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Response to letter by Lingping Zhu: Small ‘r’ research as big ‘R’ research in general practice
  1. Michael D Fetters1 and
  2. Timothy C Guetterman2
  1. 1University of Michigan, Ann Arbor, Michigan, USA
  2. 2Creighton University, Omaha, Nebraska, USA
  1. Correspondence to Michael D Fetters; mfetters{at}

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We appreciate Dr Zhu’s interest and points about the special issue on discovering and doing research in general practice (GP).1 We agree with Zhu’s assertion that general practitioners have faced barriers applying research methods and conducting original research. We specifically chose six research methods2–7 to feature in the special issue that could be used by GP researchers in low resource and low infrastructure settings. Importantly, we do not claim that these six articles or the special issue as a whole will suffice as the only resource needed for conducting GP research. In the comments about external difficulties, we agree with Zhu that some major journals have resisted publishing qualitative research. To us, this indicates a problem with the priorities and biases of these journal genres to quantitative research.

While we are unaware of any qualitative studies published in New England Journal of Medicine, we do find qualitative studies in influential general medical journals such as JAMA: The Journal of the American Medical Association (JAMA), Annals of Family Medicine, Family Medicine, Journal of the American Board of Family Medicine (JABFM), Family Practice, Journal of General Internal Medicine, JAMA Internal Medicine and other general medical/family medicine journals. Importantly, we believe that the lack of publication in some of the high-profile medical journals represents a problem of the valuing of qualitative research in family medicine and GP rather than the value of the research. Relative to health policy publications, we disagree about the lack of high-impact journals for such publications. The health policy example featured in the special issue was published in JAMA. In addition, there are a number of highly influential journals that publish health policy research, such as the American Journal of Public Health, where general practitioners can publish and have a high impact.

Regarding case study and case series research,7 first we believe it is imperative to distinguish between case reports, which are an educational tool to provide an example, and case study research, which is empirical, involving collecting and analysing data to address research questions. Many well-developed case study research studies can and have been published in high-impact journals, for example, Annals of Family Medicine and JABFM.

We agree that it is less common for major funding organisations to fund pure qualitative research studies. That does not mean qualitative studies are unimportant to primary care research, and unfortunately represent a funding bias that will require high-quality qualitative research studies to change prevailing bias to the funding of quantitatively focused studies. The selection of qualitative research as one of six feasible methodologies precisely emphasises both its feasibility, importance and potentially lower cost, which thus render it an excellent methodology for answering the questions that matter in primary care.

We also agree that general practitioners with adequate skills for full-scale research in both China and around the globe are still lacking. Precisely because of this point, we think the special issue, with its emphasis on projects feasible in low-resource and infrastructure settings, is critical for advancing GP research through small-scale projects. These projects allow emerging researchers to ‘walk’ before they ‘run’ with larger scale projects; that is, these small-scale projects can guide emerging researchers in the essential procedures.

Zhu comments further on ‘internal difficulties’ with regard to insufficient detail regarding how to conduct the six different types of studies. As to whether these articles will suffice for guiding GP research on these topics remains to be seen as the articles have just been published. However, we do emphasise that the articles were specifically written to open the eyes of researchers to specific research techniques that can be applied and useful for individuals interested in engaging in GP research. In addition, each article contains specific references for further information as needed.

In sum, we believe the special issue focus to be on the GP small-scale or ‘r’ research; that is, these articles were designed to support small-scale research that is feasible in resource-limited settings. By illustrating each of these six techniques with published studies, we have demonstrated that that small r research can be big ‘R’ research. By big R Research, we mean research that matters to primary care practitioners. Each of the six articles has chosen an exemplar to illustrate that r research can be R research when examining a problem of importance to primary care, and when executed well. We believe the introductions to qualitative analysis8 and quantitative analysis9 similarly will provide valuable references for emerging and experienced researchers as well.

We encourage general practitioners of all backgrounds to take advantage of the research approaches presented that are feasible with limited resources and to conduct research that matters. More than anything, critical issues are identifying research questions that matter to GP and using appropriate methodology for addressing these questions.10 The significance of the special issue is the demonstration that all of these methodologies are feasible and publishable through influential venues.


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  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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