Lars H Lindholm - Is primary-care research really a lost cause?

Transcript

This transcript is AI generated and may contain errors.

A very good afternoon, everyone.

I'm afraid four days ago, when I was asked to give this talk, the organizers forgot to ask me about conflict of interest.

But rest assured, I don't have any.

Four ones.

This afternoon I would like to tell you a story.

That began in March 2003, in freezing cold northern Canada, where the editor of the Lancet had travelled to learn more about primary care research at the Wonka Meet.

Dr.

Richard Horton.

Well, he stayed for three days.

He flew back to London, defrosted and wrote a rather stiff editorial published in his journal.

Reading it, it's obvious, well, four things are obvious.

First, He didn't like the weather.

Second, he didn't like the venue.

Third, He didn' like Wonka.

And fourth, didn''t care much about the research.

I have summarized his thoughts on two slides for you.

The first one with some more critical comments.

He didn't find any papers worth publishing.

Second, he found many of the GP researchers bizarre.

They acted as if they had a paradigm of their own and differed from other scientists in the world.

And third, He strongly disliked the complaining and blaming game which went on during the conference.

But there was also, if you read carefully, and it is a difficult read, I had to polish this English to make it presentable actually, he underlined that efforts to Well, I would say, let me rephrase that, primary care research needed strong support.

And this is important.

The Lancet welcomed research with a primary-care perspective, whatever that is, and provided testable questions were asked where the findings would be of value for the many people.

Oh yeah, you don't know that, do you, until you've done the job?

But never mind, is primary care research really a lost course?

Of course not.

But Rich and Horton had a point.

And the Lancet editorial is important and should be taken seriously because it was definitely better than what the Americans published one month earlier, where a group in Annals of Eternal Medicine, several papers in the Annales of eternal medicine, they concluded that primary care research was a waste of money, a total waste money.

But back to Horton now, it's clear that a reform was needed to remedy the shortcomings.

And these short comings in those days, They weren't difficult to tell.

Too many small underpowered trials with type 2 errors published in medical journals with a low impact, read by few and cited by even fewer.

But it's easier to talk about reform, it is easily said.

It is more difficult when you don't have any money, isn't it?

You can't do it on thin air.

But then all of a sudden in Sweden there was money available.

The Swedish Research Council advertised funds in 2009 for a research school in general practice.

Never heard about it before, but it was there.

And at the time we had six medical schools and I knew that that would be really hard competition.

So I turned to my friend Cecilia Björklund at that time, head of general practice in Gothenburg, and she turned Lars Boikvist in Linköping, Head of General Practice there, And the three of us applied together.

and we got the grant.

So let me say, and I really mean it, I want to thank all those co-workers in our three departments who helped not only writing the application, but also getting the research school up and running.

Under the banner, building bridges to lift a specialty.

So, sincere thanks to all.

The research school has three items.

Give the research students what others don't give them.

increase their networking within Sweden and abroad, and increase the experience of international work, including sending out as many as possible to do a pre-doc or a Pre-PhD placement at the Center of Excellence.

And I will return to that in a moment.

The teaching focuses on three key issues.

communication of science, models for advanced primary care research and implementation of Science.

And if you allow me to assess ourselves, I would say we are doing very well with communication science.

We're doing quite well with models of advanced primary care methodology, but we need to work harder on implementation.

We can do this with the help of a stunning faculty.

We have no less than 10 editors from The Lancet who help us.

They take turns.

Last year we had five.

This year, we will have three.

And we also have top speakers from the best universities around the world.

The strange thing is they come and they don't want to be paid.

They consider it an honor and want to come back.

I never heard about that before.

They keep coming for free, at least eight out of ten.

Also, and equally important, all heads of subjects, or heads in the department in general practice, attend the annual big meeting.

So we mingle international speakers and some Swedish speakers with our own heads of subjects of general practice and that is very, very important.

Moreover, we have managed and we are very grateful for having been able to integrate our alumni into the faculty as junior teachers.

So we've got all different groups here, international faculty, Swedish faculty Swedish heads of subjects and the important group of alumni, our coming professors.

The school is led by an executive with eight voting members.

I show this slide to you for two reasons.

First, to say thanks from the bottom of my heart to these dedicated people who work for Next to Nothing and they do a fantastic job doing it.

Also, as you can see, I have painted in yellow on five of them.

They are, they have gone through the research school.

So five out of eight have come through research schools, so the power of the school has been taken over by the alumni really.

And I'm immensely proud of this.

We have given the school to those who have attended the schools.

There are two left from the first generation, Cecilia Björklund, who is in the audience, and myself.

And I'm employed to finance the School, handle international matters, And be the new, my successor's, mentor.

Anna Milius is the present director.

and she's absolutely brilliant and being her mentor is a delight, believe me, a delight.

So a short summary of the research school.

As you can see, it's a three-year add-on education.

It starts with a two-day retreat, a welcome meeting, and then follow monthly seminars with the homework and two examinations.

And we have one big international three day meeting for about 100. We also have the elective pre-docs.

we send as many as possible out to visit a center of excellence.

It used to be between two and three months, now it's between three and four.

So we celebrated a jubilee last year.

After 16 years, we could have our 15th anniversary, and we did so with a Jubilee coffee mug.

And I would have loved to bring a cup to every single one of you.

But from France to Jens Scherping, that's too much.

We also made a jubilee film and I would like you to watch the film together with me.

So Zacharias, if you could please run the The National Research School in general medicine collects doctoral degrees from all medical faculties in Sweden and we offer it as the university can not always provide.

Network, collaboration and a creative international research environment.

Now we gather for our annual internship and this year it grows especially because we celebrate 15 years.

One of the fun things about the research school is that the participants have different career backgrounds and everyone does research in primary care, so it really opens up to the multidisciplinary community.

Researching general practitioners is not so common, so we are very widespread around the country, and getting to meet general doctors around in the countryside, which we do at the research school, is very, very valuable.

And you learn a lot from each other.

We welcome a new group, we examine groups one after the other, And we alumni, as it is called, who are old.

we have our own little session where we learn how to think when you are a little more senior.

The Doctoran period was very important for getting your driving license and research.

But now it is perhaps even more important to get this network and this support.

How to move forward with your research, how to build long-term and really be able to combine research and clinic.

I've never been to something like this before, you know, for primary care in particular.

I think primary-care research is quite an underdeveloped area of research and so it's really special that there's a school that's dedicated particularly to this specialty and it is so nice to see people engaging with each other, how long it has been running now and we have all the alumni that are supporting eachother.

So it was just a very nice environment to be involved with.

The breadth that this research school shows in public medicine, where it becomes both an educational institution for our doctors, but also something else that is connected to public health research in Sweden, that's very important.

As a doctor and public medical researcher, we are quite spread out in small units at different health centers, and to get a platform where we can see and exchange knowledge is very good.

We published a lot of research that came from the students at this school, so I was trying to really help make things more transparent about how we work at the Lancet, how editors work, and how to make your publications more successful.

The little techniques that you use to get things into papers into a top journal require something special but the development of the internationalisation is also something that's been really good.

I'm here today at the Swedish school to act as a lecturer and a teacher to share my knowledge you know a 26 years experience as an editor.

The Lancet has a very high standard in terms of the science that it publishes.

And I think getting across those high standards into the work of students in the school and in general practice search in generally has been a positive thing.

Many of us who have gone to the research school have done international exchange, what is called P.E.D.

My family and I were in Australia in Sydney for three months and then I studied at an institution there.

Through the Research School I got a pre-PhD placement.

before I got in touch with the research school.

It was the school that arranged this exchange.

For my research, it is crucial to be able to run these international collaborations that really improve the quality and improve research.

There, the science school has been crucial.

Having a school like this is developing academic capacity to be able to deliver on those research projects that are so important.

And without the trained scientists in general practice who do that, the research won't get done and it won´t get down well.

When I see today how this has developed, for over 15 years, I can hardly believe it's true.

These have been fantastic and inspiring days, and I'm really looking forward to next year's Summer Internet.

Could I get my slice back, please?

Ah, right, so we've entered 160 research students so far.

Ten more this year will make it 170. Three out of four are medics and the others are mostly specialized nurses, physiotherapists, pharmacists and psychologists.

and a few more, all registered as research students and all working in primary care of course.

The voting members pick 10 out of about 30 every year who apply.

Application time is right now to all of you.

before the 15th of September.

We've had 88 successful dissertations so far and four more to come this year making it 92. we lose very few in the last nine groups we only lost two who left with our unfinished projects and I'm afraid one of them died.

35 have packed their bags and gone out in the world, mostly to Australia and New Zealand for a two to three months, it's now a three to four month period, to learn new ways and to get new teachers and new materials to work on.

And we have a stunning 10 in the pipeline who want to go out in world the next year and the year after.

And, we've started some reciprocal arrangements.

First one came from Harvard Medical School and second one from Sydney from the George Institute.

And there are two more waiting.

Reciprocal means that the Sending Institute also receives one from abroad, which of course will tighten the networks.

Well, here they are.

Anna's slide is three years old, so we have double the centers.

I apologize for the discrepancy between the red dots and the European countries.

So, I mean, one red dot here covers Belgium, the Netherlands, and Luxembourg.

Please forgive us for that.

We have a long list of recognitions.

I've only listed four here.

Three honorary doctors, and that isn't easy to get at the university.

And especially the one at Lund University was tough, believe me.

It happened when I was the chair of the Center for Primary Care Research in Malmo.

and we managed to pull it through and the one I fought is now the Vice-Chancellor of Lund University so I feel just a little proud of that.

And then of course we got Richard Horton's second text which I will return to.

Well, here is one of our head teachers, the third senior executive editor at the last set, Stuart Spencer, who is receiving his ring now.

The top hat is on from the dean at that time, Professor Anders Bay.

And this is done in front of 800 people all dressed up in white tie and evening dress and long gowns, cocktail party, a dinner and a ball with a 25-man band playing.

It's a big, big event.

And Stuart Spencer is a fantastic singer.

I'm sure he has sung in the Dover Operetta company, and I am sure that he was always the emperor, the Kaiser in Vienna operettas.

So he sang his thanks on behalf of all the awardees to the university on, thank you for your music, but it was thank-you-for-the-award, of course.

And we will ask him, there were plenty of the carps.

So let's turn to Richard Horton.

In his second text here, he starts off in the same way as his previous editorial, but worse here.

But it gets better and better, and he finishes, under the banner of Building Bridges to Lift the Speciality.

This Swedish initiative deserves to be studied and copied widely as a means to strengthen primary care research.

At long last, it's time to put complaining behind us." It was awfully kind of him to write this.

You see, what we did was to invite him, to come over as the teacher, And he came and he spent three days with us and got a standing ovation every time.

And after his dinner talk, which was rather funny, he said to the audience, well, why don't you read the Lancet next week?

It will be all about you.

Well, it wasn't all of us, but at least we were mentioned.

This has helped immensely when we've been recruiting speakers because they are curious what the heck is going on in Sweden.

Now, let's talk a little bit about money.

Now, first, funding a research group is just a small part of funding primary care research.

And we do not have a tradition in Sweden with state funding of primary research, and we are envious when we look at Norway and see what they have managed to organize.

Many of us tried.

I don't know how many visits I made to Stockholm and the House of Parliament.

And I wasn't the only one.

Many, many tried, organizations tried...

It was like banging your head against the wall.

The Labour government simply was not interested.

The cabinet minister for education had seemed to be more interested in municipality-based developmental work, whatever that is.

I'm sure it has its merit, but it's not primary care research.

And I always gave up.

But it got better in 2018 because we had an election.

And after the election, there was a rift between the two parties on the left, so the Social Democrats needed the support of the Liberal Party and the Centre Party to get a Prime Minister elected.

And the MPs of The Centre party, they were our friends.

So Annemarie Leos and I were invited back to Stockholm to the House of Parliament for a big hearing after which the members of parliament for the Centre Party, or actually their leadership, said, we'll try to fix this for you.

And believe it or not, believe in the next research bill which came out later that year, that's the so-called 2020 research from parliament, all of a sudden we had 190 million SEC set aside allocated to primary care research, handled by the Swedish Research Council.

And if you look over the eight years, because the the Next Research Bill doubled that amount of money, We had half a billion sick for primary care research and for career support.

You may wonder what career supporter is.

It means someone down here you take leave 25% to carry out research, and then the research council tops up your salary so you don't lose any money.

This is absolutely outstanding and totally new for Sweden and we really owe the Centre Party politicians a lot of gratitude.

So what about the school then?

Well, it's been my job to finance it, and we trotted along nicely.

And as you can see, I've just summarized it.

We had $56 million.

It's enough for us.

But it has really been like a rollercoaster, up and down, rich, poor, very poor.

But it's gone okay.

And when everyone was so happy with all the money, all of the possibilities, it just opened up a new era for us, I think I was the only one who was a little bit concerned.

I heard the champagne corks pop.

No, wait a minute.

But I felt ill at ease because State funding cannot be topped up while it's running and we are not allowed to have red figures on our accounts.

So what are we going to do with 2026? I mean those research students will be in the school 27, 28 and 29 and, we only had money for 27. Something needed to be done.

I didn't know what to do.

I just felt I needed to get in contact with someone high up in the Ministry for Education.

You don't really phone the minister, do you?

I mean, they reside in their ivory towers, well protected by layers and layers of civil servants.

But to cut a long story short, we did manage to get in contact with them.

And the state secretary, a liberal, phoned and we had a civil meeting, which went well.

Then we were invited to a face-to-face meeting at the ministry on the 17th of March.

We packed our bags, Annabelle and I, and one of our supervisors, Anna Culling from Lund, who helped with the contacts.

And, you know, we came to the Ministry, We were vetted outside the door, inside the doors, passed through security.

I suppose it was not quite what I was used to.

told one of my grandkids, and he said, cool, granddad, that's exactly what it felt.

Cool.

We were well-received by the state secretary and also present was the most influential permanent undersecretary for education as a civil servant.

If you watched the BBC film Yes Minister, She is the equivalent of Sir Humphrey.

Anyway, we were very well received.

Very, very good meeting.

No chairperson, no slides, just a good talk on sustainability of the school and primary care research.

We had been given an extended time slot, 45 minutes instead of 30, and when we had used one hour and 25 minutes of our 45-minutes, we were left with smiles on our faces, not really knowing what's going to happen.

But we had been heard.

For the first time, at least we felt so, up on that level, primary care research.

We had being heard, and the feeling was absolutely fabulous.

And it was even better four days later at the meeting in Stockholm at Karolinska when the secretary general of the Swedish Research Council, who gave the opening address, said to everyone, ladies and gentlemen, I suppose you know that Lars Lindholm, Anna Melias and Susanna Kalling had a fabulous meeting at the Ministry for Education earlier this weekend.

I just wanted you to know yesterday, that's on the Thursday, she said this on Friday, we received a so-called letter of appropriation from the government.

ordering us or instructing us to extend the school time by five years and add 15 million to their budget.

This is totally surrealistic.

These things don't happen, but it did.

They just topped it up.

I mean, we can't do it.

Of course, the government can do what they like.

One of the reasons was that when we applied for the latest grant, All seven departments were on the application.

So there was only one application in 2022, and this made it easier for the government to help us.

Financially, we are safe well into 2033, which is reassuring when you are in my age group that I know that regardless of what, the school will survive.

So what are we doing now?

Well, we have a focus on the alumni.

We lose too many.

After one year, we lost 11%. I mean, they're not dead, but they go into administration or insurance companies or occupational health.

After five years, estimate that we've lost about a third.

Very similar to nurses and teachers, police officers.

You educate many, within five year you lost a 3rd.

We've actually planned the two-year program for them to start in 27 over three years, three groups of ten, and we thought this was fantastic.

Research school, alumni to year and program.

But old administrative regulations have made funding very difficult.

The reason for that is summarized in four words.

National, postdoctoral, training and programme.

These four word don't match after dissertation.

You see, after the dissertation, everything is individual.

research project, postdoc, career support, travel grants.

It's individual, it's not based on groups.

So it feels to me it seems that we are trying to fit a 2026 reality through a narrow doorway designed decades ago.

So we are trying to fit a 2026 reality through this narrow doorway, which is quite a challenge for some.

Now, two days ago, When I bought, I contacted the Norwegian Telegram Bureau to buy the license to be allowed to share you this slide.

I asked about the slide because it was rather funny.

It would sort of fit my presentation.

And what I learned was that the photo was taken in 1966 in Oslo.

outside a courthouse.

So I assume that it must have been an accused Norwegian who was in need of heavy support.

But I don't give up easily and I think we will be able to sort it and proceed.

I'm not quite sure about that but never mind.

So my story is coming to an end and I would like to end with a reflection.

Now the Swedish Research School continues to expand in both funding and manpower and we are sailing full speed ahead with flying colors.

We try new topics, I mean one example is a workshop on how to deal with the press.

We have ten research students and four top journalists from Swedish television spent three days and two nights together and it was really Hands-on education, I can promise you, and this research student liked it very much.

But we managed to build bridges that helped lift our speciality.

Those bridges must be maintained and supported if the progress is to be sustained.

We can't just leave it the way it is and the school has been replicated in Norway for 10 years and New Zealand have just informed us that they will start soon.

So who knows, other Nordic countries may benefit as well.

So ladies and gentlemen, from the bottom of my heart, I thank you for hearing my story today.

Thank you.