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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
the power of quotes to distance
Comorbidities have always been the reason for Primary Care
Unclear Implications
Moving "case" management to "care" management
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Harold A. Maio, Ft Myers, FL USA Consulting Editor, Psychiatric Rehabilitation Journral
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Editors: re:Comorbidity: Implications for the Importance of Primary Care in ‘Case’ Management Barbara Starfield, MD, MPH, FRCGP1, Klaus W. Lemke, PhD1, Terence Bernhardt, BA2, Steven S. Foldes, PhD2, Christopher B. Forrest, MD, PhD1 and Jonathan P. Weiner, DrPH1 I am very pleased by the quotation marks around the term "case". I would be even more pleased to circumlocute the term entirely. The label all too often falls off the file and onto the individual. Because of its historical position, it may be difficult to communicate in a brief title the serivce discussed, managing resources to help an individual with a specific problem, but it is the resources that are being managed not the "case", as your wonderfully distancing quotes shows. Thank you, Harold A. Maio Consulting Editor Psychiatric Rehabilitation Journal Boston University. Competing interests: None declared |
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Lawrence I. Silverberg, Family Physician Philadelphia College of Osteopathic Medicine
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Barbara Starfield's manuscript on "Comorbidity: Implications for the Importance of Primary Care in ‘Case’ Management", serves to cement her philosophy developed in her book "Primary Care-Concept, Evaluation, and Policy-Oxford University Press, Inc. 1992. Confirming the need for physicians trained to take care of complex patients is an interesting way to define the demands of family practice. Although from Johns Hopkins, an institution that has no experience with family practice, Dr. Starfield, in my opinion, has developed a clairvoyant understanding of the needs for paradigm change in family practice. Family practice although defined as a specialty is truly a process oriented skill (Lynn Carmichael). Experience in family practice confirms this. For family medicine ear wax removal is a comorbidity as is a patient's dysfunctional illness narrative. Although technology brings in- depth information into the office of the general practitioner the practice of family medicine is still a hands-on talent. In many ways, in order to be a successful family physician, how you deal with people is more important than what you deal them (medical skills). Dr. Starfield's article provides Re-affirmation of the mission and vision of Family Medicine. One of the answers for how to train such a super Dr. can be found in Dr. Lynn Carmichael’s concept of "a Primary Care Campus", he discussed at the Keystone meeting. I have personally enjoyed all the articles and issues raised by this first edition of the Annals of Family Medicine. Wishing you good luck in this endeavor. Lawrence Silverberg, DO Competing interests: None declared |
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Richard A Guthmann, Family Physician UIC/ Illinois Masonic Family Practice Residency
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The first issue of Annals of Family Medicine addressed an important topic for our specialty. "Chronic Illness, Comorbidities, and the need for Medical Generalism" (title of the lead editorial by Kevin Grumbach) describes a challenge that faces family medicine and the entire health care system. As the life expectancy has lengthened, the prevalence of chronic disease and comorbidity has risen. Starfield et. al provide further evidence of this reality, however their data does not provide evidence to support an increased role for family medicine(or primary care). Their data simply state that primary care is providing the bulk of health care. However, the current system is not fulfilling the potential of modern medicine. By most accounts, the system is broken and fraught with errors. Summerskill and Pope in an article in Family Practice(1) suggested that the many burdens placed on primary care physicians may hamper their ability to practice evidence based medicine. From this perspective, increasing comorbidity may be an argument for more 'case managers', but not necessarily more primary care physicians. The central question remains: What system or modification to the current system will work? And what role would primary care have in that system? Starfield et. al. address this point in their discussion. They state, "With regard to quality of care, the findings do not bear on which type of physician (generalist or specialist) provides the highest quality of care...". However, I wonder if their data might not be able to answer this question if stated differently, 'Do patients who utilize more primary care versus specialist within the same adjusted clinical group(ACG) expand less total health care expenses?' That is to say, does a patient with hypertension who only sees a primary care physician generate less expense to the system than a patient who sees a primary care physician and a cardiologist? (1)Summerskill WS, Pope C. 'I saw the panic rise in her eyes, and evidence-based medicine went out of the door.' An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease. Fam Pract. 2002 Dec;19(6):605-10. Competing interests: None declared |
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Phil Lawson, MD Ammonoosuc Community Health Services
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I particularly appreciated the first issues of "The Annals" and its focus on a key struggle in family medicine, caring for patients with multiple chronic conditions. As Grumbach notes, we are being increasingly pushed to fulfill often conflicting, specialist based disease management guidelines. I agree that the application of "The Chronic Care Model" is a means to developing a structured process to guide family practicioners in day to day care of complicated patients with multiple conditions. At our institution and in conjunction with other generalists who use the same electronic medical record (EMR), we have been struggling to develop templates to guide evidence based care on our EMR. The struggle is between templates that: a) focus on single conditions, are self contained and fulfill guidelines on which the quality of our care is being judged (and for some reimbursed); or b) templates that can be used across conditions and are patient centered, not disease centered. The former is relatively easy to achieve; the latter much more challenging. To try to address this, we are continually revising a form that we call "Self Care Management". It supports providers to work with patients to set achievable goals of care that are patient focused. For instance, the goals are defined based on: diet; exercise; tobacco, alcohol and substance use; pleasurable activities; and 'other' (a section that could include disease specific targets such as A1C, emergency room visits, peak flow...) Providers are urged to address barriers, support systems and readiness to change as they work with patients to set goals. The form is shared and available to any caregiver (MD, PA, ARNP, nurse, care manager, social worker.....) to build on as time progresses. A customized letter can be printed to give to the patient, much like a prescription that states the goals they have set. The form is attached to any patient visit to be reviewed if appropriate. We developed this process while working on the Chronic Care Model with an Institute for Health Care Improvement Collaberative. It has been challenging to implement because it moves providers from advising or telling patients what to do, to listening to patients as they struggle to set goals that are achievable and realistic in their personal context. The process takes time initially, but can have profound long term benefit. It can help us move to thinking of the 'whole' person, not the 'hole' in the person; to target behaviors that cross over between many conditions; and to work collectively with our patients in a more patient centered approach. It helps us to move from "case" management to "care" management. Competing interests: None declared |
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