Comorbidity: Implications for the Importance of Primary Care in ‘Case’ Management

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

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