annually are Family Medicine
  Research.
• The perception in many countries is that there is
  no such thing as family medicine research

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Lack of a Research Culture

• The WONCA conference titled Improving Health
  Globally and the Need for Primary Care Research
  has as its first recommendation that WONCA
  should develop a strategy to display research
  achievements in family practice to policy makers,
  health funding agencies, and academic leaders.
  18
• This statement addresses the poor recognition of
  research as integral to family practice, a common
  belief within our own ranks.

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Lack of a Research Culture

• The perception that family medicine has no
  research base puts us at a disadvantage in
  Medical Schools where there is a lack of respect.
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• Medical students are not attracted to family
  practice as a career as they perceive a non-
  scientific base and less academic opportunity
  for their future career.
• Although medical students perceive a lack of
  academic opportunity in FM, in Canada there are
  more family physician educators than in any
  other specialty discipline.

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We Need a Renaissance

• This is a direct quote from the AAFP Future
  of Family Medicine report recommending full
  implementation by 2012
• Enhancing the Science of Family
  MedicineParticipation in the generation of new
  knowledge will be integral to the activities of
  all family physicians and will be incorporated
  into family medicine training. Practice-based
  research will be integrated into the values,
  structures, and processes of family medicine
  practices. 20

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Renaissance not Revolution

• The concept of every family physician
  participating in generation of new knowledge is
  revolutionary given the current state of affairs.
• The perception of the entire medical community is
  that little important research occurs in Family
  Practice.
• Most physicians believe that there is no
  practical way to do research in the average busy
  practice.

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Is there a Research Base?

• Contrary to the perception, there are many
  examples of contributions from Family Medicine
  research that have improved health globally. Some
  examples include
• Crombies work identifying thrombo-embolism as a
  risk of oral contraceptive use.21
• van Buchen demonstrating watchful waiting as the
  most effective strategy for managing otitis
  media.22 This work was internationally verified
  by by Froom and Culpper.23
• Work from Klien finding that the episiotomy does
  more harm than good.24

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Is there a Research Base?

• The work of the Collaborative Group of the
  Primary Prevention Project finding low dose ASA
  in family practice reduces heart attacks.25
• Stewart developing and demonstrating the benefits
  of patient centered care in family practice. 26
• Neimegans Department of General Practice being
  identified as one of the top 20 centers in COPD
  research in Europe . 27

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Research in Practice

• Many strategies have been developed in many
  different countries to enhance research in busy
  clinical practices.
• The WONCA Kingston conference on Research
  identified networks as an important way to
  involve practitioners in research.
• IFPCRN is the international network of networks.
  There are national networks in U.S., UK,
  Netherlands, Denmark and Finland to name a few.
  There are innumerable local networks in through
  out the world. 28-31
• Most practitioners should participate in a
  network generating new knowledge.

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Research in Practice

• Electronic Medical Records allow physicians to
  determine gaps in their practice, take action,and
  measure outcomes.32
• In under developed countries, basic counting of
  the frequency of events or diseases, identifying
  problems and providing solutions involves basic
  research principles with very significant
  potential to improving health in a community.
  33,34
• Many physicians are now participating in creating
  systematic reviews.35

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Research Capacity Building

• European General Practice Research Network
  (EGPRN) since the 1970s provides presentation
  venues for those interested in research.Original
  mentoring programs have blossomed into a network
  of international researchers who collaborate at
  local, national and international levels.36,37
• Look at the WONCA web site for more than 50
  research educational opportunities in the UK and
  many more in 18 other countries.38
• www.globalfamilydoctor.com

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Research Capacity Building

• The Scottish School of Primary care founded in
  2000 supports developing research infrastructure,
  as well as conducting large projects in a
  network.39
• The Netherlands School of Primary Care Research
  is a virtual institute with a core mission of PhD
  training for Family Physicians to develop
  research skills to apply in clinical practice.
  This is to improve retention of academic
  physicians.40

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Research Capacity Building

• The Centro Studie de Recherche Medicina Generale
  brings family physicians together to study
  specific problems of clinical practice. They work
  collaboratively with Institute Mario Negri, a
  basic science research institute. They have
  produced internationally acclaimed research.13
• The Canadian Five Weekend Research Program
  supports family physicians developing a research
  question from their practice through five
  intensive 2 day sessions each followed by two
  months of work learning the research strategy
  that will answer their questions. More than 130
  have completed the program. 41

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Conclusions

• Significant gaps in the knowledge we require to
  best serve our patients have been identified.
• Examples have been provided of research that has
  addressed some of the knowledge gaps and
  demonstrated that Family Medicine research has
  the capacity to address important questions.

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Conclusions

• A number of strategies to increase research
  capacity in our discipline have been discussed.
  There are examples from the WONCA Europe
  countries.
• The AAFP vision statement provides a goal
• Participation in the generation of new knowledge
  will be integral to the activities of all family
  physicians and will be incorporated into family
  medicine training

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A Renaissance in FM Research

• Every family Physician present today should leave
  this wonderful meeting in the city at the heart
  of the renaissance considering how you would
  generate new knowledge in your practice.
• Could you join a network, take a capacity
  building course, generate a research question
  from your practice, or work on a systematic
  review?

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A Renaissance in FM Research

• Michaelangelo, four centuries ago, not only
  provided us with his magnificent works of art but
  also provided an inspiring statement that applies
  to our proposed renaissance
• The greater danger for most of us is not that
  our aim is too high and we miss it, but that it
  is too low and we hit it.

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A Renaissance in FM Research

• I would ask you all to consider the impact of
  everyone present participating in generating new
  knowledge from your practice. Such action would
  improve health globally

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• All the slides and 41 references for this
  presentation are available at www.globalfamilydoct
  or.com
• www.globalfamilydoctor.com
• www.globalfamilydoctor.com
• www.globalfamilydoctor.com