In This Issue: Powerful Ideas for Action

NURTURING SPACE FOR CIVIL DISCOURSE

A Perspectives editorial by Romano and Grumbach provides a balanced and powerful reflection on recent events in the United States that echo worldwide happenings. ¹ They ask us to consider what it means to be a healthy society, and they issue 4 calls to action for family physicians and all who recognize our essential interrelatedness.

I would add a fifth call to action.

Novelist, essayist, and poet Wendell Berry notes that health is (participation in) community.² In a time when what passes for public discourse are soundbites designed to elicit an immediate visceral reaction that forces us into one of 2 apparently warring camps, family physicians are uniquely positioned to nurture community. By seeing both the person and the community, by valuing both our differences and our underlying commonality, family physicians can foster healing by creating space for resistance without divisiveness, for finding common ground without giving up core principles, and for growing community, one relationship at a time.

PRIORITIZING: AN UNDERAPPRECIATED ASPECT OF PRIMARY CARE

Prioritizing is an essential feature of robust primary care.³ Scanning and focusing on the most important items⁴ among the 3⁵ or 5⁶ or 25⁷ interrelated medical, social, and environmental problems that people bring to primary care provides tremendous value to individuals, and makes more narrowly focused health care more effective when referral is needed.⁸ Prioritizing within the whole-person, relationship-centered primary care approach takes what otherwise might be crude rationing if done at the level of explicit or implicit policy,⁹ and turns it into care that focuses on what is most important for the particulars of the individual, ¹⁰ while taking into account the trade-offs for the family and community.¹¹ Prioritizing care based on knowing the person, family, and community protects people from overtreatment¹² and overcomes what otherwise can be a dangerous¹³ and lonely journey through fragmented health care.^14,15

Therefore, we are delighted that the National Commission on Prevention Priorities has chosen to publish the latest update to their work in Annals. The National Commission has developed a scientific method for what heretofore has been the art of medicine and policy—prioritizing among many good options. The latest update of their work expands this method with microsimulation modeling, and applies it to show the relative health impact and cost-effectiveness of preventive services for which the US Preventive Services Task Force found evidence of effectiveness.¹⁶ These findings can be used by individuals, practices, and policy makers to focus attention on the preventive services that are most likely to make a difference.

Two additional papers use sophisticated microsimulation analyses to identify which preventive options for cardiovascular disease are most effective for the general population and for subgroups,¹⁷ and to examine the separate and collective impact of brief clinician tobacco counseling for youth and for adults.¹⁸

Editorials by David Satcher,¹⁹ George Isham and colleagues,²⁰ and Patrick O’Connor and colleagues²¹ provide complementary and helpful perspectives in understanding this scientific evidence on prioritizing preventive services, and in applying it in policy and practice.

Also in this issue, a study by Saver and colleagues goes beyond the work of the National Commission on Prevention Priorities to address the difficult issue of assisting patients with making decisions about cancer screening that may seem beneficial, but actually have little known benefit. In a sophisticated randomized crossover study, they evaluate decision aids for controversial US Preventive Services Task Force recommendations surrounding prostate cancer screening for men and mammography testing for women aged 40 to 49 years.²² They find that the decision aid reduces intention to engage in screening tests with poor evidence of efficacy.

A CALL TO ACTION FOR PUBLIC SCHOOL TEACHERS AND PRIMARY CARE CLINICIANS

A Special Report by Saultz and Saultz, featured in Annals Journal Club,²³ highlights common ground between primary care clinicians and school teachers. Both fields are facing similar oppression from a top-down “measure and incentivize” culture that risks stomping out their personalizing work in caring for schoolchildren and patients. The authors identify alarming unintended consequences of performance management in both education and health care. These consequences of narrowing of purpose, de-professionalization, and loss of local/community control, are most likely to affect the most vulnerable.²⁴

The article should shock policy makers into reexamining a measurement paradigm that increasingly is oppressing teachers and primary care clinicians, and for many children and patients, results in less effective education and health care. The Saultz paper is a call to action for the education and health care professions to rise up together for support rather than incentives. The paper emphasizes valuing personal, local knowledge, rather than disempowering it with impersonal measures, and calls for deeper understanding and support of the personalizing, integrating, prioritizing functions that frontlines teachers and primary care clinicians do every day while swimming against a stream of measurement burden that is often irrelevant and sometimes harmful.

PRIMARY CARE INFLUENCES

In the face of evidence that excessive interventions in the last 6 months of life are associated with suffering and unnecessary, unhelpful costs, Bazemore et al use national Medicare claims data to examine primary care physician involvement in the last 6 months of patients’ lives. They find that greater primary care physician involvement is associated with less intensive end of life care, including lower expenditure, less intensive care unit days, and less hospice enrollment.²⁵

At the other end of the age spectrum, an essay by Ungar uses recent neuroscience findings to link the “joyful bond that unites mother and infant” with early brain development and the opportunities presented by even brief health care interactions during well-infant and post-partum visits.²⁶

Volkmann courageously shares her “experience as a survivor of sexual violence and as a provider for patients whose wounds from these traumas have flourished in atmospheres of shame and stigma.”²⁷ Her deeply personal insights show how clinicians can help facilitate healing.

The preferences of mothers for vitamin D supplementation of their breastfed infants is ascertained by Thacher et al.²⁸ Most preferred to supplement themselves rather than their infants.

Trends in health information technology among small primary care practices are examined by Rittenhouse and colleagues.²⁹ They find increases over time in 16 out of 18 measures of health information technology functionality, particularly among hospital-owned practices, practices with 3 to 8 vs 1 to 2 physicians, practices with more Medicare patients, and those participating in pay-for-performance or public reporting of quality data.

We welcome your reflections at http://www.AnnFamMed.org.