The Future of Family Medicine: Research

Differential access to care

We have begun to experience rationing of care: Not everyone can have renal dialysis, much less renal or liver transplants. Decisions are made every day that have a direct impact on the access to and quality of care. However, it is not at all clear that individuals in North America fully appreciate the disconnection between the possible and the actual; most of us expect access to treatment when we get sick. If we acknowledge that there is rationing, we tend to think that it will not apply to us. How will decision making by family physicians be affected by rationing?

The cultural mix in North America is changing, with different patterns of illness emerging as well as difficulties of language and cultural differences in the physician-patient relationship. Native Americans continue to face substantially higher mortality and morbidity than other citizens in all categories of major illness.³ An aging population, increasing health care costs, and maldistribution of physicians threaten the capacity of the Canadian and American health care systems to respond to the needs of the people.

Alternative medicine

The sheer prevalence of complementary and alternative medicine demands our attention. We need to understand what draws people to alternative medicine, and we should be interested in whether there is any supporting evidence for efficacy or effectiveness.

The role of family medicine research

What does family medicine research have to offer in this changing health care environment? Do we bring unique research knowledge, skills, and attitudes to bear in confronting these challenges?

How do our academic research colleagues see us? An associate dean of research told me that family medicine researchers provide essential access to patients in the practices of family physicians who belong to research networks and to particular communities for special studies. A professor of medicine similarly pointed out how essential family physicians are for engaging patients in clinical trials, what I would term the “handmaiden” role.

I asked a health promotion expert about the future of family medicine research, and he highlighted the area of behavior change—of physician and patient, particularly in the context of the relationship between physician and patient—as a key area for research. Meanwhile, an ethicist highlighted poverty as the critical social determinant of health and suggested this was the most important area for study by family physicians—the relationship of poverty to morbidity and mortality, as well as the potential for social advocacy by physicians.

I also asked a basic scientist and he looked at me blankly, as did a patient who asked, “What does research have to do with family practice?” Both saw research as irrelevant when linked with family medicine.

Ultimately, what we study will be determined by our role in the health care system. We may be the physicians who prevent interventions by counseling patients on the risks of screening tests, not pulling out all stops in treatment, and providing palliative care at the end of life. We may continue as full-service primary care physicians: making house calls, admitting patients to the hospital, delivering babies, setting fractures, stitching lacerations, counseling the troubled, obtaining advice from consultants, and providing continuity of care even for the patient with a complex illness or terminal disease. We may provide such services as individuals or, increasingly, as groups within communities. Or we may not: To the degree that we become restricted service physicians—medical technicians du jour who provide episodic care for common illnesses by algorithm, 9-to-5ers, docs in a box—we obviate the discipline of family practice. We give away our power and can likely be replaced by less expensive primary care providers. If we do not have relationships with our patients, then what does it matter if an emergency after-hours service or a nurse at the end of a telephone triage line manages them? In such situations, there is no long-term future for family medicine research.

Threats

So what might stop us? Six threats face us as we contemplate the research opportunities for family medicine. First, because we have few career tracks for researchers and academics we face the loss of our best and brightest to other disciplines, particularly epidemiology, where health services research methods are taught and practiced. This risk is compounded by the current need for practicing physicians in most communities that entices young physicians away from academic careers. Second, fewer graduates are electing family medicine training, even in Canada, where historically 50% of physicians have been general practitioners or family physicians. Third, it appears that most residents in family medicine lack interest in research; they may preferentially choose family medicine because they perceive that it has little to do with research. Fourth, we face the threat of the abandonment of traditional roles by contemporary family physicians.