Incremental heroes

We tend to overvalue the things we can measure and undervalue the things we cannot.

John Hayes

In a story in The New Yorker called “Tell me where it hurts,” American surgeon and writer Atul Gawande writes about his discovery of the healing power of what he calls incremental care.¹

What, exactly, he asks in the article, is the primary care physician’s skill?

Observing the care [in a primary care clinic in Boston, Mass], I began to grasp how the commitment to seeing people over time leads primary-care clinicians to take an approach to problem-solving that is very different from that of doctors, like me, who provide mainly episodic care.¹

Dr Gawande’s article immediately brings to mind both the seminal work of Barbara Starfield and her colleagues² as well as Kurt Stange and Robert Ferrer’s important editorial “The Paradox of Primary Care,” published in the Annals of Family Medicine in 2009.³ As they state the case, the application of disease-specific guidelines consistently shows that primary care clinicians deliver poorer-quality care than specialists do and yet the paradox is that,

compared with specialty care or with systems dominated by specialty care, primary care is associated with the following: (1) apparently poorer quality care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations.³

Stange and Ferrer go on to parse the paradox and speculate that either there is no paradox—the studies showing poorer performance by primary care physicians are flawed—or perhaps that the paradox is a function of different levels of observation, and that we have failed to sufficiently consider the effect of access to care and the appropriateness of care that patients receive— things to which strong primary care contributes.

How, then, can you measure the power and the effect of a long-term relationship with a family physician?

To date what we have been trying to measure are the relatively simple things about health care, but it is a much more difficult task to measure the effect of the “integration of care of the whole person and the development of systems that foster relationships which integrate narrow and broad knowledge to personalize care.”³

Measuring the “Starfield effect” and understanding the paradox of primary care encapsulates the work of Dr George Southey and his colleagues in the Dorval Medical Family Health Team in Oakville, Ont, profiled in the cover story (page 872) of this month’s issue of Canadian Family Physician.⁴

What is unique about their work is that it is a considered attempt to measure what we have thought to be unmeasurable: the effects of an ongoing relationship on health care outcomes using performance measures that include the key elements of relationships as defined by patients themselves.⁵

Returning to Dr Gawande’s question—what is the primary care physician’s unique skill?—the answer has, I believe, been best provided by a primary care physician.

In the 2011 Harveian Oration,⁶ British general practitioner and former President of the Royal College of General Practitioners Iona Heath beautifully articulates that generalist physicians patrol 2 boundaries in the health care landscape. The first is the boundary between illness—the symptoms brought on by life’s stresses—and disease—those theoretical constructs of modern scientific medicine. The second boundary is the one between disease that can be looked after by generalist physicians and that which requires specialist or hospital-based care.

When generalist physicians effectively patrol those 2 boundaries, she argues, it allows both specialists and health care systems to function optimally and in the best interest of patients. Perhaps the irreducible skill set generalist physicians have that makes this possible is a unique combination of biomedical knowledge and expertise (the ability to diagnose and manage a range of problems), a commitment to relationship-based care, and responsiveness to the needs of patients and communities.

Perhaps it is this unique skill that accounts for both the primary care paradox and the Starfield effect—and which Dr Southey and his colleagues are attempting to measure.

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