Scientific evidence and research in primary care.

The key areas of scientific research in general internal medicine are (1) prevention; (2) the natural history of common illnesses; (3) improving the outcomes and efficiency of the health care system and (4) orphan diseases. Disease prevention is at the top of the list because of the enormous role preventable causes play in morbidity and mortality, above all tobacco. Research in this field is difficult because it touches such questions as individual behaviour and personal choice. Research in the natural history of common illnesses is critical to informed patient decision making. Recent studies show that procedures thought to be safe bear a high percentage of complications, when viewed from the generalist's point of view: high incidence of strokes after elective coronary bypass surgery; higher mortality rates among patients having had pulmonary catheterization; high incidence of incontinence and impotence after transurethral resection of the prostate. A third area for research in primary care is how to improve outcome and efficiency through improvements in the health care delivery system. This field touches the problem of unnecessary surgical interventions and inappropriate prescription of antibiotics. Orphan diseases in this context are conditions no speciality wants to study, such as dementia and low back pain. The most important obstacle for research in the field of general internal medicine is funding. It is much easier to be funded for research in high profile conditions, like heart disease, cancer and AIDS. A second barrier to research relates to the role of special interest groups in influencing not only funding but also policy. Important examples were the pressure on consensus conference decisions on the role of spinal fusion surgery for low back pain and on the question whether women between 40 and 50 should have annual mammography. For generalist research to be fruitful it is of outmost importance to have an adequate intellectual infrastructure, i.e. support by epidemiologists, biostatisticians, economists and research methodologists.