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Fundamental research at primary care level* Two Canadian medical schools may have appointed a apparently researchable.1 Other important problems are family physician as dean, but in most of the developed those involving large numbers of people, many days in pain world primary care is held in low esteem in academic or suffering, many days lost from work or school, and those establishments. If, as I believe, primary care provides the requiring extensive human and material resources or money essential underpinning for any rationally balanced health that could be put to use more productively elsewhere. Less service why do so many in positions of academic power and common problems are also important if their origins, when influence have a negative opinion of general practitioners better understood, result in more effective prevention or resolution. Important, fundamental, and usually complex In my view, this negativity is because primary care questions should be the hallmark of primary care research.
investigators, as opposed to their biomedical colleagues, The second essential ingredient for first-rate research of have contributed little fundamental knowledge on the any kind is curiosity. Little of note is accomplished without origins and natural history of disease. Studies of physicians’ a burning curiosity. But what kind of curiosity is needed for activities, problem distributions, training schemes, primary care research? It is the curiosity of the naturalist prescribing patterns, appointment strategies, office staffing, concerned with first causes, diversity, and patterns of specimen collection, and management strategies are helpful.
growth and senescence rather than with structures and They are health services research, an enterprise with which I processes. John Ryle (1889–1950), the former professor of have been involved for decades; I welcome them and we medicine who was the first director of Oxford’s Institute of Social Medicine, observed that naturalists have “the desire Health services research, however, does not throw much to establish the truth of things by observing and recording, light on the interacting factors that predispose to, precipitate, and perpetuate ill-health and disease. Such “Certain sciences, such as chemistry, physics, and studies rarely expand our knowledge of prevention, treatment, and amelioration of disease to the extent that experimental. Others, like zoology and astronomy, are biomedical research does, although I believe primary care observational. In the biological sciences as a whole it would research could have an impact in these areas.
seem we can dispense with neither method . . . It is well to Truly important studies contribute to our understanding remember, however, that nearly all experiments have of causality; their insights endure as essential components of developed on the basis of earlier, painstaking observations medical theory and practice and are applied in many of natural phenomena, and that there is actually no great settings. At best, the results of most studies in the past few dividing line between the methods . . . The observer uses years by primary care investigators have had only a slight the slow, vast, and difficult experiments of nature”.2 impact. Only rarely does primary care research have a Unfortunately, naturalists in medical research are now in lasting influence on the practice of medicine or the short supply, especially in primary care.
Experimental methods, buttressed by ever more complex First-rate fundamental research at the primary care level statistical analyses, have contributed mightily to the should contribute substantially to buttressing the generation of effective pharmacological and technological intellectual credibility of general practice and family interventions; we should be very grateful. As engineers’ medicine in the eyes of the medical establishment. To close attention to the wiring enables them to detect accomplish this, priorities and aspirations for primary care malfunctioning of a radio’s transmitters, and receivers, so research need to change. Is there any valid reason why a the biomedical scientists’ focus on neurological, humoral, primary care investigator should not contribute landmark and chemical pathways enables them to detect malfunctioning of the patient’s neurotransmitters and How should one start? The first criterion for selecting any research problem is that it can be an important one. There receptors. Primary care scientists, on the other hand, should is little justification for wasting time on unimportant be concerned with the music and messages transmitted and matters. But how does one define important? A very received over the wiring and through the ether. There is a important question is whether there is life after death.
vast difference between the two but neither is good or bad, Unfortunately, few people are working on it although it is right or wrong, hard or soft. For effective understanding ofhealth, disease, and suffering both the wiring and messagesdeserve investigation. The role of naturalists in medicine hasbeen lost sight of in the wake of biomedicine’s growing *Adapted from the 1999 Maurice Wood Lecture at the 27th Annual hegemony. It is time to restore the balance western Meeting of the North American Primary Care Research Group, SanDiego, CA, Nov 8.
medicine needs now, more than ever, the wonder, awe, and observational instincts of the naturalist.
Another development has accompanied the evolution and 500 Crestwood Drive, Charlottesville, Virginia, 22903–4858, USA(Kerr L White MD) dominance of biomedicine. That is the myth of the single “cause” of each disease. Western medicine’s failure to For personal use only. Not to be reproduced without permission of The Lancet.
distinguish between necessary and sufficient factors in the Mere talk about the centrality of the biopsychosocial or genesis of ill-health distorts both its theoretical base and any other paradigm is simply inadequate. That is the clinical practice. The public harbours the notion that most challenge and the opportunity facing primary care physical ills are due principally to genes or germs. Both are investigators. Two public figures provide additional important but rarely sufficient to cause disease. Undue examples. The late William Casey, then director of the US focus on them tends to stifle further thought about the Central Intelligence Agency, on the day before being myriad factors that impinge on each individual’s disease.
questioned by a congressional committee about the Iran- Contra imbroglio, had a major convulsion due to a Years ago I accompanied an Indonesian doctor making previously undiagnosed malignant brain tumour. In rounds in a village. A distraught mother brought him her response to a reporter’s question, his physician, a prominent feverish, coughing infant. “What seems to be the trouble?”, academician, stated on national television that the timing of I asked. The physician replied: “The child seems to have the seizure was “just a coincidence”. Maybe so, if you bronchitis but the mother is depressed. The mother is believe in coincidences. A different view, however, was depressed because her husband is chronically drunk. The expressed by Woody Allen’s character Isaac Davis in husband is drinking because the pig, the family’s main Manhattan when he said: “I can’t express anger. That’s one source of wealth, is dying. The pig is dying because it is the of the problems I have. I grow a tumour instead!” What’s rainy season and the roof is leaking. The roof can’t be repaired because there is no money. So what is the To investigate such matters at the primary care level, we problem”, he asked “the rain pouring, the roof leaking, the should consider addressing five types of generic question.
pig dying, the husband’s drinking, the wife’s depression, or Onset circumstances—What precisely was the situation the infant’s bronchitis?” What is the point of investigating surrounding the initial signs or symptoms of the patient’s the “wiring” in such a situation when so many unspoken discomfort or illness? Where was the patient? Who was he poignant messages are ricocheting back and forth from rain or she with? What was he or she doing or thinking? What to roof to pig to husband to mother to child? Would the was new or different and what did he or she think and feel child have developed bronchitis if a kindly neighbour had about it? What were other persons in the home, at work, in the family, in the neighbourhood doing or saying? What Here is another example. One Monday an irate medical were the unspoken messages he or she was receiving? Were student assigned to a home-care service demanded to see there more or fewer messages than usual? Were they more me. “I’ve had it with this family medicine business,” he stormed. “Over the weekend I made twelve house calls Concomitant factors—Was there a constellation of two, to Mrs Jones and her eight kids. It was just one thing three, or more interacting or re-enforcing circumstances or after another; there were colds, coughs, fevers, vomiting, encounters surrounding the onset of the patient’s pains—just no end to the problems.” I said: “Did it ever discomfort or illness? For example: unusual job stress, occur to you that there was something else going on in the damp weather or a “chill”, and exposure to a “bug”, before family that was upsetting everyone?” I sent him back to the onset of a common cold; the threat of unemployment, discover the problem. Sure enough he returned with the presence of a sick child or relative, and undue fatigue word that the father had lost his job and was drinking from physical exertion on the job, before the onset of heavily; there was no money and the mother was rheumatoid arthritis; consumption of an extra cup of coffee distraught. The children were receiving the parents’ and a caffeine-laden chocolate biscuit, followed, when late desperate non-verbal messages; their immune systems were for an appointment, by a stressful drive through dense impaired allowing “bugs” to wreak their harm by traffic, immediately before an episode of atrial fibrillation? manifesting assorted physical illnesses. These are anecdotes, Predisposing factors—What is known about the patient’s however, they are not research. If such tales are to have any genetic, familial, and cultural backgrounds and “belief impact on medical practice and education, they require system”? Does the patient have or believe he or she has any particular vulnerability or susceptibility or what used to be Walter B Cannon’s 1942 article on “Voodoo death”,3 called a locus minoris resistentiae? Why me? What is the bolstered by George Engel’s brilliant description of the “biopsychosocial” paradigm in 1977,4 led to increasing calls Precipitation of help-seeking—What events, comments, for the expansion of the 17th century world view that thoughts, or behaviour triggered the patient’s decision to dominates Western medical thinking.5 The potential role of consult a a particular physician at this precise time? What, if epigenetic phenomena in modifying the substrate of many diseases provides additional support for the need to broaden Therapeutic environment—What did the patient feel, our notions of causation.6,7 No longer can we ignore vital perceive, imagine, and think about the physician’s and information describing the circumstances surrounding the nurse’s behaviour, the technology, procedures, medications, onset of each individual’s disease.
and general ambience of the setting? What were the It is hard to deny the outstanding success and effective characteristics, hallmarks, and reputation of the health-care interventions of our present medical paradigm. But if a personnel, institution, system, or clinic? broader model can accommodate a wider array of clinical Patients’ responses to these kinds of questions usually are and historical evidence and generate more enlightened best elicited at the primary care level and should go a long understanding of illness, disease, and health, is it not way toward understanding the webs of causality.
preferable? As with any hypothesis, however, acceptance is The ten problems described below are illustrative; there unlikely in the absence of credible research. Research is are scores of others that cry out for deeper understanding.
needed that will persuade the sceptics in the medical All of these problems have been studied previously, some establishment that changes in the emphasis and content of decades ago, others by several investigators. To provide medical education and scientific thinking are fully external validity, to say nothing of generalisability leading to acceptance by the medical establishment, their initial For personal use only. Not to be reproduced without permission of The Lancet.
findings require replication with large numbers in diverse patients? Answer yes or no. If “yes” provide one brief case settings. Only then are the results likely to be incorporated widely in medical education and practice. Each problem Positive results should provide a host of researchable deserves critical thought, careful refinement, and several pilot questions as well as put primary care research on the studies. Like eating an elephant, you take one bite at a time.
Collaboration with immunologists, neuroscientists, Sir James Mackenzie (1853–1925) is the patron saint of psychologists, epidemiologists, sociologists, clinical general practitioners and family physicians the world over.
specialists, and other scientific colleagues is essential.
By following patients in his general practice for decades he Research designs will necessitate the development of generic revolutionised cardiology and concluded that much was to protocols, including survey instruments that enable the be learned by meticulously studying the origins of reporting clinicians to record categories of responses derived symptoms and describing the natural history of disease. In from conservations with each patient and probably one or 1919 Mackenzie retired from his world-renowned more family members or friends. In addition to a wide range cardiology practice in London to establish an institute for of quantitative methods, a substantial armamentarium of medical research in St Andrews, Scotland. Among its qualitative research methods is available for use in primary purposes was: “To investigate disease before the occurrence care.8 Generation of adequate numbers—large numbers— of any structural change in any organ of the body, with the for studies of each clinical entity and its explanatory patterns view of providing a diagnosis at a period earlier than is at the primary care level needs substantial networks of possible by the methods now in use and in order to obtain a primary care practitioner/investigators who report to a knowledge of the circumstances that favour the onset of central co-ordinating office. Successful examples include those sponsored by the Netherlands Institute of Primary In my view, primary care can best achieve the academic Health Care’s Continuous Morbidity Registration Sentinel stature to which it aspires by internalising the clinical wisdom bequeathed us by Ryle and Mackenzie and Physicians’ Ambulatory Sentinel Practice Network.10 undertaking the serious investigation of important clinical Here are common clinical questions that I believe merit further investigation:● If Helicobacter pylori is a necessary factor in the causation of peptic ulcer, is it sufficient? Why do so many “carriers” of Shroder T. Old souls: the scientific evidence for past lives. New York: the bug not develop the disease? What other factors or experiences does it take to evoke clinical symptoms?11 Ryle J. The physician as naturalist: the natural history of disease. London ● What role does separation from a family member, and New York: Oxford University Press, 1948.
neighbour, job, or even a pet, have on the precipitation of an Cannon WB. “Voodoo death”. Amer Anthropol 1942; 44: 169–81.
Engel G. The need for a new medical model: a challenge for illness such as congestive heart failure?12 biomedicine. Science 1977 196: 129–36.
● How frequently is the manifestation of tuberculosis Pauli HG, White KL. Scientific thinking, medical thinking and medical preceded by “two years of increasingly disturbing education: questions derived from their evolution in the 20th century.
Hum Resources Health Develop 1998; 2: 155–82.
McClintock B. The significance of responses of the genome to challenge.
How frequently is the perception of inability to control Science 1984; 226: 792–801.
fundamental aspects of one’s job associated with the Strohman RL. The coming Kuhnian revolution in biology. Nat development of an illness such as coronary heart disease?14 Biotechnol 1997; 15: 194–200.
● Is the depression associated with pneumonia a precursor Crabtree BF, Miller WL. Doing qualitative research: research methodsfor primary care, vol 3. Newbury Park and London: Sage Publications, ● Are there illnesses that come from being “caught in a Foundation of the Netherlands Institute of Primary Health Care (NIVEL). Continuous morbidity registration sentinel stations in the Why do patients recover more rapidly in some hospitals 10 Green LA, Wood M, Becker L, et al. The ambulatory sentinel practice network: purpose, methods, and policies. J Fam Pract 1984; 18: 275–80.
● Why do wounds heal more quickly on some clinical 11 Melmed RN, Gelpin Y. Duodenal ulcer: the helicobacterization of a psychosomatic disease? Israel J Med Sci 1996; 32: 211–16.
● Why do healing rates for both placebo and active 12 Vernon CR, Martin DA, White KL. Psychophysiological approach to management of patients with congestive heart failure. JAMA 1959; 171:
ingredients vary widely in different study centres during clinical trials using identical protocols?19 13 Lerner BH. Can stress cause disease? Revisiting the tuberculosis research ● Why do mortality rates increase substantially after of Thomas Holmes (1948–1961). Ann Intern Med 1996; 124: 673–80.
personal, religious, ethnic, and statutory holidays, and 14 Marmot MG, Bosma H, Hemingway H, et al. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 1997; 350: 235–39.
This is difficult research but then all really important 15 Takeida K, Nishi M, Miyake H. Mental depression and death in elderly research is difficult. If it is not difficult, it may not be worth persons. J Epidemiol 1997; 7: 210–13.
doing. Others have tackled the easy problems.
16 Alvarez WC. Illness due to having become caught in a trap. Ann Intern Med 1954; 40: 774–83.
Here is another suggestion: if the biopsychosocial, or, 17 Revans RW. The hospital as a human system. Bull NY Acad Med 1996; better still, just the “broader” paradigm is an accurate 3: 418–29.
formulation of reality that can accommodate a wide array of 18 Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R.
factors impinging on the patient’s life and health, why not Psychological influences on surgical recovery: perspectives from
psychoneuroimmunology. Am J Psychol 1998; 53: 1209–18.
find out how useful it is clinically? I suggest that some group 19 MacDonald AJ, Peden NR, Hayton R, et al. Symptom relief and develop a simple but carefully designed postal survey of a the placebo effect in the trial of an antipeptic drug. Gut 1980; 21:
credible stratified probability sample of all primary care clinicians in two or three countries; the response rate should 20 Phillips DP, Smith DG. Postponement of death until symbolically meaningful occasions. JAMA 1990; 263: 1947–51.
be at least 85%. Ask this: Is the biopsychosocial paradigm 21 Mair A. Sir James Mackenzie MD—1853–1925. Edinburgh and useful in the management of most (over 50%) of your London: Churchill Livingstone, 1973.
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