 |
|
A Comparison of Family Medicine Research in Research Intense and Less Intense Institutions
Arch G. Mainous, III, PhD;
William J. Hueston, MD;
Xiaobu Ye, MD, MS;
Carol Bazell, MD
Arch Fam Med. 2000;9:1100-1104.
ABSTRACT
| |
Background Family medicine is a relatively new specialty that has been trying to develop a research base for 30 years. It is unclear how institutional research success and emphasis have affected the research productivity of family medicine departments.
Objective To examine the research infrastructure, productivity, and barriers to productivity in academic family medicine in research intense and less intense institutions.
Design, Setting, and Participants A survey of 124 chairs among institutional members of the Association of Departments of Family Medicine. Departments were categorized as being associated with research intense institutions (defined as the top 40 in National Institute of Health funding) or less intense institutions.
Main Outcome Measures Prioritization of research as a mission, number of funded research grants, total number of research articles published, and number of faculty and staff conducting research.
Results The response rate was 55% (N = 68). Of 5 potential ratings on the survey, research was the fourth highest departmental priority in both categories of institutions. Departments in research intense institutions were larger, had more faculty on investigational tracks, and employed more research support staff (P<.05). Neither category of department published a large number (median = 10 in both groups) of peer-reviewed articles per year. Controlling for the number of full-time equivalent faculty, the departments in less intense institutions published a median of 0.7 articles, while the research intense institutions published 0.5 (P = .30). Departments in research intense institutions received more grant funding (P<.005) in both unadjusted and adjusted analyses. Chairs reported a scarcity of qualified applicants for research physician faculty openings.
Conclusion Future initiatives should focus on prioritizing research and creating a critical mass of researchers in family medicine.
INTRODUCTION
FAMILY MEDICINE was first established as a medical specialty in 1967. Since the creation of the American Board of Family Practice in 1969 and the regulation of the specialty and its training programs, many in family medicine have argued that development of a research base in the discipline is essential to anchor family medicine in the academic world.1-4 For the past 30 years, family medicine has been struggling to create this research base and to define the scope of primary care research.
There is some agreement that there is a need for new knowledge about the diagnosis and management of common diseases and for research on how best to deliver patient care.5 These areas of research have been used to define where academic generalists should concentrate their efforts. When the academic status of family medicine is reviewed, it is usually research productivity, rather than scope of research, that is cited as an area in need of improvement.
The lack of research productivity in family medicine was first recognized in a study conducted after the first decade of the discipline's establishment.6 A survey of academic family medicine departments in 1980 documented a low level of research productivity and some significant barriers, including a lack of faculty time, funding, and research skills and few role models.6 Subsequent studies suggest that family medicine faculty still spend very little time on research or other scholarly endeavors7-8 and that individuals trained for research careers often veer off into clinical or administrative roles once they assume faculty positions.9
It has been noted that grant funding from the National Institutes of Health (NIH), the principal source of research support for medical schools in the United States, is not evenly distributed among the US medical schools.10 This uneven distribution of NIH funds, with less research performed at some institutions, has been explained by the high cost of biomedical facilities, equipment, and faculty research support, as well as the lower priority of research at some schools.
It is unclear how an institution's success in research affects the development of a research program in its department of family medicine. Is research in family medicine concentrated only in successful research institutions? To answer this question, the present study was undertaken to examine productivity in academic family medicine departments in research intense institutions vs those in less intense institutions.
PARTICIPANTS AND METHODS
An Internet-based survey was conducted among chairs of allopathic academic departments of family medicine in the United States. The 124 members of the Association of Departments of Family Medicine (ADFM) were eligible and were contacted for participation.
In April 1999, we sent each chair an electronic message describing the study and explaining that it was being conducted in cooperation with the ADFM and the Health Resources and Services Administration, Rockville, Md. The message included a hyperlink to a Web site for completing the questionnaire. Some of the institutions were also sent via surface mail an introduction letter that also provided the URL for the questionnaire.
A secure Web site had been created that served as a gateway to the questionnaire. Each institution was assigned a password to access the survey. This arrangement allowed the respondent to enter data and to return at a later date to correct responses, if necessary. It also enabled the investigators to monitor the responses as they were electronically received. Nonresponders were tracked through this electronic medium, as well as those who had completed their questionnaires. Follow-up electronic messages from the research team were periodically sent to the respondents, pointing out the questions that still needed to be completed and encouraging participation.
The study was approved by the Institutional Review Board of the Medical University of South Carolina, Charleston.
INSTRUMENT
The instrument was initially developed by searching the literature and developing the survey items, followed by site visits to 9 academic departments of family medicine to conduct interviews with several individuals in key leadership positions.11 Sites were chosen to maximize the diversity among the departments according to a variety of factors, such as location, size, mission, and type of school (private vs public). The survey was finalized and pretested during these site visits. Presentation and discussion of the questionnaire at 2 annual meetings of the ADFM provided additional input about the usability of the survey. In addition, a sample version of the questionnaire was made accessible to the ADFM members before actual data collection to allow for additional comments on the items and the method. Although the design of the overall survey was that of an omnibus survey that focused on a wide variety of topics, the present study primarily addresses issues regarding research in the family medicine departments.
VARIABLES
An element of particular interest was the chairs' perception of the priority of research as a key organizational mission in their department and parent institution. They were asked to rank the priority of 5 missions (research, clinical service, predoctoral education, residency education, and fellowship education) within their department, medical school, academic health center, and university. This question was asked to determine the perceived importance of research and the congruence between the different entities within an organization. Chairs were also asked to comment on the need for improvement in faculty competence in various areas as well as their impression of the quality and quantity of applicants for research faculty positions.
Research productivity was measured on 2 general metrics. First, productivity was assessed by the number of newly funded research grants during the 1997-1998 academic year to departmental faculty who served in principal investigator or coinvestigator roles. Second, peer-reviewed articles published by the faculty during the same period were counted, focusing on those in family medicine journals, other specialty journals, and what might be considered top-level general interest journals (eg, The Journal of the American Medical Association, New England Journal of Medicine, British Medical Journal, and Lancet).
The presence in departments of an established infrastructure that might serve to foster research was assessed by the size of the faculty, percentage on investigator tracks, presence of a designated research director, and the number of masters-degree level research support staff.
Although this was a departmental level analysis, the parent institutions were dichotomized as either research intense or less intense based on whether the institution was among the top 40 institutions in NIH grant funding in 1998. This variable was used because evidence suggests that research funded by the NIH is concentrated in those medical schools that are most active in research.10
A final variable used in the analysis was a department's productivity after controlling for the number of full-time equivalent faculty. This was computed to account for the logical relationship that crude or unadjusted productivity measures may simply demonstrate that larger organizations have more people and thus greater productivity but may not necessarily be more productive after controlling for faculty size.
ANALYSIS
Since the instrument was structured in modular form with a variety of different topic areas, the respondents may have chosen to complete certain sections (eg, education or research) but not others. Consequently, the present analysis is based on the 68 institutions that responded to the research module. This represents a 55% response rate among the total sample contacted.
Initially, descriptive departmental statistics were gathered. To compare departments in research intense institutions with those in less intense institutions, inferential statistics were computed. Many of the variables demonstrated extremely skewed distributions. For example, the mean faculty size, as measured by the number of full-time equivalents, in research intense departments was 49 with an SD of 71. Because of the skewing of many of the distributions for the variables, the nonparametric technique of Wilcoxon rank sum test was used to compare the 2 groups of institutions. Consequently, the analysis is based on medians rather than means.
RESULTS
Among the participating departments, the median number of years in existence was 24, 72% were public institutions, 19% were in the top 40 of NIH funding, and their median full-time equivalent faculty size was 19, with a median of 17 physicians. Departments in private institutions (39%) were more likely than those in public institutions (13%) to be in research intense institutions (P = .02).
Table 1 and Table 2 present the chairs' perception of the priority of research within the context of their organizational missions. Little difference was noted in the relative priorities placed on research between the departments in the research intense institutions and those in the less intense environments. For most of the departments in both categories of institutions, research ranked fourth in their overall goals. However, when chairs were asked about the relative priority of research within other entities of their institutions, substantial differences were found between departments in research intense schools and the others.
|
|
|
|
Table 1. Family Medicine Chairs' Perceptions Regarding Departmental Priority of Research as a Mission*
|
|
|
|
|
|
|
Table 2. Family Medicine Chairs' Perception of the Rank of Research as the Top Priority by Other Entities Within Their Organization*
|
|
|
We also examined the research productivity of departments in research intense institutions vs that of those in less intense institutions (Table 3). The groups were not significantly different in the number of articles published, but departments in research intense schools appeared to be more able to secure research grants.
|
|
|
|
Table 3. Comparison of Family Medicine Departmental Research Productivity (1997-1998)
|
|
|
One possible explanation for the greater success in securing grant funding by departments at research intense institutions was that more resources were available for obtaining grants. Table 4 presents the number of personnel in family medicine departments who were available to participate in fulfilling the research mission. The departments in research intense institutions had a larger faculty, more research support staff, and a greater proportion of faculty on investigator tracks. Even after controlling for the size of the faculty, the departments in research intense institutions were still more successful in securing grant funding (Table 5).
|
|
|
|
Table 4. Comparison of Family Medicine Departmental Availability of Research Personnel*
|
|
|
|
|
|
|
Table 5. Comparison of Research Productivity (1997-1998) After Controlling for Number of Full-time Equivalent Faculty in Family Medicine Departments*
|
|
|
The chairs were asked what were the areas in which they would like to see improvement in the level of competence of their faculty: 78% cited research, while only 22% reported clinical practice and 27%, teaching. When queried about their results when trying to recruit physician investigators, 43% of the chairs reported that they were satisfied or very satisfied with the quality of applicants, while only 17% reported satisfaction with the quantity of applicants.
COMMENT
The results of this study are similar to those of other studies showing that few family physician faculty produce any research publications5 and that only a handful have time devoted to research endeavors.9, 12 Our findings show that, although departments in research intense institutions may obtain significantly more funding for research, they publish no more articles than those departments in less intense environments.
Our results indicate that there may be a synergistic effect once departments reach a "critical mass" of researchers and infrastructure. This supports the finding that success in research is concentrated in medical schools that are most active in research.10 In our study, even after controlling for the number of departmental faculty, productivity as measured by the number of funded grants was still higher in research intense institutions than that in less intense environments. An obvious remedy on the surface of things is the recruitment of several qualified researchers, which seems to be a key strategy for increasing research productivity. Unfortunately, according to the chairs in this study, the dearth of qualified faculty-level physician researchers limits their ability to accomplish this. A potential solution to this dilemma for those within research intense institutions is that a scarcity of researchers in the family medicine department may be overcome by collaboration outside of the department.11
An element that may be hampering the success of departments of family medicine is the low priority assigned to research by academic leaders. Chairs gave residency training, medical student education, and clinical care higher priority ratings than they did research. Although chairs in research intense institutions may recognize that research is highly valued by others in their medical school or university, this did not appear to influence the priority they assigned to research in their department. The difficulty in asserting the importance of research may stem from discordant messages that departments appear to receive from different administrative bodies. Chairs consistently noted that the top priority emphasized by their medical school dean was to teach medical students. The primary goal of their hospital administration was to generate more clinical business. The keystone of the university itself was research. There appeared to be disagreement among the academic leadership on what the emphasis of a family medicine department should be about. The low priority assigned to research by departments of family medicine is likely a response to these mixed messages. The necessity to serve multiple masters may impede progress at establishing a research base within the discipline.
An additional issue that may be limiting the progress and development of research in family medicine is the shallow pool of extramural research funding. Most of the funding programs offered by the NIH dovetail with the interests, skills, and laboratory infrastructure found in basic science departments and medical subspecialties. Although several institutes have developed specific primary care initiatives (eg, the National Institute of Mental Health), family medicine research falls almost exclusively in the domain of opportunities offered by the much smaller Agency for Healthcare Quality and Research. Furthermore, research opportunities at the NIH that can help to train investigators to be successful in securing future funding are essentially nonexistent in family medicine.
These obstacles to stimulating research in primary care are not limited to family medicine. For example, data evaluating the success of graduates (N = 112) of 2 pediatric faculty development fellowships revealed that heavy clinical and teaching loads have hampered the efforts of these faculty members to conduct research.13 In addition, former fellows often cited the lack of a "research environment" and funding as impediments to their success as researchers. In an environment where dedicated research time is becoming increasingly difficult for institutions to provide, strategies to maximize and support the research efforts of busy clinicians are critical to the academic success of faculty.
Despite the recognition that faculty bring a rich array of talents to a university, their research success and productivity continue to be the academic currency that defines promotional tracks and tenure.14 Even those who are on clinician-educator tracks are not immune to the demand for research productivity, as 71% of schools with these tracks require faculty to demonstrate evidence of scholarly work to earn promotion.14 Reviews of faculty who have achieved success in academic medicine confirm that those who want to get ahead must conduct research and publish their findings.15 Any university-based primary care department must have a strong research component to enable faculty to be competitive in the larger framework of the academic medical center. Without research skills, faculty may be relegated to clinical tracks that could reduce their job satisfaction and their accomplishments in the long run. An emphasis on research in primary care will be necessary to promote its long-term success in academics and to increase the likelihood that faculty will remain in teaching careers.
There are several limitations to this study. First, the study sample included only institutional members of the ADFM. Although this population represents a good cross-section of family medicine departments in medical schools and allowed us to stratify the departments according to the research intensity of their parent institution, it lacks input from the many community hospital residencies. Second, we achieved a response rate of 55%. It is possible that there is some characteristic unique to the responding ADFM members or departments that would limit the generalizability of our findings to all allopathic academic family medicine departments in the US. Third, the data are based on self-reports. Although most of the survey items were numerical counts (eg, number of research articles) and the questionnaire directed respondents to their departmental annual report for many of these data, no validation of the self-reported tallies was made. However, a study that used actual counts of research articles in a limited number of journals published by faculty in academic family medicine departments also confirmed higher productivity in larger departments and those with more grant funding.16 Some survey questions, such as the assessment of prioritization of missions, elicited the chairs' perceptions about the subject. These responses did show, however, that the perception of their university's priorities regarding research did differ substantially depending on whether the university was research intense or less intense.
In summary, until the top priority of family medicine departments is to nurture research with the necessary infrastructure, faculty, and emphasis to be successful, great strides are unlikely.
AUTHOR INFORMATION
Accepted for publication June 6, 2000.
This study was funded in part by contract RFC-HRSA-240-BrHP-12(7) from the Health Resources and Services Administration, Rockville, Md.
Corresponding author: Arch G. Mainous III, PhD, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun St, PO Box 250192, Charleston, SC 29425 (e-mail address: mainouag{at}musc.edu).
From the Department of Family Medicine (Drs Mainous, Hueston, and Ye) and the Center for Health Care Research (Drs Mainous and Ye), Medical University of South Carolina, Charleston; and the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration, Rockville, Md (Dr Bazell).
REFERENCES
| |
1. Geyman JP. On entry into phase two in family practice development [editorial]. J Fam Pract. 1977;4:15.
ISI
| PUBMED
2. Culpepper L. Family medicine research: major needs. Fam Med. 1991;23:10-14.
PUBMED
3. Fischer PM. A note to family medicine researchers. J Fam Pract. 1994;39:221-224.
ISI
| PUBMED
4. Murata PJ, Lynch WD, Puffer JC, Green LA. Attitudes towards and experience in research among family medicine chairs. J Fam Pract. 1992;35:417-421.
ISI
| PUBMED
5. Weiss BD. The death of academic family medicine: can it be prevented? Fam Med. 1995;27:139-142.
PUBMED
6. Culpepper L, Franks P. Family medicine research: status at the end of the first decade. JAMA. 1983;249:63-68.
FREE FULL TEXT
7. Hueston WJ. Factors associated with research efforts of academic family physicians. J Fam Pract. 1993;37:44-48.
ISI
| PUBMED
8. Oeffinger KC, Roaten SP Jr, Ader DN, Buchanan RJ. Support and rewards for scholarly activity in family medicine: a national survey. Fam Med. 1997;29:508-512.
PUBMED
9. Perkoff GT. The research environment in family practice. J Fam Pract. 1985;21:389-393.
ISI
| PUBMED
10. Moy E, Griner PF, Challoner DR, Perry DR. Distribution of research awards from the National Institutes of Health among medical schools. N Engl J Med. 2000;342:250-255.
FREE FULL TEXT
11. Hueston WJ, Mainous III AG, Connor MK, Bazell C. Challenges to academic family medicine in the current health care environment. Fam Med. 2000;32:240-245.
ISI
| PUBMED
12. Hueston WJ. A comparison of university and community-based family practice physician educators. Fam Med. 1993;25:576-579.
PUBMED
13. Haggerty RJ, Sutherland SA. The academic general pediatrician: is the species still endangered? Pediatrics. 1999;104:137-142.
FREE FULL TEXT
14. Jones RF, Gold JS. Faculty appointment and tenure policies in medical schools: a 1997 status report. Acad Med. 1998;73:212-219.
ISI
| PUBMED
15. Gjerde C. Faculty promotion and publication rates in family medicine: 1981 versus 1989. Fam Med. 1994;26:361-365.
PUBMED
16. Wagner PJ, Hornsby JL, Talbert FS, Hobbs J, Brown GE, Kenrick J. Publication productivity in academic family medicine departments. Fam Med. 1994;26:366-369.
PUBMED
RELATED ARTICLE
Why Family Practice Research?
Barry D. Weiss
Arch Fam Med. 2000;9(10):1105-1107.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Off the Roadmap? Family Medicine's Grant Funding and Committee Representation at NIH
Lucan et al.
Ann Fam Med 2008;6:534-542.
ABSTRACT
| FULL TEXT
Journal Publication Productivity in Academic Physical Therapy Programs in the United States and Puerto Rico From 1998 to 2002
Richter et al.
ptjournal 2008;88:376-386.
ABSTRACT
| FULL TEXT
Research Published in 2003 by U.S. Family Medicine Authors
Pathman et al.
J Am Board Fam Med 2008;21:6-16.
ABSTRACT
| FULL TEXT
The State of Resident Research in Family Medicine: Small but Growing
Carek and Mainous
Ann Fam Med 2008;6:S2-S4.
FULL TEXT
NIH Funding in Family Medicine: An Analysis of 2003 Awards.
Rabinowitz et al.
Ann Fam Med 2006;4:437-442.
ABSTRACT
| FULL TEXT
Being Successful with Family Medicine Residency Research: Lessons Learned from Others
From the Association of Family Practice Residency
Ann Fam Med 2003;1:246-247.
FULL TEXT
Why Family Practice Research?
Weiss
Arch Fam Med 2000;9:1105-1107.
FULL TEXT
|
