Medical Research in the 21st Century

To the Editor: I was disappointed that the JAMA theme issue on opportunities for medical research gave no attention to the need to develop research in primary care. Rather, the issue centered almost entirely on biomedical research. While such endeavors are very worthwhile, research that will help improve the processes of care is equally important.

For instance, Dr Michaud and colleagues¹ described the DALYs in the United States in 1996. I note that the detection and management of most of these diseases (which often coexist) are within the realm of community primary care. Even "congenital abnormalities" are responsive, to some extent, to prepregnancy and prenatal interventions in the primary care setting. Another example is ischemic heart disease; it is clear that much remains to be done to identify patients at risk at a time when primary prevention is effective. It is similarly important to develop efficient ways to identify such patients that can be incorporated into day-to-day practice and that are acceptable to patients—who often may have multiple other medical problems. Another example is alcoholism. There needs to be as much emphasis on early detection and intervention² as on advances in transplantation technology.