Research in the Family Physician's Office Alec J. Style, MB, ChB Nashville, Tennessee
Family medicine as a specialty has now "come of age." To maintain its new status, the specialty must be able to survive the vigorous assessment that is given other specialties by the public, the profession, and the academic community. One way of achieving this is for the family physician to do research of excellent quality and quantity. Traditionally, medical research has been done by secondary and tertiary care specialists and little has been done on the primary care needs of the black patient. The research done is of limited value for the family physician's daily work, a reason why family practitioners must do their own research. A research methodology has been described which is readily applicable to the family physician's office. It is an extension of good record keeping and ihcludes Problem-Oriented Medical Records, an Age-Sex Register, a Daily Worksheet or Encounter Form, and a Morbidity Index, incorporating the "Pri-Care" (ICHPPC) code. The system is simple to use and requires only a small increase in administrative time. Every family physician is encouraged to consider its use. To assume its rightful position amongst the other specialties in medicine, family practice must be subjected to the rigors of the scientific method. I
Several years ago it was popular to describe family medicine as a "specialty whose time had come." Since then the popularity of the specialty has risen enormously. This is reflected in the increase in residency programs and practicing family physicians. Recently, speakers at the Society of Teachers of Family Medicine's annual spring meeting in Atlanta spoke of famnily medicine having "come of age." I feel this is true and find it exciting and challenging. However, this new passage in family medicine's life cycle has created new demands and tasks to be met. One of these is to form an identity and expertise that will be able to survive the same critical, vigorous assessment that is given to other medical specialties by the public, the profession, and the academic commu-
Presented at the 82nd Annual Convention
of the National Medical Association, Los Angeles, California, August 3, 1977. Requests for reprints should be addressed to Dr. Alec J. Style, Division of Family Medicine, Meharry Medical College, 1005 18th Avenue North, Nashville, TN 37208.
nity. This may be achieved by doing research of excellent quality and quantity. It should reflect the uniqueness of family medicine as a medical specialty. The health care pyramid is a familiar concept which divides care into primary, secondary, and tertiary.2 For many years medical education, prestige, and money have been devoted to the secondary and tertiary levels, in spite of the fact that the primary care level, at the base of the pyramid, is the largest and the foundation of the other two. This same paradox is demonstrated by the amount of research being done at each level. The research work pyramid is the exact opposite. Research is not being done among the health care providers who are seeing the bulk of the patients. The type and relevance of research being done has important effects on family medicine. Many, if not most journal and research articles are still being written for the family physician by tertiary and secondary care specialists. The only way to correct this situation is for family physicians to do their own research and writing. The range of health care in family medicine is unique to its specialty.2
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
The family physician cares for a small, almost static population consisting mostly of families. He/she is responsible for the total health care of this group. Not only does he/she see a wider range of diseases and in different numbers, but also at different stages in the natural history of the disease. Much of the published research work applies to established disease. No wonder, that when the family physician applies these findings to his/her everyday work, the results are different. This is another reason for family practitioners doing their own research. There is a lack of data on the unique range of care which includes the early sick, the worried well, and the prospective and preventive care cases as applied to the private physician's office.3 We need to find out how the majority of these problems are already being solved. If necessary, we need to develop alternatives to determine if problem solving can be improved. Only physicians and health care providers, facing these mundane but important problems, can begin to provide these answers. Some key questions to be asked and researched in family medicine are (1) What do family physicians do in their daily work? (2) Why do they do what they do? (3) How can they do it better? (4) How can they teach what they do? If every family physician considered these four questions, a behavioral objective of the Canadian College of Family Physicians would become reality, that objective being "the physician shall understand the need for epidemiological, clinical, and operational research."4 There is an urgent need to do research in family medicine in order to maintain the academic respectibility and growth of the specialty and to answer everyday practical questions to improve the quality of the family physician's work. So far, little research has been done and the territory is almost virgin, especially in regard to the primary health care needs of black patients, both rural and inner city. 783
The average family physician is extremely busy, and feels that engaging in research does not include him or her. Any research methodology must be simple and not time consuming. It must be directly relevant to the day-to-day work of the busy physician. The record keeping and basic research gathering system, proposed in this paper, is an exterfsion of good record keeping and has been shown to involve no more than 10 to 15 minutes per day of physician time and about 30 minutes of secretarial time.1 This does not include setting up the system or subsequent analysis of the data acquired.
Types of Family Practice Research Family practice research covers three main subject areas: (1) operational (eg, billing and appointment systems); (2) epidemiological (eg, winter vomiting disease, infectious hepatitis); and (3) clinical (eg, therapeutic trials, disease descriptions).5 All areas have importance and may provide valuable information to improve the day-to-day operation of the family
physician's office. These subject areas may be investigated by three different methodologies. The first is by ongoing data gathering (eg, morbidity and workload monitoring). This is an extension of the regular office record-keeping system and is well documented. The second method is in special surveys within the office practice (eg, emergency calls, an appointtnent system, or the treatment of diabetes mellitus). These are projects with a definite time span, either long or short, which are set up in the physician's office to investigate a specific area of interest. As soon as the data are gathered, the project is stopped. Thirdly, there are special large-scale projects. These are multicenter projects. organized by a research center, often a university department which relies on the collective experience of several family physicians' offices. The research center either does the work on family practice patients or the basic work is done by family physicians on their own patients. The center organizes the data collection and processing. Family practice departments and organizations should 784
become involved in doing studies of this type.
Using the Offite Records for Research An office record system can provide many important functions. Three needing emphasis are (i) ihterprovider communication, (2) teaching and auditing, and (3) research. The last two functions are often neglected or thought to be appropriate only to model family practice units. However, I would suggest that they are appropriate for any family physiciah's office. There is now wide agreement on the components of the system to achieve these objectives.6-8 The basic components are (1) The ProblemOriented Medical Record, (2) Age-Sex Register, (3) Encounter Forms or Worksheets, and (4) A Morbidity Index using the Pri-Care code.
The Problem-Oriented Medical Records These consist of a defined data base, problem lists, assessments and therapeutic plans, structured progress notes, and flow charts. The system is familiar and widely accepted.
Age-Sex Register The register defines the active patieiit population of the office. It is a card-index system with a chronological listing of patients in order of their date of birth. It is customary to divide the index into male and female. By totalling the number of patients for each year of birth, it is possible to get an accurate profile of the age and sex distribution of the patient population. This has important clinical auditing and research value. It has become commonplace to add additional data to the age-sex register, although it is not necessary. In one of our offices at Meharry Medical College, Division of Family Medicine, marital status, address, occupation, years of schoolingi number of people in the household, and type of welfare, if any, are included. File cards for patients who have become inactive (ie, have not visited the office for two years) are removed
annually.
Encounter Form or Work Sheet Daily, each physician (or other health care provider) keeps a record of each patient he/she sees and a record of their problems which are divided into new and tecurrent. This enables the workload of each provider to be logged and easily assessed. The Encounter Form is essential to the use of the Morbidity Index.
Morbidity Index (Pri-Care Code) The Morbidity Index is a loose-leaf book containing index cards for each rubric or group of the Intemational Classification of Health Problems in Primary Care. A more common and practical name for this classification is the Pri-Care code. The Pri-Care code was developed by the World Organization of National Colleges and Academies of General and Family Practice (WONCA) specifically for use in primary care.9 The Pri-Care code contains 371 groupings or rubrics that reflect more realistically, the problems of family medicine, than previous coding systems. It covers physical, psychological, and social problems, healthmaintenance screening, monitoring of high-risk patients, and day-to-day administrative procedures. Another important componeilt is a section on symptoms which makes it possible to code symptoms which have not been organized into diseases. This fits the reality of family medicine. For each rubric, there is an index card for new problems and another for recurrent ones. A card is completed for each patient problem encountered, making it possible to get an accurate incidence and prevalence rate of problems within each office. It allows for location of names of patients for any rubric or diagnostic category. The latter is important for research auditing an d screening of specified problems. What is the use of these data once they have been collected? The posgibilities are endless. Hodgkins has given ten usesg° which are: (1) retrospective research and analysis of disease patterns, (2) pilot studies for prospective studies, (3) causal epidemiological checks for other physicians, (4) operational research and management, (5)
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
teaching, (6) preparation of papers for journals and meetings, (7) providing outside research projects with suitable volunteers or samples of cooperative p atients, (8) identifying high-risk patients, (9) preparation of questions for examinations, and (10) writing books.
described. It will provide adequate date for auditing, teaching, and research. There is no definitive proof, but speaking intuitively, the mnore the family physician knows of him/herself, his/her office, and the functioning of both, the greater the improvement of patient care and patient satisfaction.
Conclusion Although understanding the private
Literature Cited
plysician's reluctance to increase his paper work, the urgency for research among practitioners of family medicine has been emph4sized. A method of record keeping which may be used for daily patient care has been
1. MarsIand DW, Wood M, Mayo F: A data bank for patient care, curriculum, and research in family practice: 526,196 patient problems. J Fam Pract 3:25-26, 1976 2. Fry J: Common sense and uncommon sensibility. J Roy Coll Gen Pract 27:10, 1977 3. Carson S: A Manual for General Practice. Beecham Research Laboratories, New Zealand, section A, 1976
4. The College of Family Physicians of Canada: Canadian Family Medicine. Educational Objectives for Certification in Family Medicine. Notdated, p65 5. The Royal College of General Practitioners; The future general practitioner. Br Med J 1972, p 214 6. The College of Family Physicians of Canada: Manual for the Office Record. not dated 7. Froom J, Farley ES: An integrated system for the recording and retrieval of medical data in a primary care setting. J Fam Pract 1(1):44, 47; 1(2):45, 49; 1(3):43, 48, 1974; 2:37, 43, 1975 8. Wood M, et al: A systems approach to patient care, records, curriculum, and research in family practice. J Med Educ 50:1106-1112, 1975 9. World Organization of National Colleges and Academies of General and Family Practice: The International Classification of Health Problems in Primary Care. Contin Educ MAY:31-38, 1975 10. Hodgkin K: Towards Earlier Diagnosis: A Guide to General Practice. London, Churchill Livingstone, 1973, p 86
Accreditation, AMA and Conflicts of Interest The Federal Trade Commission's Bureau of Competition has informed the US Office of Education of the Bureau's concern regarding the action of the Office of Education's Advisory Committee on Accreditation 4nd Institutional Eligibility regarding medical education. The Advisory Committee has recommended that the Office of Education continue to recognize for two years [rather than for the normal four] the Liaison Committee on Medical Education (LCME), the sole agency presently recognized by the Office of Education to accredit US medical schools. In light of the Committee's recommendation, the Bureau of Competition renewed its previously stated concern with the fact that LCME is tied to and heavily influenced by the American Medical Association. "It is our view," the Bureau stated, "that because of AMA's significant influence over it, LCME does not protect against conflicts of interest, lacks autonomy, does not adequately reflect the community of interests affected by medical school accreditation, and lacks sufficient public representation." "...[O]ur principal concern is the inherent conflict of interest faced by a professional association such as AMA which largely controls or dominates the accrediting agency whose decisions govern entry into the profession in question. Artificial standards of quality or limitations stemming from commercial motives, which may be diffi-
cult to detect or establish, could be imposed for the purpose and with the effect of limiting supply and raising prices where the accrediting agency is significantly influenced by a professional association - such as AMA which has an economic stake in such limitation .. "In our view, this conflict-ofinterest problem can best be dealt with by entrusting accreditation to autonomous groups composed of representatives of a wide range of affected interests and a substantial number of public representatives, all designated by appropriate groups knowledgeable about those interests. Such broadbased representation would guard against the possibility that accreditation decisions might be made, or might be seen as being made, on a less than impartial basis. At the same time, the participation of professionals would provide the expertise necessary for sound accrediting. We believe that such an approach is not only consistent with, but indeed is required by, the applicable Office of Education criteria [for recognition of accrediting agencies] .. . The Bureau questions the advisability of recognizing LCME in its present form for the two-year period recommended by the Advisory Committee. The Bureau recommends that, at a minimum, LCME be specifically required within a one-year period to make significant and unmistakable changes designed to bring it into compliance with the applicable criteria.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
785
Family medicine as a specialty has now "come of age." To maintain its new status, the specialty must be able to survive the vigorous assessment that is given other specialties by the public, the profession, and the academic community. One way of achieving this is for the family physician to do research of excellent quality and quantity. Traditionally, medical research has been done by secondary and tertiary care specialists and little has been done on the primary care needs of the black patient. The research done is of limited value for the family physician's daily work, a reason why family practitioners must do their own research. A research methodology has been described which is readily applicable to the family physician's office. It is an extension of good record keeping and ihcludes Problem-Oriented Medical Records, an Age-Sex Register, a Daily Worksheet or Encounter Form, and a Morbidity Index, incorporating the "Pri-Care" (ICHPPC) code. The system is simple to use and requires only a small increase in administrative time. Every family physician is encouraged to consider its use. To assume its rightful position amongst the other specialties in medicine, family practice must be subjected to the rigors of the scientific method. I
Several years ago it was popular to describe family medicine as a "specialty whose time had come." Since then the popularity of the specialty has risen enormously. This is reflected in the increase in residency programs and practicing family physicians. Recently, speakers at the Society of Teachers of Family Medicine's annual spring meeting in Atlanta spoke of famnily medicine having "come of age." I feel this is true and find it exciting and challenging. However, this new passage in family medicine's life cycle has created new demands and tasks to be met. One of these is to form an identity and expertise that will be able to survive the same critical, vigorous assessment that is given to other medical specialties by the public, the profession, and the academic commu-
Presented at the 82nd Annual Convention
of the National Medical Association, Los Angeles, California, August 3, 1977. Requests for reprints should be addressed to Dr. Alec J. Style, Division of Family Medicine, Meharry Medical College, 1005 18th Avenue North, Nashville, TN 37208.
nity. This may be achieved by doing research of excellent quality and quantity. It should reflect the uniqueness of family medicine as a medical specialty. The health care pyramid is a familiar concept which divides care into primary, secondary, and tertiary.2 For many years medical education, prestige, and money have been devoted to the secondary and tertiary levels, in spite of the fact that the primary care level, at the base of the pyramid, is the largest and the foundation of the other two. This same paradox is demonstrated by the amount of research being done at each level. The research work pyramid is the exact opposite. Research is not being done among the health care providers who are seeing the bulk of the patients. The type and relevance of research being done has important effects on family medicine. Many, if not most journal and research articles are still being written for the family physician by tertiary and secondary care specialists. The only way to correct this situation is for family physicians to do their own research and writing. The range of health care in family medicine is unique to its specialty.2
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
The family physician cares for a small, almost static population consisting mostly of families. He/she is responsible for the total health care of this group. Not only does he/she see a wider range of diseases and in different numbers, but also at different stages in the natural history of the disease. Much of the published research work applies to established disease. No wonder, that when the family physician applies these findings to his/her everyday work, the results are different. This is another reason for family practitioners doing their own research. There is a lack of data on the unique range of care which includes the early sick, the worried well, and the prospective and preventive care cases as applied to the private physician's office.3 We need to find out how the majority of these problems are already being solved. If necessary, we need to develop alternatives to determine if problem solving can be improved. Only physicians and health care providers, facing these mundane but important problems, can begin to provide these answers. Some key questions to be asked and researched in family medicine are (1) What do family physicians do in their daily work? (2) Why do they do what they do? (3) How can they do it better? (4) How can they teach what they do? If every family physician considered these four questions, a behavioral objective of the Canadian College of Family Physicians would become reality, that objective being "the physician shall understand the need for epidemiological, clinical, and operational research."4 There is an urgent need to do research in family medicine in order to maintain the academic respectibility and growth of the specialty and to answer everyday practical questions to improve the quality of the family physician's work. So far, little research has been done and the territory is almost virgin, especially in regard to the primary health care needs of black patients, both rural and inner city. 783
The average family physician is extremely busy, and feels that engaging in research does not include him or her. Any research methodology must be simple and not time consuming. It must be directly relevant to the day-to-day work of the busy physician. The record keeping and basic research gathering system, proposed in this paper, is an exterfsion of good record keeping and has been shown to involve no more than 10 to 15 minutes per day of physician time and about 30 minutes of secretarial time.1 This does not include setting up the system or subsequent analysis of the data acquired.
Types of Family Practice Research Family practice research covers three main subject areas: (1) operational (eg, billing and appointment systems); (2) epidemiological (eg, winter vomiting disease, infectious hepatitis); and (3) clinical (eg, therapeutic trials, disease descriptions).5 All areas have importance and may provide valuable information to improve the day-to-day operation of the family
physician's office. These subject areas may be investigated by three different methodologies. The first is by ongoing data gathering (eg, morbidity and workload monitoring). This is an extension of the regular office record-keeping system and is well documented. The second method is in special surveys within the office practice (eg, emergency calls, an appointtnent system, or the treatment of diabetes mellitus). These are projects with a definite time span, either long or short, which are set up in the physician's office to investigate a specific area of interest. As soon as the data are gathered, the project is stopped. Thirdly, there are special large-scale projects. These are multicenter projects. organized by a research center, often a university department which relies on the collective experience of several family physicians' offices. The research center either does the work on family practice patients or the basic work is done by family physicians on their own patients. The center organizes the data collection and processing. Family practice departments and organizations should 784
become involved in doing studies of this type.
Using the Offite Records for Research An office record system can provide many important functions. Three needing emphasis are (i) ihterprovider communication, (2) teaching and auditing, and (3) research. The last two functions are often neglected or thought to be appropriate only to model family practice units. However, I would suggest that they are appropriate for any family physiciah's office. There is now wide agreement on the components of the system to achieve these objectives.6-8 The basic components are (1) The ProblemOriented Medical Record, (2) Age-Sex Register, (3) Encounter Forms or Worksheets, and (4) A Morbidity Index using the Pri-Care code.
The Problem-Oriented Medical Records These consist of a defined data base, problem lists, assessments and therapeutic plans, structured progress notes, and flow charts. The system is familiar and widely accepted.
Age-Sex Register The register defines the active patieiit population of the office. It is a card-index system with a chronological listing of patients in order of their date of birth. It is customary to divide the index into male and female. By totalling the number of patients for each year of birth, it is possible to get an accurate profile of the age and sex distribution of the patient population. This has important clinical auditing and research value. It has become commonplace to add additional data to the age-sex register, although it is not necessary. In one of our offices at Meharry Medical College, Division of Family Medicine, marital status, address, occupation, years of schoolingi number of people in the household, and type of welfare, if any, are included. File cards for patients who have become inactive (ie, have not visited the office for two years) are removed
annually.
Encounter Form or Work Sheet Daily, each physician (or other health care provider) keeps a record of each patient he/she sees and a record of their problems which are divided into new and tecurrent. This enables the workload of each provider to be logged and easily assessed. The Encounter Form is essential to the use of the Morbidity Index.
Morbidity Index (Pri-Care Code) The Morbidity Index is a loose-leaf book containing index cards for each rubric or group of the Intemational Classification of Health Problems in Primary Care. A more common and practical name for this classification is the Pri-Care code. The Pri-Care code was developed by the World Organization of National Colleges and Academies of General and Family Practice (WONCA) specifically for use in primary care.9 The Pri-Care code contains 371 groupings or rubrics that reflect more realistically, the problems of family medicine, than previous coding systems. It covers physical, psychological, and social problems, healthmaintenance screening, monitoring of high-risk patients, and day-to-day administrative procedures. Another important componeilt is a section on symptoms which makes it possible to code symptoms which have not been organized into diseases. This fits the reality of family medicine. For each rubric, there is an index card for new problems and another for recurrent ones. A card is completed for each patient problem encountered, making it possible to get an accurate incidence and prevalence rate of problems within each office. It allows for location of names of patients for any rubric or diagnostic category. The latter is important for research auditing an d screening of specified problems. What is the use of these data once they have been collected? The posgibilities are endless. Hodgkins has given ten usesg° which are: (1) retrospective research and analysis of disease patterns, (2) pilot studies for prospective studies, (3) causal epidemiological checks for other physicians, (4) operational research and management, (5)
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
teaching, (6) preparation of papers for journals and meetings, (7) providing outside research projects with suitable volunteers or samples of cooperative p atients, (8) identifying high-risk patients, (9) preparation of questions for examinations, and (10) writing books.
described. It will provide adequate date for auditing, teaching, and research. There is no definitive proof, but speaking intuitively, the mnore the family physician knows of him/herself, his/her office, and the functioning of both, the greater the improvement of patient care and patient satisfaction.
Conclusion Although understanding the private
Literature Cited
plysician's reluctance to increase his paper work, the urgency for research among practitioners of family medicine has been emph4sized. A method of record keeping which may be used for daily patient care has been
1. MarsIand DW, Wood M, Mayo F: A data bank for patient care, curriculum, and research in family practice: 526,196 patient problems. J Fam Pract 3:25-26, 1976 2. Fry J: Common sense and uncommon sensibility. J Roy Coll Gen Pract 27:10, 1977 3. Carson S: A Manual for General Practice. Beecham Research Laboratories, New Zealand, section A, 1976
4. The College of Family Physicians of Canada: Canadian Family Medicine. Educational Objectives for Certification in Family Medicine. Notdated, p65 5. The Royal College of General Practitioners; The future general practitioner. Br Med J 1972, p 214 6. The College of Family Physicians of Canada: Manual for the Office Record. not dated 7. Froom J, Farley ES: An integrated system for the recording and retrieval of medical data in a primary care setting. J Fam Pract 1(1):44, 47; 1(2):45, 49; 1(3):43, 48, 1974; 2:37, 43, 1975 8. Wood M, et al: A systems approach to patient care, records, curriculum, and research in family practice. J Med Educ 50:1106-1112, 1975 9. World Organization of National Colleges and Academies of General and Family Practice: The International Classification of Health Problems in Primary Care. Contin Educ MAY:31-38, 1975 10. Hodgkin K: Towards Earlier Diagnosis: A Guide to General Practice. London, Churchill Livingstone, 1973, p 86
Accreditation, AMA and Conflicts of Interest The Federal Trade Commission's Bureau of Competition has informed the US Office of Education of the Bureau's concern regarding the action of the Office of Education's Advisory Committee on Accreditation 4nd Institutional Eligibility regarding medical education. The Advisory Committee has recommended that the Office of Education continue to recognize for two years [rather than for the normal four] the Liaison Committee on Medical Education (LCME), the sole agency presently recognized by the Office of Education to accredit US medical schools. In light of the Committee's recommendation, the Bureau of Competition renewed its previously stated concern with the fact that LCME is tied to and heavily influenced by the American Medical Association. "It is our view," the Bureau stated, "that because of AMA's significant influence over it, LCME does not protect against conflicts of interest, lacks autonomy, does not adequately reflect the community of interests affected by medical school accreditation, and lacks sufficient public representation." "...[O]ur principal concern is the inherent conflict of interest faced by a professional association such as AMA which largely controls or dominates the accrediting agency whose decisions govern entry into the profession in question. Artificial standards of quality or limitations stemming from commercial motives, which may be diffi-
cult to detect or establish, could be imposed for the purpose and with the effect of limiting supply and raising prices where the accrediting agency is significantly influenced by a professional association - such as AMA which has an economic stake in such limitation .. "In our view, this conflict-ofinterest problem can best be dealt with by entrusting accreditation to autonomous groups composed of representatives of a wide range of affected interests and a substantial number of public representatives, all designated by appropriate groups knowledgeable about those interests. Such broadbased representation would guard against the possibility that accreditation decisions might be made, or might be seen as being made, on a less than impartial basis. At the same time, the participation of professionals would provide the expertise necessary for sound accrediting. We believe that such an approach is not only consistent with, but indeed is required by, the applicable Office of Education criteria [for recognition of accrediting agencies] .. . The Bureau questions the advisability of recognizing LCME in its present form for the two-year period recommended by the Advisory Committee. The Bureau recommends that, at a minimum, LCME be specifically required within a one-year period to make significant and unmistakable changes designed to bring it into compliance with the applicable criteria.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
785
