Family Practice Advance Access originally published online on August 17, 2005
Family Practice 2005 22(5):471-473; doi:10.1093/fampra/cmi084
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Editorial |
Unquoted, unchallenged, general practice research will be casting pearls before swine
a St Radboud University Medical Centre, Nijmegen, The Netherlands and b Queen's University, Kingston, Ontario, Canada
Correspondence to Chris van Weel, Department of General Practice, St Radboud University Medical Centre, 229-HAG, PO BOX 9101, 6500 HB Nijmegen, The Netherlands; Email: C.vanweel{at}hag.umcn.nl
Received 20 July 2005; Accepted 29 July 2005.
van Weel C and Rosser WW. Unquoted, unchallenged, general practice research will be casting pearls before swine. Family Practice 2005; 22: 471–473.
Research is the major driving factor in further improving health care and should be directed at the clinical decisions that have the greatest impact on the health status of the population. Most people receive formal medical care in general practice,1,2 and GPs are in many countries the only physicians directly accessible to the public.3 Primary care is where research will contribute most to improve medical care for all. But the profile of primary care research is surprisingly low. Against this background the World Organization of Family Doctors (Wonca) has developed a policy to improve the status of general practice research, expand the evidence-base for GPs, and contribute to better health care worldwide—named after the place of the policy-initiating conference ‘the Kingston report’.4 Priorities in building primary care research capacity are:
- the establishment of (university based) research centres;
- linking these centres to practices (practice-based research networks)5;
- the training of GPs as researchers (and retain them in clinical and academic work); and
- more forums for the presentation and discussion of research: scientific journals and conferences.
- linking these centres to practices (practice-based research networks)5;
At present, journal publication is the established method of sharing information around the world and through PubMed it is possible to establish markers of research quality on the basis of citations by peers. In this issue Mendis and Solangarachchi present an impressive analysis of general practice research on the basis of PubMed.7 They conclude that compared to other medical disciplines, the number of general practice citations is negligible and restricted to a few countries and centres. Their distressing findings echo the experiences of an earlier Australian study.8 Particularly interesting are the methodological problems the study encountered. The emphasis on randomised clinical trials and the difficulty of tracing qualitative research through PubMed may signal a problem with this method, rather than the status of general practice research. And only 15 English language general practice journals—including Family Practice—are indexed in Index Medicus, while GPs will often publish in their own tongue, in unindexed journals. But the recent inclusion in Index Medicus of two important general practice journals should be seen as a clear sign of progress.
The most intriguing problem in the study was in identifying general practice publications as such. Lack of consistent terminology—general practice, family medicine, primary care—hampers the collection of all publications of our discipline for citation analysis, or for that matter for systematic review, as was illustrated in comparing guidelines of otitis media from different countries.9 In addition, the dominating structure of clinical and organ system related domains in PubMed and Index Medicus complicate the recognition of research from general practice. The distressing implication is that the researcher who in all probability will have studied the most general health problem or population must make a particular effort to forestall his/her publication from immersing in a sub-specialty domain.10 It can be assumed that even the most solid search will miss general practice publications. The data of Mendis and Solangarachchi7 present therefore an underestimation of the true research performance. This is in line with the Wonca findings: impressive general practice research is there, but remains unnoticed (and undervalued) despite its quality4 which in fact makes it even worse.
Part of general practice papers will be published—and cited—outside the PubMed domain. Research is to be published for the purpose of improving the care of patients and national journals are the best way to reach local GPs. In addition, research evidence must find its way into guidelines, CME programmes and other tools to implement changes in care, and analysis of citations in those areas will help drawing a picture of relevant science. Though it will not be simple to assess the scientific impact of research on these markers—the undisputed value of PubMed analysis—it will mark the societal impact11 of research and this is an undervalued aspect of clinical research.
There may be reason not to over-dramatise the perspective of general practice research in PubMed, but there are no reasons at all to underestimate the findings of Mendis and Solangarachchi.7 It is not in the interest of general practice when its research is invisible and bringing it to the attention of the scientific community is primarily the responsibility of GPs and their researchers. This would require better acknowledgement of the general practice domain of research and its concepts and foundations.
General practice researchers collaborate more and more with other groups—for example in cardiovascular, gastrointestinal and respiratory fields—and publish in subspecialty journals.12 This is to the benefit of patients and of primary care research, but only when such collaboration results in underlining the contribution of general practice expertise for that clinical field. But one cannot escape the impression that a substantial number of papers from general practice research cite, and generate further citations, of all and sundry of the (sub)specialised field of study, but ignore fellow primary care researchers and this could be an important factor in low PubMed citations of the Mendis and Solangarachchi study.7 There is a need of a better citation culture in general practice, as a scientific community is built upon common concepts and values. Acknowledgement—through critical appraisal in research—of the general practice paradigm is a binding factor of the research culture. It would be important for general practice leaders to stress that new knowledge and insights are placed in the perspective of our discipline's paradigm and here is a key role for general practice journals' editors and conference organisers.
Conferences are another forum general practice cannot dismiss in striving to develop the discipline. Conference performance can also be analysed to assess the status of general practice research, and that is what a Danish group does,13 on the basis of their experiences at the 2004 World Wonca conference in Orlando. Their critical view echoes some of that of Mendis and Solangarachchi: the status of general practice research cannot stand the comparison with more specialised groups. One may disagree with these (Danish, personal) views, as the authors bag all to do: in their view the Orlando conference presented a very strong link to research, and was prepared in close collaboration with leading general practice research groups.14 More important, though, is that the Danish observations have missed a vital point. There is, around the world, a large variation in the status of research, with different behaviour and expectations, which the Orlando conference brought to the surface: against critical appraisal the acceptance of information as the ultimate truth, pursuing discussions versus just presenting and listening. On top of this, unfortunately, a surprisingly large number of (West European) researchers submitted abstracts for Orlando and got their slot to present, but did not bother to show-up at the conference at all. Wonca and the scientific general practice community at large have to face the reality and build on it a global research culture in which its paradigms are revisited and critically analysed. This will serve our collective long-term self-interest as a discipline and requires an inclusive commitment of research leaders around the world.
More and more journal publications and conference presentations will provide a forum for our scientific discourse with citations and discussions as its noticeable markers. It is vital to add quality to quantity and make sure the scientific discourse is directed at, and cites, paradigms and core values of general practice, for their critical review.
References
1 Starfield B. Is primary care essential? Lancet 1994; 344: 129–133.[Medline]
2 Green LA, Fryer, GE, Yawn, BP, Lanier D, Dovey, SM. The ecology of medical care revisited. N Engl J Med 2001; 344: 2021–2025.
3 Weel C van. International research and the discipline of family medicine. Eur J Gen Pract 1999; 5: 110–115.
4 Weel C van, Rosser WW. Improving health care globally: a critical review of the necessity of family medicine research and recommendations to build research capacity. Ann Fam Med 2004; 2(suppl 2): S5–S16.
5 International Federation of Primary Care Research Networks http://www.ifpcrn.org/ also available http://globalfamilydoctor.com (accessed July 13, 2005).
6 Clark J. (for the International Campaign to Revitalise Academic Medicine). Five futures for academic medicine: the ICRAM scenarios. Br Med J 2005; 331: 101–104.
7 Mendis K, Solangarachchi I. PubMed perspective of family medicine research: where does it stand? Fam Pract 2005;
8 Askew DA, Glasziou PP, Del Mar CB. Research output of Australian general practice: a comparison with medicine, surgery and public health. Med J Aust 2001; 175: 77–80.[Medline]
9 Rosser WW, Starkey O, Shauhanassy R. The pond is wider than you think. Can Fam Phys 2000; 46: 103–108.
10 McIsaac W, Low D, Biringer A et al. The impact of empirical management of acute cystitis on unnecessary antibiotic use. Arch Intern Med 2002; 162: 600–605.
11 Anonymous. The societal impact of applied health research. Amsterdam, Royal Netherlands Academy of Arts and Sciences; 2002.
12 Glazier RH, Bradley EM, Lineker SC et al. Getting a grip on arthitis: educational intervention for the diagnosis and treatment of arthitis in primary care. Rheumatol 2005; 32: 137–142.
13 Vedsted P, Søndergaard J, Sandback A, Thomsen JL, Lauritzen T. The WONCA World Congress 2004 did not meet academic standards. Fam Pract 2005; 22: 576–577.
14 Response to the letter to the Editor of Family Practice entitled 'The WONCA World Congress 2004 did not meet academic standards. Fam Pract 2005; 22: 577–578.
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