‘The Expert … Is the Patient in Front of Us’
==================================================

* William R. Phillips

The *Annals of Family Medicine* seeks to serve its community by publishing work that is original and useful, and by fostering conversation that is critical and creative. The conversation takes place on the Internet at [www.annfammed.org](http://www.annfammed.org). It involves readers like you. The July/August 2003 issue of the *Annals* (Vol. 1, No. 2), published papers that stimulated several interconnected TRACKs of conversation.

The study by Grumbach, Hart, and colleagues1 documented that family physicians are more likely than other primary care physicians to provide care to underserved communities, and that physician’s assistants and advance practice nurses are playing important roles. Recognizing the compelling policy implications of these findings, Rosenblatt2 calls for implementation of personpower strategies as “relatively inexpensive ways to affect access to health care . . . , particularly given the failure of attempts to craft universal health insurance.” Rabinowitz3 agrees that “there is more than enough ‘evidence’ about what to do in order to better address this problem” of disparities in access to health care. He specifies “programs that provide preferential admissions . . . , clinical experiences, and financial and practice support.” Rabinowitz calls for cooperative strategies: “Those who are underserved need all the help they can get – from all types of primary care providers! And primary care providers will have more clout if they address these issues cooperatively.”

Making innovative use of the ecology of medical care model pioneered by Kerr White more than 40 years ago,4 Fryer and team5 showed that lack of primary care is associated with lower use of most medical services except emergency care, and that uninsured patients are more adversely affected. The editorial in the same issue by Dr. White,6 himself, reminds us that our studies are limited by the data we collect and our views of health and care are constrained by the systems we use for classification of problems and services. He calls for use of the primary care-oriented classification systems, such as ICPC (International Classification of Primary Care7), that have proved their utility around the world in investigating the natural history of illness and the process of care. Immediate opportunities exist to coordinate and improve the major US government-funded studies, such as the Medical Expenditures Panel Survey (MEPS), used by Fryer et al.

An array of online discussants from Amsterdam, Rome, and Helsinki point out the failings of current US coding systems and the greater utility of systems in use elsewhere. Okkes8 warns that MEPS data “substantially underrepresented” important chronic diseases in primary care that have been captured in other countries. She calls for adoption of systems to provide primary care researchers “the data they would deserve to have: episode oriented data routinely collected by US family doctors who are equipped with an electronic health record that is based on patients’ problems over time rather than on utilization.” Lamberts9 emphasizes that current US coding systems make it “close to impossible to effectively take the patient’s problem as the starting point, and to develop an episode of illness and an episode of care model.” He decries the recent choice of “Snomed-CT as the standard vocabulary for the US, because it can greatly harm the family practice perspective in health information systems that will be introduced on a large scale in the near future.” The development of electronic health record systems in the United States promises an “avalanche” of data, but Lamberts fears that, unless ICPC and other standard international coding systems are adopted right now, “the curtain will fall for family practice research with routine EHR data.” Kalimo and Purola10 remind us that “health care actually is a social phenomenon” and join the call for adoption in the United States of information systems based on “the care of the health of individuals and the associated health policy arrangements—and not only to the diagnosis and cure of a disease.”

Disparities in health are associated with disparities in education, and the study by Fiscella and colleagues11 showed that such differences in preventive care are buffered by HMO participation. Weiss12 notes that health literacy might be more critical than educational attainment. Green13 points to the growing body of evidence that planned systems of care14 have many benefits. “These integrated systems are an integral part of ‘reaching’ and ‘delivering’ important care services and it remains a strategic challenge as to how to integrate these services in less organized care systems.”

Becker’s qualitative study15 of cultural expressions of bodily awareness among chronically ill Filipino Americans elicited comments on method and content. “Tantalized” by the approach and findings, Culhane-Pera16 asks for further help from medical anthropologists: “How do I apply this information to the clinical setting? What format works best, and what doesn’t work? And does culturally responsive care make a difference in health outcomes?” She asks “anthropologists to be co-researchers on the team with primary care providers and community members, engaged in community-based participatory action research.” Shore17 adds insights from more than 25 years of clinical experience with similar patients and suggests, “A next-step study could be an investigation of effective strategies to increase dietary adherence for chronic illnesses.” Saba18 urges, “striking a balance between diversity and commonality. . . . Clinically, we should be careful not to assume that all people hold the same value, but inquire about how they respond to a value that is common in their culture . . . . The expert on what is culturally important in clinical care is the patient in front of us.”

Conversations continue on topics raised by articles in the first issue of the *Annals*. Similarities between the low cesarean rates reported by Leeman and Leeman21 in a Native American community in the southwest United States, and those found by North22 years ago prompt Dr. North to suggest the importance of stable factors, such as cultural attitudes, organization of care, and genetics. Other discussants report achieving low cesarean rates with childbirth services organized around primary care. Authors Leeman and Leeman23 respond in depth to the many TRACK comments their study generated and express “concern for the loss of rural VBAC (vaginal birth after Cesarean) access.”

Responding to comments on her study of barriers to self-care by persons with comorbid chronic diseases,24 Bayliss25 discusses how depression complicates both clinical care and research with patients with multiple problems. “(S)ocial factors affect not only barriers to the self-management of disease, but to the self-management of health as well. We would do well to remind ourselves of the well-worn (but very relevant) term ‘biopsychosocial’ assessment as we care for persons with multiple illnesses.”

The compelling essay and paintings, “The Face of Cancer” by patient Crommet and physician Scott26 evoked praise, passion, and personal stories. Schueler27 gives testimony from experience as a professional patient advocate. “Top Gun” consultants have their place, he says, “But when it comes to the long haul, my patients prefer a relationship with a physician who is knowledgeable yet able to hold their hand at the edge of the abyss, to respect their humanity and wholeness apart from their disease, to rework the map when the terrain changes, and to cry and laugh as part of the compassion and renewal which is embodied in that special relationship between a physician and a patient.” Maryman,28 herself a breast cancer survivor and a family physician, agrees with patient Patrick Crommet that the experience of cancer can be “a gift.” She applauds Dr. Scott “for his sensitivity and words of comfort. I guess that’s why we’re family physicians!”

*   © 2003 Annals of Family Medicine, Inc.

## REFERENCES

1.  Grumbach K, Hart GL, Mertz E, Coffman J, Palazzo L. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med 2003;1:97–104.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8yLzk3IjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Rosenblatt RA. Caring for the under-served: who, when and where? [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/97#54](http://www.annfammed.org/cgi/eletters/1/2/97#54), 29 July 2003.
    
    

3.  Rabinowitz HK. The underserved need all the help they can get! [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/97#57](http://www.annfammed.org/cgi/eletters/1/2/97#57), 30 July 2003.
    
    

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5.  Fryer GE, Green LA, Dovey SM, Yawn BP, Philips RL, Lanier D. Variations in the ecology of medical care. Ann Fam Med 2003;1:81–89.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8yLzgxIjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  White KL. Two cheers for ecology. Ann Fam Med 2003;1:67–69.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8yLzY3IjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

7.  Lamberts H, Wood M. *ICPC International classification of primary care. with a historical preface by K.L.White*. Oxford, England: Oxford University Press; 1987.
    
    

8.  Okkes IM. Three cheers for real family practice data [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/81/#59](http://www.annfammed.org/cgi/eletters/1/2/81/#59), 31 July 2003.
    
    

9.  Lamberts H. Cheers for Kerr White, tears for US family practice [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/67/#58](http://www.annfammed.org/cgi/eletters/1/2/67/#58), 31 July 2003.
    
    

10. Kalimo EA, Purola T. A fourth cheer for ecology [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/67/#68](http://www.annfammed.org/cgi/eletters/1/2/67/#68), 15 August 2003.
    
    

11. Fiscella K, Franks P, Doescher MP, Saver BG. Do HMOs affect educational disparities in health care? Ann Fam Med 2003;1:90–96.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8yLzkwIjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

12. Weiss BD. Disparities of care related to limited health literacy [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/90/#55](http://www.annfammed.org/cgi/eletters/1/2/90/#55), 30 July 2003.
    
    

13. Green BB. Good news for HMO’s and the delivery of preventive services [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/90#63](http://www.annfammed.org/cgi/eletters/1/2/90#63), 4 August 2003.
    
    

14. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511–544.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=8941260&link_type=MED&atom=%2Fannalsfm%2F1%2F3%2F177.atom) 
    
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15. Becker G. Cultural expressions of bodily awareness among chronically ill Filipino Americans. Ann Fam Med 2003;1:113–118.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMS8yLzExMyI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMS8zLzE3Ny5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

16. Culhane-Pera KA. Wanted: application of medical anthropology [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/113/#56](http://www.annfammed.org/cgi/eletters/1/2/113/#56), 30 July 2003.
    
    

17. Shore WB. Observations from practice with Filipino patients [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/113#62](http://www.annfammed.org/cgi/eletters/1/2/113#62), 4 August 2003.
    
    

18. Saba GW. Potential pitfalls in the care of Filipino-American patients [eletter]. [http://www.annfammed.org/cgi/eletters/1/2/113/#64](http://www.annfammed.org/cgi/eletters/1/2/113/#64), 5 August 2003.
    
    

19. U.S. Preventive Services Task Force. Behavioral interventions to promote breastfeeding: recommendations and rationale. Ann Fam Med 2003;1:79–80.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8yLzc5IjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

20. Guise J-M, Palda V, Westhoff C, Chan BKS, Helfand M, Lieu TA. The effectiveness of primary care-based interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US Preventive Services Task Force. Ann Fam Med 2003;1:70–78.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8yLzcwIjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

21. Leeman L, Leeman R. A Native American community with a 7% cesarean delivery rate: does case mix, ethnicity, or labor management explain the low rate? Ann Fam Med 2003;1:36–43.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8xLzM2IjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

22. North CQ. Low cesarean rate in another Native American community [eletter]. [http://www.annfammed.org/cgi/eletters/1/1/36/#51](http://www.annfammed.org/cgi/eletters/1/1/36/#51), 10 July 2003.
    
    

23. Leeman LM, Leeman R. Authors’ response on Native American community Cesarean rate [eletter]. [http://www.annfammed.org/cgi/eletters/1/1/36/#53](http://www.annfammed.org/cgi/eletters/1/1/36/#53), 25 July 2003.
    
    

24. Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med 2003;1:15–21.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8xLzE1IjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

25. Bayliss EA. Author’s response [eletter]. [http://www.annfammed.org/cgi/eletters/1/1/15/#52](http://www.annfammed.org/cgi/eletters/1/1/15/#52), 11 July 2003.
    
    

26. Scott JG, Crommet P. The face of cancer. Ann Fam Med 2003;1: 52–54.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMS8xLzUyIjtzOjQ6ImF0b20iO3M6MjI6Ii9hbm5hbHNmbS8xLzMvMTc3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

27. Schueler HK. The face of cancer [eletter]. [http://www.annfammed.org/cgi/eletters/1/1/52/#50](http://www.annfammed.org/cgi/eletters/1/1/52/#50), 6 July 2003.
    
    

28. Maryman SD. The face of cancer revisited [eletter]. [http://www.annfammed.org/cgi/eletters/1/1/52/#44](http://www.annfammed.org/cgi/eletters/1/1/52/#44), 30 June 2003.