Research Opportunities in Primary Care

Yvonne Carter, Kate Thomas

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315343563
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

'Medical technology is beneficial for well researched dangerous diseases. However, most symptoms that people bring to their primary care physician have no single clearly identifiable cause: investigations and drugs do more harm than good - and also waste resources - ' - Wilfrid Treasure Diagnosis and Risk Management in Primary Care teaches that adopting an evidence-based approach to primary care improves patient care and treatment outcomes. It demonstrates that brief clinical assessments, repeated if necessary, allow effective diagnosis while avoiding the costs and complications associated with more advanced testing. Adopting a fresh approach, this book sets consultation skills alongside evidence-based information by both itemising the specific techniques and facts that are needed in the consulting room, and providing detailed information on odds and likelihood ratios to quantify risk and deal with uncertainty. This book provides food for thought, and helps doctors develop communication skills that support their personal styles of consulting, encouraging a more traditional, intuitive treatment. It provides a map of the consultation and a compass to navigate through symptoms, signs and evidence - listening to their patients with one ear and, with the other, to the reflective inner voice of reason. General Practitioner Specialist Trainees and their teachers will find much of interest, as will established General Practitioners with an interest in maintaining traditional models of care. Undergraduate medical students and candidates for the MRCGP will find this an ideal reader for the clinical skills assessment. 'What a breath of fresh air to find an author capable of putting the patient back at the centre of the consultation and who is able to entertain at the same time as he informs and to stimulate critical reflection while nudging us in the direction of a rigorous approach to diagnosis, and the assessment and communication of risk.' From the foreword by Roger Jones

1
Research in general practice

Denis Pereira Gray

History

The history of research in general practice and primary care goes back at least to the end of the 18th century. In those days, the medical profession was not as strictly divided as it is now and doctors could and did move between generalist and specialist medicine, essentially between being a general practitioner and being a physician or surgeon, and sometimes both at once.

Thoughtful general practitioners could and did not only see research opportunities but pursued them with such effect that several of them contributed knowledge of world-class importance. Jenner, at the end of the 18th century, studied smallpox in rural Gloucestershire. From his experiments with vaccination with cowpox he was able to show protection against the disease and in effect led an initiative which 200 years later has enabled smallpox to be eliminated worldwide.

In the 1840s William Budd, working in a rural practice in mid-Devon, researched the pattern of spread of typhoid and typhus and was the first person to separate the two. Budd later moved to Bristol but his book Typhoid Fever became a classic and led to him becoming an FRS.¹

Sir James Mackenzie, in a working class practice in Burnley in Lancashire, became the world’s leading authority on the rhythm of the heart,² which he researched using an instrument he invented called the polygraph. This was the forerunner of the ECG machine.

In the 20th century, William Pickles (1939), in a rural practice in Wensleydale, Yorkshire, researched the pattern of infectivity of some common diseases and what came to be called Bornholm disease.³ After the Second World War, Crombie,⁴ Fry⁵ and Tudor Hart⁶ were among the outstanding single-practice researchers. The era of the university departments then took over, with Stott and West,⁷ Kinmonth, Angus and Baum⁸ and Howie, Heaney and Maxwell⁹ among the leading contributors.

Rationale for research in general practice

The reasons for doing research in general practice/primary care, and doing much more of it, are clear and strong. However, because general practice does not have a formal research training programme and because in the past most research in medicine has been undertaken in laboratories and hospitals, it is necessary to set out the reasons briefly.

Needs of the population

In the British, Dutch and some other systems of healthcare, patients first seek advice from their GPs and a proportion of them are then referred to specialists. In the UK, this proportion is 13%, which means that 87% of patients receive all their care in primary care.¹⁰

Unique field

The first important reason for a good deal of research being done in primary care is that there is a whole range of conditions, including most of the common infections and most of the common disturbances of mental state, which are not normally referred to hospital at all. It follows that if research is undertaken only with secondary care leadership these important problems from which patients suffer will not be adequately researched or even researched at all.

Second, laboratories and hospitals are essentially specialist institutions. They are organised by people who have developed great expertise, but in a narrow field. Specialist research of this kind has been responsible for most of the major contributions to medical knowledge and it needs to continue. However, the other side of the coin of specialism is loss of breadth and it is the particular contribution of the generalist to provide breadth and balance in medical practice. Appropriate research and research funding needs to go on whole-person medicine.¹¹

The third reason is the nature of society and family life. It is extremely difficult to research medico-social issues unless one is personally familiar with them and has first-hand experience of them. Thus problems to do with the family, family relationships, doctor-patient relationships, continuity of care, and many aspects of social deprivation and the environment are all more logically researched in primary rather than in secondary or tertiary care.

The development of general practice

Despite the world-class contributions of GPs in the 18th and 19th centuries, the quantity and quality of research in the 20th century has been disappointing. In order to plan and maximise both quality and quantity it is necessary to understand the reasons for the state of general practice research¹² and to plan carefully to develop it in the future. Three obstacles have dogged general practice research: training, technology and organisation.

Training

The most important issue is training. Research is a special skill and has its own knowledge that has to be acquired. Bad research is not only a waste of time and money, it is also unethical if it affects patients, and it may well be misleading if it wrongly influences colleagues. In all specialist branches of medicine until recently there has been a formal period of training before doctors became eligible to be appointed as consultants. During this year, which was in effect compulsory in all hospital specialties, doctors were given a day a week of protected time to develop a deep understanding of their specialty and usually to research it. It was common for them to undertake a higher university degree such as a Master’s degree or an MD.

General practitioners never had this opportunity because although the Royal College of General Practitioners originally called for a five-year programme of vocational training, including two years in general practice,¹³ the reality of vocational training as it was introduced into the UK meant that there was but a single year available for training in general practice itself. This year is fully occupied, indeed crowded, by providing opportunities for young doctors to learn about consultation skills, personal preventive care, and working in homes and families, to say nothing of the increasing complexity of practice management including fund-holding. There simply was never any time to learn about research and although some outstanding trainees did achieve excellent projects, some of which were published in the peer-reviewed literature,¹⁴ these were the exception rather than the rule. The result was that the vast majority of doctors entering general practice did not have competence in doing research and many were left ignorant and suspicious of it. Consequently even the trainers were not able to teach research and over the years a whole education system emerged, including course organisers, GP tutors, associate and regional advisers who had mostly not been trained in, and who were mostly not undertaking research. General practice thus became the only branch of medicine with a twin system of professional leadership: the university departments on the one hand and the directors of postgraduate general practice education (formerly regional advisers) on the other. A number of authors^{15, 16, 17-18} have all been urging a more integrated approach, but at the time of writing most registrars (trainees) still do not learn how to do research.

Research skills

There are now many good books available on research in general practice/primary care and Howie¹⁹ and Carter and Thomas²⁰ can be recommended. However, it is important that all those who propose doing research or learning to do it have a clear overview about what needs to be learnt.

The first issue is logical thinking and the need to be able to classify and categorise information, to separate ideas and information clearly, and to be able to think deeply about whatever question is being studied. Second, the formulation of an appropriate research question lies at the heart of deciding what is good and bad in research. Most people think that having research ideas is the difficult part but it usually is not. Most GPs can produce a good set of possible ideas. Much harder is the construction of a precise research question, which is capable of being answered to a good level of scientific reliability within the timescale and resources that are available. It often surprises those registering for research degrees to find that it may take many weeks and several supervisions before a research question can be defined and agreed.

The core business of undertaking research is the gathering of information, and the process of data collection is often arduous, frequently frustrating and usually associated with some unexpected problems in obtaining information or in the categories chosen. Data processing used to be a lengthy and laborious part of research but has become relatively easier with the advent of computers and software packages.

A new problem is that primary care workers sometimes rush into research without taking the necessary methodological advice, and particularly statistical advice, which remains just as important as before computers were invented. The final stage is the drawing of conclusions from the data and this requires an open mind, an objective approach and intellectual honesty.

Finally, there is a need to write up the results in a report or paper in a language and style which is acceptable to the editors of peer-reviewed journals and can then be published and used as another building block by the scientific community. Primary care staff have a long-standing deficit in writing skills and unfortunately much interesting research has not always been followed through and written up and published. The old aphorism that unpublished research is failed research is unpopular but true.

The peer-reviewed literature

There are two kinds of journal and the difference between them was most clearly set out by Sir Theodore Fox, who described them as journals of information and journals of record. Both are important and both have a major part to play in the development of the profession and primary care. Journals of information are concerned with the dissemination of information. They typically consist of review or summary articles where someone has worked through a large number of research reports and summarised or abstracted their main findings to make the practical implications and applications possible and practical. Journals of information include journals like Update, the medical newspapers and the various bulletins like Drug and Therapeutics Bulletin, Prescribed Journal, etc. They are indispensable tools for all busy clinicians.

Journals of record, however, are different. They are primarily concerned with reporting original research in their particular field. Their priority is simply selecting, in a highly competitive field, the most important research findings which will advance knowledge in the field.

Primary care has a serious shortage of research journals. The first was the then Journal of the College of General Practitioners, which was recognised internationally and included in Index Medicus in 1961, and is now the British Journal of General Practice.²¹ Index Medicus, however, o...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• List of Contributors
• 1 Research in General Practice
• 2 Research Networks
• 3 The MRC General Practice Research Framework
• 4 Research Practices
• 5 Research Training
• 6 Collaborative Research in the Weekly Returns Service
• 7 The RCGP Centre for Primary Care Research and Epidemiology
• 8 How to do Higher Degrees in Primary Care
• 9 Taught Masters Courses
• 10 RCGP Scientific Foundation Board
• 11 Association of University Departments of General Practice
• 12 The National Primary Care Research and Development Centre and Issues at the R&D Interface
• 13 Writing for Peer-Reviewed Journals
• 14 Going it Alone: A View from the Grassroots
• 15 University-Based Junior Academic Posts: Overview and Personal Experiences
• 16 Health Services Research in General Practice: An Inner City Perspective
• 17 Nursing Research in Primary Care
• 18 The Interface between Pharmacy and Primary Care
• 19 Social Science Research and Researchers in Primary Care
• Index