Response

I appreciate the response by Drs Pimlott and Allan to my letter and I believe we share the same good intentions on the issues we are discussing.^1,2 There is no question that primary care has made great strides in research in recent years, but as I stated in my initial letter, the premise promoted by my colleagues is not consistent with the current realities that drive guideline development. Among the principles of family medicine³ is included the notion that we are prudent stewards of scarce resources. Given the substantial economic implications of prescriptions generated in primary care, I would disagree that not participating in this type of research would not translate into a liability in terms of participation in guidelines. If family physicians were designing pharmacotherapeutic clinical trials with a better balance between internal and external validity with relevant primary care outcomes that translated into improved, cost-effective care, this would likely get the attention of policy makers and public payers and put us in a position where we might be more fiscally responsible for our clinical decisions. At a minimum, we would be more able to develop strategies to be more accountable for the health care costs we generate. The latter possibility would be an important foundational piece in moving toward the development of primary care guidelines by primary care physicians collaborating with colleagues in other specialties.

I also appreciate the suggestion that bias might come into play if researchers with focused interests (often non–family physician specialists) are driving the guideline agenda, but this is simply a symptom of the lack of primary care engagement. To suggest that the future might be different is fine, but it does not reconcile the current challenges we face and the trajectory we should launch to achieve our goals.

I have been and continue to be a strong supporter of the College of Family Physicians of Canada, but I am not able to let this loyalty stand in the way of providing constructive advice about how we might best position ourselves to be leaders in clinical care and research.

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