Domhnall Macauley: Of mice and real people
19 Nov, 09 | by julietwalker
Do you dither with your mouse? Who would have thought there could be any new angles on consultation analysis! Simon de Lusignan (St Georges, University of London) had some new insights in his keynote address at NAPCRG (North American Primary Care Research Group). Linking three way video and computer activity he showed that some doctors, at critical phases in the consultation, were busy moving their mouse but there was no computer screen activity- it was simply a ploy to buy some time to think. Analysing current systems, he feels that some of the major weakness are because they apply a biomedical framework to a human process; we think in narratives but computers think in codes. But, other parts of the communication industry are more advanced in the science of relationships. Surprised that the drug rep remembered your wife’s name and was able to talk fishing? Their company may use a much more sophisticated consultation recording system than you.
What will become of us when we are old? Running scared of ageism, doctors follow guidelines to the letter, racking up multiple medications in older patients. Dee Mangin (University of Otago), said that patients were more afraid of the mode of death than death itself. And we are in danger of making their lives miserable too. Citing the PROSPER trial, which is the only one that includes patients over 70 years of age, she pointed out that, while cardiovascular mortality was reduced, all cause mortality was not. We simply replace one illness with another. But, more than that, we make healthy older people into patients. Our unwritten contract for treating patients who present with illness does not apply when we apply preventive therapies that can cause harm. We need to think beyond all cause mortality- we need to think of all cause morbidity.
Do clinician researchers have a future? Only doctors embedded in practice have a real understanding of the implications of some of these trial findings in real patients. But, the days of the clinician researcher look soon to pass. There are exceptions and some countries, notably the Netherlands, have combined MD/PhD programmes. There are few mid career clinical research opportunities, however. One exception is the Community Based Clinical Investigator programme that David Adams (University of British Columbia) described. This enables mid career researchers to follow up their own research ideas, develop projects and publish their work. Some of their research was discussed at the conference, including studies on the health of prisoners, a mobile falls prevention programme, and screening for Chlamydia in seasonal workers. Work with an impact in real people. It is a worry that the future of this programme could be threatened by the shrinking investments of their funding agencies. Another potential casualty of the economic downturn.
Domhnall MacAuley is primary care editor, BMJ
Thanks for this welcome reminder of the vital importance of generalism. These are all partly issues of competing/conflicting values, viewpoints, and priorties. Only leaders and practitioners who are comfortable balancing multiple agendas will be able to move forward successfully. Primary care doctors are excellent at this kind of tightrope walking. But perhaps we need to work harder at making our generalist perspective heard among the clamour of voices leading to one narrow focus or another?
Robert Varnam
November 19th, 2009 at 8:53 pm
Phew
650 researchers - 50% from the US, 30% from Canada and the others from Oz, NZ, Holland and the UK mainly, but 16 countries in all -
580 different presentations, distinguished papers, SAPC selected paper, parallel sessions and posters. the variety of primary care research going on around the world is vast and the quality continues to improve. 150 presentations a day - the buzz was terrific helped by the appearance of cheerleaders, popcorn and general pzaz. This year we had more medical students as McGill held a student summit on the saturday of NAPCRG to show that research happens in primary care!
check out the abstracts on line http://www.napcrg.org/app/search09/index.cfm
The launch of the Commonwealth Fund review of the health delivery in primary care demonstrating how far behind the US and Canada are, was launched on the Tuesday generating a lot of interest
http://www.commonwealthfund.org/
Bill Hogg pointed out the slightly bizarre paranoia that the US and Canada have of becoming like the other if they make changes to their health care systems. Perhaps, as the worst two countries in the world they should look at some slightly better examples of care
In the end of 4 days though it was clear that NAPCRG is a reminder of the enthusiasm and academic activity of primary care - a true example of the 80:20 rule where the work of networks of patients and doctors addresses the common and important questions that face people every day.
declaration of interest - I am on the program committee for NAPCRG.
Martin Dawes
November 20th, 2009 at 7:44 pm