Answering the “100 Most Important Family Medicine Research Questions” from the 1985 Hames Consortium

Discussion

The Hames 100 questions and categories themselves demonstrate the values and purpose of family medicine research and can serve as a powerful tool to discuss the future of family medicine research. The varied questions illustrate the broad scope of interest of family physicians in 1985, which remains just as relevant today. Our findings indicate that relatively few (12.5%) questions were fully answered, with even fewer questions answered in family medicine journals. Family medicine is uniquely positioned to address gaps in research that impact the health of our patients and communities. The questions that were fully answered demonstrate great strides in research to understand disease processes and the value of primary care. Research has shown the value of continuity of care and coordination of care, and the clear value of family medicine (eg, Dyer et al¹² and Yang et al¹³). The Hames 100 also can also facilitate discussion on future research questions for the discipline.

Notably, 25% of questions posed were not answered, and 63% of questions were only partially answered. The paucity of answered questions causes us to reflect on how family physicians practice evidence-based medicine. Family physicians often make clinical decisions extrapolated from highly controlled research. Patients are unique and complex, and function within a unique socioecological and psychosocial context. The aggregate of many decisions, when combined into a single patient with unique circumstance, has little evidence base. The practice of medicine necessitates coping with a certain level of uncertainty.^14,15

The questions that continue to be unanswered are indicative of the complexity of family medicine and the challenges of finding clear answers to the problems our patients and communities face. These searches revealed how little we understand about some family medicine specific questions such as underlying causes of depression, differences across the life course, or specific recommendations for clinical conversations about cancer prevention and screening.

Research funding for Departments of Family Medicine remains limited, in particular compared with the proportion of the physician workforce providing clinical care.¹⁶ As noted in the 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report on Implementing High-Quality Primary Care, “the current research funding environment has prevented addressing meaningful questions critical to the advancement of primary care.”¹⁷ The disease-specific focus and limited time frame of grant funding mechanisms may incentivize a reductionist approach to health conditions, or research on “low-hanging fruit.” Although individual research studies may inform disease-specific management, broader questions on health systems, coordination of care, and comprehensive care cannot be easily answered. Investigating more complex health systems questions require full research programs (with qualitative, quantitative, and mixed-methods research expertise), interdisciplinary expertise and collaboration, as well as longitudinal, sustainable funding mechanisms.

Many questions addressed foundational constructs of family medicine,¹⁸ such as continuity, comprehensiveness, and community. However, the evidence for these questions did not uniformly conceptualize or operationalize these concepts, limiting how we can synthesize and apply findings. For example, although family medicine researchers have clearly defined continuity,¹⁹ the broader literature did not use these definitions or measures. One notable concept in this dataset is COPC.²⁰ Although family medicine is founded in the context of community, little evidence was available for the value of community-oriented family medicine. However, this lack of evidence could be connected to the rare use of this term. As researchers, we must attend to how we define and describe these concepts. Otherwise, lessons we learn from COPC or, more recently, patient-centered medical homes (PCMH)²¹ will be lost in the literature.

Although family medicine researchers are well positioned to answer questions that include layers of family, systems, and community, our results show that evidence to these family medicine questions is more commonly found in literature outside family medicine journals. This could relate to the overlap with other specialties (eg, research on cancer may be more likely to be published in cancer specific journals). However, it also reduces our ability to understand the impact family medicine researchers have on the medical literature.

Interpretations are limited to the method and search strategy. Searches were limited to PubMed; however, some of the questions would likely be better answered by social scientists and indexed in the American Psychological Association PsycINFO or the Education Resources Information Center (ERIC). The Hames 100 predates the FINER criteria,²² with many questions difficult to truly interpret or assess. These family medicine pioneers did not review the questions for feasibility, interest, novelty, ethics, and relevance when they created the list. Many research questions were specific to their time period and context and are not relevant or applicable in the current health care landscape. Some of the research questions listed are no longer important to today’s clinical practice.

As our team discussed the available evidence for some questions, we debated whether a question was answered if the existing evidence was bound by time. Ultimately, this study demonstrated that research questions must be revisited and studies replicated. Two question contexts were particularly sensitive to time: money and relationships. When the question queried the cost of health care, we were less likely to consider a question fully answered. Cost models were bound by the larger economy at the time of study. Similarly, many questions involved relationships: between the patient and physician and within families. Since relationships are culturally situated, the evidence from older studies was less applicable to today’s practice.

Furthermore, important questions may have been missing from the Hames 100. It is important to continually review these lists to guide the future of primary care research. The NASEM report on Implementing High-Quality Primary Care identified many examples of research questions that go unasked due to the current funding and peer-review environment.¹⁷

The Hames 100 questions provide a fascinating look into the values and broad scope of care of family physicians at the time of the 1985 Hames Consortium. Many questions remain practical and important today, yet few questions from this time period are fully answered. This study highlights the importance of translational research to implement care that we know to be evidence-based, but also flags the importance of increased and sustained investment in family medicine research and support for longitudinal interdisciplinary collaborations to research more complex and broad health care questions that remain unanswered. Further, these findings indicate the important role of family physicians in research.