Moira Stewart | A Career in Primary Care

I’d say that family medicine is the most interesting medical career they could have and it’s interesting because every day is different. It’s interesting because it’s got to do with their humanity and the patients humanity as well as science so, it’s a great combination of science and humanity. Not all medical specialties are like that. So, I think it provides a great balance. Most of the family doctors that I talk to, because as you know I’m not a family doctor, they are fed by their interactions with patients so the message for students is, as long as you love your work and you love your patients, you’re going to , you’re not going to burn out. You’re going to have a career that can change as you change. You’re going to have a career that has great longitudinality so the family doctors who I work with love their work, they love the fact that they can do research in their practice, they love their patients and, they’re frustrated by all kinds of systems things that get in the way. But mostly to overcome those frustrations they’re fed by their work with their patients.

DMacA: How did you get into all this research in family medicine?

MS: I got into it is because I chose epidemiology. I was a young graduate student in epidemiology and I came to that department saying I want to study the health care system. I want to study all aspects. I don’t want to study one disease. I do not want to become a cancer epidemiologist. I want to study people. Population health is a great place for that but, I had to make a case for being a sort of generalist researcher in an epidemiological field which is very single disease oriented. So, they listened to me talking about this rather odd concept of including all kinds of different patients and studies….’You need to talk to family doctors because that’s the way they think’ and so that was my first introduction to Family Medicine. As a young person I was taken to specialists. I had no concept of what family medicine was as an experience, as a patient, and so I met these academic family physicians and they showed me what family medicine was. In fact, they said, if you want to work in this field and answer these kinds of broad questions about how does it work, how does family medicine work, what is the impact of family medicine on patients, you have to view family medicine. So, off I went to 15 or 30 practices and sat with the doctors as they were working with their patients, and that’s where I saw the magic, the mystery, and the impact on the lives of these patients from all kinds of different family doctors.

DMacA: And how did that drive your research ideas because you’ve researched a number of different areas?

MS: There were a number of drivers. What I’m known for most is work on patient-centered clinical method or patient-centered medicine, which has to do with the way that patients and doctors work together to share information and to solve problems together. And I came to that because of my experience as a patient, my experience of fragmented care and uncaring care, and so that’s part of the motivation. What in your history, what is in your life story, makes you appreciate what family medicine has to offer at this level of humans trying to help humans. So that’s been a big driver but also this exposure to these wonderful family physicians and noticing the implicit ways that they would motivate patients. You know, it’s not got to do with cognitive things, it’s not just got to do with algorithms and decision-making tools, it has to do with with caring and demonstrating that caring- showing the patient that you’re there for them and that they can come back. So, that was one of the big drivers.

The other big driver is that is that I’m an introvert so I love sitting at the desk and the computer and noodling around with the data. I’ve developed an electronic medical record database that has ICPC coding and is very technical and, you know, thousands and thousands and thousands of patients and many doctors. And I love that part of the work too.

So, it’s the best possible job for somebody who, is sensitive and wants a humane environment, wants to make a contribution to the world – to the betterment of that kind of a world- but also somebody who has some sort of interest in technology and statistics and all that. So it’s been a great combination.

DMacA: If you were advising someone on future for areas that would be ripe for research in Family Medicine, what would you do?

MS: I would ask them questions. I would say, what interests you with your patients, what kind of patients are the patients who you want to see and you want to help. Are they refugee patients, are they patients with a particular condition, are they young patients? Or, I wouldn’t ask so many questions – I would just be listening – and they might say what I really like are these long visits, the ones with chronic disease patients where I actually have enough time to figure things out with patients. And that would begin a conversation about what the research question might be. So the research question might be about the process of care, it might be about what goes on between you and your patients, it might be about a certain kind of patient, it might be about a passion for vaccines. I think that the decreasing number of vaccines in young children is a travesty and I really want to change that and I’m going to do research that shows what a big problem it is, and I’m going to review the literature and make sure that I could tell the mothers of babies the good reasons why vaccines are important. So, it would be a conversation with the young person about what’s their passion, and translating that passion into research, and my job as a teacher or as a mentor would be showing them the ways that all of these different kinds of questions can be answered and measured, and that you can talk to patients about these and find out more about these issues.

DMacA: When you look back on your own work, which are the pieces of work or papers that you think have made the biggest impact, that made the biggest difference?

MS: There are two papers that made a huge impact:

One was the first paper, that was actually requested by CMAJ, that I write a review of the evidence of why communicating with patients in certain ways was better than communicating with patients in other ways. And that was, you know it wasn’t even a systematic review, because it was decades ago. It was a review of the literature and it had a tremendous impact. It was widely read. It was kind of the first of the summaries of the little bit of evidence that did exist then about the fact that the way that patients and doctors communicate with each other is an important aspect of how the patient feels, and how the patient recovers, how the patient is motivated to recover. That was huge and it was a long time ago.

The second one was probably our first quantitative study of what we call ‘Patient Centered Clinical Method’ in the patient-centered way of communicating with patients and its effect on a patients recovery after two months, and that had a large impact, the costs were less of this kind of care.

And those two papers I think have been quite influential.

DMacA: And, have you one research question that you’d really like to look in now if you were given the opportunity?

MS: Oh yes and I’m not done so I’ll be asking and answering more research questions. I’m interested in patients with multimorbidity as patients with multi-morbidity cannot be cared for in the traditional single disease model. There has to be a way of talking with these patients ,and there has to be a way of of managing the medications with these patients, and the treatments, that is better integrated, that is more holistic, that is more person oriented, rather than disease oriented. Unpacking all of that with these very complex patients is a direction that I think is very important.

Moira, thank you very much for sharing so much with us today. That was super.

Thanks