Author's response

The letter by Seamark and Seamark¹ is typical of the response from practice-based researchers on this subject. Privately, I have received several letters with the same themes — pride in the quality and publication of practice-based research, and disappointment and frustration that these efforts have not been adequately recognised. The Honiton Practice has an academic record that would be the envy of many Departments of General Practice, but Mathers et al² seems to have made them uncomfortable as to what their future role might be. The fact that it has taken 6 months for such a prestigious group of general practice researchers to ‘calm down’ indicates the level of offence that their statements have aroused.

The statements that Mathers et al made about practice-based research were short if not sweet. The message seemed to be that research is too important to leave to ‘gentleman amateurs’ and should be done by professionals working through university departments, Schools of Primary Care, MRC networks, NIHR, and the like. The reason for this was that single practitioner research ‘rarely results in a major contribution to the sum of our clinical knowledge,’ although they conceded that ‘such research has considerable benefits for the practitioner, the practice, and the patients.’ It was interesting that no attempt was made to apply the benchmark of ‘the best possible contribution to the knowledge-base of our discipline’ to the new professionalised approach, although it is ‘outstanding’ and ‘world class.’ The questions I would ask are, in whose opinion and in which world?

There is no doubt that this move towards the professionalisation of general practice research has largely come through our involvement with universities. When I became a senior lecturer in general practice in 1977, I joined a very small group of people who believed that being involved in teaching and research in that academic community would enhance the status and value of general practice. Most of us had worked for many years in ‘ordinary’ practice and had real passion for the discipline, but we joined universities that had a philosophical basis quite different from general practice. A long time has passed, and as was pointed out in my original letter, the nature of general practice research and its publication has changed. The subsequent debate has revealed a change in philosophy in academic and College circles that, I believe, we have to examine carefully.

The fundamental question is ‘What does the individual GP and their patients contribute to our body of knowledge?’

The source of the problem is that universities, research funding organisations, and presumably now the RCGP, are driven by a philosophy that Schon³ has called technical rationality. This he defined as: ‘an epistemology of practice derived from positivist philosophy, built into the very foundations of the modern research university, that holds that practitioners are instrumental problem solvers who select technical means best suited to particular purposes.’ In this model the individual GP's role becomes that of the mouse, the subject of the experiment rather than the investigator, or that of the ‘pimp for patients,’ attracting a fee for each patient recruited to a study. Schon described the desired product of this philosophy as: ‘rigorous professional practitioners who solve well-formed instrumental problems by applying theory and technique derived from systematic, preferably scientific knowledge.’

The main problem with this approach, according to Schon, is that: ‘the problems of real world practice do not present themselves to practitioners as well formed structures. Indeed they tend not to present themselves as problems at all but as messy indeterminate situations.’ If this is true, will these issues be picked up by large scale research networks driven by academics who do not know the real world? McWhinney⁴ describes the essence of our discipline as ‘an unconditional commitment to patients who have put their trust in us.’ He also deplores the fact that: ‘information is arrived at without knowing anything about those who are represented in the data. The investigator knows nothing about the most important work the physician has done listening to the patient.’ In contrast the advice by Mathers et al seems to be, that the future of general practice research lies in such a removed and abstracted method. It is interesting that an important paper on the essence of general practice⁵ identified ‘tension between a focus on interpersonal relationships and the increasing use and potentially dehumanising effects of information technology’ as a common theme throughout the project. If we are to research ‘that by which it is what it is’⁶ how else can that be done other than with our own patients?

In my view the clarification of the essence issue through research will require that at least a proportion of general practice researchers should be allied to the practice world and not to the alien academic world. In the words of Tudor Hart,⁷ why should this valid activity still be ‘regarded as a sort of personal hobby for unusual people which, like stamp collecting, should normally be unpaid’? What would be so wrong about funding real world practitioners to do research in their own practices? Who else but our own College should seek the funds for this to be done?