Carol P. Herbert, MD, CCFP, FCFP

This is a time of great change in our understanding of health and illness and in our health care systems in North America. Family medicine researchers must understand the changing landscape of health care and health care research, appreciate the threats to the status quo of primary care research, and seize new opportunities to bring their unique perspectives to health care research in this changing environment. Otherwise, we risk missing an opportunity that will not come again.

The changing landscape

The Genome

In the post-human genome era, we anticipate being able to predict disease risks in individuals and to tailor interventions to specific patients. The genetic mapping of patients with chronic illnesses is clarifying why some drugs work only in some people and why one dosage schedule does not work for all patients. There is a growing appreciation of the particularity of human illness that never existed before among bioscientists. For example, Mrs Jones’ diabetes is a different disease from Mrs Smith’s. We can therefore anticipate designer drugs tailored to individuals, and genetic alteration to prevent expression of disease. If we snip the human genome and replace bad genes with good ones, most of the illnesses that plague us will disappear.

If only it were true! The word “genohype” has been used to describe the current magical belief that genomics will provide the answer for every question.¹ Clearly genomics does hold great promise for increased understanding of molecular causation, but chronic illnesses are complex systems. Genetics only describes part of the variance.

The more molecular medicine becomes, the more we need “whole person” physicians. Simply because we can do something does not mean that we should do it. Key questions include: What are the ethical issues that concern predictive genetic testing and selective abortion for minor abnormalities? Does selective abortion for Tourette syndrome really differ in ethical terms from preferential selection for male fetuses? How will patients make choices about genetic testing and to whom will they turn for advice? What are the consequences for individuals, couples, and families of predictive genetic testing?

Technology

New technologies are expensive, often relatively untested when they hit the street, and not necessarily better than what they replace. Although I appreciate having access to ultrasound and computed tomography scans, the consequences can include unnecessary cesarean deliveries and expensive tests replacing good history taking. Access to technology depends on location, so rural patients are either differentially deprived or differentially protected, depending on the technology and your perspective.

Information technology continues to evolve, blessing us with increased access to information and cursing us with unselective provision of data. The promise of evidence-based medicine—like that of genomics—is an over-promise, a chimera: We have trial evidence to inform practice for only a minority of conditions, and even that information needs to be considered in relation to the particulars of individuals in the context of their lives. Yet there is a magical belief among some policymakers and even some specialists that evidence-based medicine will allow the development of infallible guidelines that will replace the need for physicians—at least for our kind of physician. Can a Web physician replace family physicians? Can patients and physicians problem-solve together when they are educated from trusted Web sites?

Public expectation

In this changed world, the public expects perfect care with no risk of negative outcomes, be they from birth or blood product. There is a mythical belief that perfect care is possible, and consequently disappointment and anger result when inevitable errors occur. Can we discover how to minimize risk? Can we explore the notion of informed consent?

Population health, health promotion, and ecosystem health

We know that proper nutrition, exercise, avoidance of harmful substances, and reduction of stress can only be negotiated in the context of relative economic and social stability. Prevention depends on social change, such as education (especially for women), jobs, and fair wages. At the same time, as physicians we try to motivate our individual patients to change behavior, knowing that it will improve individual health outcomes. How can such change be best facilitated? Are there potential negative consequences from focusing on the individual? What is the role of the family physician in achieving social change?

Our patients face health risks from pollution, climate change, and violence. In caring for individual patients, most family physicians rarely need to consider these issues. They may demand political and policy actions; however, since the impact of such actions on health will far surpass the usual causal pathways of human illness that we recognize, these actions must be based on sound data. Is there a role or even a responsibility here for family physicians? Should the principles of participatory action research² be a core skill for family medicine training programs, given that family physicians are ideally placed to assist community development?

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.

A fifth threat is the devaluing of research career paths, or even more generally, of academic career paths. Although this applies to all clinician scientists in an era when the emphasis in our medical schools is placed on how much clinical revenue can be derived, in many academic settings primary care physicians are particularly prone to being seen as cash cows.

The final threat is that we will be co-opted to study the unimportant, to focus on short-term outcomes research that can be turned around quickly for purposes of tenure and promotion, to carry out only what Godwin⁴ has called “navel-gazing” descriptive research about ourselves, or to engage in industrial clinical trials, many of which are thinly veiled marketing enterprises.

The future

Can we reinvent ourselves as family medicine researchers? In the new research environment, with the changes in our concepts of health and illness, there are tremendous opportunities for family medicine researchers—social scientists, economists, and behavioral scientists working in family medicine settings, as well as physicians. Family physicians truly provide a bridge between patients and communities and traditional academic settings. We have the opportunity to change the questions to be asked and to test the relevance of answers in the crucible of family practice.

As research broadens to examine systems and population groups, it is essential that communities know their rights and are able to ask their own questions and to work with researchers in collaborative partnerships. Family physicians are well placed to ensure that those who do research in communities honor the principles of participatory research.

In the world I now inhabit as dean, I hear basic scientists getting excited about cross-disciplinary research, such as the biochemists recognizing their need for physicists and chemists; the blurring of boundaries between physiologists, biochemists, pharmacologists as they study mechanisms; and the genomics folks wanting laboratories next to the proteomics folks, so they can do integrated work on particular genes and their expressed proteins. I hear an emphasis on integration and valuing groups of researchers whose questions span from the molecule to the community. This emphasis is reinforced by granting agencies’ increasing attention to a broader view of research than the traditional biomedical one. Family medicine researchers have an important role to play in this integrated research community.

It is imperative that we study what matters: major cost drivers in diagnosis and treatment; prevalent and serious illnesses; fundamentals of how decisions get made, how patients and doctors learn, the nature of relationships, and how to teach physicians about decision making and relationships; and the impact of the changes in health and illness on individual patients and families, on family physicians and other health care providers, and on the patient-physician relationship. We need to study what family physicians in the 21st century will have to know, and we need to ensure that the communities of patients with whom we interact are partners in research and never exploited. Perhaps most important, we have the opportunity to build theory in the area of behavioral health research and health care relationships. If we do this, family medicine research has a future.

An expanded version of this paper was presented at the North American Primary Care Research Group 2000 Plenary, Amelia Island, Florida, November 5, 2000. All correspondence should be addressed to Dean C.P. Herbert, Faculty of Medicine & Dentistry, University of Western Ontario, Health Sciences Addition, London, Ontario, Canada N6A 5C1.

This is a time of great change in our understanding of health and illness and in our health care systems in North America. Family medicine researchers must understand the changing landscape of health care and health care research, appreciate the threats to the status quo of primary care research, and seize new opportunities to bring their unique perspectives to health care research in this changing environment. Otherwise, we risk missing an opportunity that will not come again.

The changing landscape

The Genome

In the post-human genome era, we anticipate being able to predict disease risks in individuals and to tailor interventions to specific patients. The genetic mapping of patients with chronic illnesses is clarifying why some drugs work only in some people and why one dosage schedule does not work for all patients. There is a growing appreciation of the particularity of human illness that never existed before among bioscientists. For example, Mrs Jones’ diabetes is a different disease from Mrs Smith’s. We can therefore anticipate designer drugs tailored to individuals, and genetic alteration to prevent expression of disease. If we snip the human genome and replace bad genes with good ones, most of the illnesses that plague us will disappear.

If only it were true! The word “genohype” has been used to describe the current magical belief that genomics will provide the answer for every question.¹ Clearly genomics does hold great promise for increased understanding of molecular causation, but chronic illnesses are complex systems. Genetics only describes part of the variance.

The more molecular medicine becomes, the more we need “whole person” physicians. Simply because we can do something does not mean that we should do it. Key questions include: What are the ethical issues that concern predictive genetic testing and selective abortion for minor abnormalities? Does selective abortion for Tourette syndrome really differ in ethical terms from preferential selection for male fetuses? How will patients make choices about genetic testing and to whom will they turn for advice? What are the consequences for individuals, couples, and families of predictive genetic testing?

Technology

New technologies are expensive, often relatively untested when they hit the street, and not necessarily better than what they replace. Although I appreciate having access to ultrasound and computed tomography scans, the consequences can include unnecessary cesarean deliveries and expensive tests replacing good history taking. Access to technology depends on location, so rural patients are either differentially deprived or differentially protected, depending on the technology and your perspective.

Information technology continues to evolve, blessing us with increased access to information and cursing us with unselective provision of data. The promise of evidence-based medicine—like that of genomics—is an over-promise, a chimera: We have trial evidence to inform practice for only a minority of conditions, and even that information needs to be considered in relation to the particulars of individuals in the context of their lives. Yet there is a magical belief among some policymakers and even some specialists that evidence-based medicine will allow the development of infallible guidelines that will replace the need for physicians—at least for our kind of physician. Can a Web physician replace family physicians? Can patients and physicians problem-solve together when they are educated from trusted Web sites?

Public expectation

In this changed world, the public expects perfect care with no risk of negative outcomes, be they from birth or blood product. There is a mythical belief that perfect care is possible, and consequently disappointment and anger result when inevitable errors occur. Can we discover how to minimize risk? Can we explore the notion of informed consent?

Population health, health promotion, and ecosystem health

We know that proper nutrition, exercise, avoidance of harmful substances, and reduction of stress can only be negotiated in the context of relative economic and social stability. Prevention depends on social change, such as education (especially for women), jobs, and fair wages. At the same time, as physicians we try to motivate our individual patients to change behavior, knowing that it will improve individual health outcomes. How can such change be best facilitated? Are there potential negative consequences from focusing on the individual? What is the role of the family physician in achieving social change?

Our patients face health risks from pollution, climate change, and violence. In caring for individual patients, most family physicians rarely need to consider these issues. They may demand political and policy actions; however, since the impact of such actions on health will far surpass the usual causal pathways of human illness that we recognize, these actions must be based on sound data. Is there a role or even a responsibility here for family physicians? Should the principles of participatory action research² be a core skill for family medicine training programs, given that family physicians are ideally placed to assist community development?

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.

A fifth threat is the devaluing of research career paths, or even more generally, of academic career paths. Although this applies to all clinician scientists in an era when the emphasis in our medical schools is placed on how much clinical revenue can be derived, in many academic settings primary care physicians are particularly prone to being seen as cash cows.

The final threat is that we will be co-opted to study the unimportant, to focus on short-term outcomes research that can be turned around quickly for purposes of tenure and promotion, to carry out only what Godwin⁴ has called “navel-gazing” descriptive research about ourselves, or to engage in industrial clinical trials, many of which are thinly veiled marketing enterprises.

The future

Can we reinvent ourselves as family medicine researchers? In the new research environment, with the changes in our concepts of health and illness, there are tremendous opportunities for family medicine researchers—social scientists, economists, and behavioral scientists working in family medicine settings, as well as physicians. Family physicians truly provide a bridge between patients and communities and traditional academic settings. We have the opportunity to change the questions to be asked and to test the relevance of answers in the crucible of family practice.

As research broadens to examine systems and population groups, it is essential that communities know their rights and are able to ask their own questions and to work with researchers in collaborative partnerships. Family physicians are well placed to ensure that those who do research in communities honor the principles of participatory research.

In the world I now inhabit as dean, I hear basic scientists getting excited about cross-disciplinary research, such as the biochemists recognizing their need for physicists and chemists; the blurring of boundaries between physiologists, biochemists, pharmacologists as they study mechanisms; and the genomics folks wanting laboratories next to the proteomics folks, so they can do integrated work on particular genes and their expressed proteins. I hear an emphasis on integration and valuing groups of researchers whose questions span from the molecule to the community. This emphasis is reinforced by granting agencies’ increasing attention to a broader view of research than the traditional biomedical one. Family medicine researchers have an important role to play in this integrated research community.

It is imperative that we study what matters: major cost drivers in diagnosis and treatment; prevalent and serious illnesses; fundamentals of how decisions get made, how patients and doctors learn, the nature of relationships, and how to teach physicians about decision making and relationships; and the impact of the changes in health and illness on individual patients and families, on family physicians and other health care providers, and on the patient-physician relationship. We need to study what family physicians in the 21st century will have to know, and we need to ensure that the communities of patients with whom we interact are partners in research and never exploited. Perhaps most important, we have the opportunity to build theory in the area of behavioral health research and health care relationships. If we do this, family medicine research has a future.

An expanded version of this paper was presented at the North American Primary Care Research Group 2000 Plenary, Amelia Island, Florida, November 5, 2000. All correspondence should be addressed to Dean C.P. Herbert, Faculty of Medicine & Dentistry, University of Western Ontario, Health Sciences Addition, London, Ontario, Canada N6A 5C1.

This is a time of great change in our understanding of health and illness and in our health care systems in North America. Family medicine researchers must understand the changing landscape of health care and health care research, appreciate the threats to the status quo of primary care research, and seize new opportunities to bring their unique perspectives to health care research in this changing environment. Otherwise, we risk missing an opportunity that will not come again.

The changing landscape

The Genome

In the post-human genome era, we anticipate being able to predict disease risks in individuals and to tailor interventions to specific patients. The genetic mapping of patients with chronic illnesses is clarifying why some drugs work only in some people and why one dosage schedule does not work for all patients. There is a growing appreciation of the particularity of human illness that never existed before among bioscientists. For example, Mrs Jones’ diabetes is a different disease from Mrs Smith’s. We can therefore anticipate designer drugs tailored to individuals, and genetic alteration to prevent expression of disease. If we snip the human genome and replace bad genes with good ones, most of the illnesses that plague us will disappear.

If only it were true! The word “genohype” has been used to describe the current magical belief that genomics will provide the answer for every question.¹ Clearly genomics does hold great promise for increased understanding of molecular causation, but chronic illnesses are complex systems. Genetics only describes part of the variance.

The more molecular medicine becomes, the more we need “whole person” physicians. Simply because we can do something does not mean that we should do it. Key questions include: What are the ethical issues that concern predictive genetic testing and selective abortion for minor abnormalities? Does selective abortion for Tourette syndrome really differ in ethical terms from preferential selection for male fetuses? How will patients make choices about genetic testing and to whom will they turn for advice? What are the consequences for individuals, couples, and families of predictive genetic testing?

Technology

New technologies are expensive, often relatively untested when they hit the street, and not necessarily better than what they replace. Although I appreciate having access to ultrasound and computed tomography scans, the consequences can include unnecessary cesarean deliveries and expensive tests replacing good history taking. Access to technology depends on location, so rural patients are either differentially deprived or differentially protected, depending on the technology and your perspective.

Information technology continues to evolve, blessing us with increased access to information and cursing us with unselective provision of data. The promise of evidence-based medicine—like that of genomics—is an over-promise, a chimera: We have trial evidence to inform practice for only a minority of conditions, and even that information needs to be considered in relation to the particulars of individuals in the context of their lives. Yet there is a magical belief among some policymakers and even some specialists that evidence-based medicine will allow the development of infallible guidelines that will replace the need for physicians—at least for our kind of physician. Can a Web physician replace family physicians? Can patients and physicians problem-solve together when they are educated from trusted Web sites?

Public expectation

In this changed world, the public expects perfect care with no risk of negative outcomes, be they from birth or blood product. There is a mythical belief that perfect care is possible, and consequently disappointment and anger result when inevitable errors occur. Can we discover how to minimize risk? Can we explore the notion of informed consent?

Population health, health promotion, and ecosystem health

We know that proper nutrition, exercise, avoidance of harmful substances, and reduction of stress can only be negotiated in the context of relative economic and social stability. Prevention depends on social change, such as education (especially for women), jobs, and fair wages. At the same time, as physicians we try to motivate our individual patients to change behavior, knowing that it will improve individual health outcomes. How can such change be best facilitated? Are there potential negative consequences from focusing on the individual? What is the role of the family physician in achieving social change?

Our patients face health risks from pollution, climate change, and violence. In caring for individual patients, most family physicians rarely need to consider these issues. They may demand political and policy actions; however, since the impact of such actions on health will far surpass the usual causal pathways of human illness that we recognize, these actions must be based on sound data. Is there a role or even a responsibility here for family physicians? Should the principles of participatory action research² be a core skill for family medicine training programs, given that family physicians are ideally placed to assist community development?

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.

A fifth threat is the devaluing of research career paths, or even more generally, of academic career paths. Although this applies to all clinician scientists in an era when the emphasis in our medical schools is placed on how much clinical revenue can be derived, in many academic settings primary care physicians are particularly prone to being seen as cash cows.

The final threat is that we will be co-opted to study the unimportant, to focus on short-term outcomes research that can be turned around quickly for purposes of tenure and promotion, to carry out only what Godwin⁴ has called “navel-gazing” descriptive research about ourselves, or to engage in industrial clinical trials, many of which are thinly veiled marketing enterprises.

The future

Can we reinvent ourselves as family medicine researchers? In the new research environment, with the changes in our concepts of health and illness, there are tremendous opportunities for family medicine researchers—social scientists, economists, and behavioral scientists working in family medicine settings, as well as physicians. Family physicians truly provide a bridge between patients and communities and traditional academic settings. We have the opportunity to change the questions to be asked and to test the relevance of answers in the crucible of family practice.

As research broadens to examine systems and population groups, it is essential that communities know their rights and are able to ask their own questions and to work with researchers in collaborative partnerships. Family physicians are well placed to ensure that those who do research in communities honor the principles of participatory research.

In the world I now inhabit as dean, I hear basic scientists getting excited about cross-disciplinary research, such as the biochemists recognizing their need for physicists and chemists; the blurring of boundaries between physiologists, biochemists, pharmacologists as they study mechanisms; and the genomics folks wanting laboratories next to the proteomics folks, so they can do integrated work on particular genes and their expressed proteins. I hear an emphasis on integration and valuing groups of researchers whose questions span from the molecule to the community. This emphasis is reinforced by granting agencies’ increasing attention to a broader view of research than the traditional biomedical one. Family medicine researchers have an important role to play in this integrated research community.

It is imperative that we study what matters: major cost drivers in diagnosis and treatment; prevalent and serious illnesses; fundamentals of how decisions get made, how patients and doctors learn, the nature of relationships, and how to teach physicians about decision making and relationships; and the impact of the changes in health and illness on individual patients and families, on family physicians and other health care providers, and on the patient-physician relationship. We need to study what family physicians in the 21st century will have to know, and we need to ensure that the communities of patients with whom we interact are partners in research and never exploited. Perhaps most important, we have the opportunity to build theory in the area of behavioral health research and health care relationships. If we do this, family medicine research has a future.

An expanded version of this paper was presented at the North American Primary Care Research Group 2000 Plenary, Amelia Island, Florida, November 5, 2000. All correspondence should be addressed to Dean C.P. Herbert, Faculty of Medicine & Dentistry, University of Western Ontario, Health Sciences Addition, London, Ontario, Canada N6A 5C1.