A lot of hopes are being pinned on primary care.
It's the medical discipline that healthcare reformers are deputizing to prevent illness or catch it in early stages-keeping the average citizen and the national health budget as healthy as possible.
But some researchers are saying that American medicine doesn't have the arsenal of insight and proven routines that it needs to fight the battle on the primary-care front. That's because patients present themselves as complex bundles of unremarkable ailments and not as classic sufferers of one disease that's been studied in isolation.
Research on specific afflictions, which makes up the bulk of medical inquiry, has produced unparalleled sophistication in tertiary-care treatment, according to a new task force on primary care. But there's no similar body of research that tells what works and what doesn't in primary-care settings, said the task force in its report, "Putting Research into Practice: Building Capacity for Research in Primary Care."
"We consider the chronic neglect of primary care to be responsible for many of the major inadequacies of our current system," the report concluded.
Primary care sometimes is left with more questions than answers when the medical profession tries to generalize research conducted in highly specialized settings, said Carole Bland, professor of family practice and community health at the University of Minnesota and chairwoman of the task force.
One costly result is that a remedy for a full-blown condition is sought for milder cases. Primary-care physicians may realize the remedy is inappropriate in a lot of cases, but they don't have a study to back up their judgment when patients "come in with an article from Redbook," Ms. Bland said.
Physicians in the past may have just done what made patients happy, but now they're being put in the position of "gatekeepers." That means it's their job to prevent overtreatment, but they're also going to have to justify situations in which they prescribe a less-intensive course, she said.
Remedies for fully developed conditions ignore the full range of disease development, and early stages may call for a different remedy altogether, Ms. Bland said.
Primary-care physicians amass a body of knowledge on appropriate treatment, although "a lot of it is just learning by their experience," she said. "But that's not a very effective way to learn, and not a good way to be sending physicians out there."
Treatment of headaches is one example of a condition that has a number of causes and courses of treatment. Major research has gotten to the root of headache pain, but it's been done mostly on patients who were sick enough to be hospitalized with enduring misery. "Eighty percent of people who walk in with headaches don't have the kind that researchers see," said Ms. Bland.
On the practical level, family doctors can't be expected to make certain hospital-developed treatments work for the average patient even if the treatment is appropriate, she said. Captive and suffering inpatients tolerate unpleasant medication and side effects in controlled trials, which primary-care patients might not want to endure to get the resultant benefits.
Most medical research leaves out the patient context that's central to managing a person's health rather than intervening only for acute illness, the task force report said. "It doesn't fully inform the practice of primary care, in which a variety of interventions, including drugs, education, reassurance, diet, exercise, counseling and watchful waiting are used sequentially or in combination," the report said.
Health outcomes are usually measured in "hard" terms such as death prevention or easing of a particular condition, the report said. "Perhaps more relevant to the healthcare needs of most Americans are studies that focus on prevention, the restoration of function, relief of suffering and the values that patients place on different health outcomes."
There's also the psychological and social side of a patient. A headache may show up as a pain between the temples, but it may be a result of a pain in the neck at home or on the job.
"More research is needed on the effect of the psychosocial context of the patient on both the care process and the outcomes achieved," the report said. "For example, the social forces within the family are known to have the capacity to create, sustain, modify, cope with, protect against, increase susceptibility to, and cure illness."
So-called "lifestyle diseases" such as stress, smoking and alcoholism are getting more attention as preventable conditions that could reduce healthcare spending and illness. But it's not enough to know how to relate these factors to medical problems, Ms. Bland said.
Physicians also need more techniques to help people kick bad habits, and that requires research outside the teaching hospital setting, she said.