Research opportunities for family physicians: contributing to evidence based health care

Y H Carter

"Good research, thoughtfully planned and carefully carried out, is one of the most compelling and absorbing of the many professional activities open to the general practitioner".

This statement was made by Professor John Howie in Scotland nearly twenty years ago in the introduction to his book "Research in General Practice".¹ I was given a copy of the book during a community based undergraduate attachment as a medical student in 1982 and his enthusiasm for research has stayed with me. Unique opportunities for research continue to be provided in Family Medicine but much of this research is still done by those from other disciplines. In the UK, over 90% of contact between doctors and patients takes place in a Family Medicine setting, but historically family physicians and their teams have regarded research as a minority option.

For those who decide to become actively involved in research, there are numerous rewards. Besides enabling personal professional development, it provides the opportunity to pursue an original line of enquiry, to acquire new skills, to collaborate with other like minded people, to have the satisfaction of completing a piece of research and seeing it published or disseminating its findings and ultimately observing the application of the findings in changes to recommended clinical practice. On the downside, research can be frustrating, severely test problem solving skills and can, unless care is taken to identify protected time for training and conducting research, start to impinge on family and personal time. Nevertheless, I believe the benefits still outweigh the possible negative aspects.

The development of research in Family Medicine does not just benefit the individual researcher. Increasingly, patients expect their care to be informed by robust and relevant evidence. The development of evidence-based practice needs an appropriate research base to support it. We cannot simply continue to extrapolate the research findings from randomised controlled trials in acute settings to the community. Much of the evidence required by family physicians can only be obtained by conducting research involving primary care teams and their patients. This will necessitate a body of appropriately trained researchers in Family Medicine and will require the existence of mechanisms to ensure the effective dissemination of research findings and their incorporation into every day clinical practice.

Over the last decade in the UK, the Department of Health has promoted a research and development strategy for the National Health Service. Family physicians and their attached staff are recognised as being in an ideal position to address the health needs of their patients, to create a critical mass of research activity and to bid for specific funding for primary care based research. However, many family physicians want to do research, but still have no idea how to go about it. Training for family physicians and nurses usually provides little experience in research methods. Lack of protected time, resources and infrastructure have been persistent barriers to progression.

A number of policy documents talk about improving the research capacity in primary care. We often hear how family physicians are being encouraged to take a more active role in research, with improved access to funding, but many are unsure how or where to start. A slowly increasing number of books and courses now cover the basics of why we should conduct research in Family Medicine, how to ask research questions, how to write a research proposal and get funded, and how to publish and disseminate the fruits of our work. An outline of qualitative and quantitative methods is frequently given with attempts to demystify some of the fear associated with statistics! There are also texts aimed at improving evidence based practice including mastering MEDLINE and critically appraising the literature.

Discovering the pitfalls and the successes from a family physician's perspective will, I hope, also help to bring a sense of reality to choosing how to get involved. In my books,^2,3 I aim to give information on a range of options for individuals and practice teams who want to be involved in research: everything from being part of a primary care research network to undertaking a higher degree. By describing doing research in a workplace setting, I hope it will give a "hands-on" feel of what it means in practical terms to integrate research activities into the business of seeing patients, achieving high quality evidence based health care and now getting involved in new primary care organisations.

At present there is no easy way for an "ordinary" family physician who is interested in research to find out about what it is really like to be involved without contacting someone who is already doing it. This may be difficult as it involves a certain commitment even to declare an interest. The individual may not know who to ask.

Research should not be regarded as just the preserve of academic family physicians or the enthusiast in service delivery. There is an increasing need for research to become part of every family physician's working life. Although the expectation would not be for all family physicians to become active researchers, the expectation has to be that we should all be in a position to make use of research findings and, by doing so, improve the quality of patient care. For those who wish to become involved in research, there are opportunities at different levels: from collaborating in a colleague's project by agreeing to provide specific data or recruiting patients, to formulating a personal question and then undertaking the research to answer it.

Academic Family Medicine is now established in every undergraduate medical school in the UK. Many departments are providing teaching on research methods with an increasing number of diploma courses and masters degrees being developed for postgraduate students. New posts are being created for GP registrars and young principals with protected time for personal development and research. Primary care based research networks are gaining support and momentum around the UK; the number is increasing almost monthly.⁴

The medical undergraduate curriculum is also going through a period of substantial change. In the past, doctors had little specific teaching on research methodology as a medical student. The General Medical Council has recently recognised the importance of a more student centred curriculum to equip tomorrow's doctors with a range of skills relevant to their future needs. The ability to access the literature and critically appraise scientific papers are seen as prerequisites for a career that will encompass evidence based medicine. Basic research skills are increasingly needed to permit good quality project work when a student has the opportunity to ask a research question for the first time. If these skills are learnt at an early stage, the enjoyment of research will continue. Increasingly students will be spending more of their time in a community based setting. Departments of Family Medicine are taking a lead in new aspects of learning and teaching which will mean that students will be undertaking research projects in Family Medicine. It is important that courses and lecture notes are available that are easy to understand, and guide the student or practitioner through the range of skills necessary for community based research.

In the UK, the future appointment and possible "accreditation" of formally recognised research practices⁵ receiving dedicated infrastructure funding and the development of new research strategies within primary care organisations can only increase both the quality and quantity of research in Family Medicine. The opportunities are numerous and I hope that the number of family physicians who engage in the research agenda will continue to flourish.