1. Community based research in primary care: a parable New opportunities for family medicine research WREN annual meeting 2008

2. Research (as we know it) is new Prior to the 1950’s much research was case reports, case series, expert opinion and the methods were primitive. Medical journals in the 40’s and 50’s were heavily surgical technique as medical treatments were new. Potions, notions, tonics and were popular as “new medicine”

4. Austin Bradford Hill and the RCT used randomization for the first time in1948 and described method of randomized controlled trial in 1952 Used streptomycin to treat tuberculosis in randomized patients Dealt with the issues of treatment vs. no treatment

5. Sir Richard Doll and smoking Found increased incidence of lung cancer in newly diagnosed patients who smoked over those that didn’t in 1950 The British doctor’s study, a longitudinal cohort study from early 50’s found similar relationship using statistical methods – correlational studies

8. First twenty years for family medicine We studied what we did –Educational research Residents, students, doctor/patient We measured what we could –Descriptive work was first – what did family doctors do?? We followed the money –Title VII, RWJ funding for faculty development –AHCPR became AHRQ

9. What we didn’t do Collaborate –Within academic medicine (we became our own worst enemy) –With each other – no networked research, no comparative studies. –We didn’t value our own (first class vs. coach) REALLY study what we did –Short term educational outcomes for residents, students and faculty – survey research –We would rather do it than study it Describe our role in the health system –No policy, Clinical Health Services research

10. We didn’t have the right tools No tools to count with (computer punch cards, data entry, surveys) Weren’t sure what to count – the denominator obsession No tools to measure results – intermediate measures of health – national data, not practice data (the Virginia Study) We were not able to visualize the forest

11. But is wasn’t ALL our fault Family medicine departments lacked intellectual venture capital We were treated like Bible salesmen in academic medical centers MPH was only avenue to research training –MPH is not a research degree –Epidemiology is not the godhead We only had one product to sell…graduates

12. But a lot of it was….. We had no academic tradition, journals or incentives in our systems We had no research pipeline We were led by results-oriented, publically responsive founders We kept looking internally rather than externally We wallowed in our anti-intellectualism and waited until the rest of education came to us, except….

13. ….they didn’t

14. Things changed, as they always do Fellowship training with research emphasis – NRSA for primary care “Research” could be said out loud Academic journals required better quality work and our work appeared in other journals Young faculty found friendly mentors – in other departments The research money for primary care came with HMO’s

16. The umtyumpth health care crisis to be continued in 2009 CostSafetyQuality

17. New opportunities for family medicine Focused research training led to funding –Areas of “expertise” such as prevention, chronic disease, AODA, Beginning to network across departments Beginning to link practice with research We began to do research on things that matter to the public

18. NIH funding ( Rabinowitz Ann Fam Med ) From $18 million to >30 million in 10 years (2003) (is >$50 2007) Half were in family medicine core departments (others in other fields such as cancer, health services, etc) Half were PhD’s Most new career development awards were family physician PI’s

19. But….. Percentage of overall NIH funding had not changed though amounts had AHRQ funding was flat to down Connection with non-core family medicine may mean that relevance is harder to see Departments were divided into haves and have nots (50% had grants) What is the future metric???

20. The Ketchup bottle theory of change the “bloop” of the “naughts” The NIH Roadmap and Clinical Translational Research Public health is struggling for relevance and needs partners Public/public partnerships Medicine is looking outside of the walls of medical schools and discovering applied research We are pushing national health care up the hill again

21. Clinical Translational Science Award (CTSA ) NIH funding for translational research to improve clinical practice and increase quality of patient care Community involvement is a requirement in grant development Infrastructure support for clinical research Opportunities to address improving health disparities

22. Family medicine is crucial to success of CTSA awards We have links to and are trusted by communities We understand translational research better than others We have experience with research networks We know how to listen

23. One reason that medical care may have less influence over community health than one might expect is a health care organization’s limited view of disease in a community. That is, most of the health care needs of a community never come to the attention of most health care providers.

24. Biomedicine Bench to beside Family Medicine And Communities Public Health Society

25. Clinical Population Health includes health outcomes, patterns of health determinants, patterns of health determinants, policies and interventions that link these two. policies and interventions that link these two. Begins with the practice but MUST include the community to be useful

26. Population-Based Health Service Delivery Model Feasible Community Health Services Needs of Population Environmental Influences Capabilities of Organization or System

27. We have new tools for research A Ubiquitous world –My first (palm) Pilot study Not just registries but population based knowledge –From health systems, public health and practices Electronic Health Records GIS and Health – health mapping Community health mashups

36. New tools: WEB 2.0 technology The practice as a social network Patient subgroups on the Practice website –Education, social support Portable web based EHR –Google – The Shared Care Plan of Whatcom County

37. New resources to fund ideas State, county, local health departments CDC Public Health Emergency preparedness Large Health Systems Clinical Translational Research through NIH Large employers