Power to Advocate for Health

My comments are in view of the recent citation in the family medicine list-server group discussion.

"Power to Advocate for Health" calls for the development of moral authority. While commendable, this complex article challenges the leaders of family medicine with a seemingly impossible task. Moreover, it leaves out the most important decision-makers, receivers of healthcare. Is the healthcare profession the one who decides the direction of healthcare?

Unfortunately, history shows the medical profession has not been adept on codifying any common goal or defended itself against the changes demanded by the medical-industrial complex. An interesting example was brought home by a recent article which showed that the vast majority of decisions in the field of cardiology are expert opinion with very little back up of evidence (shunt versus bypass). How is it that such a sophisticated specialty allows this to persist?

I would not argue that family medicine has gone astray. Medicine is a microcosm of the bigger picture of society. Our society is currently struggling with many social, financial and political issues.

In my opinion, this highly complex article, is not very practical. Changes in our profession will only come after the hard political choices are made. Physicians/healthcare providers must play an important role in sorting out the direction but politics and societal decisions are going to shape what family physicians do.

As a side note, I feel other professions are of course critical in the educational process but every day battlefield healthcare providers must retake the reins of teaching future doctors in order to provide a practical experience. Lawrence Silverberg

Competing interests:   None declared

Recently I’ve become education dean at my medical school resulting in much opportunity to reflect on how medical education contributes to the problems you describe, and on how changing the learning environment could potentially address some of those problems. Although you emphasize the moral dimension, one can also trace a good part of the problem to cognitive deficits that limit the way doctors think.

At our medical school, like so many others, we cram students into lecture halls in the first two years and spoon feed them information. We give them lots of tests to see how good they are at memorizing and regurgitating what they’ve heard. There is a chasm between this learning experience and skills the students will need to become effective healers. Because they are so bright, they are able to adapt to real life clinical problem solving challenges that they confront during their clinical training in the third year. But here is what’s still missing:

a) A lack of curiosity about their patients’ beyond the biomedical framework they’ve been taught. b) A habit of making assumptions about their patients that explain away the puzzles that should be setting off all kinds of alarm bells c) A failure to ask the questions that would bring to the fore the particulars of a patient’s life situation that are critical to providing appropriate care. These questions are never asked because the answers are presupposed.

Note, these are cognitive, not moral, deficits. The training they have has simply not equipped them with the habits of mind they need to do their jobs well. I do a lot of undercover recording of physician patient encounters, when the patients are unannounced standardized patients or (more recently) real patients whose doctors have agreed to be randomly recorded.(1) The research assistants on my team (who are not clinicians) say that over and over again they hear the patient say things that cry out for the physician to ask “why?” and the physicians rarely do. They have been trained to pass over these red flags.

Some schools (like Case Western) have pioneered efforts to change the learning environment so that it is more self directed and active, to promote higher order thinking skills. These programs are a vast improvement over the traditional lecture based model I describe. To be optimal, however, I think they need the following characteristics (and I’ve not seen any that have all of them):

1. All learning should be centered around problem solving with an emphasis on a rigorous and systematic thinking process. Students must learn to (a) identify the salient characteristics of clinical problems; (b) frame questions that characterize those problems; (c) pose hypothetical answers to their questions; (d) articulate the gap between what they know and what they would need to know to test their hypotheses; (e) seek out the information to close those gaps; (f) assess the quality and limitation of the information obtained; and finally (g) apply what they’ve learned to the problem. The best PBL programs do all this. Most fall short.

2. In addition, the problems themselves need to incorporate the full context of clinical care. Every clinical case should involve contextual elements (such as a patient's economic situation, competing responsibilities, implied preferences, cognitive limitations etc…) that are essential to address to provide appropriate care. I’ve not yet come upon a curriculum that incorporates these elements habitually into problem solving. My colleagues and I have demonstrated the efficacy of this approach outside the standard curriculum (2).

Finally there is the curious and potent resistance to transitioning from a passive lecture based curriculum to a learner centered approach that nearly every medical school not started de novo must face if it wants to change. In medical schools the faculty typically “own the curriculum” but that ownership often does not result in good stewardship and I think the implications for the profession and for patients is immense. Reasons given for maintaining the status quo are always the same: “the students are not capable of learning on their own;” “what evidence is there that we should change?” (no amount of evidence is convincing enough), “how are we going to pay for this” (pointing out that students pay lots of tuition currently not going to their education triggers defensiveness), and “the students really aren’t interested in learning anyway. If they were they’d come to lecture.” In sum, the faculty are themselves a product of an educational system that’s failed them. They can apply their critical thinking skills in their narrowly defined areas of expertise, but tend towards the judgmental (ie make assumptions) to explain away cognitive dissonance.

Much greater emphasis on the developmental process of learning to become a physician is needed if we want to alter the way physicians approach patient care.

Thanks for opening up a dialogue on such an important theme in your editorials in Annals of Family Medicine.

References

1. Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Schapira M, Persell SD, Jacobs E, Abrams R. Contextual errors and failures in individualizing patient care: A multicenter study. Ann Intern Med. 2010;153(2):69-75.

2. Schwartz A. Weiner SJ, Harris I, Binns-Calvey A. An educational intervention for contextualizing patient care and medical students’ abilities to probe for contextual issues in simulated patients. JAMA. 304(11):1191-1197.

Competing interests:   None declared

Medical specialties have traditionally been defined by content areas that are typically exclusive to that particular specialty. Family medicine, on the other hand, has been defined not by what it excludes, but by what it includes: all ages, all diseases, all organs, all severity of illness, all locations, both genders, mind/body/emotions/spirit, all areas of prevention and wellness.

Beyond the content, however, family medicine has emphasized the process of thinking and problem solving. Family physicians frequently use a different mental construct for thinking about patients--a process that includes aptitude in complexity, ambiguity, undifferentiation, prioritization, integration, value clarification, conflict management, empiricism, collaboration and teamwork.

Additionally, family medicine from its inception has further defined itself by its relationships: patients, spouses, children, extended families, communities, public and global health. Family systems theory, along with behavioral change and counseling, moved into physicians' offices under the leadership of family medicine.

Yet, as Stange has pointed out in his brilliant set of seven essays, the story of family medicine does not end with content, process or the personal. The story ends, if there is such a thing as an ending, with the results that are achieved. Family medicine leads the medical community in the three fundamental outcomes that garner much of the attention of the public and the press: access, quality, economy. The highest quality of care at the greatest value that is most accessible still comes from one source: the family physician.

This is not a new story, of course, just a story that has been repeated many times over the past 41 years since the beginning of family medicine as a specialty. The roots of family medicine lay in the work of such luminaries as Koestler, Szasz, McWhinney, Balint, Stephens and Pellegrino--many of whom were not even family physicians by profession. These themes were echoed in the three conferences in Keystone, Colorado (1894, 1988, 2000) organized by G. Gayle Stephens and family medicine organizations. Now, Stange has picked up the theme once again, replete with newer studies that reinforce the old refrain. Yes, family medicine is about content, process and relationships. Yet, ultimately it is about results. Is anybody listening?

Competing interests:   None declared

We are grateful to Dr. Stange and his colleagues for this insightful, moving, thought-provoking, and motivating series of articles. Through our Center for Primary Care at AHRQ, we are striving to build the evidence- base and the infrastructure to allow our nation to create a primary care health system that fulfills the promise of the generalist approach as described here. From our perspective a few insights in Dr. Stange’s framework resonated with us:

- We agree that reforming our health system will require transforming our primary care health system and that this will require workforce development, alignment of reimbursement and incentives, and expanded roles for primary care teams.

- We are committed to envisioning, developing, and implementing a new generation of health information technology that supports generalist functions – systems that allow clinicians to see connections, prioritize, and understand the needs of communities.

- We echo the call for a new generation of quality measures that balance more narrow process measures with more global outcome measures and new measures that reflect the value of the whole-person integrative functions of generalist care and that measure quality for complex diseases, patients, and populations.

As partners with the many stakeholders involved in these complex opportunities, we pledge to embrace the generalist approach and remain humble, connected, and open. We know that many are ready to join us and that together we can improve health and health care for all Americans.

Carolyn Clancy Director, Agency for Healthcare Research and Quality

David Meyers, Director, AHRQ Center for Primary Care

Competing interests:   None declared

In a series of 7 articles in the Annals of Family Medicine, Editor Kurt Stange, in some cases working with others, catapults the crisis in US health care to a level of analysis far beyond the usual access-cost- quality description of our health care failings. To summarize this unified series is difficult for those of us living at a lower level of abstraction, but here are some of the themes.

Healing requires not simply disease-focused evidence-based medicine but meaningful relationships in which physicians know their patients as people. The worsening fragmentation of medicine destroys those healing relationships. Generalism is a way of thinking required for the development of healing relationships. Primary care faces a paradox in which specialist care is better for specific diseases but primary care is better for the health of individual people and populations. We embrace team-based care (moving from I-knowledge to we-knowledge), but need to address the reality that, compared with care provided by the physician alone, teams may dilute continuity of care. Modern medical care is progressing in its smallest units – the gene, the enzyme, the cell – but downplays the importance of its largest units – the health of the entire population. Social systems evolve in cycles, and the US health care system may be awakening from a dysfunctional stage toward a period of turbulent renewal; primary care is positioned to lead this renewal process.

Readers are well-advised to take a break from the usual data-driven, evidence-based article fare to discover the fascinating thoughts explored in this series. Rather than discuss the particular issues addressed Dr. Stange’s series, I would like to add some thoughts related to the reality that health care can only be understood as part of our global economic system.

Article number five of the series, "Making Sense of Health Care Transformation as Adaptive-Renewal Cycles," introduces adaptive renewal cycles, and proposes that "the US health care system is poised to experience the strong turbulence of creative destruction from an impending release phase in which rapid environmental changes, perhaps in related economic or other cycles, overwhelm old ways of operating, and a new reorganization phase ensues." In other words, US health care has been a mess, it’s about to improve, but the improvement process will be tumultuous (as the 2009-14 health care reform dramatically demonstrates). Considering health care by itself, the concept of renewal cycles rings true, but viewing health care within the larger economy, the cycles may be far less important that the unidirectional trajectory of US society. A number of analysts have persuasively argued that the United States is an empire in decline. Recent events make the empire in decline thesis undeniable: the rise of China; the flight of jobs to nations with low wages and poor worker protections, suggesting permanent high unemployment; the growing indebtedness of the US federal government, with other nations (China a major player) propping up the government by lending billions of dollars and thereby able to bring our nation to its knees if they so desired; never-ending military expenditures not paid for by revenue increases; and a lack of investment in internal infrastructure and education. The adaptive cycles described by Stange et al. take place within this considerably more potent national deterioration.

When empires fail, bad things happen internally. For the US, the internal sickness is accelerating quite rapidly. Gridlock in Washington reveals a paralysis of government even in the face of fiscal unsustainability. The widening of the gap between rich and poor, which worsens health care disparities, is related to endemic corruption and selfishness and a refusal of higher income people to pay their fair share of taxes. The cowardly behavior of political candidates who refuse to support tax increases, to rein in corporate excesses, or to eliminate multi-billion dollar waste (whether military or health care) guarantees the very indebtedness that destabilizes the economy and hastens decline. Within health care, the "look out for yourself and screw everyone else" -- so characteristic of a declining empire – is shown by the drive by specialist physicians, hospital systems, and suppliers to "get what we can while it lasts" attitude.

Does that mean we should just give up? Join the "get what we can" philosophy? Despair the inevitable? No, no no. First, we don’t know how long the decline will take. Might the Obama presidency succeed – against almost insuperable odds – in slowing down national deterioration? Hopefully Yes. Whatever the timescale of events, we can celebrate that even within a declining empire a thousand local flowers can bloom, and they are blooming in primary health care. The primary care innovation taking place represents the upswing of a renewal cycle within health care which can proceed even within the downward trend of society. Another reason to keep active is that the worst internal strife characteristic of some empires in decline can be avoided by a population that supports a national leadership with the moral strength of a Ghandi or Mandela, allowing the nation to experience a soft landing rather than a violent crash.

Tom Bodenheimer

Competing interests:   None declared

I would like to commend Professor Stange for the breadth of scope and comprehensiveness of vision articulated in the series. In short, the series is a timely challenge to family physicians to begin the task of creating a concept map of what we should strive to achieve. I am particularly pleased to see equal concern for the epistemological and ethical bases of our disciplne. That what we know, or more precisely, believe to be true, strongly influences what we do or think we should do, is often not recognized because of a rather rigidly taught adherence to the fact/value distinction. However, I wonder whether what we need is to enhance or regain moral authority as physicians or whether we should be exploring alternative grounds for moral authenticity and legitimacy? I think the analysis of power that Prof. Stange has provided is an important one. I am, though, somewhat skeptical of whether physicians have or need moral authority. An alternative point of view may come from virtue theory. Broadly speaking virtue theory includes a concern for both ethics and epistemology. It seeks to examine and justify the qualities and characteristics of virtuous agents. The concern for virtue has a long lineage in the western philosophical tradition. It is strongly associated with Aristotlean thought. It has been eclipsed in modern medical ethics by principle based approaches. A recent paper of note explores virtue theory and clinical practice in some detail. James Marcum, in a paper entitled "The epistemically virtuous clinican" uses concepts from virtue ethics and virtue epistemology to outline how virtues such as curiosity, humility, honesty and courage are linked to both theoretical and practical wisdom in clinical practice. Aristotle used the term phronesis to describe practical wisdom, particularly with regard to action in particular cases, which is the essence of clinical medicine. So perhaps what needs to be cultivated is a greater attention to practical wisdom, which may give moral legitimacy as well as authenticity. These may be necessary preconditions to any claim to authority. I hope this series of essays attracts a wide readership and stimulates a serious discussion on the nature and future of family medicine. Well done and hats off!

References

Marcum, James. The epistemically virtuous clinician. Theoretical Medicine and Bioethics 2009;30:249-265

Competing interests:   None declared

This series illuminates the foundations required for reintegrating people-centred [1-3] health care in the US. Much of the fragmentation documented in the "Problem Of Fragmentation" has resulted from a reductionist perspective around discrete disease entities, body parts and economic self-interest. Static and average metrics cannot model nonlinear and dynamic phenomenon to reflect real patient needs [4] yet underpin the commoditisation of health care. Only through an old but now seen as “new focus” on the person can the system be reintegrated. Understanding health care through complexity science – the science of interconnectedness [5] – as espoused indirectly in this series opens us to the opportunities inherent in complex adaptive systems.

"Paradox Of Primary Care" alludes to the notion of health as a subjective experience in the context of this person. Rather than the sum of the disease-specific outcomes, the health of people and a nation are emergent phenomena reflecting personal and societal values. An integrated primary care system promotes the health of the population cognisant of that nation’s environmental, social and economic contexts.

"Science of Connectedness" highlights the interconnectedness of health and health care. Just as power laws are seen throughout health care, from alcohol detoxification [6] to back pain disability [7], so too we should expect power law dynamics with its scale-free interdependence to be true of all health care. If so, nonlinear dynamics should characterize all levels of care (compromising predictability) and interventions (even unintended ones), as they potentially ripple through the system and its hierarchy in unexpected way [8].

Finally, if we are to attempt intervention, we must extend our understandings of the nonlinear processes and personnel that comprise the system. Our "Ways Of Knowing, Learning And Developing" cannot be limited to the reductionist perspective of "It" – as tacitly argued throughout the series. All things are interconnected and interdependent. The nonlinear behavior typically observed in patients is usually due to the influence that the collective "We" and "Its" as well as the personal "I" have on the "It" that we measure. These domains provide the context for understanding the measurements.

It is this complexity science lens that permits us to visualize the interconnectedness, diversity, and interdependence of health, health care and healthcare organizations to recognize the opportunities for change inherent in all complex adaptive systems. We must embrace adaptive leadership with key stakeholders based on sensemaking in dynamic environments,[9] and primary care values with adaption to local needs.[10]

1. Sturmberg, J.P., The Foundations of Primary Care. Daring to be Different. 2007, Oxford San Francisco: Radcliffe Medical Press.
2. WHO - Western Pacific Region, People at the Centre of Health Care. Harmonizing mind and body, people and systems. 2007, WHO Western Pacific Region: Geneva.
3. Pellegrino, E. and D. Thomasma, A Philosophical Basis of Medical Practice. Towards a Philosophy and Ethic of the Healing Professions. 1981, New York Oxford: Oxford University Press.
4. Cartwright, N., Are RCTs the Gold Standard? BioSocieties, 2007. 2: p. 11-20.
5. Sturmberg, J.P., C.M. Martin, and M. Moes, Health at the Centre of Health Systems Reform - How Philosophy Can Inform Policy. Perspectives in Biology and Medicine, 2010: p. in press.
6. Campbell WG: Is self-organized criticality relevant to alcoholism? J Addict Dis 1997; 16(1):41-50.
7. Love T, Burton C: General practice as a complex system. Fam Pract 2005; 22:347-52.
8. Sturmberg, J.P. and C.M. Martin, The Dynamics of Health Care Reform – Learning from a complex adaptive systems theoretical perspective. Nonlinear Dynamics, Psychology and Life Sciences, 2010: p. in press.
9. Kurtz, C. and D. Snowden, The new dynamics of strategy: Sense-making in a complex and complicated world. IBM Systems Journal, 2003. 42(3): p. 462- 483.
10. Martin, C.M. and J. Kasperski, Developing Interdisciplinary Maternity Services Policy in Canada. Evaluation of a consensus workshop. Journal of Evaluation in Clinical Practice, 2009. 15(5).

Competing interests:   None declared

This series is genuine, intellectual work, worth the read. The seven article package is going to join the published work to which I direct young physician leaders.

This last article reminded me of a conversation with Dr. Stange in which I claimed that the purpose of health care in the US is to generate expenditures and distribute wealth. In the context of mediocre outcomes for population and personal health (as Dr. Grundy notes in these track changes), the cancerous growth of expenditures for decades, even through the great recession, supports my claim--if it is assumed that the purpose of a system can be determined by what it produces. I asserted that the US has, not at all the best Healthcare System in the world, but rather, the best Wealthcare system in the world. Moments later, Dr. Stange passed me a note with this annotation: "wHealthcare system." What a profound difference a "w" can make!

Let's just accept that the profession of medicine in the US no longer lives with "congruence between thought, word, and action." Let's just accept that the recent and current actions of medicine in the US have resulted in the profession's moral authority being "diminished when power, particularly power that is conferred by others or society, (was) used for personal advancement." And let's ignore dissent that the practical results of these conditions often, if not typically, include, "health care in the modern age is an experience of loneliness and abandonment in a sea of technology and fragmentation."

This is serious. Once we physicians know something important that needs attention, it is not proper to remain passive and silent. Particularly for family physicians and their primary care friends, what's next?

This article claims that: "Biomedical health care can foster moral authority when it moves beyond clinician-centered care to patient-cetnered care to relationship-centered care to goal-oriented care. Each step in this path transcends and includes the one before." The struggle to get to patient-centered care is tough and not a done deal. Nonetheless, maybe it is time to focus on the actions needed to assess this sequence and devise strategy to move along this sequence. If the country allowed us to do so, would we family physicians deserve an opportunity to learn how to be the best personal physicians possible in the information age, operating on a transformed platform of integrated health care? I think the answer can still be a hearty, "yes!!"

Family medicine is almost a decade out from the third Keystone Conference, cited in this paper. Maybe it is time for Keystone IV. This Annals series should be preparatory reading for such a conference, and perhaps galvanizing questions could be something like this: "Now that the redesign of family medicine's practice model and residencies is underway, what do people need from their personal physician?" "What is the map for the way forward for family physicians to be the best personal physicians-- ever?"

Competing interests:   None declared

Kurt Stange's 7 articles reaffirm the Hippocratic tradition of medicine. He presents a scholarly basis for the values and behaviors we cherish most in medicine. William Osler modernized the Hippocratic tradition of using the physician's power in the best interests of the patient. Osler's writings are not well known to a new 21st century generation of physicians. I hope that these articles will form an anthology of medicine that will be used and cherished for some time to come. I hope that a small book of these articles will published and made available widely in our medical schools and residency programs.

Competing interests:   None declared