Office-based research: A new era and new opportunities

Paediatric office-based research provides evidence for disease management and preventive care in the primary care setting. Despite the importance of office-based practice, there is relatively little office-based research done. As a result, the knowledge base available to paediatricians and family physicians in improving the primary health care of children is limited. New opportunities, however, are emerging, given that it is now recognized that clinical care, education and research can and are being done in settings other than major hospitals. There are many factors that make office-based research attractive, aside from the fundamental need for the advancement of medical knowledge. Research in the community office makes paediatrics feel ‘alive’ and broadens its scope beyond the basic delivery of service. For physicians and trainees, research also increases the challenge of dealing with minor illnesses on a daily basis, and counteracts inertia, fatigue and burnout. The excitement of office-based research occurs at many levels, beginning with framing the initial question, followed by the intellectual stimulation that accompanies the collaboration with academic faculty in establishing a hypothesis and developing the research protocol. Completion of the project brings a sense of great satisfaction, being accepted to present the findings at a scientific meeting is rewarding, and the eventual publication in a peer-reviewed journal brings a feeling of accomplishment and immense personal fulfillment. There are also many factors that make research in the community advantageous compared with institutional research. Most paediatric health care delivery is in the community and it may be argued that in many published articles there is a distortion of results because of the hospital-based perspective of most studies (1). Community-based research allows for access to nonreferred patients, large sample sizes, easy recruitment and the inclusion of a large number of paediatricians who are willing to do collaborative research. By promoting the excitement of a question-based academic office practice, paediatricians can be instrumental in helping to enhance critical inquiry by students and residents. Special sensitivities are required for office-based research, particularly those related to obtaining informed consent. Practitioners need to avoid pressuring parents who may say ‘yes’ to participating in a study to keep from offending the physician. Extra visits to the office specifically for research purposes need to be minimized, where possible, by doing home visits or by making follow-up phone calls. If office visits are unavoidable, reimbursement for travel expenses should be made available to participating families. So why is it that most practising paediatricians do not do research in their offices? There are many barriers, including lack of training and experience, lack of interest and motivation, perceived limited time available, anticipated increased workload, and funding difficulties. Community paediatricians are often interested in a number of potential research topics that arise from daily practice, but they have difficulty translating these ideas into coherent research projects. They need to be encouraged to approach these research questions in much the same way as they would a clinical problem, in consultation or collaboration with a subspecialist in an academic centre. A ‘research consultant’, such as a clinical investigator, epidemiologist or statistician can be approached to provide the clinically oriented paediatrician with the basic analytical tools needed to plan a research project. The consultant or coinvestigator will help to develop an appropriate research hypothesis, help to select proper outcome measures, and give advice on the type of data and analyses needed. Paediatricians who initiate or are recruited to assist in a research study need to be given proper recognition for their contribution and ought to garner appropriate continuing professional development credits. This recognition may be in the form of coauthorship if the paediatrician plays a major role as a coinvestigator, or acknowledgement if the role is more collaborative in nature or if the paediatrician is a member of a larger research group or network. For those recruited to participate in a research project, education in the form of lectures, workshops or article reprints preceding and during the research study is vital in keeping the clinicians interested, informed and motivated. Precious time for the busy community paediatrician can be protected by training and paying existing office staff, or by using students or research assistants, to provide basic information to parents about the research project by enrolling subjects and by performing data collection and data entry. Funding for office-based research is competitive and is definitely a major barrier, but it is one that is not insurmountable. There are many funding opportunities available, including funding agencies, government, and clinical research funds at some hospitals. The American Academy of Pediatrics (AAP) has a competitive paediatric practice fund that is specifically available for practitioners in office practices. An equivalent fund has not been established by the Canadian Paediatric Society (CPS). The AAP also promotes primary care research, and has established a national practice-based research network, the Pediatric Research in Office Settings. This network has a steering committee, a database and substantial funding, has grown over the years to include more than 1400 practitioners at more than 470 practice sites, and has resulted in a number of peer-reviewed publications (2). There are other models of formal and informal research networks of family physicians or paediatricians that have evolved from local university centres such as those in Chicago, Illinois and Rochester, New York (2). In Canada, the model for office-based research is practitioner-initiated and this could be enhanced substantially by expanding to collaborative networks such as those in the United States. This expansion would require the input, manpower, expertise and resources of much larger organizations such as academic centres, the CPS or government. Office-based practitioners can answer many important clinical questions that are not necessarily relevant to hospitalized children. Examples from our community-based research activities include the following. Is acetaminophen prophylaxis following vaccination effective? How knowledgeable are physicians about fever management? Does topical anesthesia diminish the pain of vaccination? Do physicians follow the guidelines for annual influenza vaccination? How accurate are office-based paediatricians at diagnosing heart murmurs? Is Helicobacter pylori associated with childhood recurrent abdominal pain? What is the prevalence of rotavirus-associated gastroenteritis in the ambulatory setting? How can the severity of acute respiratory illnesses be measured? These completed projects have been published in peer-reviewed journals (3–10). Studies such as these most often result from a joint contribution of office-based and hospital-based faculty, and have their major impact in community practice, where the results are most applicable. It is this complimentary approach of ‘town and gown’ that is so fundamental and so important in encouraging more productive and sound research in the community. This era of shifting patient care from hospitals into the community ought to provide new opportunities for improved education and office-based research. Academic centres need to emphasize the value of community sites as models for both teaching and research, and need to protect and nurture this vital and underutilized resource. Primary care research could be significantly enhanced in Canada by the establishment of collaborative networks that would be able to provide substantial resources and expertise to expand on existing community-based research.

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