The recent Annals online discussion strikes at the heart of family medicine and primary care—what it means to be a family doctor, the design and tools of primary care practice, and the ethical foundations that guide us.
A PERSONAL DOCTOR
An essay honoring the legacy of John Anderson1—“a doctor who lived as an integral part of his community”2—resonated with family members, policy experts, medical students, and seasoned physicians. The essay prompted many writers to reflect on the deep connection that can arise between doctor and community, a connection that includes shared stories3 and shared pain: “[Doctor Anderson’s] participation in the life of his community penetrated into mystery wherein communities become the true loci of healing by absorbing each others griefs.”4
Dr Anderson’s qualities as a physician stand in sharp contrast to the current health care environment, according to several comments:
What is most striking to me about the stories told about Dr. Anderson at a time that often seems to prioritize algorithmic efficiency and productivity in medicine is the personal knowledge he demonstrated about his patients, and his creativity in tailoring treatment approaches that honored their individual values and preferences.5
Indeed, his focus on the individual guided not only his medical practice but his work in health care policy:
The thing about Dr. John Anderson was that, regardless of the issue we discussed—managed care, certificate-of-need, Medicare reform, whatever—he always, always kept his eye on one ball: what would be best for the care and well-being of patients.6
Several medical students found inspiration in Dr Anderson’s example and encouraged the sharing of such stories “publicly, boldly, and unapologetically.”7 Doing so may inspire new generations of physicians, as well as those already in practice, “to stop and listen, and to care courageously for those in their own communities.”2
The story of John Anderson generated reflections on other aspects of primary care as well. One comment noted the link between a new measure of complexity8 and both the joys and challenges of primary care practice: “…somehow, healthy patients and healthy communities emerge out of the nonlinear dynamics that form complex systems. John Anderson shows us how it is done.”9 Another comment expressed concern over the implications of electronic medical records that do not allow for adequate narrative and honest documentation:
We cannot allow the “Technologic Imperative” to change the entire culture of Clinical Medicine without a fight…. John Anderson would not have stood for it…. Perhaps his memory can be our touchstone for gathering together to make certain that the potential advantages of Electronic Medical Records are not sacrificed to the causes of the Financial Offices and Information Technology people….10
TECHNOLOGY, CHRONIC CARE, AND ORGANIZATIONAL ETHICS
While electronic health records (EHRs) engender concerns among some, they are welcomed by others. A study by Shield et al,11 in which residency clinic patients maintained strong trust in the doctor-patient relationship during EHR implementation, convinced one reader that, “if the verdict was not in, it is now. The benefits of EHR far outweigh the various costs associated with their implementation.”12 Another reader, however, questions whether the study’s positive findings could be replicated in a nonacademic setting.13 Still another reader is looking ahead:
The next step is to make [the EHR] accessible online, particularly to patients, so that equal access to information can lead to truly shared decision making by patients and their doctors.14
In an evaluation of physician satisfaction with a Guided Care intervention,15 physicians enrolled in the study reported increased satisfaction with patient and family communication and improved knowledge of patients’ clinical characteristics. This discussion of efforts to improve care of complex elderly patients in primary care struck a chord with readers. Several commented that such successful programs demonstrate the need for ongoing health care reform to support similar efforts, and that programs in turn have the potential to inform the implementation of such reforms.16–19 Other readers emphasized the importance and complexity of team-based care and suggested that the use of such programs can promote and enhance the development of specific roles of team members in multiple ways.20 Suggestions included encouraging further training in team leadership for physicians, using qualitative debriefing of team-based processes, expanding teams to include roles for other clinical professionals, and conducting needs assessments of clinicians.21–23 Finally, one of the sponsors of the investigation re-emphasized the importance of studying care processes for complex elderly patients and provides a list of additional committed sponsors.24
A pair of essays recently provided an ethical point/counterpoint on the potential for conflict of interest in Coca-Cola’s funding of American Academy of Family Physicians’ patient education materials on obesity prevention.25,26 Essay author Brody further commented on the link between conflict of interest and an organization’s ability to maintain the public’s trust,27 and another ethicist admonished professionals and organizations to exercise their moral obligation to avoid conflict of interest situations.28 Readers voiced concerns that conflicts of interest create bias “in subtle and hidden ways”29 through such tools as language30 and advertisements31 and expressed fears that “all of us in medicine are truly being duped by big money.”32 They called for “responsible partnerships”33 and efforts to protect the “integrity, credibility and independence of the medical organization.”34
EVALUATING THE PATIENT-CENTERED MEDICAL HOME
The relationship between patient and physician, at the heart of John Anderson’s practice, was a theme in the American Academy of Family Physicians’ Patient-Centered Medical Home National Demonstration Project (NDP). In June of 2010, the Annals published a supplement evaluating the NDP, the country’s first national demonstration of the patient-centered medical home concept.35 Using a range of different descriptions, readers reminded us that the patient-centered medical home (PCMH) is many things (a political construct, a series of practice criteria, team-based care, a new mental model of care), but in no way does it replace a personal, continuous relationship between patient and clinician.36–40 Several readers expressed concerns about the potential financial cost and viability of the PCMH model in the absence of a cost-effectiveness analysis for the project—especially in the absence of concurrent primary care payment reform.41,42 Others expressed concerns about the generalizability of equivocal patient-level outcomes.39,43 There were also expressions of enthusiasm for newly developed research methods that can be used to gauge progress with necessary practice changes as primary care adapts to the 21st century, and celebration of the practices that were willing to initiate some of these changes as part of the NDP.36,44,45 In acknowledging these current and future complexities, clinicians from multiple backgrounds emphasized the importance of facilitation and mutual support during periods of change.36,37,46,47
Share your comments on Annals articles at http://www.AnnFamMed.org.
- © 2010 Annals of Family Medicine, Inc.
