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Rapid Responses: Rapid Responses published:
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Would you like chocolate sprinkles with that?
- Richard Fieldhouse (28 March 2008)
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Profit overriding Knowledge
- Joachim Sturmberg, Carmel Martin - A/Prof of General Practice, Northern Clincal School, Ontario - Canada (1 April 2008)
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Understanding dynamic interdependencies in whole person health and health systems
- Carmel M Martin, Joachim P Sturmberg (2 April 2008)
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Richard Fieldhouse, CEO National Association of Sessional GPs and Clinical Director of Pallant Medical Chambers Chichester, PO19 1BL
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Would you like chocolate sprinkles with that? Martin Roland states that the general practitioner contract should be modified to incentivise personal continuity of care in order to improve continuity of care, especially as three recent studies suggest that many patients in England value personal continuity more highly than rapid access to care. So, if a survey showed that patients wanted a cappuccino and a croissant with their consultations, does that mean we need to place a Starbucks in every practice? Continuity of care is so often cited as the Holy Grail of General Practice, yet there is no research to suggest that the patient is better off because of it. Indeed, there are arguments to suggest that no patient should see the same doctor more than three times in a row. Familiarity breeds complacency, and that leads to errors. Unfortunately continuity, complacency and institutionalization are all uncomfortable bedfellows and it is difficult to have one without the other. Instead, with the 50 million + consultations we have a year performed by peripatetic GP locums, not to mention those cross-covered by other GPs in the same practice, we need to focus more on the continuity of the patient’s record as the engine that drives quality of care. If we’re going to pursue continuity of care, let’s at least make sure we know that there aren’t better and more attainable alternatives. Competing interests: CEO National Association of Sessional GPs and Clinical Director of Pallant Medical Chambers |
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Joachim Sturmberg, A/Prof of General Practice Monash University - Australia, Carmel Martin - A/Prof of General Practice, Northern Clincal School, Ontario - Canada
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We will comment on Roland's editorial separately, however, Fieldhouse's comments can't be left standing unchallenged. Yes, Dr Fieldhouse, personal continuity of care is the main 'instrumental path' to good medical care and good 'patient health'. There is ample evidence for this, and by the way, the personal doctor-patient relationship is highly salutogenic and has survived the test of time (1). This is no more so than for patients with multiple morbidities who in particular seek personal relationship based continuity and care coordination amongst multiple providers (2). Health is not 'absence of disease', the majority of the community has some chronic condition, but even people with major diseases describe their health as 'good' most of the time. 'Health care' is more than disease management, and doctoring is more than diagnosing disease. Medical care requires wisdom (3) based on the real knowledge about the patient which is largely tacit and thus resides in the health professional's head (4). And lastly beware of the fallacy of equating information with knowledge; unfortunately information is just about all the patient record can provide. (1) Sturmberg, JP (2007). The Foundations of Primary Care. Daring to be Different. Oxford San Francisco: Radcliffe Medical Press. (2) Martin CM, Attewell R, Nisa M. Chronic Care in Adulthood and Old Age: Physical and Psychosocial Management in General Practice Encounters. Australian Journal of Primary Health Care 2000;6(1):57-67. (3) Fugelli, P. "Clinical practice: between Aristotle and Cochrane", Schweizer Medizinische Wochenschrift 1998;128:184-188. (4) Polanyi, M (1958). Personal Knowledge. Towards a Post-Critical Philosophy. London: Routledge. Competing interests: None declared |
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Carmel M Martin, Associate Professor Northern Ontario School of Medicine, Joachim P Sturmberg
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Professor Roland’s Editorial: Assessing the options available to Lord Darzi. Time to look at both the system and the patient as a whole,(1) presents a coherent overview of the contemporary challenges facing primary care in many countries, as well as England. His recommendations are consistent with existing evidence and knowledge. Continuity of care is a defining (2) and essential component of primary care that is demonstrated in much international research,(2-4) although is always room for improvement in any jurisdiction. The aims of primary care should be to improve health.(4) Health is neither solely an individual construction nor solely a reflection of societal expectations, nor only the absence of objective disease. As Rosenberg pointed out health, illness and disease are interdependent concepts that can only be fully understood at the personal level.(5) Relational continuity is an important prerequisite to understanding the subjective nature of this patient’s health, illness and/or disease and to providing person-centred care, support and care coordination.(3, 6-8) In addition we agree with Reich and colleagues that health system reform is not an issue of simply changing one aspect, as they said: ‘Health system improvement involves more than metrics; it requires attention to the political economy, values, and cultural dimensions of how health systems work.’(9) Ultimately, a dynamic model of systems redesign centred on understandings of individual health should inform therapeutic approaches, policy decision-making and the evolution of health service models, rather than continued ad hoc redesign. Barriers to implementation centre, on the one hand, on the confusing of different types of knowledge that inform our understandings of health, illness and disease and care and on the other, the misunderstanding of health systems as simple and complicated (like flying a plane) rather than complex (like raising a child).(10) To achieve substantial health system and policy reform that benefits our patients we must strengthen the discourse between theory and evidence and we must embrace the knowledge emerging about complex adaptive systems. 1. Roland M. Assessing the options available to Lord Darzi. British Medical Journal 2008;336(7645):625-626. 2. McWhinney I. The Importance of being Different. William Pickles Lecture 1996. British Journal of General Practice 1996;46(7):433-436. 3. Starfield B. Primary Care. Balancing Health Needs, Services, and Technology. revised ed. New York, Oxford: Oxford University Press, 1998. 4. Sturmberg J. The Foundations of Primary Care. Daring to be Different. Oxford San Francisco: Radcliffe Medical Press, 2007. 5. Rosenberg C. The Tyranny of Diagnosis: Specific Entities and Individual Experience. Milbank Quarterly 2002;80(2):237-260. 6. Hjortdahl P. Continuity of Care: General Practitioners' Knowledge About, and Sense of Responsibility Toward Their Patients. Family Practice 1992;9:3-8. 7. Hjortdahl P. The Influence of General Practitioners' Knowledge about their Patients on the Clinical Decision-Making Process. Scandinavian Journal of Primary Health Care 1992;10:290-294. 8. Martin C, Attewell R, Nisa M. Chronic Care in Adulthood and Old Age: Physical and Psychosocial Management in General Practice Encounters. Australian Journal of Primary Health Care 2000;6(1):57-67. 9. Reich MR, Takemi K, Roberts MJ, Hsiao WC. Global action on health systems: a proposal for the Toyako G8 summit. Lancet 2008;371:865-869. 10. Sturmberg JP, Martin CM. Knowing – in Medicine. Journal of Evaluation in Clinical Practice 2008. Competing interests: None declared |
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