Stewart, Moira PhD; Reid, Graham PhD; Brown, Judith Belle PhD; Burge, Fred MD, MSc; DiCenso, Alba PhD, RN; Watt, Susan DSW; McWilliam, Carol EdD, MScN; Beaulieu, Marie-Dominique MD, MSc; Meredith, Leslie MEd
Dr. Stewart is professor, Centre for Studies in Family Medicine and Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.
Dr. Reid is associate professor, Department of Family Medicine, Schulich School of Medicine & Dentistry, and associate professor, Department of Psychology, The University of Western Ontario, London, Ontario, Canada.
Dr. Brown is professor, Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada, and professor, School of Social Work, Kings University College, London, Ontario, Canada.
Dr. Burge is professor, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
Dr. DiCenso is professor, School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
Dr. Watt is professor, School of Social Work, McMaster University, Hamilton, Ontario, Canada.
Dr. McWilliam is professor, School of Nursing, The University of Western Ontario, London, Ontario, Canada.
Dr. Beaulieu is professor, Médecine Familiale, Faculté de Médicine, Université de Montréal, Montréal, Québec, Canada.
Ms. Meredith is coordinator, TUTOR-PHC program, Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.
Please see the end of this article for information about the authors.
Correspondence should be addressed to Dr. Stewart, Centre for Studies in Family Medicine, The University of Western Ontario, 245-100 Collip Circle, London, ON, Canada N6G 4X8; telephone: (519) 661-2111, ext 22133; fax: (519) 858-5029; e-mail: email@example.com.
Primary health care (PHC) research has been recognized as an important force for the renewal of the health care system.1,2 PHC encompasses comprehensive health services that promote health by providing preventive, curative, supportive, and rehabilitative care, with emphases on the health of individuals and communities, on promoting and supporting good self-care and family care, and on self-reliance and self-determination regarding health.3,4 PHC serves patients with acute and chronic disease as well as those with more complex, undifferentiated, physical and emotional conditions.
PHC is delivered in the context of groups of practitioners and, increasingly, by interdisciplinary teams of providers. The research in this field should reflect this trend in order to maximize its relevance to practice and policy.
Why Does a Country Need Research in PHC?
Most medical research is conducted at academic tertiary care institutions.5,6 However, U.S. data indicate that only 4.3% of individuals of all ages receive hospital-based health care (0.7% from academic medical centers), whereas 21.7% of individuals receive health care from an office-based physician,7 and others receive care from nurses, social workers, and psychologists through both publicly and privately funded community-based services. However, findings from hospital-based research often cannot be applied to a PHC setting. For example, the accuracy of diagnostic tests varies according to prevalence of the condition; diagnostic tests evaluated in specialty clinics will not be accurate for a PHC setting in which the prevalence is lower.8 Furthermore, health services delivery issues (e.g., those issues associated with communication and coordination) and the nature of the health problems addressed (e.g., the natural history of herpes zoster) differ substantially in the two settings, which limits the applicability of research findings across the two sectors. We therefore conclude that more needs to be known about PHC, especially given the relatively high proportion of people seen in the PHC setting. At the population level, the international studies conducted by Starfield4 showed that the research evidence base for primary care is worth investing in because of the demonstrated positive association between the strength of primary care and a country's health status (e.g., low birth weight, low postneonatal mortality, low disability-adjusted life expectancy) and system costs (e.g., lower per capita health care expenditures).
What Challenges Exist in Training Excellent and Productive PHC Researchers?
In Canada, the core disciplines in PHC, including family medicine, nursing, epidemiology, psychology, pharmacy, and social work, should develop their research capacity, in that relatively few graduate programs exist, and career tracks for clinician–scientists are just beginning to be created. The exception among these disciplines, psychology, has well-developed programs for research training at the MSc/MA and PhD levels, for which the PhD clinician–scientist is the standard training model; however, the focus on psychology research is that relevant to PHC is relatively new.9 Another challenge is that the community of PHC researchers in any one country is small.10 There is a dearth of curricula for developing such researchers and creating a community of scholars that can transcend the barriers of distance.
What Training Is Being Done in the Area of Interdisciplinary PHC?
Primary care research training programs have various focuses. Among those that are discipline-focused are such programs as those in dentistry (e.g., a primary care research training program for general dental practitioners at the University Dental Hospital, Manchester, United Kingdom) and those training family medicine researchers (e.g., a PhD program at The University of Western Ontario, London, Ontario, Canada). One of the programs that is graduate-degree-focused is the MSc/diploma in international primary health care at University College London (London, United Kingdom). A disease-specific program focuses on arthritis (at the Arthritis Research Campaign National Primary Care Centre, Keele University, Staffordshire, United Kingdom). Finally, there are fellowships within the structure of a primary care research network, such as the Primary Health Care Research and Information Service (Flinders University, Adelaide, Australia) and the School of Primary Care Research (London, United Kingdom). We could find no training programs that are equivalent to the experience a participant would gain through the Transdisciplinary Understanding and Training on Research–Primary Health Care (TUTOR-PHC) program.
To meet the challenges of research in PHC, a consortium of five Canadian universities led by the University of Western Ontario created the TUTOR-PHC research training program in 2002 under the auspices of the Canadian Institutes of Health Research (CIHR) Strategic Training Initiative in Health Research. The goals of the new national program for research training in PHC were, first, to build a critical mass of skilled, independent researchers to enhance the meager evidence base for PHC practice through both student opportunities and faculty (supervisor) development and, second, to increase the interdisciplinary focus in PHC research.
Funded in 2002, TUTOR-PHC was officially launched in May 2003. This training initiative is built around three groups: the teachers, called mentors, who represent a variety of disciplines (Table 1 provides a complete list); the trainees, from a variety of PHC-related disciplines (Table 2 provides a complete list); and the trainees' supervisors (usually the trainees' graduate studies program supervisor at their university).
Each trainee accepted into the TUTOR-PHC program remains in the program for one year. Concurrently, most of the trainees attend a graduate program at their home university. TUTOR-PHC provides supplementary training equivalent to one full graduate course. Most receive a TUTOR-PHC fellowship at CIHR levels congruent with their experience.
All aspects of the TUTOR-PHC program are interdisciplinary in nature, and they focus on three components: (1) a three-day on-site symposium, which is hosted on a rotating basis by each of the founding Canadian universities, (2) four online workshops, lasting three weeks each, and (3) two online interdisciplinary discussion groups, lasting seven weeks each. After the symposium, for which all participants are in one location, the online components allow continuation of the program for participants who are scattered across Canada. Trainees participate in forming the curriculum by completing a needs assessment on admission to the program. These needs assessments identify potential topics for the symposium workshops and the online portion of the program. List 1 provides a complete list of workshops offered.
The three-day on-site symposium kicks off the yearlong program. It provides the opportunity for the trainees to get to know each other, both permitting an introduction of topics and experiences that are most suited to face-to-face interaction and providing a foundation for the trainees to interact later in the online segments of the program. Interdisciplinary discussion groups are a key component of the symposium, in which participants are asked to contribute feedback on research proposals from the perspective of their own PHC discipline. The symposium also serves to introduce and define PHC and the function of interdisciplinary teams through the conduct of interactive, small-group exercises and six methods-based workshops (two that are chosen through needs assessment and four that are mandatory; List 1). As a preamble to this smorgasbord of methods workshops, the mentors present succinct (five-minute) introductions (called “snappers”) about the various methodologies to all trainees. All workshops are facilitated by program mentors, who ensure experiential learning through interaction and practice.
After the trainees return to their universities, they participate in the two online workshops selected via the trainees' needs assessments. The purpose of these workshops is to fill in gaps in research methods knowledge and skills that are highly relevant to PHC. These workshops have a three-week, modular format, are facilitated by experienced PHC researchers, and cover theory and practice (e.g., an evaluation of PHC reform and an overview of qualitative research methods) (List 1).
Online interdisciplinary discussion groups
The approach to interdisciplinary discussion groups has been intentionally crafted to foster interdisciplinary research team building. Each group is composed of six or seven trainees from different disciplines who participate in asynchronous discussions that allow for the various time zones in which participants live and the frequent time challenges for practicing clinicians. The groups are moderated by program mentors, although trainees are encouraged to lead the discussions to build their skills in facilitating an interdisciplinary group. This online experience comprises two overarching tasks. The first of these tasks has two parts: The trainee provides feedback on his or her peers' research project from the perspective of the trainee's own discipline, and then the trainee receives feedback on his or her own project from the perspective of peers representing at least four other disciplines. This input can reframe the research projects and mold them into truly interdisciplinary undertakings. The second of these tasks requires each group to create a team grant proposal. In this exercise, each trainee leads the group in creating a different part of an interdisciplinary PHC proposal (e.g., research question, sample, methods, or knowledge translation). The realities of group process, such as time pressures, team conflicts, effective use of member strengths, and the effort to create a product that can be endorsed by all team members, are some of the challenges trainees must face. The online nature of the exercise also prepares trainees for the realities of leading a geographically dispersed research team.
Guidance during the TUTOR-PHC program
Each of the trainees has a supervisor from his or her home institution, usually his or her graduate studies thesis supervisor. Each trainee's supervisor attends the symposium and participates in the online interdisciplinary discussion groups. At the symposium, supervisors attend a facilitated workshop that is aimed at discussing issues related to interdisciplinary graduate supervision and research team leadership. The interdisciplinary nature of the program draws supervisors—who are faculty members at various stages of their careers—into PHC research and gives them the knowledge and skills needed to weave PHC into their research agendas. Thus, the TUTOR-PHC program builds PHC research capacity at the trainee level, as well as at the faculty level, through supervisor participation. Collaboration among PHC-relevant disciplines and across geographic distances is also enhanced.
Trainees are also guided by mentors; each trainee chooses a mentor from among the program's pool of nationally recognized faculty. This part of the program allows each trainee access to an experienced interdisciplinary PHC researcher who provides support during the program and who is available after the program for career advice, feedback on proposals and/or papers, advice on project design and methodology, and/or collaboration on research.
Evaluation, Evolution, and Outcomes
TUTOR-PHC has graduated 77 trainees from 14 disciplines. Seventy-four supervisors have participated, of whom 15 were program mentors. Each year, nearly four times as many applicants seek TUTOR-PHC trainee positions as can be accepted (i.e., approximately 50 applicants for approximately 14 positions per year).
Twenty-two educational products have been created for TUTOR-PHC, including 11 online research workshops with train-the-trainer manuals. A complete list of these workshops appears in List 1. The manuals are available at the TUTOR-PHC Web site (www.uwo.ca/fammed/csfm/tutor-phc).
Program graduates have received questionnaires after their year in TUTOR-PHC and yearly from 2005 on. The evaluation questionnaires revealed a high level of productivity among the 77 TUTOR-PHC graduates, who are at various stages of their careers. The graduates have published 367 peer-reviewed papers and had made 675 conference presentations as of August 2008. Trainees have produced many grant proposals during or immediately after their year in TUTOR-PHC. For example, in the years 2007 and 2008 alone, TUTOR-PHC fellows received funding for 125 grant proposals. A high proportion of TUTOR-PHC fellows now hold faculty appointments; two trainees have returned as supervisors in the TUTOR-PHC program, and two have been invited to join the mentor team. One graduate now holds the only Primary Care Applied Chair in Health Services and Policy Research, which is funded by the Canadian Institute for Health Services and Policy Research, and another graduate is now director of evaluation for the Pharmaceutical Services Division of the British Columbia Ministry of Health Services. Other positions currently held by TUTOR-PHC graduates are those of principal scientist, C.T. Lamont Primary Health Care Research Centre, Elizabeth Bruyère Research Institute (Ottawa, Ontario, Canada); clinician scientist, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto (Toronto, Ontario, Canada); and head, Division of Preventive Dentistry and Oral Health Promotion, Dental Clinical Sciences, Dalhousie University (Halifax, Nova Scotia, Canada). These outcomes indicate both the selection of highly productive trainees and the impact of the TUTOR-PHC program.
Several features of the TUTOR-PHC program have received very high ratings by trainee participants, among them the interdisciplinary discussion groups. Participants were surprised at the varied perspectives that emerged with respect to the same research topic. After the symposium, the trainees engaged in online interdisciplinary discussion groups (six to seven trainees from different disciplines per group). Projects can range from clinical research (e.g., evaluating the relationship between diabetic nephropathy and related risk factors and other clinical variables in a cohort of primary care patients with type 2 diabetes) to health services research (e.g., factors associated with adolescent family physician utilization) to community interventions (e.g., cardiovascular health promotion in communities) to knowledge-translation-focused research (e.g., knowledge translation practices within multidisciplinary health care teams). Each trainee was given one week to facilitate a discussion on his or her research (proposed or under way). The trainees presented their research and responded to the feedback and/or queries from their interdisciplinary colleagues. The trainees thought that this experience was unique and invaluable. As one trainee stated, “I was amazed at the high level [of discussion] and [the] interesting perspectives provided by the cross-disciplinary exchange! Thanks for the valuable insights.” Another trainee said, “I have spent the most exciting week of my junior research career!”
The trainees considered the creation of an interdisciplinary research team to produce a grant proposal to be a most valuable, albeit difficult, exercise. For example, in 2008, the trainees received a call for proposals based on a CIHR call for Operating Grants on Childhood Obesity Prevention and Treatment. The trainees' task is to create a proposal that is interdisciplinary, preferably of a mixed-method design, and specific to PHC.
Many trainees commented on the evaluation of this task. A 2006 graduate said, “It wasn't easy, but I think it gave us some real-life insights into the practicalities of working as a team and trying to consider everyone's varied agendas, backgrounds, and strengths.”
A 2007 graduate said,
We were provided with an opportunity to delve as [deeply] as we wanted into a topic that was not clearly defined for us. As such, we were able to go through the problem-solving cycle that all researchers go through—identifying the problem/research question before proceeding further with the proposal.
A 2005 graduate commented,
The application of research knowledge gained throughout the course allowed for consolidation of learning… . The group and facilitators [also] provided additional references for future learning. I was very fortunate [in] the outstanding communication abilities of my group, and many [concepts] were clarified through the RFP process.
A most rewarding aspect of TUTOR-PHC is the high proportion (75%) of clinician–researchers from a variety of disciplines in the trainee pool. As a result of the evaluation of and reflection on the program, several noteworthy changes enhanced the original program. One of these changes was the addition of other disciplines to the original five from which the coinvestigator team was derived (we added pharmacy, sociology, education, and health services research); moreover, among the trainees, we added the disciplines of sociology, physiotherapy, occupational therapy, philosophy, anthropology, dietetics, and community dentistry. Another change was the addition of an assessment of trainees' needs, which has allowed TUTOR-PHC to be more responsive to individual needs. In particular, with regard to workshops, TUTOR-PHC enacted a learner-centered approach by conducting a needs assessment of trainees that led to a relevant list of potential workshops and by permitting trainees to choose from this tailored list. A further change, which took place during implementation, was enacted to ensure that the main disciplines were represented in each cohort of fellows; we stratified all applicants into the categories of family medicine, nursing, epidemiology, psychology, social work, and other. This arrangement is now TUTOR-PHC selection policy.
Discussion of Interdisciplinary Training in PHC Research and Lessons Learned
The TUTOR-PHC training program on interdisciplinary research had many strengths. It attracted a large pool of applicants every year. Each cohort of trainees had an acceptable mix of disciplines, as mandated by the selection process. Trainees have been exposed to multiple research methods during highly rated, succinct presentations. The interdisciplinary concepts and experiences produced rave responses from trainees. The productivity outcomes of trainees were impressive.
TUTOR-PHC has had several specific curricular successes. One successful aspect of the program is the process that combines readings, discussion, and experiential learning within each three-week online workshop. A second is the enacting of the principle of interdisciplinarity by placement of trainees from various disciplines into each discussion group. A third successful aspect of TUTOR-PHC is the structure and process created by the mentors for the online discussion groups, including the request for proposals to which the interdisciplinary team of trainees is required to respond by creating an interdisciplinary grant proposal. In a fourth success, experienced mentors reflect, as part of the symposium, on what they bring to an interdisciplinary research team from their discipline and from their personal skills and experience (this part of the symposium is highly rated, and it provokes much discussion and reflection). A fifth successful aspect is the requirement that the trainee's graduate program supervisor attend the symposium to experience the interdisciplinary and PHC learning. A sixth successful aspect is the exposure of trainees and supervisors to peers from different disciplines, in the retreat-like setting of the symposium, which has inspired and built networks for future collaborations, just as it was designed to do. To date, we have seen the development of several teams that are now pursuing interdisciplinary PHC research.
The TUTOR-PHC program faced, and met, at least two significant structural challenges. The first of these challenges—the discovery that the applicants and trainees had a more senior status than was anticipated—was a challenge with a silver lining. The positive aspect of this situation was that TUTOR-PHC became more focused on training future leaders (midcareer professionals, postdoctoral fellows, and PhD students) and not so focused on training undergraduate students, residents, and MA/MS students. The negative side of this situation was that the financial support needed for these fellows was higher than anticipated, and thus fewer trainees could be funded. TUTOR-PHC's response to this challenge was to invite some trainees to participate without a fellowship; the trainees' acceptance of this invitation enabled TUTOR-PHC to exceed the projected number of trainees. The second of the challenges was the ongoing effort to maintain the interdisciplinary mix of trainees. Recruitment strategies were refined and enhanced during the first two years of the program to include more systematic advertising in a broader range of disciplines, better use of the mentors' professional contacts, and more frequent repetition of the announcements.
Every yearlong course of TUTOR-PHC presented challenges that we addressed, over time, which created a more balanced and more learner-centered experience. Although the interdisciplinary experiences have been highly rated by trainees, the amount of delicate facilitation needed to move trainees to a point of being prepared to contribute to an interdisciplinary research team was unexpected. To prepare each trainee to constructively bring his or her discipline's perspective to a team meeting, mentors modeled their disciplinary contributions. Mentors imparted their tacit knowledge, which is based on their many years of experience, through a variety of exercises that they conducted before trainees were ready to participate meaningfully in their interdisciplinary discussion groups. To prepare the interdisciplinary team of trainees to write a grant proposal together, the mentors worked to create a request for proposal that was challenging but not overwhelming; this process took several years.
Several value-added features are noteworthy. As TUTOR-PHC mentors have reflected on the educational approaches in the program, it has become clear that TUTOR-PHC has surpassed the goal of teaching and learning research skills and the theoretical knowledge of methods and of the nature of PHC. The new level or goal reached is the imparting of the tacit knowledge of the experienced mentors to the trainees—that is, the “how-to's” of combining research methods, of being a researcher in an interdisciplinary team, and of synthesizing one's personal qualities with one's research skills and knowledge to become a truly collaborative researcher.11,12 In addition, collaborations among supervisors and mentors who met during the TUTOR-PHC program have been a benefit. This informal networking has spawned PHC research initiatives that are more representative nationally as well as being inclusive of a wider range of disciplines. Moreover, the addition of international trainees from 2006 through 2008 widened the perspectives of the Canadian participants and provided an opportunity to disseminate Canadian PHC research to international colleagues.
In summary, then, TUTOR-PHC has succeeded, but not without considerable reflection and continued effort. It has attracted trainees from a rich mix of disciplines and offered them a transformative opportunity to become collaborative leaders of future PHC research.
The authors would like to thank Sandi Richard-Mohamed of the TUTOR-PHC staff for her contributions to the planning and successful implementation of the program.
The Canadian Institutes of Health Research funded the Transdisciplinary Understanding and Training on Research–Primary Health Care (TUTOR-PHC) training through the Strategic Training Initiative in Health Research, and Dr. Stewart is funded by the Dr. Brian W. Gilbert Canada Research Chair.