GPs should have a scientific role in society

Ninety per cent of all medical care is delivered via primary care providers, but scientific research is not part of their remit. On Friday 16 October Research Professor Jacobijn Gussekloo will deliver her inaugural lecture entitled: 'We can carry on for years. On minor complaints, prevention and geriatric medicine.'

Underdog

‘How many GPs have PhDs?' asks Jacobijn Gussekloo, Professor of 'the Scientific Foundation of Clinical Practice, who has been appointed to head research in the department of Public Health and Primary Care at the Leiden University Medical Center. 'Most patient research is carried out on hospital patients. The Netherlands, Great Britain and the Scandinavian countries may well be ahead of most other countries in scientific research in primary care because of the structure of their healthcare systems, but in the Netherlands it is a kind of underdog, relatively small in terms of budget and impact. I am trying to get as many people as possible interested in primary care research, including GPs who are already working in the field. Fortunately, it's not so difficult because GPs are generalists, who are interested in most aspects of medicine.'

Jacobijn Gussekloo

Reading and assessing research

Of course, not every GP can also carry out research. As Professor Gussekloo says: ‘The main thing is to encourage GPs to learn to become more involved in the science of the field. We teach them to read and assess research. To use scientific search engines. To ask the right counter questions if they have a visit from a representative of a drug company wanting to get a particular medicine into the market. One of the most important skills is keeping your knowledge up to date, but there is so much knowledge available, how can you possibly keep it up to date? When I trained as a doctor, there was far less concern about keeping up with new research. The training is now also a year longer: it's no longer two years, but three.'

Gaps in the knowledge

There are still big gaps in knowledge in primary health care, whether you're talking about minor complaints such as warts or colds, about the prevention of illnesses and the consequences of chronic diseases, or about the complex and growing issue of ageing. Yet the implications of a solid scientific foundation for care are enormous: for GPs, hospital doctors or institutional doctors, for policies on care and for the daily lives of the mass of the population.

The training to be a GP is now three years. It used to be just two years.

Warts

Gussekloo: ‘Obviously, a person with a cold doesn't go to hospital. This means that very little research is done into such everyday complaints. We have a 'minor complaints' research theme. We do research into warts,for example, a common cause of visits to GPs. One doctor might recommend doing nothing, while another might treat the warts, or the decision may be left to the patient. But nowhere in the world is there any real knowledge about it. We don't even know what types of virus are involved, which treatment works best, what exactly patients want. It's sensible to be able to substantiate the medical treatment applied. You also know that the knowledge you come up with will be implemented in GP practice within three years. It is relevant research, but difficult to get it financed.'

Geriatric medicine

There is one growing group of - potential - patients for whom the lack of scientific knowledge about their health and illnesses is very radical, because the new knowledge that is gathered is often surprising and treatment and completely overturns current treatment methods. This is the group of older people in our society. It was through her research on this particular group that Gussekloo herself earned her stripes.

‘You know a neighbourhood like the back of your hand’

‘When I was studying I knew for certain I wanted to be a GP. I did it for seven years, from 1995 to 2002, and I really enjoyed it. You visit people in their homes, you have both feet firmly in real community life; you know a neighbourhood like the back of your hand.' Gussekloo was then tempted by research and she obtained her PhD under the supervision of Dick Knook and Rudi Westendorp in the field of geriatric medicine. 'In practice, I found elderly people extremely difficult, the whole issue of healthcare for the elderly is difficult. But its complexity is also what makes it scientifically so fascinating. And the good thing is that you can also take a very generalistic approach.'

Risk factors no longer predict outcomes

Research into geriatric medicine in the LUMC is a very important field. 'We have shown that classical risk factors for heart attacks or strokes - high blood pressure and high cholesterol - are not such good predictors of outcomes in old age. However, an elderly woman of 81 will still be told: you have a nice low blood pressure, there's no need for you to worry. But it's by no means the case that a person can't suffer a heart attack at age 81 and older. So, how can you trace risk cases then? Should you treat an 85 year old with high blood pressure? We don't know the answers, and we have to thoroughly investigate a number of patients scientifically to discover what you should do in clinical practice. Another puzzling area in which known risk factors do not play a role, is anaemia in elderly patients.'

Why is an old body different from a young body?

Scientific substantiation of research is not easy, as Professor Gussekloo well knows. 'It's about the fundamental question of whether an old body is different from a young body. A lot of things happen after the age of 80. That's whan the big differences become apparent. The mortality rate is higher; a fact that is difficult for us as people, but for scientists it's very interesting. Older people are complex beings. Different things get mixed up together; all those pills and all those different minor complaints.'

Health centre for the elderly

The department also conducts research into depression among the elderly. Gussekloo asks: ‘Is it adequately recognised? How are patients treated? What are the benefits of treatment? What should you do about people who don't visit their doctor with their complaints? In a few months we will have the results of this research. We will then be able to include the findings in the guidelines. Health centres for the elderly are springing up all over the place; there's one in Leiden, for instance. THowever, there's very little in the way of scientific foundation for their work. They by no means meet all the scientific conditions for screening. But once you know that screening for depression is useful, that can certainly be done in such health centres.'

Prevention in the GP's practice

As well as the minor complaints and geriatric medicine, there is a third theme to the research carried out at LUMC's department of Public Health and Primary Care: 'prevention in primary care'. According to Gussekloo, 'This used to be a matter for General Health Departments. Prevention research is generally separated from GP care, but we look at it from the point of view of the GP's practice. There are a number of advantages to this: the path to GPs is much more accepted, and you already have the medical data. It would be fantastic if we were to see some of these results being applied in clinical research in a few years. For example, promoting a new way of stopping smoking. How can you do this as effectively as possible? GPs are themselves prevention-oriented, partly as a result of the rise in chronic diseases.'

Better GPs?

Are GPs today better than ten years ago? Gussekloo: ‘It's still difficult to have research play a role in practice. We would prefer all medical treatment to be evidence-based, but then you have to have the evidence. We are the ones who have to supply the evidence. Apart from this, it remains an issue of interaction between people. Should you give in and arrange an x-ray for someone if he insists on having one, even f you know that is serves no purpose? I'm not sure whether I would be a better GP now than when I started.'

Health, prevention and the human life cycle is one of the research profile areas of Leiden University.

Last Modified: 17-11-2010