Academic outreach: Fostering learning and research in general practice

UK general practitioners (GPs) are invited to describe their involvement in research in their annual appraisal. As far as we are aware, this is the first time that GPs’ research activities will be “officially” audited in this country, and yet researchers report increasing difficulty recruiting practitioners as participants in primary care research. For many practitioners, the reasons for not engaging in research remain the same as those reported by Olsen almost a decade ago, namely low morale, increasing workload and bureaucracy, problems with recruitment, and retention of general practitioners [1]. Today general practices may be involved in research either on a specific project or as part of a research network. However, most GPs, even in “research-active” practices do not design the project, much less analyse or interpret the data. Their involvement is often limited to the decision to allow their practice to host a project, with practice staff facilitating access to data and occasionally helping to recruit patients. One stimulus to developing a greater involvement in the research process may be the habit of reading and evaluating published work. A prerequisite is competence in critical reading. An effective strategy for introducing critical appraisal skills or establishing “journal clubs” in primary care clinical settings has not been established [2]. The challenges of establishing “journal clubs” in primary care include those that limit the involvement of practitioners in higher professional education courses, namely the need to invest time and the availability of local or accessible courses [3].

Research in primary care appears to be dichotomized into research “on” general practice and research “in” general practice. The former consists largely of projects in which clinicians recruit patients to pharmaceutical trials. The latter addresses questions posed by that discipline cognisant of the constraints imposed by complex but concise consultations. The prized outputs of such projects may include innovations or insights informed by the realities of serving patients with co-morbidities, exercising autonomy and presenting undifferentiated illness. We report one way to engage the primary care clinical community in research.

The scheme consists of short clinical and academic outreach visits by a university clinical lecturer in general practice aimed at establishing journal clubs and stimulating interest in research. Outreach visits are variously called university-based educational detailing, public interest detailing and academic detailing. Such visits, particularly when combined with social marketing, appear to modify health professionals’ behaviour [4]. The use of local opinion leaders to influence professional practice is promising but inadequately researched, as is the use of interactive workshops, including journal clubs [5], [6]. General practitioners are ambivalent about participating in research or engaging formally in critical reading. Academic outreach, when allied to the offer of clinical support, may nurture an interest in research in general practice and primary care. It may result in an interest in critical reading as well as stimulate correspondence in academic journals

A university funded the participating general practitioner (MJ). He was employed primarily to develop research capacity and lead research studies. University clinical academic contracts require practitioners to undertake a prescribed amount of clinical work. Clinical lecturers in the UK have a choice of how this obligation may be met. The GP offered 12–24 clinical sessions (amounting to 18 clinical consultations per day for 6 to 12 days) to different practices at no financial cost to the practice. Practices were invited to participate because of their association with the academic department either on a specific project, because a member of the practice was employed as teaching staff, or by way of recommendation from a previous participant in the scheme. In recognition of the clinical support, the practice agreed either to host a lunchtime journal club or to develop protocols for research, audit or service evaluation on topics that were perceived by the clinicians as relevant to that practice. The visiting academic facilitated these meetings or development work.

We recorded a good response to a follow-up questionnaire survey administered by a different member of the academic department (DG), obtaining the views of six out of eight practices, including their GPs, practice nurses and practice managers. We noted research activity in most practices and confirm ongoing interest in research at others. However, this was not a universally successful strategy, and some practices failed to engage fully and did not appear to benefit.

Clinical support

All managers agreed that clinical support as detailed was a vital aspect of the outreach sessions, and were inclined to agree that the practice was attracted to host the sessions mainly by the offer of cost-neutral clinical support at a time when the availability and cost of locums was becoming prohibitive. For most clinicians, this support was critically important for their involvement in the scheme, and all declared an interest in further outreach visits. Furthermore, most respondents said they would recommend outreach to other practices. The doubters were from practices that did not host a journal club. For the academic practitioner, the commitment to maintain contact with patients in a variety of clinical settings was important for personal and professional development. It was considered essential to be familiar with a wide variety of practices and patients to be a productive, informed and effective researcher.

Journal clubs

Most managers reported that the journal club format had been an attractive element of the proposal. The format was an hour-long meeting at lunchtime. A paper from an academic or professional journal was presented by one nominated participant, circulated in the week before the meeting and discussed in round-robin fashion during the club. Occasionally, the team was moved to submit a response or critique to the journal editor. Despite the positive outcomes, including lively debates, clinical colleagues remained anxious about the commitment to meet for this purpose once a week. Anxiety was generated to some extent because it was perceived that the practice had agreed to accept clinical help on this basis. It was therefore important to accept with good grace that occasionally journal clubs would be cancelled or curtailed because of unforeseen calls on practitioner time or a shortage of participants. In one practice, attendance was so poor that the planned meetings had to be permanently shelved. Indeed, most participants in all the practices declared that the journal clubs had been difficult to timetable into an already full week. In the questionnaire, a minority of participants recalled attendance at journal clubs as “patchy”, although the academic described attendance at all practices as variable. Yet most participants maintained that the journal clubs did not disrupt their routine, even though many had to rearrange other commitments. Most said that the journal clubs led to helpful discussion about aspects of their clinical care. Even more agreed that their interest in reading journals was changed, and everyone thought that it was easier to understand papers with reference to an “in-house expert”. Only one of the six practices reported continuing with the clubs after the outreach had ended, although we can only speculate about the long-term effect in any practice of having participated in the scheme. Practices that were disinclined to host a journal club appear to benefit the least from the scheme. In this case, their reasons for the reluctance were not articulated.

Research

For the majority of participants, the outreach visit changed their understanding of clinical research, but only a minority reported a change in interest in research. The majority of respondents published letters or e-letters in academic journals as a result of discussions stimulated by reading published papers [7–11]. These outputs were of particular value to the academic, fulfilling the requirement to maintain intellectual rigor even when sustaining clinical contact with patients and working alongside clinical colleagues. Unexpectedly, the majority of participants in those practices that did not set up a journal club also reported that the outreach visit stimulated research interest in the practice. Some respondents even stated that they would like to develop their own research ideas with the help of a university-based colleague.

Overall, practices were more likely to participate in research after the academic outreach sessions. It was not possible to verify whether this translated into actual engagement in “research”, but the impression at the academic department is that it was easier to recruit these practices on projects. At the very least, the practices were prepared to consider the request even if they were not always willing or able to participate. That said, practices that have been visited are all currently involved in some aspect of research, and in a few cases research questions have been proposed by the practice. Such goodwill was an important end point for the academic department. It remains to be seen whether this interest in research is sustained.

Conclusion

Academic outreach sessions were welcomed by the practices in our locality but were clearly boosted by the offer of cost-free manpower. However, reticence to host a journal club diminished the perceived value of the visit. Therefore, what we describe was not a universally successful strategy, and some practices failed to benefit as much as others. On the other hand, if relevant research activity is to grow and retain the interest and commitment of practitioners at the coalface in meaningful, cooperative and growing partnership with academic departments of general practice, then our scheme was a success.

We proffer this as one way of encouraging general practices to be involved in the design and evaluation of primary care research rather than merely being a source of data. Furthermore, the participating GP found this approach increased his contacts in general practice, and generated research proposals and funding for facilitation by his university department.

We wish to express our thanks to the practitioners and practices that agreed to participate in this scheme; to Dr Katie Ward for providing expertise in evaluating the scheme; to Drs Helen Joesbury, Patrick Garratt and Paul Wilson for cogent and constructive criticism; and to the University of Sheffield for facilitating the scheme.