A study of research adequacy in Australian general practice
General practice is a fundamental and essential component of the Australian health care system. It is both a gate keeper to other aspects of the health care system, and a provider of long-term care of people in the community. Despite its importance, many general practice decisions are not based on good evidence. In part, this is due to general practitioners (GPs) not incorporating available evidence into their clinical decision-making, but more significantly, it is the result of a lack of available, accessible, applicable and appropriate research. This problem is not unique to Australia, and the need to understand, and address, the research adequacy question is on the international general practice agenda.
This thesis aims to comprehensively explore this issue and to investigate potential strategies for encouraging the development of a research culture. Underpinning this investigation are the hypotheses that firstly, the development of a research culture in general practice requires the development of positive attitudes to general practice research, and secondly, a means of prompting this attitudinal change is to provide GPs with the opportunity to engage in clinically relevant research that could provide evidence that is relevant to the care of individual patients. N-of-1 trials were hypothesised to be one such intervention.
In order to investigate these hypotheses, four discrete phases of research were conducted:
1 .analysis of research training and productivity of Australian general practice, as compared to medicine, surgery and public health;
2. a cross-sectional postal survey of research activity and attitudes of GPs in South East Queensland;
3. a systematic review of strategies aiming to develop a research culture in general practice; and
4. an investigation of the feasibility of using N-of-1 trials to change GPs' attitudes to research.
Research training was not incorporated in any practical sense into general practice registrar training. Even worse, research participation could actually prolong training. In contrast, the training programs of medicine, surgery and public health incorporated research training and research activity was mandatory. The comparative publication rate of general practice was very poor - during the 1 990s, only one research article per 1 000 GPs per year was published: 1/60th that of surgery, 1/100th that of medicine, and 1/150th that of public health.
The cross-sectional study of GPs' research activity and attitudes identified that GPs had a somewhat paradoxical relationship with research. On one hand, they believed it was necessary, but on the other, they preferred clinical experience over research evidence when making clinical decisions. Additionally, GPs were unaware of the information resources they had access to, although they acknowledged a lack of access being a barrier to research involvement. One third of GPs would have liked to have increased their involvement in research, and may have done so if provided with opportunities sympathetic to the general practice working environment.
The systematic review of strategies to develop a research culture and build research capacity in general practice identified 50 studies although very few were controlled intervention studies. The development and maintenance of a research culture appeared to be dependent upon trained, motivated and resourced researchers, working in supportive environments, collaborating with service GPs and other primary care clinicians who are both committed to, and willing participants in research. A work environment that supported research, both culturally through the norms and values of the organisation and practically through the allocation of resources, was a fundamental component of a research culture and its importance should not be underestimated.
N-of-1 trials use the research process to optimise prescribing for individual patients. However, the GPs' narrow conceptualisation of research limited their ability to recognise this. The empirical evidence resulting from N-of-1 trials was not always incorporated into the patient's clinical management, particularly if discordant with the GPs' clinical interpretation of the outcome. The impact of involvement in N-of-1 trials on the GPs' research attitudes and behaviours was difficult to measure.
Australian general practice lacks a research culture. N-of-1 trials are a theoretically promising intervention to change GPs' attitudes to research but their impact is difficult to measure. The entrenched culture of general practice militates not only against the introduction of novel interventions into routine clinical practice, but also the development of a research culture. However, there are GPs with positive attitudes to research and a desire for greater involvement in general practice research. Strategies are needed to identify these GPs, and provide them with opportunities to encourage and enable their active engagement in research.