Frederick Banting and the opportunities of research by general practitioners.

776 CMAJ, April 19, 2011, 183(7) © 2011 Canadian Medical Association or its licensors Iwish I could have been in Banting’s audience when he addressed the Canadian Medical Association in June 1926. I suspect that there would have been few women present, and I wonder what the audience made of the youthful speaker with his already extraordinarily distinguished resumé. The text of the lecture was published in the Canadian Medical Association Journal in August of the same year. Born in November 1891, Frederick Grant Banting was only 34 years old at the time. Yet three years earlier, he had already become the youngest ever Nobel laureate in Medicine for his work in the discovery of insulin. He had qualified as a doctor in 1916 and enrolled in the Canadian Army Medical Corps immediately afterward. He served in France, was wounded at the battle of Cambrai and, in 1919, was awarded the Military Cross for heroism under fire. On his return from the war, Banting worked as a general medical practitioner in London, Ontario, and studied both orthopedics and pharmacology before embarking on the research that would lead to his Nobel Prize. In his lecture, Banting set out “to treat the subject of medical research from the standpoint of a general practitioner, in the hope that helpful suggestions may be given to all such who are here today.” Much of what he went on to say remains relevant and helpful almost 85 years later. Paying tribute to the great general practitioner–researchers of history, including Harvey, Sydenham, Addison and MacKenzie, Banting noted that “they were invariably workers and thinkers and accurate observers.” That description brings to mind the crux of many of the problems facing researchers today. The bureaucratic constraints and imperatives of modern research have made it increasingly difficult to combine a career in research with sufficient clinical general practice to allow for this peculiarly productive combination of work, thought and observation. Banting asserted that the great general practice researchers “observed every sign and symptom of disease, and then by weight of clinical experience, made deductions and elaborated theories.” He wonders whether “today ... we sometimes get lost in a maze of less important details and lose sight of the main issue.” If that was already true in 1926, how much more so today, when the temptation is all but irresistible to identify associations within computer-analyzed data that are informed neither by clinical experience nor a plausible theory of causation? Banting emphasized the importance of meticulous medical record-keeping. “At the time that these records were made, they might not appear of value, but memory is variable and inaccurate, and the written record is useful not only for the present but for all time.” The difficulty we face at the beginning of the twenty-first century in the United Kingdom, for example, is that we now have financial incentives and quality standards for medical record-keeping that dictate how records are kept. These are based on computer codes and on our existing understanding of the evidence of biomedical science. The problem is that such records leave little space for the unexpected observation that may provide the clue to future knowledge. And so, despite Banting’s hopes, they may have no relevance for the future. I am reminded of my favourite “Memorable patient” article from the British Medical Journal, submitted in 1997 by a general practitioner who had been summarizing his patients’ records and discovered the record of a memorable consultation from 10 years earlier. The patient had come for a repeat prescription of antibiotics for his acne rosacea and mentioned in passing that the antibiotics helped his indigestion. The doctor made a note: “Occ. indigestion. Says oxytet Frederick Banting and the opportunities of research by general practitioners