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The Curious Family Doctor: Research by family doctors in Canada in the early years

by Dr. William A. Falk

162 pages; quality trade paperback (softcover); catalogue #01-0177; ISBN 1-55212-777-X; US$17.00, C$25.00, EUR16.30, £11.30

A history of of early research (pre 1975) by family doctors in family practice.

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About the Book Before there was a well-organized effort in Canada to encourage research by general practitioners, many individuals had the curiosity to do studies of their own work. This book is written to remind us of the work of the pioneers, many of whom are unknown in the year 2001. In the late sixties ad early seventies there was a great surge of interest and activity in family medicine research in Canada. This interest was largely the result of pioneering work done by individuals and committees who saw the potential value of such research before it became a major theme of the College of Family Physicians of Canada, or of most departments of family medicine in our teaching centres. In the eighties and nineties there has been a progressive increase in the volume of research in Canadian family medicine, to the point where it is difficult to keep track of it. This book is written to bring together scattered records of studies done by the pioneers, mainly limited to the third quarter of the twentieth century. It does not claim to be complete, but at least provides a record of much of the early work, and as such is archival. In writing this book, I feel qualified mainly as an admiring observer of the early workers, as well as having some part in development of research by doing studies in my own practice and working with various research committees. Work done in other countries is mentioned, as it has has a direct and large influence on our progress in Canada. ---------------------------------- "I believe the work you have done has been an outstanding contribution not only to the history of family medicine research, but also to the development of the discipline of family medicine nationally and internationally and I want to extend my appreciation for your efforts in this regard." Peter D. Taylor, MA, CFRE Director of Publications College of Family Physicians of Canada ----------------------------------

About the Author Curious = Eager to learn; inquisitive..." This is the word chosen by Dr. Falk to describe his fellow family doctors who, like himself, had an interest in doing medical research based on their practices. Family doctors are uniquely situated to study disease in that they care for patients of all ages, often for all members of a family or an extended family, for all conditions, from the onset of symptoms to their resolution. His interest led him to a Nuffield Fellowship that took him to Britain, Europe, Jerusalem, Australia and New Zealand to meet and exchange ideas with other family doctors involved in research work. That was in 1965, before an organized support system for research was available in Canada. Stimulated by this experience, Dr. Falk has served as chairman of research committees of The College of Family Physicians of Canada in both British Columbia and Alberta, and as chairman of the National Research Committee of The College, and also of the Research Committee of the World Organization of General Practitioners (WONCA). He has received the Fellowship of the College of Family Physicians of Canada, Honorary Fellowship in the Royal College of General Practitioners (Britain), and the Queen's Jubilee Medal. Dr. Falk practised in Victoria, B.C., for 25 years before undertaking a two-year program in Health Services Planning at the University of British Columbia in Vancouver, B.C. He then joined the Department of Family Medicine at the University of Calgary, Alberta, in 1978. He retired in 1987. In this book he seeks to recognize and record the work of the pioneers in family practice research in Canada between the years 1950-1975.

Table of Contents

Chapter 6

Communications

   When a question is posed, a hypothesis stated or a project started, it is with the assumption that there is an answer somewhere. Research is a process of communication, to find the answer and to report it in a form which can be understood and put to work to benefit our patients or the community at large. Often the findings of the day are proven to be wrong when further research produces different and better answers.
   Communication, then as now, was vital to the conduct of research. Using and contributing to the literature was recognized as a basic need. Personal interaction, whether by meetings or through the mail, was necessary to coordinate and critique activities. In a large country, such as Canada, face-to-face meetings were expensive and could be held only on a limited basis.

Libraries

   When the National Research Committee was formed, the Canadian literature of family medicine research was meager. The number of studies done was small, and those published in the Canadian Family Physician would not show up in a search of the Index Medicus (IM), which was generally accepted as the major reference for medical publications world-wide. Until the advent of computer access to the literature, a search meant long hours reading pages of fine print. In his survey of the literature in 1971 Michael Livingston found few original studies by general practitioners in Canada. He described nine case reports and twelve research articles published from 1957 to 1971, presumably listed in IM although two articles from the Canadian Family Physician were included in his list (Livingston, M.C.P., 1972). Livingston expanded on his list of researchers in a report in the Canadian Family Physician (Livingston, M.C.P., 1974), a useful attempt to "rescue from obscurity the work of 21 Canadian family physician researchers in the period 1950-1970".

The Canadian Library of Family Medicine

   One of the first activities of the new national research committee was the establishment of the Canadian Library of Family Medicine. It was the idea of Dr. Robert Westbury of Calgary, who worked on its organization and chaired the library committee. The library was given space in the medical library at Western, and was supported financially by the College. Rather than being a collection of books, it was set up as a reference centre to which College members from across Canada could write or phone to ask for reprints or literature searches on any topic. The references available included more than the Index Medicus, as the library aimed to include any publications relevant to family medicine. It was one of the early steps towards development of a much- needed academic base for family medicine. The first librarian was Mr. Ashford Johnson in 1972, succeeded by Dorothy Fitzgerald, and by Lynn Dunikowski. Other sources of information were described by Westbury (Westbury, R.C., 1970).

Medical schools

   Just as the school at Western had a library which could accommodate the small library of family medicine, each medical school served the medical community as well as the students. As an example, even the library at U.B.C., one of the youngest medical schools, had an extensive collection of books and journals, as well as an archival section.

Medical organizations

   As an example of a provincial service, the library of the B.C. College of Physicians and Surgeons has been available for many years, having evolved from the early establishment by the Vancouver Medical Association. This library was linked to local medical libraries throughout the province. The Victoria Medical Society library, another old one, has been helpful in providing references for this book. It has a collection of current and old journals, some of which are from the nineteenth century. It is likely that the other provinces have similar services available.
   The library of the RCGP, mentioned above for its bibliography, is also a prime source of books and journals related to general practice. It has encouraged contact with family doctors from other countries, offering help to search the literature.

Personal

   The large volume of material arriving because of membership in various organizations creates a problem of storage. A selection process was necesssary to preserve those which were considered most likely to be of interest in future, or to file tear-outs so they could be retrieved easily. Books also could be useful, although some clinical texts could be out-dated too soon while others have basic knowledge which remains pertinent. Some books had historical interest and value, according to the interests of the individual, and some had basic principles which stood the test of time.

Bibliographies

   Various lists of research work done by general practitioners have been prepared. The following include the best available, and contain many more references than can be included with the examples chosen for this book. They show the range and breadth of subjects and of researchers.

The RCGP list

   The best source of information about general practice projects was the library of the Royal College of General Practitioners, in London, England. The librarian, Margaret Hammond, maintained and published a record of general practice studies throughout the world. For years, this was the only reasonably complete list available for family medicine.

The ACGP Digest

   The Australian College of General Practitioners published the Research Digest (Rowe, I.L., [Ed., 1968, 1972 ]), a list of studies done in Australia during the ten-year period up to 1968. An abstract was written for each entry. This was followed in 1972 by another list of recent projects. Some of these are descibed in Chapter 3, as examples, but the total number is overwhelming when we consider the size of the country and the relatively small population compared with other world powers.

Zaborenko

   In 1968 Zaborenko and Zwell published a list of studies in general practice, most of which were from the U.S.A. or Britain (Zaborenko, L., 1968). Many were from the JRCGP, and most had been published since 1960. They noted that the number of publications in the 18-month period in which they were collecting data equalled the number in the preceding six years, and that many were from individual general practitioners reporting on their own practices. In a follow-up bibliography on training for family practice, they included many additonal references (Zwell, M.E., 1970).

Tenney

   Another useful list of studies of the content of medical practice was compiled by Dr. James Tenney and published by Johns Hopkins University (Tenney, J.B., 1969).

RAP

   The Research Awareness Publication (RAP) was another brainchild of Dr. Robert Westbury, who originated and produced an occasional current list of projects by Canadian family physicians. It appeared first in December, 1970. Seven issues were published at irregular intevals until August, 1976. Projects were listed according to category of research, in four main groups: epidemiological, organizational, clinical and therapeutic. RAP was unique in classifying projects also according to the stage of development: idea-planned-underway-completed-published-or abandoned. Successive issues showed progress from the idea stage to the final outcome (Westbury, R.C., 1971 and 1973). RAP included many more studies than I have listed as examples. Apart from those published, RAP showed many ideas which never proceeded to completion, although it showed topics which were considered to be important enough to be worth studying.
   By 1976, the College had developed a research office at its headquarters in Toronto, and the listing of projects was taken over by research associate Daniel Brackstone, Ph.D. The general idea of RAP was continued and in 1980 was expanded into a new publication called Family Medicine Research: a Current Canadian Index.

FAMLI

   Also in 1980, WONCA published the first edition of the Family Medicine Literature Index '(FAMLI), using the same format as Index Medicus, to provide a record of work done in any country. It would have been useful in the early years.

Journals

   From its early days as a newsletter Between Ourselves, the RCGP record of the results of research by general practitioners was ahead, in time and scope, of any general practice journal in the world. The newsletter grew to become The Journal of the Royal College of General Practitioners (JRCGP), providing a medium for publishing papers from around the world. It is now called the British Journal of General Practice.
   In Canada and the U.S.A., the general practice journals were publishing many articles by specialists, often in the how-to-do-it category, but little original research by family doctors. It seemed that the reason for a lack of published articles was the lack of research by general practitioners, along with failure to take the final step of preparing results suitably for publication. The Canadian Family Physician (CFP) was not listed in the Index Medicus, so there was a disincentive to submit research papers to it. However, after the research committee started its new approach in 1968, space was provided by the supportive editor, David Woods, for a monthly newspage to promote an interest in research. A latent interest became apparent when readership surveys gave the research newspage a consistently high rating. In time, more research papers were submitted by family physicians. Eventually the journal was listed in Index Medicus, possibly because of the increased number of research papers.
   Other publications appeared, directed primarily at promoting and printing research reports by family practitioners. The Journal of Family Practice (JFP) in the U.S.A., was started by NAPCRG in 1978 and published monthly. As well as publishing studies in general practice, it produced useful special editions devoted to the general principles and methods of research, and to some of the basic studies of the content of family practice.
   Examples of the work in other countries were published in journals such as the American Family Physician (AmFP)and the Australian Family Physician (AuFP), known originally as the Annals of General Practice.
   The international WONCA News, which started in 1974, eventually was included in a new publication by Oxford University press, Family Practice. Along with general information about activities in family practice, WONCA News included reports on research by the many member countries.

Committee Activities

   Even with all the literature available, there was still a need for face-to-face contacts at reasonable intervals, to allow for discussion and planning of objectives and projects. Nowadays the prevalence of aids such as fax machines, conference calls, and E-mail might reduce the need for meetings, but those things were not readily available in the early days.

Meetings

   When Dr. Jim Collyer's new national committee took shape, with members from each province, the major benefit was the establishment of personal links between members. These were strengthened at two-day meetings of the committee, usually in Toronto. Each provincial member would report on developments, leading to a detailed discussion of progress. Plans to promote and assist research activity nationally as well as provincially were presented for critique and possible action. It was still necessary for the committee to convince the Board of the College, which had provided good support and encouragement, of its capabilities in research. Other committees of the College tended to undertake surveys and projects without using the potential benefit of advice from the research committee members, who might have benefited from the experience of evaluating plans.
   An omnipresent problem in all Canadian committees was the size of the country. A British visitor to the Muskoka Workshop, Ruth Pinsent, wearily commented on a boat cruise "but there's so much of everything!". Communication in any form was expensive. The cost of airfare and accommodation for a two-day meeting of fifteen members required a large budget, and two meetings per year were the limit. It was necessary to conduct much of the work of the committee by mail, or by telephone. We could envy the relative ease of communication in Britain, where the small size of the country made meeting much easier. On the other hand, Australia had the same difficulty as Canada, with an even smaller population spread mostly over the southern portion of a large country, with its largest population centres in the east. In spite of the similar geographical problems, the Australian College had produced a large and useful body of research.
   Some of the papers presented at workshops and scientific sessions of the College, NAPCRG and WONCA were published in 'proceedings' which were distributed to registrants but not usually published elsewhere. Many of these were based on recent research or works in progress, and were printed as abstracts rather than complete descriptions of the work. Discussions with the audience had the potential to improve a final publication or to improve the planning for a project.

Delphi

   To help provide timely advice to those planning projects, a major initiative was undertaken by Dr. John Garson, of Saskatoon. He developed a postal network for long-range discussion of research proposals by family physicians, to provide a variety of informed feedback. This network, named Delphi, involved making and mailing copies of proposals to members of the national research committtee, with a request to study them and return a critique within a specified time.
   To follow the theme of the Delphic Oracle, Dr. Garson was given the name 'Oribasius' in his communications with his widely-scattered team of minor oracles. The first project, started in December, 1970, was to give opinions and suggestions about the proposed Illness Observation Unit. The mnemonic 'IOU' was intended to indicate that we owe it to our patients to study their problems so that we might improve their treatment. This project went through a long process of planning, and eventually surfaced as the National Research System (NaReS). Over the next four years, opinions were requested by Delphi on a variety of projects, such as:
* Use of a Physician's Associate
* Package Programs, in cooperation with the Research Unit of the RCGP
* The Canadian Library of Family Medicine
* Family Life Education
* The Diagnostic Process
* Trace elements related to Morbidity
* Vitamin E in Coronary Heart Disease
* Chronic Obstructive Lung Disease
* Group Therapy Evaluation of a patient information manual
* A Social Worker in a general practice
* FACMIS, a system of keeping medical records.
   The work of sending out requests to the oracles and reporting their opinions to the applicants was done by Dr. Garson, with help from his office and from his best friend and critic, his wife, Ruth. What a help it would have been if we had had the later benefits of clear and easy photocopies, fax machines, computer word-processing and E-mail!!!

Other communications

The patient records

   The gold mine of information, described by Jim Collyer, could be used for retrospective studies if the records were reasonably complete. For prospective studies, details could be recorded in ways that made extraction or transfer of data accurate, but a system of checking and confirming data was advisable.
   Records of patient contacts in or out of the office were especially important in group practice where several doctors might become involved with a patient over time. Even for the usual doctor, good notes served as reminders of past contacts and an advantage in assessing current problems. Dr. Wayne Weston described the gradual adoption of the problem-oriented system in his group practice, and the apparent improvement in care as a result (Weston, W. W., 1973). That might be a benefit to the practice, but not necessarily set up in a way that results could be copied and compared in other practices. For any project, the objectives must be clear, and recording consistent so that results can be useful for comparison and publication.

Patient - doctor communication

   The essential for good care is the ability for both parties to listen, and to say the things necessary to identify the problems and to deal with them effectively, together.

Writing for publication

   A study might have provided valuable results, of great interest and satisfaction to the researcher, but it was necessary to learn how to put all the relevant details of planning and execution into a form which was complete and concise. In the absence of word-processors, there was usually a requirement for a type-written double-spaced manuscript, with multiple copies. Each journal might have variations in its format, until the Convention of Vancouver provided a format which was accepted by most journals which we were likely to use. However, each journal publishes the advice about its own requirements, and should be consulted before anything is prepared for submission.
   There are many reference books on the process of writing, the organization of data and the economy of words. Dr. Jim Collyer found that an editorial consultant could be very helpful, and advised other researchers that they would have a better chance of publication if such expert advice was obtained.
   It is important for researchers to publish the results of their work whenever possible, to add to the body of family medicine. The sharing of their experience can be of benefit to others, as well as providing the opportunity of feedback to the author to confirm, challenge, or expand on the results. Even negative results are of value, both for the information obtained and perhaps to help others to avoid wasting time in doing the same thing.

Summation

   The result of all research is expected to be of benefit to patients, by the process of communication. Research can find answers, but they need to be passed along so that they can be used in practice.

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