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The general practitioner’s potential for research in British Columbia Falk, William Andre 1981

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THE GENERAL PRACTITIONER'S POTENTIAL FOR RESEARCH IN BRITISH COLUMBIA by Wil l iam Andre Falk MD, Univers i ty of A lbe r ta , 1949 FCFPC 1970, CCFPC 1971, FRCGP(Hon.) 1973 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology We accept th i s thesis as conforming to the required standard The Univers i ty of B r i t i s h Columbia *July, 1981 © Wil l iam Andre Falk, 1981 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I ag r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f Hea l th Care and Epidemiology The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Date 2 7 August 1981 ABSTRACT The study was designed to explore the proposit ion that conduct of and par t i c ipa t ion in research by general pract i t ioners in B r i t i s h Columbia would be both desirable and feas ib le . Des i r ab i l i t y was defined in terms of benefits for knowledge, for the medical prac t i ce , and for society at large. Feasi-b i l i t y was defined in terms of being acceptable for the general p rac t i t i oner , for the pat ient , for the prac t i ce , and for the requirements of research. To answer spec i f i c questions related to de s i r ab i l i t y and f e a s i b i l i t y of research by general p rac t i t i oners , information was obtained from the l i t e r a t u r e , from a questionnaire survey of the tota l general p rac t i t i oner population of B r i t i s h Columbia, and from a random sample of patients in pract ices selected at random from respondents to the questionnaire to general p rac t i t i oners . In the survey of general p rac t i t i oners , 2,344 questionnaires were mailed. Of the 563 (24%) which were returned, 508 were ava i lab le for ana lys is . Five were returned by the post -of f i ce undelivered, seven were too la te for ana lys i s , and forty- three were returned with information ind icat ing that the respondent was not in general pract ice . Forty;,--eight respondents were anonymous, and the remainder i den t i f i ed themselves. The response of general pract i t ioners represented a var iety of geographic locat ions , ages, types of p rac t i ce , and medical schools. Members of the College of Family Physicians of Canada had a response rate of 39%. In the survey of pat ients , 15 out of 20 general pract i t ioners who were contacted agreed to submit questionnaires to the i r pat ients. Of the patients surveyed, approximately 90% completed the questionnaires. Most were regular patients of the doctors, and represented a f u l l range of ages, and both sexes. i i General pract i t ioners and the i r patients agreed that research by general pract i t ioners was des i rab le , and suggested many areas sui table for research. The benefits of research to the general p rac t i t i oners , pat ients , and society were considered to be incent ives, encouraging research a c t i v i t y . Important among the benefits were the discovery of new knowledge and the contr ibut ion to the academic base of general pract ice. The f e a s i b i l i t y of research was explored in terms of the condit ions required for i t s conduct. Att i tudes were receptive to the concept of research, as many of the general pract i t ioners had previously been involved in projects. Major deterrents were heavy workload and lack of time, for the general p r a c t i -t ioners , and in the i r pract ices the high overhead and pressure of work on the s ta f f were problems. Training for research was var iab le , with some general pract i t ioners having none and a few having much t ra in ing . Inadequacy of the usual o f f i ce records was recognized, so that research would usual ly require special methods. General pract i t ioners had l i t t l e awareness of resources ava i lab le for help, advice or f inanc ing, but most were aware of the need for such resources. Patients were w i l l i n g to cooperate in studies. They suggested that the cost of research should be borne pr imar i ly by govern-ments, and to a lesser extent by foundations and the pub l i c . Recommendations were made for the support of research, to help overcome the problems which decrease i t s f e a s i b i l i t y . There should be encouragement of t ra in ing in research methods, at both undergraduate and postgraduate l eve l s . This would include presentation of research f indings to s c i e n t i f i c meetings of medical soc i e t i e s , and v i s i t s to and from eminent research workers in general pract ice. Some assistance should be given to the general p rac t i t i oners , such as help in developing o f f i c e records for research or payment for time spent on research. Resources for help in planning studies and processing resu l ts i i i should be read i ly ava i l ab le , including both consultant advice and the provis ion of grants. Conclusions from the study were that research by general pract i t ioners in B r i t i s h Columbia is des i rab le , and that i t i s feas ib le but has several major deterrent factors which can i nh i b i t research a c t i v i t y . Because of these fac tors , the great potent ia l for research in B r i t i s h Columbia is s t i l l far from being rea l i zed . i v TABLE OF CONTENTS Page Abstract i i Table of contents v L i s t of tables v t i Acknowledgement x Introduction 1 Chapter 1 Review of the l i t e r a tu re 5 Chapter 2 Def in i t ion of the problem 26 Chapter 3 Method 31 3.1 Strategy 31 3.2 The populations surveyed 31 3.3 Data co l l e c t i on instruments 36 3.4 Data co l l ec t i on procedure 42 3.5 Analysis of resu l ts 43 3.6 Limitat ions of the study 43 Chapter 4 Results 49 4.1 Response 49 4.2 Character is t ics of respondents 53 4.3 Responses to questions in the survey 60 Chapter 5 Discussion 81 5.1 Response 81 5.2 Character is t ics of respondents 84 5.3 Responses to questions in the survey 85 Chapter 6 Recommendations 98 Conclusion 103 v Page L i s t of references 105 Appendices 112 1 L i s t of journals containing reports on research studies by general p rac t i t i oners , as published in "New Reading for General Prac t i t ioners" . 112 2 Declaration of Hels ink i 114 3 Reasons for exclusion from general pract i t ioner mai l ing l i s t and numbers excluded, according to group on combined l i s t 115 4 Letter to selected general p rac t i t i oners , requesting par t i c ipa t ion in patient survey 116 5 Letter to persons selected for interviews in development of quest ionnaire, with interview guide, and l i s t of persons consulted 117 6 Final draf t of general p rac t i t ioner questionnaire . 121 7 Final draft of patient questionnaire . . . . 122 8 Letter accompanying general pract i t ioner questionnaire 123 9 Instruct ions -for administering questionnaires to patients 124 10 Responses stat ing that physicians were not general p rac t i t i one rs , and reasons given, according to BCP1A d i s t r i c t 126 11 D is t r ibut ion of school or country of graduation of general pract i t ioners in survey . . . . . 127 12 Most frequent suggestions for areas needing study by general pract i t ioners 128 13 Importance of workload as a deterrent to research . 129 14 General pract i t ioner response to question dealing with possible types of research a c t i v i t y . . . 130 15 General p rac t i t i oner response to question dealing with informed consent by patients 131 16 General p rac t i t ioner response to question dealing with resources needed for undertaking research . . 132 Glossary 134 vi LIST OF TABLES TABLE Page • 1.1 D is t r ibut ion of c i t a t i ons from Medlars II search, by country of publ icat ion 6 1.2 D is t r ibut ion of journals c i ted in "New Reading for General P rac t i t i oners " , (January to September, 1977), . by country of publ icat ion 7 1.3 Topics of publ icat ions on general pract ice research, as l i s t e d in "New Reading for General P rac t i t i oners " , January to September, 1977 8 3.1 General p rac t i t ioner population in B r i t i s h Columbia, as l i s t e d in survey of 17-23 March, 1978 . . . . 34 3.2 15 General pract i t ioners par t i c ipa t ing in survey of patients . 35 4.1 Response rates of physic ians, re lated to category on mai l ing l i s t s . . . . . 50 4.2 Response to general p rac t i t ioner questionnaire by D i s t r i c t of BCMA, 1978 51 4.3 Response rate of patients to questionnaire according to BCMA d i s t r i c t of general p rac t i t ioner . . . . 52 4.4 Age groups of 508 general pract i t ioners responding to survey 53 4.5 Year of graduation in medicine 54 4.6 Length of time in pract ice for 508 general pract i t ioners responding to survey 55 4.7 Size of pract ice of 508 physicians answering questionnaire 55 4.8 D is t r ibut ion of respondents by membership in College of Family Pract i t ioners of Canada 56 4.9 Age groups of patients surveyed 57 4.10 Sex of patients surveyed 57 4.11 Reason for v i s i t , for patients surveyed . . . . 58 4.12 Age groups of par t i c ipa t ing general pract i t ioners 58 v i i ! LIST OF TABLES (continued) TABLE Page 4.13 "Do you think that research in family/general pract ice can provide new knowledge which would otherwise not be ava i lab le?" 60 4.14 "Do you think that i t i s a good idea for general pract-i t i oners to be involved in research studies related to the i r work?" 61 4.15 Number of topics suggested as sui table for research by general pract i t ioners and patients 62 4.16 "How important are the fol lowing factors in encouraging par t i c ipa t ion in research projects?" . . . . . 62 4.17 Factors in the pract ice which might be affected by par t i c ipa t ion of the general pract i t ioners in research 64 4.18 "How important are the fo l lowing factors in encouraging par t i c ipa t ion in research projects?" 64 4.19 "In.your opin ion, what e f fect might par t i c ipa t ion in research have on the fol lowing factors?" . . . . 65 4.20 "How important are the fol lowing factors in encouraging par t i c ipa t ion in research projects?" . . . . 66 4.21 Importance of academic base as a reason for research • 67 4.22 Factors considered by 508 general pract i t ioners to discourage the i r par t i c ipa t ion in research projects • 68 4.23 Interest in workload studies related to s ize of pract ice 70 4.24 "How important are the fol lowing factors in discouraging par t i c ipa t ion in research projects?" . . . . 71 4.25 Patient response to question #8 - "Would you be w i l l i n g to help your doctor to do research studies, by cooperating in important deta i l s? " 71 4.26 "Have you or any of your patients experienced a breach of con f i den t i a l i t y in a research project?" . . . 72 4.27 "How important are the fol lowing factors in discouraging par t i c ipa t ion in research projects?" 74 4.28 Formal t ra in ing in epidemiology, according to memory of 508 respondents • • • • 75 v i i i LIST OF TABLES (continued) TABLE Page 4.29 Formal t ra in ing in s t a t i s t i c s , according to memory of respondents 75 4.30 Formal t ra in ing in methodology, according to memory of 508 respondents 76 4.31 Residency t ra in ing reported by the 508 respondents 77 4.32 Par t i c ipa t ion in previous research studies . . . 78 4.33 Patient response to question #10: "For the support of research, which of the fol lowing do you think should provide money?" 79 i x ACKNOWLEDGEMENT My thesis committee, consist ing of Dr. Nancy Schwarz, Dr. Richard D. Sprat ley, and Dr. Michel C. Vernier (chairman), has been a great help in guiding me through the complexities of conducting a research project. They have been supportive and encouraging, while being construct ive ly c r i t i c a l , and have adapted well to the d i f f i c u l t i e s created by the prolonged duration of the process. Thanks are due also to the Univers i ty of B r i t i s h Columbia, for provid-ing the opportunity and the f a c i l i t i e s , espec ia l ly the l i b r a r y and the computer. The Department of Health Care and Epidemiology provided both the thesis program in Health Services Planning, and support from facu l ty and o f f i ce personnel. Outside the un ivers i ty , the B r i t i s h Columbia Medical Associat ion and i t s Section of General Prac t i ce , and the College of Physicians and Surgeons of B r i t i s h Columbia have helped by providing approval of the study, information, and access to f a c i l i t i e s . Other agencies and people have helped with information, espec ia l ly in preparation of questionnaires. A Student Fellowship from the Department of National Health and Welfare during my second year in the program helped to finance the time needed for planning and conduct of surveys. Special help was given by the B r i t i s h Columbia Chapter of the College of Family Physic ians, both through i t s o f f i ce and through the response of the membership. A l l the planning would have been wasted i f i t had not been for the many general pract i t ioners who responded to the survey. The general pract i t ioners who accepted the extra task of giv ing questionnaires to the i r pat ients , and the i r pat ients , deserve special thanks. x INTRODUCTION There are too many unanswered questions in a l l aspects of the general p rac t i t i one r ' s work. This lack was wel 1-described by Mc Whinney* when he l e f t pr ivate general pract ice to become the f i r s t professor of family medicine at the Univers i ty of Western Ontario. There are gaps in the knowledge of the presentation and diagnosis of disease, and of the natural h istory of disease. There are discussions about the best system of providing 2 3 health care within a pract ice or a community ' , and there are changes of po l icy for reasons which often seem more p o l i t i c a l than medical. Graduates from medical schools and hospital t ra in ing programs in the past have had most of the i r experience with patients and teachers in i n s t i -tu t ions , and r e l a t i v e l y l i t t l e with patients and doctors in community pract ice . Since 1968, family pract ice t ra in ing programs have been ava i lab le in Canada to give students and graduates a community pract ice experience which would be more relevant to the i r eventual work. At f i r s t the emphasis was on pract i ca l t ra in ing to prepare graduates for dealing with problems they would face in pract ice . The need for research applied to the problems in general pract ice has been recognized only a f ter teaching programs have been s t ab i l i z ed . There has also been an expectation that the new d i s c i p l i ne of Family Medicine must j u s t i f y i t s existence by development of a broad base of research. Research in general pract ice i s not the laboratory or i n s t i t u -tionaljtype of research, but covers a wide range of interests in pract ica l problems - c l i n i c a l , therapeutic, operat iona l , epidemiological , and educational. Why should there be so many gaps in knowledge, considering the great progress in medical knowledge over the l as t few decades? One major factor is that almost a l l research has been done by spec ia l i s t s or in i n s t i t u t i on s , and very l i t t l e by general p rac t i t i oners . - 1 -2 Although i t may seem log ica l that research should be done by spec ia l i s t s to provide the most credib le resu l t s , there are several reasons that th i s approach i s inadequate. Spec i a l i s t s , in general, are dealing with selected groups of patients in spec i f i c categor ies, usual ly referred by general pract i t ioners because the i r problems are d i f f i c u l t to manage. General pract i t ioners also see the same problems but at an ea r l i e r stage, when the presenting signs and symptoms may be d i f fe rent or absent, the diagnosis may be more d i f f i c u l t , and the methods and resu l ts of treatment may be d i f fe rent . While spec ia l i s t s have access to patients only for l imi ted times and condit ions, the general p rac t i t ioner may have access from the presymptomatic stage through longterm followup. The spec i a l i s t may be l imi ted by his expert ise in one f i e l d , whereas the general p rac t i t ioner can be involved in a l l areas. The s pe c i a l i s t , in general, treats indiv idual pat ients , but the general p rac t i t ioner can t reat a l l members of a fami ly , whether separately or in a 4 5 6 group. Studies such as those by White , the author , and Metcalfe , have shown that 90% or more of problems can be managed by general p rac t i t i oners , and that most of these problems do not require the use of complicated tests or hosp i ta l i za t i on . The combination of access to patients of a l l ages and both sexes, for care of condit ions in a l l categories up to the level of the i r a b i l i t i e s , and the long-term care from pre-conception to old age provide general prac t i t ioners with opportunit ies for research which are not matched in any other se t t ing . With such opportuni t ies, i t would be reasonable to expect that general pract i t ioners would be doing a much larger proportion of medical research than they do. One reason for the lack seems to be the f ee l i ng , among general pract i t ioners as well as spec i a l i s t s , educators, and granting agencies, that general pract i t ioners should not do research, but should confine the i r 3 a c t i v i t i e s to the provis ion of care based on the f indings of the experts. This fee l ing may be a resu l t of a perception of the general p rac t i t ioner as being incapable because of inadequate t ra in ing in research methods, lack of t ime, or lack of f a c i l i t i e s , perhaps a l l a resu l t of lack of in te res t . In sp i te of such negative fac tors , there has been increasing a c t i v i t y in research by general p rac t i t i oners , and increasing pressure on departments of family pract ice in the medical schools to become more involved in both conduct and teaching of research^. Teaching of research methods during the t ra in ing for general pract ice would be expected to increase the capab i l i t i e s and the research a c t i v i t y of graduates who enter pr ivate prac t i ce , to provide a continuing source of information from the community experience. Because of the con f l i c t i ng views of the need for research by general pract i t ioners and the i r capab i l i t i e s to do i t , there i s s t i l l considerable doubt about the ro le of the general p rac t i t ioner in research. This study was conducted to explore the issues of d e s i r ab i l i t y and f e a s i b i l i t y of research by general pract i t ioners in B r i t i s h Columbia. Des i r ab i l i t y was defined in terms of benefits for knowledge, for the medical pract ice and for society at large. Fea s i b i l i t y was defined in terms of being acceptable for the general p rac t i t i one r , for the pat ient , for the pract i ce , -: and for the requirements of research. Review of the l i t e r a tu re provided par t ia l answers to these issues. To obtain more information, related to B r i t i s h Columbia, a survey was conducted in 1978, by questionnaires mailed to a l l general pract i t ioners in the province. A survey was then conducted on a sample of patients of the responding doctors, to obtain the i r opinions related to the de s i r ab i l i t y and f e a s i b i l i t y of research by general p rac t i t i oners . Results of the surveys were analyzed, and related to information from the l i t e r a tu re and to acknowledged l im i ta t ions of the study. The f indings from the study led to recommendations to be considered in future planning by medical organizat ions, medical schools, and governments. Areas and topics for further study were suggested, to f i l l some of the gaps i den t i f i ed during the study. CHAPTER 1 REVIEW OF THE LITERATURE The l i t e r a tu re was reviewed for "research by general p rac t i t i oners " , and organized under headings that would re late to the layout of the thesis text . For th i s reason, the fol lowing format was used: Sources of references (.1.1): - Medlars II - "New Reading for General Pract i t ioners" - Other sources References re lated to de s i r ab i l i t y of research by general p rac t i t i oners : - Is i t benef ic ia l to knowledge? (1.2) - Is i t benef ic ia l for the pract ice? - Is i t benef ic ia l for society? References re lated to f e a s i b i l i t y of research by general p rac t i t i oners : - Is i t acceptable for the general pract i t ioners? (1.3) - Is i t acceptable for the patient? - Is i t acceptable for the pract ice? - Is i t s c i e n t i f i c a l l y va l id? 1.1. Sources of references 1.1.1. Medlars I I . A search of the medical l i t e r a tu re included in Index Medicus from 1972 to 1978 was conducted, using the key words "research", "family p rac t i ce" , and "general prac t i ce" . A tota l of 63 c i ta t ions was l i s t e d , an average of about 10 per year (Table 1.1.). An increasing trend was seen in the numbers c i ted from the United States of America pub l i cat ions, and a decreasing trend in c i ta t ions from B r i t i s h journa ls . There were very few c i ta t ions from other - 5 -6 countr ies, including Canada. These numbers might r e f l e c t the bias of the Index Medicus, based in the United States, rather than the actual output of studies by general p rac t i t i oners . Table 1.1 D is t r ibut ion of c i ta t ions from Medlars by country of publ icat ion II search, Country 1972-74 1975 1976-78 U.S.A. 4 7 19 U.K. 14 6 4 Canada 1 2 0 Aust ra l ia 0 1 1 India 1 1 0 New Zealand 1 0 0 Scandinavia 0 0 1 Total 21 17 25 1.1.2. New Reading for General Pract i t ioners . The Royal College of General Pract i t ioners has kept the best record of research studies in general prac t i ce , s ta r t ing with a l i s t of publ icat ions from 1960 to 1968. A second l i s t was produced, of publ icat ions from 1969 to 1973. These occasional l i s t s have developed into a quarter ly cumulative l i s t , contain-ing references from a l l areas of the world, and also l i s t i n g English summaries of some a r t i c l e s in foreign language journa ls . The l i s t i n g for the nine months, January to September 1977, was used as the l a tes t ava i lab le l i s t at the time of the l i t e r a tu re search. I t was examined to count the number of references and to see which journals were publ ishing general pract ice research reports or a r t i c l e s . There were 202 c i t a t i ons , 6 of which were books or pamphlets and 196 were journal a r t i c l e s . A tota l of 47 journals was l i s t e d , with the top four publ ishing 100 a r t i c l e s (Appendix 1). At least ten countries were represented (Table 1.2) and there were two internat ional journals (Appendix 1). 7 Table 1.2 D is t r ibut ion of journals c i ted in "New Reading for General P rac t i t i one r s " , (January to September, 1977), by country of publ icat ion Country Number of journals United Kingdom 22 United States of America 5 Aus t ra l i a 2 Canada 2 Scandinavia 2 Netherlands 1 New Zealand 1 Singapore 1 South-Africa 1 Unknown 10 Total 47 There was a wide range of top ics , but the predominant in terest was in c l i n i c a l subjects and the del ivery of care. Topics were l i s t e d in the pub-l i c a t i o n according to areas of s im i la r content, and grouped by the author in broader categories (Table 1.3). 1.1.3. Other sources. References were obtained from the author's contacts from 1960-78 as a member and chairman of research committees of the College of Family Physicians of Canada (provinc ia l and nat ional) and the World Organization of National Colleges and Academies of General/Family Pract ice (WONCA), a l l of which have contributed to a personal l i b r a r y . Others have been co l lected in the course of the Nuf f ie ld Foundation Trave l l ing Fellowship in 1965, and subsequent continuing contacts with general pract i t ioners involved in research in B r i t a i n , Aus t r a l i a , New :Zealand, and I s rae l . 8 Table 1.3 Topics of publ icat ions on general pract ice research, as l i s t ed in "New Reading for General P rac t i t i oners " , January to September, 1977 Topic area Number of c i t a t i ons CI in i ca l 72 Del ivery of care 36 Community medicine 29 Drug t r i a l s 21 Medical education 19 Patient att i tudes 11 Ger ia t r i cs 3 Epidemiology 3 Social work 3 Qual i ty of care 2 Computer 1 Research 1 Alcohol 1 Total 202 1.2. References related to de s i r ab i l i t y of research by general pract i t ioners This section examined the question whether there was any advantage to be gained when a general p rac t i t ioner attempted to do research while simultaneously carrying on a pract ice . Would his studies be of su f f i c i en t ca l ib re to make a worthwhile contr ibut ion to the body of medical knowledge? (1.2.1) Would his studies in any way contr ibute to the e f f i c i ency of his pract i ce , or might they prove detrimental? (1.2.2) Would society as a whole derive any benef it from the contr ibut ions that general pract i t ioners produce? (1.2.3) 9 1.2.1. Is research by general pract i t ioners benef ic ia l to knowledge? A pioneer in general pract ice research, Wil l iam Pick les of England, published in 1939 a book that was destined to become a c l a s s i c in general pract ice research c i r c l e s , "Epidemiology in P rac t i c e " 9 . P ick les represents the self-motivated indiv idual fol lowing his own bent and making an unso l i c i ted contr ibut ion to medical knowledge. By 1952, as noted by Crombie and P i n sen t 1 0 , the need for research in general pract ice had been recognized to the extent that the Foundation Council of the Royal College o f General Pract i t ioners in B r i t a in set up a research committee 1 0 . In 1957, in Canada, the B r i t i s h Columbia Chapter of the board of d i rectors of the College of General Pract ice of Canada also recognized the need and acted upon i t , voting to estab l i sh a research committee 1!. The general pract i t ioners were not alone in the i r recognit ion of a need for the development of research in the i r f i e l d . Urging for such research had 12 come from a d i ve r s i t y of other f i e l d s . An economist, Kalton , in 1968 in B r i t a i n , described the contr ibut ion of research to the study of morbidity and pointed out the s u i t a b i l i t y of general pract ice to longitudinal morbidity studies. Like P i ck les , he considered the cont inu i ty of care by general 13 pract i t ioners a major conducive fac tor . A ped ia t r i c i an , Berwick , lauded the practice-based research done by the Long Beach Group in Ca l i fo rn ia as " top i ca l " and "conceptually sound", and c i ted three simple requirements for the general pract ice researcher - an inquir ing s p i r i t , a good record system, 14 and a wi l l ingness to ca l l in consultants. To Finkel , in an ed i to r i a l in 1978 describing some recent or ig ina l observations in industry, the general p rac t i t ioner was a spark to ever-broadening medical knowledge; he, l i k e Berwick, pointed out the necessity for the general p rac t i t ioner to ca l l in spec i a l i s t colleagues on de f i n i t i v e studies. While the need and opportunity for observations from solo general pract i t ioners were recognized, the d i f ferent requirements for group; research 15 were described by Dalton in a 1973 B r i t i s h journal a r t i c l e : "The large schemes, such as the Royal College of General P rac t i t i oners ' study into the long-term ef fects of oral contraceptives, ca l l for methodical f o rm - f i l l e r s , obediently completing special ly-designed forms, and forwarding the par t i cu lars for further processing. The personal involvement is so small that there i s r ea l l y no reason why every prac t i t ioner should not par t i c ipa te . The ultimate resul ts promise to be a valuable addit ion to medical knowledge." g P ick les , pointing out the unique posi t ion of the general p rac t i t ioner for research, had quoted Mackenziejto the ef fect that the general p r a c t i t i one r 1 alone could fol low the progress of disease from i t s ea r l i e s t onset to i t s ult imate end, be i t in the indiv idual patient or in a spreading epidemic. Stuart-Harr is , observing in 1977 that one of the f i r s t decisions made by the Royal College of General Pract i t ioners had been to study the incidence and prevalence of infect ious diseases, noted that under i t s encouragement work had gone forward on a number of studies in re la t ion to problems of spec i f i c diseases, studies of drug therapy, and studies in operational research on problems of organization or the del ivery of primary care. Stuart-Harr is urged that academics in general pract ice fol low the lead of the Royal College and provide the stimulus to encourage worthwhile studies in research among general p rac t i t i oners . In Canada, between 1950 and 1970, only f i f t een studies by general pract i t ioners were l i s t e d in the Index Medicus. L i v ings ton^ noted a tendency for un ivers i ty-or iented general pract i t ioners to do th i s work and appealed to pract ice-or iented general pract i t ioners to make a contr ibut ion l e s t the f u l l p icture of general medical prac t i ce , pa r t i cu l a r l y the country pract i ce , be d i s tor ted . 11 1.2.2. Is research by general pract i t ioners benef ic ia l for the pract ice? 18 In the opinion of Mackenzie , patients would be better served i f more work were done on the ear ly recognit ion of disease, rather than on the study of disease a f ter i t has k i l l e d i t s v i c t im. He was a strong advocate in 1919 for improvements in medical t r a i n i ng , education and pract i ce , to d i rect attent ion to the detection and cure of disease in the ear ly stages. 19 Potent ia l benefit to the pract ice was described by Eimerl and Laidlaw in a guide to research in general pract ice published in 1969 in B r i t a in by the Royal College of General P rac t i t i oners . For them, the family doctor who had mastered the s e l f - d i s c i p l i n e required to carry through research would achieve better standards of care through improved e f f i c i e n c y and broadened in te res ts . This concept of improvement in the del ivery of care through the ef fect on the indiv idual general pract i t ioner of his doing research work into his own pract ice was echoed by the World Health Organizat ion's Expert Comm-i t tee on General Pract ice ' They believed that the general p rac t i t ioner who does act ive research becomes more broad-minded, more knowledgeable and experienced, and consequently more able to provide better service to his pat ients. 22 In the United States of America in 1975, Wood et al described the use of demographic and morbidity data in the evaluation of health care de l ivery . They foresaw that , in the future, audit of de l ivery of care could be made through the use of the da i l y work sheet, providing access to indiv idual 22 patient problems and evaluation of patient care. In Canada in 1975, Col lyer demonstrated the pract ica l use of such studies in the evaluation of qua l i ty of care. His one-year study of the work done in his own pract ice provided a basis for comparison with other pract i ces , which would, in time, provide a broader consensus and lead to a r e a l i s t i c measurement of s k i l l s . The expected benef it to patients in the pract ice was well-expressed by 12 Garson : "The very reason for our research work must be to examine what we are doing to , w i th , and for our patients in order to change our patterns of pract ice when good research work so d i c ta tes . " Studies of prescr ib ing 24 patterns in the Saskatoon Community C l i n i c led to the development of a C l i n i c Formulary, and the economy of bulk purchasing, which enabled the c l i n i c to add a pharmacist to the group. Other measures for improving health care effected by th is group through the i r research, related to (1) adverse ef fects on people in ambulatory care, (2) updated drug p ro f i l e s of long-term pat ients , and (.3) prescr ib ing pro f i l es of doctors. The general pract i t ioners in Vancouver, B r i t i s h Columbia, surveyed by 25 Warner in 1975, were asked "How important is doing research to personal sa t i s fac t ion with your pract ice?" Of 91 respondents, 40% thought that i t was very important, and 45% important; there was however no ind icat ion in the report whether these respondents had been involved in research themselves. 1.2.3. Is research by general pract i t ioners benef ic ia l for society? At a symposium in health care research held at the Univers i ty of B r i t i s h Columbia in 1975, Rice , executive d i rec tor of the College of Family Physi-cians of Canada, stated that the socia l factors that influence society estab-27 l i s h trends that should be c r i t i c a l l y examined. At the same symposium, Doll , a B r i t i s h epidemiologist, described such a trend in the sh i f t in emphasis of medical care from the prevention and r e l i e f of suffer ing and the reduction of morta l i ty to such problems as the rate of world population growth, with consequent research emphasis on the control of f e r t i l i t y by safe and soc i a l l y acceptable means. He also described a sh i f t from the study of the immediate benefits of a procedure advanced by research to the broader view of the tota l e f fect of an intervent ion, which may have socia l s ide-ef fects as counterproduc-t i ve as the medical s ide-ef fects of drugs. Doll maintained that the present emphasis of research should be for provis ion of medical care in a way that i s 13 ava i lab le and acceptable to a l l who need i t . In a committee report on the f i e l d of work of the family doctor in B r i t a i n , 28 G i l l i e had recommended in 1963 that research should be a normal a c t i v i t y for family doctors, espec ia l ly in the natural h istory and epidemiology of diseases. She had further recommended the conduct of operational research at two- l eve l s , in the doctor 's pract ice and in the wider f i e l d of the National Health Service 29 as a whole. In a major report on Health Care in Canada Robertson in 1972 assessed the focus of community research, c i t i ng research f a c i l i t i e s and personnel as the greatest need. In his opinions, the general pract i t ioners in act ive research were the l inks needed between advances and developments where-30 every they were occurring and loca l condit ions. Verby , in Minnesota, in 1973, maintained that society would be best served i f the general populat ion, general pract i t ioners and other health profess ionals , could be re-educated to concentrate on methods for c reat ive ly solv ing family health problems. He pointed to the family in the community as the unit for study. He also stressed the need for research in e f fec t ive and e f f i c i e n t health and disease care de l i ve ry , father than "the biomedical electron microscope type of research." 31 A Canadian surgeon, Robertson , suggested in 1974 that the work in evaluation of health care to society could s tar t with the general p rac t i t ioner - here the data have been co l lected and stored, and here l i e su f f i c i en t data for planning and assessment. He considered measurement to be the weakest factor in the progress of research. 1.3. References re lated to f e a s i b i l i t y of research by general pract i t ioners This section enquired into the condit ions, educat ional, a t t i tud ina l , and phys ica l , under which research has been carr ied out in general p rac t i ce , and sought to determine whether i t i s pract i ca l for a general p rac t i t ioner to do research and carry on a normal pract ice . Would the general p rac t i t ioner f ind i t possible to blend the two areas of work and interest? Would the patient be w i l l i n g to accept any changes in doctor-pat ient re lat ionsh ip that might develop as a d i rec t resu l t of the doctor 's research work? Would the pract ice as a whole, whether solo or group, be able to accomodate a doctor engaged in act ive research? Would the capab i l i t i e s for conduct of research be adequate, considering both the a b i l i t y of the general p rac t i t ioner and the a v a i l a b i l i t y of resources? 1.3.1. Would condit ions imposed on the general p rac t i t ioner by the demands of a research project be acceptable in the opinion of the general pract i t ioner? The number of published reports of research studies in general pract ice has increased rapid ly since L iv ingston 's observations in 1972. This may be taken as an ind icat ion that at least for some general p rac t i t i oners , whether alone or in mult i-observer groups, research i s feas ib le . The l i t e r a tu re records research a c t i v i t y at a l l leve ls of organization from the indiv idual to the national l e v e l . An ear ly example of ind iv idual research in Canada was carr ied out in the iso lated Pemberton va l ley of B r i t i s h Columbia on thyroid def ic iency by 32 33 Keith . Another r e l a t i v e l y ear ly example was Postuk's morbidity recording , an 8 year record of the group in which he worked in Duncan, B r i t i s h Columbia, followed by a broader survey in which 54 general pract i t ioners contributed 34 35 deta i l s of pat ient contacts for up to 50 days . Co l lyer in 1969 obtained approximately a 50% response from the membership of the College of Family Physicians of Canada to his survey by means of postcards of the recent incidence of inf luenza. Interest in contr ibut ing to future surveys was indicated by 90% of respondents. At the community level studies have been proven feas ib le . Garson and his fel lows in the Saskatoon Community C l i n i c completed studies on such re lev-36 ant topics as soc ia l problems of the hospi ta l ized e lder ly , the s ign i f i cance 37 of routine electrocardiograms , and the checkup centre as part of an ongoing medical pract ice . At the provinc ia l l e v e l , an example of proven f e a s i b i l i t y was seen in the Perinatal Morbidity Study in Nova Scot ia , conducted from 1972-75 by Hebb 39 et al , which involved about half the general pract i t ioners in the province. A second example was an inf luenza survei l lance study conducted in several provinces, beginning in 1976; the recorder for th i s study in B r i t i s h Columbia, Hoogewerf^0, received 120 rep l ies to his f i r s t request s o l i c i t i n g 50 volunteers. Studies have also proven feas ib le at the national l e v e l . In both B r i t a in and Hol land, continuous recording of morbidity has been carr ied out for over ten years, with data from over 50 pract i t ioners being co l lected and processed 41 cen t ra l l y . In B r i t a i n , tota l morbidity was recorded , using the diagnostic 42 index (see 1.3.3). In Holland, Sentinel Stations reported on spec i f i c cond-i t ions of current in te res t , usual ly ten or twelve in each one-year recording period. In Aus t r a l i a , as we l l , another major project in morbidity recording was carr ied out, using copies of prescr ipt ion forms to record patient encounters in a sample of pract ices throughout Aus t ra l i a . Results have been 43 published in a ser ies of reports in the Medical Journal of Aust ra l ia , and 44 the Austra l ian Family Physician . Conducive to such studies has been the a v a i l a b i l i t y of help. The College of Family Physicians of Canada provided central coordination for the inf luenza 40 survei l lance . Help has been ava i lab le from such units as the Birmingham 45 46 Research Unit and the Netherlands Inst i tu te of General Pract i t ioners These functioned as advisory serv ices, with the potent ia l of providing help in processing data. The use of computers for data storage and analysis has been one of the 47 inev i tab le steps in progress. Shires , in Ha l i fax , Nova Scot ia , has wr i t ten 16 a book on computer technology for the health sciences, based part ly on work 48 done in the Div is ion of Family Pract ice at Dalhousie Univers i ty . McQuitty , in Calgary, A lber ta , developed a comprehensive program for recording patients reg is tered, morbidity, and treatment, using encounter forms from patient contacts as the source of data. Such methods, although technologica l ly feas ib le , have proven cost ly because of the need for extra c l e r i c a l assistance and for the cost of computer storage and ana lys is . On a smaller sca le , 49 packaged programs, such as the S t a t i s t i c a l Package for the Social Sciences , are ava i lab le for the use of ind iv iduals with small or large projects , and are reasonably easy to use. 1.3.2. Would conditions imposed on the patient by the demands of a research project be acceptable in the opinion of the patient and the general pract i t ioner? 50 The College of Family Physicians of Canada, in i t s Research News Page , printed as a guide to research workers the text of the Declaration of Hels inki for protect ing the r ights of pat ients. (Appendix 2) The expectation was that any research a c t i v i t y by general pract i t ioners would observe the pr inc ip les set forth in the dec larat ion. Of major concern to the patient i s the maintenance of con f i den t i a l i t y . In a report from the Awards and Ethical Committee of the Royal College of 51 General P rac t i t i oners , Donovan et al made a number of recommendations about con f i den t i a l i t y in pract i ce , including one to the Research Committee to the ef fect that the pat ient ' s r ight to privacy and anonymity must be guarded. 52 Crombie dealt s pe c i f i c a l l y with the problem of con f i den t i a l i t y in research, and stated that even s t r i c t e r measures must be taken to maintain con f iden t i a l i t y in the handling of data for research because, as opposed to purely c l i n i c a l records, the patient may not stand to benefit from the d isc losure. He distinguished between primary records, from which the pat ient can be i den t i f i e d , and secondary records, from which the patient can not be i d en t i f i e d , except by reference to the primary f i l e . Such reference would be necessary only when addit ions were to be made from time to time or where information had to be checked or matched with other f i l e s . Problems of con f i den t i a l i t y might be magnified or mul t ip l ied by use of the computer, with access to data banks and the po s s i b i l i t y of record l inkage. Crombie suggested that data processing s ta f f might be asked to sign an e xp l i c i t declarat ion or undertaking to maintain con f i den t i a l i t y . 1.3.3. Would condit ions imposed on the pract ice by the demands of a research project be acceptable to the medical and non-medical s t a f f , in the opinion of the general pract i t ioner? The low output of research studies by general pract i t ioners in Canada 17 53 (Livingston ' ) suggests that problems existed that discouraged production and pub l i cat ion. One i nh ib i t i ng condit ion might be the lack of space, espec ia l ly i f a research ass istant needs to be accomodated in a small o f f i c e . A solo general p rac t i t i oner , Dr. Ian Watson, solved th i s problem by using the corr idor in a small surgery attached to his home, to f i l e the returns from his Epidemic Observation Unit. General pract i t ioners had sent reports of diseases being studied, using a form included in each issue of the Journal of the Royal College of General P rac t i t i oners . In 1972, the 100th no t i f i c a t i on form was celebrated in an e d i t o r i a l 5 4 as th is pioneer e f fo r t had shown both the capa-b i l i t y of one general p rac t i t ioner to bui ld and maintain a unique epidemio-log ica l report ing serv ice , and also the compatabil i ty of the system with the routines of the reporting pract ices. At the other end of the spectrum, Hope-Simpson in the town of Cirencester was financed by government grants, to provide space for a v irus laboratory, attached to his surgery. Among his 55 56 studies he made or ig ina l observations on the nature of herpes zoster ^' . A greater i nh ib i t i ng condit ion might be the cost of a study, espec ia l ly 18 57 i f partners in a group must provide support in time and resources. Falk noted that a lone general p rac t i t ioner might regard a small research project as a hobby and wri te of f the expense, but the larger projects would need f inanc ia l help. The i nh ib i t i ng factor that would then ar i se would be the careful and time-consuming preparation of appl icat ions for grants, an e f fo r t that might prove f u t i l e as i t might be d i f f i c u l t to convince granting agencies that general pract i t ioners were capable of doing worthwhile research. He suggested that general pract i t ioners who become involved in research should sometimes be compensated by grants, to al low for the time los t from the i r usual work. He saw the tendency of granting agencies to give p r i o r i t y to un ivers i ty departments with sa lar ied personnel as a formidable i nh ib i t i ng factor to research by general p r a c t i t i one r s Jn pr ivate pract ice . Recording methods normally in use in pract ice w i l l usual ly be inadequate for research purposes. Special recording was necessary as an addit ion to normal rout ines, as reported in the major prospective study on "the p i l l " , 58 done by Kay in B r i t a i n , which involved very careful recording of deta i l s about subjects and controls and a long-term fol low-up. At the s ta r t in 1968, 1400 general pract i t ioners and 46,000 patients were pa r t i c i pa t i ng . In spi te of the amount of recording needed, the dropout rate was very low, as about 28,000 of the or ig ina l patients remained in the study 7 years l a t e r . The l i t e r a tu re shows that recording methods are ava i lab le i f the pract ice i s w i l l i n g to adapt to them. Recording methods for use by ind iv idua ls have been wel1-developed by the Royal College of General P rac t i t i oners . The best-known and most widely-used is the Diagnostic Index, developed in B r i t a i n by 59 Eimerl . Cal led the E-book at f i r s t , i t evolved into the Disease Index and then into the Diagnostic Index, which i s a better term for i t s -function of recording problems at the highest level of certa inty ( e . g . , "abdominal pain" rather than ' 'possible cho l e c y s t i t i s " ) . The Diagnostic Index i s now used in countries other than B r i t a i n , for example in Aust ra l ia , New Zealand , Canada 5 ' 6 2 , and the United S t a t e s 6 3 ' 6 4 . I t provides a basis for comparison among pract ices and among countr ies, i s cheap, simple, computer-compatible, and does not require any drast ic change in o f f i ce equipment or rout ine. Simpler recording methods have been developed, as ways of recording a 65 spec i f ied l i s t of condit ions of in te res t . Walford , in B r i t a i n , used a format s im i la r to the Diagnostic Index for recording the names and ages of people with conditions of current in terest such as hypertension, diabetes, or taking "the p i l l " . This reg is ter provides access to records, for review or research, for a l l diagnoses included. Using the Diagnostic Index in a s imi la r approach, El ford , in A lber ta , devised a chronic i l l n e s s reg is ter for use as a diagnostic l i s t and also as a mechanism for reca l l of patients for follow-up v i s i t s , i l l u s t r a t i n g the use of the Index as a pract ice manage-ment t oo l . Once e f fec t ive recording methods are introduced, the pract ice may be faced with addit ional c l e r i c a l tasks, for example, the necessity for careful i den t i f i c a t i on of the pat ient. The general use of nicknames or a second Chr ist ian name would be confusing, as would the recording of age (which w i l l be advancing stead i ly) instead of date of b i r t h . Advice for development of an age-sex reg is ter came from Pinsent 6^, in B r i t a i n , who suggested the use of the f i r s t three l e t te r s of the surname and the f i r s t i n i t i a l of the f i r s t name, along with the date of b i r th in order, day-month-year. Other factors that provide more exact i den t i f i c a t i on are sex, marital s tatus, socia l s tatus, 19 and occupation. Eimerl and Laidlaw added the suggestion that the surname be entered in cap i t a l s , to avoid confusion in names such as James Thomas. Farley 68 et al used the same data, adding the census t rac t in which the patient l i v ed . Points of d i f ference, such as the month-day-year sequence for date of b i r th in the United States, as opposed to Pinsent 's day-month-year use in B r i t a i n , would need to be c l a r i f i e d . Evidence ex is ts in the l i t e r a tu re to indicate that such adaptations in 69 recording methods have proven acceptable to the pract ice. An ed i to r i a l published in B r i t a in noted the increasing acceptance of the age-sex reg is ter as a recording t oo l . Goodman^ wrote that the use of the age-sex reg is ter had extended from i t s research appl icat ions to becoming an essent ia l i n s t ru -ment in monitoring health care in general pract ice. He had determined that of 320 pract ices that had begun to use the cards developed by the Birmingham Research:Unit by 1971, about half were using the reg is ter for checking on immunization and cytology and about a th i rd for general health checks and research. The Birmingham Research Unit had estimated that the number of pract ices with age-sex reg is ters had more than doubled to at least 850 between 1971 and 1977. The f inanc ia l cost of developing such a reg is ter should not be prohib-i t i v e . Sloan et al^* estimated the cost of developing a reg is ter from scratch, for a pract ice of 10,000 pat ients , at 217 pounds s t e r l i n g , less a proportion for expenses against income tax, which would leave the doctors paying about 150 pounds. 1.3.4. Would the general p rac t i t ioner and the pract ice set t ing provide conditions compatible with va l i d s c i e n t i f i c research, in the opinion of the general pract i t ioner? 72 In 1976, White , a world-renown^ed epidemiologist, described primary care research as a long-neglected f ron t i e r and stated that medicine at a basic b io log ica l and psychological level urgently, needed the observational powers of the general p rac t i t i oner . He named three requirements for the e f fec t ive execution of general pract ice research - c l a s s i f i c a t i o n , terms and denominator. 21 Over the past two decades, the f i r s t of these requirements, c l a s s i f i c a t i o n , has been tack led. Finding the International C l a s s i f i c a t i on of Diseases too unwieldy for use by general p rac t i t i oners , the College of General Pract i t ioners of Canada created i t s own version of a c l a s s i f i c a t i on more relevant to the 73 problems seen in pract ice . The or ig ina l version of 1959 was followed by a rev is ion in 1963^4. Various modif ications were made by ind iv idua l s , and a s imi la r c l a s s i f i c a t i o n more appropriate for use in Canada was developed by 75 Tarrant and Westbury . From these beginnings i t became apparent that internat ional agreement was needed, to provide va l i d comparisons between countr ies. As chairman of the c l a s s i f i c a t i on committee of the World Organi-zation of National Col leges, Academies, and Academic Associations of General Pract i t ioners/Fami ly Physicians (WONCA), Westbury worked with delegates from other countries to develop a mutually agreeable c l a s s i f i c a t i o n . This appeared in 1975 as the International C l a s s i f i c a t i on of Health Problems in Primary 7fi Care (ICHPPC) . After widespread use in pract i ce , and consultat ion with the World Health Organization (WHO), a rev is ion was published in 1979^ with WHO approval. White's second requirement, for terms, has been met in part by the develop-ment of g lossar ies to define terms used in the c l a s s i f i c a t i o n and in other aspects of pract ice . An ear ly s ta r t was made by the Royal College of General Pract i t ioners which published the second ed i t ion of i t s General Pract ice 78 Glossary in 1973 This work has been followed by the C lass i f i ca t ion 1 Committee of WONCA, which has taken on the task of compiling a glossary as a 79 companion to ICHPPC . A great deal of work has been done oh White's th i rd requirement, the denominator. Most attempts to provide a denominator, i . e . , to define patient populations so that incidence and prevalence of disease could be ca lcu la ted, have consisted of maintaining a l i s t of the patients considered to be re lated 22 Of) a pract ice . Pinsent suggested that where a pract ice l i s t i s impossible to maintain, a su i tab le denominator could be the number of consultat ions or the number of female patients seen. The l i s t of patients "at r i sk" has usual ly been kept in an age/sex reg i s te r , to provide a p ro f i l e of the recording Ol pract ice . Eimerl and Laidlaw pointed out that under the National Health Service in B r i t a in the number of patients on each doctor 's l i s t i s known, enabling doctors to ca lcu late the age and sex d i s t r i bu t ion of patients in the i r prac t i ce , thereby read i ly obtaining a p ro f i l e of the pract ice which, when maintained, would allow an accurate census to be taken of the pract ice at any time. Falk questioned the accuracy of th i s p r o f i l e , observing several discrepancies - patients who move would often f a i l to reg is ter with a new doctor unt i l the need arose, while there was no incentive for the previous doctor to remove names from his l i s t and thereby reduce his cap i t -at ion payments; when a transfer of records was requested, there was often considerable administrat ive delay; some patients who were l i s t e d might attend the general p rac t i t ioner only for minor ai lments, but go to another doctor for other problems. Attempts in other countries to develop a r e l i ab l e denominator have focussed mainly on the age/sex reg i s te r . Various methods have been described Q O OA by Garson , including use of the census l i s t by Bentsen , reg i s t ra t ion by o r Q C 0 7 0 0 intent ' ' , de facto reg i s t ra t ion , episodes of i l l n e s s as demonstrated o n po by K i l pa t r i ck , and the medicare ra t i o used in Garson's study . The number of methods used has helped to stimulate debate and further attempts to develop simple and consistent methods of estimating the pract ice population. 90 Boyle proposed the use of the family unit as one factor which could increase the accuracy of a reg i s te r . The population at r i sk was based on a l l members of fami l ies in which at least one member had v i s i t ed the pract ice with in the previous two years. A somewhat obvious requirement for s c i e n t i f i c c r e d i b i l i t y i s access 91 to a reference l i b r a r y . Westbury , aware of the need for access to reference material not l i s t e d in the Index Medicus, convinced the College of Family Physicians of Canada to set up the Canadian Library of Family Medicine at the Univers i ty of Western Ontario in 1970. It provides a b ib l iographic service to general p rac t i t i oners , ava i lab le by mai l . I t has also taken on the job of 92 producing the Family Medicine L i terature Index (FAMLI) , s im i la r in format to the Index Medicus, but l imi ted to the l i t e r a tu re relevant to family pract ice. This publ icat ion was produced for WONCA as an internat ional guide to the l i t e r a t u r e . Other bibl iographies have been published by the l i b r a r y of the Royal College of General Pract i t ioners , the Royal Austra l ian College of 93 94 General Pract i t ioners , and the College of Family Physicians of Canada . The B r i t i s h publ icat ion was comprehensive, including a l l relevant countr ies, whereas the Austra l ian and Canadian l i s t s were nat iona l . Research became feas ib le for more general pract i t ioners as support was shown by concerned medical bodies and government agencies. Advisory services have been provided by col leges of general prac t i ce , such as the Royal College AC. of General Pract i t ioners , and the B r i t i s h Columbia Chapter of the College of Family Physicians of Canada which col laborated with the Univers i ty of 95 B r i t i s h Columbia to form a Family Pract ice Research Unit in 1978. Workshops for t ra in ing general pract i t ioners in the basic techniques of research have been presented by the College of Family Physicians of Canada on a national level - at Muskoka, Ontario , in 1970 9 6 ; at Banff, A lber ta , in 1971 9 7 ; and at 98 Chester, Nova Scot ia , in 1972 . Prov inc ia l chapters of the College of Family Physicians of Canada have held workshops, such as those in B r i t i s h Columbia in 1974 9 9 , and in Saskatchewan in 1 971 1 0 0 . A Health Care Evaluation Seminar was held in V i c t o r i a , B r i t i s h Columbia in 1 975 1 0 1 , co-sponsored by the College of Family Physicians of Canada and the Research Programs Directorate of the Department of Health and Welfare. The involvement of 102 family pract ice residents in research projects was described by Geyman 103 in Seat t le , Washington, in 1977. Hodgkin examined the educational impl icat ions of a major study of morbidity in V i rg in ia and concluded that the analysis of survey material re lated to the facts of pract ice enriched and encouraged research att i tudes in the residents of the family pract ice teaching program. Acceptance by the s c i e n t i f i c community i s implied when an appl icat ion for a grant succeeds. Although d i f f i c u l t to get, f inanc ia l support has been 5 42 39 22 40 obtained from the federal government ' ' , prov inc ia l governments ' , 34 and univers i ty . High-level f inanc ia l support has been provided in B r i t a in 104 by the Nuf f ie ld Prov inc ia l Hospitals Trust , which responded to the need and provided funds for the establishment of the General Pract ice Research Unit in Birmingham in 1960. Three years l a t e r , longer-term support was provided by the Min ist ry of Health. A Task Force on the cost of health 105 service in Canada in 1970 revealed the need for research into the de l ivery of medical services and reported that "More publ ic funds must be spent on medical care research now i f the escalat ing costs of medical services are to be contro l led without adverse ef fects on the qua l i ty of these serv ices ." Important though not f inanc ia l support has come from the establishment of internat ional organizat ions, which bring together general pract i t ioners and consultants in a s c i e n t i f i c a l l y st imulat ing environment. W0NCA formed a Standing Committee on Research in 1974 , to develop the potent ia l for internat ional projects by advice and communication. The North American 107 Primary Care Research Group , started in 1972 as a grass-roots organization of interested family physicians who saw the need for working together to develop a research movement, holds annual s c i e n t i f i c meetings at which papers are presented by general pract i t ioners and family pract ice res idents. In Europe, internat ional cooperation through the years has helped to develop a 108 European General Pract ice Research Workshop , in which part ic ipants from eleven countries have met to discuss and plan combined projects. Summary of Chapter I The l i t e r a tu re has shown much evidence of an increasing interest in research over the past two decades. After a long period of r e l a t i v e l y iso lated work by ind iv idua l s , there was more group a c t i v i t y and there were more supporting structures. There were many indicat ions that research in and into general pract ice was des i rab le , for physic ians, for pract i ces , and for sgeiety. Many of the studies and reports indicated that such research was feas ib le , because (1) i t was done, (2) i t was apparently acceptable to the general p rac t i t i oners , the pat ients , and to the pract i ces , and (3) res-earch methods and support have been developed espec ia l ly for th i s f i e l d of work. Most of the references l i s t e d were from outside B r i t i s h Columbia. I t was the intent of th is present study to determine whether general p r a c t i -t ioners and the i r patients in B r i t i s h Columbia would be l i k e l y to support increasing research a c t i v i t i e s in future. CHAPTER 2 DEFINITION OF THE PROBLEM The study was designed to explore the proposit ion that conduct of and par t i c ipa t ion in research by general pract i t ioners in B r i t i s h Columbia would be both desirable and feas ib le . 2 . 1 . Des i r ab i l i t y The issue of de s i r ab i l i t y was explored among general pract i t ioners and the i r patients by seeking answers to the fol lowing questions: 2 . 1 . 1 . Would research by the general pract i t ioner be benef ic ia l to knowledge in the view of general pract i t ioners and the i r patients? It was assumed that such research would be considered as benef ic ia l to knowledge i f there were perceived gaps in knowledge which could be f i l l e d best by research a c t i v i t y of the general p rac t i t i oner . Such perceptions would be more convincing evidence i f they were shared by general pract i t ioners without an interest in research, as well as by those with an in te res t . Further support would be given by s im i la r perceptions by persons who were not general p rac t i t i oners , but who were in a pos i t ion to make relevant statements. 2 . 1 . 2 . Would research by the general p rac t i t ioner be benef ic ia l to the pract ice in the view of general pract i t ioners and the i r patients? It was considered that such research would be benef ic ia l to the pract ice i f i t could be shown that i t would lead to improvements in patient care. There could also be benefit for the general p rac t i t i oners , or the o f f i ce s t a f f , of adding interest to the normal routine of pract ice and increasing job sa t i s f a c t i on . Potent ia l benefits in improved o f f i ce management and better medical records might be addit ional benefits of research a c t i v i t y . Such benefits must not be counterbalanced by interference with the normal care of pat ients. _ 9K _ 27 2.1.3. Would research by the general pract i t ioner be benef ic ia l to society : in the view of general pract i t ioners and the i r patients? It was considered that such research would be benef ic ia l to society i f i t could be seen that improvements would resu l t in education, p o l i t i c a l decis ions, the system of care, or the cost-benef i t r a t i o . There could be benefit from improved medical education and education of the pub l i c . Perhaps the greatest benefit could be in the relevance of p o l i t i c a l dec is ions, i f research f indings were used, in improving the health care system. Changes to the system of care might also resu l t from acceptance of research f indings by medical bodies or by indiv idual p rac t i t i oners . There could also be economic benef i ts , for example in studies of the decision-making process, which could help to reduce the amount of invest igat ion or consultat ion required. Apart from benef it to the indiv idual from reduction in time, inconvenience, or anxiety, there could be benefit to society in reduction of the cost of the health care system. 2.2. F ea s i b i l i t y The issue of f e a s i b i l i t y was explored among general pract i t ioners and the i r patients by seeking answers to the fol lowing questions, which were intended to assess the a b i l i t y of general pract i t ioners to do research, as well as the acceptab i l i t y of research a c t i v i t y to the pat ients , the pract ice , and the prac t i t ioners : 2.2.1. Could condit ions imposed by research a c t i v i t y be acceptable for the general pract i t ioner? It was considered that conditions would be acceptable i f i t could be shown that the general pract i t ioner had a record of par t i c ipa t ion in previous projects in the same pract ice se t t ing . Formal t ra in ing in research methods would be important, i t being l i k e l y that very few would learn on the i r own to 28 be capable of or ig inat ing and conducting studies. However, wi l l ingness to s tar t or par t i c ipate in a group or co l laborat ive project would suggest that capab i l i t y would develop to the necessary level i f help or guidance were ava i lab le . The a v a i l a b i l i t y of consultat ion in planning a study would make condit ions more acceptable , as would the a v a i l a b i l i t y of f a c i l i t i e s for developing a project and for processing the resu l t s . 2.2.2. Could the conditions imposed by research a c t i v i t y be acceptable for the patient? Minimizing r i sks and costs to the patient has been one of the primary concerns and must be considered in any project as one of the essent ia l aspects of planning. Protect ion would include several fac tors : safety from side effects of any treatment used, and awareness of symptoms or signs which might indicate problems; preservation of con f i den t i a l i t y ; and protect ion from possible harmful effects of questions or information included in the study. The question of cost would have to be considered, pr imar i ly out of pocket expenses, but also time and inconvenience. F i na l l y , but perhaps most important, the po s s i b i l i t y of a research project in ter fe r ing with the usual care of the patient would have to be considered. 2.2.3. Could the conditions imposed by research a c t i v i t y be acceptable for the pract ice? The imposition of a research project on a busy o f f i c e could cause some problems, so that i t would be important to consider the factors which might be most af fected. Time required of o f f i ce s ta f f could be more than they could manage w i l l i n g l y . Space could be a problem, espec ia l ly i f an extra person i s brought in as a research ass i s tant . Recording methods would l i k e l y be d i f fe rent from the usual rout ine, and might not be eas i l y understood. I f any extra cost were involved, i t could cause some stress in the pract ice . Ident i f i ca t ion of patients for a study must be prec ise, and would often require more documentation than the usual rout ine. 2.2.4. Could the general p rac t i t ioner and the pract ice sett ing provide conditions compatible with va l i d s c i e n t i f i c research? The amount of t ra in ing in research methods required by the general p rac t i t ioner would depend on the needs of any project undertaken. Such t ra in ing could include par t i c ipa t ion in previous studies, and attendance at t ra in ing workshops. Recording methods might require some extra work in the o f f i c e , such as par t i cu la r care in i den t i f i c a t i on of ind iv idua l s , se lect ion of patients su i table for a project , or communication with patients in a study. The a b i l i t y of a pract ice to adjust to these requirements would need to be considered. The possible need for assistance would have to be considered, both for advice in planning and for technical de ta i l s . Access to computer f a c i l i t i e s might often be needed,' along with the help of programming and data entry. There could also be a need for help in wr i t ing reports and preparing them for pub l i cat ion. The a v a i l a b i l i t y of such resources would be important, as would the knowledge of the general p rac t i t ioner of where to go for needed advice or assistance. Summary of Chapter II This study was designed to assess the potent ia l of the general p r a c t i -t ioner in B r i t i s h Columbia to conduct or par t i c ipate in research, by sur-veying general pract i t ioners and the i r pat ients. Questions in the survey included some statements of f ac t , and some expressions of opionion. Measure-ment of indiv idual opinion was subject ive and could be expressed numerically 30 only as group responses. Strongly supportive responses in a l l of the study questions would suggest that there i s a perceived need for research and that the condit ions for under-taking research are good. Strongly negative responses would suggest the opposite. Responses between the two extremes might suggest a reasonable degree of support for the proposit ion that research i s des i rab le , and indicate some of the problems to be overcome in planning for research, in order for i t to be feas ib le . CHAPTER 3 METHOD To answer the questions about de s i r ab i l i t y and f e a s i b i l i t y of research by general p rac t i t i oners , information was obtained from the l i t e r a t u r e , from a questionnaire survey of the tota l general pract i t ioner population of B r i t i s h Columbia, and from a random sample of pat ients. 3.1. Strategy General pract i t ioners were surveyed, to determine the i r : opinions about the value of research, perceptions of incentives and deterrents to research, ideas about appropriate topics for research, wi l l ingness to become involved in research projects , and awareness of eth ica l problems in research. Infor-mation was also obtained about age, year and univers i ty of graduation, years in pract i ce , previous t ra in ing and experience related to research, and" membership in the College of Family Physicians of Canada. Patients were surveyed to determine the i r : wi l l ingness to become involved with the i r doctors in research, knowledge about research, ideas for appropriate topics for research, and suggestions for f inancing research. Information was also obtained about age, sex, and deta i l s related to the v i s i t to the doctor. 3.2. The populations surveyed To obtain a reasonable ::number of responses, i t was considered necessary to survey a l l general pract i t ioners in B r i t i s h Columbia. From those who responded, a random sample was selected to obtain opinions from the i r pat ients. 3.2.1. General p rac t i t i oners . A l l general pract i t ioners in B r i t i s h Columbia were surveyed. Names and addresses of general pract i t ioners were obtained from two sources: - 31 -32 (a) UBC l i s t , compiled by the Div is ion of Health Services Research and Development at the Univers i ty of B r i t i s h Columbia, from data supplied by the College of Physicians and Surgeons of B r i t i s h Columbia (CP&S) and the B r i t i s h Columbia Medical Services Commission (MSC). Detai ls include name, address, postal code, medical school attended, year of graduation, and MSC i den t i f i c a t i on number (which i s not always unique, as when|members of a group use the same b i l l i n g number). Data are stored in the univers i ty computer system and are revised monthly according to reports received from both agencies. For th i s study, the most recent ed i t ion of the l i s t (18 February, 1978) was used for mai l ing questionnaires in March. There were two sect ions: an "act ive reg is ter" contained 2,180 names of physicians considered to be act ive general pract i t ioners because of b i l l i n g to medicare over an arb i t ra ry amount in one year ( e . g . , $15,000 in 1978); an " inact ive reg is ter" contained 242 names of physicians who b i l l e d less than the arb i t ra ry amount. (b) BCMA l i s t , compiled by the B r i t i s h Columbia Medical Associat ion from i t s membership r o l l , which includes the majority of physicians in B r i t i s h Columbia. It i s divided into two sect ions, for which address-ograph plates are kept separately. One section consists of those who have spec i a l i s t qua l i f i c a t i ons . The other section consists of those who do not, and th i s section is used to provide the l i s t of general p rac t i t i oners . The l i s t i s revised once a year, with renewal of membership in the BCMA, the l a tes t rev is ion in November , 1977, including 2,121 as general p rac t i t i oners . Detai ls include name, address, and postal code. For th i s study, the addressograph plates for the section of general pract i t ioners were used on 7 March, 1978, to address the 33 envelopes in which the questionnaires were to be enclosed. When the two l i s t s were compared for concordance, i t was found that each l i s t contained some names which the other did not have. The tota l number of ind iv iduals in the combined l i s t was 2,612, compared with 2,422 in the UBC l i s t , and 2,121 in the BCMA l i s t . However, only 1,931 appeared on both l i s t s . The number included in both the UBC Act ive l i s t and the BCMA l i s t was 1,802. This was considered to be the most act ive group of general p rac t i t i on -ers. The number included in both the MSC Inactive l i s t and the BCMA l i s t was 129. General pract i t ioners included in the UBC l i s t but not in the BCMA mail ing l i s t were divided into Act ive (378) and Inactive (113). An addit ional 190 physicians were in the BCMA l i s t but not in the UBC l i s t . A l l those included in e i ther l i s t of general pract i t ioners were included in the survey populat ion, except the 268 who were excluded for reasons given in Appendix 3. Names were el iminated from the mail ing l i s t s because of deta i l s which indicated that they were not funct ioning as general p rac t i t i oners . The most common reasons for exclusion were spec i a l i s t s tatus, working in publ ic health, retirement, or working for an agency or i n s t i t u t i o n . In cases of doubt, or i f reasons were not apparent from the information on record, the names were l e f t i n , even when i t was known that the ind iv iduals were not working as general p rac t i t i oners . Depending on the i r status on the BCMA and the UBC l i s t s , the general pract i t ioners surveyed were divided into 5 categories: 1- BCMA mail ing l i s t + UBC Act ive l i s t 2- BCMA mail ing l i s t only 3- UBC Act ive l i s t only 4- BCMA mail ing l i s t + UBC Inactive l i s t 5- UBC Inactive l i s t only Table 3.1 shows the d i s t r i bu t i on of the 2,344 general pract i t ioners in the 34 population surveyed, according to BCMA d i s t r i c t and category on the mail ing 1 i s t s . Table 3.1 General pract i t ioner population in B r i t i s h Columbia, as l i s t e d in survey of 17-23 March, 1978 Category of general p rac t i t i oner : D i s t r i c t of BCMA - 1 - -2- -3 - -4- -5 - Total 1 V i c to r i a 213 - 33 14 9 269 2 Upper Island 161 - 32 5 5 203 3 Vancouver C i ty 360 14 100 26 21 521 4 North Burrard 122 5 27 10 7 171 5 Burnaby 69 2 6 3 4 84 6 New Westminster 190 1 24 10 15 240 7 Fraser Val ley 142 - • 18 5 3 168 8 Richmond - Delta 79 2 14 - 4 99 9- Prince Rupert 49 1 16 8 1 75 10 North Okanagan 78 - 22 2 1 103 11 Cariboo 66 - 14 1 1 82 12 Peace River 22 1 6 - - 29 13 South Okanagan 150 - 17 1 2 170 14 West Kootenays 49 - 18 2 1 70 15 East Kootenays 52 - 6 - 2 60 Totals 1802 26 353 87 76 2344 3.2.2. Patients To gain access to patients to be surveyed, a 5% random sample was selected by a computer program from the 506 general pract i t ioners who had returned the i r completed questionnaires. Of the 22 numbers selected by the computer, 2 were anonymous, leaving an i den t i f i ab l e sample of 20. These were sent a l e t t e r (Appendix 4) asking them to present a short questionnaire to a l l of the i r patients on a weekday to be chosen at random. 35 Of the 20 who were asked to help in the survey, 13 agreed, 4 said they would not (2 were about to go on "sabbat i ca l " ) , and 3 did not reply to a second request. Replacements, next on the l i s t from the same BCMA d i s t r i c t s , were selected for the 4 who declined and provided 3 more who agreed to par t i c ipa te . One of these did not fol low through by returning any completed questionnaires, but the other 2 and the f i r s t 13 who had agreed a l l cooperated, providing a tota l 15 (75%) of the target of 20 pract ices . A l l were in Category l in the mail ing l i s t except for one (B) who was in Category 4. The general pract i t ioners who part ic ipated (Table 3.2) represented 9 of the 15 BCMA d i s t r i c t s , with 1,849 (78.9%) of the doctors on the mail ing l i s t . The 9 d i s t r i c t s had provided 391 (77.3%) of the 506 responses included in the population sampled. Table 3.2 . 15 General pract i t ioners par t i c ipa t ing in survey of patients G.P. Id. Place and year of graduation BCMA D i s t r i c t Questionnaires requested A UBC '75 10 20 B UWO '74 9 20 C U of A '62 4 35 D .. UBC '63 8 40 E India '54 3 5 F UBC '66 3 60 G Manitoba '51 3 •40 H London '58 3 40 I UBC '64 3 30 J McGil l '76 4 30 K UWO '75 1 30 L Ireland 157 3 30 M London '55 6 35 N Netherlands 1 '61 7 35 0 UBC '72 2 40 36 3.3. Data Co l lect ion Instruments 3.3.1. General p rac t i t ioner questionnaire. The questionnaire was designed to provide answers to the questions about the de s i r a b i l i t y and f e a s i b i l i t y of research by general p rac t i t i oners . To~ develop questions most l i k e l y to provide answers to the study top i c , two sources of advice were consulted. F i r s t , the l i t e r a tu re review helped to ident i fy relevant areas of enquiry, espec ia l ly considering the appl icat ion in B r i t i s h Columbia of work which had been done elsewhere. Second, a var iety of ind iv idua ls was interviewed, because of the i r special knowledge re lated to the aspects of research, of soc ie ty ' s needs, or of general pract ice out l ined in Chapter 2. Interviews followed the format shown in Appendix 5 and most took t h i r t y minutes or more. Individuals consulted are l i s t ed in Appendix 5, but the i r rep l ies are con f i den t i a l . The questionnaire evolved through a ser ies of drafts ending with the f i na l draf t as shown in Appendix 6. Each draf t was prepared with the study questions as a framework, then presented to colleagues for c r i t i c i sm of content, format, comprehensiveness, and c l a r i t y . The matter of d e s i r a b i l i t y was explored by asking the general p rac t i t i on -ers a ser ies of questions regarding the potential benefits resu l t ing from research a c t i v i t y , for knowledge, the pract i ce , and society; Could research by general pract i t ioners be benef ic ia l for knowledge? Do you think that research in family/general pract ice can provide knowledge which would otherwise not be avai lable? (Ql) L i s t three spec i f i c topics which you have thought about studying, or which you consider to have high p r i o r i t y . (Q2) How important are the fol lowing factors in encouraging par t i c ipa t ion in research projects? (a) contr ibut ion to knowledge (b) cu r i o s i t y . "' (Q 7.1, 7.2) 37 Could research by general pract i t ioners be benef ic ia l for the pract ice  of medicine? In your opin ion, what ef fect might par t i c ipa t ion in research have on the fol lowing factors? (a) income (b) le i sure time (c) o f f i ce management (d) o f f i ce records (e) patient care (f) pat ient records (g) pat ient sa t i s fac t ion (h) your sa t i s fac t ion with work. (Q 5.4 to 5.10, 5.13) How important are the fol lowing factors in encouraging par t i c ipat ion in research projects? Ca) to add interest to pract ice (b) to co-operate with partner(s) (c) to improve o f f i ce management (d) to improve patient care. (Q 7.3 to 7.6) Could research by general pract i t ioners be benef ic ia l for society? In your opin ion, what ef fect might par t i c ipa t ion in research have on the fo l lowing factors? (a) cost of care (b) education - medical (c) education - publ ic (d) p o l i t i c a l decisions (e) the health care system (Q 5.1 to 5.3, 5.11, 5.12) How important are the fol lowing factors in encouraging par t i c ipa t ion in research projects? (a) to improve the health care system (b) to provide an academic base for family practice/general pract ice. (Q 7.7, 7.8) The matter of f e a s i b i l i t y was explored by asking the general pract i t ioners a ser ies of questions related to the acceptab i l i t y of research a c t i v i t y to general p rac t i t i oners , to the i r pat ients , and to the i r pract ices (considering the condit ions which could resu l t from the general p rac t i t i oners ' involvement in research), and also questions regarding the qua l i ty of the research which could be done in the general pract ice se t t ing: Could the condit ions imposed by research a c t i v i t y be acceptable for the general pract i t ioner? How important are the fol lowing factors in discouraging par t i c ipa t ion in research projects? (a) heavy workload (b) inadequate t ra in ing Cc) Tack of awareness of potent ia l (d) lack of in terest (e) lack of time (_f) not convinced of i t s value (Q 6.5, 6.7 to 6.11) How much interest would you have in the fol lowing types of research a c t i v i t y , assuming that planning is rat iona l and that projects would be compatible with your pract ice? (a) c l i n i c a l studies (b) economic studies (c) epidemiological studies (d) drug studies - new drug t r i a l s (e) ongoing evaluation of treatment (f) evaluation of medical education (g) group studies, with a central recorder to arrange de ta i l s (h) indiv idual studies of your pract ice ( i ) laboratory studies ( j) sett ing up pract ice records to al low easier par t i c ipa t ion in research (k) time and motion studies (1) workload studies. (Q 8, 8.1 to 8.12) Are you now involved in or ac t i ve ly planning a research project? (Q 9) Could the condit ions imposed by research a c t i v i t y be acceptable for  the patient? How important are the fol lowing factors in discouraging par t i c ipa t ion in research projects? Cost to patients in (a) time (b) travel Cc) discomfort. (Q 6.1 to 6.3) Have you or any of your patients experienced a breach of con f iden t i a l -i t y in a research project? (Q l i b ) How importantjdo you think i t i s to obtain informed consent from pat ients , i f you are engaged in the fol lowing a c t i v i t i e s ? (a) a diagnostic or therapeutic procedure to be used i s not the customary procedure (b) a patient i s asked to complete a questionnaire 39 for a research study (c) a patient i s interviewed for a research • project (d) c l i n i c a l t r i a l s (e) providing incidence data from patient records (f) reporting spec i f i c diagnoses, with patients anonymous (g).report ing spec i f i c diagnoses, with names of patients (h) using a placebo in treatment. (Q 11.5 to 11.12) Could the conditions imposed by research a c t i v i t y be acceptable for  the pract ice? How important are the fol lowing factors in discouraging par t i c ipa t ion in research projects? (a) high o f f i ce overhead (b) o f f i ce s ta f f too busy (c) partners not cooperative (d) space in o f f i ce inadequate. (Q 6.6, 6.12, 6.13, 6.15) Could the condit ions for research be s c i e n t i f i c a l l y acceptable? During your education, what was your exposure to the fol lowing subjects? (a) s t a t i s t i c s - in medical school, interneship, residency, (b) epidemiology - in medical school, interneship, residency (c) methodology - in medical school, interneship, residency (d) national workshops on research (e) prov inc ia l workshops on research (f) national health grant seminar. (Q 3) Have you taken part in any of the fol lowing projects in B r i t i s h Columbia, or studies elsewhere? (a) Study of content of pract ice (Postuk, 1965) (b) ' f l u ' survey, 1969 (College of Family Physicians) (c) survey on nut r i t i on (Schwartz, 1974) (d) inf luenza survei l lance (1976-78) (e) prevalence of mult ip le sc le ros i s (Vernier 1977) (f) drug t r i a l s . (Q 4) How important are the fol lowing factors in discouraging par t i c ipat ion, in research projects? (a) record system unsuitable. (Q 6.14) I f you were planning to do a research project , would you need any of the fol lowing resources? (a) advice on f e a s i b i l i t y (b) advice on planning (c) consultat ion with expert (d) f inanc ia l help (e);-.help in processing resu l ts (f) help in wr i t ing report (g) technical help (h) secretar ia l help ( i ) special f a c i l i t i e s . (Q 10) Have you taken part in any research projects? (Q 11a) Addit ional questions re lated to the doctor 's t r a i n i ng , experience, type of prac t i ce , and age. Provis ion was made for the respondent to remain anony-mous, simply by cutt ing o f f the ident i fy ing MSC number on a corner of the form. Questions were worded as much as possible so that respondents would not be steered to the "best" answer. Choices were l i s t e d in chronological or alphabetical order, to avoid placing some at the top or bottom of a l i s t which might have biased the responses. The format was designed to be a t t rac t i ve to the busy general p rac t i t i oner , and r e l a t i v e l y easy to fo l low. One object ive was to l im i t the questions to those which could be included on one sheet of paper, even though i t was printed on both sides with the pr in t reduced in s i ze . Good qua l i ty paper of pleasant colour was chosen. Type faces were chosen to provide var iety and emphasis, with a p la in le t raset heading, IBM sc r ip t for the questions, and l e t t e r gothic type for the responses. 3.3.2 Patient questionnaire. To develop questions which would al low patients to express the i r i n te res t , concerns, and degree of support for research in general p rac t i ce , areas considered to be important were the possible effects on medical care, cost , con f i den t i a l i t y , and wi l l ingness to cooperate. Several drafts were developed, each being presented to colleagues who had had the experience of being pat ients , for c r i t i c i sm of content, format, comprehensiveness, and c l a r i t y . The f i na l draf t appears in Appendix 7. Instruct ions to the pat ients , at the top of the page, included an assur-assurance of c o n f i d e n t i a l i t y . Informat ion was obta ined about age and sex , whether the respondent was v i s i t i n g or was b r i ng i ng someone e l s e to the doc t o r , and whether t h i s was the r egu l a r doc to r . An op in i on on the d e s i r a b i l i t y o f research was sought by a s k i n g : Do you t h i nk t ha t i t i s a good idea f o r general p r a c t i t i o n e r s to be i nvo l ved i n research s tud i e s r e l a t e d to t h e i r work? (Q 6) What t op i c s do you th i nk are most i n need of study by general p r a c t i t i o n e r s ? (Q 7) An op in i on on the f e a s i b i l i t y o f research was sought by a s k i ng : Would you be w i l l i n g to help your doctor to do research s t u d i e s , by coopera t ing i n important d e t a i l s , such as : (a) a l l ow ing her/him to prov ide in fo rmat ion from your medical records (wi thout g i v i n g your name)? (b) keeping a d i a r y about d e t a i l s o f your hea l th? (c) r e t u rn i ng a t monthly i n t e r v a l s f o r checkups ( e . g . , blood pressure check)? (d) a l l ow ing a blood sample to be taken f o r t e s t i n g ? (Q 8) Have you ever donated blood to the Red Cross? (Q 9) For the support o f r e s ea r ch , which of the f o l l ow i ng do you th i nk should prov ide money? (a) the government - f e d e r a l , p r o v i n c i a l , or l o c a l (b) p r i v a t e foundat ions ( e . g . , Vancouver, K e l l o gg , or Rocke-f e l l e r Foundat ions) (c) the pub l i c (through donat ions or bequests) (d) the doc to r s . (Q 10) Quest ions were chosen w i th the ob j e c t i v e s of keeping the t o t a l number reasonably smal l and answering main ly by check ing . Quest ion 9 was intended to f i n d out whether those who i nd i c a t ed coopera t ion i n Quest ion 8 had demonstrated w i l l i n g n e s s to donate b lood . Format was intended to be of a p leasant appearance, w i th heading and i n s t r u c t i o n s i n s c r i p t , quest ions i n l e t t e r go th i c t ype . Paper was ye l l ow (goldenrod) and high q u a l i t y . 3.4. Data Co l lect ion Procedure 3.4.1. Survey of general pract i t ioners Questionnaires to general pract i t ioners were prepared for mail ing so as to maximize response rate. Envelopes were white, and large enough (27x19 cm.) to hold the questionnaire folded once, an unstamped return-addressed envelope, and a covering l e t t e r . Specia l - issue stamps were used, rather than a postal meter. The covering l e t t e r (Appendix 8) explained the purpose of the survey and asked for cooperation from the general p rac t i t i oner . The questionnaires were mailed in batches, from Fr iday, 17 March, to Thursday, 23 March 1978, to the 2,344 general pract i t ioners in the groups shown on page 3#. No reminders were sent out, and no further questionnaires except for one which was sent on request. I t was expected that anyone with enough interest in research to answer would e i ther answer promptly or save the questionnaire unt i l a convenient time, so that the fact of answering might be one measure of in teres t . 3.4.2. Survey of patients To each of the 16 general pract i t ioners who agreed to par t i c ipate in the study, a package was sent during July or August, 1978, containing: - a l e t t e r to the physician (Appendix 9.1) - instruct ions for administering the questionnaire (Appendix 9.2) - the number of questionnaires requested by the physician - small envelopes in which patients were asked to seal the i r completed questionnaires - a large stamped and addressed envelope for returning a l l question-naires (used and unused) I f the returns were delayed more than seemed reasonable, a reminder was sent, asking about the phys ic ian 's progress and intent ions. 43 3.5. Analys is of Results 3.5.1. Questionnaires returned from the survey of general pract i t ioners were separated into two groups; one included those who were in fact not general p rac t i t i oners , and the other included those who were general p rac t i t i oners . The f i r s t group of questionnaires was analyzed by hand, to show the reasons ; that they were not general p rac t i t i oners . The second group, except for the 7 which arr ived too l a t e , were coded and entered on fortran sheets by a research ass i s tant . Computer cards were punched and ve r i f i ed by the computer serv ice , and then processed by computer methods, using the SPSS:7 program on the IBM 360 computer at the Univers i ty of B r i t i s h Columbia. Frequencies were obtained for a l l var iables which related to the responders and the i r responses. Responses were arranged in re la t ion to the research questions as described in section 3 .3 .1 , to show the weight of opinion or extent of experience for each item in the questionnaire. Comments of the responders were recorded and assessed i nd i v i dua l l y . 3.5.2. Results from the survey of patients were coded and transferred to punch cards by a research ass i s tant . They were processed by computer methods, using the SPSS:7 program on the CDC computer at the Univers i ty of Calgary. Frequencies were obtained for a l l var iables re lated to the patients and the i r responses, and these were correlated with the physician responses in re la t ion to the study questions. 3.6. L imitat ions of the Study An attempt was made to recognize l im i ta t ions and sources of b ias , and to avoid them or to take them into account in evaluating resu l t s . The major l im i ta t ions were described in re la t ion to the stages of the study. 3.6.1. L imitat ions imposed by the strategy General p rac t i t i oners . Response to mail questionnaires can be low, 44 espec ia l ly for those which contain as many questions as were in the survey of general p rac t i t i oners . The topic of research was not expected to be of wide general i n te res t , so that a r e l a t i v e l y low response was expected. An assumption was made that any response would indicate at least a minimum level of i n te res t , and that the time and cost for follow-up questionnaires and phone ca l l s were not j u s t i f i e d . Therefore, the respondents would be a biased group, more l i k e l y to support the concept of research than would the non-responders. Their reponses would be referable only to the responding group, and not general izable to a l l general pract i t ioners surveyed. Pat ients. The survey of pat ients , based on a random sample of general p rac t i t i oners , would also be biased towards a pos i t ive response for two reasons. F i r s t , the sample was chosen from those general pract i t ioners who had responded to the f i r s t survey, and not from the general p rac t i t ioner population as a whole. Second, i t i s quite possible that the 15 pract i t ioners who agreed to the survey of patients would somehow have influenced the i r pat ients ' a t t i tudes . 3.6.2. L imitat ions imposed by the sample se lect ion General p rac t i t i oners . Select ion bias might occur in development of the l i s t of general p rac t i t i oners . Apart from the obvious errors of inc lus ion of some l i s t e d as spec i a l i s t s , there were less obvious errors which were noted by chance rather than by the method of exc lus ion. Examples of these chance observations were: - one l i s t ed as an MSC act ive general pract i t ioner who had been out of pract ice for 18 months - at least two l i s t ed as inact ive general pract i t ioners who were known to be hospital administrators, but who were not i den t i f i ed as such on the mail ing 1 is ts - at least three l i s t e d as inact ive general pract i t ioners who were in fact r e t i r ed . I t i s quite l i k e l y that there should be other exclus ions, so that the true count of general pract i t ioners would be lower than the number shown in the corrected l i s t s . There could also be errors of omission, but these would be r e l a t i v e l y few, as there was a regular monthly addit ion of new regist rants in the B r i t i s h Columbia College of Physicians and Surgeons to make the l i s t current. Most new addit ions to the l i s t are in June and Ju ly , so that those in February would be r e l a t i v e l y few. Some may have been out of pract ice for other reasons, although s t i l l l i s t ed with home addresses and maintaining membership in both the BCMA and the CP&S. Spec ia l i s t status could not always be considered an accurate c r i t e r i on for decis ion about general pract ice a c t i v i t y , as some c e r t i f i e d spec i a l i s t s were in fact providing general pract ice serv ices , while some l i s t ed as general pract i t ioners were in fact providing only spec i a l i s t serv ices. C le r i ca l error could also place ind iv idua ls in the wrong categories. The highest response rate was expected from the group of 1,802 physicians who were included in both the BCMA l i s t and the MSC l i s t of act ive general p rac t i t i oners . Pat ients. Select ion bias could also occur with the patient sample, as i t was res t r i c ted to those who were current ly attending the doctor, thereby el iminat ing ind iv idua ls who might be healthy or who might stay away from the doctor for other reasons. The number and type of pract ices selected might have ref lected excessive numbers of certa in age groups, ethnic groups, or socia l c lasses. These errors should have been minimized by the process of random se lect ion which was used. 46 3.6.3. L imitat ions of the questionnaires General p rac t i t i oners . Content of the questionnaires to general pract-i t i oners was l imi ted by the expected l im i t of tolerance of the respondents, so that the number of questions was kept to the minimum needed to answer the study questions. An attempt was made to encourage acceptance of the question-ma i re by development of an a t t rac t i ve and concise format. Instrument bias was a major po s s i b i l i t y in the questionnaire, so that great care was taken to avoid leading questions which would be l i k e l y to steer the rep l ies in the d i rec t ion favored by the surveyor. To compensate for the l im i ted number of a l ternat ives in some of the questions, an opportunity was given to add other a l te rnat ives . Pat ients. Possible se lect ion bias might occur because the sample was too small or was not representative of a l l pat ients , or of a l l the populations, but the trend indicated would l i k e l y be a reasonable re f l ec t i on of opinions in the population most concerned. Attempts by the o f f i ce s ta f f to help patients with the i r answers could also add bias in providing "acceptable" opinions, and var ia t ion in instruct ions by o f f i ce s ta f f might a f fect the answers. To minimize the ef fect of o f f i ce s t a f f , as well as possible re luc t -ance to have answers seen by the doctor or the s t a f f , patients were supplied with envelopes in which to seal the i r completed questionnaires. 3.6.4. L imitat ions of the survey General p rac t i t i oners . One major l im i ta t i on was expected to be the normal reluctance to complete questionnaires from any source, so that attempts were made to encourage the rec ip ients to respond. The covering l e t t e r described b r i e f l y the purposes and potent ia l value of the survey. To increase the acceptab i l i t y of the study, the return envelope was pre-addressed to the o f f i c e of the B r i t i s h Columbia Chapter of the College of Family Physicians of Canada, and to the attent ion of the author. For economy, no stamp was included 47 on the return envelope, so that some potent ial respondents might have refused to contr ibute. The lack of follow-up;' questionnaires or reminders was expected to reduce the response ra te , but th i s resu l t was considered to be acceptable as one measure of the degree of in te res t . The timing of the survey was not l i k e l y to a f fect the response, except that the mail ing of questionnaires was done jus t before the Easter hol iday. However, the greatest response was received in the week af ter Easter. Pat ients. The lack of cooperation from 25% of the pract ices randomly selected for the survey of patients would have some ef fect on the response, and l im i t the general izat ions which could be made. The po s s i b i l i t y of se lect ion bias was considered, and o f f i ce s ta f f were asked to submit question-naires to a l l patignts in the session selected. They were also asked to report the number of patients seen who did not complete the questionnaire. Conduct of the survey during the summer might have contributed to non-response, although instruct ions provided for a delay unt i l the next appropriate session. 3.6.5. L imitat ions of the analysis To avoid se lect ion of only those answers which might support the views of the invest igator , the frequencies of a l l items were reported. However, only selected cross-tabulat ions could be presented because of the large number of poss ib i l i t i .es,so that bias might a f fec t the se lec t ion . The po s s i b i l i t y of error in entry of data was present, and was avoided by random check and by spec i f i c review of resu l ts which did not seem reasonable. Summary The method used to study the question of d e s i r ab i l i t y and f e a s i b i l i t y of research by general pract i t ioners in B r i t i s h Columbia involved several 48 steps, the f i r s t of which was to decide on the strategy. The primary approach was to the general p rac t i t i oners , with the point of view of patients to be considered as we l l , in an exploration of opinions and experience re lated to the study questions. The advice of author i t ies in re lated f i e l d s was sought during preparation of the questionnaires to be used, and great care was taken to make the questions relevant to the topic and acceptable to the respondents. The mail survey was to a r e l a t i v e l y large number of physicians so that only one mail ing was done. From the respondents, 15 (from a random select ion) presented a questionnaire to a random se lect ion of the i r pat ients. Analysis of data included computer processing, to provide frequencies for a l l var iables and some cross-tabulat ions. L imitat ions of the study were considered, to be taken into account in the evaluation of r esu l t s . CHAPTER 4 RESULTS Results of analysis of the questionnaires returned by general pract i t ioners and patients were arranged according to response rates , charac ter i s t i cs of the respondents, and the content of rep l ies to the study questions. 4.1. Response 4.1 .1 . Survey of general p rac t i t i oners . From the 2,344 questionnaires which were mailed, 563 (24.0%) were returned. Of these, 508 (21.7%) could be used for ana lys is . The other 55 (2.3%) included 7 which were too la te for ana lys i s , 5 which were returned as undel iv-ered, and 43 which were returned with information ind icat ing that the respondent was not in general pract ice . (Appendix 10) Response rates according to category on the mai l ing l i s t are shown in Table 4 .1 . Of the 508 usable responses, 482 (94.9%) were on the UBC Act ive l i s t (categories 1 and 3) . Of these,447 (92.7%) were also on the BCMA l i s t , so that 88% of the usable response was from category 1, with 1,802 physicians on both UBC and BCMA l i s t s . An addit ional 24 responses from thfscgroup (1.3%) indicated that the physicians were not in general pract ice. Late returns from 6 increased the tota l response to 477 (26.5%) in category 1, with a usable response of 447 "(24.8% of 1,802.) From the remaining 542 questionnaires mailed to the other 4 categories of physic ians, there were 72 rep l ies (13.3%), 52 of which were usable (9.6%). One was too l a t e , and 19 (3.5%) stated that the physician was not in general pract ice. There were 48 anonymous r ep l i e s , but most of these could be placed in one of the groups in the mail ing l i s t because of colour-coding or answers in the questionnaires, leaving 9 which could not be placed. - 49 -Table 4.1 Response rates of physicians, related to category on mail ing l i s t s Numbers on l i s t s Numbers returned Category of physician Total Excluded Included No. % Q's came back not opened Responses Total Not Late Usable G.P. 's returns returns No.- % No. % No. % 1. BCMA mail ing l i s t + UBC Active l i s t 2. BCMA mail ing l i s t only 3. UBC Act ive l i s t only 4. BCMA mail ing l i s t + UBC Inactive l i s t 5. UBG Inactive l i s t only 6. Anonymous returns, un ident i f iab le 1802 190 378 129 113 0 164 25 42 37 1802 100.0 26 13.7 353 93.4 87 67.4 76 67.3 478 26.5 24 1.3 6 447 24.8 8 30.8 4 :15.4 37 10.5 1 0.3 25 32.2 14 16.1 6 3.9 - -9 4 15.4 35 9.9 10 11.5 3 3.9 9 Totals 2612 268 2344 89.7 563 24.0 43 1.8 508 22.0 51 Response rates according to BCMA d i s t r i c t are shown in Table 4.2 Responses were received from a l l d i s t r i c t s , the rates ranging from 7.1% to 30.5% of the general pract i t ioners surveyed, with an overal l response rate of 23.8% There were 558 responses from physic ians, not including the 5 which were undel iverable. Af ter subtracting the 43 who rep l ied that they were not in general pract ice and the 7 usable rep l ies which were too l a t e , there were 508 rep l ies ava i lab le for analys is at the cut-of f time of 100 days af ter mail ing the questionnaire. These gave an overal l response rate of 21.7%, with a range from 7.1% to 27.9%. Table 4.2 Response to general p rac t i t ioner questionnaire by D i s t r i c t of BCMA, 1978 Hi c t r i " r t n f RPMfl Number surveyed Total rep l ies Usable rep l ies U l o i l I L L U 1 D o l Irt Number % Number % Number % 1 Capitol region 269 11.5 79 29.4 75 27.9 2 Upper Island ,203 8.7 45 22.2 40 19.7 3 Vancouver c i t y 521 22.2 127 24.4 115 22.1 4 North Burrard 171 7.3 30 17.5 26 15.2 5 Burnaby 84 3.6 6 7.1 6 7.1 6 New Westminster 240 10.2 57 21.7 46 19.2 7 Fraser Val ley 168 7.2 36 21.4 32 19.0 8 Richmond - Delta 99 4.2 22 22.2 19 19.2 9 Prince Rupert 75 3.2 19 25.3 18 24.0 10 North Okanagan 103 4.4 22 21.4 20 19.4 11 Cariboo 82 3.5 / 25 30.5 21 25.6 12 Peace River 29 1.2 8 27.6 8 27.6 13 South Okanagan 170 7.3 37 21.8 35 20.6 14 West Kootenays 70 3.0 17 24.3 15 21.4 15 East Kootenays 60 2.6 17 28.3 16 26.7 16 Anonymous - 16 16 Totals 2344 100.1 558 23.8 508 21.7 52 There were 16 anonymous rep l ies which could not be assigned to any BCMA d i s t r i c t . The other 32 anonymous rep l ies could be located in a d i s t r i c t e i ther by the postal code or by i den t i f i c a t i on on the envelope or questionnaire. 4.1.2. Survey of pat ients. From the 16 general pract i t ioners who had agreed to submit a question-naire to the i r pat ients , returns were received from 15. These provided a 75% response rate from the 20 pract ices or replacements randomly selected. The response from""patients varied from 5 to 30, with an average of 20.3 patients per pract ice (Table 4 .3) . Ten physicians reported the number of v i s i t i n g patients who had not completed a questionnaire. . Table 4.3 Response rate of patients to questionnaire according to BCMA d i s t r i c t of general p rac t i t ioner a P BCMA # of Q 's Patients Response u . r . Dist . completed seen rate A 10 6 20 30% B 9 12 13 92.3% C 4 25 25 100.0% D 8 21 * N/A E 3 5 5 100.0% F 3 26 * N/A G 3 30 31 96.8% H 3 24 * N/A I 3 14 14 100.0% J 4 28 * N/A K 1 18 19 94.7% L 3 28 * N/A M 6 25 28 89.3% N 7 17 22 77.3% 0 2 24 26 92.3% Anon. - 1 N/A Totals 304 330 * = not reported 53 In these pract ices , 149 out of 176 patients co-operated, a response rate of 84.7%. If the one pract ice in which 14 out of 20 patients did not complete the questionnaire could be ignored, the response rate in the other 9 would have been 143/156, 91.7%. In the f i ve pract ices where non-responders were not reported, the average number of patients responding was 25.4, whereas the average in the other 10 pract ices was 17.6 pat ients. 4.2. Character is t ics of respondents 4 .2 .1 . Survey of general p rac t i t i oners . Age was reported by 97.2% of respondents, with 42.7% under 35 years, 28.0% 36-44 years, 17.7% 45-54 years, and 8.9% over 54 years. The median age was 37 years. (Table 4.4) Table 4.4 Age groups of 508 general pract i t ioners responding to survey Age group Number Percent Under 35 217 42.7 35-44 142 28.0 45-54 90 17.7 55 and over 45 8.9 Not stated 14 2.8 Year of graduation ranged from 1935 to 1977, with 7.4% graduating before 1950, 21.1% from 1950 to 1959, 31.3% from 1960 to 1969, and 38.1% since 1969. The median year of graduation was 1966. (Table.4.5) 54 Table 4.5 Year of graduation in medicine Years Number Percent 1935-39 4 0.8 1940-44 13 2.6 1945-49 20 4.0 1950-54 46 9.1 1955-59 61 12.0 1960-64 61 12.0 1965-69 98 19.3 1970-74 146 28.7 1975 + 48 9.4 No reply 11 2.2 Totals 508 100.1 The school of graduation for 138 (27.2%) of the respondents was the Univers i ty of B r i t i s h Columbia. 45 (8.9%) had graduated from the Univers i ty of A lber ta , and 163 (32.1%) from twelve other Canadian medical schools. 100 (19.7%) were from the United Kingdom. The remaining 42 (8.3%) who rep l ied had graduated in the United States of America, the Antipodes, or a country in continental Europe, As ia , or A f r i ca (Appendix 11). The length of time im pract ice ranged from less than 1 year to 42 years, with up to 35 years in the same pract ice . The median length of time in pract ice was 10 years, with 6 years in the same pract ice . 120 (23.6%) had been in the same pract ice for over 10 years (Table 4 .6) . Pract ice s ize varied from 1 to 40 p rac t i t i oners , including spec i a l i s t s . The largest group included 22 general p rac t i t i oners . 153 (30.1%) of respondents were in solo pract i ce , 72 (14.2%) were in two-physician pract ices , and 168 (33.1%) in groups with 3 to 5 general pract i t ioners (Table 4 .7) . Table 4.6 Length of time in pract ice for 508 general pract i t ioners responding to survey Years in pract ice Total time In present pract ice Number Percent Number Percent 1 year or less 27 5.3 64 12.6 2-5 years 130 26.7 173 34.1 6-10 years 120 23.6 102 20.0 11-15 years 58 11.6 45 8.9 16-20 years 76 15.1 46 9.2 21-25 years 37 7.3 13 2.6 26-30 years 26 5.2 10 2.0 31-35 years 9 1.8 6 1.2 36-40 years 4 0.8 - -42 years 1 0.2 - -No reply 20 3.9 49 9.6 Table 4.7 Size of pract ice of 508 physicians answering questionnaire Total physicians General pract i t ioners Number in Number of 0, Number in Number of f pract ice pract ices pract ice pract ices A J 1 153 30.1 1 153 30. 1 2 70 13.8 2 72 14. 2 3 59 11.6 3 60 11. 8 4 56 11.0 4 61 12. 0 5 46 9.1 5 47 9. 3 6-10 64 12.6 6-10 67 13. 2 11-15 12 2.4 11-15 8 1. 6 16-20 8 1.6 16-20 3 0. 6 30 3 0.6 22 2 0. 4 -,40 2 0.4 No reply 35 6.9 No reply 35 6. 9 Membership in the College of Family Physicians of Canada, as l i s t e d in the current reg is ter at the B r i t i s h Columbia Chapter o f f i c e , was maintained by 165 (32.5%) of respondents (Table 4 .8) , of which 95 (57%) were c e r t i f i c an t s . This response by 165 members represented 39% of the 423 current membership. Table 4.8 D is t r ibut ion of respondents by Membership in College of Family Pract i t ioners of Canada Status Member Non-member Previous member Unable to ident i fy No. % No. % No. % No. % Member 165 32.5 288 56.7 9 1.8 46 9.1 Ce r t i f i can t 95 18.7 366 72.0 1 0.2 46 9.1 Summary of general p rac t i t ioner response. Response to the survey came from a wide var iety of p rac t i t i oners , representing a l l age groups, a l l areas in B r i t i s h Columbia, many d i f fe rent medical schools, urban and rural pract i ces , and solo and group pract ices . A better-than-average response came from members of the College of Family Physicians of Canada. Most were w i l l i n g to be i d en t i f i e d , as fewer than 10% chose to remain anonymous. 4.2.2. Character is t ics of patients surveyed, and the i r general p rac t i t i oners . Age was reported by 99.0% of patients responding, with 22.4% under 25 years, 39.5% in the 25-44 year range, 23.4% in the 45-64 year range, and 13.8% over 64 years. (Table 4.9) Table 4.9 Age groups of patients surveyed Age group No. 0 •i 0 Under 25 68 22. .4 25-54 120 39. .5 45-64 71 23. .4 65 and over 42 13. .8 No reply 3 1. .0 Total 304 100. .1 Sex d i s t r i bu t i on was predominantly female (68.8%), with a female/male ra t io of 2.38/1. (Table 4.10) Table 4.10 Sex of patients surveyed Sex •:: - No. % Female 209 68.8 Male 88 28.9 Not spec i f ied 7 2.3 Total 304 100.0 The reason for v i s i t i n g the doctor, as reported by a l l but one pat ient , , was for a consultat ion for him/herself (85.2%) while 14.5% were there only to bring someone e lse . Another 14 patients (4.6%) who were there on the i r own behalf also brought someone e lse . Of the respondents 85.9% considered them-58 selves as regular pat ients , while 13-2% did not. (Table 4.11) Reason for Table 4.11 v i s i t , for patients surveyed Reason given Yes No No reply No. % No. % No. % V i s i t i n g for se l f 259 85.2 44 14.5 1 0.3 Bringing another 58 19.1 227 74.7 19 6.3 Regular patient 261 85.9 40 13.2 3 1.0 The pract ices in which the patient surveys were conducted included 10 urban, 2 r u r a l , and 3 in rural-urban areas. Three of the general p rac t i t i on -ers were in solo pract i ce , two in groups of 3, eight in groups of 4, and one in a group of 10. One, in pract ice for one year, was doing locums which i s subst i tut ing for other physic ians. Age-groups of the physicians par t i c ipa t ing in the patient survey included 5 under the age of 35, 6 in the 35-44 year range, 3 in the 45-54 year range, and one over the age of 54. (Table 4.12) Table 4.12 Age groups of par t i c ipa t ing general pract i t ioners G.P. survey Patient survey Age group No. % No. % Under 35 217 42.7 5 33.3 35-44 142 28.0 6 40.0 45-54 90 17.7 3 20.0 55 and over 45 8.9 1 6.7 Not stated 14 2.8 Of the 15 par t i c ipa t ing general p rac t i t i oners , 9 were members of the College of Family Physicians of Canada, and 6 were c e r t i f i c an t s . These 9 represented 90% of the 10 who received requests. Among non-college members there were 12 requests resu l t ing in 6 part ic ipants (50%). Summary of patient response. A random sample of general pract i t ioners agreed to submit the survey questionnaire to a random sample of the i r pat ients , and 15 returned the completed questionnaires. The sample of phys ic ians represented a l l age groups, urban-rural se t t ings , solo and group pract i ces , arid both members and non-members of the College of Family Physic ians of Canada. Patients cooperated well in providing demographic data as well as answers to the survey questions. A l l adult age groups were repre-sented, and the female/male ra t i o was 2.38/1. Most were regular pat ients , v i s i t i n g for the i r own problems, but some were bringing others as pat ients. 60 4.3. Responses to questions in the survey Replies to the questions are shown in frequency tables arranged in the order of the subquestions of the thes i s , as out l ined in Chapter 3, rather than in the order in which they appear in the questionnaires. 4 .3 .1 . Opinions about the de s i r ab i l i t y of research a c t i v i t y by general pract i t ioners were shown by rep l ies in the questionnaires to general pract i t ioners and to pat ients. Could research by general pract i t ioners be benef ic ia l for knowledge? In response to question 1, asking whether research in general pract ice could provide new knowledge which would otherwise not be ava i l ab le , 89.2% of general pract i t ioners said "yes" and 5.7% said "no". (Table 4.13) Table 4.13 "Do you think that research in family/general pract ice can provide new knowledge which would otherwise not be ava i lab le?" Reply Number Percent Yes 453 89.2 No 29 5.7 Questionable 3 0.6 No reply 23 4.5 Total 508 100.0 To a~similar question, asking i f i t i s a good idea for general p r a c t i -t ioners to be involved in research studies related to the i r work, 93.1% of patients said "yes" and 3.3% said "no". (Table 4.14) Table 4.14 "Do you think that i t i s a general pract i t ioners to research studies related good idea for be involved in to the i r work?" Reply ' Number Percent Yes 283 93.1 No 10 3.3 Doubtful 1 0.3 No reply 10 3.3 Total 304 100.0 In response to the request for spec i f i c suggestions about topics considered for study, or having a high p r i o r i t y (Question 2) , a to ta l of 896 topics or areas were given by 347 (68.3%) of the general p rac t i t i oners , and 192 were given by 120 (39.5%) of the pat ients. The suggestions most frequently given by general pract i t ioners were treatments of various kinds (39), nu t r i t i on (37), hypertension (36), nervous and mental disease (35), preventive medicine (35), and del ivery of care (28). Most frequent suggestions by pat ients were cancer (27), heart disease (17), nervous and mental disease (17), nu t r i t i on (14), and preventive medicine (12). These and other rep l ies are l i s t e d in Appendix 12. Three or more topics were suggested by each of 231 (45.5%) of the general p rac t i t i oners , while 76 (15.0%) suggested 2 each, and 40 (7.9%) suggested one. A maximum of three topics per respondent could be analyzed, so that eleven suggestions were not included. Of the 120 patients with suggestions, 19 (6.2%) had three, 53 (17.4%) had 2, and 48 (15.8%) had one. (Table 4.15) 62 Table 4.15 Number of topics suggested as sui table for research by general pract i t ioners and patients Number of topics per G.P. " Respondents Total # of topics Patient Respondents Total # of topics respondent No. % No. % No. % No. % 1 40 7.9 40 4.5 48 15.8 48 22.7 2 76 15.0 152 17.0 53 17.4 106 50.2 3 221 43.5 663 74.0 19 6.2 57 27.0 4 9 1.8 36 4.0 - -5 1 0.2 5 0.5 - -0 161 31.7 - 184 60.5 -Total response 347 68.3 896 100.0 120 39.5 211 99.9 Incentives to par t i c ipate in research included cu r i os i t y and the contr ibut ion to knowledge (Questions 7.1, 7.2). General pract i t ioners rated the contr ibut ion to knowledge as a very important (47.2%) or important (42.1%) incent ive, while 8.1% thought i t was not important. Cur ios i ty was said to be very important by 42.5%, important by 45.7%, and not important by 8.9% (Table 4.16). Table 4.16 "How important are the fol lowing factors in encouraging par t i c ipa t ion in research projects?" Rating by 508 general pract i t ioners FACTOR Very important Important Not important No reply No. % No. % No. % No. % Contribution to knowledge Cur ios i ty 240 47.2 216 42.5 214 42.1 232 45.7 41 8.1 45 8.9 13 2.6 15 3.0 63 Could research by general pract i t ioners be benef ic ia l for the pract ice? Sections of the general p rac t i t i one r ' s questionnaire related to th is question dealt with expected effects on the pract i ce , for f e t t e r or worse, resu l t ing from conduct of or par t i c ipa t ion in research by the general p rac t i t i oner . Factors which might be improved were thought to be physician sa t i s fac t ion C69.3%), patient records (68.7%), patient care (68.5%), and o f f i ce records (62.2%). Some thought that these factors would be worse (2.2%, 2.8%, 1.2%, and 9.3% respect i ve ly ) , and some thought that they would remain the same (23.8%, 23.8%, 25.6%, and 23.6% respect ive ly) . (Questions 5.13, 5.7, 5.8, and 5.9). The greatest adverse ef fect was expected to be on le i sure time, with 62.6% thinking i t would be worse, 23.0% the same, and 10% better. The ef fect on income was expected to be worse by 48.6%, the same by 39.4%, and better by . 7.5%. (Questions 5.5 and 5.4) Off ice management could be better as a resu l t of research a c t i v i t y according to 41.3%, while 36.6% said i t could be the same, and 16.1% thought i t could be worse. (Question 5.6) Patient sa t i s fac t ion was expected to improve by 40.7%, to remain the same by 47.0%, and to become worse by 4.9%. (Question 5.10) (Table 4.17) Other factors related to the pract ice which could encourage p a r t i c i -pation in research were also rated by the general p rac t i t i oners . Improving patient care was rated as very important by 46.3%, important by 42.1%, and unimportant by 8.7%. Adding interest to the pract ice was a very important incentive to 39.8%, important to 48.8%, and not important to 8.1%. (Questions 7.6 and 7.3) The least incentive was to cooperate with partners, 43.5% thinking i t was not important, 36.0% important, and 8.3% very important. Improving o f f i ce 64 management was rated as very important by 16.5%, important by 41.1%, and not important by 36.2%. (Questions 7.5 and 7.4) (Table 4.18) Table 4.17 Factors in the pract ice which might be affected by par t i c ipa t ion of the general pract i t ioners in research Effect Better Same Worse No reply No. % No. % No. % No. % Income 38 7.5 200 39.4 247 48.6 23 4.5 Leisure time 51 10.0 117 23.0 318 62.6 22 4.3 Off ice management 201 41.3 186 36.6 82 16.1 30 5.9 Off ice records 316 62.2 120 23.6 47 9.3 25 4.9 Patient care 348 68.5 130 25.6 6 1.2 24 4.7 Patient records 349 68.7 121 23.8 14 2.8 24 4.7 Patient sa t i s fac t i on 207 40.7 239 47.0 25 4.9 37 7.3 Physician sa t i s fac t i on 352 69.3 121 23.8 11 2.2 24 4.7 Table 4.18 'How important are the fol lowing factors in encouraging par t i c ipa t ion in research projects?" Rating by 508 general pract i t ioners Factor Very important Important Not important No reply No. % No. % No. % No. % Add in terest to pract ice 202 39. 8 248 48. 8 41 8. 1 17 3. 3 Cooperate with partners 42 8. 3 183 36. 0 221 43. 5 62 12. 2 To improve o f f i ce management 84 16. 5 209 41. 1 184 36. 2 31 6. 1 To improve patient care 235 46. 3 214 42. 1 44 8. 7 15 3. 0 Could research by general pract i t ioners be benef ic ia l for society? Sections of the general p rac t i t i one r ' s questionnaire related to th i s question considered the broader changes which might involve indiv idual pat ients , but also society as a whole. Par t i c ipa t ion in research by general pract i t ioners could have bene-f i c i a l ef fects on medical education, according to 85.0% of respondents, while 10.0% said i t would be the same, and 0.6% worse. Publ ic education could also improve, according to 72.8%, wtth 21.5% saying i t would remain the same and 1.2% worse. (Questions 5.2 and 5.3) Benefit to the health care system could be seen by 58.7%, while 32.5% thought i t would be'unchanged and 2.2% worse. The ef fect on p o l i t i c a l decisions was rated as better by 38.6%, worse by 5.1%, and the same by 47.2%. (Questions 5.12 and 5.11) Reduction in the cost of care was seen as a potent ia l benefit by 43.3% but 19.7% thought the cost would be greater, and 28.7% thought i t would remain the same. - (Question 5.1) (Table 4.19) Table 4.19 "'In.your opin ion, what ef fect might par t i c ipa t ion in research have on the fol lowing factors?" Rating by 508 general pract i t ioners Factor Better Same Worse No reply No. f No. % No. % No. % Cost of care 220 43. 3 146 28. 7 100 19. 7 42 8.3 Medical education 432 85. 0 51 10. 0 3 0. 6 22 4.3 Publ ic education 370 72. 8 109 21. 5 6 1. 2 23 4.5 Po l i t i c a l decisions 196 38. 6 240 47. 2 26 5. 1 46 9.1 The health care system 298 58. ,7 165 32. 5 11 2. 2 34 6.7 Incentives to par t i c ipate in research a c t i v i t y for the benefit of society were seen as important. To improve the health care system was rated as very important by 37.2%, important by 43.5%, and not important by 14.4%. (Questions 7.7) To provide an academic base for family practice/general pract ice was very important for 39.2%,-important for 40.9%, and not important for 15.9%. (Question 7.8) (Table 4.20) Table 4.20 "How important are the fol lowing factors in encouraging par t i c ipa t ion in research projects?" Rating by 508 general pract i t ioners FACTOR important important important reply No. % No. % No. % No. % 221 43.5 73 14.4 25 4.9 208 40.9 81 15.9 20 3.0 To improve the health g^g 37 ^ care system To provide an academic base jgg 2 for general pract ice Crosstabulations showed that the importance of research to provis ion of an academic base was rated most highly by those who had been in pract ice for the longest time. I t was considered very important by 60.0% of respondents who had been in pract ice for 26-30 years, and by 53.9% of those in pract ice for over 30 years. (Table 4.21) Among those who could be i den t i f i ed as members of the College of Family Physicians of Canada, 47.1% thought i t was very important to provide an academic base for general/family prac t i ce , compared with 39.7% of non-college members with that opinion. However, 37.9% of col lege members said i t was important, compared with 41.9% of non-members. It was not important to 15.0% of col lege members, 18.4% of non-members. 67 Table 4.21 Importance of academic base as a reason for research Rating by general pract i t ioners of time in pract ice_ Very important Important Not important Total number of G.P. 's % of No . % No. % No. % Total 1-5 years 63 41.2 61 39.9 29 18.9 153 32.5 6-10 years 41 35.3 59 50.9 16 13.8 116 24.6 11-15 years 20 35.7 23 41.1 13 23.2 56 11.9 16-20 years 34 47.2 28 38.9 10 13.9 72 15.3 21-25 years 13 36.1 16 44.4 7 19.4 36 7.6 26-30 years 15 60.0 8 32.0 2 8.0 25 5.3 31 + years 7 53.9 4 30.8 2 15.4 13 2.8 Totals No reply 193 41.0 199 42.3 79 16.8 471 37 100.0 4.3.2. Opinions about the f e a s i b i l i t y of research by general pract i t ioners were.related to the condit ions imposed by the research process, with i t s requirements for time, space, and money, as well as the a b i l i t i e s of the general p rac t i t ioner and his colleagues and s ta f f in the o f f i c e , and the cooperation of pat ients , expressed as responses to the questions to general pract i t ioners and to pat ients. Could the condit ions imposed by research a c t i v i t y be acceptable for  the general pract i t ioners? Questions were re lated to the degree of interest in research and to the factors which would make i t d i f f i c u l t for the general p rac t i t ioner to do research. Major deterrents were heavy workload and lack of time. The heavy workload was a very important factor to 59.6%, important to 31.5%, and not important to 5.5% of those returning the questionnaires, while 3.3% did not reply. Lack of time was considered very important by 58.7%, important by 30.3%, and not important by 7.7%. (Questions 6.5 and 6.10) Other deterrent factors were considered important, but less so than the two mentioned above. Inadequate t ra in ing was very important for 28.5%, important for 46.5%, and not important for 20.5%: Lack of awareness of potential was very important to 23.0%, important to 49.0%, and not important to 23.4%. Lack of in terest was considered very important by 26.8%, important by 39.4%, and not important by 28.3%. (Questions 6.7, 6.8, and 6.9) The factor rated as least important as a deterrent was "not being convinced of the value of research", which was very important to 16.5%, important to 34.6%, and not important to 42.9% of those who answered. (Question 6.11) (Table 4.22) Table 4.22 Factors considered by 508 general pract i t ioners to discourage the i r par t i c ipa t ion in research projects Rating V e r y ImDnrtant N o t N o Deterrent factors important important important reply No. °k f No. t No. % No. % Heavy workload 303 59. 6 160 31. 5 28 5.5 17 3.3 Inadequate t ra in ing 145 28. 5 236 46. 5 104 20.5 23 4.5 Lack of awareness of potential 117 23. 0 249 49. 0 119 23.4 23 4.5 Lack of in terest 136 26. 8 200 39. 4 144 28.3 28 5.5 Lack of time 298 58. 7 154 30. 3 39 7.7 17 3.3 Not convinced of i t s value 84 16. 5 176 34. 6 218 42.9 30 5.9 Of those who found that the heavy workload was a major deterrent, there was some var ia t ion among BCMA d i s t r i c t s . In no d i s t r i c t was there a strong fee l ing that the workload was not a deterrent, and in a l l but one there were more than half who stated that the workload was a very important deterrent. In a l l but two d i s t r i c t s , over 901 (. a range from 90.6% to 95.0%) of those who answered the question, rated workload as an important or very important deterrent. In those two d i s t r i c t s , the rat ings were 78.9% and 80.0%. (Appendix 13) Interest in possible research projects was shown by many of the respondents, (Appendix 14).. The most favourable responses were in the area of c l i n i c a l s tudies, in which 83.3% were interested or very interested, and in the on-going evaluation of treatment with 81.1% interested. The least interest was shown in laboratory studies (34.6%), time and motion studies (43.1%), drug studies (50.2%), and economic studies (51.4%). Between the top and bottom groups, several areas of research a c t i v i t y were indicated by over 60% of respondents as "very interested" or " interested" - evaluation of medical education (64.4%), indiv idual studies (63.6%), and epidemiological studies (61.9%). Three other research areas received less than 60% expression of interest - workload studies (56.5%), set t ing up pract ice records (55.9%), and group studies (53.3%). To test the uniformity of response among pract ices of various s i zes , crosstabulations':were done on several of the research types l i s t e d in Appendix 14. There was a r e l a t i v e l y uniform response for each type from d i f fe rent s izes of pract i ce . A typ ica l example (Table 4.23) shows the degree of in terest in workload studies. The greatest interest was expressed by physicians in smaller pract ice groups, with 64.3% in groups of 2-5 p rac t i -t ioners interested or very interested, and 61.5% in groups of 6-10. In larger pract ice groups there was less in te res t , with a low of 37.5% in groups of 11-15, and 50% in groups over 15 prac t i t i oners . The solo pract i t ioners were lowest in the "very interested" category at 13%, but second-highest in the " interested" category at 45.2%. 70 Table : 4.23 Interest in workload studies re lated to s ize of f i rac t i ce Degree of i nterest Number of G.P. 's in the Very i n f .p rps i f .pH Interested Not i n f p r o c f . PH Total % of Total pract ice No. . % No. % No. % 1 19 13.0 66 45.2 61 41.8 146 32.3 2 - 5 37 16.3 109 48.0 81 35.7 227 50.2 6 - 10 14 21.5 26 40.0 25 38.5 65 14.4 11 - 15 2 25.0 1 12.5 5 62.5 8 1.8 over 15 1 16.7 2 33.3 3 50.0 6 1.3 Total 73 16.2 204 45.1 175 38.7 452 100.0 No reply 56 Could the condit ions imposed by research a c t i v i t y be acceptable for the  Patient? The general pract i t ioners surveyed thought that demands on patients could be deterrent fac tors , discouraging par t i c ipa t ion in research. The costs in t ime, t r a v e l , and discomfort for the patient were rated as very important by 23.8%, 20.3%, and 23.6% respect ive ly , important by 43.9%, 43.9%, and 41.4% and not important by 26.6%, 29.3%, and 28.3%. (Table 4.24) Patients seemed to be less concerned about the cost fac tors , in the i r rep l ies to spec i f i c questions about wi l l ingness to cooperate in research studies. As an example of cost in t ime, 87.8% were w i l l i n g to keep a diary with de ta i l s of heal th, while 7.9% were not. At a cost in both time and t r a ve l , 88.2% were w i l l i n g to return at monthly interva ls for checkups, while 8.6% were not. At the cost of some discomfort, 89.5% were w i l l i n g to allow a blood sample to be taken, while 7.6% were not. (Table 4.25) 71 Table 4.24 "How important are the following factors in discouraging participation in research projects?" Rating by general practitioners • w e , J ImDortant . Deterrent factors important K important No. % No. % No. % No. % Cost to patient - time 121 23. .8 223 43. 9 135 26. 6 29 5. 7 Cost to patient - travel 103 20. ,3 223 43. 9 149 29. 3 33 6. 5 Cost to patient -discomfort 120 23. .6 209 41. 4 144 28. 3 35 6. 9 Ethical problems 92 18. .1 201 39. 6 189 37. 2 26 5. 1 Table 4.25 Patient response to question #8 - "Would you be wi l l ing to help your doctor to do research studies, by cooperating in important details?' .IT 4. 4. A * - i it Yes No No reply "Important details No. S 7 No. \ No. 51 0 Allowing information to be taken from your medical records, without your name 279 91. ,8 18 5. ,9 7 2. ,3 Keeping a diary about details of your health 267 87. .8 24 7. ,9 13 4. .3 Returning at monthly intervals for checkups (e .g . , blood pressure checks) 268 88. ,2 26 8. .6 10 3. .3 Allowing a blood sample to be taken for testing 272 89. .5 23 7. .6 9 3. .0 As a check on the question about w i l l ingness to al low a blood sample to be taken, patients were asked about donations of blood to the Red Cross. Compared with 272 who were w i l l i n g to have blood tests done, 88 (28.9%) had donated blood. Several others noted that there were medical contraindie cations to donation. Ethical problems were seen as very important deterrent factors by 18.1% of general p rac t i t i oners , and important factors by 39.6%, while 37.2% thought they were not important. Experience of a breach in con f i den t i a l i t y was reported by 13 physicians (2.6%), but deta i l s provided were inadequate for evaluating the de ta i l s of reports. (Question 6.4) (Table 4.26) Table 4.26 "Have you or any of your patients experienced a breach of con f i den t i a l i t y in a research project?" Response Number Percent Yes 13 2.6 No 170 33.5 No reply 325 64.0 Total 508 100.1 Informed consent was considered by general pract i t ioners to be most important for new procedures and for c l i n i c a l t r i a l s . For new diagnostic or therapeutic procedures, 84.4% thought i t was very important, 8.3% important, and 2.4% not important. For c l i n i c a l t r i a l s , 78.7% considered i t very import ant, 13.8% important, and 2.6% not important. (Questions 11.5 and 11.8) There was less concern about use of a placebo, in which 51.4% thought that informed consent was very important, 22.6% important, and 17.5% not important* (Appendix 15) (Question 11.12) General pract i t ioners were concerned also about reporting spec i f i c 73 diagnoses, with names of patients included. Informed consent was very important to 73.4%, important to 16.3%, and not important to 4.9%. (Question 11.11) There was less concern about patient questionnaires or interviews. For a quest ionnaire, consent was considered very important by 50.4% of physic ians, important by 33.7%, and not important by 11.4%. For interviews, i t was considered very important by 52.6%, important by 33.7%, and unimportant by 9.1%. (Questions 11.6 and 11.7) Providing incidence data from patients was thought to require informed consent by some general p rac t i t i oners , with 20.7% considering i t very important, 23.2% important, and 50.2% not important. The least concern was expressed about spec i f i c diagnoses, with patients anonymous, for which 14.2% thought consent was very important, 11.4% important, and 68.9% not important. (Questions 11.9 and 11.10) Patients seemed to be even less concerned about these fac tors , with 91.8% w i l l i n g and 5.9% unwi l l ing to have information provided from medical records without using names. (Table 4.25) Could the condit ions imposed by research a c t i v i t y be acceptable for  the pract ice? Even i f the condit ions for the general pract i t ioner and for his patients might-be acceptable, condit ions within the pract ice might be incompatible with any extra a c t i v i t y required by a research project. The greatest deterrents were considered to be the high o f f i ce overhead and the o f f i c e s ta f f being too busy. (Question 6.6) High overhead was thought to be very important by 49.6%, important by 33.5%, and not important by 13.0%. The o f f i ce s ta f f being too busy was rated as very important by 37.2%, important by 41.5%. and not important by 16.1%. (Question 6.12) Cooperation of partners was not important for 46.1% of physic ians, important for 28.9%, and very important for 11.2%. Lack of space in the o f f i ce 74 was not important to 39.4%, important to 34.3%, and very important to 19.7%. (Questions 6.13 and 6.15) (Table 4.27) Table 4.27 "How important are the fol lowing factors in discouraging par t i c ipat ion in research projects?' Rating by general p rac t i t ioner Deterrent factors Very important Important Not important No. % No. % No. % No reply No. % High o f f i c e overhead 252 49.6 170 33.5 66 13.0 20 3.9 Off ice s ta f f too busy 189 37.2 211 41.5 82 16.1 26 5.1 Partners not cooperative 57 11.2 147 28.9 234 46.1 70 13.8 Space inadequate 100 19.7 174 34.3 200 39.4 34 6.7 Could the condit ions for the conduct of research be s c i e n t i f i c a l l y  acceptable? Conditions considered were the t ra in ing of the general p rac t i t ioner in research methods, experience in research projects , s u i t a b i l i t y of the record system in the o f f i c e , and the need for resources to help with research. Training in research methods was reported separately for s t a t i s t i c s , epidemiology, and methodology. Few of the 508 respondents indicated that they had received much t ra in ing at any l e v e l , the highest rat ing being for epidemiology in medical school, for which 15.7? had received much, 76.6% had received some, and 5.1% had received no t r a in ing . Some had received t ra in ing in epidemiology during interneship, with 1.0% having much t r a i n i ng , 26.4% some, and 64.4% none. During residency, 1.4% had received much, 15.6% some, and 50.8% none. Apart from medical t r a i n i ng , whether before or af ter such experience, 4.5% reported much t ra in ing in epidemiology, 15.0% had some, and 39.4% none. (Questions 3.5 to 3.8) (Table 4.28) Table 4.28 Formal t ra in ing in epidemiology, according to memory of 508 respondents Place of t ra in ing Amount estimated Much . S o m e None No reply No. % No. % No. % No. % Medical school 80 15.7 389 76.5 26 5.1 13 2.6 Interneship 5 1.0 134 26.4 327 64.4 42 8.3 Residency 7 1.4 79 15.6 258 50.8 164 32.3 Other 23 4.5 76 15.0 200 39.4 209 41.1 The science of s t a t i s t i c s was taught to most medical students, with 6.1% reporting much, 66.7% some, and 24.4% no t ra in ing . During interneship, 0.8% had much, 15.9% some, and 75.8% no t ra in ing . S im i l a r l y , during residency 1.6% received much, 13.2% some, and 56.3% no t ra in ing in s t a t i s t i c s . Outside of the medical t r a i n i ng , 9.1% had received much t ra in ing in s t a t i s t i c s , 18.9% some, and 37.6% none. (Table 4.29) (Questions 3.1 to 3.4) Table 4.29 Formal t ra in ing in s t a t i s t i c s , according to memory of 508 respondents p i a c e Amount estimated ° ^ a i n i n g Much Some None No reply No. % No. % No. % No. % Medical school 31 6.1 339 66.7 124 24.4 14 2.8 Interneship 4 0.8 81 15.9 385 75.8 38 7.5 Residency 8 1.6 67 13.2 286 56.3 147 28.9 Other 46 9.1 96 18.9 191 37.6 175 34.4 76 Training in methodology received lower scores than epidemiology or s t a t i s t i c s . Much t ra in ing was received in medical school by 7.1%, some by 49.2%,"and" none by 37.4%. During interneship, 2.4% had much, 20.7% some, and 65.2% no t r a in ing . In residency, 3.7% had much, 12.2% some, and 50.4% no t ra in ing . Apart from medical t r a i n i ng , 6.7% reported much, 11.6% some, and 40.2% no t ra in ing in methodology. (Questions 3.9 to 3.12) (Table 4.30) Table 4.30 Formal t ra in ing in methodology, according to memory of 508 respondents Amount estimated Place of Much Some None No reply t ra in ing No. % No. No. % No. % Medical school 36 7.1 250 49.2 190 37.4 32 6.3 Interneship 12 2.4 105 20.7 331 65.2 60 11.8 Residency 19 3.7 62 12.2 256 50.4 171 33.7 Other 34 6.7 59 .11.6 204 40.2 211 41.5 In a l l three of these areas - epidemiology, s t a t i s t i c s , and methodology -most of thosee who had had no t ra in ing at any one level indicated some t ra in ing at another l e ve l . Those who had had no t ra in ing at any level were a much smaller number than the f igures in the tables would suggest. Combining the reports of t ra in ing at d i f fe rent l e ve l s , i t was seen that some had received no formal t ra in ing at any of the l eve l s . Not including those who had not answered the questions, there were 61 (12.0%) with no t ra in ing in s t a t i s t i c s , 12 (2.4%) with no t ra in ing in epidemiology, and 145 (28.5%) with no t ra in ing in methodology at any l e v e l . For those who had received some t ra in ing in research methods during residency, thetype of residency was l i s t ed (Table 4.31). The residency in Family Pract ice was the most frequent (8.1%), but the majority of residencies^ 77 was in other spec ia l t i es (20.6%), pa r t i cu l a r l y in medicine and surgery. Table 4.31 Residency t ra in ing reported by the 508 respondents F i r s t residency Second residency spec i f ied spec i f ied Number Percent Number Percent Family pract ice 41 8. ,1 1 0. .2 Medicine 37 7. .3 1 o. .2 Surgery 21 4. .1 9 1. ,8 Ped iat r ics 12 2. .4 1 0. ,2 Obstetr ics and gynecology 11 2. ,2 2 0. ,4 Anesthesia 7 1. .4 4 0. .8 Psychiatry 1 0. ,2 1 0. ,2 Orthopedics 0 0 3 0. .6 Other 16 3. .1 3 0. .6 Total 146 28. .7 25 4. .9 Another level of t ra in ing which was ava i lab le to general pract i t ioners in B r i t i s h Columbia was the ser ies of workshops on research methods, sponsored by the College of Family Physicians of Canada. A tota l of 66 workshops were attended by 53 of the respondents, 11 of whom had been to 2 workshops each, and one of whom had been to 3. Some experience in research projects was reported in both general and spec i f i c terms. To the general question (Q 11-a) "Have you taken part in any research projects?" , 225 (44.3%) said yes, 259 (51.0%) said no, and 24 (4.7%) did not reply. To the more spec i f i c question (Q 4) about previous studies, there had been part ic ipants in a l l studies l i s t e d , amounting to 476 involvements. Th i r t y - s i x (7.1%) had contributed to the 1965 study of the content of pract ice . 78 Twenty-three (4.5%) had responded to the ' f l u survey in 1969, for ty (7.9%) to the survey on nut r i t i on in 1974, and 129 (25.4%) to the mult ip le sc le ros i s study in 1977. Forty-eight (9.4%) reported in the inf luenza surve i l lance during 1976-78. Drug t r i a l s were included by 72 (14.2%), other group studies by 40 (7.9%), and personal studies by 88 (17.3%). (Table 4.32). Of those who mentioned personal studies, s ix were refresher courses rather than research projects. Table 4.32 Par t i c ipa t ion in previous research studies Research study Number Percent Study of content of pract ice (Postuk, 1965) 36 7.1 1 !Flu survey, 1969 (College of Family Physicians) 23 4.5 Survey on nu t r i t i on (Schwartz, 1974) 40 7.9 Influenza surve i l lance (1976-78) 48 9.4 Prevalence of mult ip le sc le ros i s (Vernier, 1977) 129 25.4 Drug t r i a l s 72 14.2 Other group studies 40 7.9 7P-SPsonal studies 88 17.3 The s u i t a b i l i t y of the o f f i ce record system was considered to be a very important deterrent factor by 19.7% of the respondents, important by 37.4%, and not important by 35.4%, (Question 6.14). The need for help (Question 10) was seen in a l l phases of planning a research project , espec ia l ly advice on planning, which was spec i f ied by 75.6%, and help in processing r e su l t s , needed by 75.8%. Advice on f e a s i b i l i t y was needed by 70.7%, f inanc ia l help and technical help both by 62.4%, and other expert consultat ion by 53.3%. The least need for help was seen for wr i t ing a report, for which 31.3% did not need 79 help and 52.6% d id . Secretar ia l help was needed by 58.5%, and not needed by 24.0%. There was r e l a t i v e l y l i t t l e need for special f a c i l i t i e s , as indicated by 19.3% of respondents. For most of the perceived needs, the source of help was not apparent, being known to only 20.5% of respondents in the category in which the sources were best known, ranging down to 5.7% in the least-known category. (Appendix 16) Among needs, f inanc ia l help was l i s t e d by 62.4% of general p rac t i t i oners , but only 12.8% knew where to get such help. The pat ients , who were asked where money for research should come from, saw the government as the major source, as indicated by 93.4%. Pr ivate foundations were chosen by 60.2%, and the publ ic by 51.3%. A minority of 15.8% thought that i t should be provided by the doctors. (Table 4.33). Table 4.33 Patient response to question #10: "For the support of research, which of the fol lowing do you think should provide money?" Source of funds Yes No No reply No. 5 I No. ? 1 No. % The government ( federa l , p rov i nc i a l , or loca l ) 284 93. .4 11 3. .6 9 3.0 Pr ivate foundations ( e . g . , Vancouver, Kel logg, or Rockefel ler Foundations) 183 60. .2 41 13. .5 80 26.3 The publ ic (through donations or bequests) 156 51, .3 57 18. .8: 91 29.9 The doctors 48 15. .8 131 43. ,1 125 41.1 Summary of questionnaire surveys (4.2 - 4.2. 1. and 4. ,2. _ 2 J . The idea of general pract i t ioners being involved in research was supported by both the general pract i t ioners and the patients surveyed. The de s i r ab i l i t y of research was seen by both general pract i t ioners and pat ients , who suggested many areas su i tab le for research. The benefits of research to the general p rac t i t i oners , pat ients , and society were considered to be incent ives, encouraging research a c t i v i t y . Important among the benef i t s , were the discovery of new knowledge and the contr ibut ion to the academic base of general pract ice . The f e a s i b i l i t y of research was explored by questions which revealed a var iety of t ra in ing and experience among general p rac t i t i oners . Co l l ec t -i v e l y , they had been involved in many research projects. They showed an awareness of the problems which might discourage research a c t i v i t y . A need was expressed for help in the conduct of s tudies, both in advice and in f inance. Patients were w i l l i n g to cooperate in studies, and f e l t that the doctors should be given f inanc ia l support, mainly by governments. CHAPTER 5 DISCUSSION 5-1• Response The population of general p rac t i t i oners , when determined from the standard mai l ing l i s t s , exceeded the actual number of physicians who were providing general pract ice service to pat ients. The f i r s t step - the e l im-inat ion of 268 names from the combined l i s t of 2,612 - represented a 10.3% error but s t i l l l e f t some who were very l i k e l y to be inappropriate. As examples, there were some physicians who had previously been in general pract ice but who were now known to be in fu l l - t ime administrat ion; some who were l i s t ed with the psych iatr ic i n s t i t u t i on s , and were l i k e l y to be providing psych iat r ic serv ices; some who were in fu l l - t ime post-graduate work. To these were added the 43 who responded with spec i f i c d e t a i l s , s tat ing that they were not in general prac t i ce , inc luding some who had never been in general pract ice . Five were returned as undel iverable. Assuming that others who were not in general pract ice did not bother to respond, the error would be even greater than the known error of (268 + 43 + 5)= 12/1%. 2612 For prac t i ca l purposes in sending out questionnaires to general p rac t i t i oners , the UBC Act ive l i s t appeared to provide the best value for the cost of mai l ing, as 482 of the 508 rep l ies used (94.9%) were in th i s l i s t . However, such a l im i ta t i on in th i s study would have el iminated one teacher of family medicine and several formerly act ive general p rac t i t i oners , respondents who were included in the UBC Inactive l i s t . The inaccuracies in the mai l ing l i s t s might be mainly of academic in te res t , except for the probab i l i ty that the UBC l i s t s would be used to provide data on manpower, and to af fect po l icy which might l im i t placement of new physic ians. Using the UBC Act ive l i s t only, - 81 -25 were excluded before the mail ing and 25 were excluded because of the i r responses. This error of 2.3% (50/2180) was a minimum, and could have been much greater in fac t . The opportunity to remain anonymous was taken by 48 of the respondents, providing 9.4% of the rep l ies analyzed. Apart from the answers to the questions, most of the demographic data were avai lab le from these r ep l i e s , par t ly from area codes on return envelopes, and part ly from some on which the doctor 's name was stamped on the envelope. The combination of postmark, year and school of graduation, and the UBC reg is ter could often be used to ident i fy an i nd i v i dua l . I t seems that anonymity i s hard to achieve, and care m Let be taken to preserve i t when requested. For the purposes of th is study, the main problems ar i s ing from the large mail ing l i s t were the cost ( in time and money) of sending quest ionnaires, and the s l i g h t l y lower response rates based on the higher numbers in the denomin-ators. The overal l response of 24% was good for a survey o f th i s type where i t was ant ic ipated that the level o f in terest would be r e l a t i v e l y low and where the time required to complete the questionnaire was r e l a t i v e l y long. The response came from a representative group, considering locat ion and type o f p rac t i ce , year and school o f graduation, and pract ice experience. The best response was from members of the College of Family Physicians o f Canada, who provided at least 32.5% o f the response, representing 39% of the member-ship o f the B r i t i s h Columbia Chapter o f the Col lege. This good response might have ref lected greater in terest on the part o f col lege members, or greater commitment to contribute to studies of th i s type. I t might also have been because the questionnaires were mailed from and returned to the col lege o f f i c e in Vancouver, or because the invest igator had been an act ive col lege member in the previous two decades. In choosing the sample of patients to survey, the computer provided a 5% random sample of physicians from the 506 responses ava i lab le at that time. Although 22 names were se lected, 2 were rejected because they were anonymous. From the remaining 20, and replacements, the resu l t ing 75% response rate was considered to be good, and to provide a f a i r representation of the views of pat ients. In retrospect, i t would have been better to f ind replacements for the 2 anonymous responses, rather than to re ject them. Those who agreed to the d i rec t request for help in the survey of patients provided a good example of the potent ia l of general p rac t i t i oners , and the i r wi l l ingness to cooperate without any tangible reward. This level of cooperation, in a small study, i s 34 s imi la r to that found in larger group studies, such as those by Postuk v , 83 Garson , and the Influenza Survei l lance Working Party of the College of 40 Family Physicians of Canada . However, acceptance would rare ly be automatic but would depend on relevance of the request to the general p rac t i t i one r ' s perception of needs, and on the p r a c t i c a l i t y of the study within the o f f i ce se t t ing . Cooperation by those who agreed' to submit the questionnaire to patients was general ly good. Comments which accompanied the returns indicated interest and support, except for one general p rac t i t ioner who found that the patients were not cooperative. The high response rate in a l l other pract ices suggested that att i tudes of the o f f i ce personnel could be responsible for acceptance by pat ients. The response might have been improved i f there had been a personal contact, such as by telephone or v i s i t , but th i s was impract ica l . The next best a l ternat ive was to make the mail presentation as appealing as poss ib le, and the imposition on the phys ic ian 's time with in reasonable l im i t s . In the f i ve pract ices where the tota l number of patients seen in the day was not reported, the average number of questionnaires returned (25.4%) was well above the average number in the other ten pract ices (17.6%), so that i t i s l i k e l y that the response was nearly complete. 84 5.2. Character i s t i cs of the Respondents The responding group of general pract i t ioners would be biased, because the f i r s t requirement of the survey was for the respondent to have enough interest in research to complete the questionnaire. However, th i s biased sample did represent a f u l l spectrum of the range in a l l charac ter i s t i cs which were recorded. Age groups corresponded well with the year of grad-uation from medical school, and a wide var iety of medical schools was represented. Length of time in pract i ce , as well as in the same prac t i ce , covered the f u l l range of pract ice experience. Size of pract ice also var ied, and there were respondents from mul t i - spec ia l ty groups as well as from solo pract ice and from general p rac t i t ioner groups of various s i zes . There was a r e l a t i v e l y large response from members of the College of Family Physicians of Canada, who might reasonably be expected to have more interest in research than non-members would have. Although the resu l ts do not necessar i ly represent the views of a l l general pract i t ioners in B r i t i s h Columbia, they do indicate substant ia l support for research from a wide var iety of general p rac t i t i oners . The pat ients , although selected by random methods, would also be a biased group because of the i r se lect ion from the group of general p r a c t i -t ioners who responded. However, a l l adult age groups were represented, and a var iety of locat ions , from metropolitan Vancouver to small rural d i s t r i c t s . The female/male ra t io of the respondents was greater than the 3/2 ra t io which i s often seen in studies of o f f i c e pract ice. A large number of patients indicated that they regarded the general pract i t ioners as the i r regular doctors. This suggested that pract ices were r e l a t i v e l y stable and that patients were w i l l i n g to cooperate with the i r own doctors when asked. The sample of pat ients was probably smaller than would be i d ea l , but the responses to most questions provided a convincing weight of opinion. 85 5.3. Responses to Questions in the Survey Most questions were answered by over 90% of the respondents. Most of the exceptions were related to t ra in ing for research, suggestions for top ics , and the need for resources. 5.3.1. Opinions about the de s i r ab i l i t y of research a c t i v i t y by general p rac t i t i oners . Could research by general pract i t ioners be benef ic ia l for knowledge? In response to the general questions about research by general p r a c t i -t ioners being benef ic ia l for knowledge, there was an almost unanimous agree-ment by general pract i t ioners that i t could provide new knowledge which would not otherwise by ava i l ab le , and that th i s po s s i b i l i t y gave incentive to take part in projects. Patients surveyed expressed a supporting opinion by 93% that general pract i t ioners should be involved in research re lated to the i r work. While the f i r s t step of the B r i t i s h Columbia Chapter of the College of Family Physic ians, in 1957, had been simply to develop a research committee 11 without any c lear d i rec t ion , th i s survey of general pract i t ioners in 1978 produced a large number of suggested areas of research, some of which were spec i f i c . As incent ive, most of the respondents rated cur ios i t y highly and equal to contr ibut ion to knowledge. Responses to the questions re lated to new knowledge corresponded well with ideas expressed in the survey of l i t e r a t u r e , and indicated agreement in p r inc ip le to the involvement of general p rac t i t i oners . Support from some general pract i t ioners was not surpr i s ing , and many more could be added to the 10 9 17 examples of Crombie and Pinsent , P ick les , and Livingston . However, the 12 need for information from general pract ice was seen also by an economist , 13 14 a ped iat r i c ian , and a journal ed i tor , each of whom added weight to the 25 opinions of the general p rac t i t i oners , and a soc io log i s t , Warner , in his survey of general pract i t ioners in Vancouver, B r i t i s h Columbia. The f i r s t question, asking whether research in general pract ice could provide new knowledge might be regarded as a motherhood question. However, i t was important to estab l i sh the agreement on th i s basic point. The number of topics or areas suggested for study required some thought about p r i o r i t i e s . Some of the rep l ies were general but many others were spec i f i c and suggested that there had been some previous thought or a c t i v i t y . There were s ign i f i can t differences between patients and doctors in the i r p r i o r i t i e s for research, as well as some agreement. Both groups assigned high p r i o r i t y to topics re lated to nu t r i t i on , nervous and mental disease, and preventive medicine. Patients gave top p r i o r i t y to cancer and heart disease. Cancer was well down the l i s t for general p rac t i t i oners , but heart disease was quite high and adding hyper-tension would make i t the top choice. Hypertension, received only 1 vote from pat ients , compared with 36 from physic ians, and was the best example of divergent views. Other areas in which general pract i t ioner p r i o r i t i e s were not shared by patients included infect ious diseases, obes i ty, compliance, economics, hypnosis, epidemiology, sports in ju r ies and a lcoho l . Some areas in which the pat ients ' suggestions were r e l a t i v e l y more numerous were cancer (by 2:1), nu t r i t i on , adverse ef fects of drugs, doctor-patient a t t i tudes , a r t h r i t i s , and qua l i ty of care. Their in teres t in nu t r i t i on i s in contrast to the i r lack of in terest in obesity. However, the p r i o r i t i e s l i s t ed might serve as a guide to predict ing patient cooperation in future studies, as well as a guide to potential involvement of general p rac t i t i oners . Could research by general pract i t ioners be benef ic ia l for the pract ice? Compared with the large majority opinion that research could be bene-f i c i a l for new knowledge, there was less unanimity in response to questions about benefit to the pract ice . A smaller majority of about two-thirds of the general pract i t ioners thought that there would be improvements in patient care, patient records, and o f f i ce records, while very few thought that factors would be worse. Such improvements might contribute to the expected improve-ment in physician satisfaction (69%) and to a smaller improvement in patient satisfaction (41%), although the difference in these ratings suggests that improvements would likely be more apparent to the physicians than to the patients. Patient care was expected to improve by 68% of general practitioners, but 88% s t i l l felt that the possibility of such improvement provided important or very important incentive for research. A similar number recognized the incentive to add interest to the practice, which may contribute to the expect-ed improvement in physician satisfaction. These findings correspond with the experience of general practitioners who have done research in their own practices, as learned from personal contact or from reports in the literature. 3 2-2 Garson and Collyer described improvement in the provision of care, and 18 19 Zl" opinions were expressed by authorities such as Mackenzie ~, Eimerl' -, Wood-'-', 2Q-and the World Health Organization that practice would be improved by inter-est and activity in studying the content and methods of providing care. However, there may be too l i t t l e appreciation of the possibility of patient care becoming worse, as suggested by only 6 (1.2%) of the respondents. It is too easy to get immersed in the interest and the demands of a research project so that the time and attention needed for patient care might be affected. This risk is especially high in general practice, where there is seldom any provision in the payment system or adjustment of workload to provide the time needed for research. The possible effect on leisure time was recognized by 63% of respondents, who felt that this would be adversely affected. The effect on working time was also recognized by half of the respondents, who expected that income would drop i f research activity were undertaken. Feelings were equally divided about the question of doing research in 88 order to cooperate with partners. These fee l ings are borne out by pract ice experiences, in which partners or colleagues might par t i c ipate in research in order to be he lp fu l , but the demands must be within reason and not unduly prolonged. Such cooperation would be reinforced by resul ts that are seen to be of benef it to the pract ice in any of the ways mentioned. Could research by general pract i t ioners be benef ic ia l for society? Potent ia l benefit to society could be seen by most respondents in a l l of the areas included in the questionnaires. The greatest ef fect could be on medical education, with publ ic education a close second. These ant ic ipated ef fects were l i k e l y a major influence on the high rat ing given to the incentive of providing an academic base for general pract ice. The need for an academic base was appreciated most by those longest in prac t i ce , presumably having had more time in which to become aware of the p o s s i b i l i t i e s of producing new knowledge. This awareness does not necessar i ly guarantee cooperation in research studies, because of the d i f f i c u l t y in adding new requirements to wel l -establ ished rout ines. However', the recognit ion of the need was equal for members and non-members of the College of Family Physicians of Canada, so that the pleas by L i v i ngs ton 1 7 and S tua r t -Ha r r i s 1 6 for involvement of practice-based general pract i t ioners could f a l l on receptive ears in future. There was r e l a t i v e l y l i t t l e optimism about the impact of general pract ice research on p o l i t i c a l dec is ions, with less than 40% thinking that there would be any benef i t . Even th i s low degree of optimism about the reaction of the p o l i t i c a l system suggests that some improvement in decisions might be seen, and perhaps another question should have been asked - "Should general p rac t i t ioner research be encouraged and used as a basis for decisions on po l icy af fect ing primary care?" There was a s im i la r minority opinion that the cost of providing care would be reduced by the appl icat ion of research resu l ts from general pract ice. I t would seem log i ca l to expect some improvement in costs , i f the topics of nu t r i t i on , preventive medicine, and health education were to receive more support in studies, as suggested by both patients and doctors. These areas of study could provide better knowledge of ways to maintain good heal th, so that there would be less need for treatment of i l l n e s s e i ther in or out of hosp i ta l . The impl icat ion for health care planning i s that is would be wise to provide more resources for prevention of i l l n e s s , including research, in order to decrease the demand on services for treatment. These 27 ideas would support Do l l ' s emphasis on control of world population growth. More optimism was shown for the po s s i b i l i t y of improvements in the health care system, with almost 60% of general pract i t ioners expecting that improvements would resu l t from par t i c ipa t ion in research, and 80% rat ing th is as an important incentive for doing research. These views support those of 27 31 Doll , who advocated research on the provis ion of medical care, Robertson , who law the general p rac t i t i one r ' s ro le in evaluation of health care to socie-76 ty , and Rice , who stated that socia l factors a f fect ing health care should be examined c r i t i c a l l y . Robertson pointed out the d i f f i c u l t i e s of measure-ment, which could be the greatest problem in producing credib le resu l ts in many of the areas needing study. Planning for the optimum use of health care resources and for sett ing p r i o r i t i e s in new developments would be great ly improved i f i t was based at least par t ly on information from research by general p rac t i t i oners , who provide approximately half of the medical services to soc iety. 5.3.2. Opinions about the f e a s i b i l i t y of research by general p rac t i t i oners . Could conditions imposed on the general p rac t i t ioner by research a c t i v i t y  be acceptable to the general pract i t ioner? As reported in the l i t e r a t u r e , some general p rac t i t i oners , even in Canada, have been able to complete projects in sp i te of the demands of pract ice . The small number of reports in the Canadain l i t e r a tu re from 1950 17 to 1970, as noted by Livingston , could have been far below the number pub-l i shed , because Index Medicus did not include Canadian Family Physicians in i t s l i s t of publ icat ions. However, during that time even the Canadian Family Physician did not have many studies by general pract i t ioners to publ ish. Since 1970 there has been an increase in research a c t i v i t y by general p rac t i t i oners , but the Medlars search from 1972 to 1978 revealed only three studies published in Canadian journa ls , compared with f i ve l i s t e d in 9 months of 1977 in "New Reading for General Pract i t ioners" (Appendix I ) . The fact remains that some indiv idual general pract i t ioners have found the interest and the time to undertake projects and to publ ish the resu l t s . Of the respondents to the questionnaire, 88 stated that they had p a r t i c i -pated in personal s tudies, but no de ta i l s about resul ts or publ icat ion were requested. Many more had been involved in group studies or surveys. Postuk's morbidity recording was mentioned by 36 respondents, who would represent 2/3 of his recording group of 54 in 1965. I f the i r rep l ies are cor rect , i t would seem that the i r experience in the survey had stimulated a las t ing i n t -erest , to give a high response rate in th i s survey. A s im i la r stimulus might have resulted from some of the other studies in which they had been involved. None of these has appeared to be so demanding as the continuous morbidity 41 42 44 recording in B r i t a in , Holland , and Aust ra l ia , but some of the respondents have used the diagnostic index in the i r own pract ices without having the benefit of a central processing serv ice. Major deterrents to research, heavy workload and lack of time, were not important to only a few of the respondents. This f ind ing corresponds well with experience in pract i ce , where these two factors were most often given as reasons for not gett ing involved in research. These reasons, to some 91 extent, might be a soc ia l ly-acceptable response to which there can be l i t t l e comeback, in contrast to other reasons (inadequate t r a i n i ng , lack of in te res t , or lack of awareness of potent ia l ) which might be revers ib le by education. The hal f of the respondents who were not convinced of the value of research by general pract i t ioners might also change the i r minds some day, as more resul ts from studies are seen to be relevant to the i r needs. The fact that 43% apparently were convinced of the value of research, or at least accepted the p o s s i b i l i t y , suggests that many of them might become more act ive i f the other deterrent factors were reduced. The topics selected most often by the responding general pract i t ioners were c l i n i c a l , applying to d i rec t pat ient care. These f indings correlated well with the.topics volunteered as sui table for study, as l i s t e d in Appendix 12. There was r e l a t i v e l y less in terest in economic studies although over half the respondents did express an in te res t . Even greater interest might have been expected, because of the preva i l ing controls by the prov inc ia l govern-ment on fee increases, and the consequent pressure to work longer and harder. The high interest level in c l i n i c a l studies suggested that well-planned group studies related to common problems might be wel l - rece ived. This was the case with Hebb , in involv ing hal f the general pract i t ioners in Nova Scot ia , where per inatal morbidity was a frequent concern of most p r a c t i -t ioners in the province. The po s s i b i l i t y of gett ing some enjoyment out of research might encourage more pa r t i c i pa t i on , perhaps by regarding research as a hobby. One incent ive, not l i s t e d in the quest ionnaire, could be the opportunity to use a computer for analysis of personal studies. Where access to a un ivers i ty 49 computer is ava i l ab le , the SPSS methods could be used. Otherwise, min i -computers for personal use are becoming ava i lab le at prices with in reach, and 92 they could soon become standard o f f i ce equipment. Could condit ions imposed on the patient by research a c t i v i t y be acceptable  to the patient and the general pract i t ioner? Although the general pract i t ioners had great concern about time, t r a ve l , and discomfort as deterrents to patient pa r t i c i pa t i on , the patients were almost a l l w i l l i n g to cooperate in studies. This f ind ing coincides with experience in pract i ce , where patients tend to be cooperative when the need for a study i s explained to them. I t would be less cred ib le i f the pat ient questionnaires had not been con f i den t i a l , as patients might have provided answers which they thought the i r doctors wanted. The issue of con f i den t i a l i t y 51 52 as i den t i f i ed by Donovan and Crombie was important to most general p r a c t i -t ioners , who would not ident i fy a patient in studies without obtaining consent. It seems that con f i den t i a l i t y i s usual ly preserved, as there were only 13 reports by general pract i t ioners of a breach in con f i den t i a l i t y . Of those giv ing de t a i l s , ha l f were not about patients but were about surveys by medical associat ions or the un ivers i ty . Informed consent was considered very important by the general p r a c t i -t ioners when patients would be subjected to the r i sks of new drugs and new procedures, and when patients could be i den t i f i ed . These views supported the pr inc ip les expressed in the Declaration of Hels inki (Appendix 2). When patients were anonymous, there was very l i t t l e concern by pat ients , but a surpr is ing number of general pract i t ioners thought that informed consent would be necessary. This degree of caution might be a resu l t of experience in prac t i ce , where "anonymous" reports can provide enough deta i l s to provide pos i t ive i den t i f i c a t i on of an i nd i v i dua l , espec ia l ly in a small community. Even in th i s study, some of the general pract i t ioners who had removed the ident i fy ing numbers from the i r questionnaires could be i den t i f i ed by the i r responses. The general pract i t ioners seemed to appreciate the d i f fe rent needs of research, compared with pract i ce , in the use of a placebo. A majority thoughtthat informed consent would be needed i f a placebo might be used in a study. In prac t i ce , informing the patient about a placebo would probably n u l l i f y i t s e f fec t . Although no questions were asked about experiences with the computer, 52 the warning raised by Crombie must be heeded. The tremendous amount of information about patients which is being fed into government computers provides great opportunit ies for misuse. This po s s i b i l i t y could inf luence the cautious physician to reduce the reporting of diagnoses to the minimum level needed to j u s t i f y payment in the Medicare system. Data supplied for b i l l i n g purposes is not l i k e l y to be adequate for epidemiological or c l i n i c a l studies. Responses from patients gave l i t t l e ind icat ion that they had many worries about involvement in research, and i t seemed that they accepted the need for i t . Could the condit ions imposed on the pract ice by research a c t i v i t y be  acceptable according to the general pract i t ioner? Space did not seem to be a major problem for most general p rac t i t i oners , 54 55 jus t as Watson and Hope-Simpson . managed to f ind the space needed to carry out the i r projects. Cost was much more important, with high overhead in the o f f i c e being given as the major deterrent. There seemed to be a need for more awareness of the prospect of having the government contribute to projects by income tax deduction for the o f f i ce costs . Cooperation of partners seemed to be a reasonable expectat ion, but a much greater problem was the o f f i ce s ta f f being too busy. Part of the problem with the o f f i ce s t a f f , perhaps more important but not stated, might be a reluctance to add a research project to the fami l i a r rout ines, possibly to the d e t r i -ment of patient care. Recording methods in use in the pract ice were considered to be inadequate by over ha l f the general pract i t ioners responding. There were s t i l l over one th i rd who f e l t that the system was adequate. However, the many examples c i ted in the l i t e r a tu re review indicated that special methods would general ly be developed as needed for planned studies or continuing recording systems. The diagnostic i ndex 5 9 has been used by ind iv iduals who wanted to know more deta i l s about the i r pract i ces , as well as by some who kept track in order to contribute to group studies. One aspect of diagnostic recording which i s not usual ly mentioned i s the d i s c i p l i ne accepted by the physician to a r r i ve at a decis ion on the diagnosis for each pat ient , based on the best knowledge avai lab le at the time of entry. fi7 The age-sex reg is ter , or pract ice reg i s te r , has made i t possible to ca lcu late rates of incidence and prevalence, al lowing comparison among pract ices . As a basic tool for taking stock, i t has been used also for pract ice management. A f a i r l y small number (14%) of respondents were "very interested" in sett ing up o f f i ce records for research pa r t i c i pa t i on , but even th i s number could provide a large nucleus of interest from which to develop a working group. Could the condit ions for the conduct of research be s c i e n t i f i c a l l y  acceptable? Training for research did not appear to be a high p r i o r i t y at any l e v e l , but at the medical school over 90% of respondents had received much or some t ra in ing in epidemiology, three-quarters had received t ra in ing in s t a t i s t i c s , and jus t over hal f in methodology. Methodology had the highest number (28%) with no t ra in ing at any l e v e l . Looking on the pos i t ive s ide , a large majority of respondents had had some t ra in ing in research methods, although 95 the extent of t ra in ing could not be assessed and could be inadequate for anyone undertaking research. Over 10% had taken advantage of addit ional t ra in ing in workshops sponsored by the College of Family Physicians of Canada, directed spec i f i c a l l y to the needs and condit ions of general pract ice . 72 The basic requirements for research, as described by White , have been accepted well by the general pract ice organizations with a major interest in research, and have been dominant factors in researclr'workshops and in committee a c t i v i t i e s . The c l a s s i f i c a t i on of health problems in primary care and the developments of r e a l i s t i c denominators have been the f i r s t major p r i o r i t i e s , with the de f in i t i on of terms gaining prominence af ter the c l a s s i f -i cat ion was we l l -es tab l i shed. The survey d id not ask opinions about these fac tors , but did f ind that a majority (57%) considered that the o f f i c e record system was inadequate for research. The 35% who did not consider the o f f i ce record system a deterrent could provide a good nucleus for s tud ies , although some changes in the records would l i k e l y be necessary. I t would have been appropriate to ask in the survey whether there was a diagnostic index or age-sex reg is ter in the prac t i ce , and what use was made of them, but the response would l i k e l y have been low, and there was a need to l im i t the number of questions. Perhaps some future studies w i l l f ind more such registers than were expected. Support for those general pract i t ioners w i l l i n g to do research,.,ass advocated by the agencies c i ted in the l i t e r a t u r e , was seen as a need by most of the respondents. The general pract i t ioners saw the greatest need for help was in the de ta i l s of planning and ana lys i s , but also a great need for secretar ia l and technical ass istance, which was about equal to the need for f inanc ia l ass istance. The least need was for special f a c i l i t i e s . These perceptions r e f l e c t the s i tuat ion which i s often seen, and which is the opposite of the need. Funds can often be obtained more read i ly for special equipment than for the personnel to operate i t . There seems to be a desire on the part of donors, whether pr ivate or government, to see tangible evidence of a grant. However, the greatest need in pract ice i s often for the time and a b i l i t y of an ass is tant who can do much of the deta i led work. For smaller projects , general pract i t ioners have often prevai led on family members to help, but there are l im i t s to the i r capacity. The respondents f e l t most confident (31%) about wr i t ing reports, but over hal f thought that help would be needed, perhaps re f l ec t ing the lack of experience in research projects during the i r medical t r a i n ing . For a l l of the perceived needs for help, few of the general p rac t i t ioner respondents knew where to turn , with one- f i f th or fewer ind icat ing that they knew where help was ava i lab le . The patients had a c lear major i ty , almost unanimous, ind icat ing that f inanc ia l help should come from governments at a l l l eve l s . Many (60%) would also expect the pr ivate foundations to provide funds for general pract ice research, and hal f thought the publ ic should provide funds. Only a few (16%) thought that the doctors should finance the i r own research. This reaction from pat ients , who are also voters and taxpayers, should encourage the government to increase i t s a l l oca t ion for research, as 105 was recommended by the Task Force in 1970 . I r on i ca l l y , that recommend-ation was followed by a decl ine in the money ava i lab le for research during the 70's . In spi te of the d i f f i c u l t i e s of obtaining funds, there has been substan-t i a l support, as noted in the l i t e r a t u r e , for many projects. I t seems l i k e l y that more would have been supported i f general pract i t ioners had received more t ra in ing in the basic research methods which are important in planning projects and grant app l i cat ions , and i f general p rac t i t i oners , as a group, had establ ished a broad base of c r e d i b i l i t y . Another important factor has been the emphasis on basic research, maintained by many agencies, whereas 97 most general pract i t ioners are concerned with research applied to needs seen in the pract ice . The surveys of B r i t i s h Columbia general pract i t ioners and the i r patients have indicated interest and a c t i v i t y in research, in sp i te of the problems i den t i f i ed . The f e a s i b i l i t y of research could be considered as proven by the projects which have been done. The qua l i ty of the work may be subject to debate, but i t can be expected to improve with increasing support for t ra in ing and for development of basic methods. The spec ia l i zed base of l i t e r a tu re 91 avai lab le from the Canadian Library of Family Medicine and the Family 92 Medicine L i terature Index are national projects of benefit to those in B r i t i s h Columbia. Other a c t i v i t i e s sponsored by the College of Family Phys-99 i c ians of Canada in B r i t i s h Columbia include the research t ra in ing workshops , formation of a Family Pract ice Research Unit based at the Univers i ty of B r i t i s h Columbia, and co l laborat ion with the federal government in a Health Care Evaluation Seminar at V i c to r i a . -The combination of t ra in ing opportunit ies for general p rac t i t i oners , development of a l i t e r a tu re base, formation of the Family Pract ice Research Unit , and the wi l l ingness of general pract i t ioners to contr ibute to group studies in the past, a l l indicate a cl imate of increasing acceptance of the challenge for general pract ice to develop a research base founded on s c i e n t i f i c methods. 98 CHAPTER 6 RECOMMENDATIONS The review of some of the l i t e r a t u r e related to general practice research, preparation of questionnaires, and the responses to the surveys.; have combined with ideas collected from contacts with a variety of research., workers and from attempts to do research while in practice. Many of the impressions and facts learned in practice have been reinforced by the l i t e r a t u r e and by the surveys. Some of the findings have implications for health care planning, both in the d i s t r i b u t i o n and i d e n t i f i c a t i o n of general practitioners, and in the delivery of medical care. The following recommendations include some which arise l o g i c a l l y from this study, and some which may be seen as needs which were not dealt with adequately. 1. Mailing l i s t s vs manpower s t a t i s t i c s The many sources of error in the mailing l i s t s , especially that of BCMA, can create false impressions about the number of general practitioners available to provide care to the public. With so much attention being paid to medical manpower, d i s t r i b u t i o n of doctors and access to medical care, i t becomes more important to identify the numbers and functions of doctors more cl e a r l y . Arbitrary patient/doctor ratios should be adjusted to allow for the age-sex d i s t r i b u t i o n of the patients, the pattern of morbidity, and the need for more doctors and f a c i l i t i e s in refer r a l centres. 2. The effect of research on the practice Assistance should be given to general practitioners who would maintain an age-sex register of patients and who would undertake the recording of their problems by use of a standardized recording system, such as the Diagnostic Index. Assistance could be in the form of small grants to help in the cost o 99 of equipment and recording or in the provis ion of a central f a c i l i t y for processing data, which could be coordinated through the Family Pract ice Research Unit , loeated'at the Univers i ty of B r i t i s h Columbia. Benefit would accrue to the pract i ce , through more complete information about patients and the i r problems, and to the body of knowledge about general pract ice in ' B r i t i s h Columbia. 3. Benefit of research to society in planning for health care Leg is la t ion or po l icy changes which w i l l a f fect the provis ion of care in general pract ice should be enacted only a f ter appropriate research into the need for change, and should provide for evaluation of resul ts a f ter changes are made. Planning of f a c i l i t i e s or services which are intended to provide better health care should include input from the providers and the rec ip ients of care. While the opinions of representatives of each group might be adequate for many questions, some would be better answered by properly-designed and conducted studies. 4. Conditions for general pract i t ioners undertaking research The major deterrents, heavy workload and lack of t ime, could be re l ieved by provis ion for payment for the time of researchers in pr ivate general pract ice . This would be espec ia l ly important in the case of the pr inc ipa l invest igator , who is expected by granting agencies to be paid by an i n s t i -tut ion for his t ime, so that the physician in fu l l - t ime pract ice w i l l usual ly f ind i t d i f f i c u l t to be a pr inc ipa l invest igator . 5. Training for research Research methods should be taught thoroughly as one of the subject areas in medical schools, and the po s s i b i l i t y of requir ing a small research project should be considered. Postgraduate t ra in ing in research methods should be ava i lab le 6n a continuing bas is , whether as spec i f i c courses or as part of the s c i e n t i f i c meetings of medical organizat ions. Family pract ice residency 100 programs should include research a c t i v i t y , at least as an e lec t ive but preferably as a requirement. 6. Travel ! ing scholars Encouragement should be given to general pract i t ioners to take courses or sabbaticals to obtain more exposure to research in centres which of fer t ra in ing opportuni t ies. The present support mechanisms through some granting agencies might be ava i lab le to help, but the leve ls of support are often too low for a pr ivate p rac t i t i oner , whether general p rac t i t ioner or s pe c i a l i s t , whose income stops when he does. Special consideration should be given for longer absences. One important benefit now ava i lab le i s the B r i t i s h Columbia Education Fund, but the benefits can accumulate for only three years. There should be a capab i l i t y of accumulating funds for a much longer time, even i nde f i n i t e l y , for the purpose of taking part in a wel l-organized and recog-nized t ra in ing program, meeting a reasonable set of c r i t e r i a . Such t ra in ing would not always involve t r a ve l l i n g , as the f a c i l i t i e s in the Department of Health Care and Epidemiology at the Univers i ty of B r i t i s h Columbia could provide courses accessible to general pract i t ioners in the lower mainland area, e i ther on a part-time or fu l l - t ime bas is . Travel should also be supported for bringing outside experts to B r i t i s h Columbia to provide advice and st imulat ion for general pract i t ioners with an interest in research. Funds now ava i l ab le , such as in the Vancouver Foundation or the B r i t i s h Columbia Medical Research Fund, could be used for th i s purpose i f the p r i o r i t i e s are properly determined. 7. Topics for research While general pract i t ioners should be encouraged to study any researchable question which arouses the i r cu r i o s i t y , special incentives should be found for studies in the areas which have been mentioned most by the respondents, both patients and doctors, as being in need of study. These included heart disease, 101 nu t r i t i o n , nervous and mental disease, and preventive medicine. Special concerns of pat ients , such as cancer, should also have p r i o r i t y , as well as the doctors' concerns about the resu l ts of various kinds of treatment and about the de l ivery of health care. The main emphasis in studies should be on the natural h istery of diseases, espec ia l ly the ear ly course and the epidemiology. 8. increasing the awareness of research in general pract ice To counteract the deterrent factors i den t i f i ed as important - lack of awareness of po ten t i a l , lack of in te res t , and not being convinced of the value of research - there should be greater opportunity and encouragement for general pract i t ioners to present resu l ts of the i r studies at s c i e n t i f i c sessions of medical organizat ions, including the spec ia l ty sect ions. 9. Development of resources to help general pract i t ioners in research  a c t i v i t i e s There was a surpr is ing lack of awareness among the general pract i t ioners about the resources ava i lab le to help in the development of research projects. Communication should be improved between the resource centres, mainly the univ-e r s i t i e s , and general pract i t ioners in the community, who may be represented well by the College of Family Physicians with i t s research committee and the Family Pract ice Research Unit . Representation on committees would be some help in increasing the awareness of resources, but co l laborat ion on research projects and the Jo int presentation of resu l ts would be the best demonstration of the help ava i lab le . The experts in the univers i ty must be able to accept the po s s i b i l i t y of a pr ivate general p rac t i t ioner having inadequate t ra in ing in research methods and perhaps an impatience to get quick resu l t s . The general p rac t i t ioner must learn the need for s c i e n t i f i c r igor in studies, and also the need for those in the un ivers i ty to receive sui table acknowledgement of the i r help, whether through consultant fees or in published reports. 1(32 10. Financing As part of the t ra in ing process, general pract i t ioners should be given some advice on preparing of appl icat ions for grants, and on the references ava i lab le about granting agencies. Appl icat ions from general pract i t ioners would have a better chance of being assessed f a i r l y i f the advisory committees which judge the projects had at least one member with experience of research in general pract ice . To provide more money for research, the federal government should pay heed to the recommendations of i t s Task Force in 1970 - to increase the amount of money ava i lab le for medical care research. 11. Further studies I t would be of in terest to conduct a review of a l l research publ icat ions by general pract i t ioners in B r i t i s h Columbia. This present study has referred to a number of projects , but many other good projects have not been mentioned, and a l l of these might serve as good examples of the potent ia l fo r research by general p rac t i t i oners . 12. Research methods in general pract ice It has become apparent that there i s a need for a guide to (or manual of) research methods appropriate for a Canadian general pract ice . Such a guide might properly have been included in th i s thes i s , except for the length and complexity of i t s preparation. I t might be a su i tab le task for the College of Family Physicians of Canada or i t s research committee. 13. Development of pol icy Current pol icy of most granting agencies i s to provide funds only for projects. There is a need to support the development of f a c i l i t i e s and personnel, as resources ava i lab le to general pract i t ioners in pr ivate pract i ce , for provis ion and coordination of consultat ion and processing. 103 CONCLUSION Th i s study was conducted to exp lo re the i s sues o f d e s i r a b i l i t y and f e a s i b i l i t y o f research by general p r a c t i t i o n e r s i n B r i t i s h Columbia. De s i r -a b i l i t y was de f ined in terms of bene f i t s f o r knowledge, f o r the medical p r a c t i c e , and f o r s o c i e t y a t l a r g e . F e a s i b i l i t y was de f ined i n terms o f being acceptab le f o r the general p r a c t i t i o n e r s , f o r the p a t i e n t , f o r the p r a c t i c e , and f o r the requirements o f r e sea r ch . Review of the l i t e r a t u r e prov ided many examples o f research by general p r a c t i t i o n e r s i n va r ious c o u n t r i e s , but r e l a t i v e l y few from B r i t i s h Columbia. There seemed to be no doubt of the d e s i r a b i l i t y and f e a s i b i l i t y o f general p r a c t i c e r e sea r ch , judg ing from the works done, but there was doubt about the degree o f acceptance o f research as an a c t i v i t y by the genera l p r a c t i -t i o ne r s of B r i t i s h Columbia. Surveys were done by que s t i onna i r e s , to general p r a c t i t i o n e r s and to p a t i e n t s , to determine t h e i r a t t i t u d e s towards research by general p r a c t i -t i o n e r s . A good response was obta ined from both su rveys , and both revea led a s t rong support f o r the concept of research as a d e s i r a b l e and approp r i a te a c t i v i t y . Many suggest ions were made about s p e c i f i c areas i n which research was needed. As we l l as the po t en t i a l b ene f i t s i n new knowledge, o ther bene f i t s were seen i n improvements i n the p r a c t i c e and i n p a t i e n t c a r e , improved medical and pub l i c educa t i on , and improvements i n the hea l th care system. There was l e s s opt imism tha t research by genera l p r a c t i t i o n e r s would have much i n f l u ence on p o l i t i c a l d e c i s i o n s . There was agreement among most general p r a c t i t i o n e r s on the need f o r research to prov ide an academic base f o r general p r a c t i c e . The f e a s i b i l i t y o f research was cons idered i n terms o f the cond i t i on s requ i r ed f o r i t s conduct , w i th the need f o r r e cep t i v e a t t i t u d e s , app rop r i a te 104 t ra in ing and experience, adequate f a c i l i t i e s , cooperative pat ients , and a v a i l a b i l i t y of resources for advice, help, and f inances. In general , at t i tudes were receptive to the concept of research, as many of the general pract i t ioners had previously been involved in projects. However, major problems were seen as deterrents, espec ia l ly the heavy workload and lack of time. Training was var iab le , a few having had no t ra in ing in research methods, and some having had much. Space was expected to be a problem for many pract i ces , but even greater problems were the high overhead and pressure of work on the s t a f f , making i t d i f f i c u l t for the f a c i l i t i e s to accommodate research a c t i v i t y . There was not much awareness among the general p r a c t i -t ioners about the resources ava i lab le for help, advice, or f inancing but most of them were aware of the need for such resources. The inadequacy of the usual o f f i ce records for research purposes was recognized, so that special methods appropriate for studies would be needed. Patients were prepared to cooperate in studies, even at the cost of some time and inconvenience. They suggested that the cost of research should be borne pr imar i ly by governments, and to a lesser extent by foundations and the pub l i c . In considering a l l the data, i t seems log ica l to conclude that research by general pract i t ioners in B r i t i s h Columbia i s des i rab le , and would be of benefit to knowledge, to the pract ice of medicine, and to society as a whole. I t seems also that such research i s f eas ib l e , but that there are numerous factors which are deterrents to research, and which are l i k e l y to i nh i b i t much of the a c t i v i t y which may be des i rab le. Much of the work noted in the l i t e r a t u r e and many of the responses to the surveys indicate a great potent ia l for research, but the f u l l potent ia l i s far from being rea l i zed in B r i t i s h Columbia. Some recommendations have been made which could help the general pract i t ioners in B r i t i s h Columbia to come c loser to the i r f u l l potent ia l for research. LIST OF REFERENCES McWhinney, I.R. September 1969. The family physician as a research worker. Canadian Family Physic ian. 15(9) :37-39. Gibson, W.C., ed. 1975. Health Care, Teaching and Research. Vancouver: The Univers i ty of B r i t i s h Columbia Alumni Associat ion and the Faculty of Medicine. Garson, J .Z . 1974. Research into group pract ice: a p rac t i t i oner -researcher's view. Health Care Research: a symposium, pp.152-155. Calgary. The Univers i ty of Calgary Offset Pr in t ing Services. White, K..L., Wi l l iams, T .F . , and Greenberg, B.G. 1961. The ecology of medical care. New England Journal of Medicine. 265:885-892. Falk, W.A. 1971. Detai led study of a pract ice population and i t s i l l n e s s . Report on study, National Health Grant #609-7-260. Metcalfe, D.H.H., and Sischy, D. August 1974. Patterns of re fer ra l from family pract ice . The Journal of Family Pract i ce . 1(2):34-38. Hennen, B.K.E. 1980. Status of research in Canadian departments of family medicine. A report to the National Research Committee of the College of Family Physicians of Canada. Hammond, M., ed. 1977. Royal College of General Pract i t ioners Library L i s t of current publ icat ions on general pract ice . New Reading for  General P rac t i t i oners . 18:104. P i ck les , W.N. 1939, Epidemiology in Country Pract ice, p.8. B r i s t o l : John Wright & Sons L t d . , and London: Simpkin Marshall Ltd. Crombie, D.L., and Pinsent, R.J.F.H. August 1969. Letter from the College Research Unit. Journal of the Royal College of General  P rac t i t i oners . 18:104. Minutes of annual meeting. ., B r i t i s h Columbia Chapter of the College of General Pract ice of Canada. 1957. Vancouver, B r i t i s h Columbia. Kalton, G. 1968. The contr ibut ion of research in general pract ice to the study of morbidity. Journal of the Royal College of General  P rac t i t i oners . 15:87. Berwick, D.M. March 1978. Are we what we eat? Ped ia t r i cs . 61(3):496-497. F inke l , A . J . March 1978. Rewards of careful observation ( ed i t o r i a l ) . The Journal of the American Medical Assoc iat ion. 239(11): 1072. Dalton, K. June 1973. The general p rac t i t ioner and research. The Prac t i t i oner . 210:784-788:. (785-1 ines 12-18). 106 16. Stuar t -Harr i s , C. 1977. Academic general pract ice - i s i t relevant? Medical Education. 11:308-310. 17. L iv ingston, M.C.P. Apr i l 1972. The background of some Canadian general pract i t ioner-observers. Canadian Medical Associat ion Journal . 106:797-799. 18. Amulree, Lord. 1969. James Mackenzie and the future of medicine. The Journal of the Royal College of General P rac t i t i oners . 17:3. 19. E imer l , T .S . , and Laidlaw, A . J . 1969. A Handbook for Research in  General Pract ice, p p . v i i - v i i i . Edinburgh and London: E. '& S. Livingstone Ltd. 20. General Pract i ce . Report of a world health organization expert committee. 1964. World Health Organization Technical Report Ser ies. No.267. 21. Wood, M., Mayo, F., and Marsland, D. December 1975. A systems approach to patient care, curr iculum, and research in family pract ice. The Journal of Medical Education. 50:1106-1112. 22. Co l l ye r , J.A. June 1975. A measure of a family doctor 's work. Part I I : drugs, time, charges, morbidity. Canadian Medical Associat ion  Journal. 112:1357-1360. 23. Garson, J .Z . 1974. Research into group pract ice: a p rac t i t i oner -researcher's view. Health Care Research: a symposium, pp.152-154. Calgary: The Univers i ty of Calgary Offset Pr in t ing Services. 24. Bury, J .D . , and Gold, R.J.M. 1969. Proceedings of conference on costs and organization of medical care. Saskatoon Community Health Foundation. 25. Warner, M.W. Apr i l 1975. Family Medicine in a Consumer Age, p.170. Vancouver: The Univers i ty of B r i t i s h Columbia, Department of Health Care and Epidemiology. 26>, Rice, D.I. 1975. Education for tomorrow's family physic ians. Health Care, Teaching and Research, p.153. Vancouver, B r i t i s h Columbia: Univers i ty of B r i t i s h Columbia Alumni Assoc iat ion. 27. Do l l , R. 1975. Medical research in the publ ic in te res t . Health Care,  Teaching and Research, pp.178-179. Vancouver, B r i t i s h Columbia: Univers i ty of B r i t i s h Columbia Alumni Assoc iat ion. 28. G i l l i e - , A. 1963. Standing Medical Advisory Committee, Central Health Services Counci l . Report on a Study of the F ie ld of Work of the Family  Doctor, p.23. London: Her Majesty's Stat ionery Of f i ce . 29. Robertson, H.R. March 1973. Health care in Canada: a commentary. Background study for the Science Council of Canada, p.231. Mimeographed. 30. Verby, J .E . May 1973. Research in family medicine. Minnesota Medicine. 56(5):433-435» ( l ines 32-33, p.433). 107 31. Robertson, H.R. 1974. Health care research in Canada: report to the Science Council of Canada. Health Care Research: a symposium. Larsen, D.E., and Love, E . J . , eds. Calgary: Univers i ty of Calgary Offset Pr int ing Services. 32. Gibson, W.C. 1978. Personal communication, Woodward L ibrary , the Univers i ty of B r i t i s h Columbia. 33. Postuk, P.D., Mackenzie, C . J .G . , and Coleman, J .U. January 1969. An analysis of the pract ice of four physicians in B r i t i s h Columbia. Canadian Family Physic ian. 15:51. 34. Postuk, P.D., and Mackenzie, C.J.G. 1964. Report of an analysis of  general pract ice in B r i t i s h Columbia from a study of the pract ices of  54 physic ians. Vancouver: Monograph, B r i t i s h Columbia Chapter, College of Family Physicians of Canada. 35. Col Iyer, J .A. February 1970. An epidemic inf luenza study. Canadian Family Physic ian. 16(2):107. 36. Garson, J . Z . , and Wolfe, R.R. November 1975. Social problems of the hospi ta l i zed e lde r l y . Canadian Family Physic ian. 21(11) :85. 37. Garson, J . Z . , Boor, S . , and Macintosh, M. October 1972. The s i g n i f i c -ance of routine electrocardiograms. Canadian Family Physic ian. 18(10): 59. 38. Garson, J . Z . , Boor, S. , McAsk i l l , M., Altwasser, M., and Lorass, S. February 1972. The checkup centre as part of an ongoing medical pract i ce . Canadian Family Physic ian. 18(2):93-100. 39. Hebb, A.M.O. December 1980,.... Nova Scotia feta l r i s k project. Canadian Family Physic ian. 26:1664-1673. 40. National Survei l lance Working Party, Canadian Influenza Surve i l lance. Apr i l 1979. Fourth Report of the National Recording System. Canadian Family Physic ian. 25:431-436. 41. The Research Unit of the Royal College of General P rac t i t i oners . October 1971. The diagnostic index. The Journal of the Royal College . of General P rac t i t i oners . 21:609. 42. The Netherlands, the Foundation for the Netherlands Ins t i tu te for General P rac t i ce , Min ist ry of Publ ic Health and Environment, Chief Medical Off ice of Health, Springweg 7, 3511 VH Utrecht. 1979. Continuous morbidity reg i s t ra t ion sentinel s tat ions. 43. Rowe, I.L. 1973. Prescr ipt ion of psychotropic drugs by general p rac t i t i oners : I. General. Medical Journal of Aus t ra l i a . 1:589. 44. Hutchinson, J.M. 1971. The Austra l ian morbidity survey 1969-70. Annals of General Pract ice. XVI:68. 108 45. Crombie, D.L., and.Pinsent, R.H.F.H. June 1974. The Research Advisory Service - what i t i s and what i t does. The Journal of the Royal College  of General P rac t i t i oners . 24:416-417. 46. The Netherlands. 1980. Prospectus on s c i e n t i f i c research with in the  Netherlands Inst i tu te of general p rac t i t i oners . The Netherlands Ins t i tu te of general p rac t i t i oners , S. Van der Koo i j , d i rec tor general. Utrecht. 47. Sh i res, D.B. 1974. Computer Technology in the Health Sciences. Sp r ing f i e l d , I l l i n o i s : Charles C. Thomas. 48. McQuitty, G.D.H. November 1971. Medical records and b i l l i n g systems in family pract ice . Canadian Family Physic ian. 17(11):29. 49. Nie, N.H., Hu l l , C.H., Jenkins, J .G . , Steinbrenner, K., and Bent, D.H. 1975. S t a t i s t i c a l Package for the Social Sciences (SPSS), second ed i t i on . Toronto: McGraw-Hill Book Company. 50. Declaration of He l s ink i . January 1974. Research news page. Canadian Family Physic ian. 20:41. 51. Donovan, T . , Grant, D., Woodhall , J . , and Zander, L. December 1973. Conf ident ia l i t y in the sett ing of general pract ice . Journal of the  Royal College of General P rac t i t i oners . 23:881-885. 52. Crombie, D.L. December 1973. Research and con f i den t i a l i t y in general pract ice. Journal of the Royal College of General P rac t i t i oners . 23:863-879. 53. L iv ingston, M.C.P. 1973. Observations on family pract ice research. Canadian Family Physic ian. 19(5):106-108. 54. Watson, G.I. 1972. One hundred up! Epidemic observation un i t : 100th no t i f i c a t i on form. The Journal of the Royal College of General  P rac t i t i oners . 22:729-730. 55. Hope-Simpson, R.E. 1954. Studies on shingles ( is the virus ordinary chickenpox v irus?) Lancet. 2:1299-1302. 56. Hope-Simpson, R.E. 1965. The nature of herpes zoster; a long-term study and a new hypothesis. Proceedings of the Royal Society of  Medicine. 58:9-20. 57. Falk, W.A. May 1979. Research in general pract ice . Canadian Medical  Associat ion Journal . 120:1198-1200. 58. Kay, CR . 1970. B r i t i s h experience of the p i l l . Journal of the  Royal College of General P rac t i t i oners . 19:251-257. 59. E imer l , T .S . , and Laidlaw, A . J . 1969. A Handbook for Research in  General Pract ice, p.39-62. Edinburgh and London: E.&S. Livingstone Ltd. 60. Radford, J .G. 1963. Morbidity recording in one year of general p rac t i ce , Part I. Annals of General Pract i ce . 8:134-142. 109 61. Marsha l l , E.J. 1963. Morbidity recording for research. New Zealand  Medical Journal . 62:484-485. 62. Group study by the Research Unit of the Royal College of General P rac t i t i oners , Great B r i t a i n , and the Newfoundland Chapter of the College of Family Physicians of Canada. September 1969. A t ransat lant i c morbidity study. The Journal of the Royal College of General P rac t i t i oners . 18:137-147. Published simultaneously in Canadian  Family Physic ian. 15:133. 63. Froom, J . August 1974. An integrated system for the recording and re t r i eva l of medical data in a primary care se t t ing . Part 3: the Diagnostic Index-E-Book. The Journal of Family Pract ice. l (2):45-48. 64. Shank, J .C. 1977. The content of family pract ice: a family medicine res ident ' s Th. year experience with the E-book. Journal of Family  Pract i ce . 5(3):385-389. 65. E imer l , T .S . , and Laidlaw, A . J . 1969. A Handbook for Research in  General Pract ice, pp.71-73. Edinburgh and London: E.&S. Livingstone Ltd. 66. E l f o rd , R.W. July 1975. The "E-Book" turned chronic i l l n e s s reg i s te r . Canadian Family Physic ian. 21:35. 67. Pinsent, R.J.F.H. 1968. The evolving age-sex reg i s te r . Journal of  the Royal College of General P rac t i t i oners . 16:127-134. 68. Far ley, E.S., Treat, D.F., Baker, C.F. , Froom, J . , and Henck, S.H. May 1974. An integrated system for the recording and re t r i eva l of medical data in a primary care se t t ing . The Journal of Family  Pract ice . 1(1) :44-48. 69. E d i t o r i a l . September 1977. Age-sex reg i s te rs . Journal of the Royal  College of General P rac t i t i oners . 27:515-517. 70. Goodman, M. 1975. Using an age-sex reg i s te r . Journal of the Royal  College of General P rac t i t i oners . 25:379-382. 71. Sloan, R.E.G., Norman, M., and Adams, D. September 1977. The cost and advantages of estab l ish ing an age-sex reg i s te r . Journal of the Royal  College of General P rac t i t i oners . 27:532-533. 72. White, K.L. 1976. Primary care research and the new epidemiology. The Journal of Family Pract i ce . 3(6):579-580. 73. Research Committee. 1959. C l a s s i f i c a t i on of disease. Journal of the  College of General P rac t i t i oners . 2:140-159. 74. Research Committee. 1963. C l a s s i f i c a t i on of disease, amended vers ion. Journal of the College of General P rac t i t i oners . 6:207-216. 75. Tarrant, M., and Westbury, R.C. 1969. C l a s s i f i c a t i on of a disease in pract i ce; a comparative study. Canadian Medical Associat ion Journal . 101:603-608. 110 76. C l a s s i f i c a t i on Committee of the World Organization of National Col leges, Academies, and Academic Associations of General Pract i t ioners/Fami ly Physic ians. 1975. International C l a s s i f i c a t i on  of Health Problems in Primary Care. Chicago: American Hospital Assoc iat ion. 77. Ib id . 1979. International c l a s s i f i c a t i o n of Health Problems in Primary  Care, 1979 rev i s i on . (ICCHPPC-2). Oxford, New York, Toronto: Oxford Univers i ty Press. 78. The research unit of the Royal College of General P rac t i t i oners . June 1973. A general-pract ice glossary. Second ed i t i on . Supplement number  3, volume 23, 1973. .The Journal of the Royal College of General P rac t i t i oners . ~ 79. Westbury, R.C. (Chairman). In process. 80. Pinsent,- R.J.F.H. 1968. The evolving age-sex reg i s te r . Journal of the  Royal College of General P rac t i t i oners . 16:127-134. 81. E imer l , T .S . , and Laidlaw, A . J . 1969. A Handbook for Research in  General Pract ice, p.72. Edinburgh and London: E.&S. Livingstone Ltd. 82. Falk, W.A. 1966. Research in and about general pract ice. A report  to the Nuf f ie ld Foundation, p.4. 83. Garson, J .Z . July 1976. The problem of the population at r i s k in primary care. Canadian Family Physic ian. 22:871-874. 84. Bentsen, B.G. July 1976. I l lness and general pract ice, p.22. Denmark: Scandinavian Univers i ty Books. 85. Newell, J . P . , Bass, M.J . , and Dick ie , G.L. An information system for family pract ice. Part I: def ining the pract ice population. The Journal of Family Pract ice . 3(5):517-520. October 1976. 86. Bass, M.J. , Newell, J . P . , and Dick ie , G.L. October 1976. An information system for family pract ice . Part 2: the value of def ining a pract ice population. The Journal of Family Pract ice. 3(5):525-528. 87. Falk, W.A. 1972. Proceedings of the th i rd National Research Committee Workshop, Nova Scot ia , May 29-30, 1972. College of Family Physicians  of Canada. . . . 88. Wolfe, S. , and Badgley, R.F. Apr i l 1972. The family doctor. Milbank  Memorial Fund Quarterly. 50(2, part 2):27. 89. K i l pa t r i c k , S . J . . September 1975. The d i s t r i bu t i on of episodes of i l l n e s s - a research tool in general pract ice? Journal of the Royal  College of General P rac t i t i oners . 25(158):686-690. 90. Boyle, R.M., Rockhold, F.W., M i t che l l , G.S. J r . , and Van Horn, S. 1977. The age/sex reg i s te r : estimation of the pract ice population. The Journal of Family Pract i ce . 5(6):999-1003. 91. Westbury, R.C. November 1970. The national l i b r a r y of family medicine. Canadian Family Physic ian. 16(11):97-101. I l l 92. Fitzgerald, D., ed. 1980. FAMLI (Family Medicine Literature Index).  Volume I. The World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA) in cooperation with the National Library of Medicine, Bethseda, Maryland. 93. Rowe, I .L . , ed. 1972. Research Digest, volume 2, The Royal Australian  College of General Practitioners. F.H. Faulding and Co. Ltd. 94. Westbury, R . C , ed. 1970-1976. Research Awareness Publication (RAP). Toronto: The College of Family Physicians of Canada. 95. Update. 1978. Occasional publication. College of Family Physicians of Canada. 96. Research News Page. November 1970. Muskoka workshop. Canadian  Family Physician. 16(11):84. 97. Research News Page. November 1971. Research workshop held in Banff. Canadian Family Physician. 17(11):83. 98. Research News Page. April 1972. Nova Scotia training workshop planned for May. Canadian Family Physician. 18(4):45. 99. Dixon-Warren, B. September 1974. The B.C. scene: research workshop 1974. Canadian Family Physician. 20(9):50. 100. Research News Page. May 1971. Prair ie provinces workshop held in Regina. Canadian Family Physician. 17(5):73. 101. Clews, A.G. January 1976. Health care evaluation seminar. Canadian Family Physician. 22:29. 102. Geyman, J.P. August 1977. Research in the family practice residency program. The Journal of Family Practice. 5(2):245-248. 103. Hodgkin, K. 1976. Educational implications of the Virginia study. Content of Family Practice, a Statewide Study in V i rg in ia , with i ts .1 c l i n i c a l , educational, and research implications, p.11-12. 104. Ed i tor ia l . The Birmingham research unit. Journal of the Royal College  of General Practitioners. 23:386. June 1973. 105.. .Canada. Department of National Health and Welfare. Task Force Reports  on the Cost of Health Services in Canada, Health Services, 1970. p.21. Ottawa: Information Canada. 106. Research News Page. 1975. WONCA research committee formed. Canadian Family Physician. 21(1):54. 107. North American Primary Care Research Group. Wood, M., president. (Professor of Family Medicine, Medical College of V i rg in ia , Richmond, V i rg in ia , 23298). 108. Kuenssberg, E.V. July 1979. European general practitioners research workshop. Journal of the Royal College of General Practit ioners. 29(204):445. 112 APPENDIX 1 L i s t of journals containing reports on research studies by general p rac t i t i oners , as published by the Royal College of General Pract i t ioners in "New Reading for General P rac t i t i oners " . (Quarterly cumulative l i s t , January to September, 1977) T i t l e of Journal Number of c i ta t ions Journal of the Royal College of General Pract i t ioners 48 Journal of Family Pract ice 21 The Prac t i t ioner 16 B r i t i s h Medical Journal 15 Journal of International Medical Research 8 Medical Education 7 Medical Care 6 Ugeskri ft for laeger 6 Austra l ian Family Physician 5 Huisarts en Wetenschap 5 Canadian Family Physician 4 Medical Journal of Aus t ra l i a 4 C l i n i c a l T r i a l s Journal 3 General Pract ice International 3 Health Bu l l e t i n 3 New Zealand Medical Journal 3 B r i t i s h Journal of C l i n i c a l Pract ice 2 B r i t i s h Journal of Obstetr ics and Gynecology 2 B r i t i s h Journal of Social and Preventive Medicine 2 Current Medical Research and Opinion 2 I r i sh Medical Journal 2 Singapore Family Physician 2 Socio logica l Review 2 Update 2 Acta Therapeutica 1 Applied S t a t i s t i c s 1 B r i t i s h Heart Journal 1 B r i t i s h Journal of Addict ion 1 Appendix 1 continued (page 2 of 2) 113 T i t l e of Journal NuTbeT o f c i ta t ions B r i t i s h Journal of Psychiatry Canadian Medical Associat ion Journal C l i n i c a l Science and Molecular Medicine Community Health Elan Journal of the American Medical Associat ion Journal of Family Planning Doctors Journal of Hygiene Journal of the I r i sh Medical Associat ion Journal of Medical Ethics Journal of the North of England Faculty Modern Ger ia t r i cs Pharmatherapeutica Postgraduate Medical Journal Psychological Medicine Social Science and Medicine South Afr ican Medical Journal Southwest England Faculty News Wessex Faculty News Books and pamphlets 6 Total 202 APPENDIX 2 114 Research News Declaration Of Helsinki W I L L I A M F A L K , M D AI T H O U G H IT m a y not be c o n -sidered as hot news , it is qu i t e likely that this i m p o r t a n t dec l a r a t i on ul principles has escaped the a t t en t i on ol many of ou r m e m b e r s . A d o p t e d by the I Xih W o r l d M e d i c a l A s s e m b l y at H e l s i n k i in 1964 , it is a s e r o f r e c o m -mendations gu id ing doc to r s in c l i n i c a l ' research. It is per t inent to us n o w because o f our increas ing interest and activity in fami ly .practice research. We inns! c o n t i n u a l l y r e m e m b e r that the Inst cons idera t ion is for the pat ient -u:.Ni':wch comes next in i m p o r t a n c e . Hie Nat ional C o m m i t t e e on Resea rch . ;it its meet ing in O c t o b e r , adop ted these r e c o m m e n d a t i o n s as a guide in us work. T h e y are p r in t ed here in f u l l , as in the W o r l d M e d i c a l J o u r n a l o f September, 1964. R e c o m m e n d a t i o n s G u i d i n g D o c t o r s In C l i n i c a l Resea rch Introduction 11 is the mission of the doctor to -.il'i'sztt:trtl the health of the people. His knowledge and conscience are dedicated to the fulfilment of this mission. The Declaration of Geneva of The World Medical Association binds the doctor with the words: "The health of my patient will he my first consideration" and the Inter-national Code , of Medical Ethics which declares that "Any act. or advice which could weaken physical or mental resistance •cif a human being may be used only in his interest". Because it'is essential thai the results of lahoralory experiments lie applied lo human beings to further scientific knowledge and to help suffering humanity. The World Medical Association has prepared the fol-lowing recommendations as a guide to each doctor in clinical research. It must be stressed that the standards as drafted are only a guide to physicians all over the world. Doctors arc not relieved from criminal, civil, and ethical responsibilities under the taws of their own countries. In the field of clinical research a funda-mental distinction must be recognised between clinical research in which the aim is essentially therapeutic for a patient, and the clinical research, the essential object of which is purely scientific and without thera-peutic value to the person subjected to the research. t. Basic Principles 1. Clinical research must conform to the moral and scientific principles and justify medical research and should be based on laboratory and animal experiments or other scientifically established facts. 2. Clinical research should be conducted only by scientifically qualified persons and under the supervision of a qualified medical man. 3. Clinical research cannot legitimately be carried out unless the importance of the objective is in proportion to the inherent risk to the subject. 4. livery clinical research project should be preceded by careful assessment of inherent risks in comparison to foreseeable benefits to the subject or to others. 5. Special caution should be exercised by the doctor in performing clinical research in which the personality of the subject is liable • to be altered by drugs or experimental procedure. II. Clinical Research Combined With Professional Care 1. In the treatment of the "sick person, the doctor must be free to use a new therapeutic measure,, if in his judgment it offers hope of saving life, re-establishing health, or alleviating suffering. If at all possible., consistent with patient psychology, the doctor should obtain the patient's freely given consent after the patient has been given a full explanation. In case of legal incapacity, consent should also be procured from the legal guardian; in case of physical incapacity the permission of the legal guardian replaces that of the patient. 2. The doctor can combine, clinical research with professional care, the objec-tive being the acquisition of new medical knowledge, only to the extent that clinical research is justified by its therapeutic value for the patient." • ) III . Non-Therapeutic Clinical Research 1. In the purely scientific application of clinical research carried out on a human being, it is the duty of the doctor to remain the protector of the life and health of that person on whom clinical research is being carried out. 2. The nature, the purpose, and the risk of clinical research must be explained to the subject by the doctor. 3a. Clinical research on a hum an being cannot be undertaken without his free consent after he has been informed: if lie is legally incompetent, the consent of the legal guardian should be procured.. 3b. The subject of clinical icsearch should be in such a mental, physical and legal state as to be able to exercise fully his power of choice. 3c. Consent should, as' a rule, be obtained in writing. However, the respon-sibility for clinical research always remains with the research worker; it never falls on the subject even after consent is obtained. 4a. The investigator .must respect the right of each individual to safeguard his personal integrity, especially if the subject is in a dependent relationship to the investi-gator.' 4b. A l any time during the course .of clinical research the.subject or his guardian should be free to withdraw pernri.ssi.on for research to be continued. The investigator or the investigating team should discontinue the research if in his or their judgment, it may, if continued, be harmful to the individual. C O R R E C T I O N In Dr. H . H . Epstein's article "The Manage-ment of Adult Diabetes" (CFP October 1973 p. 69) the first" word of line 9, 1st para, should have been 'hyperglycemia'. C A N A D I A N F A M I L Y P H Y S I C I A N / J A N U A R Y , 1 9 7 4 41 Appendix 3 115 Reasons for exclusion from general p rac t i t ioner mai l ing l i s t and numbers excluded, according to group on combined l i s t STATUS 1 2 GROUP* 3 4 5 Total Spec ia l i s t 74 1 _ _ 74 Retired 20 3 - - 23 Publ ic health physician 25 4 4 6 39 Interne or resident 13 - - - 13 Non-resident in B.C. 12 - - - 12 Previous member 5 - - - 5 Faculty at U .B .C , spec i a l i s t - 5 2 6 2 15 Temporary reg is ter 3 - - - 3 Reasons not c lear 7 - 2 - 9 Psych ia t r i s t ( i n s t i t u t i ona l ) - = 2 3 5 10 Cancer control agency o r •7 and research L 0 7 Chi ldren's hospitals - 2 - - 2 Hospital administrat ion - 1 2 1 4 Workers Compensation Board - - 2 16 18 Federal government agency - 1 3 5 9 Canadian Armed Forces - 1 3 1 5 Medical Associat ion - - 1 - 1 • Other agencies - - 3 3 6 Woodlands School - - 3 1 4 Osteopath - - 7 - 7 Acupuncture c l i n i c - - 1 - 1 Hospital department - 6 4 3 11 Occupational medicine - - - 6 6 Total 164 25 49 49 291 Note: Questionnaires were subsequently mailed to 23 of those excluded, most of whom were working in i ns t i tu t i ons where some general p rac t i t ioner care might be needed. * Groups: 1. BCMA mai l ing l i s t + UBC Act ive l i s t 2. BCMA mail ing l i s t only 3. UBC Act ive l i s t only 4. BCMA mai l ing l i s t + UBC Inactive l i s t 5. UBC Inactive l i s t only APPENDIX 5 (continued) INTERVIEW GUIDE (Research potent ia l of G.P. 's) 118 Introduct ion: Comments are con f i den t i a l , w i l l not be quoted d i r e c t l y Time i s l i k e l y to be about hal f an hour Des i r ab i l i t y : Benef ic ia l to knowledge - source of new knowledge - c loser access to information Benef ic ia l for the pract ice - improved medical care - evaluation methods - job sa t i s fac t ion Benef ic ia l for society - education - p o l i t i c a l decisions - system of care - value for money APPENDIX 5 (continued) Feasibility: Conditions acceptable for the g.p.? - is he interested? - is he capable? - is he willing? - are facilities available? - is consultation available? Conditions acceptable for the patient? - confidentiality - medical care - cost Conditions acceptable for the practice? - space - personnel - recording methods - cost - patient identification Conditions acceptable for research? - recording methods - denominators - assistance APPENDIX 5 (continued) 120 L i s t of persons consulted during preparation of questionnaire for survey of general p rac t i t i one rs , and viewpoints E E O O •r— •P— -t-> 4-> +J ro CU rO E •r— C_> N •i— o >> •r- •i— O o o 4-> E Q. to E O ro s (/) cu rO CD cu cC CD S- S- •1— E rO Q. o > s- o sz cu •r— CD i — 1— +-> o £ 4-> E rO ro E s-(C •r- S- O CU <0 to o -o <D • r— •r— cu sz zz E E •a 4-> to o -o CU cu rO cu o LU Li- CJ3 s; D_ or Dr. A.N. Cherkezoff x x Mrs. J . Curry x Mr. R.H. Davies x x x Dr. F. Demanuel x x x Dr. J.M. Elwood x x Dr.-W.C. Gibson x Dr. P.E. Hoogewerf x x x Dr. J .A. Hutchinson x x Dr. N. Kle iber x x •Dr. D.M. LOW X X Ms. W. Manning x x Dr. J .H. Milsum x x Mr. P. Nerland x Dr. G. Page x x Mr. J . Paul x x Dr. R.K.L. Percival-Smith x x x Dr. F.N. Rigby x x Dr. J.M. Robinson x x x Dr. N. Schwarz x Dr. R.C. Slade x Dr. R.D. Spratley x Dr. G. Szasz X Dr. M.C. Vernier x x APPENDIX 6 RESEARCH in General Practice/Family Practice This survey of general/family practitioners In Br it ish Columbia 1s to assess their present levels of Interest and experience in research. Your answers wi l l help to show how the resources available to assist researchers in general/family practice can best be used. 1. WHAT IS DIFFERENT IN FAAIIH7GENERAL PRACTICE? Do you think that research in iomilyI general practice can provide new knowledge which mould otherwise not be available.? YES( ) N0( ) I. LIST THREE SPECIFIC TOPICS which you have thought about studying, or uhich you consider to have, high priority. 3. TRAINING FOR RESEARCH (al During your education, what utu your exposure to the. fallowing subjects? IciAcU one x on each line)  ^ $ m m E 3.1 Stat ist ics: Medical school X X X 3.2 Interneship X X X 3.3 Residency X X X 3.4 Other X X X 3.5 Epidemiology: Medical school X X X 3.6 Interneship X X X 3.7 Residency X X X 3.8 Other X X X 3.9 Methodology: Medical school X X X 3.10 Interneship X X X 3.11 Residency X X X 3.12 Other X X X (If residency, state type ) (b) Have, you attended any o& the fallowing activities sponsored by the College o£ family Physicians? 3.14 National workshops on Research YES( ) N0( ) 3.15 Provincial Workshops on Research YES( ) N0( ) 3.16 National Health Grant Seminar * YES( ) N0( ) 4. EXPERIENCE > Have you taken pant in any o{ the fattouiing projects in B.C., o i studies elsewhere? {check those vjlUch apply) 4.1 Study of content of practice (Postuk, 1965) 4.2 'F lu ' survey, 1969 (Col l . of Fam. Phys.) 4.3 Survey on Nutrition (Schwartz, 1974) 4.4 Influenza Surveillance (1976-78) 4.5 Prevalence of Multiple Sclerosis (Vernier *77)i 4.6 Drug tr ia ls 4.7 Other group studies (specify) 4.8 Personal studies (specify) 5. PARTICIPATION IN RESEARCH In t/mui opinion, what tifact night participation in research have on the fallowing factors? iciAcJU. the appropriate x's ) BETTER SAME WORSE 5.1 Cost of care X X X 5.2 Education -medical X X X 5.3 Education -public X X X 5.4 Income X X X 5.5 Leisure time X X X 5.6 Office management X X X 5.7 Office records X X X 5.8 Patient care X X X 5.9 Patient records X X X 5.10 Patient satisfaction X X X 5.11 Pol i t ica l decisions X X X 5.12 The health care system X X X 5.13 Your satisfaction with work X X X 5.14 Other (specify) X X X i. DETERRENTS TO PARTICIPATION IN RESEARCH Hou) important are the fallowing factors in discouraging participation in research projects? (circle one number in each line) , . v v t y ^ . ^ ^ 2 * important 3 • not important 6.1 Cost to patients - time 6.2 " " " - travel 6.3 " " " - discomfort 6.4 Ethical problems 6.5 Heavy workload 6.6 High off ice overhead 6.7 Inadequate training 6.8 Lack of awareness of potential 6.9 Lack of interest 6.10 Lack of time 6.11 Not convinced of i ts value . 6.12 Office staff too busy 6.13 Partners not cooperative 6.14 Record system unsuitable 6.15 Space inadequate in of f ice 6.16 Other (specify) 7. INCENTIVES TO DO RESEARCH How important are the fallowing factors in encouraging participation in research projects? {circle one number in each line) 7.1 Contribution to knowledge 7.2 Curiosity 7.3 To add interest to practice 7.4 To cooperate with partner(s) 1 • very important t • important 3 • not important 2 3 2 3 2 3 2 3 7.5 To improve office management 7.6 To improve patient care 7.7 To improve the health care system 7.8 To provide an academic base for family practice/general practice 7.9 Other (specify) APPENDIX 6 (continued) 8. GENERAL INTEREST How much. interest would you have, in the fallowing types o& research activity, assuming that planning is rational and that projects would be compatible wiXh your practice? I • vtry interested {circle one number on each tine) 2 « interested 3 • not interested 8.1 C l i n i c a l s t u d i e s 8 . 2 Economic s t u d i e s 8 . 3 E p i d e m i o l o g i c a l s t u d i e s 8 . 4 Drug s t u d i e s - new drug t r i a l s 8 . 5 Ongoing e v a l u a t i o n o f t reatment 8 . 6 E v a l u a t i o n o f medical e d u c a t i o n 8 .7 Group s t u d i e s , w i t h a c e n t r a l r e c o r d e r to ar range d e t a i l s • 8 . 8 I n d i v i d u a l s t u d i e s o f y o u r p r a c t i c e 8 . 9 Laboratory s t u d i e s 8 . 1 0 S e t t i n g up p r a c t i c e r e c o r d s to a l l o w e a s i e r p a r t i c i p a t i o n In r e s e a r c h 8 .11 Time and motion s t u d i e s 1 ? 8 .12 Workload s t u d i e s 1 2 8 . 1 3 Other ( s p e c i f y ) 1 2 1 2 9. SPECIFIC INTEREST Are you now involved in or actively planning a research proiect? y E S ( } N Q ( } 10. RESOURCES NEEPED H you were planning to do a research project, would you need any o$ the fallowing resources? {circle appropriate x's ) 10.1 10.2 10. A d v i c e on f e a s i b i l i t y A d v i c e on p l a n n i n g 3 C o n s u l t a t i o n w i t h e x p e r t ( s p e c i f y ) F i n a n c i a l h e l p Help i n p r o c e s s i n g r e s u l t s Help i n w r i t i n g r e p o r t T e c h n i c a l help S e c r e t a r i a l h e l p S p e c i a l f a c i l i t i e s ( s p e c i f y _) 10.10 Other ( s p e c i f y ) 10.4 10.5 10.6 10.7 10.8 10.9 Po you Po you know need where to help? get help? YES NO YES NO X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X USE THIS SPACE TO ELABORATE ON YOUR ANSWERS. OR TO APP FURTHER COMMENTS IF VOU WISH. I ) . ETHICAL CONSIPERATIONS la) Have you taken part in any research projects? VES{ ) N0( (6) Ha i^ you or any oi your patients experienced a breach o£ coniidentiality in a researcii project? 1& so, plzase describe belou:. |c| How important do you think it is to obtain infanmtd consent \rom patients, ii you axe engaged in the fallowing activities? [circle- apfVLopwafe numbers) , , V M y i j ! V o n j b u d -I • important i ' not important A d i a g n o s t i c o r t h e r a p e u t i c procedure to be used 1s n o t the customary procedure A p a t i e n t Is asked to complete a q u e s t i o n n a i r e f o r a r e s e a r c h s tudy A p a t i e n t 1s I n t e r v i e w e d , f o r a r e s e a r c h p r o j e c t C l i n i c a l t r i a l s P r o v i d i n g i n c i d e n c e data f rom p a t i e n t r e c o r d s 11 .10 R e p o r t i n g s p e c i f i c d i a g n o s e s , w i t h p a t i e n t s anonymous 11.11 Repor t ing s p e c i f i c d i a g n o s e s , w i t h names o f p a t i e n t s 11.12 Us ing a p l a c e b o , i n t r e a t m e n t 11.5 11.6 11.7 11 .8 11.9 1 2 3 1 2 3 1 2 3 12. PRACTICE PATA 12.1 How long have you been In p r a c t i c e ? . . . . 12.2 How long 1n y o u r p r e s e n t p r a c t i c e ? 12.3 How many d o c t o r s a r e i n y o u r p r a c t i c e ? 12.4 How many are f a m i l y / g e n e r a l p r a c t i t i o n e r s ? 13. PERSONAL PATA 13.1 Age group: -35( 13.2 Medica l schoo l ) 35-44( ) 45-54( ) 55+( Grad y e a r 14. IPENTIFICATION H your address has changed recently, please put your name and new address here. H, far any reason, you wish to remain anom<nou4 cut oU your identiiying M . S . C . number in the lower right comer.. NAME ADDRESS Telephone APPENDIX 7 ATTITUDES OF PATIENTS TOWARDS RESEARCH IN GENERAL PRACTICE Vout opinion* would be heJLp&ul in a btudy o& the definability and ieaiibiJUty o{ nulOAck by gzntnal pnactitioneAi*. Voun docXol ha& agnezd to let u* a&k you a £ew quutuim, on the. undejutanding that youn a*u>weju> will be. coniidential and that youn pantlcipation it, voluntary. Vo not put youn nam on thu iontn. Tku iunvty ij> pant oi a itudy in the faculty oi Mzdicine at U.B.C: tile, hope that it will help to improve, health cane, and education. * * » • * » * * * » * » » * * • » * » • Plea&e. indicate youn amwvu> by checking the. appnopniate choice*. 1. Your age: Under 25( ) 25-44( ) 45-64( ) 65 and over( ) > 2. Your sex: Female( ) Male( ) 3. Are you visit i n g the doctor today for yourself? Yes( ) No( ) 4. Have you brought someone else to v i s i t the doctor? Yes( ) No( ) 5. Is this your regular doctor? Yes( ) No( ) 6. Do you think that i t i s a good idea for general practitioners to be Involved in research studies Yes( ) No( ) related to their work? 7. What topics do you think are most in need of study by general practitioners? 8. Would you be willing to help your doctor to do research studies, by cooperating in important details, such as: (a) allowing her/him to provide information from your Yes( ) No( ) medical records (without giving your name)? (b) keeping a diary about details of your health? Yes, ) No( ) (c) returning at monthly intervals for checkups Yes( ) No( ) (e.g., blood pressure check)? (d) allowing a blood sample to be taken for testing? Yes( ) No( ) 9. Have you ever donated blood to the Red Cross? Yes( ) No( ) 10. For the support of research, which of the following do you think should provide money? (a) The government (federal, provincial, or local) Yes( ) No( ) (b) Private foundations (e.g., Vancouver, Kellog, or v f 1 Not" ) Rockefeller Foundations) 1 ; 1 ; (c) The public (through donations or bequests) Yes( ) No( ) (d) The doctors Yes( ) No( ) Thank you ion. youn heJLp. Plexue put thii £onm in the envelope, &eal it, and neXunn it to the. nexieptLoncit. APPENDIX 9.2 The G e n e r a l P r a c t i t i o n e r ' s P o t e n t i a l f o r R e s e a r c h INSTRUCTIONS FOR ADMINISTERING QUESTIONNAIRES TO PATIENTS 1. On t h e f i r s t on w h i c h i t c a n be g i v e n , a q u e s t i o n n a i r e and r e t u r n e n v e l o p e a r e t o be g i v e n t o each p a t i e n t who v i s i t s Dr i n t h e o f f i c e . 2. A s k p a t i e n t s i f t h e y w o u l d mind h e l p i n g i n t h i s s u r v e y o f p a t i e n t a t t i t u d e s . I f t h e y a r e u n c e r t a i n , a s s u r e them t h a t t h e i r answers w i l l be anonymous, and t h a t t h e y a r e u n d e r no o b l i g a t i o n t o t a k e p a r t . I f t h e y a r e w i l l i n g t o h e l p , i t w i l l be e n t i r e l y v o l u n t a r y . 3. C o l l e c t t h e c o m p l e t e d q u e s t i o n n a i r e s ( i n t h e s e a l e d e n v e l o p e s ) and r e t u r n them t o me i n t h e l a r g e , stamped, a d d r e s s e d e n v e l o p e s . 4. I f t h e day on w h i c h t h e s u r v e y was done i s d i f f e r e n t t h a n t h e one s p e c i f i e d above, p l e a s e s t a t e 5. P l e a s e n o t e t h e number o f o f f i c e p a t i e n t s t h a t day who d i d n o t c o m p l e t e t h e f o r m 6. R e t u r n t h i s page w i t h t h e q u e s t i o n n a i r e , i n c l u d i n g u n u s e d q u e s t i o n n a i r e s . Many t h a n k s f o r y o u r c o o p e r a t i o n . Appendix 10 Responses stat ing that the physicians were not general p rac t i t i oners , and.reasons given, according to d i s t r i c t of the B r i t i s h Columbia Medical Associat ion BCMA D i s t r i c t Reason for exclusion 1 2 3 4 6 7 8 9 11 13 14 15 Total Doing locums only 1 Left Canada 2 No deta i l s given 1 Not in pract ice _ _ _ _ _ 1 _ _ _ _ _ _ 1 Occupational medicine 2 Publ ic health - - 2 1 - - 1 - 1 - - - 5 Research 2 Residency t ra in ing - 1 2 - - - 1 - - - - - 4 Retired general p rac t i t ioner 2 Ret i red, never a G . P . 1 Spec ia l ty: A l lergy 1 Anesthesia - - - - 1 - - - - 1 1 - 3 Electroencephalography 1 General surgery _ _ 1 _ _ _ _ _ _ _ _ 1 2 Ger ia t r i cs _ _ - _ i _ - _ - - _ - 1 Obstetr ics and Gynecology - 1 - - - 1 - 1 - - - - 3 Ophthalmology _ _ i _ _ _ _ _ _ _ _ - 1 Orthopedics 2 Pathology 1 Pediatr ics 2 Psychiatry _ _ _ _ 2 - - - - - - - 2 Radiology _ _ _ _ _ _ 1 _ _ _ _ _ 1 Rectal surgery 1 Workers' Compensation Board _ _ i _ _ _ _ _ _ _ _ - 1 Totals 2 4 12 3 5 4 3 1 4 2 2 1 43 Appendix 11 School or country of graduation in medicine of 508 general pract i t ioners responding to survey Place of graduation Number Percent Canadian Univers i ty: B r i t i s h Columbia 138 27.2 Alberta 45 8.9 Calgary 3 0.6 Saskatoon 18 3.5 Manitoba 23 4.5 Toronto 35 6.9 Western Ontario 22 4.3 McMaster 5 1.0 Quebec 14 2.8 McGill 26 5.1 Dalhousie 10 2.0 Memorial 3 0.6 Ottawa 3 0.6 Montreal 1 0.2 Country other than Canada: United States of America 11 2.2 United Kingdom 100 19.7 Aust ra l ia and New Zealand 9 1.8 Continental Europe 10 2.0 Other 12 2.4 No reply 17 3.3 Total 508 100.0 Appendix 12 129 Most frequent suggestions for areas need pract i t ioners Topic Suggested by : G.P. Patient T 0 D i c Suggested by; p G.P. Patient Treatments 39 7 Alcohol 11 1 Nutr i t ion 37 14 Dermatology 11 1 Hypertension 36 1 Respiratory disease 10 3 Nervous & mental d i s . 35 17 A l lergy 10 2 Preventive medicine 35 12 Per i -nata l condit ions 10 -Delivery of care 28 4 Emergencies 9 -Drugs of choice 22 7 Screening 9 2 Cardio-vascul.ar. d i s . . 22 17 Drug t r i a l s 9 -Pregnancy and del ivery 21 3 Immunology 8 -The aged 21 3 Ear diseases 8 -Infectious diseases 20 1 Adverse e f fec t s , drugs 8 4 Endocrine diseases 19 4 Pract ice p ro f i l e 8 -Obesity 19 . 1 Dr.-pat ient att i tudes 8 7 Stress 19 3 C.N.S. disease 7 2 Health education 19 5 Urinary problems 7 -Various spec ia l t i es 18 1 Medical records 7 1 Family Problems 18 4 Laboratory studies 7 1 Pract ice management 17 - Gastro- intest ina l 6 1 Compliance 17 1 Abortion 6 -Bi r th control 15 3 Muscu loske leta l 6 -Economics 15 - A r t h r i t i s 6 4 Hypnosis 15 - Ethnic groups 6 -Epidemiology 14 - Qual ity of care 6 4 Cancer 13 27 Accidents 5 -Childhood, adolescence 13 3 Adverse, e f fec t s , other 5 1 Genital problems 13 1 Occupational problems 5 -Sports in ju r ies 13 - Marital problems 5 -Drug use and abuse 13 1 Hereditary disease 5 -Back pain 13 1 Chronic diseases 4 1 Demand for care 12 1 Computer use 4 1 Sexual and behavioural 11 2 Other 58 13 problems Appendix 13 Importance of workload as a deterrent to research Rating by general pract i t ioners BCMA D i s t r i c t Important Important i m p o ° t a n t _. -No. % No. % No. % 1 V i c to r i a 37 51.4 29 40.3 6 8.3 72 2 Upper Island 23 62.2 14 37.8 0 37 3 Vancouver c i t y " 68 60.7 37 33.0 7 6.3 112 4 North Burrard 17 65.4 9 34.6 0 26 5 Burnaby 5 83.3 1 16.7 0 6 6 New Westminster 30 66.7 12 26.7 3 6.7 45 7 Fraser Val ley 25 80.6 6 19.4 0 31 8 Richmond - Delta 13 68.4 5 26.3 1 5.3 10 9 Prince Rupert 12 66.7 6 33.3 0 18 10 North Okanagan 13 65.0 6 30.0 1 5.0 20 11 Cariboo 11 57.9 4 21.1 4 21.1 19 12 Peace River 5 71.4 2 28.6 0 7 13 South Okanagan 18 56.3 11 34.4 3 9.4 32 14 West Kootenays 6 40.0 6 40.0 3 20.0 15 15 East Kootenays 9 56.3 7 43.8 0 16 16 Anonymous 11 68.8 5 31.3 0 16 Total No reply 303 61.7 160 32.6 28 5.7 491 17 Appendix 14 "How much interest would you have in the fol lowing types of research a c t i v i t y , assuming that planning i s rat ional and that projects would be compatible with your pract ice?" Type of research a c t i v i t y interested C r e s t e d interested reply No. % No. % No. % No. % C l i n i c a l studies 202 On-going evaluation of treatmentl30 Evaluation of medical education 103 Individual studies of your - o pract ice Epidemiological studies 78 Workload studies 77 Sett ing up pract ice records to al low easier par t i c ipa t ion in 70 research Group studies, with a central g , recorder to arrange deta i l s Economic studies 87 Drug studies - new drug t r i a l s 73 Time and motion studies 58 Laboratory studies 31 39.8 221 43.5 54 10.6 31 6.1 25.6 277 54.5 64 12.6 37 7.3 20.3 224 44.1 143 28.1 38 7.5 15.4 245 48.2 150: 29.5 35 6.9 15.4 236 46.5 155 30.5 39 7.7 15.2 210 41.3 183 36.0 38 7.5 13.8 214 42.1 185 36.4 39 7.7 12.0 210 41.3 184 36.2 53 10.4 17.1 174 34.3 209 41.1 38 7.5 14.4 182 35.8 217 42.7 36 7.1 11.4 162 31.9 240 47.2 48 9.4 6.1 145 28.5 287 56.5 45 8.9 Appendix 15 Importance of informed consent by pat ients , as perceived by 508 responding general pract i t ioners Opinion important Important i m p o r t a n t No reply No. % t No. % No. \ t No. % A diagnostic or therapeutic procedure to be used is not the customary procedure 429 84. 4 42 8.3 12 2. 4 25 4.9 A patient i s asked to complete a questionnaire for a research study 256 50. 4 171 33.7 58 11. 4 23 4.5 A patient i s interviewed for a research project 267 52. 6 171 33.7 46 9. 1 24 4.7 C l i n i c a l t r i a l s 400 78. 7 70 13.8 13 2. 6 25 4.9 Providing incidence data from patient records 105 20. 7 118 23.2 255 50. 2 30 5.9 Reporting spec i f i c diagnoses, with patients anonymous 72 14. 2 58 11.4 350 68. 9 28 5.5 Reporting spec i f i c diagnoses, with names of patients 373 73. 4 83 16.3 25 4. 9 27 5.3 Using a placebo in treatment 261 51. 4 115 22.6 89 17. 5 43 8.5 Appendix 16 Resources needed for undertaking a research project , as perceived by the 508 general pract i t ioners who responded to survey Help needed? Source of help known? Resource Yes No No reply Yes No No reply No. % No. "/, r No. % No. % No. % No. f Advice on f e a s i b i l i t y 359 70.7 73 14. 4 76 15.0 89 17.5 287 56.5 132 26. 0 Advice on planning 384 75.6 -,48 9. 4 76 15.0 93 18.3 289 56.9 126 24. 8 Consultation with expert 271 53.3 71 14. 0 166 32.7 104 20.5 202 39.8 202 39. 8 Financial help 317 62.4 93 18. 3 98 19.3 65 12.8 283 55.7 160 31. 5 Help in processing resul ts 385 75.8 47 9. 3 76 15.0 92 18.1 291 57.3- 125 24. 6 Help in wr i t ing report 267 52.6 159 31. 3 82 16.1 78 15.4 244 48.0 186 36. 6 Technical help 317 62.4 91 17. 9 100 19.7 72 14.2 247 48.6 189 37. 2 Secretar ia l help 297 58.5 122 24. 0 89 17.5 103 20.3 219 43.1 186 36. 6 Special f a c i l i t i e s 98 19.3 116 22. 8 294 57.9 29 5.7 135 26.6 344 67. 7 134 GLOSSARY In th i s study, the fol lowing terms are used according to these def in i t ions Denominator: in general pract i ce , describes the pract ice populat ion, from which incidence and prevalence rates can be ca lcu lated. Family medicine: the body of knowledge relevant to family pract ice. Family physic ian: for the purposes of th i s study, the same as the general p rac t i t i oner . General pract i ce: (T) a term used to describe the combination of pat ients , premises, and s ta f f with which a general p rac t i t ioner works, (.ii) a term used to describe the type of work done by general p rac t i t i oners . General p rac t i t i oner : unless there i s evidence to the contrary, a physician who is l i s t ed as a general pract i t ioner by ( i ) -the B r i t i s h Columbia Medical Assoc iat ion, or ( i i ) the combined l i s t of the College of Physicians and Surgeons of B r i t i s h Columbia and the Medical Services Commission MSC Act ive physic ian: one whose b i l l i n g to the Medical Services Commission exceeds an arb i t ra ry amount ($15,000 in 1978). MSC Inactive physic ian: one whose b i l l i n g to the Medical Services Commission does not reach an arb i t ra ry amount ($15,000 in 1978). Primary care physic ian: physician of f i r s t contact for a problem, without the need for re fer ra l from another physic ian; usual ly a general p rac t i t i one r , ped ia t r i c i an , or i n t e rn i s t . Research: in general p rac t i ce , research i s seldom of the type requir ing laborator ies or complicated equipment. Areas of relevance are c l i n i c a l , therapeut ic, epidemiological , operat iona l , and educational. GLOSSARY (continued) Abbreviations: BCMA: B r i t i s h Columbia Medical Associat ion CFPC: The College of Family Physicians of Canada CP&S: The College of Physicians and Surgeons of B r i t i s h Columbia GP: a general pract i t ioner ICHPPC: International C l a s s i f i c a t i on of Health Problems in Primary Care MSC: Medical Services Commission of B r i t i s h Columbia NAPCRG: North America Primary Care Research Group RACGP: Royal Austra l ian College of General Pract i t ioners RCGP: Royal College of General Pract i t ioners UBC: Univers i ty of B r i t i s h Columbia WCB: Workers Compensation Board WONCA: World Organization of National Colleges and Academies of General Pract i t ioners/Fami ly Physicians and A l l i e d Academic Ins t i tu t ions PUBLICATIONS: 1966 Research in and about general pract ice. A report to the Nuf f ie ld Foundation. Ser ia l publ icat ion in Canadian  Family Physic ian. Dec. 1967 to May 1968. 1967 Notes on "The Nu f f i e ld " . Canadian Family Physic ian. 13(7}:37-41, Ju ly . 1969 Family pract ice research; world viewpoint. Canadian  Family Physic ian. 15(5):30-39, May. 1971 Detai led study of a pract ice population and i t s i l l n e s s . Report for National Health Grant #609-7-260. 1973 The challenge of the emergency c a l l . Austra l ian Family  Physic ian. 1(7):376-378, Dec. A study of G.P. hospital admissions in B.C. With J.A. Fowler. Canadian Family Physic ian. 19(6):56-59, June. A study of wait ing time in an emergency department. With A.B. A l l e n , B.G. Bernard, E.R. Higgs, and J .G. Mc Cracken. Canadian Medical Associat ion Journal . 109:373-376. Sept. 1. ^ The manpower problem: towards better f igures . Canadian  Family Physic ian. 19(9):85-89, Sept. 1979 Research in general pract ice . E d i t o r i a l , Canadian  Medical Journal . 120:1198-1200, May 19. The family doctor as researcher. Canadian Family  Physic ian. 25:1479-1482, Dec. 

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