Vol 59: MARCH • MARS 2013
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Canadian Family Physician•Le Médecin de famille canadien315
Section of Researchers
•Section des chercheurs | Hypothesis
Family medicine research
One man’s road
Marshall Godwin
MD MSc FCFPI
n recent years, I’ve taken up writing novels. I think perhaps I have a different approach to novel writ- ing than most people. When I start to write, I have a sense of what the book will be about generally, but I don’t have a detailed plot outline or character descrip- tions. Those details work themselves out as I meander down the road before me. I’m sort of making it up as I go, to paraphrase Indiana Jones.1 My approach to my research career has been a bit like that too. Yet, in the end, it has been successful—so it seems.*Setting out
When I started down the path of family medicine research, or primary care research, if you like, I didn’t know where I was going exactly, or how to get there. I only knew I wanted to do research to better understand the field of practice and study I had chosen for my life’s work. In fact, I was so unfocused (apart from my fascination with fam- ily medicine), and so wet behind the ears, that I was ec- static when Canadian Family Physician agreed to publish a manuscript I had written on the results of a small chart- based project I’d completed. It didn’t bother me one bit that they were publishing it as an example of “how not to do research.” All I heard was that they were going to publish it—my first article in a peer-reviewed journal! My research career was off to a blazing start!2
I bumbled my way along for a while. Having no formal research training, I had to learn on the job. I discovered that not every theory, no matter how brilliant, proves true. I found a few experiences especially helpful: the back and forth of the peer review process; working with small local granting agencies; and collaborating with more senior colleagues as a co-investigator on bigger projects. Eventually I was ready to take the leap to be principal investigator on grants from agencies such as the Canadian Institutes of Health Research and the Heart and Stroke Foundation of Canada.
Exploring
In health and medical research there is an assumption that to be successful one must have a focus, an area of
study that is narrow and in which one becomes expert.
On the surface, this seems reasonable. But the problem is that as family physicians we are, by definition, gener- alists. We are interested in nearly everything—our spe- cialty is generalism! Narrowness is the antithesis of who we are. As a result, I have completed research and pub- lished on a range of topics, including but not limited to Papanicolaou smears; thrombolytic therapy; interacting with pharmaceutical representatives; children’s growth charts; diabetic neuropathy; sex bias in end-stage renal disease; hypertension; graduating physicians’ practice choices; blood pressure monitoring; measuring lifestyle;
diabetes management; and care of the elderly.No real pattern in or focus to that range of topics—at least, none that is obvious—but they do share a theme. Every sub- ject I research is viewed from the perspective of family medicine or primary care. To capture this perspective demands a wide-angle lens.
My work has developed more of a focus over time—
not so much on content, although there are areas that have drawn more of my attention over the years—but on methodology. Most of my success in the past 10 years has involved the use of a specific methodology—
the pragmatic randomized controlled trial (RCT), usu- ally with cluster randomization, but not always. I am not referring to RCTs on drug efficacy using placebo control, which are important in the advancement of drug treat- ments but which I have found totally unrewarding. I tried those types of studies years ago and decided that they were my own idea of “how not to do research.”
Nonetheless, I found that an adaptation of the RCT methodology can be very useful in studying interven- tions in primary care. When studying, for example, home blood pressure monitoring, algorithmic approaches to hypertension management, the use of care plans for the elderly, or health coaching to improve lifestyle, there are certain standard RCT things you can’t do. You can’t design a placebo pill for the control group; you have to use something like “usual care” as the control. And it is not possible to keep the study subjects blind to which group they are in—or to keep the researchers in the dark, for that matter—but it is possible to collect baseline data before randomization and have the stat- istician do a blind analysis without knowing which is the intervention group and which is the control group.
You often need to use cluster randomization and then, because many patients have the same family doctor, use a larger sample size and various statistical procedures
*In 2012, Dr Godwin was named Family Medicine Researcher of the Year by CFPC’s Section of Researchers.
The award recognizes a family medicine researcher who is also a CFPC member and who has made original con- tributions to research and knowledge building for family medicine in Canada. This article is based on the speech Dr Godwin gave for Family Medicine Research Day at Family Medicine Forum on November 14, 2012, in Toronto, Ont.
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Canadian Family Physician•Le Médecin de famille canadien|
Vol 59: MARCH • MARS 2013Hypothesis
to compensate. It is effectiveness outcomes you are looking for, rather than efficacy, which means the exclu- sion criteria need to be limited; you have to balance internal validity with generalizability. I won’t belabour the idea, but suffice to say my focus has been on this methodology rather than on a specific content topic.
Focusing
My road started off very bumpy and very wide; over time it became smoother, and less broad, but its narrowing was more due to how I did research than to a narrow- ing of research topics, although there is only so much one can do. My main focal points now are hypertension, lifestyle, and the elderly, but my methodology is almost always the same—the pragmatic randomized trial.3 It has been the small successes along the way that have kept me going, I think. Perhaps it’s like golf: you spend days, weeks even, doing poorly, and then you get that one solid connection with the ball and it goes straight and true. The feeling is so good you keep coming back, just to get that wonderful sensation one more time, even if it takes days, or weeks. And, yes, it has been like writ- ing a novel. Making it up as you go along, little by little the blank pages fill with events and people and some
kind of a story line. And when your peers read and rec- ognize your work it makes the journey all the sweeter.
Dr Godwin is Interim Chair of Family Medicine, Director of the Primary Healthcare Research Unit, and Professor of Family Medicine at Memorial University of Newfoundland in St John’s.
Competing interests None declared References
1. Spielberg S, director. Raiders of the lost ark. San Francisco, CA: Lucasfilm Ltd;
1981.
2. Godwin M. Treating urinary-tract infections: which antibiotic? Can Fam Physician 1987;33:2242-4. Available from: www.ncbi.nlm.nih.gov/pmc/
articles/PMC2218540/pdf/canfamphys00188-0076.pdf. Accessed 2013 Jan 31.
3. Godwin M, Ruhland L, Casson I, MacDonald S, Delva D, Birtwhistle R, et al. Pragmatic controlled clinical trials in primary care: the struggle between external and internal validity. BMC Med Res Methodol 2003;3:28. Epub 2003 Dec 22. Available from: www.ncbi.nlm.nih.gov/pmc/articles/PMC317298/
pdf/1471-22883-28.pdf. Accessed 2013 Jan 31.
Hypothesis is a quarterly series in Canadian Family Physician, coordinated by the Section of Researchers of the College of Family Physicians of Canada. The goal is to explore clinically relevant research concepts for all CFP readers. Submissions are invited from researchers and nonresearchers. Ideas or submissions can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website www.cfp.ca under “Authors and Reviewers.”
