Published 7 January 2010, doi:10.1136/bmj.c94
Cite this as: BMJ 2010;340:c94
Editor's Choice
Questions for research
Fiona Godlee, editor, BMJ
fgodlee@bmj.com
Continuing last week’s focus on the BMJ’s research papers (BMJ 2009;339:b5632,
doi:10.1136/bmj.b5632) it’s gratifying to see them performing so well in Journal Watch’s first ever listing of
the medical stories that were most read in the past year.
Journal Watch, run by the Massachusetts Medical Society, which owns the New England Journal of
Medicine, gets its team of contributors to summarise what they see as the most interesting and important
articles published in each field. Now Journal Watch has also summed up readers’ choices during 2009.
BMJ research articles feature more than those from any other general medical journal in the top 10 "most
read" lists for hospital medicine, general medicine, emergency medicine, and psychiatry (www.jwatch.org).
Interestingly there’s no primary care list, which says something about the Massachusetts Medical Society’s
priorities, or US medicine, or both. Or could primary care research itself be to blame? Back in 2003, the
editor of the Lancet, Richard Horton, provoked an indignant response from academics in primary care by
asking whether primary care research was a lost cause. A report from the Academy of Medical Sciences
has now explored this question more deeply.
As Chris Del Mar summarises in his editorial (doi:10.1136/bmj.b4810), the report rightly credits primary
care with championing prevention as a key priority for clinicians (something we now take for granted) and
for increasing our understanding of what happens when patients talk to doctors, which has led to the
concept of patient centredness. But the report goes on to warn of the need for more research into the
clinical care of diseases encountered in primary care, and for more translational research, which Del Mar
usefully equates with evidence based medicine.
Del Mar blames a lack of self confidence within the discipline for the change in research focus from clinical
management to the organisation of care. What we need, of course, is research into both. Funding is
growing. In the UK about £50m of the National Institute for Health Research’s £1bn budget is now devoted
to primary care research. The harder task is getting clinicians to take up research. The UK’s School for
Primary Care Research, set up in 2006 and now comprising eight centres of excellence, has a crucial part
to play (www.nspcr.ac.uk).
Meanwhile, this week’s journal throws up at least one intriguing primary care question ripe for research. As
Mona Nabulsi (doi:10.1136/bmj.b3540) and Alan Fowler (doi:10.1136/bmj.b3874) point out, fever is a
beneficial immunological response to disease. So why do we dose our feverish selves and children with
antipyretics? Fowler says the lack of research into the effects of body temperature in people with influenza
is down to "a deep seated fever phobia stemming from pre-scientific medicine when fever was perceived
as an illness in itself." Nabulsi calls for education of parents about the immunological usefulness of fever
and the risks of antipyretic abuse. And Chris Barrett (doi:10.1136/bmj.b5660) admires the iconic 19th
century painting of The Doctor waiting for nature to take its course.
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Relevant Articles
The Doctor
Chris Barrett
BMJ 2010 340: b5660. [Extract] [Full Text]
Fever as nature’s engine?
Alan W Fowler
BMJ 2009 339: b3874. [Extract] [Full Text]
A few changes for 2010
Fiona Godlee
BMJ 2009 339: b5632. [Extract] [Full Text]
Is primary care research a lost cause?
Chris Del Mar
BMJ 2009 339: b4810. [Extract] [Full Text]
Is combining or alternating antipyretic therapy more beneficial than monotherapy for febrile
children?
Mona Nabulsi
BMJ 2009 339: b3540. [Extract] [Full Text]
Published 6 January 2010, doi:10.1136/bmj.b5660
Cite this as: BMJ 2010;340:b5660
Views & Reviews
Medical Classic
The Doctor
Chris Barrett, specialist registrar in neurosurgery, Newcastle General Hospital, Newcastle Upon Tyne
chris.barrett@nuth.nhs.uk
The Doctor, painted in 1891 by the royal academician Luke Fildes, is perhaps one of the most positive
images of the medical profession to disseminate widely in British art.
Tate, London 2008
View larger version (94K):
[in this window]
[in a new window]
[PowerPoint Slide for Teaching]
It shows a family doctor sitting impassively and calmly contemplating his patient, a child, sleeping fitfully in
the grip of a fever. A moment of crisis has passed, and there is little the doctor can do but wait; his
scientific knowledge (represented by the oil lamp in the darkened room) is of little use against infectious
diseases in the era before antibiotics. The child’s parents loom in the background: the mother distraught,
with her head on the table; the father upright, concerned but with confidence in the physician. The outcome
is uncertain; the doctor’s quiet stoicism in the presence of disease and possibly death pervades the
painting. Nevertheless, although the outcome is ambiguous, it is not devoid of hope, and a few faint rays of
daybreak filter through the window to the right.
Sir Luke came to prominence when he joined The Graphic, an illustrated weekly newspaper with an
agenda to promote social justice. Many of his illustrations depicted the social problems of Victorian Britain,
such as poverty, hunger, and homelessness. These images came to the attention of Charles Dickens, who
was similarly inspired by the injustices of the era. As a result Sir Luke became the illustrator for Dickens’s
final, unfinished novel, The Mystery of Edwin Drood.
As an established artist Sir Luke was commissioned by the sugar baron Henry Tate to create a
composition for the opening exhibition of the Tate Gallery. The subject was left to the discretion of the
artist, and Sir Luke drew on his personal grief over the death of his son Philip on Christmas Day 1877.
Philip was attended by Dr Gustav Murray during his fatal illness, and Sir Luke was deeply impressed by the
physician’s care and devotion, despite his powerlessness to treat the disease. The subject matter was
therefore deeply personal, both a cathartic expression of grief and a demonstration of admiration to a
dedicated family doctor.
The painting was an immediate success and became one of the major attractions at the Tate. It captured
the public imagination, and numerous prints and engravings were made, often to be found in local
surgeries. The presentation of the practice of medicine in such a strongly positive way was not lost on the
profession itself.
The Doctor is undoubtedly of another era, creating a paternalistic image of doctors as dedicated,
compassionate men of science. Nevertheless, it still has a great deal to say about the vocational nature of
medicine. Perhaps the greatest irony for today’s profession is that while the science has changed beyond
measure for the better, the high water mark of public perception represented by The Doctor has long
passed.
Cite this as: BMJ 2010;340:b5660
The Doctor
By Sir Luke Fildes
Painted in 1891
Published 18 November 2009, doi:10.1136/bmj.b4810
Cite this as: BMJ 2009;339:b4810
Editorials
Is primary care research a lost cause?
A new report points to a direction out of the doldrums
Six years ago Richard Horton asked the provocative question, "is primary care research a lost cause?"1
The result was an initial mixture of dismay and an indignant sense of betrayal among primary care
researchers, then some deeper reflection. General practice research was once great, as shown by a report
from the Academy of Medical Sciences,2 which is based on a conference held last year.3 Exemplary
general practitioner researchers include Sir James McKenzie (who did primary research in cardiology,
especially arrhythmias, in the late 19th century), William Pickles (who showed that hepatitis A was an
infectious disease with a three week incubation period by meticulous record keeping in Wensleydale in
1930), and more recently Julian Tudor Hart (with his 1960s view of preventive care based on an
epidemiological viewpoint in Welsh valleys) and John Howie (with his 1970s analysis of prescribing in
acute respiratory infections).
Since then it seems that primary care research has hit the doldrums. It drifted into regions with little
relevance to our clinical colleagues, who have remained so indifferent to this storm 1 that few are even
aware of it. Since the middle of the last century, the research focus seems to have shifted from diseases
(which are of immediate interest to practising clinicians) to processes (table ).
View this table:
[in this window]
Evolution of areas of primary care research
[in a new window]
The problem with researching illnesses in primary care is how to avoid stepping on the toes of researchers
who specialise in specific illnesses and be relegated to the system seen in clinical practice—where general
practitioners refer patients to specialists for the treatment of particular illnesses. This lack of self confidence
within the discipline of primary care may be one reason for the change in research focus from diseases to
models of care and health services research.4
For research to be relevant to primary care clinicians, it has to be new, important, and have the potential to
change clinical practice and patient outcomes. Perhaps in the past, research has too often looked at
processes such as the doctor-patient consultation, patient centredness, and holistic care. Although these
form the essence of traditional general practice it is hard to show that they make much difference to patient
outcomes. Besides, they were discarded as soon as primary care was forced to modernise with a
workforce no longer expected (or expecting) to work all hours and the requirement for convenience and
quick service.5
As intended, the report by the Academy of Medical Sciences is a stimulus for those in academic primary
care to think about where they should direct their research efforts. The report applauds the leadership role
of primary care research in introducing the notions of preventive care as a primary responsibility for
clinicians (surprisingly recently6) and understanding what goes on when patients talk to doctors, which led
to the development of patient centredness. But it warns that it might be time to remember disease research
and move on. It also mentions the importance of translational research, usually known as evidence based
medicine, which synthesises empirical research in such a way that clinicians can apply it to clinical
practice. For example a recent Cochrane review has shown that aerobic exercise improves functional
ability for patients with rheumatoid arthritis—the opposite of what many clinicians were taught at medical
school.7
Primary care researchers need to know what to research. They need to ensure that clinically relevant
disease orientated research, perhaps done in conjunction with basic scientists,8 is combined with other
research on how to improve patient outcomes.
One last thing—even the quantity of research we produce for practising general practitioners in relation to
the denominator of our numbers in clinical practice is small compared with other disciplines (for example,
<2% of that produced for surgeons9). So we still need more research funding and support. We have a lot of
catching up to do.
Cite this as: BMJ 2009;339:b4810
Chris Del Mar, dean of primary care research
1
Faculty of Health Science and Medicine, Bond University, Australia
cdelmar@bond.edu.au
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
References
1. Is primary-care research a lost cause? Lancet 2003;361:977.[CrossRef][Web of
Science][Medline]
2. The Academy of Medical Sciences. Research in general practice: bringing
innovation into patient care. Workshop report. 2009.
www.acmedsci.ac.uk/p20.html.
3. McAuley D. BMJ group blogs. A defining moment in UK primary care research.
18 December 2008. http://blogs.bmj.com/bmj/2008/12/18/domhnall-mcauley-adefining-moment-in-uk-primary-care-research/.
4. Del Mar CB, Freeman GK, Van Weel C. "Only a GP?": is the solution to the
general practice crisis intellectual? Med J Aust 2003;179:26-9.[Web of
Science][Medline]
5. Heath I. Life and death: only general practice can save the NHS. BMJ
2007;335:183.[Free Full Text]
6. Stott NCH, Davis RH. The exceptional potential in each primary care
consultation. J R Coll Gen Pract 1979;29:201-5.[Medline]
7. Hurkmans E, van der Giesen FJ, Vliet Vlieland TPM, Schoones J, Van den
Ende ECHM. Dynamic exercise programs (aerobic capacity and/or muscle
strength training) in patients with rheumatoid arthritis. Cochrane Database Syst
Rev 2009;(4):CD006853.
8. Harnden A, Grant C, Harrison T, Perera R, Brueggemann AB, Mayon-White R,
et al. Whooping cough in school age children with persistent cough: prospective
cohort study in primary care. BMJ 2006;333:174-7.[Abstract/Free Full Text]
9. Askew DA, Glasziou PP, Del Mar CB. Research output of Australian general
practice: a comparison with medicine, surgery and public health. Med J Aust
2001;175:77-80.[Web of Science][Medline]