General practitioners' attitudes towards research in primary care: qualitative results of a cross sectional study

Compared to other European countries, Germany still has little of a research tradition in general practice. Increasingly policy-makers have realized that the continuity and the efficacy of the healthcare system have to be improved. For this a well-developed primary medical care system is needed. In recent years a number of new chairs of general practice have been established and a national funding programme was created in order to promote General Practice as an academic discipline in Germany. The University of Heidelberg, which is the oldest university in Germany, is among the beneficiaries of these developments. Despite of a well established network of teaching practices, the research group for general practice and health services research was only created in 2002 [1]. This group faces the challenge to perform studies with general practitioners who have little experience with participation in scientific research. It is known, that by specifically addressing strategies significant improvements in participation rates can be achieved [2]. The aim of the study was to investigate the willingness of GPs to participate in research and to learn about their attitude towards research in their field in general. These data should help to create successful approaches for further projects.

A total of 18 GPs (23.8%) of the approached GPs was female, 58 GPs (72.2 %) were male. Only two GPs faxed their agreement-sheet within the first week, before they were phoned and interviewed by the principal investigator. During the telephone calls 25 GPs (32.8 %) agreed to participate and promised to fax the sheet. Out of this group 5 GPs (18.5%) sent their fax during the subsequent two weeks. A total of 8 (10.5 %) faxes were returned. Five female (27.7 %) and 22 male GPs agreed (37.9 %) to participate. A total of 27 GPs agreed to participate ultimately.

Table 2 shows the GPs reasons for non-participation. 24 (31.5 %) of the GPs argued they had no time, because of overwork in their practice caused by the daily routine work. The second most frequent reason named was the regular administrative workload. Seven GPs specified this argument by blaming especially the newly introduced "disease management program, DMP", founded by German sick funds for chronic illnesses like diabetes and hypertension. This program was perceived to increase the daily paperwork tremendously. Other important reasons for non-participation were disbelief that possible results can be implemented in daily work without financial incentives. GPs argued that changes, which are accompanied by any additional time effort, could only be implemented in daily practice if they receive adequate financial reimbursement. "Money sets the course", as one GP stated. Two GPs declared they had no problem in dealing with osteoarthritis and regarded also dealing patients suffering from osteoarthritis quite easy. Four GPs named participation in courses and congresses as a reason for non-participating. One GP mentioned that this kind of research is only for academic interest and helps only the career of the researcher. An other GP argued that he already feels monitored by all the data collected by health insurance and the government.

As can be seen in table 3, 85.6 % of the GPs had positive attitudes regarding research in their field. They consider it reasonable and eligible, but in most of these cases the answer was not substantiated with a further argumentation. Interestingly, answers, which were allocated to the category „makes sense because it improves the reputation of GPs and documents our quality of care", were only given by GPs who agreed to participate in the study. So this aspect seemed to be the most important motivation for an GP to take part in research. In addition, this particular group of GPs regularly added further comments regarding role of the GP in the German health care system. Important reasons for scepticism were the gap between theoretical research and practical work and the domination of research by specialists. One GP argued it would be better to spend more money on treatment than on research.

There were three main conclusions that can be drawn out of our interview results. Firstly, the research topic improving the quality of care for patients suffering from osteoarthritis was considered as highly relevant by the interviewed GPs. This is concordant to our assumptions based on epidemiological data, which led to the fictitious research topic. The same reasoning causes GPs to seek support in the daily treatment of patients with osteoarthritis. Consequently this will be subject of future research projects.

Secondly, most of the GPs appreciate research in general practice, but a few were very sceptical. German GPs still don't realise it as a professional obligation as their colleagues in countries like e.g. the Netherlands or the United Kingdom, with a much longer tradition in research, do [7].

The third main result of our survey has not yet been shown in former studies. It is the fact that the willingness for participating in research emanates mainly out of the motivation to improve the reputation of family medicine in general by documenting the high quality of care with data attained in solid surveys. This may reflect the increasing self-confidence of German GPs, which are about to expend the influence in the health care system, and their awareness that an own research culture helps to enhance this. Facing decreasing financial resources in the Health care system, GPs may also be aware that a solid database documenting the quality of care will get more important for the distribution of financial resources in the near future.

The revealed barriers against participating in studies mentioned in our telephone survey are in line with results from previous studies in other countries [8]. According to those former results, relevance of the research topic, reimbursement and compatibility with routine general practice work are important factors. Ideally the GPs are embedded in an existing research culture [7, 9, 10]. Study nurses or mentors could be an important factor to enhance GPs' preparedness to participate in General Practice research because they reduce the administrative workload for GPs and enhance the motivation to participate in research [8, 10, 11]. Furthermore financial incentives for participation are essential because of time constraints and overwhelming administrative work that compete with research and represent important barriers [8, 11]. An unexpected quantitative result of this study was that being involved with the training of medical students and being linked with the University is not reflected per se in a higher motivation in participating in research. Participating rates of about 30 % are usually achieved in random postal mailings to GPs without academic affiliation [5, 9, 13, 14]. Previous studies have shown that involvement in student teaching represents a positive predictive factor for participation in research, so we assumed to achieve a much higher participation rate. It appears that a well-established teaching network does not necessarily yield much benefit for research purposes [11].

Previous studies were mainly focused on formal or external barriers for GPs against participating in research, or revealed approaches that cannot easily be transferred, as e.g. the enrollment of friendly GPs [15]. What this study adds is that there is an important target to aim at, if GPs have to be involved in research: the motivation to underline their daily work with solid data reflecting their high quality of care. With this knowledge GPs may be easier approached if they need to be motivated to participate in future projects. Aiming more on psychological targets, this approach should be transferable to other countries as well. However, researchers should be aware that beside the chance of motivating GPs, this strategy also contains a risk: GPs could be discouraged and kept away from future participation if the anticipated demonstration of their quality of care is not as obvious as expected.