The Future of Family Medicine: Research
This is a time of great change in our understanding of health and illness and in our health care systems in North America. Family medicine researchers must understand the changing landscape of health care and health care research, appreciate the threats to the status quo of primary care research, and seize new opportunities to bring their unique perspectives to health care research in this changing environment. Otherwise, we risk missing an opportunity that will not come again.
The changing landscape
The Genome
In the post-human genome era, we anticipate being able to predict disease risks in individuals and to tailor interventions to specific patients. The genetic mapping of patients with chronic illnesses is clarifying why some drugs work only in some people and why one dosage schedule does not work for all patients. There is a growing appreciation of the particularity of human illness that never existed before among bioscientists. For example, Mrs Jones’ diabetes is a different disease from Mrs Smith’s. We can therefore anticipate designer drugs tailored to individuals, and genetic alteration to prevent expression of disease. If we snip the human genome and replace bad genes with good ones, most of the illnesses that plague us will disappear.
If only it were true! The word “genohype” has been used to describe the current magical belief that genomics will provide the answer for every question.1 Clearly genomics does hold great promise for increased understanding of molecular causation, but chronic illnesses are complex systems. Genetics only describes part of the variance.
The more molecular medicine becomes, the more we need “whole person” physicians. Simply because we can do something does not mean that we should do it. Key questions include: What are the ethical issues that concern predictive genetic testing and selective abortion for minor abnormalities? Does selective abortion for Tourette syndrome really differ in ethical terms from preferential selection for male fetuses? How will patients make choices about genetic testing and to whom will they turn for advice? What are the consequences for individuals, couples, and families of predictive genetic testing?
Technology
New technologies are expensive, often relatively untested when they hit the street, and not necessarily better than what they replace. Although I appreciate having access to ultrasound and computed tomography scans, the consequences can include unnecessary cesarean deliveries and expensive tests replacing good history taking. Access to technology depends on location, so rural patients are either differentially deprived or differentially protected, depending on the technology and your perspective.
Information technology continues to evolve, blessing us with increased access to information and cursing us with unselective provision of data. The promise of evidence-based medicine—like that of genomics—is an over-promise, a chimera: We have trial evidence to inform practice for only a minority of conditions, and even that information needs to be considered in relation to the particulars of individuals in the context of their lives. Yet there is a magical belief among some policymakers and even some specialists that evidence-based medicine will allow the development of infallible guidelines that will replace the need for physicians—at least for our kind of physician. Can a Web physician replace family physicians? Can patients and physicians problem-solve together when they are educated from trusted Web sites?
Public expectation
In this changed world, the public expects perfect care with no risk of negative outcomes, be they from birth or blood product. There is a mythical belief that perfect care is possible, and consequently disappointment and anger result when inevitable errors occur. Can we discover how to minimize risk? Can we explore the notion of informed consent?
Population health, health promotion, and ecosystem health
We know that proper nutrition, exercise, avoidance of harmful substances, and reduction of stress can only be negotiated in the context of relative economic and social stability. Prevention depends on social change, such as education (especially for women), jobs, and fair wages. At the same time, as physicians we try to motivate our individual patients to change behavior, knowing that it will improve individual health outcomes. How can such change be best facilitated? Are there potential negative consequences from focusing on the individual? What is the role of the family physician in achieving social change?
Our patients face health risks from pollution, climate change, and violence. In caring for individual patients, most family physicians rarely need to consider these issues. They may demand political and policy actions; however, since the impact of such actions on health will far surpass the usual causal pathways of human illness that we recognize, these actions must be based on sound data. Is there a role or even a responsibility here for family physicians? Should the principles of participatory action research2 be a core skill for family medicine training programs, given that family physicians are ideally placed to assist community development?
