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RESEARCH IN AND ON PRIMARY HEALTH CARE

by PAUL BACKER

Paul Backer: General practitioner, Copenhagen. Professor and head, Department af General Practice, University of Copenhagen, DK-2100 0.

ABSTRACT. There is a need for much more research in the primary health services especially in general practice.

Epidemiological and clinical studies in this fleld can greatly improve our knowledge about modern concepts of health and disease in that large section of the population who do not come into contact with the institutionalised health services.

Furthermore such research will complement work in other medical fields, thus reducing bias caused, for example, by short doctor-patient relationship.

A maor problem of research in primary care is the evalua- tion of what is often soft and complex data derived kom multi-practice and inter-disciplinary studies. Research aimed at statistical sipiflcance may result in low clinical significance and vice versa.

KEY WORDS: Primary health care. General practice. Mul- tipractice studies. Single practice studies. Soft data.

Research in primary health care most often starts from the key position of the general practitioner. The core content of general practice is inherent in well- known international definitions.

Some of the key words are personal, primary and continuous doctor-patient relationship. The perspec- tive is inevitably broadened, if the activity comprises familiestgroups and if the contact takes place under varying circumstances, in the consulting rooms, in the patients home and in the local community, the general practitioner himself being a member of this milieu. The perspective can also be broadened, if other health professionals in the primary health care team are involved in the individual problems.

These working conditions have caused the general practitioner to abandon a static concept of disease. A separate disease and period of illness should be re- garded as a brief, static episode in an otherwise dyna- mic course of life. The physician’s responsibility is by tradition - and quite naturally so - to deal with this episode and its immediate social and psychological consequences for the patient. The general practition- er, however, has also the possibility of viewing the episode as one of a series of many different episodes and life events in the patients lifetime, all of which have accumulating consequences for the patient -

Scand J Primary Health Care I

physically, psychologically, socially and existentially. It is this possibility of obtaining information on a

broad front that plays an important role in the specific identity of research in general practice and primary health care.

Epidemiological population studies give us valu- able information about the distribution of a problem and its eventual course over a certain period of time. This method, often based upon impersonal ways of gathering information about persons and milieu in- volved, gives only modest opportunities to procure more than approximate demographic data from the population observed. Likewise, epidemiological stu- dies of hospital records have their limitations. Many determinants causing admission to hospital are irrelevant to the studied probleddisease. This invali- dates studies aimed at examining prevalence and natural history of disease as seen in general practice or in populations.

It is feasible to close the gap between clinical hospit- al research on the one hand and population studies on the other, by carrying out clinical epidemiological research in primary health care.

It is feasible to remedy the shortcomings of epidemiological, population and hospital studies by furnishing information from the primary level through epidemiological studies in general practice.

It is feasible to use basic information about the individual patient and his family, which is often only available to the general practitioner/primary health care team. This will facilitate the synthesis of biologi- cal and sociopsychological epidemiology. This would certainly serve the practical purpose of improving the physician’s ability to apply prevention and treatment at the same scientific level.

It b feasible to focus especially on those persons, who on account of illness, draw on the resources of society, because primary contact takes place in gener- al practice/primary health care and further contact most often depends on this service.

It is feasible to examine, in the population in con-

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tact with the general practitioner, the patient’s con- The key lessons must be, cept of illness and disease. This concept is verbalized at the primary contact to general practice by the patients themselves for initial decision and is inde- pendent of professional attitudes to health and dis- ease. Recurrent or continuous morbidity studies in general practice Will reflect the individual’s decision to consult and, above all, the consequences this would have in regard to primary health care. Thus it may give us an idea of the optimal structure and dimension of health care. Furthermore it will give us an idea of what kind of public education should be employed in order to promote appropriate and rational self-care. This might expediently influence the physician’s consulting pattern.

It is feasible to use daily contact with individuals and families to examine the influence and stress of the local milieu upon individuals and groups-physical- ly, psychologically, socially and existentially-and to use the knowledge obtained in preventive local com- munity work.

The greatest problem of research in these fields is connected with a realistic evaluation of the soft data, by which we characterize the individual, who has become a patient. So far medical research has only explored this field to a modest extent. This is under- standable, because traditional medical science has, and has had, very restrictive criteria for reliable and valid research. The sad consequence, however, is that we have acquired less knowledge about the sick indi- vidual than about diseases afflicting mankind. This demands from all primary health care personnel abil- ity for critical thoughts. With an ever increasing volume of scientific knowledge to be taught to the student the newly qualified will have lost (or never have been allowed to develop) this ability to observe and think for himself. This is particularly serious for the doctor of first contact-the general practitioner. General practitioners need to be capable of flexibility in adapting knowledge and skills, more appropriate to hospitals, to the different environment of care in the community.

The concept of critical thinking can be reduced to three subheadings:

1. Clinical significance. 2. Validity and reliability. 3. Statistical significance.

that inaccurate information is not suitable for sub- mission to the rigours of statistical testing. that statistical testing is a means of assessing the probabilities that accurate observations and asso- ciations represent chance or real relationships, that statistical significance does not, ips0 facto, signify clinical significance, and that though information may have clinical signifi- cance, it may not be able to support this statistical testing due to sample size.

In the same way we can examine abstractions like diagnoses, that are an important part of scientific method. They also represent a hazard in that we may fall prey to them. It is essential to break through these abstractions and use clinical experience viewing the problems in new ways and in a broader perspective. Such independent and critical thinking may lead to theories, which are not founded in a strictly scientific manner and are thus difficult to recognize formally. Nevertheless, we must regard these experiences as very valuable. Given recognition of this concept, “the service” and “the academic wings” of general prac- tice can grow together. Without these links both could conceivably collapse.

These remarks, as an overture to counter the heavyweight research described in the beginning of this article, that put emphasis on grander designs, with more collaborators and computers and less emphasis on simplicity and singlemindedness of approach. The heavy weight research is necessary and important. In general one can say, however, that large studies tend to collect less valid and reliable information. Althought they have a greater capacity to produce statistically significant tables, they are often associated with a high risk, that the work will be of low clinical significance. Smaller, tighter studies, on the ofther hand, tend to produce a better quality of information and say what is really going on, but often in too small a quantity to allow easy interpretation.

Good research need not be expensive, complicated to design or difficult to analyse. A careful balance has to be struck between the multi-observerstudy which produces much information and the smaller one which, although sometimes offering relatively little in the short-term, may have greater long-term import- ance. We hope to be able to bring a wide panorama of such research in primary health care to this Journal.

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