In This Issue: Raise the Gaze
=============================

* Kurt C. Stange

Articles in this issue subtly beseech us to move from ogling the ordinary to perceiving the possibilities at other levels of focus. They entreat us to raise our gaze from:

*   the medical to the social determinants of health1

*   the policies and particulars of case management programs, to their effects on people and populations2,3

*   caring for disadvantaged, disenfranchised individuals, to helping people participate in the political process4

*   designing portals to enable patients to access personal health records, to assessing how this technology can be implemented in small and medium sized practices5

*   referring to advising6

*   rigor to relevance in research7,8

*   bemoaning reductions in the contribution of family physicians to the child health workforce, to knowing some of the factors that underlie recent changes9

*   lamenting that so many people die in the hospital, to understanding how family physicians can deftly take on different roles to help terminally ill patients spend their last days in familiar surroundings10

*   depersonalized, inflexible, unsustainably expensive care in one health care system, to patient-centered, transparent, and affordable care in another system11

*   literal to meaningful translation and communication12

*   the personal turmoil of being the target of legal action, to the transcendent effects of helping another person13

Ian McWhinney observed that a uniquely important (and often unsupported and undervalued) facet of family medicine is “an acquaintance with the particulars.”14 The articles in this issue incite the notion that personal knowledge is vital to the effectiveness of primary care.15 They also remind us that a unique and essential element of the generalist approach involves iteration16—between the particulars of the person in front of us, the social environment that shapes their possibilities for health, and the systems that influence their health care. At whatever level we work in health care, the ability to periodically raise and lower the gaze increases the possibilities for doing good, and provides the opportunity to minimize unintended consequences.17,18 This iterative raising and lowering the level of focus is the essence of the generalist approach.16 It is the subtle need and the abundant opportunity to improve the station of vulnerable people, communities, and systems.

## Forthcoming

A movement is trying to happen in the United States to cultivate a commons for integrated, personalized, and sustainable health care that releases resources upstream toward the social and environmental determinants of health. Some of these uprisings cancel each other out, as opposing individual interests undermine change. But others are uniting to trigger tides of transformation toward health care that is integrated, personalized, and relationship-centered.

Into this foment, 8 family medicine organizations based in the United States have come together to inaugurate Family Medicine for America’s Health “to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care and lower cost for patients and communities (the Triple Aim).”19 This new collaboration builds on the decade-old work of 7 family medicine organizations in the Future of Family Medicine project, which instigated a series of efforts to “renew the specialty to meet the needs of people and society.”20

This new plan is a small ripple, a starting point for iterative interactions in the big pond of US health care and other societal movements that demand a healthy populace. But the family medicine organizations are “all in,” and are committing a substantial portion of their resources to continuing to evolve a plan to improve family physicians’ ability to contribute to the emerging movement. There will be dampening forces. But also the possibility that the ripples of these organizations’ collective efforts will resonate with enough other forces and efforts to create a sea change towards a more rational, sustainable, and effective system.

An article describing the initial steps of Family Medicine for America’s Health will be published online as an *Annals* supplement on October 23, 2014.

We welcome your reflections at [http://www.AnnFamMed.org](http://www.AnnFamMed.org).

*   © 2014 Annals of Family Medicine, Inc.

## References

1.  Trachtenberg AJ, Dik N, Chateau D, Katz A. Inequities in ambulatory care and the relationship between socioeconomic status and respiratory hospitalizations: a population-based study of a Canadian city. Ann Fam Med. 2014;12(5):402–407.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80MDIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Phillips RL, Han M, Petterson SM, Makaroff L, Liaw WR. Cost, utilization, and quality of care: an evaluation of Illinois’ Medicaid primary care case management program. Ann Fam Med. 2014;12(5):408–417.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80MDgiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  Khanassov V, Vedel I, Pluye P. Barriers to implementation of case management for patients with dementia: a systematic mixed studies review. Ann Fam Med. 2014;12(5):456–465.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80NTYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Liggett A, Sharma M, Nakamura Y, Villar R, Selwyn P. Results of a voter registration project at 2 family medicine residency clinics in the Bronx, New York. Ann Fam Med. 2014;12(5):466–469.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80NjYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  Krist AH, Woolf SH, Bello GA, et al. Engaging primary care patients to use a patient-centered personal health record. Ann Fam Med. 2014;12:418–426.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80MTgiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  van der Zwaard BC, van der Horst HE, Knol DL, Vanwanseele B, Elders PJM. Treatment of forefoot problems in older people: a randomized clinical trial comparing podiatric treatment with standardized shoe advice. Ann Fam Med. 2014;12(5):432–440.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80MzIiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

7.  Peek CJ, Glasgow RE, Stange KC, Klesges LM, Purcell EP, Kessler RS. The 5 R’s: an emerging bold standard for conducting relevant research in a changing world. Ann Fam Med. 2014;12(5):447–455.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80NDciO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

8.  Ewigman B. Could 5R research help achieve the Triple Aim? Ann Fam Med. 2014;12(5):399–401.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS8zOTkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

9.  Makaroff L, Xierali IM, Petterson SM, Shipman SA, Puffer JC, Bazemore AW. Factors influencing family physicians’ contribution to the child health care workforce. Ann Fam Med. 2014;12(5):427–431.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80MjciO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

10. Reyniers T, Houttekier D, Pasman HR, Vander Stichele R, Cohen J, Deliens L. The family physician’s perceived role in preventing and guiding hospital admissions at the end of life: a focus group study. Ann Fam Med. 2014;12(5):441–446.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80NDEiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

11. Rao SR. A tale of 2 countries: the cost of my mother’s cardiac care in the United States and India. Ann Fam Med. 2014;12(5):470–472.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80NzAiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

12. Brown BP. Interpreting medicine: lessons from a spanish-language clinic. Ann Fam Med. 2014;12(5):473–474.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80NzMiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

13. Kannai R. It finally happened to me. Ann Fam Med. 2014;12(5):475–477.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTIvNS80NzUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEyLzUvMzk4LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

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16. Stange KC. The generalist approach. Ann Fam Med. 2009;7(3):198–203.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy8zLzE5OCI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMTIvNS8zOTguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

17. Stange KC. Refocusing knowledge generation, application and education: raising our gaze to promote health across boundaries. Am J Prev Med. 2011;41(4)(Suppl 3):S164–S169.
    
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18. Aungst H, Ruhe M, Stange KS; PHAB Staff and Writing Committee. Boundary spanning and health: invitation to a learning community. Lond J Prim Care. 2012;4(2):109–115.
    
    

19. Phillips RL, Pugno PA, Saultz JW, et al; Family Medicine for America’s Health Writing Group. Health is primary: family medicine for America’s health. Ann Fam Med. In press.
    
    

20. Martin JC, Avant RF, Bowman MA, et al. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2(Suppl 1):S3–S32.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6MTI6IjIvc3VwcGxfMS9zMyI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMTIvNS8zOTguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9)