Domhnall MacAuley: Tops docs at NAPCRG

Domhnall MacauleyBritain’s top doctors. The headline caught my attention in the supplement to last Saturday’s “Times.” At a time when doctors seem under almost daily attack, it was good to see a UK national newspaper list some positives. Excellent doctors. Medicine in the headlines for the best reasons.

But where were the general practitioners? There was no mention of family doctors who provide most of the frontline care in the UK.  Does it really matter? It does, because articles like this reinforce the message that specialists are more important than general practitioners; they are the ones who really make a difference to health care, more valuable, more significant, more influential. It perpetuates a traditional hierarchy and subtly denigrates almost half the medical profession. The difficult patients with difficult problems are hidden in general practice and their care is less important. Family doctors – still invisible. 

Reading this supplement as I boarded the plane to one of the leading international primary care research meetings (NAPCRG), I wondered why we value specialists so much. Perhaps it’s because we prefer simple solutions to illness. And, in a research context, straightforward questions with uncomplicated patients are easier to address.

Jane Gunn (Melbourne), in her keynote address to open the meeting, quoted from Dorothy Hodgkin (“A Life”) and called for primary care to research the serious problems. As Jane described, the future will not be about single issue disease. The serious issues will be the treatment of chronic conditions, polymorbidity, and multiple care from multiple care providers. She illustrated this from her own work by pointing out the large gap internationally in long term research on depression disability, and how we need to devise prognostic models and, look at the relationship between physical symptoms and mood, patterns of depression over time, and long term effect of anti depressants.

Most research, to date, has been on single disease states and patients with multiple illness are deliberately excluded. Jose Valderas (Oxford) told us that 41.7% of patients have more than one disease- so almost half of patients in general practice would be immediately excluded from most studies.  It’s a real challenge, an issue Denise Campbell-Scherer (Canada) will address in her editorial in the next issue of the journal Evidence Based Medicine. Afterwards, Martin Fortin (Canada) and I discussed what outcomes were most suitable for studies of multiple morbidity. Process measures are relatively easy but designing studies with meaningful health outcomes is much more difficult.

Martin Dawes (Canada), who introduced the meeting suggested we look for a new title and acronym for NAPCRG as it is rather clunky and uninformative.  Should we even think in terms of primary care? The big topics are best researched in the community but, in collaboration with others in cross speciality initiatives. Time to think in a different paradigm?

And, finally, Larry Culpepper (US) in his Wood award acceptance speech gave an example of novel health promotion thinking. In a collaboration with the Rhode Island Police department, when legislation requiring child seats in cars was introduced, they had a funded research project where, instead of giving a ticket, the police gave a free car seat to those breaking the law.

Domhnall Macauley is primary care editor, BMJ