
Early in his research career in South Africa, Dr Merrick Zwarenstein witnessed how the discriminatory policies of apartheid affected health care delivery and patterns of illness in that country. His interest in social justice led him to work in disadvantaged communities and to focus on the power of using data to evaluate practical solutions to difficult health care problems.
In a study published in the May 2024 issue of Canadian Family Physician, Aggarwal et al reported on the contributions of highly productive primary care researchers in Canada and identified individuals whose work has been cited widely in the medical literature.1 Dr Zwarenstein was recognized as the individual primary care researcher with the fifth-highest total number of citations. Additional statistics from Dr Zwarenstein’s career are highlighted in Box 1 and his most-cited peer-reviewed articles as first author are listed in Box 2.
Dr Merrick Zwarenstein, by the numbers: Data as of January 2023.
Number of publications: 315
Number of publications as first author: 51
Number of citations as first author: 3593
Total number of citations: 17,151
Author h index score,* 2007 to 2022: 58
*The h index score is calculated as the highest number of manuscripts (h) from an author that all have at least the same number of citations (h).
Most-cited publications as first author
Zwarenstein M, Treweek S, Gagnier JJ, Altman DG, Tunis S, Haynes B, et al. Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ 2008;337:a2390. Epub 2008 Nov 11.
Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2009;(3):CD000072.
Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, Atkins J. Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2001;(1):CD002213.
Zwarenstein M, Schoeman JH, Vundule C, Lombard CJ, Tatley M. Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis. Lancet 1998;352(9137):1340-3.
Zwarenstein M, Reeves S. Knowledge translation and interprofessional collaboration: where the rubber of evidence-based care hits the road of teamwork. J Contin Educ Health Prof 2006;26(1):46-54.
This interview with Dr Zwarenstein, Professor in the Department of Family Medicine and the Department of Epidemiology and Biostatistics at Western University in London, Ont, is the final installation in our 5-part series profiling the most-cited primary care researchers in Canada.
Your research has addressed a range of health services and methodologic issues. How did your research program originate and develop?
Yes, you might reasonably doubt that this wide range of topics connect at all! But I found links from microbiology of cholera vectors to maldistribution of health resources due to apartheid, to randomized controlled trial (RCT) evaluations of tuberculosis care, [and to] ethnography of teamwork in tertiary care hospitals, systematic reviews of interprofessional collaboration and education, and implementation and RCT evaluation of a range of interventions to promote delivery of evidence-based care by family physicians, nurses, and lay health workers.
My work has usually been multistranded, with several areas of disease or health care research and methodologic research activities under way at once. Although seemingly unconnected, these strands generally converge and inform each other as I deepen the most rewarding lines of inquiry, pause others that are making slow progress, and prune some that are unsatisfying, unfundable, untenable, or unable to attract like-minded collaborators. I have never had an explicitly planned personal research program. Instead I have been drawn to trying to solve important health care problems in collaboration with like-minded clinical, policy, program, and methodologic collaborators. I discovered along the way that methodologic skills are underappreciated but essential for progress on any problem, and that methodologic problems are themselves rewarding areas of research.
I was born into apartheid-era South Africa, an extremely unjust society with intentional, legislated inequity in life chances that produced differential patterns of illness and health care both by state-designated race and by state-enforced place of residence. Societies like South Africa drive many people into political engagement beyond self-interest, and so amid the general anti-apartheid activism, I and others with prior interest in health concentrated on exposing and opposing apartheid health policies. Under hostile state security surveillance and with limited space for maneuver I learned descriptive epidemiology and geographic information systems to describe inequities arising from racist policies, and I learned qualitative and randomized methods to work with disadvantaged communities to implement and evaluate practical interventions in local health systems.
I was inspired to focus on human resources for primary care delivery by my work in the South African Voluntary Service, an extracurricular student service organization, and by books including David Werner’s Where There Is No Doctor and David Morley’s Paediatric Priorities in the Developing World.2,3 From these books I learned that physicians are a scarce, expensive, and predominantly urban resource, that most South Africans would depend on nurses and community-based lay health workers for their primary health care delivery, and that these providers could be woven into an effective primary care collaborative team if supported by communities and if they had context-appropriate training and guidelines. We students worked in disadvantaged rural areas, initially to build school classrooms but with growing ambitions to build clinics and to train and support local lay health workers. We did so guided by migrant worker members of a rural community and by a heroic nun and nurse-midwife at a nearby Catholic clinic. This project had temporary success, but it was eventually undermined by unlucky tragedy, security police, and local authorities, and by our own limited capacities.
This confirmed for me the importance of primary care teams, training and guidelines, and community leadership. I was also convinced of the importance of evaluating such interventions and aware that I was sorely ill-equipped to do so. I had been mentored in evaluation by a South African Medical Research Council (SAMRC) epidemiologist, Les Irwig, who in turn brought Dave Sackett, the famous Canadian trialist, to South Africa on a lecture tour. Dave was an inspiring teacher who enthralled many, including me, with examples of simple and unbiased RCTs evaluating complex interventions. These 2 themes of my earliest work as a student (RCT evaluation methods and organizing and training nonphysician human resources for primary care in disadvantaged communities) have been the basis for most of my work since.
You have said you regret giving up clinical work at the start of your research career. How did you make that decision?
South Africa was of course short of physicians, especially in disadvantaged communities, but even though the clinical challenge was exciting, I found the responsibility overwhelming and burned out quickly. Perhaps there was too little supervision or support to help young clinicians manage the heavy burden of very ill patients.
But if primary care doctors were rare, South Africans with an interest in solving health system problems through research were even more scarce, and so research opportunities arose. My interest attracted the attention of entrepreneurial leaders in the growing epidemiology research unit at the SAMRC. It was an exciting place and time. I had so much to learn that it occupied all my attention, and I detached from clinical practice. I won a British Council–funded scholarship to study community health and epidemiology at the London School of Hygiene and Tropical Medicine [in the United Kingdom], returning soon after graduation to a full-time research position at the SAMRC, where my break from clinical work became permanent.
Although continued clinical contact might have grounded my research more deeply in a specific health problem or specialty, that is not the reason I regret the loss; the short time I spent providing personal care to patients and families was the most emotionally rewarding work I have ever experienced. Even though the responsibility seemed frightening at the time, if I had continued I think I may have been able to find a supportive clinic where I could have grown my skills and confidence, avoided burnout, and continued part-time clinical work.
Who and what experiences have contributed most to your acquisition of research knowledge and skills?
South Africa had a rich history of engaged community health innovation, including the Karks in the 1940s (founders of comprehensive community-centred primary care), and a similarly rich history of engaged epidemiology, including the Sussers in the 1960s (founders of analytic epidemiology at Columbia University in New York, [New York]). Les Irwig, Duncan Saunders, and the late Alan Herman of the SAMRC inspired in me the need to evaluate interventions. I learned self-education from my parents, Sam Zwarenstein, a cabinet maker and lifelong socialist, and Esther Rootshtain, a bank clerk who never left a job unfinished. Teddy Matsetela taught me to work with his community. Colleen Butcher encouraged me to lead the South African Voluntary Service in new directions. David Webster and the Roussos brothers showed me how to be a better citizen (and a better listener). Scott Reeves showed me how social theory underpinned qualitative research and vice versa. And to look behind the curtain of my profession, Vinod Diwan demystified global health organizations. Mary Lou Thompson and Carl Lombard enriched my slight knowledge of biostatistics, Dave Sackett inspired me to randomize. Andy Oxman, Jeremy Grimshaw, and Sir Iain Chalmers exposed me to systematic review and to implementation research. Lucy Wagstaff revealed the hidden powers of nurses and David Naylor helped me move to Canada. And many others along the way.
To what extent has your career been shaped by unexpected opportunities as opposed to thoughtful career planning?
Almost entirely by passing on opportunities! I would like to believe that I steered by seizing only on those that could best take me in directions that already interested me, a kind of career-long reinforcement learning approach.
Which of your research accomplishments are your greatest sources of pride?
The CONSORT [(Consolidated Standards of Reporting Trials)] statement extension on pragmatic RCT reporting, PRECIS [(Pragmatic–Explanatory Continuum Indicator Summary)], and PRECIS-2 guidelines for design of RCTs to support decision making.4-6 Also, RCTs of directly observed treatment for tuberculosis,7 RCTs of nurse clinician training on evidence-based guidelines, large-scale RCTs of printed educational materials conducted by using administrative data at minimal cost,8 systematic reviews of lay health worker training, systematic reviews of interventions to promote interprofessional education,9 and systematic reviews of interventions to promote in-service interprofessional collaboration.10,11
What career challenges and disappointments have you faced?
It was challenging to move countries midcareer, but I found a welcoming and incredibly knowledgeable community of researchers at the University of Toronto [in Ontario], ICES, and Western University, which has made it a growth experience. I think my major disappointment has been finding funding for research to improve research methods, particularly RCTs. This may change with the CIHR’s [(Canadian Institutes of Health Research’s)] investment in RCT capacity building.
How have you managed to balance your personal and professional life?
Over time and with coaching, I have learned how to arrange them to complement each other.
What thoughts would you like to pass on to aspiring primary health care researchers?
Work in supportive teams, read much more widely than seems sensible, and follow your curiosity but stay open to your critics. Use reliable research methods and invest in making them better. Strive to create an annual Nobel Prize for demonstrating that a widely lauded innovation has not (yet) achieved its claimed benefits under real-world conditions.
Notes
Impact Interviews was a limited series in Canadian Family Physician coordinated by the Section of Researchers (SOR) of the College of Family Physicians of Canada. In highlighting the 5 most widely cited Canadian primary care researchers, the SOR’s goal was to celebrate their contributions and inspire others to engage in this field. Find out more about the SOR at https://www.cfpc.ca/en/member-services/committees/section-of-researchers.
Footnotes
Competing interests
None declared
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de novembre/décembre 2024 à la page e213.
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