Response

Dr D’Urzo has responded to our articles^1,2 and suggested that the most important issue driving family physicians’ underrepresentation in their own guidelines is that they do not participate in or perform original research.

We agree that in the past family physician researchers have not been well represented in clinical research. The causes of this have been multifactorial, ranging from issues such as the lack of training and career tracks for family medicine researchers to the lack of funding opportunities for family medicine research. However, even several decades ago, many family physicians were making inroads in clinical research.

We disagree that this is currently true. Over the past decade or more family physicians have been leading a multitude of clinical research projects and networks within primary care research. The future of family medicine research looks brighter with each passing year.^3,4 One area of research where non–family physician specialists are far more likely to be involved than family physicians is in randomized controlled trials of pharmacotherapies (for a multiplicity of reasons), but this might not be a liability when it comes to participating in guidelines.

All that said, we believe this alone would have little effect on family physicians’ ability to participate in developing their own guidelines. Family medicine–driven clinical research will undoubtedly improve the care of our patients. However, we think it is a mistake to assume that the ability to carry out solid clinical research alone will lead to inclusion of primary care clinicians in guidelines. Further, we would argue that researchers focused in specific areas might not be ideal guideline participants. The predisposition bias and overreliance on their own research would compound the known challenges experts seem to have when interpreting evidence.

For those of us who have participated in clinical practice guidelines led by non–family physician specialists, we have seen that the selection of those with specific areas of interest and research focus is a pervasive problem contributing to many of the common biases and issues seen in clinical practice guidelines. In addition, many of these same individuals have industry affiliations that can compound their biases. So, even as family physicians participate in more primary care research, we would argue that any researchers (primary care, specialty, doctoral, etc) should only play a minor role in any guideline team.

We would like to address 2 final issues raised by Dr D’Urzo.

First, critical appraisal skills alone cannot be considered the primary requisite for guideline inclusion. To clarify, critical appraisal often implies the ability to use simplified checklists of criteria to determine validity and reliability. We believe that the skills required for a thorough analysis of the medical literature and its application to primary care go far beyond that and those are the precise skills we require in guideline participants. Paradoxically, these skills are not consistently found in all researchers. So yes, critical analysis and application skills are necessary over research experience.

Finally, we do not believe it is unrealistic for our leadership, including the College of Family Physicians of Canada, to limit endorsement of guidelines targeting primary care that have not had adequate primary care involvement or governance. It is somewhat sad that any primary care clinician believes otherwise. It will take leadership from the highest levels to ensure this becomes the priority it so desperately needs to be— otherwise, this pervasive problem will never change.

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