Tension Between Access and Continuity
=====================================

* Kurt C. Stange

The online discussion since the last issue reveals a tension between efforts designed in part to improve the ease of access to care and fostering continuity in the relationship aspect of care. This tension, as well as the need to understand when and to whom a continuous relationship is important, is apparent in the discussion of both the experience of the highly successful Group Health of Puget Sound patient-centered medical home project,1 which reassigned patients to allow primary care clinicians to reduce panel size, and in discussion of a study of patient experience of primary care during recent health service reforms in England.2

Other discussion brings an emerging experimental literature on the effects of alcohol on sleep quality3–5 to the interpretation of an observational study of alcohol and sleep problems.6

Interchange around a study of a Web-based monitoring system for medical errors reflects the still relatively nascent state of efforts to monitor and improve patient safety in primary care.7

Discussion of a systematic review of guidelines for the primary care of lesbian, gay, and bisexual people exposes the need for both research to develop systematic evidence about what is helpful on average, and the development and application of individualized knowing.8

The essays in the last issue were particularly evocative.

Readers put their foot down about “Dr. Bodenheimer’s Dilemma,”9,10 the “special vulnerability of physicians,”11 and the challenges of living with and caring for chronic illness.10–13

The “two-way street”14 of a mentoring relationship15 stimulated readers to reflect on the value of “teaching using the whole self,”16 “peer mentoring,”17 and “the One Minute Preceptor.”16,18

Robert McKersie’s lived experience of providing health care in Haiti after a 7.0 magnitude earthquake evoked diverse but uniformly grateful responses19 to “the feeling of being inside the life lived.”20

Please join the ongoing discussion of articles in this and prior issues at [http://www.AnnFamMed.org](http://www.AnnFamMed.org). Both in-depth analysis and brief reactions are welcome.

*   © 2011 Annals of Family Medicine, Inc.

## REFERENCES

1.  TRACK discussion in response to: Coleman K, Reid RJ, Johnson E, et al. Implications of reassigning patients for the medical home: a case study. Ann Fam Med. 2010;8(6):493–498. [http://www.annfammed.org/cgi/eletters/8/6/493](http://www.annfammed.org/cgi/eletters/8/6/493).
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiOC82LzQ5MyI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vOS8xLzg1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  TRACK discussion in response to: Campbell SM, Kontopantelis E, Reeves D, et al. Changes in patient experiences of primary care during health service reforms in England between 2003 and 2007. Ann Fam Med. 2010;8(6):499–606. [http://www.annfammed.org/cgi/eletters/8/6/499](http://www.annfammed.org/cgi/eletters/8/6/499).
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiOC82LzQ5OSI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vOS8xLzg1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  Muench JP. Alcohol and insomnia—more definition needed [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/484#17049](http://www.annfammed.org/cgi/eletters/8/6/484#17049), 23 Nov 2010.
    
    

4.  Peppard PE. Alcohol use near bedtime [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/484#17061](http://www.annfammed.org/cgi/eletters/8/6/484#17061), 25 Nov 2010.
    
    

5.  Zgierska AE, et al. The effects of alcohol on sleep [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/484#17067](http://www.annfammed.org/cgi/eletters/8/6/484#17067), 25 Nov 2010.
    
    

6.  Vinson DC. Responses to letters to the *Annals of Family Medicine* re alcohol and sleep paper [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/484#18402](http://www.annfammed.org/cgi/eletters/8/6/484#18402), 9 Dec 2010.
    
    

7.  TRACK discussion in response to: Hickner J, Zafar A, Kuo GM, et al. Field test results of a new ambulatory care medication error and adverse drug event reporting system—MEADERS. Ann Fam Med. 2010;8(6):517–525. [http://www.annfammed.org/cgi/eletters/8/6/517](http://www.annfammed.org/cgi/eletters/8/6/517).
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiOC82LzUxNyI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vOS8xLzg1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

8.  TRACK discussion in response to: McNair RP, Hegarty K. Guidelines for the primary care of lesbian, gay, and bisexual people: a systematic review. Ann Fam Med. 2010;8(6):533–541. [http://www.annfammed.org/cgi/eletters/8/6/533](http://www.annfammed.org/cgi/eletters/8/6/533).
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiOC82LzUzMyI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vOS8xLzg1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

9.  Bodenheimer T. Lessons from my left foot. Ann Fam Med. 2010; 8(6):550–551.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiOC82LzU1MCI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vOS8xLzg1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

10. Frank AW. Dr. Bodenheimer’s dilemma [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/550#16627](http://www.annfammed.org/cgi/eletters/8/6/550#16627), 18 Nov 2010.
    
    

11. Herbert CP. The special vulerability of physicians [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/550#15708](http://www.annfammed.org/cgi/eletters/8/6/550#15708), 10 Nov 2010.
    
    

12. Kozakowski SM. Thank you for opening my eyes [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/550#15694](http://www.annfammed.org/cgi/eletters/8/6/550#15694), 9 Nov 2010.
    
    

13. Krell DI. Thank you, Dr. Bodenheimer [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/550#15643](http://www.annfammed.org/cgi/eletters/8/6/550#15643), 9 Nov 2010.
    
    

14. Seehusen DA. The two-way street [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/552#16892](http://www.annfammed.org/cgi/eletters/8/6/552#16892), 22 Nov 2010.
    
    

15. Jones K, Reis S. Learning through vulnerability: a mentor-mentee experience. Ann Fam Med. 2010;8(6):552–555.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiOC82LzU1MiI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vOS8xLzg1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

16. Jones K. Re: Teaching using the whole self [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/552#18400](http://www.annfammed.org/cgi/eletters/8/6/552#18400), 9 Dec 2010.
    
    

17. Launer J. Peer mentoring [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/552#18386](http://www.annfammed.org/cgi/eletters/8/6/552#18386), 6 Dec 2010.
    
    

18. Neher JO. Teaching using the whole self [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/552#15755](http://www.annfammed.org/cgi/eletters/8/6/552#15755), 10 Nov 2010.
    
    

19. TRACK discussion in response to: McKersie RC. Snapshots of Haiti: a physician’s relief work in a country in crisis. Ann Fam Med. 2010;8(6):556–558. [http://www.annfammed.org/cgi/eletters/8/6/556](http://www.annfammed.org/cgi/eletters/8/6/556).
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiOC82LzU1NiI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vOS8xLzg1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

20. Eckenfeis E. The feeling of being inside the life lived [eletter]. [http://www.annfammed.org/cgi/eletters/8/6/556#16071](http://www.annfammed.org/cgi/eletters/8/6/556#16071), 15 Nov 2010.