Peterson, Chris. L. Ph. D
School of Public Health
La Trobe University,
Martin, Carmel MBBS, Ph.D
Australian Medical Association
AbstractIntroduction Research and method challenges Methods and paradigms Paradigm shift Transdisciplinary research Conclusion References Previous Page
General practice as a discipline operates using a range of different models which include biomedical psychosocial, economic and public health. Current developments in GP research and evaluation include significant use of a number of methodological approaches and incursions across research paradigm boundaries. Research focus and emphasis are being driven, not only by contemporary research issues but also by an evolving process of conceptualisation of the research question. Transdisciplinary models can provide a solution to problems of researchers confronted by issues requiring the integration of multiple research paradigms. This paper agues for further development of transdisciplinary research in general practice and identifies an emergent new general practice paradigm to deal with the complexities of information needs. The mechanisms of transdisciplinary research and its contributions to General Practice are discussed. Problem focussed research rather than discipline based research is a key feature of this development. Mechanisms include incorporating key stakeholder perspective and paradigms and the development of feedback loops which can link researchers of different disciplines and research consumers. Pitfalls which can occur however are skimming, dilution of methodological rigor, and reduction of one paradigm to another. Paradigm and cultural shift is an often unrecognised and creative component of this process.
General practice in Australia is
a nationally funded system of comprehensive primary medical care based on principles
of universal access with a predominance of fee-for-service payment. It also
acts as a filter to secondary and tertiary health care services. General practice
service provision is in the process of major restructuring towards a fixed payment
system with greater cohesion and accountability with expanded systems of evaluation
driven by both intra professional and external policy forces.
General practice research is one of the more recent fields of medical and health investigation. It has covered numerous areas during the last two decades including service provision characteristics, disease treatment and management, workforce characteristics and training, and consumer and patient issues. The research covers characteristics of general practitioner and other agencies including government in providing care: research includes areas such as service provision and utilisation as well as into how care is delivered. Much of the research into care delivery forms the basis of evaluative research directed towards better provision of disease management and treatment programs.
In Australia the links between research and practice have been developing, but Australia lacks a journal focussing on general practice research together with the dissemination of research efforts is relatively lacking. This has led to some fragmentation between research activity and implementing results.
General practice research in Australia (principally funded by the Federal Department of Human Services and Health), the bulk of which is health services evaluation has rapidly expanded in the past 3-4 years. This expansion has been in volume, content covered and type of research, with a new cadre of evaluative researchers, recruited from general practice and a range of other disciplines. There are a number of experienced researchers, but many are newcomers to the field.
Research in general practice has absorbed a range of methodological approaches. This has led to a sophistication in research design and implementation which has occurred quite rapidly. Yet there has been little comment on the effects of such GP research, or the impact of the range of methodologies on reorienting research interest, or on changing research outcomes.
In the face of restructuring of general practice in Australia, outcomes in service provision has become an important area of research. There are a series of outcomes of service provision which need appropriate indicators. Martin and Douglas  have identified these as important stakeholder inputs into the review process of general practice.
Firstly there is the consumer perspective. For the individual this involves satisfaction with the process; problem resolution or clarification; diagnosis, prognosis or uncertainty clearly explained; care sequences clearly defined; affordable costs of health care; access to integrated services; and clinical, health and functional status and health perceptions. For groups and organisations there are, costs of GP care; the met needs of vulnerable groups; met needs of groups with specific conditions or tracers; and efficient and humane service integration. Secondly, there is the GP perspective. For individuals this involves satisfaction with the process and with the working environment; length of stay in practice; career fulfillment; utilisation of professional skills; and adequacy of remuneration. The professional and organisational aspects involves diagnostic accuracy; appropriate use of investigations; the effective and appropriate use of primary care support services; appropriate secondary and tertiary care; functional status of the patient over time; appropriate valuation of general practice services; and the preservation of the pivotal role of general practice in the health care system.
Thirdly, the funding agent perspective involves the efficient and effective use of resources, and the appropriate integration of general practice with other health services. The political perspective involves equitable access to GP services; the appropriate sharing and containment of costs; and improved population health with respect to longevity, well being; quality of life, workforce participation, and the absence of sickness.
The issues identified by Martin and Douglas  above, together with traditional research into disease and treatment process produce very complex research and information needs in this relatively underdeveloped field.
There have been relatively few attempts to describe the field of general practice research, as an arm of the broader medical and health research process. There has been little review of general practice research paradigms.
Social and behavioral sciences have been incorporated into medical research since the 1970's and are an integral part of research design, methodology and theorising. Biomedicine has been the basis of medical research and formed the primary influence in general practice research: however epidemiological approaches and the developing individual social and behavioral sciences has caused important shifts in emphasis to approaches to general practice care. Importantly, these have provided the breadth and depth of a variety of the perspectives now researched.
Multidisciplinary and interdisciplinary approaches to research have developed fairly rapidly as ways of addressing more complex issues in health research. Much has been gained from models of health research in developing countries which have forced creative approaches to difficult problems. These have essentially covered the need to combine health research approaches between medical researchers (operating with both biomedical and epidemiological approaches), and those from other disciplines (i.e. economics, sociology, psychology, anthropology and demography). They produce very useful approaches and models for researching a variety of illness, disease, service provision, health management and treatment outcomes, more so than many single discipline research programs.
The need to realistically evaluate health care provision using multiple approaches highlights the need to expand the paradigm of general practice and research. Much interdisciplinary research has not produced a combination or synthesis which would go beyond disciplinary boundaries, and hence produce innovative solutions to policy questions (Rosenman ). Given that policy makers have complex bases on which to make health decisions, and that much general practice research has been driven by some disciplinary concerns, there is a need to clarify the theoretical issues involved in crossing boundaries. A more responsive paradigm is called for.
There are a range of disciplines important to general practice research. Different disciplines and methodologies integral to general practice research have combined more recently. Values and issues important to the research effort have developed to meet changing needs of consumers and policy makers. A model of General Practice research includes a number of disciplinary approaches, incorporating biomedical, behavioral sciences, and the social sciences. Qualitative, quantitative and mixed methodologies including triangulation are employed. Economic, political, organisational and clinical values are fostered, and the primary issues for research include medical, social, behavioral, economic, ethical, financial, educational, public health, cultural and personal. Within general practice a vital link is established between these dimensions by information technology which is rapidly becoming and agency linking various activities and outcomes.
Diversities and continuities still exist in a unique combination in general practice research and evaluation. Will there be a bland skimming over the richness of the range and depth of the contributory methods and theoretical frameworks, characterised by fragmentation and breakdown of communication, or will there be integration which retains much of what is unique and valuable in the diversity?
Transdisciplinary approaches, as opposed to other interdisciplinary approaches calls for a synthesis of research at the stages of conceptualisation, design, analysis and interpretation by integrated team approaches. In successful transdisciplinary projects in the third world, paradigm shifts have occurred. However in other fields, despite the often-acknowledged need for a new paradigm or paradigms, in practice, there have been many obstacles (Lyons , Foss and Rothenberg ). There has been little discussion or utilisation of transdisciplinary approaches in general practice.
This paper aims to analyse key issues in the general practice research process and evaluative program design which can have implications for effective and responsive research endeavor. The use of multiple methods across different disciplines is analysed in the context of paradigm and transdisciplinary process. This paper employs the concept of paradigm shift as a theoretical framework for the newly developing field of transdisciplinary research. A new transdisciplinary general practice paradigm and its development are considered. Finally it proposes a number of solutions to problems in the operationalisation of transdisciplinary research dealing with the need for that research to provide policy makers as well as consumers, practitioners and other grassroots stakeholders with effective and innovative information.
The debates in general practice research often focus on the place, rigor and quality of the methods used. Confusion or disquiet often accompany the use of multiple methods using theoretical frameworks from different disciplines. This section reviews research both at the operational level, those dealing with methods, and at the conceptual level, dealing with the assumptions and values underpinning the research process itself, those of the paradigm. It is argued that in order to truly integrate research from the perspective of the different disciplines pertinent to general practice, it is necessary to work at both of these levels.
The research question is the pivotal focus for a research program. A question is often raised about where research questions derive from. Does the question emerge from the field, waiting for the researcher to recognise and respond, or is the question a construct developed out of the researcher framework? Both of these answers are true. However, identifying the source of the research question brings about a more fundamental typology of research approaches and orientations. There needs to be a focus on understanding the reasons for using a particular method, the context in which it might be most effective and how research outcome might be affected.
Single disciple approaches are used frequently in general practice research. One-dimensional approaches to the collection and interpretation of data often rely on their own method to validate their approach. When a number of indicators are used there is an improvement in measurement: a greater confidence can be gained with wider range of measures. Greater validity can be expected from increased numbers of measures . The use of multiple methods within a study of triangulation of methods  has been recognised as playing a significant role in the validation of GP research, notably in the complex area of the psychosocial domain  They have also been important in the determination of needs and outcomes of service provision based on the utility of self-rated health and functional status 
Several criticisms of triangulation have been outlined by Kuzel and Like  including questions of the efficacy of interpretations confirmed by two theoretical frameworks as being more convincing than one approach. Agreement among results of research using different methods to study the same topic may simply reflect similarities of process rather than confer any additional validity. Another issue is the potential for the dilution of 'rigor' of methods used by those untrained in the discipline of origin, as noted by Krefling : that when applying different methodologies, appropriate validation criteria needs to be applied across the disciplines and methods. Fielding and Fielding  argues that the use of multiple methods does not necessarily confer additional validity beyond that inherent in the study components but should create broader and deeper understanding of the problem under investigation.
These approaches can give the researcher a 'look in' from many different stances at issues in general practice research and reduce 'one dimensional' evaluation. Kuzel and Like  refer to the multiple sources of data and the variety of approaches to collecting data which create an opportunity to scan wider data sources with different types and levels of analysis than that limited to one method. This gives an opportunity to create a much more broadly contextualised understanding of the subject being investigated. The utility of different methodological approaches has been acknowledged as an important component of general practice research, yet if the discourse remains primarily at the level of method alone many research problems cannot be addressed adequately.
It is argued that the current practice of using multiple methods and techniques should be grounded in a comprehensive theoretical and pragmatic framework, if results are to be integrated and interpreted in a meaningful way for the clinicians and stakeholders of general practice. They have been used more recently to outline processes involved in newer fields of research. Wadsworth and Hargreaves  refer to the 'new paradigm' in feminist research, while Wadsworth  identifies 'new paradigm' assumptions for the method of participative action research. Post modernist paradigms have also been developed in public health .
Different assumptions exist about what is knowledge, notions of causality and 'inference' and processes of knowledge creation. For example a feminist perspective and a bio-medical perspective may have few common points in perceiving the world. Different assumptions exist about what is knowledge, notions of 'causality and inference', and processes of knowledge creation. Paradigms can also have vastly different methods of processing created knowledge. The Kunian idea of paradigm shift helps to explain how a new paradigm replaces an older, inadequate body of knowledge in medicine in order to provide appropriate answers to questions .
The imperative in general practice research in Australia is centered around integration of the interpersonal, the psychosocial, the biomedical with economic, ethical, and public health perspectives when evaluating general practice performance. While this is not a new imperative in Australia nor internationally, the impetus of rapidly introduced nation-wide evaluation has created a climate with much activity, but with limited theoretical debate.
A number of writers have proposed paradigm revisions, or the need for new paradigms in health and medical research. McWhinney  has consistently called for a new approach in general practice in order to deal with the human aspects of service provision and delivery, that current biomedical models of service provision are incapable of. Underwood, Owen, and Winker  call for the need to incorporate social medicine, where the model of social medicine has for so long been dominated by a mechanistic model based on specific causes of illness for individuals and groups. In addition they argue that social and personal environmental paradigms are needed to deal with overspecialised and inadequate tools of modern medicine. Their view is echoed by White  in acknowledging the struggle between linear biomedical paradigms and the paradigms of social and behavioral science in forging a more relevant medical paradigm.
Consequently, combined clinical/biomedical and psychosocial/emotional paradigms can create highly successful paradigms ( . 'This view has been echoed for some time: we need a paradigm today that will help us to conceptualise the issues and solve the problems that complicate or thwart the care of our patients' ( ). The need to find an adequate research paradigm or niche for general internal medicine physicians has been identified (. They argue that outmoded paradigms in medicine do not adequately fit today's clinical practice.
Deyo  identifies the need for a new paradigm in back pain research in order to replace outmoded clinical research concepts. De la Haye ( assess the relevance and generality of current research paradigms in interpersonal cognition, and evaluates the need to generate a new paradigm to describe what is not covered in major paradigms.
The other pressing drive is for 'effectiveness
and efficiency' , equity and accessibility in general practice. [8 9 22]
. The ethics of health care rationing and consumer choice in resource utilisation
by physicians area where paradigmatic boundaries need challenging and are in
fact in the process of shifting. In addition, Titterton  argues the old
social welfare paradigm is inadequate for explaining essential elements of human
reactions, and calls for a new paradigm which can direct research efforts to
incorporating these vital elements.
Quinn Patton  describes the recent breakdown of the debates between the qualitative and quantitative paradigms in the field of evaluation with the emergence of utilisation focussed evaluation. In essence he describes a new 'evaluation paradigm' of interdisciplinary endeavor, methodological flexibility and appropriateness rather than paradigmatic orthodoxy, broader conceptualisation of evaluation and evaluation training and outcomes which have practical applicability.  While this evaluation research paradigm has enormous international momentum in a very wide range of public programs including health, education and welfare, there are still highly specialised debates pertinent to the medical sphere.
Integration of research methods within one paradigm, is itself not without some element of controversy. When moving between subject areas, methods and shifting from one paradigm to another, there needs to be an account of more than the methods and techniques. When employing methods from a variety of disciplines a careful approach is needed. A limited investment in understanding a paradigm will yield limited results in research. Shifting paradigms means that there are different appropriate interpretations and explanations 
The development of transdisciplinary process and paradigm shift, must be therefore be structured around some level of reflexive theoretical linkage and integration. Analysis can take place at several different levels. Paradigms can be combined and integrated in order to form new paradigms and approaches in research endeavors ( . At several different levels one paradigm can be integrated and incorporated.
Discourses on research program design have addressed a range of approaches to research practice. Rosenman , for example has provided an evaluation of multidisciplinary, interdisciplinary and transdisciplinary approaches to conducting research in health and medical sciences. These however need to be clearly identified in the contributions that they, and other approaches can provide.
Rosenman's concept is important in dealing with the need for more productive results in health research. However the model of research approach proposed needs to be contextualised as greater than a useful method for research. It should be seen as an essential component in the evolution and development of a more creative paradigm in health research, and in general practice research in particular.
Mono or single discipline research is the basis of most health research efforts. For example, biomedical, physiological, biophysiological, psychological and sociological research has been undertaken extensively in a whole range of health and medical areas as single discipline topics. In general practice research the trend has been for biomedical, epidemiological, sociological and psychological research to predominate. One discipline, publishing results usually in journals read mostly within that discipline ensure that knowledge is kept within discrete disciplines, and may lead to a number of disciplines researching the same issues, largely unaware of the findings of other research groups.
However, there has been a rapidly expanding interdisciplinary effort incorporating social and behavioral sciences into researching areas such as modes of treatment, service provision, doctor-patient and broader treatment relationships. Interdisciplinary approaches have been evident for some time in health research. In general practice for example, a number of Australian research projects (for example in doctor and patient satisfaction, decision making processes, referrals, and consumer issues) have involved research investigators from a range of faculties such as general practice, sociology and psychology. These researchers largely retain their discipline-based affiliations. A number of Australian and international research teams have comprised researchers from medicine as well as well as sociologists, psychologists, demographers, anthropologists and health economists.
Multidisciplinary teams have evolved as a way of addressing some more complex and innovative solutions to research problems. With team members from different disciplines working together a fuller absorption of their respective paradigms can be gained in research programs. Team members are usually located together and may coopt members. Many of the 'skimming effect' problems in mono-disciplinary research can be overcome through more in-depth interactions amongst team members. Of course the degree to which paradigm merging, development and expansion occurs will depend on some of the politics involved, funding bases, and career factors for members. Multidisciplinary teams have been involved in expanding the GP research paradigm in addressing issues such as patient response or environmental aspects of ill health.
Transdisciplinary research has developed over a long period of time in areas outside of health research. According to Rosenman  transdisciplinary research involves team member blurring their discipline boundaries at the level of conceptualisation, method, analysis and theoretical interpretation of the research process. Method and paradigm issues involved in this process have been discussed in previous sections of the paper.
There are three methods: interdisciplinary, multidisciplinary and transdiciplinary, represent various blending of discipline contributions to the same problems. Interdisciplinary (according to Rosenman ) represents research programs carried out co-jointly by a range of disciplines.
Interdisciplinary and multidisciplinary approaches can be seen on the continuum between mono-discipline researchers and the transdisciplinary approach. They each move more closely towards the benefits of expanding paradigm development, and overcoming a number of the problems that can be associated with moving (and skimming) between paradigms, faced by the mono-discipline researcher. While 'good' interdisciplinary or multidisciplinary research teams may already undertake some transdisiplinary process, it is argued however, that there is considerable need to reflect upon and further develop this process in general practice research because of the expanding and increasingly complex information needs of the relatively underdeveloped field.
Three approaches to research show the contrast of the mono or single discipline researcher, the transdisciplinary research team, and the emerging researcher who combines many of the skills and attributes important to a transdisciplinary approach. The transdisciplinary or crossdisciplinary trained researcher can give some direction to merging of discipline approaches: these researchers are trained in a medical and at least one other discipline (e.g. anthropology). This emerging group of researchers are more easily able to merge and cross between discipline boundaries.
There are potentially three types of researchers incorporated into a transdiciplinary research model. The first, by contrast is the mono-disciplinary researcher who has an orientation towards one of the major disciplines. They have a highly focussed methodology which is potentially narrow, are constrained by disciplinary perspectives and limitations, and have a lack of cross-disciplinary linkages. Transdisciplinary researchers, on the other hand have an orientation directed by the individual researchers' discipline mix, are trained in two or more disciplines, and have the potential for less disciplinary expertise, offset by a conceptual understanding of knowledge construction in different disciplines, and deal with complex research issues in combining medical and social sciences research. The transdisciplinary research team has the potential for the creative redefinition of problems and solutions, and an orientation which is problem versus paradigm driven. In addition there is the potential for the creative expansion of research paradigms, and the immediate cross-disciplinary links within team teaching, and the cross fertilisation of ideas.
We propose here that the transdisciplinary model forms a method of research at the end of a continuum, and is not necessarily appropriate to all health research endeavors. Some of the techniques for transcending disciplinary boundaries have not yet been outlined in the literature and in the earlier sections of the paper we have attempted to the areas which need consideration. Research teams working within a transdisciplinary framework in a climate of open-ended inquiry are identified as the way to most likely to further the development of creative and innovation solutions to the complex issues related to providing high quality health care. Figure 4 shows that activities such as cross teaching amongst team members to provide a technical base for all members to address the problem can be employed. In addition, brainstorming ideas and alternative conceptions to the research problem definition, and ways of addressing it can be used. Other creative techniques of information sharing, and cross fertilisation of discipline based approaches to problems, including clinical, social, behavioral, and economic are appropriate. The model of transdisciplinary trained researchers is most evident in health research in developing countries. At the University of Western Australia for example, medical graduates have been trained in cross disciplines (e.g. anthropology, sociology) to give them a problem oriented approach and paradigm flexibility in investigating developing countries' health needs.
The feedback loop in Figure 1 shows that issues in turn affect values, choice of method and use of the mix of disciplines. In turn, the issues researched and results found need to influence choice of future method. The research process should allow for insights and experiences with issues in the field to affect the researcher's values, as well those in the wider community, and have social and policy impacts.
However there are some problems associated with an approach requiring researchers to merge their paradigm boundaries, and these need to account for: firstly, individual disciplines (social and behavioral sciences in particular) have maintained important boundaries to a number of health based inquiries. For example in providing direction in the use of qualitative methods in projects. Secondly, the politics of the research team (i.e. which discipline may be represented by the principal investigator) may lead less powerful representations to concede important viewpoints gained from their disciplines. Finally, opportunities for disciplines to increase their potential for discipline based research funding: this may preclude some discipline blurring.
There are a number of possible positive outcomes for a transdisciplinary approach. There may be innovative solutions in areas of major importance which have received little research attention due to methodological barriers. For example, in chronic illness and disease management, the experiences of sub-groups of the general practice population could be improved and resources rationalised, if the processes of social support, rational repeat prescribing, and the doctor patient relationship within a broader medical and socio-economic context are addressed by a team prepared to redefine the problem creatively. Policy implications of integrated research should be more accessible to policy makers and practitioners(. There may be pronounced disciplinary shifts. Crews and Garret  in a discussion of aging and biological anthropology, argue that anthropological research into the variations in human aging has become dominated by the transdisciplinary model. In particular, there may be cultural and paradigm shift within general practice itself.
A forum where reflexive research processes has taken take place in GP evaluative research is the General Practice Evaluation Program Work-In-Progress Conference (held annually in Australia since 1992 as part of the national grants program). The feedback provided by researchers on the research process, the linking of issues in research to investigate how best a particular paradigm and methodology might approach that issue, and the evaluation of methodological approaches make it an important forum for the construction and development of GP evaluative research and theory. Without such forums, the danger is that research will just continue in one vein until something more suitable for solving general practice problems comes along.
Another transdisciplinary activity of the Program is the linking of researchers and who have received grants to work on a similar topic, but are using different disciplinary approaches perspectives. The linking is not merely at the level of encouraging personal networking, but through other mechanisms such as joint funding and working (sometimes using a transdisciplinary approach) with the Program's Technical Advisory Group who have diverse research backgrounds. The final but possibly most important transdisciplinary element to this program is the composition of the Evaluation Steering Group of the national Program which covers a broad range of research and interest groups. It has consistently dealt with the practical delineation of the general practice transdisciplinary paradigm, through the process of being the major funding for general practice research: it has included a combination of different social, behavioral and medical approaches. This process is mirrored, in the grass roots evaluation of the recently established regionally based structures called Divisions of General Practice with their emphasis on integrated service delivery. This very untried area has precipitated an enormous need for evaluative research.
The transdisciplinary research team in general practice by implication should have inputs from both consumers and providers of the service. Arguably, such teams should also include academic general practitioners. As demonstrated earlier, there is no research (nor clinical) discipline specific to general practice, therefore it would be logical for the training of general practitioner academics to be generalists or primarily transdisciplinary to enable working with transdisciplinary researchers from specific disciplinary areas such as sociology, economics, public health.
Broader issues need to be considered in presenting results of research. Groups such as consumers and practitioners, not only policy makers need to have research results presented to them. In general practice research they need results to implement changes, and as informed stakeholders, to affect policy makers decisions.
Researchers may have some difficulty in getting their transdisciplinary research published, and consequently much is not being read by those who could implement changes (including health and medical professional, allied health scientists and consumers) . Future developments in the research effort need to incorporate accessible dissemination channels. Dissemination of research is integral to a developing paradigm being accepted, acted upon and consequently furthering the general practice paradigm as a highly relevant and flexible approach to providing creative solutions.
GP research incorporates a range of disciplines and methodological approaches. When this research is complex, involving the application of different research techniques associated with different theoretical frameworks it is argued that it should be accompanied by a process of reflection and extensive discussion amongst practitioners, researchers, policy makers and the broader community. The discourse should go beyond method, discipline, and paradigm to incorporate philosophy and theory of research. It must deal with disunity of analytical perspective and diversity of theoretical approaches of the social sciences and medicine and the biological and physical sciences by attempting to establish commonality at least at a fundamental theoretical level. This process of transdisciplinary research and paradigm shift is essential, because of the existence of external imperatives of circumstance, need and theoretical climate. The main imperative is the complexity of processes within general practice with which to understand and evaluate demand synthesis and integration of multiple perspectives.
The new models of general practice research need to be developed through a series of research and methodological activities, to deal with the identified complex information and research needs as well as tradition of research in disease and disease process. A clear exploration of issues, a further refinement and development of methods, and a consideration of the components of changing paradigm need to be included in future general practice research developments. The dangers in adopting an approach that ignores the perspective of a number of stakeholders is at times evidenced in health planning. When data from communities of users and of health providers is not accounted for, one-dimensional solutions can result, posing problems for future planners.
A mission statement for general practice research should include developing and enhancing a flexible research paradigm that can provide innovative solutions to policy makers, as well as empower consumers and stakeholders with effective information for making decisions and implementing the results of research. This will require some fundamental development and refinements of models of research, and recognition and understanding of changing research practice in the general practice field. The training of general practice researchers needs to be responsive to the demands for transdisciplinary generalists and those with a strong discipline basis.
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