Is primary care research a lost cause?

Six years ago Richard Horton asked the provocative question, “is primary care research a lost cause?”1 The result was an initial mixture of dismay and an indignant sense of betrayal among primary care researchers, then some deeper reflection. General practice research was once great, as shown by a report from the Academy of Medical Sciences,2 which is based on a conference held last year.3 Exemplary general practitioner researchers include Sir James McKenzie (who did primary research in cardiology, especially arrhythmias, in the late 19th century), William Pickles (who showed that hepatitis A was an infectious disease with a three week incubation period by meticulous record keeping in Wensleydale in 1930), and more recently Julian Tudor Hart (with his 1960s view of preventive care based on an epidemiological viewpoint in Welsh valleys) and John Howie (with his 1970s analysis of prescribing in acute respiratory infections).

Since then it seems that primary care research has hit the doldrums. It drifted into regions with little relevance to our clinical colleagues, who have remained so indifferent to this storm1 that few are even aware of it. Since the middle of the last century, the research focus seems to have shifted from diseases (which are of immediate interest to practising clinicians) to processes (table⇓).

The problem with researching illnesses in primary care is how to avoid stepping on the toes of researchers who specialise in specific illnesses and be relegated to the system seen in clinical practice—where general practitioners refer patients to specialists for the treatment of particular illnesses. This lack of self confidence within the discipline of primary care may be one reason for the change in research focus from diseases to models of care and health services research.4

For research to be relevant to primary care clinicians, it has to be new, important, and have the potential to change clinical practice and patient outcomes. Perhaps in the past, research has too often looked at processes such as the doctor-patient consultation, patient centredness, and holistic care. Although these form the essence of traditional general practice it is hard to show that they make much difference to patient outcomes. Besides, they were discarded as soon as primary care was forced to modernise with a workforce no longer expected (or expecting) to work all hours and the requirement for convenience and quick service.5

As intended, the report by the Academy of Medical Sciences is a stimulus for those in academic primary care to think about where they should direct their research efforts. The report applauds the leadership role of primary care research in introducing the notions of preventive care as a primary responsibility for clinicians (surprisingly recently6) and understanding what goes on when patients talk to doctors, which led to the development of patient centredness. But it warns that it might be time to remember disease research and move on. It also mentions the importance of translational research, usually known as evidence based medicine, which synthesises empirical research in such a way that clinicians can apply it to clinical practice. For example a recent Cochrane review has shown that aerobic exercise improves functional ability for patients with rheumatoid arthritis—the opposite of what many clinicians were taught at medical school.7

Primary care researchers need to know what to research. They need to ensure that clinically relevant disease orientated research, perhaps done in conjunction with basic scientists,8 is combined with other research on how to improve patient outcomes.

One last thing—even the quantity of research we produce for practising general practitioners in relation to the denominator of our numbers in clinical practice is small compared with other disciplines (for example, <2% of that produced for surgeons9). So we still need more research funding and support. We have a lot of catching up to do.