The time is right to unite - Guest Editorial - Editorial

Journal of Family Practice, Oct, 2002 by William Wadland, Henry Barry, Mindy Smith, Barbara Yawn, Lee Green

"A house united is strong, and a house divided is weak."--Abraham Lincoln

There is a schism in our discipline. We are divided in many ways, but perhaps the most worrisome is the schism between the community of practitioners and the community of researchers. Do not misunderstand us. We see a lot of activity to promote and develop research in family medicine, but something is missing. In this editorial, we will review briefly a few observations about research and practice and provide a modest proposal to help reconstruct family medicine into a more robust discipline.

BUILDING RESEARCH CAPACITY

The American Academy of Family Physicians, by funding centers of excellence, has invested a great deal of its resources in training researchers, creating a research laboratory, investing in research incubation, and in the promotion of policies to support family medicine. We have also seen the Grant Generating Project (GGP), (1) through its intense mentoring, result in improved productivity and increased extramural funding by researchers. The researchers who participated in the GGP have generated 58 grants and contracts, representing approximately $19.3 million. This enhanced productivity is the result of multiple collaborations across many departments to provide key mentorship for faculty that otherwise would not be available. The Robert Wood Johnson Generalist Faculty Scholars Award is an example of another endeavor with a pooling of resources across disciplines that involves numerous institutions. A recent survey showed that two thirds of the awarders reported an increase in the number of research publications in peer-reviewed journals since receipt of their award (unpublished survey report distributed on June 9, 1999 to 81 award recipients spanning 5 classes since 1993, The Robert Wood Johnson Foundation, Generalist Faculty Scholars Program Evaluation). In addition, 90% have become peer reviewers and nearly one third have joined the editorial board of a peer-reviewed journal. Since entering the program, 78% have been principal investigators for major grants and more than one quarter have become members of study sections for either the National Institutes of Health or Veterans Administration.

DEMANDS OF CLINICAL PRACTICE

We wonder, however, if these endeavors are sufficient to enhance the stature of our discipline and meet the needs of the practitioner and the patients. Weiss (2) recently reported reduced scholarly production by family practice faculty over the past decade. Among the many plausible explanations, the increasing demands to enhance clinical productivity stands out as a serious impediment. Clinical practice demands are a very real barrier to scholarship in our discipline. Spann (3) recommended that we reinvent clinical practice to make it more efficient and, perhaps, easier to study.

THE SCHISM

The keynote address by Herbert (4) at the North American Primary Care Research Group meeting summarized the changing landscape of health care and health care research. In her speech, she highlighted a number of barriers, perhaps the most critical being the temptation to study the unimportant and the temptation to focus on short-term outcomes. We have seen repeatedly the effect of these errors on practice. The Women's Health Initiative (5) demonstrates the importance of conducting rigorous research that answers the questions of practitioners and patients, but with the disadvantage of leaving gaps in the translation of findings for women in our communities and practices. Too often primary care research has been simple surveys, the study of primary care physicians' compliance with guidelines, or comparisons of isolated outcomes. Questions for these studies may be defined by those outside family medicine and such studies fail to address the context of care or even ask "why" instead of only "what." No one doubts that there is plenty of room to improve practice. We need more patient-oriented evidence that matters: studies that demonstrate an improvement in important patient outcomes and that would change our current practice.

The journals representing our discipline should appeal to all family physicians including full-time clinicians, educators, and researchers. Our journals should be committed to not only publishing systematic reviews and critical summaries of important studies by researchers from other disciplines, but also original studies by researchers from our own discipline. For example, family physician researchers have shown us that episiotomies are not necessary in all deliveries and should, in fact, be avoided (6); baseline ultrasounds in low risk pregnancies have no benefit (7); and family physicians when directly observed provide much more care than is documented in medical records. (8) Research that originates from questions based on our own clinical practices should be both highly relevant and likely to change the way we and others practice medicine.

A MODEST PROPOSAL

What does this mean? Without engaging practitioners or their patients, we risk widening the schism between practice and research even further. We believe that creating infrastructure, while important, is insufficient. Redefining clinical practice, while important, may take a generation or two. In the meantime, we continue to have disjointed meetings of clinicians (the American Academy of Family Physician's Annual Meeting), researchers (the North American Primary Care Research Group), and educators (Society of Teachers of Family Medicine). Yes, there is some overlap at these meetings, but the amount is insufficient to create the types of conversations that need to occur. Given increasingly limited time and money for travel, fewer family physicians are able to attend multiple meetings. Why should this situation be of interest?