The authors, led by Ryan M. Kane of Tufts University School of Medicine and the Duke Clinical Research Institute, describe primary care as the “first and last mile” of the US healthcare system. It is where patients first present with symptoms, where prevention and screening happen, and where long-term relationships between patients and trusted clinicians accumulate over years. That structural position, the article contends, makes primary care uniquely suited to generate real-world evidence that reflects the diversity of the population rather than the narrow, highly selected cohorts typical of specialty clinics and academic hospitals. Because care is delivered by general internists, family physicians, pediatricians, and med-peds clinicians across in-person, urgent, and telehealth settings, the patient pool available for research is both enormous and representative.

Recruitment is one of the most concrete advantages the Think Tank identified. Clinical trials frequently stall because they cannot enroll participants quickly enough; recruitment failures and delays are behind an estimated 80% of premature trial discontinuations. Research on trial participation suggests that personalized outreach from trusted recruiters substantially increases patients’ willingness to enroll, and patients consistently report deep trust in their primary care teams—physicians, advanced-practice providers, nurses, and staff. Similarly, physicians are more likely to refer patients to studies when they trust the research team. Embedding recruitment in primary care could therefore shrink timelines and costs while producing cohorts that generalize far beyond a single specialty population.

Primary care also offers scientific opportunities unavailable elsewhere. Because it is the frontline for diagnosis, researchers can study new screening and diagnostic tests in clinically “naïve” patients before specialist referral changes the picture. The setting supports a wide methodological spectrum: pragmatic observational cohorts, implementation science, quality improvement initiatives, phase 4 post-marketing surveillance, and target trial emulation studies that mimic randomized controlled trials through careful patient matching. As demand grows for real-world evidence generated in ordinary care environments rather than artificial experimental conditions, the authors argue that primary care is arguably the most powerful laboratory medicine has yet failed to fully exploit.

Yet the barriers are formidable. The United States has only 67.2 primary care physicians per 100,000 people, compared with 133 in Canada and 114 in Switzerland—countries that achieve better population health outcomes at lower national expenditure. The workforce shortage is driven by high educational debt, lower salaries than subspecialties, burnout from excessive documentation and short visits, and an aging physician population. The arithmetic is stark: one widely cited analysis estimates that fully delivering guideline-recommended care to a typical adult panel would require 27 hours per day. Clinicians operating at that level of overload have little capacity to participate in research, and the pipeline of new primary care researchers is dwindling accordingly.

Infrastructure and money compound the workforce problem. Effective primary care research requires trained clinical and non-clinical staff to handle regulatory documentation, recruitment, data collection, and participant navigation, along with sustained bidirectional communication between research teams and practices. Systematic reviews cite missing dedicated time, limited research training and confidence, and weak administrative support as recurring obstacles. Funding has grown more precarious, not less: federal freezes and workforce reductions have hit agencies with a historic commitment to primary care research, notably the Agency for Healthcare Research and Quality, whose grant function analysts have described as collapsing under impoundments. Incentives add another layer of misalignment—fee-for-service reimbursement rewards clinical throughput, and with roughly four out of five physicians now employed by hospitals, health systems, or corporations, practice consolidation prioritizes revenue over research participation.

The Think Tank’s first proposed solution is to scale up practice-based research networks, or PBRNs. These networks embed longitudinal research infrastructure into community-based primary care by connecting clinics to an operational hub, often based at an academic medical center, that supplies onsite research staff, training, and facilitation. In their foundational description, Westfall and colleagues argued that PBRNs can identify the gaps between recommended and actual care, test whether efficacious treatments remain effective in real ambulatory settings, and serve as laboratories for system improvement. Evidence suggests PBRNs improve recruitment, reduce clinician burden, and generate more generalizable evidence, while community-based participatory approaches build durable relationships among researchers, clinicians, staff, and patients.

Existing national networks demonstrate the model’s scale. PCORnet, the Patient-Centered Clinical Research Network funded by the Patient-Centered Outcomes Research Institute, links more than 75 health systems through thousands of academic, community, and federally qualified health centers, with standardized electronic health record data on over 45 million patients seen in the past year. That combination of rural and urban representation and standardized data makes such networks suitable for everything from large multisite pragmatic trials to rare disease studies. The Think Tank also emphasized a second lever: technology. Interoperable EHRs with built-in artificial intelligence, secure patient portals for identifying and contacting eligible participants, digital consent and randomization platforms, EHR-embedded interventions, and remote collection of patient-reported outcomes and wearable data can all engage participants asynchronously and minimize disruption to busy practices. The authors caution, however, that digital approaches risk worsening technology-related health disparities, particularly in rural areas, and must be deployed deliberately.

The third pillar is investment. Because primary care practices are pressured by high daily clinical throughput, financial remuneration is needed to offset research-related losses in clinical revenue, along with resources for health information technology, laboratory processing, and startup costs. The authors call for expanded public, private, and nonprofit funding for research training at every career stage—fellowships comparable to those routinely funded in specialty medicine, training for non-clinician researchers, and short-term or asynchronous programs for practicing clinicians—so that research can be embedded without destabilizing patient care.

The article’s conclusion is blunt: strengthening primary care research is a scientific imperative, not an optional reform. With chronic disease at the center of national health policy debates, the setting best positioned to deliver prevention, coordinate care, and reach the whole population remains almost entirely disconnected from the machinery of evidence generation. Research networks, digital tools, and sustained funding, the authors argue, are the three levers that can close the gap between where Americans receive care and where knowledge is made. If the enterprise takes that prescription seriously, the waiting room may become one of the most productive research spaces in medicine.

Subject of Research: Integrating clinical research into primary care through practice-based research networks, digital health technology, and increased funding

Article Title: Rewiring the Research Enterprise: Why Primary Care Is the Next Frontier

Article References: Kane, R. M., Jackman, J. G., Henningfield, M. F., Hester, C. M., Cherrington, A. L., Sanchez, K., Tapp, H., Hornik, C. P., Hernandez, A. F., Dolor, R. J., & Rothman, R. L. (2026). Rewiring the Research Enterprise: Why Primary Care Is the Next Frontier. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10760-5

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10760-5

Keywords: primary care, clinical research, practice-based research networks, real-world evidence, clinical trials, PCORnet, digital health, workforce shortage, research funding, learning healthcare system, chronic disease, implementation science

Pragmatic clinical trials are designed to evaluate the effectiveness of interventions in real-world clinical settings, providing evidence that is directly applicable to routine healthcare practice. However, engaging older adults in these trials presents unique obstacles, including issues related to consent, cognitive decline, and physical frailty. The study leveraged a multi-methods approach, combining qualitative interviews, focus groups, and survey data to paint a comprehensive picture of how researchers engage with patient and public contributors throughout the research lifecycle.

One of the technical highlights of this study is the methodological rigor employed to capture the diversity of experiences among researchers. By adopting mixed qualitative and quantitative strategies, the authors were able to dissect not only the strategies used but also the underlying motivations and barriers faced when attempting to foster genuine partnership with older adults. This is crucial because pragmatic trials often demand flexible but robust protocols that can accommodate varying degrees of patient participation without compromising scientific integrity.

The study underscores the importance of tailoring communication strategies to meet the cognitive and sensory needs of older participants. Researchers reported adapting consent materials and engagement techniques to improve comprehension and retention of information. Such adaptations often require the integration of gerontological expertise into research teams, highlighting an interdisciplinary approach that extends beyond traditional biomedical paradigms. This intricate coordination exemplifies the technical sophistication required to execute PPI effectively in this context.

In addition to communication, logistical considerations form a significant technical challenge in involving older adults. Mobility limitations, transportation issues, and the necessity for home-based assessments were recurrent themes. These logistical constraints necessitate innovative trial designs that minimize participant burden while maximizing data validity. For instance, incorporating remote monitoring technologies and telehealth consultations can help bridge accessibility gaps, but require researchers to navigate data security, user-friendliness, and ethical considerations.

Moreover, the study reveals the ethical imperatives embedded in PPI with older populations. Issues such as autonomy, beneficence, and justice take on heightened significance when dealing with vulnerable groups. The researchers emphasized establishing trust and transparency to mitigate fears and misconceptions regarding trial participation. This ethical dimension adds a layer of complexity that must be thoughtfully managed to uphold the principles of patient-centered research.

A particularly compelling aspect of the research is the identification of both facilitators and impediments to effective PPI. Facilitators include the presence of dedicated PPI coordinators, institutional support, and training programs that equip researchers with skills to engage older adults sensitively and effectively. Conversely, barriers such as limited funding, time constraints, and a lack of standardized guidelines pose significant hurdles. These findings provide a roadmap for stakeholders aiming to enhance PPI frameworks in pragmatic trials.

Technological innovation also plays a transformative role in this domain. The deployment of digital platforms for patient engagement, data collection, and feedback loops represents a frontier in clinical research. Yet, the digital divide among older adults necessitates a dual approach: leveraging technology while maintaining traditional, accessible communication channels. The interplay between these modalities underscores the need for flexible, adaptive trial methodologies.

From a scientific perspective, involving patients and the public enriches the research process by embedding lived experience into study design, implementation, and dissemination. This alignment ensures that trial outcomes reflect real-world concerns and priorities, ultimately enhancing the relevance and uptake of research findings. The study by Spinewine et al. substantiates this assertion, demonstrating how PPI contributes to the robustness and applicability of pragmatic trials targeting geriatric populations.

The implications of this research extend beyond geriatrics, offering transferable insights for broader clinical research fields. The nuanced understanding of PPI dynamics can inform policy recommendations, training curricula for researchers, and infrastructure development to support inclusive research practices. Such systemic changes are essential to dismantle the historical exclusion of older adults from clinical research, promoting equity and innovation simultaneously.

In conclusion, the 2026 multi-methods study by Spinewine and colleagues presents a comprehensive examination of patient and public involvement in pragmatic trials with older adults. By unpacking the technical, ethical, and logistical facets of PPI, this research charts a path toward more inclusive, effective, and ethically sound clinical research paradigms. As the global population ages, the importance of such work cannot be overstated—ushering in a new era of clinical trials that truly resonate with the needs and voices of older adults.

The study heralds a paradigm shift in the clinical research community’s approach to PPI, demonstrating that meaningful engagement requires more than token gestures; it demands innovative methodologies, interdisciplinary collaboration, and a steadfast commitment to ethical principles. Future research will undoubtedly build upon these foundations, exploring novel strategies and technologies to further refine PPI in various clinical contexts.

Ultimately, this research underscores an essential truth: that patients and the public are not mere subjects of research but active partners whose involvement can elevate the scientific endeavor. For researchers, clinicians, and policymakers, embracing this philosophy will be key to advancing clinical science and improving health outcomes in an aging world.

Subject of Research: Patient and public involvement in pragmatic clinical trials with older adults

Article Title: Patient and public involvement in pragmatic trials with older adults: a multi-methods study of researchers’ experiences

Article References:
Spinewine, A., Evrard, P., Nevins, P. et al. Patient and public involvement in pragmatic trials with older adults: a multi-methods study of researchers’ experiences. BMC Geriatr (2026). https://doi.org/10.1186/s12877-026-07619-z

Image Credits: AI Generated