EXPANDED PRIMARY CARE CAN FILL CRITICAL HOLES IN HEALTH CARE
The study of outpatient treatment of opioid addiction in the last issue of Annals1 stimulated a dialogue between the lead author2–4 and an international group of clinicians sharing their experience with buprenorphine-naloxone and relevant literature, pharmacology, and politics.5–8 Together, these comments point the way toward expanded use, training, and research on this important intervention in primary care.
The study of a primary care response to Hurricane Katrina9 kindled sharing of a parallel response from those caring for evacuees in the Houston Astrodome.10 Commentary from public health and emergency care experts11–13 draws the larger lessons about the holes in the emergency response system and the vital role of primary care in meeting emergency needs. “This pragmatic study needs to be read by every community-based department of health and disaster planner.”13
Coyne14 challenges an inference by Gaynes et al that depressed patients should be treated as aggressively in primary care as in psychiatric care.15 He calls for reinterpretation of “potentially misleading implications,” as well as further research on representative patient samples using semistructured interviews for diagnosis of depression.
Keller’s discussion16 of the Wadland study17 linking primary care practice with quit lines provides evidence and expert interpretation of this promising and challenging strategy for expanding tobacco control.
The risk adjustment models used by James and colleagues18 generated gratitude for their utility in preventing those providing care by rural hospitals from being unjustifiably maligned19,20 and detailed discussion of the challenges of adjusting for confounding.21,22
DTC PHARMACEUTICAL MARKETING
The discussion of direct to consumer (DTC) marketing started by the study by Frosch and colleagues23 continued to percolate, further stimulated by an editorial24 and a news item from one of the Annals’ sponsoring organizations in the last issue.25 Among several discussants,26,27 Krueger notes the conflict of interest of a wide variety of media outlets that have become dependent on DTC pharmaceutical ads, yet are responsible for reporting adverse effects of drugs as part of their news reporting. Frey suggests that DTC advertising bans could be a potent portion of presidential candidates’ health care plans.28 Shropshire calls for redirecting American Academy of Family Physicians (AAFP) leadership away from support for the pharmaceutical industry toward “our patients’ ultimate well-being.…”29 Rather than banning DTC ads,30 Hallgren suggests that “our lobbying bodies (AAFP, American Medical Association) should be campaigning against it and providing the outlets of unbiased information.”31
OTHER THREADS OF DISCUSSION
Diverse discussants of research capacity building32–35 bring out multiple opportunities for stimulating primary care research, while challenging us to examine the impact of that research.36
The discussion of the study by Krist et al37 advances our understanding of the appropriate outcomes for use of patient decision aids.38,39
The study of standardized patients40 raises important questions41 and experiential validation and interpretation of this method42–44 of growing importance for health care research.
The challenge and need for expanding clinical performance measurement45 is well articulated in discussion by Milstein,46 de Brantes,47 and Bennett.48 These calls for increased rigor in performance assessment are echoed somewhat differently in reaction to the essay on jazz as a metaphor for the art of improvisation in the medical encounter.49 This essay stimulated analysis and experience-based reflection,50,51 and a call for increased training in the “seventh competency” of reflective practice.52
Please join the exchange of ideas at http://www.AnnFamMed.org.
- © 2007 Annals of Family Medicine, Inc.
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