‘Do you have a history of diabetes in your family?’
This question is so often asked by our GPs, medical practitioners and specialists. And unfortunately, for many Australians the answer is yes.
A debilitating condition that requires an individual to change their lifestyle and daily routine, diabetes has escalated in Australia at such alarming rates that the need for medications and management routines must allow for the increase in problems.
At the heart of diabetes diagnosis and treatment is evidence-based research. For years, Dr John Furler, GP and Principal Research Fellow at the Department of General Practice of The University of Melbourne, has been driven to try to understand not just the level of treatment that patients receive, but also the how individual environments can impact the onset of diabetes.
Type 2 diabetes is described as ‘a progressive condition in which the body becomes resistant to the normal effects of insulin and/or gradually loses the capacity to produce enough insulin in the pancreas’1.
Understanding how a patient’s lifestyle can lead towards a diabetes diagnosis is not straightforward. It is not just about test results, it is about empathetic treatment and truly gaining an honest understanding of how the patient lives their life.
Dr Furler’s research, funded by the RACGP Foundation and Diabetes Australia, is dedicated to improving how GPs can provide people with diabetes with the service and care they truly deserve. This enables GPs to improve quality of care for people with diabetes through evidence-based research and allows patients to open up the conversation of their lifestyle and how to make holistic changes for a better outcome.
How did you become involved in diabetes research?
The first project I really did was exploring the notion of health inequity, or the social gradient in health within diabetes.
People from more socioeconomically disadvantaged backgrounds (where diabetes is more common), have more complications, and there was some evidence that they were getting different sorts of treatments both in general practice and in specialist care.
I really wanted to understand how social class and socioeconomic status played a role in the sort of care GPs were able to give people with diabetes, and the sort of experience people had and how it depended on their social class or socioeconomic background.
How does someone’s socioeconomic background influence the management of the disease or how they are treated by their GP?
I found there was a commonality across what GPs and patients told me. Inadvertently, GPs implicitly make assumptions about the social position - I suppose - of the patients they’re working with, and wrapped up in that are some assumptions about that patient’s capacity to engage actively in their diabetes care and self-manage.
That can shape the sort of outcomes that are possible for a patient with diabetes and it can shape the sort of care that a GP delivers.
I think the concrete outcome of this is that I was able to identify ways that GPs could self-reflect upon those sorts of assumptions and maybe make sure they didn’t contribute to unequal care experiences for people with diabetes from different social class backgrounds.
The idea of care and how to ensure that everyone receives equal treatment is no doubt something that can have a significant impact on our wider communities. How did this experience and introduction to diabetes management influence your research career?
That was my introduction to research: the first piece of research I did on my own, or led, and it really taught me something very concrete about the realities of my own practice.
I’ve always been a clinician researcher, so I’ve always maintained an active clinical practice in a community health centre in Melbourne and I’ve worked in Indigenous communities overseas in the UK, in London. A lot of my clinical work has always been with people from relatively more socioeconomically disadvantaged backgrounds, so I’m really interested in how to make care for GPs working in those environments easier and make it easier for them to optimise outcomes.
Since then, I’ve gone on to complete a PhD and, with the help of some small grants, been able to undertake some larger pragmatic clinical trials set in general practice around diabetes care.
Much of the general public don’t understand what the benefit of GP research can be - especially when Australia already has great organisations that specialise in specific research areas such as cancer, women’s health, diabetes, and mental health.
How does GP research stand apart from these and how does it contribute to the health of Australians?
Certainly there is a challenge to generate research and undertake research that is meaningful to GPs and their practices and their patients and communities that they serve. For example, a lot of clinical research and biomedical research is conducted in tertiary centres on quite a different patient group that we’re seeing day-to-day in general practice. These may be patients that are hospitalised or have a very late stage disease. Often in clinical trials, the patients that we see that have multiple chronic conditions, or other disadvantages, other challenges, are excluded from clinical trials so we end up with a body of evidence that is not easily applicable to the patient group we’re working with.
The second challenge I suppose is, we’re going to do some research in general practice, around our patient group, we want to make sure it’s informed by clinician researchers themselves, coming from general practice.
We don’t want to be seen as simply a site for hospital specialists or career researchers to take our patients and do the research in our practices. We want a collaborative, sustainable model of research where questions are generated by practicing clinicians and patients, and we have clinician researchers, we have consumer input and we’re able to design studies that come from the ground up and are meaningful to the practitioners and patients in general practice.
It’s a very important area for growing medical research where most patient care occurs in our communities. It helps prevent hospitalisations, it gets at conditions earlier and it’s more applicable to the broad mix of people that are seen in general practice.
From your years of experience, how do you think your work as a GP has evolved alongside your work as a researcher?
My research continues to inform my own practice on a daily basis.
It’s made me much more humble about the idea of gaining knowledge and being certain about things. I’ve become much more aware of uncertainties in medicine.
I’m certainly more reflective about my context and influence that I bring to interactions with patients and the way I contribute to organising my practice. I’m interested in ensuring that we have an open, inclusive practice and that I have an open, inclusive practice style.
What I’d like to see is a research-engaged general practice community that is happy to take on not just clinical questions that matter to them, but are also happy to take on a research agenda that engages their communities and delivers better outcomes for Australians consulting their GPs in their communities, whether they be remote indigenous or rural communities, regional cities, or inner city suburbs.
In all of those environments people deserve the best quality care and the best outcomes that can be achieved and I think an enthusiastic, actively engaged clinician research community in general practice is a fundamental strategy to do that.
Diabetes in Australia:
The prevalence of diabetes has been escalating over the last 3 decades, with rates tripling over this period—diabetes affected around 1.2 million people in 2014–15.
Indigenous Australians are around 4 times as likely to have type 2 diabetes prevalence, hospitalisation and death rates as non-Indigenous Australians
1 million hospitalisations were associated with diabetes (principaland/or additional diagnosis) in 2014–15—10% of all hospitalisations in Australia.
The lowest socioeconomic group has diabetes hospitalisation and death rates that are 2 times as high as the highest socioeconomic group
A million reasons why: tackling the diabetes epidemic.
- Diabetes Australia. Type 2 Diabetes. www.diabetesaustralia.com.au/type-2-diabetes
- Australian Institute of Health and Welfare. Reports and Statistics, Diabetes. Canberra, ACT, 2017. Available at www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/diabetes/overview
We're always looking for partners who want to create a healthier Australia. To find out more about the RACGP Foundation's work, or how you can partner with us to create a healthier Australia, visit foundation.racgp.org.au/foundation
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