A Science of Connectedness

In this article, Kurt Stange says: "Lower-level tasks, done faithfully over time, can build relationships that enable higher-level tasks", and Ann Reichsman said: "It is often hard for patients to understand that by seeing the same provider at each visit, no matter how amenable the presenting complaint might be to a brief visit with "whoever is available," they are creating a relationship which may in the future be lifesaving."

I suspect that both of these statements assume that it is a general practitioner (GP) or family physician who is seeing the patient to perform these 'lower level tasks' for what may be 'brief visits'. However, we now have nurses and physician assistants whose roles are to perform some or many of the 'lower level' tasks in general practices, reducing the numbers of occasions on which the patient and the GP meet and can get to know each other. This will change the dynamics of what happens when the patient needs the GP's diagnostic and therapeutic knowledge and skill, and support, but knows the practice nurse or physician assistant better.

Competing interests:   None declared

I very much enjoyed Kurt Stange's seminar on the Science of Connectedness at The University of Melbourne last September and it was exciting to see Ken Wilbur's ideas which have such potent explanatory power when dealing with complex difficult to understand systems, used in a health setting.

I agree with David Katerndahl that levels of care are not distinct holons within a holarchy but increasingly integrated levels of interaction within the one holon and this is why the levels of care don't seem to conform to the behaviour of holons, ie destroy the parts (lower holons) you destroy the whole (higher holons) which is because levels of care aren't holons.

The holons are the patient holon (which is part of the patient/health worker holon which is part of the organisational holon, community, society, nation, culture, civilisation, planet and so on, going down the patient holarchy would see a organ or disease holon as part of the patient, and cellular processes as parts of the disease holon etc.)

So all the levels of healthcare can be seen as concentric rings with fundamental care at the core and that all these levels of care can be mapped onto all the holons described above.

I look forward to this discussion continuing.

Competing interests:   None declared

With this fourth in a series of scholarly editorials, Kurt Stange has advanced the intellectual basis of family medicine and primary care. Gayle Stephens provided that scholarship for family medicine in the 1970s and defined the intellectual basis of the discipline. Much scholarship has been written since then, and the Annals of Family Medicine has advanced our scholarship as a journal. Now, the Stange editorials and their amazing collection of references has taken us to a new level. I look forward to using these writings to inspire the best medical student scholars to explore the underlying systems theory and connectedness that makes primary care and family medicine the most intellectually stimulating of the healing professions in medicine. Thank you Kurt. I remember you as a student and you have helped the current students like you to see their true calling.

Competing interests:   None declared

This paper responds to pleas that I have heard for at least 3 decades for theory to guide and teach family physicians and investigators of family medicine. I appreciate it because it made me think, even as I realized I probably didn't really grasp key concepts.

From a host of statements and ideas that I find appealing, one phrase really lept out: "Silos of understanding that misrepresent the world in ways that block advancement." This characterizes our practice and research environmemnt succinctly. And the notion of uniting professionalism and friendship, using the term multimorbidity in addition to comorbidity, the foundational notion of it being a time to develop relationships, adding "more evolved care" to our language about "fundamental knowledge"----these are signals that probably merit wide- ranging discussion amongst those committed to establishing a proper science base for personal doctoring and primary care.

The ongoing struggle to uniting so-called mental health with so- called medical care to actually solve problems for people with emotional and behavioral problems exemplfies how the thinking in this paper might guide and teach. Maybe understanding and making explicit the holarchy of healthcare can help us reorganize to be effective?

Is there a research agenda that could be developed around holons? Could explaining the primary care paradox be a galvanizing focus?

Competing interests:   None declared