Family Medicine and Scholarly Activity: The Need to Move from Consuming to Producing

1. Family Medicine and Scholarly Activity: The Need to Move from Consuming to Producing Arch G. Mainous III, PhD Presentation to USAFP Annual Meeting March, 2007

2. If we knew what it was we were doing, it wouldn’t be called research, would it? Albert Einstein

3. The Bad News

4. Limited Research Productivity in Family Medicine • 1977--Geyman argued that an FM research base was essential to the specialty • Most assessments of research in FM have not shown much progress even among academics • 92% of STFM members did not author a Medline article in 1999 • 50% of FM residencies produced no publications in 3 years (2002-2004)

5. Limited Success in Grant Funding • 2003 data from NIH • 149 NIH grants were given to 45 of 110 FM departments • 61% of FM grant PIs were not full-time family medicine faculty • 35,000 applications were submitted to NIH • Success rate in 2003 was 30% • 2007 NIH expects 50,000 applications • Expected success rate for 2007 is 20%

7. Impact of FM Research on FM Questions • Review of POEMs in JFP 4/1/2001—4/1/2006 • 428 total articles used to answer the clinical question • 8 were authored by investigators in Family Medicine departments • 7 were published in Family Medicine Journals

8. Indications of Progress

9. NAPCRG Attendance

10. Recommendations of Future of Family Medicine Project • “Enhancing the Science of FM” • Participation in generation of new knowledge incorporated into FM training • Practice-based research • Academic departments will do collaborative research • Need for new federal funding agency • Increase funding of AHRQ to $1 billion per year

11. Views of Primary Care Research • Prevailing view is for research to focus on “what is done in primary care” • Another view is to focus on “who is seen in primary care”

13. Ask Questions and Be Creative

15. Erasmus Darwin

16. Lunar Society

17. Accomplishments of Erasmus Darwin • One of the first formal theories of evolution • Creator of talking machine • Designed a horizontal windmill

18. Barry Marshall Robin Warren

19. Helicobacter Pylori

20. 2005 Nobel Prize

21. Attitude Works if you Win a Nobel Prize

22. Examples of Research

23. Studies on “How We Do Things” • Continuity of Care • Continuity and risk of future hospitalization • Value of continuity among doctors in US, UK and Netherlands • Overuse of antibiotics • Antibiotics prescribed for the common cold • Length of visit and antibiotic prescriptions • Quality of Care • Continuity and quality of care for diabetes • Impact of acculturation on diabetes care for Latinos

24. Studies on “Who we See” • Risk Stratification of Undifferentiated Patient Population • Evaluation of biomarkers as CHD risk factors (CRP, insulin resistance) • Evaluation of impact of prehypertension • Undiagnosed diabetes and complications • Behavior of Patients and Implications for Health • Can one be “fat but fit”? • Latinos’ use of antibiotics without a prescription

25. Evaluation of Importance of Prehypertension • JNC 7 made a new recommendation to consider the condition of “prehypertension” • Controversial and not much data to support this recommendation • We knew that prehypertension is associated with development of hypertension • We didn’t know if there is an independent risk associated with having prehypertension • Time for a study!!

26. Evaluation of Importance of Prehypertension • Study 1—Evaluation of independent risk of prehtn on CVD mortality (NHANES II cohort) • No independent risk • Study 2—Evaluation of independent risk of prehtn on CVD morbidity (NHANES I cohort) • Independent risk but basically just “borderline htn”

27. Editorial on Prehypertension and CVD Morbidity Article • Lee Green, member of JNC 7 panel said • “Well-done studies from several populations and using varying research methods are essential to assessing the validity of the JNC 7 recommendations.” • “Liszka et al’s analysis is technically exemplary; more importantly, it is clinically representative of the patients we see in daily practice.”

28. Other More Exotic Questions for Study • Fiber supplementation and its impact on systemic inflammation • Role of Telomeres with Insulin Resistance and Coronary Disease in Health Care Disparities

29. Barriers and Challenges to Scholarly Success

30. Extreme was his skepticism to human truth Anna Seward discussing Erasmus Darwin

31. Action Shot of a Researcher

32. Ideas for Scholarship • What do we know & what don’t we know

33. Ideas for Scholarship • What do we know & what don’t we know • Observations from practice

34. Ideas for Scholarship • What do we know & what don’t we know • Observations from practice • Questions from the literature • Stuff you read • Presentations at meetings • Questions at journal club

35. Ideas for Scholarship • What do we know & what don’t we know • Observations from practice • Questions from the literature • Stuff you read • Presentations at meetings • Questions at journal club • Observations of the environment your patients live in

38. Funding for Research • Big funders • NIH, AHRQ, CDC, AHA, ADA, RWJ • Advantages: A)More money, B) overhead funding, C) variety of types of grants, D) high prestige • Disadvantages: A) Very Competitive, B) almost impossible without track record and infrastructure

40. Funding for Research • Little funders • AAFP-F, USAFP, small foundations, local hospital • Advantages: A) Not so competitive, B) short proposal, C) may be oriented to local issues • Disadvantages: A) Modest amount of money and usually no salary support, B) little to no overhead funding, C) low prestige

41. Lack of Time and Research Skills • Lack of time is a BIG barrier

42. Lack of Time and Research Skills • Lack of time is a BIG barrier • Lack of research skills is a barrier but maybe not as much as a lack of ideas and time

43. Lack of Time and Research Skills • Lack of time is a BIG barrier • Lack of research skills is a barrier but maybe not as much as a lack of ideas and time • Potential Solution—Collaborate • Academic colleagues • Practice based research networks

44. NAPCRG Consultants Directory • Contact information for consultation in more than 80 methodological topics • Content expertise can be found in the special interest groups • Currently there are 73 consultants • Average more than 16 years of research experience • Directory lists which roles the consultant is willing to play • www.napcrg.org (you have to be a member to access the directory)

45. Practice Based Research Networks • AAFP National Research Network (grew out of ASPN) • Largest network with 334 clinician members • The Federation of Practice-Based Research Networks (FPBRN), established in 1997 • 50 member networks and 5 US affiliate networks • EHR related networks like PPRNet

46. Take Home Messages

47. Take Home Messages • Much of the intellectual base of family medicine is created by folks outside of family medicine • Time to draw upon intellectual resources in family medicine • Everyone can play a role in developing new knowledge • Don’t be afraid to get involved • New discoveries are part of improving care

48. The world is not governed by the clever men, but by the active and energetic. Erasmus Darwin