The Problem of Fragmentation and the Need for Integrative Solutions

Kurt, this is a very important series. Congratulations! The basic problem is that so many GPs have ceased to honour the first principle of general practice (Family Medicine). The principle is that whatever problem our patients bring to us, we will never say: “I don’t do this.” If I think you need a specialist, I will find an appropriate specialist for you, but whatever he or she does for you, I still will be your doctor.

As it happens, nearly all the problems I see in my practice are dealt with myself.

My commitment to you is not just to look after one particular illness, but to care for you as a person, whatever problem you may have. As a patient said to me once: “I want a doctor who specializes in me.”

For our relationship to work well I ask you to call on me or one of my colleagues for all your needs. If you feel that a specialist is required I will be pleased to advise you as to the best one. The most important level is the generalist (or family medicine) which are concerned with relationships. We don’t have specialties (except as a side interest). A functioning generalist level make things much easier for the specialist level.

If we fail to honour the first principle, we will break up into one hundred pieces and general practice will die.

Could it be that we are not teaching the first principle?

Competing interests:   None declared

Fragmentation of healthcare has been branded in the Editorial [1]. At about the same time of its publication, the Dutch Inspectorate of health care aired its concerns of the fragmentation of cancer care in The Netherlands: even within the care of a single patient, oncologists, surgeons and radiotherapists are often working from their own agenda – an observation stressing the essential point of the editorial.

Fragmentation stands in the way of capitalizing from the important progress that has been made in medical science. What is haunting health care, is the ill considered copying of the model of focus in science, into profound specialization in clinical practice: the experience that every disease should be understood in its own patho-physiologal right, and the gains this brought in knowledge, have been mirrored by sub- specialization in health care. The enhanced knowledge of diseases and its mechanisms did lead to ‘a physician for every disease’. And this, in turn, has now translated in disrupted and uncoordinated care. In particular now co-morbidity is becoming a regular, rather than an exceptional, feature of the population [2], this is rapidly reaching the point where it is becoming a threat to the effectiveness of health care.

What is particularly worrying when looking back to the development of sub –specialization is the absence of any evidence of its wisdom. Or even more frustrating, it has taken place against the emerging evidence of how integrating, rather than segregating, skills is essential to secure good health outcomes. Sub-specialization as furthered clinical expertise, but ignored the trusting, ‘healing’ relation [3] between doctors and their patients. Clinical expertise is essential in the treatment of patients with major disease – for example: depression – but its effect is co- determined by a trusting physician – patient relation [4]. And probably even more important: clinical expertise can be transferred from subspecialists to generalists – much more readily than the individual trusting relation.

Current developments in co-morbidity may indicate how a solution is to be found – or how this solution may further split the medical world of specialists and generalists. There is a clear push to approach ‘co- morbidities’ through an adding-up of available, single-disease derived evidence, and maximize interventions. On the other hand, a recent study in the UK on depression made clear that family physicians are reluctant to prescribe the full range of available, evidence-based interventions in patients with co-morbidity – in particular antidepressants – even when these performance was financially incentivized [5, 6]. A logical explanation of this could be that generalists are seeking generic interventions that are relevant for more than one condition at the same time (like empowerment and lifestyle changes) [7].

It is more than time, to revisit the expanding domain of primary care research and as a form of secondary analysis look for the evidence of why integration, person centeredness and a generalist approach are determining effectiveness. These concepts have been valuable hypotheses – but it is more than likely that there is more, and that the evidence is already there, before our very eyes.

References
1 Stange Stange KC. The Problem of Fragmentation and the Need for Integrative Solutions Ann Fam Med 2009;7:100-103.
2 Weel C van. Chronic diseases in general practice – the longitudinal dimension. Eur J Gen Pract 1996; 2: 17-21
3 McWhinney IR. Family Medicine, a textbook. Oxford: Oxford University Press, 1997 2nd edition.
4 Van Os TW, van den Brink RH, Tiemens BG, Jenner JA, van der MK, Ormel J. Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment. J Affect Disord 2005;84:43-51.
5 Kendrick T, Dowrick C, McBride A, Howe A, Clarke P, Maisey S, et al. Management of patients assessed with depression severity questionnaires in UK general practice: analysis of medical record data. BMJ 2009;338:b 750
6 Dowrick C, Leydon GM, McBride A, Howe A, Burgess H, Clarke P, et al. Patients’ and doctors’ views on depression severity questionnaires incentivised in the UK quality and outcomes framework: qualitative study. BMJ 2009;338: b663
7 Weel C van, Weel-Baumgarten E van, Rijswijk E van. Treatment of depression in primary care. BMJ 2009, 338:934

Competing interests:   None declared

I congratulate this Annals’ series, and am very impressed with your first article. The US system faces similar problems [1] as all developed nations, plus the inequality of only 67% of easiest access to low quality and cheap primary preventive and healing centered-patient care. This contrasts with 100% of the smoothest egalitarian entrance in the world highest quality and expensive emergency and therapeutic hospital disease-care.

The US system has top increasing costs, not only because of the free market economy, but also due to a political will, investing highest funding in the world leading scientific and technological, most expensive research in hardest sciences for hardest evidence.

The preventability of chronic sub-clinical or clinical diseases’ progression has less and softer evidence;[2] depends of health education, freedom of choice, and individual responsibility for her/his health, which cannot be totally assumed by the primary care. Whereas, the therapeutic of diseases’ complications, are easier controlled by the hospital.

There are two core realities. The US medicine, health, and living systems function under a successful and complex equilibrium achieved by a freest partnership of strong private and public sectors, difficult to regulate. Even, having so many needs of improvement,[1] thanks to 200-year US results, at least the non-poorest 5.5 billions of the world 6.5 billion population, are increasingly enjoying a great part of the top scientific achievements in global medicine, health, and living cares, levels and standards, of all the times.

The crisis of low-quality primary preventive and healing centered-patient research and care in the US is part of a long world health research and care crisis. In it, both patient and doctor feel the lack of a comprehensive propedeutics and clinical approach to the health problems, because the clinical method is truncated mostly for physical health.[3]

Research field fragmentation is the key approach of contemporary empirical sciences. Since the 1700s, it disintegrated family medicine and primary health care in internal medicine, pediatrics, obstetrics, and psychiatry for the modern hospital research and care. The individual’ health process was divided in “body” and “mind”, because the mind was not reachable then as well as the body with the scientific empirical methods of validation, obviating her/his feelings, fears, and expectations, utter understanding and care. From 1945, hundreds of hospitals and institutes’ subspecialties, atomized patient care.[3,4]

The re-integration and re-classification of the individual’s health process need of the most original discoveries and inventions of family medicine science, to reach a high-quality primary preventive patient and healing-centered care, comprehensive clinical method. This will allow reaching a highest-level family medicine research and care of 70-80% of the patients’ main primary health problems --so far, “functional”, “psychosomatic” or “non-organic” disorders. It will permit including more complex mental and social issues, reducing the costs in unnecessary technology, because the comprehensive clinical management of the whole patient health, will be considered the main scientific approach.

We must research the evolution of sickness and self-healing, family-healing, and member healing of an immediate group, from the earliest historical phases until the beginnings of modern scientific medicine with the doctor healing.[5] Now, we count with oceans of higher qualitative and quantitative levels of empirical and theoretical contemporary knowledge on medicine, physics, chemistry, biology, psychology, and social sciences.

Thank you and good luck!

References:
1. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med 2009;7(2):100-103. http://www.annfammed.org/cgi/content/full/7/2/100
2. Le Fanu J. The Rise and Fall of Modern Medicine. 1st ed. New York: Carrol & Graf Publ., Inc., 2000.
3. Stusser RJ. Reflections on the scientific method in medicine. In: Medical Sciences, Encyclopedia of Life Support Systems (EOLSS). Developed under the Auspices of the UNESCO. Oxford: Eolss Publishers, 2006. http://www.eolss.net
4. McWhinney IR. (1986). Are we on the brink of a major transformation of clinical method? CMAJ 1986;135(8):873-8.
5. Fabrega H Jr. Earliest phases in the evolution of sickness and healing. Med Anthropol Q. 1997;11(1):26-55.

Competing interests: None declared

Great article! As the President of an acute care inner-city hospital and a board certified family physician, my perspective has a peculiar twist. The fractured care is a direct result of the way we organize ourselves and the way we keep score. We organize ourselves by design and by history into small units of care that are linked loosely to form channels of care. Most of these units are independent and narrowly focused. The intent to meet the broader community need is unfocused and generally not tightly connected. Since each entity is on its own balance sheet and has its own shareholders, they are motivated further to focus on their own business rather than the larger good. While a medical home is desireable and even necessary it is insufficient to bring all entities together in a coordinated and integrated care continuum for the good of a population. Moreover, primary care continues to be a contact and individualistic activity rather than a team reality. Finally, because we keep score and reward ourselves as individual units the motivation is to grow and prosper continuously even at the expense of other care units. In this way, through financial controls and rewards, we undermine the very desire we have to form a seamless, coordinated, and superior care delivery system for the benefit of a population. The present economic crisis gives us the burning platform to jump from the security of the known system to the uncertainty and promise of something bigger and better. This article should be a call to arms by every physician for something better rather than calling support for established and past practices.

Competing interests:   None declared