Becoming a Community-Based Physician Researcher

Abstract

Years ago, as a contented community family physician practicing with 4 physician colleagues, I focused on applying medical knowledge to help patients. After a young patient’s death from smoking I became interested in improving our strategy for helping smokers quit. A researcher offered us the opportunity to test a cessation intervention that had been successful in an academic setting. I was concerned that this study would interfere with my patient care duties until I visited a practitioner researcher in Wales. I was inspired and worked with a research professional to build colleague support and carry out this project. After this gratifying experience I had similar experiences working with other research teams. As an ordinary practitioner I had expanded my role to become significantly involved in research. In this role I was working with a team to improve patient care. It was a fundamental change that brought me great satisfaction.

Years ago, I was content practicing in a 5-physician office within a large multispecialty group. It was rewarding to have long-standing relationships with patients and to be part of an exemplary care system.

When a 34-year old patient who smoked died from lung cancer, I resolved to improve our strategy for helping smokers quit. A university investigator, Leif Solberg, ¹ MD, recommended an office cessation system that was effective in his setting but remained untested in community practice. His intervention involved medical assistants, an RN, and included brief cessation advice on every visit. He and his associates offered to help me organize a team to test the new strategy.

I hesitated because involvement might interfere with patient care duties. Also, my charges to patients were below average, a situation which could only be made worse by adding research responsibility. Nevertheless, I wondered what it might be like to work with a research team.

I had heard of JT Hart, a general practitioner researcher in Wales, during my military service in England. ² My family and I had planned a trip to England, and at Dr. Hart’s invitation we arrived in this bleak coal mining country on a rainy day. The office was unassuming on the outside; inside, high-quality education posters lined the waiting area. His wife Mary, an epidemiologist, greeted me at the door. As we walked around the office Mary explained their practice and projects. Dr. Hart and his team were addressing the high incidence of hypertension; they were implementing strategies to help patients reduce dietary salt and measuring their urinary sodium levels. Dr. Hart committed most of his time to patient care, Mary noted, but his role on the research team was crucial.

When I told her about my practice and research opportunity, Mary replied, “Work with that research team. You could contribute.”

I was inspired. Here was a physician doing exactly what I was considering, and it was working.

I set out to replicate Dr. Hart’s model of research working with a team that included a research scientist, Susan Sullivan Ph.D. We faced a number of hurdles. The experienced physician researchers on our institution’s research board questioned whether the study could be completed. They noted that the proposed intervention would be challenging to carry out and had been tested only at a practice site markedly different from our own. They were concerned about my lack of research experience and my limited time for this work. They noted the absence of a family medicine research tradition in our institution.

I felt like I did in my first year of college when my studies were overwhelming. I had attended a rural high school with a weak academic program and was poorly prepared for rigorous college work. But I was motivated and I succeeded.

We said that that the proposed intervention was innovative and deserved pilot testing at a community clinic. Dr. Sullivan noted that we had an experienced research team that was committed to collaborating with me to evaluate the intervention. I told the board that, as an established member of the medical group, I was committed to working with my colleagues to implement the system and to working with the research team.

Later that day that the chairperson called to say that board approved the project.

My office colleagues were concerned that the intervention would slow the pace of care and that the medical assistants smoked and might not cooperate. My colleagues agreed to try the strategy after Dr. Solberg met with us, expressed confidence that the strategy was workable and emphasized that we would be providing better care.

After a few months it was clear that the medical assistants willingly asked about tobacco use status, the physicians advised cessation routinely, referred frequently to an RN, and she counseled extensively. From time to time my colleagues and I had brief discussions about the challenge of providing brief cessation advice in various clinical situations and we gradually improved. ³ These informal discussions with colleagues were a major source of support for me as I worked on the study.

Two research nurses entered the data into a database, and I had brief regular meetings with the research team. After 31 months we found that the new system had substantial merit. I was astonished that 23 smokers, whom I knew well and did not think would quit, stopped smoking. ⁴

Through this experience, I became an ordinary practicing physician working with a research team on a significant project. I was energized by this scholarly activity. This work was manageable. I was able to make important contributions to this investigative work but also able to carry out my practice duties. My patient schedule did not change and my productivity was stable. This research was needed in the real world of practice and was one of many important issues that can only be studied in the office setting with practicing physician involvement. I had similar experiences as I continued to provide the practitioner perspective as a member of other research teams for 15 years.^5-7

My approach to my professional activity changed in a fundamental way. I continued to study to take care of patients but also, in my new role, I studied to advance medical knowledge. It was a change that brought me great satisfaction.

Addendum

Physicians can learn more about practice-based studies by attended a meeting where these investigations are presented. One such meeting is the annual North American Primary Care Research Group practice-based Network conference. There is information at NAPCRG.org. Also, physicians could join one of the many primary care practice-based research networks associated with Departments of Family Medicine. Members can participate in network organized studies. When this happens, it is important to understand not only the main issue of the study and the research question but also exactly what is required to participate.