Rodolfo J. Stusser, MD.

Researcher & Professor of Clinical Epidemiology

Plaza Community Polyclinic Centre - Clinical Research Centre - Havana University.

Family medicine scientific progress needs the creation of new research spaces. The aim of this paper is to argue some first ideas about why this necessity, suggesting a way of how it could be satisfied. Up-to-date reductionist, mechanical and biomedical, ways of thinking about disease, and empirical and quantitative, modes of searching, conventional paradigms, distorted the humane nature of family medicine proto-science. They marked its academic beginnings, mainly as an interface discipline, with lack of man wholeness and healthfulness content, second-hand knowledge extension and technology validation and transference to population, generated in its sub-disciplinary spaces by other clinical and basic sciences. Other ways of scientific thinking and enquiring, should be used in a special meta-scientific research agenda, to open and develop new own disciplinary spaces of firsthand scientific creation. These should allow more synthetic and integrative research of the man, family, and community, bio-psychosocial centred of disease and illness dynamics ways of thinking, dialectically complemented, with more reductive biomedical oriented research of health and well-being statics, and integrative research of man, family, and community bio-psychosocial centred of health and well-being dynamics, and more hermeneutic, theoretical and qualitative searching strategies too. Multiple psycho-sociomedical interdisciplinary research spaces should be developed to support family medicine own research spaces generation, and some super-disciplinary ones seeking a more universal scientific frame foundation ought to be created, also, to increase its maturity and efficiency as human science.

Family medicine, the most general clinical speciality [1], is still a developing science with an immature body of conceptual and methodological scientific knowledge [2-7]. When general medical research in the last fifty years was evaluated in most read journals [8-10], the results reflected too little about its own --unique or pathognomonic-- family medicine research results, even including a young family journal [3, p. 58]. Although, some studies examined historically some criteria about the interface arena, subject matter and scope of family medicine research up to date [2, 4-7], therefore, most of them did not search deeply in the ontology, epistemology, logic and methodology of its single scientific objects, goals, focus, theory, as exceptionally others have begun to do [3, 11-13].

It has been said that something is still lacking in general and family medicine research, throughout the developed and medicalised world health primary care systems [14]. The main thesis of this essay is that family medicine lacks mainly its own well delimited new research spaces, and therefore, maturation and efficiency as human science. To develop them is a meta-scientific challenge, which relapses principally on its researchers and policy makers. This not well studied main factor [15, 16] seems to be influencing on family medicine still few research possibilities, academic credibility and prestige [2-5], which could explain a part of its low choice as general speciality by medical students [17-18]. The aim of this paper is to argue some first ideas about why family medicine scientific progress needs the creation of its new research spaces, suggesting a way of how it could be satisfied.

Since the ancient times, family or general practice and general surgery, were the first medical proto-sciences. Its clinician researcher explored, discovered and described facts metaphysically and qualitatively observing the phenomenological whole surface of the ill and healthy person in his family and environment guided by the thoughts of vitalism till the medieval times. On the 17^th century were used primitive measuring and assay techniques too, beginning in medical science a dehumanisation process, is to say, the exclusion of human being's nature, affairs and believes about its illness and physician's relation, by virtue of the Cartesian body-mind dualism. Also, it experienced a differentiation process upon the Newtonian analytical reductive, empirical, linear causal, and mechanical ways of thinking and inquiring too. These processes in contemporary times, initiated to upset wholly the physical system of the ill person, towards infinite smaller parts and mechanical subsystems [19, 20].

On the last half of the 1800s, surged controlled animal experiments and clinical trials, and intermediate measuring and intervention techniques for static physical disease oriented diagnosis, therapy, and prevention. The family medicine researcher also explained and predicted facts, searching in the hospital, house, and field, and sporadically in rudimentary biomedical and bioepidemiological research laboratories, along with generalists and specialists. Whereas, in those laboratories, arose also, full-time biochemists and biophysicists, conforming medical cross sciences, which expressed the beginnings of an integrative but biomedical mode of thinking. Pasteur's microbiology, one of the most successful laboratory science s of all the times, opened an acknowledged golden era of medical science progress and of other sciences too. That paramedical force made many valuable contributions, also introducing the dimensional quantitative measurement [21]. Medical science splits its clinical nature, into basic laboratory and clinical sciences, which rose from the increased clinical specialisation number of new subdisciplines, developing special programmes [22-25].

After the World War I, rose holism, a whole-system way of scientific thinking as an alternative to the prevailing reductionism and mechanicism ones. It said that whole organism and its systems are greater than the sum of their parts. Holistic medicine, arose as a mixture of western medicine practice along with alternative techniques, including eastern ones, with health promotion, illness prevention, the patient as unique case, using its potential self-healing capacities, principles [26]. Holistic medicine not influenced towards a man and health centred medical research progress for the following reasons: 1) the difficulties to study the healthy physical person along with his mind, interacting in his environment, when many of their elements and relations were not known yet, 2) the absence of the general systems and emergence theories, not allowing the acquisition of knowledge through a grounded synthetic and integrative searching strategy, 3) its hermeneutic and qualitative methods, not well understood in this epoch completely ruled by the empirical and quantitative models.

After Einstein, Heisenberg, Plank and Bohr's greatest contributions to physical sciences during the first half of this century, sequentially surged Shannon's information theory, Wiener and Rosenblueth's cybernetics, and Bertalanffy and Weiss' general systems and emergence theories, upon biological scientific basis, built precisely to open living systems to holism [22-25, 27-30]. Also, after the World War I, was inaugurated health primary care as an organised societal subsystem, but its expansion only commenced after the World War II. Simultaneously to the extreme medical science fragmentation during that period of scientific revolution and technological explosion [2], was developed even more family medicine, concerning earlier with the family individual patients, but nominally later with family and community as "patients" too [2, p. 63, 3, p. 57, 31]. Also, proliferated other cross sciences, with the increased participation of psychologists, anthropologists, sociologists, etc., in psycho-medical and socio-epidemiological laboratories, rising the biopsychosocial model, but prevailing the biomedical one.

In this half-century, were developed research models of nucleic acids, cell culture, randomised clinical trials, etc. Fragmentation of clinical sciences was increased and narrowed reductively much more their objects and focus till the smallest internal subsystems of human being ever described. A new great and more complex era of medical science progress within other sciences, were inaugurated with the prosperous Watson and Crick's molecular biology, but accompanied by the complete dissolution of human medical science. This progress occurred simultaneously, with the development of refined measurement and intervention high technology, which exceeded extraordinarily in cognitive depth the diagnostic and therapeutic arsenal of the general clinical sciences of the whole human system. Thus, they increased its differentiation in dozens of subspecialised clinical sciences, united to the limited biomedical laboratory sciences' ontology, epistemology, logic, and methodology, farther of the psycho-sociomedical ones [20, 22, 30].

However, this progress stayed back in the scientific inquiry of the generals and essences of the healthy man with his thinking mind and "organic" and "functional" diseases, in his family, community, and environment. These objects need another way of thinking and inquiring mode to use the enormous number of outcomes achieved by the precedent way inherent to the sick person, though less to his family and community [3, 13, 31, 32], with their social conscience. Therefore, general internal medicine and general paediatrics, and much more family medicine were from that time keeping the broadest scientific subject matters and extent. The first ones broke the family and kept the whole ill patient as object at his late and early stages of life, seen at the hospital, house and office for instants or short periods. The last, has kept first, the generally sick entire person, and after with his ill family and community as objects too, interacting in the environment along all his life, seen at the consulting office, house and community [2, p. 63].

Family medicine speciality, till the 1960ies began its conscious conversions in academic discipline. This was the first expression of the requirement of the extension and advance of the dialectic synthetic and integrative tendency in medical scientific thinking. Its main practical features were comprehensive and continuing caring of persons, families, and community, within their environment [2, p. 63, 3, p. 58, 5]. Therefore, in human activities always have been easier to divide than to join . . . The young family medicine science was attempting conceived in teaching programmes as an organic unitary system, but in its care, education and research, practices, it remained as a superficial summation of partial objects, skills, theories and corpus of knowledge, particularly of the other primary care medical sciences (general internal medicine and paediatrics, community psychiatry, epidemiology, obstetrics-gynaecology, etc.) and non medical sciences (psychology, sociology, genetics, education, management, communication, etc.).

The family medicine researcher continues searching isolated or with other colleagues, accordingly to the subdiscipline towards he is inclined. However, these associated subdisciplines continue limiting more than ever the generals and essences' complexities of the whole sick and healthy person in their environment, to their singular ontologies, epistemologies, logics and methodologies, even the most generals [20]. Due to this reason, the family and the community, as a patients" or object-system, not as summation of persons without social conscience, have been so scarcely searched [33, 34]. Family therapy, and family dysfunctions as risk factors, of children or adults diseases, are the issues more studied. That is why family medicine has exceeded so little general practice research [33-35], and in spite of the exceptional privilege of this physician to use the rising integrative human and health dynamics centred thoughts [3, p. 58, 11, 27, 28, 31] upon a biopsychosocial model, these have passed too little of not well-understood notions and frustrated operational intentions.

In this stage of so prolixity of biological particularity in medical science, rose the idea that most of its main successes became from the basic laboratory sciences, so-called sciences of complexity. Accordingly, in the last 130 years most of the core knowledge about diseases' aetiology, pathogenesis, means for diagnosis, therapy, prevention, and about health's causes and promoter means, appeared consequently of their creation. Less knowledge seems to be produced by the subspecialised clinical services, which doing high technology research were reconsidered as clinical research laboratories [36]. Whereas, family medicine research is still conceptualised constrictively as embryonic science of simplicity, understood practically as an applied non orthodox science of interface [2, p. 64, 3, p. 56], for clinical, epidemiological and statistical output investigations, mainly of scientific extension of clinical second-hand knowledge as of technology validation and transference, from hospital and laboratory research, clinical and pre clinical outcomes, from the individual to the population [37-39].

It is becoming an imperative to define with precision the boundaries of family medicine science own scientific interests of knowledge, technology, and techniques of these times. This is needed, just when it has been transformed in one of the most complex research fields of present medical sciences, unapproachable solely with the traditional ways of thinking and searching. Sometimes it appears as if it were lost practically its first human's health object by the subspecialisation process, and relegated to the most eclectic medical speciality and science. The scientific focus of family medicine rising science, should be developed not replacing but exceeding the reductionist, mechanical, biomedical, disease, empirical and quantitative, conventional paradigms, including: 1) the current interface research arena that marked its academic beginnings, with its still man wholeness and healthfulness content scientific second-hand knowledge extension, as of technology validation and transference, generated in its sub-disciplinary spaces by other clinical and basic sciences, 2) the present not well developed and specially the new own disciplinary spaces not created yet, solely approachable on a firsthand basis by the family medicine researcher due to his exceptional position into the wide reality of the human being's healthy living process, 3) the novel interdisciplinary areas that have remained untouched and inaccessible among all existing medical sciences, not even seen as important by the optic of other general and cross medical sciences' researchers, 4) the original most general scientific super-disciplinary spheres, farther of all the other general and cross medical sciences, even joined, which required reconstruction of old and generation of new highly abstractions.

Most medical sciences, e.g. clinical oncology and cardiology, and clinical psychology and genetics, have enlarged its own disciplinary spaces testing new outcomes in the community, through static disease oriented, biomedical structural and functional man's subsystems approach, through the interface family medicine research in its sub-disciplinary areas, achieving enormous progress [37-39]. It is quite important to continue enlarging those applied research spaces with the relatively more known and easier algorithmic methods of extension to the community of knowledge as of validation and transference of high technologies and clinical programmes, becoming of the research laboratories and hospital services, inclusive as a way to deduce new knowledge about health from the disease results.

Notwithstanding, the family medicine researcher should stop to be only a passive recipient of the mechanical diffusion of the laboratory and hospital research scientific outcomes in the community practice, filling the forms without participation in the analyses and interpretations of his own data. He ought to be an adviser and actor of the evaluation search of the special medicine researchers and results, since the logic of the survey or trial design, with its multiple determinants and plurality of manifestations, in all the cognitive reductive and integrative levels of the human being's healthy life. In the future, he could even state pre and post clinical phases of foundation and validation in research laboratories and hospital services, from the original results of community surveys and trials on.

Family medicine needs simultaneously to what it does now, to develop the highest cognitive and intervention level for a clinical science not reached yet by anyone: its own basic creations [40], with its inherent more difficult heuristic methods. This only would be possible, if family medicine opens an effective health centred approach to primary care, embracing its main hypercomplex scientific objects: the real health reproduction processes of the person, the family, and the community, over long periods, which have remained in the land of nobody, to produce its single corpus of knowledge, instead of solely continue the unilinear self-perpetuating investigation of the apparent healthy person, the risk of disease, the diseases, the risk of disability or the death, and the disabilities. By one hand, it has to incorporate really an integrative biopsychosocial scientific thinking at his "community laboratory." By the other, it has to search for the essentials of the "intact human being's transitions from health to disease and back to health again" [11], beyond the static disease concept that is retarding its progress. It has to search qualitatively for new causes and meanings, new levels and categories of that dynamic life process, and for effective means to promote human being's health and control its health problems, from his preconception stage through all his free living time, non hospitalised, including the familial reproduction of his individual nature into his community, refunding thus, its conceptual and operational scientific basis [3, p. 58, 11].

Since fifty years ago, family medicine science seems pre-destinated by its core subject matter to re-examine the isolated ideas of illness and disease, specially, nowadays that medical science is on the brink of change of this paradigm in medicine [3, 12], also promoting much more research of scientific problems about well-being and health of the person, family and community, as single and interacting scientific objects. New unique scientific disciplinary intact spaces of this developing science, could be generated in a distinctive way through a finer systems approach [29], to the whole man, family, other groups, community, and even bigger populations, much broader and complex than the developed by the classical general and emergence systems theories over biomedical basis, but upon a higher cognitive biopsychosocial and infomedical basis [22-24]. The main goals of a meta-scientific research to create own family medicine research spaces, ought to include the aims of eastern and holistic medicine as well as the aims of western medical sciences, but should be beyond of all of them logically, ontologically, and epistemologically. They could be conceived as follows:

First, to redefine health and well being in a more substantial, broader and dialectic form quite related with human living process and not practically as how it really means, the formal dichotomic pole of non disease or illness state [3, p. 58]. This could be done, opening its really distinct disciplinary spaces of scientific creation, with more synthetic and integrative research of man, family, and community biopsychosocial centred of disease and illness dynamics ways of thinking, but these complemented dialectically, with much more reductive biomedical oriented research of health and well-being static, and integrative research of man, family, and community biopsychosocial centred of health and well-being dynamics, comprehensively interrelated.

Second, consequently, to seek the health and well-being promoter factors or causes and the means and methods to improve, maintain and recover the health of the person, family, and community. This should be done with the integrative human biopsychosocial centred and dynamic health and well being centred ways of conceiving and approaching them, as their more general interactions with human genome continuously reproducing and changing within its expanding human living environment in ecological extension and complexity.

Third, to find out a distinctive way of viewing and understanding with the hermeneutic and theoretical scientific methods too [20, 30], the whole human being's health process, and of making new unbiased and powerful explorations, discoveries, descriptions, also in a qualitative form, to evoke original, broader and grounded new hypothetical explanations and predictions [35, 40, 41], involving new concepts, feelings and strategies, absents on the present isolated physiological, psychological, lower-levels of cognition, or physical and cultural anthropological and social [42, 43] higher-level, theories, and interpreting their new meanings.

Also, in family medicine, has to be interrelated in a dialectic unique theory, all its research outcomes from nearly fifty years ago, about dysfunction, failure of action, symptom, suffering, sorrow, despair, pain, illness, disease, disability, handicap, sterility, abortion, divorce, family crisis, poverty, ageing, dying and death, states or processes; with their better known risk factors and/or causes, as well as their protective, diagnostic, taxonomic, prognostic, therapeutic and rehabilitation means and technologies, with their respective better known responses and/or effects.

Also, unified into that unique theory, it has to be interrelated through its major efforts, the relatively very poorly known promoter factors and/or causes of the events, states or processes of preconception, conception, intrauterine life, birth, free-living, growth, development of whole function and action capacity of human-being, joy, gratification, happiness, marriage, reproduction of its nature in a new family, family equilibrium, migration, survival, longevity, social and economic prosperity and security, comfortable quality of life, well-being and health; with their promoter, evaluative, taxonomic, recovery means and fewer technological procedures with their worse known responses.

Moreover, it is necessary a more dynamic conceptual analysis to redefine better the not well delimited movable line or interface between health and disease or illness and when health rises repeatedly, accumulating more, equal or less health and life levels and qualities than before, analysing under another dynamic, relative, and dialectical theoretical frame, the concepts of inter-slipping states or spiral processes among them, in the health reproduction process with a new optic as the following: a) causes, meanings, moments and means for the health improvement process, b) determinants, senses, instants of the health deterioration process and procedures of protection, c) grounds, interpretations, jiffy and techniques of the health maintenance and recovery process.

In other words, it might be also written more than the natural history of human well-being and health processes and states, a d) dynamic health and well-being taxonomy with new concepts about levels and categories, complementing dialectically the natural history of disease and illness processes and states, and a new more dynamic disease and illness classification, in a unified one. The new health problems have to be defined, not solely as the needs of recovery of risk factors or of disease or illness process in a man's specific subsystem, but as e) the dynamic promotion and maintenance of a stationary health process of the whole man, family, and community. Then, it could be easier to create f) more powerful medical diagnostic and therapeutic, promoter and preventive, decision support computed systems with its data and ideas bases, for the inhabitants, families, and communities of an area, in interaction with all the environment where they live and reproduce.

It is also necessary to generate family medicine new multiple interdisciplinary research areas of its own interest, and to contribute to some super-disciplinary research spheres, poorly investigated too. Regarding the interdisciplinary ones, determined areas of research integration very scarce developed are: a) several clinical domains with the anthropological, behavioural, psycho-dynamical, interpersonal and social [30, 43, 44] epidemiological research laboratories, to search for the unknown causes and meanings of health and well-being states, events and processes, and for more effective means to improve their levels and qualities, in the individual, familial, and other societal dimensions; b) different clinical dominions with the psychological, and socio-epidemiological research laboratories to search for the still not well-known aetiology and senses, therapy and prevention of the main old diseases (e.g. cancer, atherosclerosis, psychosis, neurosis, addictions, etc.) and the main emerging and re-emerging diseases (e.g. AIDS, Alzheimer, tuberculosis, cholera, ebola, etc.), in the individual, familial, and other societal dimensions; c) numerous clinical spheres with not only the biomedical research laboratories, but also with the anthropological, behavioural, psycho-dynamical and socio-epidemiological research laboratories, to search for the unknown causes and interpretations of several states, events, and processes of health and illness not well classified, and for more effective means to promote health, and to prevent, control and cure those old and emerging health problems, respectively, in their genetic dimension; d) several clinical areas with the biological, anthropological, behavioural, psycho-dinamical and socio-epidemiological research laboratories to study comprehensively many states of health and illness in their simultaneous bio-genetic and socio-ecological dimensions; e) different clinical spheres with medical informatics research laboratories to search by simulation for the unknown and not well-known causes and significance of diverse states, events, and processes of health and illness, and for more effective means of computed systems to aid health promotion and illness prevention, and control, in their artificial intelligence dimension. The psycho-medical, cultural and applied medical anthropology and socio-medical research spaces of integration with family medicine [42, 43], should be the most developed due to decisive needs of this science to generate its own research spaces of firsthand creation in the future, to increase its academic maturation and efficiency.

With relation to the super-disciplinary research spheres, most general spaces very scarce searched up to date constitute necessities of creation of an essential and general theory and methodology of a horizontal and comprehensive medical science. These, should include reconstruction and new notions, approaches, models, and paradigms, enfolding the conventional ones rather than replacing them [12], about disease and illness processes' origins, pathogenesis, meanings and control, and specially, about health and well-being processes' roots, "healthgenesis", understanding and promotion of the person, family, and community, in their environment. These unifying efforts and outcomes, would be accompanied by the development of an own scientific philosophy, ontology, epistemology, axiology, logic and methodology, with the aid of general and special medical sciences, but particularly of the most general: family medicine [Stüsser R. J. Human Health: Medical Scientific Principles to Increase It., 1995, Unpublished project.]. This, might contribute to it more than any other science, due to its possibility to interrelate the physical, chemical, biological, behavioural, psycho-dynamical, interpersonal, social determinants and conditions of the man, family, and community, giving ultra-complex scientific hypotheses about disease and health with most deep meanings, impossible to be evoked at the best research laboratory, and even at the best hospital and consulting rooms, places where the entire person does not live nor reproduce his natural and social life. With it, also family medicine would get a more universal medical frame and foundation over which could rest for further scientific progress.

The spontaneous development of family medicine new research spaces would be achieved, but very slowly, within the present world organisation research activities at primary care community settings. In a recent study, are doing research only the 7% of non teaching physicians, and 20% of the teaching ones belonging to family medicine (and general practice) faculty departments [44]. It is necessary to promote international meta-scientific research projects through Internet and personal contacts within family medicine researchers, other researchers, and policy makers' world experts, capable to confront this challenge in all its broad levels of complexities, to obtain the cardinal precepts to develop this medical science [14]. Thus, each country could be then in conditions, in its National Health Service, using those principles, to make its own national meta-scientific research programme from the basis [7]. It could be addressed different issues developed as priorities for national and local research, mapping out the new frontiers of research, gaps in training or support, opportunities for collaboration, and specially, the primary care practice-based research networks [45], as have done successfully in the last 50-years biomedical research with the powerful tertiary care hospitals and laboratories networks, to support much better its programmes of medical research [46].

Nationally, this meta-scientific research has to begin with selected family medicine mature researchers' groups by faculty departments and/or scientific societies, which had showed good theoretical motivations and conditions to enlarge its speciality scientific frontiers, and could work in inter professional teams with other generalists, specialists, biological and psychosocial scientists, etc., but with the management of this meta-scientific research on their own hands. Part of these researchers previously should get training in medical science theory and methodology. This work has to be well supported within the operational framework of the health primary attention organisation level. The teamwork has to integrate more the research interface of family medicine in primary care research at community settings, with the secondary and tertiary levels of care, education and research, including care hospitals, institutes, and research laboratories [47]. For their works, should be organised all the necessary resources, specially the family physicians precious time, up to date computed ideas-bases for research (Current Contents, Medline, and maybe a special disks created for this research), and data-bases in their computers, connected with a network of a health area, and with Internet.

On the next years, it is necessary to undertake a clear reconsideration of family medicine own scientific objects, aims, focus, single theory, and methodology, to promote more general firsthand scientific creation, within a stronger and better supported structure of research, education and care, which allows its maturation, acknowledged own canon, in the next century, and hence, major scientific efficiency of care, with more well being and health for the people. International and national meta-scientific projects, seems to be necessary to materialise this. If these measures are applied creatively and are developed family medicine new research spaces in the next years or decades, increasing research possibilities, academic credibility and prestige, this could mark the beginning of a new successful stage of its progress, subsuming old paradigms in new ones, strengthening this science with the knowledge of more humanist basic research. Nevertheless, this only would be a reality, if part of the next century for medicine, would come to be considered as the psycho-sociology era, as there was the microbiology era in the last century, and still is the molecular biology era today.

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