Research in General Practice PDF
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Research in General Practice Research in General Practice SECOND EDITION J.G.R. Howie Professor of General Practice University ofE dinburgh SPRINGER-SCIENCE+BUSINESS MEDIA, B. V. © J.G.R. Howie 1989 Originally published by Chapman and Hall in 1989 Typeset in 911211 1112 Times Roman by Leaper & Gard Ltd, Bristol ISBN 978-0-412-33730-7 ISBN 978-1-4899-2981-5 (eBook) DOI 10.1007/978-1-4899-2981-5 This paperback edition is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, resold, hired out, or otherwise circulated without the publisher's prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent purchaser. All rights reserved. No part of this book may be reprinted or reproduced, or utilized in any form or by any electronic, mechanical or other means, now known or hereafter invented, including photocopying and recording, or in any information storage and retrieval system, without permission in writing from the publisher. British Library Cataloguing in Publication Data Howie, J.G.R. (John Garvie Robertson) Research in general practice. - 2nd ed. 1. Great Britain. Medicine. Research by general practitioners I. Title 610'.72041 ISBN 978-0-412-33730-7 Contents Acknowledgements vii Preface ix 1. Change, practice and research 1 Part one Thinking about research 2. Asking questions 19 3. Forming ideas 24 4. Reading the literature 31 5. Aims and hypotheses 40 6. Six ideas 42 Part two Doing research 7. Designing studies 59 8. Funding research 87 9. Organizing the work 95 10. Six projects 100 Part three Looking at results 11. Analysing results 137 12. Interpreting results 151 13. Successes and disappointments 168 Part four Telling about research 14. Writing about research 193 15. Speaking about research 199 16. The end of one story ... 208 17. . .. and the beginning of another! 224 Index 241 Acknowledgements In my first edition I wrote about my indebtedness to the many colleagues and friends who had helped develop my research ideas in general and had contributed to the projects which illustrated the book in particular. Many of them were friends and colleagues from my days in Glasgow and in Aberdeen and my indebtedness to them has not changed over the decade that has passed since then. Since moving to Edinburgh in 1980 I have had the help of all my colleagues in the Department of General Practice in Edinburgh, sometimes directly with the researchers described in this book and often through their taking on a much larger share of the clinical work involved in running our Department Practice than I do. In addition, new friends and supporters in the general practice and academic communities in Edinburgh have provided consistent and practical help without which the background material for this edition would not have been avail able. Even if it is invidious to name particular individuals when so many have played important parts, I could not do other than put on record my special thanks to Mike Porter whose hand and heart gave guided and contributed to so many of the issues the book explores. Others, including Fiona Paxton (or McCallum) Andrew Bigg, Jo Butt, Jack Taylor and Marjan Kljakovic, have made major contributions to the projects which illustrate the theory of research method; Ianthe Dingwall-Fordyce helped again with Chapter 12, in particular with the part on 'statistical techniques', and Bill Dodd contributed the part on 'computers' in Chapter 11. Pat Oliver, my secretary, produced an immaculate typescript against pressures of time and difficulties with handwriting, and did so with a patience and commitment that I have come to rely heavily on. To all, I want to express my most sincere thanks. For more than 25 years now, my wife Margot has been an unfailing support to me - and also a very considerable influence in helping my thinking and practice develop in the way they have; again my thanks. This book is yours too! Preface One of the paradoxes of general practice is that we emphasize on the one hand how important it is that the general practitioner learns to tolerate uncertainty, and then regret on the other hand that so few general practitioners research the uncertainties they find in their every day work. In the first chapter of my first edition of this book I suggested that general practitioners were missing opportunities to take part in a fascinating and rewarding professional activity because of an unnecessary fear of the unknown, and tried to encourage more to try research for themselves. There has been an impressive increase in what has been asked about, researched and written about in the last decade and this second edition tries to bring up to date the advice I think may help others to become involved in research for themselves. The basic principles of good research are of course timeless and apply to enquiry in any discipline. However, detail changes; there are new aids to reviewing literature, the increased emphasis in social science research has been matched by a range of new methods of collecting information, computers have revolutionized how data is handled and statistics is an ever-developing science in its own right. The chapters in this book which describe what can be referred to as the technology of the research process have been revised to reflect the impact of these recent developments rather than re-written. The context in which the researchers of general practice take place changes much more and in a more complex and less predictable way. The studies we carry out reflect new understandings of the cause of disease and of its natural history, new systems for delivery of care and changed and changing public and professional beliefs about illness, sickness and health. And each research project reflects something of the researcher himself and also of the community he belongs to. The chapters in this book which try to describe the practice of research as against its theory have been largely re-written and a new first chapter and two new chapters at the end of the book will hopefully mean that the second edition is different enough from the first to be of help and interest to old as well as to new readers. x Preface In one way the book has not changed. I have continued to write about research from a personal position partly because I know why I have done what I have done, and its strengths and weaknesses, in a way I cannot for the researches of others, and partly because I do believe research is at its best when the researcher believes in his question and feels for his project as it develops. I have learned a lot from doing research and enjoyed the challenge of writing about it. I hope that those who read this text will come to share my belief about the inseparability of the processes of questioning and caring in the work of a family doctor and will ask and try to answer some questions of their own. John Howie Edinburgh CHAPTER ONE Change, practice and research TIMES CHANGE Any contemporary history of general practice in the United Kingdom would almost certainly use the 1966 Charter as one of its central points, and to explain its importance would go back some 20 years further to the introduction of the National Health Service in 1948. The idea of easily accessible and free general practitioner services is one that has appeal to profession and public alike. It was perhaps pre dictable that provision of such a service would result in a high level of demand, and it was quickly apparent that the consequence of this, when matched with a quite insufficient level of clinical and admin istrative support, was going to be harmful to both general practice and general practitioners alike. Morale fell; emigration rose. Although many general practitioners rightly retained their personal standing, the status of the discipline as a whole fell to a level at which it readily assumed the mantle of the second-class profession which some, who should have known better, wished for. The 1950 Collings report on the standard of general practice in the United Kingdom was a significant marker for change. The foundation in 1952 of the College of General Practitioners was another key event, achieved despite difficulties which are impossible to comprehend now but were splendidly captured in the 25th anniversary issue of the Journal of the College (Watson, 1977). The Charter in 1966 was the end of the beginning of better times. The general practice of these two decades was almost devoid of academic content. There was virtually no teaching of general practice in the medical schools, although not quite none: there was only token vocational training, and what continuing postgraduate education there was was largely designed and delivered by people outwith the field. Almost no research was being undertaken. Again not quite none, because some giants of our past were attempting the crucial measure ments of the boundaries of our discipline and of the broad work within 2 Change, practice and research it on which so much of our present has been founded. Pickles, the first president of the College, showed that - as Mackenzie before him had rightly predicted - epidemiology belonged as much to generalists as to specialists (Pemberton, 1984). Fry (1966) and Hodgkin (1963) organ ized, recorded and described the details of their work across long periods of time. In 1955, 171 doctors in 106 practices collaborated to produce the first National Morbidity Study (an important census now repeated about once a decade) and local studies of equal ambition were carried out in various parts of Britain. Eimerl and Laidlaw's Handbook of Research for General Practitioners, first published in 1963 and reprinted in 1969, was a proper testimony to the then state of the art. The Charter paved the way for appointment systems, for proper reception, administrative and nursing support and for the chance to plan and deliver care purposefully. Health centres and group practices brought benefits to patients and doctors alike, reducing some of the isolation which limited and sometimes destroyed personal and pro fessional growth. Education developed at all levels. The undergraduate story has been told on several occasions (most recently in the Mackenzie Report (Howie, Hannay and Stevenson, 1986), and the Vocational Training Act of 1981 defined the postgraduate training now necessary for young doctors entering the discipline. Continuing education now has a proper diversity of faces, and the main current concern is how many doctors in practice it reaches. The clinical work and the organization of services has been widely researched and reported on. The literature of the subject owes its development to nurses, social scientists and specialists as well as to general prac titioners and is stronger because of this. The Government's 1986 discussion paper entitled Primary Health care - an Agenda for Discussion (Secretaries of State for Social Services, 1986) was another challenge or milestone ... or warning! It questioned whether primary medical care and primary health care were being given adequate room for separate development on the one hand and for integration on the other. It implicitly asked whether the general practice of the early 1980s had been synonymous with either, both or neither. Even if the document did not refer to the World Health Organisation's Alma Ata target of Health for All by the year 2000, other commentators on it have sensed the need to paint on a broad international as well as on a narrower national canvas. The paper picked up issues like audit and record keeping, like screening and prevention, like care for continuing health problems. It asked what were the special needs of client groups like the young, the elderly and those in inner cities. It questioned the way the 'team' works, and it
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