FAMILY MEDICINE RESEARCH IN THE UNITED STATES: FROM THE LATE 1960’S INTO THE FUTURE

Abstract

When the new field of family medicine research began a half century ago, multiple individuals and organizations emphasized that research was a key mission. Since the field’s inception, there have been notable research successes for which family medicine organizations, researchers, and leaders – assisted by federal and state governments and private foundations - can take credit. Research is a requirement for family medicine residency programs but not individual residents, and multiple family medicine departments offer research training in various forms for learners at all levels, including research fellowships. Family physicians have developed practice-based research networks (PBRNs) to conduct investigations and generate new knowledge. The field of family medicine has seen the creation of new journals to support the publication of research relevant to practicing family physicians. Nonetheless, in spite of much growth and many successes, family physicians and their research have been underrepresented in research funding. Clinical presentations in family medicine are often complex, poorly-differentiated, and often exist as one of several patient complaints and diagnoses, and are not well-covered by the narrow basic-science and specialty research that defines most of the biomedical research enterprise. Overall health in the United States would benefit from a more robust research participation and greater support for family medicine research.

INTRODUCTION

Although the Society of Teachers of Family Medicine traces its history back to its first meeting in 1967, the field of family medicine officially started in the United States (US) in 1969 with the approval of family practice as a specialty by the Liaison Committee for Specialty Boards. Family medicine was not created to advance science, rather to provide medical care to any and all US communities. Within that context, a key question for this new discipline was whether it would have its own intellectual scholarship. The answer was that it would engage in both practice and scholarship -- through support of evidence-based medicine and by identifying new areas of investigation. A clinical discipline with academic rigor that included research as a key intellectual underpinning. This paper highlights how family medicine research emerged concurrently with the profession, the types of research done by and for family physicians, how the discipline developed its research capacity and funded family medicine research, and the history of the family medicine journals emphasizing research. While we provide select examples to illustrate some of the discipline’s challenges and successes over the first 50 years, our review is neither exhaustive nor complete.

FAMILY MEDICINE RESEARCH IN THE EARLY YEARS

Before 1967

Research in family medicine developed out of the research traditions of ‘general practice’. Epitomizing a general practice researcher in the United States was Dr. Curtis Hames. Known for collecting and storing blood samples and tracking medical histories from his patients in rural Georgia, Dr. Hames was funded from 1958 to 1995 by the National Institutes of Health (NIH). His Evans County Heart Study produced more than 560 published research articles.^1,2 Dr. Hames’ research exemplifies one of the most common research methods in family medicine – the observation of patients over time.

Within 5 years of Dr. Hames’ pioneering work, the World Health Organization Expert Committee on General Practice released a report that stated family practice had a ‘peculiar’ responsibility to do research.³ With the founding of the field of US family medicine soon thereafter, family medicine leaders clearly articulated that no other specialty was paying attention to research that addressed the needs of general-practice patients, as exemplified in Kerr White’s “Ecology of Medical Care” article in 1961.^4,5 The extant research was based in the laboratory, or at referral centers, and did not reflect patient populations of family physicians. Family physicians argued for person-centered, whole-person, symptom-based -- not disease-based -- research and medical-care classifications. The problems patients bring to their family physicians often exist between wellness and illness – leaving a research chasm that still exists today.

Major Successes in the First 10 Years

Within 10 years of the first formal residency training in 1969 and board certification, family medicine research experienced early successes. The North American Primary Care Research Group (NAPCRG) formed and age/sex registries, encounter forms, and indices of health status were in common use.⁶ A major study, the Virginia Study, involved tracking of 526,196 patient-care problems for 88,000 patients by 118 family physicians during a two-year period.^7,8 This report defined the early practice content of the discipline of family medicine.⁹

THE WHAT, WHERE, AND HOW OF FAMILY MEDICINE RESEARCH

To try to capture the need for pertinent, useful research, various classifications have been used, such as by disease, by level of prevention (primary, secondary or tertiary), by methodology used, or by the type of patient. Early in the family medicine research trajectory, Dr. Geyman noted the general taxonomy for family practice research areas to be: 1) epidemiological and clinical research; 2) health services research; 3) behavioral research (including the impact of social changes); and 4) educational research.⁶ Much of family medicine research today fall one within one of these categories. And, while most of that research would be considered “clinical”, there is also much educational research, driven by the need to ensure family physicians provide excellent patient care.

The concurrent needs for real-world research and collaboration between academic centers and practicing family physicians led to the emergence of Practice-based Research Networks (PBRNs).⁷ One of the earliest was the WWAMI PBRN coordinated by the University of Washington, created with a grant from the Kellogg Foundation in 1975 (Personal Communication John Geyman MD). The later establishment of the national Ambulatory Sentinel Practice Network (ASPN) in 1981 was critical to the further development of PBRN’s.⁸ When ASPN had financial difficulties, the American Academy of Family Physicians (AAFP) provided core support, and then created the National Research Network for practice-based research in 1999.

As to other types of exemplar research with family physician involvement, there was widespread participation of family physicians in the large Women’s Health Initiative. And the seminal observational study, the Direct Observation of Primary Care study, was undertaken by family physician Dr. Kurt Stange and his research group.⁹

Within the realm of health services research, multiple changes, many about the financing of health care, have led to substantial increases in research on how to improve the practice of family medicine, such as research on Patient-Centered Medical Home models.¹⁰ More recently, the Center for Medicare and Medicaid Services has funded research on innovative models of care delivery at the state level relevant to the practice of family medicine.¹¹ The increasing recognition of the behavioral and social determinants of health further increases the need to incorporate appropriate measures.

Another type of scholarship that is of particular interest to family medicine is synthesis research, which includes systematic reviews, meta-analyses, narrative reviews and commentaries that lead to statements on how and what to do in practice. As an early example, Drs. Frame and Carlson organized important preventive medicine concepts for clinicians in a series in the Journal of Family Practice (JFP).^12–15 Another type of synthesis research is exemplified by the US Preventive Services Task Force (USPSTF) that was authorized by the U.S. Congress to evaluate and make recommendations about preventive services in 1984. Given its emphasis on issues pertinent to family medicine, the USPSTF has had multiple family physician members and leaders.

CAPACITY BUILDING AND RESEARCH TRAINING

From the early years, some family physicians argued that the development of new knowledge required more training of family physicians in research.¹⁹ Specific requests by that early group that have become reality include the Residency Review Committee (RRC) requiring the inclusion of research opportunities in family medicine residency accreditation, the establishments of research fellowships, and “Family Medicine Research Centers.”

Residency Research Requirements

The first accreditation standards for “family practice” residencies in 1969 mentioned research training,²⁰ which was not true for the accredited “general practice” residencies that predated the family medicine programs. Research participation by the trainee was not required, but “encouraged.” Currently, there is a “must” in the residency training language for “an environment of inquiry and scholarship with an active research component” with “some members of the faculty demonstrating scholarship”.²¹ The language for the residents advanced to include “residents should participate in scholarly activity” and “the curriculum must advance residents’ knowledge of the basic principles of research.”²²

Post-Residency Research Fellowship Training for Family Physicians

Family Medicine research fellowships have existed since the early years of the discipline, primarily in family medicine departments that were at major research institutions. Some early research fellowships were funded by the Robert Wood Johnson Foundation, such as the research fellowship at the University of Washington in the early 1970’s (Personal Communication Dr. John Geyman). By 1980, 38 US academic fellowships associated with family medicine programs with 85 fellows existed, of which 57 required research, yet survey respondents identified only 185 family physicians with more than 10% of their time spent in research.²³ However, graduates of some research fellowships have had excellent success rates, including with NIH funding and publications. For example, with a mean of 5 years after completion of the University of Pennsylvania family medicine research fellowship, the first 15 graduates had been the principal investigators on 39 and coinvestigators on 24 funded studies, and had 236 publications.²⁴

In 2010 Bolon and Phillips²⁵ were able to identify 43 research fellowships open to family physicians. Over one–half offered a master’s degree, grant–writing courses, and IRB experience. The most common sources of funds were department funds, Public Health Services Act Title VII Section 747 Funds (Title VII), and National Research Service Award (NRSA) T32 funds. Many research fellowship programs do not have fellows every year, some because of funding difficulties. Others lack applicants willing to commit the time needed for adequate research training, perhaps because medical students who consider family medicine have less interest in research careers than those who chose other disciplines,²⁶ low fellowship salaries compared to practice, or the uncertainty of funding for their future research. Some family physicians also undertake fellowships not sponsored by family medicine departments, like those now offered by the National Clinician Scholars Program (nationalcsp.org; formerly Robert Wood Johnson Foundation Clinical Scholars Program) and the American Cancer Society. Junior investigators also take advantage of the NIH Loan Repayment Program, which offers loan reimbursement for engaging in NIH priority research.²⁴

RESEARCH SUPPORT FROM FAMILY MEDICINE ORGANIZATIONS

An early example of funding from with family medicine comes in 1966, when the American Academy of General Practice Foundation funded the Harvard Health Care Program for “a fellowship in family medicine and a program in collaborative research” over several years (personal correspondence Angela Curran from the Center for the History of Family Medicine housed at the American Academy of Family Physicians). The AAFP Foundation (formerly called the Family Health Foundation of America) has since funded 583 research grants for a total of $6.5 million since 1980 (Personal Communication Angela Curran).

There is some data on the outcomes of these investments. From 1990 – 2000, AAFP Foundation grants (none over $25,000), were associated with an increase in the number of publications in the 5 years after the grant application compared to the non–funded applicants. Further, over 1/3 of the funded recipients obtained more grants.²⁷ An even greater investment was the 28 family physicians funded by the AAFP Research Committee for 2–year Advanced Research Training fellowships from 1998 – 2001, in amounts up to $100,000. As of December 2003, about half of the fellowship recipients had published papers and most had written grant proposals.²⁸ The AAFP Foundation Joint Grant Awards Program continues to annually fund 1–2 year research projects to ‘build research capacity’.²⁹

The field of family medicine has also encouraged research development through the Grant Generating Project (GGP) (http://www.napcrg.org/Programs/GGP), initiated through NAPCRG. This program has been shown to increase the receipt of grants by its participants.³⁰ NAPCRG itself is an organization that continues to increase in size, complexity, and research–enhancing capacity. More recently the Association of Departments of Family Medicine (ADFM) joined with NAPCRG to create an initiative to enhance overall departmental research capacity.³¹

FUNDING FOR FAMILY MEDICINE RESEARCH FROM OUTSIDE THE FIELD

The overview in Table 1 highlights the limited nature of external funding for family medicine research. While sources of funding for research in Family Medicine have included private foundations and governmental agencies,^32,33 the National Institutes of Health (NIH), the largest health research funding mechanism in the US, has provided relatively little support. The NIH focus on disease, mechanisms of disease, drugs and technology fits poorly with the purpose and intent of family medicine, which by its nature is health–focused on health in the context of family and community.³⁴ In the late 1980’s, several individuals called “The Washington Project Group” attempted to change this ‘lack of fit’. They lobbied, wrote documents, met with NIH and others to advocate for a Center for Family Medicine Research (Personal Communication with Dr. Robert Graham and Angela Curran). Related to this effort, the Agency for Health Care Policy and Research was established by Congress in 1989, later renamed to the Agency for Healthcare Research and Quality (AHRQ) in 1999.

Table 1.

Reports on Family Medicine External Research Funding by Year, Source, Funded Entity, and Amount

Year	Funding Source	Type of Search	Reported funded entities	Data on Funding	Detail
1980- current	AAFP Foundation	Personal Communication Angela Curran	Family Medicine Faculty	$6.5 million	583 research grants
198032	Public Health Service	PHS document search	15 Family Medicine Departments	Total ~$4 million per year	41 projects: 33 NIH, 5 NCHSR, 3other
198133	60 Private Foundations	Private Foundation Funding Reports	Family Medicine Research	1 grant to family medicine
198323	All Sources	Survey of Family Medicine Units and Residencies	Family Medicine University Units and Residencies	In 1979 $3.4 million, with $2.6 million from Federal Government
200647	National Institutes of Health	NIH Data	Family Medicine Departments	2002 $25.6 million (0.20% of awards);2006 $44.6million (0.33% of awards)	10 departments got ½ of the awards
201231	All Sources	Survey of Department Chairs	Family Medicine Departments	$157 million (0.13% of all US Medical Research funding)
201437	National Institutes of Health	NIH Office of Extramural Research	Family Medicine Departments	$59 million	Average for other disciplinary departments was $266million
2002–201435	National Institutes of Health	NIH RePORTER Tool	Family Medicine Departments	$204 million,0.2% of NIH awards dollars

Sources: Journal websites and Personal Communication with Dr. Leif Solberg and Dr. John Hickner.

Departments of Family Medicine have had relatively consistent – but tiny – grant funding at about 0.2% of the total NIH funding and 0.3% of total grants awarded from 2002 through 2014.^35,36 Federal research money is also highly concentrated: three departments have received a quarter of all NIH, Centers for Disease Control and Prevention (CDC), and the Agency for HealthCare Research and Quality (AHRQ) research dollars awarded to family medicine departments.³⁷

Within AHRQ, the National Center for Excellence in Primary Care Research recently came into existence, and provides some funding as well as a variety of resources to support primary care research. Unfortunately, over the years AHRQ has suffered from defunding efforts by special interest groups³⁸ and is substantially underfunded compared to its mission.

Other health disciplines have found support from other federal entities such as the CDC but family medicine has not found a reliable home there either. More recently, the Patient Centered Outcomes Research Institute has raised expectations for family medicine investigators, but a recent review showed that the majority of the monies did not go to support primary care.³⁹

Bottom line: In 2006, only 19% of departments of family medicine reported having significant/self-sustaining research capacity and only 3% extensive/replication research capacity.³³ No matter which metric is used, family medicine research funding is low, and far below what is needed to answer relevant to the practice of family medicine.

ACADEMIC JOURNALS OF AND FOR FAMILY MEDICINE RESEARCH

Publication of research is essential for dissemination and perpetuation of research capacity. To move fields forward and to have confidence in the findings and recommendations for practice, medical specialties rely on scientific journals that feature original research relevant to the specialty.

Responding to a lack of journals featuring research relevant to family practice, the discipline created and funded journals to nurture the intellectual research basis of the discipline (Table 2). The Journal of Family Practice (JFP) was the pioneering U.S. journal for research in family medicine. Dr. John Geyman deserves the credit for the launch of JFP, as he pulled together the group that became the founding editorial board and got Appleton-Century-Crofts to be the initial publisher (personal communication, John Geyman MD). In 1979, Family Medicine Teacher, later called Family Medicine, joined the fold, with greater emphasis on educational research than JFP. The Journal of the American Board of Family Practice (renamed the Journal of the American Board of Family Medicine [JABFM] in 2006) was first published in 1986 by the American Board of Family Practice, now the American Board of Family Medicine (ABFM), with a goal of expanding research by and for family medicine. JABFM has wide readership throughout the world.

Table 2.

Summary of the History of Selected United States Journals with “Family Practice” or “Family Medicine” in the Title

Journal Name	Editor, by year	Major thrust of the manuscripts	Journal Sponsor	Frequency	Other
Journal of Family Practice (JFP) 1974-present	1974–1990 John Geyman MD 1991–1996 Paul Fischer MD 1997–2000 Paul Nutting MD MSPH 2000–2002 Mark Ebell MD MS 2003–2012 Jeffrey Susman MD 2012–present John Hickner MD MSc	Evolved over time. Originally most content was family medicine research. Now 90% clinical reviews, 10% original research.	Has been owned by several different companies, currently Frontline Medical Communications	Monthly	Past issues available Aug. 1999-present http://www.jfponline.com/the-publication/current-issue-past-issues-table-of-contents.html (can request PDFs from 1974–July 1999 via email link)
Family Medicine Teacher 1979–80 → Family Medicine (Fam Med) 1981– present; indexed 1987	1979–1983 Lynn Carmichael MD 1984–1991 John Frey MD 1992–2010 Barry Weiss MD 2010- present John Saultz MD	Educational and clinical research	Society of Teachers of Family Medicine	10/year	Electronic Archives through Society of Teachers of Family Medicine 2000-present http://www.stfm.org/NewsJournals/FamilyMedicine/PastIssues
Family Practice Research Journal (FPRJ) 1981– 1994	1981–1983 Jack Stack 1983–1984 Jack Stack MD and C. Merle John PhD co- Editors 1985–1990 Jack Stack MD and Leif Solberg MD, co- editors 1990–1994 Leif Solberg MD	Research	1981–1984 Family Health Research, Education and Service Institute; 1984–1990 Michigan Academy of Family Physicians and Ohio Academy of Family Physicians also; and 1990– 1994 American Academy of Family Physicians 1990–1994	Quarterly. Discontinued due to of lack funding	Substantially supported inexperienced researchers; Indexed in 1986
Journal of the American Board of Family Practice 1988– 2006 →Journal of the American Board of Family Medicine (JABFM) 2006 - present	1986–1991 Paul Young MD 1991–2002 John Geyman MD 2003-present Marjorie Bowman MD, MPA	Mixture, more research than other types	American Board of Family Medicine	Bi- monthly	2003 became primarily electronic for free, or hard-copy can be purchased through subscription, archives available through www.jabfm.org
Archives of Family Medicine (Arch Fam Med) 1992– 2000	1992–2000 Marjorie Bowman MD MPA	All types, clinical research focus	JAMA	Discontinued due to lack of sufficient funding (primarily advertising dollars)	Archives available through www.clockss.org/clockss/Archives_of_Family_Medicine
Annals of Family Medicine (AFM) 2003- present	2003 – present Kurt Stange MD PhD	Primarily Research, including research methodology	Multiple sponsors2	bimonthly	Primarily electronic for free, or hard-copy can be purchased through subscription, available through www.annfammed.org

Sources: Journal websites and Personal Communication with Dr. Leif Solberg and Dr. John Hickner.

Unfortunately, two of the early family medicine journals, the Family Practice Research Journal (supported by a local Michigan Institute, and then by several state Academies of Family Practice) [personal communication, Leif Solberg MD], and the Archives of Family Medicine (a JAMA publication), were discontinued, both over funding problems. The cessation of the Archives of Family Medicine in 2000 resulted in an uproar, with submissions of resolutions to the AAFP annual meeting, including from the National Congress of Family Medicine Residents.⁴⁰ As a result, the field of family medicine including the AAFP,^41,42 the ABFM, NAPCRG and STFM came together and started a new jointly funded journal called the Annals of Family Medicine (AFM), which was first published in 2003 and has proven to be highly successful. AFM has the 14^th highest impact factor in 2015 in the world in the category of General & Internal Medicine journals.⁴³

The founding and funding of several research journals is a testament to just how important research is in family medicine. The ABFM has essentially self-funded JABFM, as well as a substantial portion of AFM, highlighting the importance of the academic and research mission of ABFM. Similarly, the AAFP, funds both its own American Family Physician and Family Practice Management, and also financially supports AFM.

The editors of the family medicine journals are intent on clarity in the level of evidence for clinical recommendations made in articles. Several family medicine editors developed the Strength of Recommendation Taxonomy (SORT),⁴⁴ which was published simultaneously in several family medicine journals in 2004, and is used both with family medicine and outside of the field by authors, journals and organizations around the world.

Notably, family medicine research--or research important to the practice of family medicine--is not only published in family medicine specific journals. For example, a search conducted in 2012 found that the 250 most-cited family-medicine authored research articles were published in 71 different journals, only 5 of which could be described as “family medicine” journals.⁴⁵

CREATING THE FUTURE FOR FAMILY MEDICINE RESEARCH

Since the founding of family medicine, and dating back through many years of general practice, family physicians and their collaborators have made much progress in the realms of research and scholarship. To advance, the field will need to continue to prioritize research as an inherent component. Understanding research should be a required part of training for family medicine residents. Physicians in training should understand how to critique and interpret the literature, and understand the need for, and benefits of, systematic investigation. Some research (whether synthesis, practice-based, community-informed, or other) should be a mandatory component of residency training. Fellowships that focus on research opportunities should also be readily available.

Family Medicine chairs should work to build research within their departments. Chairs and other department leaders should make purposeful, relevant connections between research and the other family medicine mission areas including clinical care, education, and advocacy. Chancellors, deans, and hospital administrators should prioritize family medicine and community and population health research within Academic Medical centers. And practicing family physicians should engage with existing research infrastructure, both within family medicine (e.g. NAPCRG, STFM, AAFP Committee on Research, journals, research fellowships, PBRNs) and outside of it (e.g., specialty, disease, and organ-system-based research centers at academic institutions). There should be advocacy at all levels (universities, funders, legislatures, medical organizations, health systems, etc.) for greater support for family medicine research and research training. The recent large project, “Family Medicine’s Agenda for Health”⁴⁶ also provides strong agenda-setting for family medicine research.

Family physicians are ideally situated to identify the issues and do research related to enhancing care and outcomes for the life-long care of people and populations. Greater support for family medicine research would broadly translate to better care and better health.