Domhnall MacAuley: Achievements of academic primary care in the last decade

Domhnall MacauleyWhat do you think were the achievements of academic primary care/ general practice in the last decade? We discussed this recently by email in a BMJ advisory group of primary care academics; the dialogue was fascinating. 

Trisha Greenhalgh (UK) led the way with ”the systematic attention to developing research capacity out there in the down and dirty world of general practice.”  In response, Tony Kendrick (UK) listed advances in managing major clinical issues, such as infections, cardiovascular disease, mental health, connective tissue disorders, gastroenterological diseases, prescribing, diabetes, continuous improvements in service delivery; and developments in primary care research methods. Tiago Villanueva (Portugal) added research on rational drug use and misleading drug promotion. Others added advances such as the development of research infrastructures (especially practice-based research networks) but also the availability of routinely collected data and the ability to search databases in primary care.

Primary care research extends beyond the boundaries of clinical disease and Jan De Maeseneer (Belgium) believed we should include research on deficiencies in access to care, social inequities in health, and reaching vulnerable groups. Primary care was the first to recognize that, apart from ‘medical evidence’, we need ‘contextual evidence’ and ‘policy evidence’. As an example, he said that primary care was important in changing undergraduate training and improving ‘social accountability’ in our medical faculties. He mentioned primary care initiatives in vulnerable countries and continents, of which his own work in Africa is a shining example.

Academic primary care has come far from its early days when it was carried out by amateurs in a “cottage” industry although, as others added, Willie Hamilton (UK) should certainly get a mention as a prime example of the dying breed of GP-entrepreneur-researchers. Hugh McKenna (UK) was worried that the focus on general practice could ignore the wealth of multidisciplinary research where physicians, nurses, physiotherapists etc creatively used a mixture of quantitative and qualitative methods to tackle interesting research topics. Bruce Arroll (New Zealand) too, endorsed the breadth of research methods; qualitative, quantitative and mixed methods but he felt that the major difference today is that most primary care researchers are trained for their work. Richard Hobbs (UK) agreed but, while acknowledging the enlarged pool of trained academics, wondered if this expansion was enough for the dual priorities of teaching and learning as well as research.

The message from the US was less encouraging. Chip Mainous (US) was concerned that departments had had to focus so intensely on getting research funding (primarily to provide salary support for investigators) that asking big research questions tended to take a back seat to paying one’s way. Indeed, some key individuals, in order to follow up their research interest, felt the need to slide away from academic primary care into more disease oriented research centres. Larry Green (US) was more forthright. He felt the major achievement of primary care research in the US was its survival, a sentiment echoed by many others.

We often look to our Scandinavian colleagues for leadership in health care systems and, interestingly, Peter Vedsted (Denmark) considers that academic primary care has made huge contributions to the way health care systems see themselves, citing chronic care as an example. This has changed health care planning and has put primary care/general practice at the centre.

Jane Gunn (Australia) felt it was important that we had retained a focus on patient experience as this experience drives health care use, drives concepts of disease and illness, and influences the course and prognosis. Many endorsed the hope that individual patient advocacy will be retained, despite the thrust towards the primacy of evidence based population healthcare, and that the individual patient and their lives be retained at the centre of the research agenda. As Cindy Lam (Hong Kong) put it “ the change of  the paradigm is from “ the disease of the person” to “the person with the disease”.

Les Toop (New Zealand) doesn’t feel so uniformly positive and, while the academic spotlight has fallen on research, particularly because of various research assessment exercises in different countries, there are inevitably opportunity costs.  He is concerned about single disease guideline development and simplistic “performance” measures that cut across patient centred-ness – this doesn’t match with messy truths of complexity, uncertainty, and individual choice. He feels we have accepted some aspects of health policy with less critical rigour than we would apply to new clinical treatments and is unhappy about our continued dependence on industry funding for continuing education. He also feels that we may be abrogating our unique role, as academics, to be the “critic and conscience of society”. 

But, “where would we be if academic primary care had not existed over the last decade?” asked Liam Smeeth (UK). He thinks that research (and indeed undergraduate teaching) would have been ever more focused on secondary and tertiary care. Many undergraduate teaching innovations have come from general practice / primary care and these have gained recognition from the older more established disciplines although, as David Fitzmaurice (UK) added, there is still a lot of work to do in terms of sustaining academic credibility with our specialist colleagues. Liam also feels that research would have been less pragmatic, more about efficacy in highly selected  “subjects” and less about effectiveness in real patients with all their complexity. Martin Roland (UK) agrees that without a constant feed from high quality research, there would have been an inexorable drift towards specialist medicine. Primary care is also widely regarded as the key to providing a high quality cost effective health service. And, this may not have happened without general practice researchers.
John W. Beasley (US), wonders about the critical challenges that we should be prepared to meet in the next 10 years and what ecological niches in either the practice world or academia may open up for us “small furry mammals”?  George Freeman (UK) lists some of those challenges: Why GPs appear to be slow in diagnosing cancer? Can we make more sense of the muddle that is mental health care – the diagnosis of ‘depression’ in particular? And, which model of general practice works best in urban primary health care in our new decade? Phil Hannaford (UK) thinks that primary care needs to work with symptoms as these are what usually bring people to see us, not well defined/differentiated diagnoses. But, I will leave the final word to George Freeman, who asked more fundamental questions “Why general practitioners? Indeed, why generalists?”

Above is a brief summary of a vibrant email discussion. Some points are directly attributed but the content is based on the comments of all those names below. Please forgive me; it was not possible to list every contribution.

Bruce Arroll
Anders Baerheim
Peter Croft
Margaret E. Cupples
Martin Dawes
Perry Dickinson
Mieke van Driel
David Fitzmaurice
George Freeman
Larry Green
Trisha Greenhalgh
Jane Gunn
Phil Hannaford
Julian A. Herrera
Richard Hobbs
Amanda Howe
Roger Jones
Tony Kendrick
Kamlesh Khunti
Cindy Lam,
Hugh McKenna
Jan De Maeseneer
Manfred Maier
Arch (Chip) G. Mainous III
Richard G. Roberts
Martin Roland,
Walter Rosser
Liam Smeeth
Igor Švab
Les Toop
Peter Vedsted
Tiago Villanueva
Nick Zwar
Richard Wender

See also Chris Del Mar’s editorial “Is primary care research a lost cause?” and Fiona Godlee’s Editor’s choice “Questions for research