Stavovi lekara primarne zdravstvene zaštite o istraživanjima u opštoj medicini General practitioners` attitudes towards research in general medicine

Introduction: General medicine is a specific scientific discipline and research is a constituting part of each medical discipline. Objective: We reviewed general physicians` (GPs) attitudes towards scientific research and their reasons for participating or not participating in them. Method: We made a specific questionnaire for the sake of this research. We got the data on age, gender, service periods, place of work (city/country), and specialty: GP or specialist in general medicine, as well as their opinions on research. We forwarded the questionnaire to 550 physicians` email addresses in November 2016. The acquired data were statistically processed using SPSS 20.0 for Windows. Results: The questionnaire was filled out by 233 physicians, of whom 83,3% were women, 67% specialists in general medicine, 68,7% physicians worked in city clinics; the average age of the participants was 46.46±10.29, the average service period 17.85±10.99 years. Out of the total number, 67.8% of the participants thought research was important and useful, even more so by specialists in general medicine, which was statistically significant (p=0.000). There were 71.2% of the physicians who already participated in the research projects, mostly working in the cities ( p =0.008), physicians older than 50 ( p =0.000), and physicians with service period >20 years ( p =0,000). Physicians 30 or younger ( p =0.017) and physicians with ≤ 10 years of service ( p =0.002) thought research improved work quality. The most frequent reason for not participating in the research projects was lack of time due to a patient and administration overload. The most frequent reason for participating, for physicians with 11-20 and over 20 years of service, was improving work quality (p=0.007). Conclusion: Physicians think research is necessary and useful in general medicine and it improves work quality. The most frequent reason for not participating in the research projects was lack of time due to a patient and administration overload.


Introduction
Primary health care (PHC) is a foundation of every efficient and high-quality health care system. It`s a complex, specific, and all-inclusive system delivering health care services in the areas of health improvement, disease prevention, acute and chronic disease treatment. PHC is not only about the health of an individual but the social community`s as well and it is also into sociological problems of its members, ecological, and socio-economic risks. 1 Quality PHC needs high-quality research. 2,3 General/family medicine is an academic and specific scientific discipline, and research is an integral part of every scientific discipline. General physicians (GPs) participated in numerous researches but little is known about their attitudes on research. John Furler and Hummers-Pradier E et al. say there are still not enough research projects in PHC. 1,4 Since the 90s, professional institutions have been emphasizing the need for organized research in general medicine in order to improve people`s health. 5 The research in general medicine is specific because it`s aimed at a patient in his social surrounding. 6 Therefore, general medicine has its specific needs for research and the spectrum of research activities is very wide (as mentioned in the curriculum of the Royal Australian College of General Practitioners: General practice and PHC research are the missing links in the development of high-quality health care) 7 . Due to this specificity, PHC can`t simply lean on the results and evidence of other medical disciplines but it must think through and organize its own research, with a recommendation to found national or regional research networks. 1,2,6,8 The research projects of the Section of General Medicine, of the Serbian Medical Society, have got long tradition. There were many cross-sectional, interventional, and prospective studies in which a lot of GPs from all over Serbia took part. The research projects in general medicine are important, they improve its reputation, affirm it and make it more popular among other medical specialists. They also improve the quality of health services. The research results may teach us a lot which can be one of the key factors in improving the quality of care in PHC. Lately, the number of physicians partaking in these research projects is ever decreasing. The physicians explain it with work and administration overload, obstructions by the management and CEOs in general medicine, as well as Ethical boards. Therefore, the Scientific Committee of the Section of General Medicine designed the research project for GPs and specialists in general medicine to review their attitudes towards participating in research projects.

Objective
We aimed at reviewing the general physicians` attitudes towards research projects and their reasons for participating or not participating in them.

Method
For the sake of this research, we designed a questionnaire to gather the data on age, gender, service periods, place of work (city/country), and specialty: GP or specialist in general medicine (SGM). Every question had several offered answers, with a possibility to circle several answers, if so desired. Besides offered answers, the participants were able to add their own answers. On the first Friday of November 2016, emails were sent to 550 general physicians from our databas. Gathered data were presented as frequencies (%), and Pearson`s X 2 test was used to measure the differences between observed categories. We used program package SPSS (Statistical Package for Social Sciences) 20.0 for Windows. Statistical difference was defined for level p<0.05.
The majority of the participants thought the greatest achievement of the research projects was that the results could be used in everyday practice in order to improve the quality of health care (38.1%). A bit more than a third of the participants circled simultaneously the first three answers (Table 4).  U dobijenim odgovorima nema statistički značajne razlike u odnosu na pol (p=0,777) i specijalnost lekara (p=0,340) (Tabela 5). Za lekare u gradu najznačajnija korist je porast ugleda OM kao akademske discipline, ugleda lekara OM i specijalista OM, i što se rezultati istraživanja mogu primeniti u svakodnevnom radu (p=0,008).
The questionnaire gave us the answers to the reasons why some physicians didn`t participate in the research projects. The most common reason was the lack of time due to work and administration overload (16.4%), and 13.5% of the physicians also mentioned these two reasons: patient and administration overload (Graph. 3). Besides offered answers, some physicians stated their own reasons: no one ever offered them to participate in the research project, they didn`t know how to join the research, some didn`t believe the research would change anything, some said there were obstructions by their clinic managers, some said they had family obligations and also wanted to devote their leisure time to some other things. A lot of offered answers and the possibility to circle simultaneously several answers produced a lot of answers combinations (33.9%). In 53.4% of these combinations, one of the answers was there was no financial reward for their participation (Table 6).    Tabela 7). Lekari opšte medicine, u odnosu na specijaliste opšte medicine, češće kao razlog navode nepremostiv jaz između istraživanja i praktičnog rada, a od nekih drugih razloga: odabir ispitanika, reprezentativnost uzorka, socioekonomsko-demografske karakteristike ispitanika (p=0,030). Lekari u gradu su, češće od onih na selu, navodili neke druge razloge kojih nije bilo među ponuđenim odgovorima (p=0,048). U odnosu na starost ispitanika, lekari stariji od 50 godina su daleko manje kao razlog neučestvovanja navodili opterećenost administracijom, dok su lekari u starosnom dobu od 41 do 50 godina mnogo češće, u odnosu na druge, navodili istovremeno tri razloga: nedostatak vremena zbog velike opterećenosti administracijom, nepremostiv jaz između istraživanja i praktičnog rada i da istraživanja doprinose samo afirmaciji onih koji organizuju ta istraživanja, a lekari opšte medicine služe samo za prikupljanje podataka za istraživanje (p=0,007). Lekari, pak, sa radnim stažom dužim od 20 godina češće su kao razlog neučestvovanja u istraživanjima navodili nedostatak vremena zbog opterećenosti velikim brojem pacijenata (p=0,016). Tabela 6. Razlozi ispitanika za neučestvovanje u istraživanjima u opštoj medicini There was no statistically significant difference in answers in regards to observed parameters (p=0.137) ( Table  7). General physicians, unlike specialists in general medicine, more frequently quote the dividing gulf between research and practice. Other mentioned reasons are the choice of the participants, sample representation, socio-economicdemographic characteristics of the participants (p=0.030). Physicians working in the cities, unlike those working in the country, quoted other reasons that were not among offered answers (p=0.048) more often. In regards to participants` age, physicians over 50 mentioned administration overload far less as a reason for not participating in the research projects. Physicians aged 41-50 mentioned these three reasons simultaneously much more than other colleagues: lack of time due to administration overload, dividing gulf between research and practice, the research affirms only those who organize it, and general physicians are there only to gather the research data (p=0.007). Physicians with over 20 years of service more frequently mentioned patient overload, as the reason for not participating (p=0.016).

Tabela 7.
Razlozi ispitanika za neučestvovanje u istraživanjima u opštoj medicini u odnosu na posmatrane parametre For the majority of the physicians, the main reason to participate in the research would be the results applicable in everyday practice and the results which would improve work quality (Graph. 4). A large number of offered answers induced many answers combinations.

. Reasons that would make physicians participate in research projects in general medicine
Odgovori/Answers

Rezultati istraživanja su merilo kvaliteta rada
Research results are a measure of quality.

Dobijeni rezultati u istraživanju omogućuju poređenje sa rezultatima sličnih istraživanja u drugim sredinama i zemljama
Research results enable comparison with research results from similar research projects in other environments and countries.
There was no statistically significant difference in answers in regards to age, gender, specialty, and place of work, but there was a highly significant difference in regards to physicians` service period. Physicians with service period from 11-20 years more often than others mentioned material gain. Physicians with over 20 years of service would participate in the research because its results could confirm or improve their work quality and enable them to compare them with the results from similar researches in the world (p=0.007) ( Table 8).  Diskusija U našem istraživanju upitnik je popunilo 46,6% lekara. Procenat odgovora o motivacijama i spremnosti lekara opšte medicine da učestvuju u istraživanjima veoma je različit. U istraživanju Hummers-Pradiera i saradnika 4 iznosio je 37%, a nešto više od nas u istraživanju Peters-Klimma i saradnika 9 50,7%. U velikom istraživanju u Štajerskoj 10 iznosio je tek 14%, a u istraživanju u Francuskoj 63% lekara opšte medicine odazvalo se da učestvuje u ovakvom istraživanju 8 .
Većina ispitivanih lekara u ovom istraživanju smatra da je najveća korist od istraživanja da se rezultati mogu Discussion There were 46.6% of the physicians who filled out the questionnaire. The percentages of motivation and readiness to participate in the research projects hugely vary. In the research of Hummers-Pradiera et al 4 this percentage was 37%, and in Peters-Klimmaet et al`s 9 study it was 50.7%. In the big research in Styria, this percentage was 14% 10 , and in France 63% of general physicians responded to the research 8 .
Two-thirds of the physicians in our study think research projects in general medicine are necessary and useful, while the study of Hummers-Pradiera et al.finds this percentage to be 91.7% among German general physicians 11 . John W. Beasley et al. emphasize in their work the research in PHC is of essential importance for the development of better healthcare systems and health politics. General physicians must be an integral part of the research projects because an evidence-based PHC approach will soon become a rule. 12 Nevertheless, as quoted in some studies, PHC research projects are still insufficient 1,4,13 , and a huge number of researchers plainly showed it`s necessary to educate GPs in order to involve them in the research projects 4,5,7,14,15 . The study of Lire H.et al. in Finland, followed the physicians opting to participate in the research projects after finishing a year-long multilevel course in research. The course taught them critical thinking, they gained basic knowledge in research, and were also inspired to join the research projects 6 .
Among our particpants, 71.2% of our participants have already participated in research projects in general medicine. There were more female physicians, and general physicians as compared to specialists in general practice. Physicians working in the cities, physicians over 50, and physicians with over 20 years of service more often participated in the research projects. Frank Sullivan et al. indicated two-thirds of the Scottish physicians actively participated in the research projects, and there were 50-60 of them each year 16 . The research of I. Supper et al. showed only 29.2% of the polled general physicians in France participated in the research projects, but just as many would be ready to accept to participate in some research 8 .
The study of Tawo S. et al. showed 43% of the physicians would like to participate in the research projects, and more often those were males younger than 40 and working in the city clinics. 17 In the Styer`s study in 2017, by Stephanie Poggenburg 10 , and Peters-Klimma 9 , et al.`sstudy in Germany in 2013 it was shown women were less interested in participating in the research than men. In regards to job location, physicians working in the country were more interested to do the research, the Styer study showed 10 .
Za najveći broj lekara u ovom istraživanju najčešći razlog za učestvovanje bio bi da rezultati istraživanja mogu da doprinesu unapređenju kvaliteta njihovog rada. Rezulta-general medicine`s reputation improvement, and the fact that the research results might be applied in everyday practice to improve healthcare services. Many studies showed general physicians believe the research projects might improve the quality of healthcare services 2,5,7,10,12,[18][19][20] . WHO (World Health Organisation) pointed out in the last decade of the 20 th century the importance of PHC in the improvement of people`s health. WONCA (World Organization of Family Doctors) organized a conference in Ontario, Canada in 2003 on the future of research in PHC, wanting to point out the necessity of the research in general/family medicine which would improve the healthcare service quality. 19 The questionnaire gathered the data on why some physicians didn`t participate in the research projects in general medicine up till now. The most frequent reason was the lack of time due to work and administration overload which was consistent with the findings of other researchers 5,10,17,18,[21][22][23][24] . Hummers-Pradiera et al.`s 11 research showed 56% of the participants said they wouldn`t accept participating in the research, and their reasons were: they were against the use of EHC (electronic health records) data of their patients, there was a possibility of data abuse, they had little influence on the research process, and some said it was just their principle. Some physicians pointed out these obstacles: clinical trials were mostly done on hospitalized patients 21 , PHC research projects were considered less valuable 1 and the only role of GP was to gather the data 5 , research participation was inadequately valued, 5,15 there was no affiliated time for the research and it would lead to losing patients 4 . It`s a general belief there is a dividing gulf between research and practice 5 and they don`t believe in the usefulness of the research 22 . Besides offered answers, the participants in our research pointed out some other reasons: they were never offered to participate in the research, they didn`t know how to join the research, they didn`t believe it would change anything, there was obstruction by the management team, family obligations, and the desire to devote their leisure time to something else. A large number of offered answers and the possibility to opt for several answers simultaneously led to a large number of answer combinations. More than half of the participants said there was no material gain in it for them. The research among general physicians in Styer 10 , Great Britain 18 , and Germany 24 also showed that financial gain would lead to a higher number of the participants.
as not occupying a great deal of their time, and continuous education on research and financial gain were of less importance. In a plethora of similar research projects general physicians also mentioned the research questions of importance for their everyday work in general medicine as highly motivating 3,9,18,19 . The physicians from the study of J. Furlera et al. 1 thought the research projects should be supported by PHC management to ensure their sustainability. The problems are diverse and very complex but the research potential in PHC is huge. An opportunity to participate in research projects some physicians see as a chance to gain an academic title 1 and the possibility to participate in research results publishing 6,18 .