The recruitment of members into networks and specific research studies depends on their interest and willingness to contribute to research. Each network allows clinicians to make their own decision about whether to be involved in studies. Networks consist of self-selected practices, and in the United States and the United Kingdom not all practices agree to participate in all studies. This has implications for selection bias, particularly in studies where the clinician or the practice is the subject of study. However, given the fact that care is provided for unselected patients, practice self-selection will have less impact on patient-directed research. The Nijmegen experience illustrates that there may be a time in the development of the network when membership becomes more demanding, and members may be even less representative of clinicians in general. However, none of the network directors mentioned the retention of practices and physicians as a problem. Apparently this is related to the flexible approach in recruitment.
The Wisconsin and Wessex networks hope to stimulate physicians’ personal involvement in research to create a questioning environment. This is an additional bottom-up development in creating a research culture. In this respect the Nijmegen network seems at first to be very different, functioning more as a top-down university-centered research program. This is not true, however, as the Nijmegen network has provided family practice input to the medical school for more than 20 years, and 8 of the 25 physicians to date have received the highest academic degree of MD, PhD. The Nijmegen situation represents the full circle of changed research culture, with networked family physicians in charge of an independent family practice research program.
Ownership of the research is a particularly sensitive issue that can make or break the success of a study. Only when family physicians are confident that the data collection is relevant to and compatible with the demands of routine practice will it be possible to pursue a study.32 A key function of PBRN management is close communication and negotiation between researchers and physicians. An important outcome of this communication is the role of the network in providing direct input from primary care clinicians about the relevance of proposed studies for the development of family medicine. There is a need for direct research into the interests of clinicians who have to cope with the full complexity of patient care in the community setting.
A second key function of PBRN management is to develop research methodology in the network: Better research methodology will facilitate physician involvement, assist funding, and assure the obtained data are valid. Networks develop their own momentum. Initially, simple descriptive studies are conducted, but with increasing experience PBRNs can address larger and more complex collaborative projects. This process in the Nijmegen network has already been analyzed.33
PBRN studies may support current care practices and have a quality assurance focus in improving interventions, or cast doubt on current care practices and contribute to the development of new ones. A variety of primary care settings need to be used for these studies, given the impact of environment on the outcome of care. Evidence from small specialty settings can only be introduced directly into routine family practice to a limited degree.
The relationship between practice and research
The 3 networks expressed the need to support routine practice, do research, and, at the same time, raise the quality of care in the network. An integral relationship between practice and research is apparent in each of the networks. Questioning and supporting primary care simultaneously, however, is more ambivalent than it may seem at first sight. For family medicine it is particularly important to demonstrate that interventions work under most prevailing primary care conditions (evidence-based practice).34 But because a substantial number of interventions are used mainly in primary care settings, the potential of these interventions (efficacy) must also be studied in primary care. The studies of the pathophysiology of asthma fall into this category; these require ideal rather than prevailing practice conditions. This requires a choice from networks about how to perform these types of studies. The Nijmegen network represents an academic primary care setting tuned to the requirements of efficacy research. The Wisconsin and Wessex networks reflect more the existing variations in actual care, and this provides excellent opportunities for studying effectiveness of care under primary care conditions. A number of studies in the networks were descriptive, detailing the natural course of illness and disease under primary care conditions. These are important as they demonstrate to what extent evidence from other studies can be directly translated to practice.