Examining the health of family medicine research

This is part one of a special four-part series. To access the other parts, follow the links below:

+ Part 2: Outcomes of Foundation-supported research
+ Part 3:TAFP Foundation-based support for research in Texas
+ Part 4: Supporting the future development of research in Texas

In the 35 years that family medicine has been a specialty, it has struggled with the tensions between its commitment to patient care and its position as an academic discipline. There is an inherent conflict between family medicine as a “counterculture” focused on patient care and family medicine as an “evidence-based” specialty focused on generating that evidence. Consequently, the growth of family medicine research has been slow and often unsupported by federal granting agencies and practitioners.

Yet, from the start, many of the leaders in family medicine recognized the necessity of research if the discipline was to achieve equal recognition within the academic community and if the specialty was to provide cutting-edge quality of care to its constituency. Hence, the 1970s was the “age of the research trailblazer” while the ’80s was the “age of the research evangelist,” trying to get the word out and grow converts. The ’90s finally saw the “age of research commitment” with family medicine organizations like AAFP throwing their full support behind the movement. But did 2000 mark the blossoming of those efforts? Has the 30-year process finally come to fruition?

Status of Research Productivity in the United States

The most recent studies of the family medicine research literature summarized the research productivity in 2000 (Pathman et al., 2005) and again in 2003 (Pathman et al., 2008). The 2003 study found that 801 family medicine researchers generated 790 articles published in 285 journals (see Table 1). Compared with the 2000 results, the total number of articles increased by 58 percent and the number of researcher-authors had increased by 41 percent. Although only 60 percent of these articles included a family medicine researcher as lead author and the increase in physician researchers was only 29 percent, these still represent significant increases in both the volume of research articles and the number of family medicine researchers publishing. As might be expected, family medicine journals could not meet this growth so the proportion of these articles published in family medicine journals declined.

In addition to an increase in volume, there are signs that the quality of the research is also improving. Sonis and Joines (1994) found that the quality of the clinical trials published from 1974 to 1991 in the Journal of Family Practice was increasing. Pathman reported that the number of articles published in top-tier general medicine journals (i.e. JAMA, New England Journal of Medicine), though small, increased by 57 percent from 2000 to 2003. Yet, when the content of family medicine research articles was compared with the rank order of the content of family practice patients, good agreement was found. The only major differences found were an under-representation in the research literature of minor but common problems (e.g. cerumen) but an over-representation of serious but uncommon problems (e.g. cancer and AIDS). This speaks to the relevance of the family medicine research literature (Katerndahl et al., 1998).

Status of the Practice-based Research Network

The research tool that was developed by family medicine is the practice-based research network, or PBRN, linking physician practices together to conduct research studies in representative settings. The 86 primary care PBRNs that responded to a survey in 2003 reported that they included 1,871 practices, 12,957 physicians and 14.7 million patients. These PBRNs had generated over 600 publications. However, only 20 were PBRNs consisting exclusively of family physicians. As a group, they were young PBRNs with little research experience and continued to struggle for funding (Tierney et al., 2007).

Continuing Barriers

Although family medicine has finally begun to achieve a substantial level of research productivity and its PBRNs have reached a critical mass to ensure an ongoing supply of generalizable studies, significant barriers to research still exist. Although we may have a critical mass of experienced researchers in academic departments, many of the beginning researchers and those affiliated with community-based residencies still lack adequate research training and skills. With the termination of Title VII federal funds that were used for faculty development and research infrastructure, the lack of research skill development and infrastructure opportunities is critical to the ongoing support of our research effort.

In addition, there remains a lack of research mentors, particularly for non-university-based researchers. Opportunities for mentor development and non-local mentor-protégé pairing must be sought.

Finally, without an Institute of Primary Care in NIH, there remain serious funding barriers to the conduct of major primary care research. The Agency for Healthcare Research and Quality is underfunded to meet this need. Even though existing NIH institutes are beginning to fund some family medicine projects on a modest scale, research funding continues to be the single greatest barrier to family medicine research (Katerndahl, 2006).

Evidence shows that family medicine continues to increase its research productivity. The number of PBRNs has reached a critical mass and should yield important results for practice. However, in addition to the stress imposed by the end of Title VII funds, the perpetual problems of lack of mentorship and federal research funds continue to represent important barriers to further development of the family medicine research base.

References

Katerndahl DA, Burge S, Schneider FD, Legler J: Clinical content of the Family Practice research literature. Texas Fam Physician 1998; July/August issue:26-27.

Katerndahl DA: Directing Research in Primary Care. Seattle: Radcliffe Publishing, 2006.

Pathman DE, Gamble G, Thaker S, Newton WP: Metric of progress for Family Medicine research. Ann Fam Med 2005; 3:88-9.

Pathman DE, Viera AJ, Newton WP: Research published in 2003 by U.S. family medicine authors. J Am Board Fam Med 2008; 21:6-16.

Sonis J, Joines J: Quality of clinical trials published in the Journal of Family Practice, 1974-1991. J Fam Pract 1994; 39:225-35.

Tierney WM, Oppenheimer CC, Hudson BL, Benz J, Finn A, Hickner JM, Lanier D, Gaylin DS: National survey of primary care practice-based research networks. Ann Fam Med 2007; 5:242-50.