A Giant Standing on the Shoulders of Giants
President Elect of NAPCRG, a senior researcher in primary care at Radboud University who has addressed some of the most difficult research topics in contemporary family medicine. Tim builds on the legacy of Chris Van Weel and Frans Huygen.
Tim olde Hartman is a general practitioner in the academic general practice Oosterhout (Nijmegen) and senior researcher at the Department of Primary Care Medicine of the Radboudumc. He received his PhD in medicine on his research into ‘persistent medically unexplained symptoms in primary care’. He contributed to the multidisciplinary guideline, GP guideline and care standard on Persistent Somatic Symptoms. His passion is providing personalized care to his patients and conducting scientific research on the effectiveness of person-centered care in general practice. He is head of the Primary Care Research Group at Radboudumc and chair of the Research Unit of the Department of Primary and Community Care, one of the largest research department at Radboudumc. He serves on several national and international research committees, councils and consortia and supervises multiple PhD students on research projects on mental health and persistent symptoms with a focus on doctor-patient communication, therapeutic relationships and person-centered care. Recently he was appointed as Vice President of NAPCRG, the global organization of primary care research.
“The focus on the doctor patient communication, doctor patient relationship, is very important and very specific or very key to primary care physicians. It’s one of the core values of family medicine. My further research work also went into doctor patient communication, doctor patient relationship, and the effect of these factors on patient outcomes.”
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A portrait of Frans Huygen and, below, his home and study looking out on his garden pond. Frans was an accomplished artist and is was one of his own paintings.
Leading one of the most dynamic research institutes in primary care in the world, . Tell me about your current role and how you got there…
Tim olde Hartman: I’m a General Practitioner and I’m a primary care researcher and I work in the Department of Primary and Community Care of Radboud University Medical Centre in Nijmegen. And, yes, our department has quite a rich history of primary care research. One of the first professors in primary care, Frans Huygen, was at our department and was quite a famous general practitioner who, for the first time, showed the epidemiology of symptoms and diseases in primary care. He worked in the north of Nijmegen, exactly where my practice is now, which is quite an honour. And, Frans Huygen was very important for our department and I think he still is because much of his thinking is still around.
DMacA: And, after that, you followed in the footsteps of another ‘great’ in primary care, Chris Van Weel.
ToH: Yes, that’s true… when I studied medicine, I studied medicine in Rotterdam. And when I studied medicine I knew quite early that I would like to become a general practitioner, but I was also very interested in research so I thought, where should I go to do good primary care research, and I knew that in Nijmegen, Chris Van Weel was the head of the department here, that he was very famous, a well-known primary care researcher around the world. So, I just called him, and I visited him, and I said to him “Chris, we don’t know each other but I’m Tim and I want to be a general practitioner, and I want to do research, and I think you can arrange that…” So that was our first contact and I got my place in general practice residency here. It was also at a time in the Netherlands that there was a new combined residency and research program set up in which it was possible to do your GP residency together with a research program and to get your PhD in primary care research.
I started in that program and so it was possible for me to combine this with primary care research- my PhD project together with my residency- and Chris Van Weel was my main supervisor in that project and I’m still very grateful for that. He retired a couple of years ago but I still have a lot of contact with him because he’s still a very important person within my International Network and all the International work I’m doing in primary care research.
“And when I studied medicine I knew quite early that I would like to become a general practitioner, but I was also very interested in research so I thought, where should I go to do good primary care research, and I knew that in Nijmegen, Chris Van Weel was the head of the department …”
DMacA: I’d like to ask you about the combined GP training and PhD program but, before that, I’d like to ask you about your own research because you took on research in one of the most challenging topics in Primary Care. Tell us about your work…
ToH: My PhD project was on medically unexplained symptoms (MUS) or persistent somatic symptoms as we call it now. And yes, a very challenging group of patients for most GPs because these patients visit you very often with all kinds of bodily symptoms for which you can’t find a clear-cut disease. That makes most GPs feel quite inadequate so they have great difficulty managing these patients. I noticed in my own work that I was quite irritated by these patients, that I couldn’t help them, I didn’t know what to do with them, so that was the moment when I thought, when something irritates me, then I’m going to do research on that topic because that’s quite a good of finding your intrinsic motivation to do research.
What we did is that we looked at videotapes of patients visiting general practitioners with medically unexplained symptoms, and we just watched and studied what happened within these consultations. I had a lot of preconceptions about these patients and I always had the idea that these patients were pressurising me into doing all kinds of investigations, unnecessary investigations. But what we found in our research was that this wasn’t the case. It was most often the doctor offering all kinds of additional investigations without the patients asking. The preconception I had was completely wrong. As we studied the consultations we saw that it was completely the other way around.
The other preconception I had was that these patients would not like to talk to me about different psychosocial issues or the psychosocial background to their symptoms. But, when we looked at the consultations, and Chris Dowrick’s group in Liverpool also did a lot of very important work at that time, we found that in 95% of the consultations patients gave psychosocial cues in their consultation. My idea that patients did not want to talk to me about these issues was completely wrong because these patients gave all kind of cues but, what we found in our research, was that general practitioners didn’t pick up those cues.
So, one of the things that I now teach to general practitioners is that, when you meet patients with medically unexplained symptoms, it’s very important that you listen very carefully to them because that might be a key in helping those patients. That led me to become very interested in doctor patient communication and doctor patient relationships, as I think those two are key in helping patients with medically unexplained symptoms. But, it’s key in helping every patient. The focus on the doctor patient communication, doctor patient relationship, is very important and very specific or very key to primary care physicians. It’s one of the core values of family medicine. My further research work also went into doctor patient communication, doctor patient relationship, and the effect of these factors on patient outcomes.
“… when you meet patients with medically unexplained symptoms, it’s very important that you listen very carefully to them because that might be a key in helping those patients… But, it’s key in helping every patient. “
DMacA: That brings us very nicely into some of your work in trying to define the core values of primary care, which you’ve written about.
ToH: I think that’s the main reason why I got into research because I want to prove why primary care or general practice is effective and efficient. We know from the work of Barbara Starfield, and from the work of many giants in family medicine research, that the place of primary care or family medicine in the health care system is the most important component for good health care so the more central it is, the better the healthcare system functions, the lower the cost of health care, and the better the quality of care and outcomes in patients. So that’s my main driving force in doing research- showing the importance of Family Medicine/ Primary Care.
DMacA: Its not unrelated, but I was interested in reading what you had said about, it’s not quite depression but what you described as ‘beating the blues’ which is a variation along that spectrum of how one feels. Tell us about that…
ToH: That’s a discussion that has been ongoing for a long time in our department, especially within my research group on mental health and persistent symptoms, about how you frame depression or depressive symptoms or low mood. Again, Professor Chris Dowrick from Liverpool was also a very important actor in that because he wrote a lot about it, and we came very much to the conclusion that when you see a patient with depressed mood, a lot of GPs have the intention of going into some form of diagnostic process with patients to see whether they fulfil the criteria for a major depression because, when it’s a major depression then you have to do all kinds of interventions. Most of the time, I think, it’s not the right way to go into the diagnostic trajectory, but that a narrative approach to those symptoms and trying to understand the patient and understanding the symptoms will result in far more effective consultations and be a far better help and, ultimately, in the outcomes for patients with depressive symptoms.
And then, we have much overprescribing of anti-depressants, which is a huge problem at the moment both in Europe and all around the world, as we know that anti-depressants are not that effective yet we prescribe them far too often. And I think it has to do with a medical view on depression where I think we should have a more narrative view on depression.
” I think that’s the main reason why I got into research because I want to prove why primary care or general practice is effective and efficient.”
DMacA: I love the way you were trying to disentangle sadness and depression…
ToH: I think it’s also part of normal life and you have to prevent medicalizing all these kind of feelings that patients have but you have to take notice of them and you have to talk about them with them and you have to follow them up and sometimes these might evolve into a psychiatric diagnosis or into a major depression but we already know that most of the time they don’t.
DMacA: Let’s go back to what we talked about earlier. I’m very interested in this postgraduate general practice training- PhD program, the integration of the two together.
That was a great initiative in Nijmegen. It’s continuing and you have lots of people coming through in new cohorts?
ToH: Its not only in Nijmegen, it’s in the whole of the Netherlands so that all Departments of Primary Care in the Netherlands have such a program in which there are GP residents who combine it with research so it’s a really huge way of building research capacity in primary care. Recently there was a major evaluation of this program at national level and they found that almost all these people on the combined program got their PhD and almost all stay in primary care, in clinical care. Some of them continue in academia after the combined program but most of them don’t and go into practice where, they say, they first have to learn to become good general practitioners. But after some years you see that they end up in leadership positions, for example on guideline committees, on different grant committees, in management in primary care. So, the conclusion of the report was that it was a very effective way of building research capacity and
providing primary care with a talented enthusiastic group of family physicians, general practitioners, who know how it works in daily practice but who can also make the transition into management, research, and all kind of things.
DMacA: You mentioned the importance of developing this new generation of researchers, managers, administrators, and leaders, but primary care is having a tough time internationally. How is primary care surviving in the Netherlands?
ToH: In the Netherlands we are still lucky in a way, although my colleagues in the Netherlands may not be happy with me for saying that, because what I heard last October at the NAPCRG meeting, the global organization of primary care research, was that next year in Canada, 10 million people won’t have a general practitioner anymore. We know in the US that Family Medicine is having a very tough time. I know how difficult it is for the NHS in the UK at the moment. So, all over the world there are very big problems keeping General Practice, Primary Care, on its feet. That is also, in part, in the Netherlands where we have a shortage of general practitioners. We are looking for ways to respond. The population is changing because of all the elderly people coming up now and so the workforce has to increase. We try to increase the work force but that’s still quite difficult. Maybe we will have to search for other ways of delivering care but, when you look at the core values of family medicine, that is not that easy. So, it’s also a difficult time in the Netherlands. We don’t have a solution for that except that we also see in the Netherlands, when I talk to the medical specialists here in the University Medical Centre, they also see a tendency for young doctors to want to get out of the hospital. They don’t want to work in the hospital so there is also some flux from the hospital to Primary Care. Most doctors have the opinion that it’s better to work in primary care because, when you want to combine it with a social life, with kids and a family, that it’s easier to do that in primary care than in a medical specialty setting. But, we are facing the same problems all around the world.
“Its not only in Nijmegen, it’s in the whole of the Netherlands so that all Departments of Primary Care in the Netherlands have such a program in which there are GP residents who combine it with research so it’s a really huge way of building research capacity in primary care.”
DMacA: This is the hardest question of all, I guess. We’ve identified the problems and, let’s put you on the spot as you’re now one of the world leaders in primary care, what are the solutions?
ToH: I think we should invest in primary care because we know from the work of Starfield and all the others that investing in primary care and having a strong primary care system is the solution for the problems we face. But the government also has to see that and to invest. I know from the Netherlands, that there is quite a big gap between primary care and secondary care with regard to, for example, finances. It’s not about the income of doctors but it’s about how primary care is financed, and how secondary care is financed, and it’s completely split and that’s strange. So, I think we should shrink secondary care and the money that we are saving should be put into primary care. That’s one solution.
There is a lot of push from the government on eHealth because they think that’s the solution. I don’t think so. It might be a part of the solution but, in the end, my patients just want to see me, or want to see a doctor in the office, to talk about their problems and their symptoms. Part can be managed, maybe, by eHealth but not all.
There is also a problem in society- the development in society of medicalizing a lot of the problems. So, when I look at my practice list and the patients I see in my daily work, I see a lot of problems that I think don’t belong in primary care because these are problems, for example, with housing. There is so much related to the social components of society which the government should address and come up with solutions. Its about the social determinants of health. The government has a very important job to do there and, I think, when they don’t address those problems, we see it in our practice.
DMacA: It’s always a pleasure to talk to you. Clearly the future of primary care is in really good hands. Thank you very much for talking to us today.
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