Domhnall McAuley: Plane crash scare at NAPCRG

Domhnall Macauley The plane didn’t crash. I was pretty sure I had turned it off, but there was no mistaking the message signal and vibration in my jacket pocket as we circled Miami, close to landing. It wasn’t just one message but five in quick succession. I had to do something. I switched it off, conscious of a great imaginary finger pointing at me. I must have accidentally pressed against it during the transatlantic flight (oh yeah … I can hear you). But it made me wonder if mobile phones do have any effect. With hundreds flying, there must be at least one phone accidentally live on every aircraft landing. A myth, factlet, or a remote theoretical possibility that has evolved with time into dogma. Is this a guideline, a rule, an algorithm that has grown without being properly researched?

James Meigs, in the keynote address opening the North American Primary Care Research Group (NAPCRG) meeting looked at Diabetes in Primary Care. As common as take-off and landing in aviation and just as important, it is one of the key chronic diseases in everyday family medicine. Good care in managing diabetes is directed by multiple rules and guidelines, goals for best practice, and performance indicators. But, precious little research from and embedded in primary care with few real useful outcomes. Much of what we know is based on research by specialists and his superb work is mostly in partnership with epidemiologists using large databases, principally Framingham and its relations.

Similarly, Richard Hobbs reviewed some of his achievements in the UK and excellent research funded often, in the early days, by pharmaceutical companies. Hi s achievements are remarkable but adding to that is a legacy of at least eight senior academics trained in his department.
It is salutary, at a major research meeting like this and, NAPCRG is one of the best, to question how much research is focused on really key questions n every day practice. Reading the abstract book we must ask how much really makes a difference to patients. In primary care and, I suspect, many other disciplines, there are easier research pathways. We can look are process, prevalence, attitudes and career development issues, or try to wring another marginally statistically significant finding from last years cohort study. Important, perhaps, but minor subplots in the real business of caring for people.

One paper that stood out with a new idea and approach was Jochen Cals’s distinguished paper on c-reactive protein, clinician education, and respiratory tract infections. This is a paper that may make an impact and change the way we treat a common illness. It was greatly praised in informal coffee conversation peer review. I had asked members of the BMJ Primary Care Listserver Group, earlier this year, what papers published in the BMJ, they felt had really made a difference to primary care, there were many suggestions but Paul Little’s work on sore throats featured highly. One of the opportunities in going to a meeting like this is to meet some of these innovative and inspirational researchers. His presentation on a RCT of Dipsticks, symptom score and self help advice caught my eye as a paper to make a difference. Worries about recruitment issues are common themes of meeting around the world, particularly in rural areas, of Australia and Canada. In response, researchers from the College of Family Physicians in Canada, took a different angle looking at doctors at the later part of their career, asking what it physicians understood by being semi retired. They wanted to encourage these experienced doctors to stay.

There were some fascinating gems among the ordinary. Perhaps the most eye catching title was “Show me the money”- a workshop on to attain research grant funding. Perhaps the most misleading because of its acronym, although it caught my eye, was the DRINK study. This had nothing to do with alcohol and was a RCT of a probiotic supplement in children, Clearly, they hadn’t heart of “Father Ted”. One unusual paper showed that asthma was worse on windy days in Colorado and many GPs will be interested to learn that clinician empathy predicted the duration and severity of the common cold.

Big research meetings like this usually, leave you with a sense of warmth, well being and optimism for the profession. Just like the expectations of the weather on this Caribbean island. When we arrived, it rained like an Irish summer, the wind rattled palms trees along the beach, with a grey blown sea-as bleak as a Brighton seafront. The future for primary care research could be stormy too unless we focus on what really matters.

Domhnall McAuley, primary care editor BMJ, 20 November 2008

  • Hi Domhnall – I completely disagree with your last sentence!
    Research is two things – it is answering questions and it is answering them well.
    Whether the question is clinically relevant is not the point. Whether it changes practice is not the point. Whether “it really matters” is not the point.

    Questions either answer a clinical question or they answer a research informing question. So the question “will education of GP’s reduce prescribing of antibiotics for acute bronchitis” is the former. “Do Low Income Children in Rural Areas Have Different Access to Health Care?” does not appear to have direct high clinical impact but the findings would inform more research that certainly would have an impact. There is a complancency, maybe in the minds of journal editors, that research just happens. As you know this is not the case and every element of the study needs to be well informed from rather boring incidence data that determines sample size to validation of the outcome assessment tools. Each of these are as of equal importance as the final paper that shows the ‘clinical benefit’. NAPCRG is there to provide a forum for all these stages of research as well for the people at the different stages of research career. It’s size allows us to encompass this in a way that many conferences do not.
    I would argue that focusing on what really matters is like looking at where the ball (or puck as I now watch more hockey than football) is now. What NAPCRG provides is a forum for people to suggest where the puck is going to be. Yours sounds like an argument for responsive research that would stifle the basic and innovative. Using that approach we might still be treating people with PPI’s for their peptic ulcers rather than with antibiotics. Other less dramatic questions that might have been unanswered might have been “why do apples fall” “what is this fungus contaminating my petri dish” and “what is this fuzzy interference on my tv screen”
    This rather unstructured response is to argue that as long as the question is new, and that it is answered well, who knows the impact it may eventually have.
    Lets follow this up while eating some tremendous cuisine in Montreal at NAPCRG November 2009.