Outliers: extended families, better health outcomes

In his recent bestseller, Outliers: The Story of Success,1 Malcolm Gladwell shares the fascinating story of the people of Roseto, Pa, a town entirely made up of citizens who came from the village of Roseto Valfortore in Italy. Intrigued by the extremely low incidence of disease in Roseto, including no coronary artery disease in anyone younger than 55, medical researchers in the 1960s dedicated themselves to studying this phenomenon. The results shocked them. Rosetans did not follow a healthy diet and obesity was prevalent; they did not exercise; smokers were everywhere. Their relatives living elsewhere had a high incidence of disease, ruling out a genetic explanation. Nearby towns with the same climate and environmental influences had an incidence of heart disease 3 times that of their Rosetan neighbours.

With no answers offered by the medical research team, social scientists were consulted. They described a unique sharing of experiences that defined the town’s social structure. They discovered a feeling of trust and security among Rosetans because the people of the town always had someone they knew and who knew them to turn to for support. They concluded that the extraordinary health of this unique population could only be explained in terms of “extended family” and “community.”

Flash forward 4 decades to the research findings of Dr Barbara Starfield and her colleagues,2 showing better health outcomes for populations with regular access to primary care settings and personal physicians. Beyond the social determinants of health, these contacts might play the most important role in determining the well-being of our population.

Patients who have regular health care settings and physicians experience many benefits, including earlier and more accurate diagnoses, improved immunization rates, lower likelihood of being a smoker, higher likelihood of using seat belts, less obesity, fewer emergency visits and hospitalizations, better chronic disease management, fewer adverse drug reactions, lower costs, and better overall satisfaction with care.2 Macinko et al looked at 19 Organisation for Economic Co-operation and Development countries and found that the stronger the primary care orientation, the lower the all-cause mortality and the cause-specific mortality for respiratory and cardiovascular diseases.3 A UK study showed that an increase of 1 general practitioner created a decrease in hospital admissions (14/100 000 for acute illnesses and 11/100 000 for chronic diseases).4 Several studies reported substantial decreases in population death rates for every single unit increase in the number of primary care physicians. The evidence suggests that, while having both a primary health care setting and a regular physician is important to these outcomes, it is those who report having personal doctors as their ongoing source of care who do best.2

Why primary care and family practice have so powerful an effect on health outcomes is usually explained by the elements that define family medicine: comprehensiveness, continuity, and coordination of care. Underlying all of these is the ongoing relationship between the patient and physician—the personal family doctor who provides the trusted advice and care for any medical problem throughout the lifespan of individuals and their families.

As was the case in Roseto, the health outcomes of populations are better when people have a trusted resource they can turn to when they have problems—someone whom they already know and who has come to know them over time. Family doctors and their primary care practices have been proven to be that trusted resource. The confidence and sense of security that patients have knowing they have their own skilled and knowledgeable family physicians to care for them can keep them well and, when they are not well, give them a better chance of recovery. Family physicians who provide comprehensive continuing care become like extended family for their patients.

Overwhelming evidence of better health outcomes justifies the call for increased system investment in primary care and family physicians. Come hear Barbara Starfield speak more about this in her keynote address at Family Medicine Forum on October 29 in Calgary, Alta, and join our College in communicating to those responsible for our health system the indisputable value of all Canadians having their own family doctors.

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