Summary

There are major difficulties facing academic family medicine in Hong Kong. Academic positions are limited and resources for research are restrained. However, we believe there is much that family physicians in private practice can contribute. Private family physicians can research and publish by themselves, or in collaboration with local and international researchers. The major strengths are that private family physicians are exposed to a wide spectrum of diseases, different from hospital specialists. They are exposed to diseases at their early stages and can make observations from long continuous care. They might have difficulties such as the lack of motivation and initiatives, the lack of well defined research topics, lack of skills and experience, of funds, of access to research laboratories and other support, problems with ethics approval, and lack of computerised medical records which can all be overcome by various strategies.

摘要

香港家庭醫學的學術發展受到缺少學術性職位和資源的限制，但我們深信私人執業的家庭醫生可以在研究方面做出巨大貢獻。家庭醫生可以個人發表或者和本地以至國際性的研究組織合作。家庭醫生與醫院專科醫生不同，他們的強項在於可以診治各種不同疾病，在疾病早期接觸到病人，並可以做長期跟進觀察。主要的困難包括：積極性不夠；欠缺嚴謹選擇的研究題目；技術經驗不足；缺乏資金；使用實驗室不夠方便；醫學倫理的問題，還有缺乏電子化醫療記錄，但以上種種問題都可通過各種方法解決。

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Introduction

Family physicians have much to contribute to clinical research. One of the authors (AL) has described that the major difficulties facing academic family medicine in Hong Kong are limitations in academic positions and restraints in resources.¹ We believe that apart from full-time family physicians in academic practice, family physicians in private practice can also contribute much to research.

Private family physicians can do research and publish by themselves,² or in collaboration with their local academic counterparts,³ with local specialists in other specialties,⁴ and also in collaboration with overseas researchers.⁵ We discuss here the strengths of private practitioners in research and suggest solutions to overcome difficulties.

The strengths

Family physicians, especially private family physicians, are exposed to a spectrum of diseases which are highly dependent on the demographic characteristics of their practice not readily seen by specialists in other fields. A doctor in a residential district with a large number of new immigrants might be alerted to specific health problems among immigrants. One of the authors (AC), for example, has developed interest in paediatric viral exanthems.

Private family physicians are highly accessible to treating, and thus in excellent positions to investigate, diseases at their very early stages. Viral infections serve as good examples. To demonstrate that a systemic viral infection is associated with a clinical illness, the investigator needs to identify the viral DNA or RNA in tissue samples, in plasma and in some cases in peripheral blood mononuclear cells at the acute stage. For viruses such as the herpes viruses with inherent properties of having latent infection and reactivation, the gold standard for diagnosing primary infection is seroconversion. To demonstrate this, both acute and convalescent sera must be available to be investigated in parallel. By the time these patients are referred to hospital specialists, only the convalescent serum would be available, and thus although active infection can still be ascertained for some cases, the distinction between primary infection and reactivation may be impossible. One of us (AC), for example, had been able to demonstrate that some cases of Gianotti-Crosti syndrome were related to human herpesvirus 6B infection as he was able to recruit children in the very early phase of the eruption.⁶

The long-term continuous care offered by private family physicians confers definite advantages for research. Studies on long-term complications of chronic diseases are made possible. Data on relapse of disease can also be collected. One example is a case report by one of us (AC) describing the extremes in duration of the rash in a viral exanthem.⁷ However, unlike in countries such as the United Kingdom where each patient is registered with a specific general practitioner, patients in Hong Kong tend to shop around for their doctors, thus significantly weakening the quality and advantages of such continuous care.

Albeit without any solid evidence, we believe that the rates of successfully recruiting study- and control- subjects are higher for private family physicians who are usually familiar with their patients. The default rate following recruitment is also likely to be lower as the researcher is also the personal doctor of the patients.

Private family physicians do not have an obligation to publish for contract renewal or assessments to get promotion. This allows them to work at their own pace and along their own lines of interest relatively independent of departmental policies or politics. Bureaucratic considerations and interference are minimal.

The weaknesses and how to overcome them

The lack of initiative is probably the commonest reason for private family physicians not participating in medical research. In a local study evaluating the outcomes of a postgraduate diploma course in family medicine,⁸ many students reported that the research component was not useful for their subsequent professional development.

We believe that research is interesting and exciting, and can provide an alternative to the otherwise mundane routine in office work. To provide motivation, universities may assist in organising research networks and grant research degrees. Honorary and part-time academic appointments can also be granted to recognise one's achievements in research. Private family physicians might be invited to deliver seminars or lectures to disseminate their research results, and provoke further discussion among peers. More space can be allotted in medical directories for the doctor's indexed publications. Moreover, research performance might be considered to be included as one of the components for higher training and for exit assessment by our Hong Kong College of Family Physicians and the Hong Kong Academy of Medicine.

Private family physicians might find it difficult to define suitable research topics. Research should have some element of originality. Private practitioners in their less busy schedule might reflect on questions for which answers are incomplete or absent in the medical literature. The advantage of choosing common conditions seen in their clinics is that study subjects are readily available. However, it might be intriguing to think of original or unanswered questions for such conditions. One of the authors (AL), when he was in private practice, thought of a research question whether family doctors should advise hepatitis A vaccination for adolescents. This led to a study on the sero-epidemiology of hepatitis A.⁹ On the other hand, quite original research questions are usually readily available for the not so common but not so rare conditions. A low subject recruitment rate can be compensated by having collaborative research with other family physicians.

The lack of skills and experience in research is another hurdle to overcome. Local universities can train students with adequate research techniques. We believe that an interest in research is best cultivated during the undergraduate years. The incorporation of research into the medical curriculum may act as a way forward. The term bimodal medical school has been applied to medical schools which excel in both training primary care physicians and securing research grants.¹⁰ The local universities have timely introduced diploma and masters courses in biostatistics and biomedical sciences. Family medicine units of the local universities can offer support in study design. Discussion with experienced investigators helps overcoming the novice inertia for budding investigators.

Statistics play an important role in quantitative research. Online courses¹¹ offer solid background knowledge. Some websites¹² compute online and import data directly from excel files. These are indispensable for projects needing only elementary statistics. For projects involving high profile statistics, one may have to collaborate with academic family medicine units or medical statisticians with special interests.

The role of qualitative method is increasingly being recognised, although there are still difficulties for acceptance in some scientific communities.¹³ Private family physicians might consider a flexible combination of qualitative and quantitative methods when approaching their projects. For systematic reviews, free software is available from the Cochrane Collaboration¹⁴ for investigators appointed as reviewers.

Funds for private family physicians to apply for research are scarce. Local academic family medicine units can assist in writing grant applications. Should the practitioner belong to one of the Royal Colleges or overseas medical organisations, more sources for funding are possible. Another option is to collaborate with local and overseas universities. As long as the research project is potentially publishable, and that the practitioner has study- and control- subjects at hand, many academic colleagues are more than happy to collaborate. Moreover, there have been much research conducted in the primary care sector which is not funded and yet successfully published.¹⁵ Innovative studies need not be expensive studies.

Limited access to research laboratories, statisticians, clinical trial specialists, and research assistants inhibits research activities.¹³ As long as the research topic is of great potential for publication, specialists in academic sectors are usually keen to collaborate. Other family physicians in the same district or with similar interests can be mobilised to participate. Local academic family medicine units can also offer logistical support.

However, as local academic colleagues may not always be pursuing the same lines of research as private family physicians, collaboration has to be international in some circumstances. One of us (AC) has been able to collaborate with researchers in the two local universities as well as researchers in America, United Kingdom, France, Turkey, Kuwait, and India in his current research projects. Collaborations have been in terms of laboratory support, statistical results, provision of expert advice, and recruitment of research subjects.

It has been shown that the most efficient way to recruit practices for participation in research is targeted mailings and phone calls, followed by on-site practice meetings.¹⁶ Library access can be provided by universities and medical associations.

The lack of access to ethics approval is a frequently unrecognised lacuna in the local private research scene. Institutional ethics committees usually only consider applications with the principal investigator or one of the co-investigators being their full-time staff. Unless and until medical organisations such as the Hong Kong College of Family Physicians or the Hong Kong Academy of Medicine establish ethics committees for their members, private family physicians are best to collaborate with a full-time staff of the universities or the Hospital Authority.

In the United States, it has been shown that computerised medical records facilitate research for physicians in institutions, whereas manual retrieval of such mostly in private settings is slower and incomplete.¹⁷ This may also hold true in Hong Kong. The adoption of computerised records and disease registers facilitates both research and clinical audit and should be encouraged. However, some private family physicians may need assistance for themselves and training for their staff in the adoption of computerised records, which has time and cost implications.

The familiarity with study subjects is a two-edged sword. The patient might feel himself subject to coercion in being recruited as a subject for study in a research project. Most recruitment consent forms state that the management of the patient is not be affected whether the patient participates in a project or not. Investigators should explicitly endorse such statement in words and deeds. Any financial reward by participating in a research must be approved by the ethics committee. The provision of free medical consultation and treatment is a kind of financial reward, and thus should not be offered as a bait to recruit subjects unless this has been properly endorsed by the ethics committee.

Discussion

Private practitioners in other specialties such as in paediatrics¹⁸ and psychiatry¹⁹ are increasingly contributing to clinical research. In the United States, a national clinical research enterprise is being proposed to be established for public-private partnership in research.²⁰ Should our vocational programme incorporate some elements, perhaps optional, of research for our trainees? Should there be a streamlined career path they can pursue to academic family medicine? Are private family physicians necessarily less curious than their academic colleagues? Most family physicians in Hong Kong, vocationally trained or not, are not engaging in active research. Appropriately motivated and mobilised, they can contribute greatly and complement their academic colleagues to put Hong Kong on the world map of family medicine research.

Conclusion

Research is the backbone of a clinical discipline. Research by private family physicians in Hong Kong is possible, if they are appropriately motivated and mobilised. There are both strengths in having private family physicians engaging in research as well as problems to be encountered but the latter are not impossible to overcome.

Key messages

1. Research is interesting and exciting. It is the backbone of a clinical discipline.
2. Family physicians in private practice can conduct research by themselves, and in collaboration with local and overseas researchers. They have unique advantages.
3. Most of the difficulties can be overcome. Support from local universities and institutions as well as from overseas researchers are vital.

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References