Search

Pharmacists are more often being recognized as a critical component of the primary care team. Previous literature has not clearly made the connection to how pharmacists and comprehensive medication management (CMM) contribute to recognized foundational elements of primary care. In this reflection, we examine how the delivery of CMM both supports and aligns with Starfield's 4 Cs of Primary Care. We illustrate how the delivery of CMM supports first contact through increased provider access, continuity through empanelment, comprehensiveness by addressing unmet medication needs, and coordination through collaborating with the primary care team and broader team. The provision of CMM addresses critical unmet medication-related needs in primary care and is aligned with the foundational elements of primary care.

We are now at the end of the beginning of re-envisioning the future of residency education in Family Medicine. On December 6-7, 2020, after almost a year of preparation, representatives of the specialty came together at the fourth Starfield Summit to review the past and present, and to envision the

Amidst a pandemic that has acutely highlighted longstanding failings of the US health care system and the graduate medical education (GME) enterprise that serves it, educators prepare to embark on another revision of the program requirements for family medicine GME. We propose in this article a conceptual framework to guide this endeavor, built on a foundation of the core functions that Barbara Starfield suggested might explain primary care’s salutary effects. We first revisit these “4C’s”—first Contact, Continuity, Comprehensiveness, and Coordination—and how they might inform design thinking in primary care GME guideline revision. We also propose the addition of Community engagement, patient-Centeredness, and Complexity. Training residents to deliver on these “7C’s,” functions critical to the delivery of high-performing primary care, is essential if family medicine residency graduates are to serve the clearly articulated, but unrealized, quadruple aim for US health care: improved patient experience and population health at lower costs while preserving clinician well-being. Finally, we highlight and illustrate examples of four critical enablers of these 7C core functions of primary care that must be accommodated in training guidelines and reform, suggesting a need for resident competencies in Team-based, Tool- and Technology-enabled, Tailored (“4T’s”) care of patients and populations.

Several middle and upper income countries carry out household surveys that seek to trace the profile of access and use of health services. Probably one of the most ambitious examples is Brazil, with its National Health Survey (PNS-2019). We evaluated PNS-2019, presenting in an unprecedented way, one of its innovations, which refer to Starfield and Shi's adult Primary Care Assessment Tool (PCAT).Based on a cross-sectional study, we evaluated Module H of the PNS-2019, which interviewed a probabilistic sample of about 10,000 adults in 2019 in all 27 Brazilian states. According to the PCAT methodology, an average score equal to or above 6.6 indicates a greater orientation and quality of the evaluated primary care services.Brazilian overall PCAT score [5, 9] reveals the need to improve primary health care services across the country. There were no statistically significant differences in the scores by sex (men and women, 5.9), and race (whites 5.9 [5.7; 6.0] and brown / black 5.9 [5.8; 6.0]). On the other hand, there was a difference in terms of age. The elderly evaluated the services in a more positive way (score = 6.1 [6.0; 6.2]), when compared to those aged 40-59 years (5.9 [5.7; 6.0]) and 18 to 39 years (5.6 [5.5; 5.8]). First results of PNS-2019 show that the population that most needs primary care services in SUS is the one with the best perception and the most positive evaluation of the actions and procedures offered in health facilities.During 2019, Brazil undertook important structural reforms in PHC based on a new financing model with the aim of inducing an improvement in efficiency and strengthening its attributes. It is essential that countries with universal health coverage (UHC) guarantee access to their population and, especially, the most vulnerable, seek better efficiency of these services and regularly assess PHC based on the population's perception, through an independent methodology that monitor the quality of services and the strength of PHC, generating value for public resources applied to health services.INTRODUçãO: Vários países de renda média e alta realizam pesquisas domiciliares que procuram traçar o perfil de acesso e uso dos serviços de saúde. Provavelmente um dos exemplos mais ambiciosos é o Brasil, com sua PNS. Avaliamos esse inquérito e apresentamos, de forma inédita uma de suas inovações, que se refere ao uso do instrumento Primary Care Assessment Tool (PCAT). MéTODOS: Com base em um estudo transversal, avaliamos o Módulo H da PNS-2019, que entrevistou uma amostra probabilística de cerca de 10.000 adultos em 2019 em todos os 27 estados brasileiros. De acordo com a metodologia do PCAT, um escore médio igual ou acima de 6,6 indica uma maior orientação e qualidade dos serviços de atenção primária avaliados.O escore médio geral do PCAT no Brasil foi de 5,9, revelando a necessidade de melhoria dos serviços de atenção primária à saúde em todo o país. Não houve diferenças estatisticamente significantes nos escores por sexo (homens e mulheres, 5,9) e raça (brancos 5,9 [5,7; 6,0] e pardos / pretos 5,9 [5,8; 6,0]). Por outro lado, houve diferença em termos de idade. Os idosos avaliaram os serviços de forma mais positiva (escore = 6,1 [6,0; 6,2]), quando comparados aos de 40–59 anos (5,9 [5,7; 6,0]) e 18 a 39 anos (5,6 [5,5; 5,8]). Os primeiros resultados da PNS-2019 mostram que a população que mais necessita dos serviços de atenção básica no SUS é aquela que tem melhor percepção e avaliação mais positiva das ações e procedimentos oferecidos nas unidades de saúde. DISCUSSãO: Durante o ano de 2019, o Brasil fez reformas estruturais importantes na APS a partir de um novo modelo de financiamento, com o objetivo de induzir uma melhoria da eficiência e fortalecer seus atributos. É fundamental que países com sistemas de saúde de cobertura universal, garantam acesso a sua população e, em especial, aos mais vulneráveis; busquem melhor eficiência desses serviços e avaliem regularmente a APS a partir da percepção da população, por meio de uma metodologia independente que monitore a qualidade dos serviços e a força da APS, gerando valor aos recursos públicos aplicados nos serviços de saúde.

The second Starfield Summit was held in Portland, Oregon, in April 2017. The Summit addressed the role of primary care in advancing health equity by focusing on 4 key domains: social determinants of health in primary care, vulnerable populations, economics and policy, and social accountability. Invited participants represented an interdisciplinary group of primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. The Pisacano Leadership Foundation was one of the Summit sponsors and held its annual leadership symposium in conjunction with the Summit, enabling several Pisacano Scholars to attend the Summit. After the Summit, a small group of current and former Pisacano Scholars formed a writing group to highlight key themes and implications for action discussed at the Summit. The Summit resonated as a call to action for primary care to move beyond identifying existing health inequities and toward the development of interventions that advance health equity, through education, research, and enhanced community partnerships. In doing so, the Summit aimed to build on the foundational work of Dr. Starfield, challenging us to explore the significant role of primary care in truly achieving health equity.

The core function of medical schools is to produce the doctors the nation needs1 and the NHS is clear that it now needs 50% of medical students to choose training for general practice. However, only 16.4% of newly qualified British-trained doctors seek postgraduate GP training.2 Moreover, one-third of British-trained doctors thought that their medical schools had not put them in a position to assess a career in general practice.3 I have met several junior doctors who have not heard of, let alone read, the writings of Professors McWhinney4 and Starfield,5 two world-class thinkers about general practice. GPs without understanding of the principles of their role have a shallower vision and often lower job satisfaction. How has this happened? When the NHS was established in 1948 many arrangements were made with the medical schools at a time when general practice was not a discipline and there was no professor of general practice in the world. The medical schools were initially entirely specialist led, linked to tertiary specialist hospitals with many special privileges. Training specialists was the priority and leading specialists, like Lord Moran, a Dean of St Mary’s Medical School, saw GPs as: ‘… having fallen off the ladder’.6 Professors of general practice came late to the party, first in Scotland in 1963, and in England in 1972. They were vigorously resisted by the Bristol, Cambridge, and Oxford medical schools, which appointed late in the 1990s. General practice/primary care struggled to gain entry to medical schools and even in 2017 …

Direct Primary Care (DPC), where patients pay a fee to a primary care provider to obtain access to services, is a delivery model that has received notable attention and enthusiasm from some providers. Proponents of DPC believe that the model increases accessibility, reduces overhead, and ultimately improves care for patients; however, there is little evidence in the peer-reviewed literature to support these claims. The objective of this analysis was to apply Starfield's adaptation of Donabedian's Structure-Process-Outcome conceptual model to evaluate primary care to formally display the links between potential changes in clinical structure and processes from DPC adoption. Based on existing literature on the constructs in Starfield's model, expectations of DPC's impact at the patient, clinic, and system levels were defined. DPC uses changes to financing and the population eligible to trigger potential gains in continuity and accessibility to subsequently improve care processes. There is evidence to support DPC as a theoretically sound approach to improve attributes of primary care, such as first contact care and longitudinality at the clinic level for participating patients. At the health system level, DPC has low-construct validity that would suggest a positive impact on the potentially eligible population's health due to membership fees that exclude patients who are more likely to be vulnerable and complex than patients who are willing and able to stay in the practice. Descriptive and comparative research of included and excluded patients is needed to inform providers, patients, and policy makers of the DPC's ability to attain the attributes of primary care and ultimately achieve better outcomes over alternative primary care delivery and financing models. Meanwhile, theoretic application informed by years of research on primary care provide insight as to what changes to expect and to monitor as practices consider DPC adoption.

Comprehensive primary care describes the long-term relationship between patient and provider in which medical services, support for self-care, and care coordination are the foundation. Research has associated comprehensive primary care with better system quality, equity, and efficiency. A performance measurement method is needed to enable teams delivering such care to optimize their performance and to evaluate the benefits over time. This article describes “The Starfield Model”—an approach to measuring quality, capacity, and total cost of care at this scope of service—and the results achieved by a small family health team in implementing this model. This experience suggests that real benefits arise from meaningful feedback to providers. The model has the potential to work in any payment system of primary care, thereby providing insight into all types of comprehensive primary care practices.

The inaugural Starfield Summit was hosted in April 2016 by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care with additional partners and sponsors, including the Pisacano Leadership Foundation (PLF). The Summit addressed critical topics in primary care and health care delivery, including payment, measurement, and team-based care. Invited participants included an interdisciplinary group of pediatricians, family physicians, internists, behaviorists, trainees, researchers, and advocates. Among the family physicians invited were both current and past PLF (Pisacano) scholars. After the Summit, a small group of current and past Pisacano scholars formed a writing group to reflect on and summarize key lessons and conclusions from the Summit. A Summit participant's statement, "a paradox persists when the paradigm is wrong," became a repeated theme regarding the paradox of primary care within the context of the health care system in the United States. The Summit energized participants to renew their commitment to Dr. Starfield's 4 C's of Primary Care (first contact access, continuity, comprehensiveness, and care coordination) and to the Quadruple Aim (quality, value, and patient and physician satisfaction) and to continue to explore how primary care can best shape the future of the nation's health care system.

The Starfield Summit crystallized key challenges and opportunities as primary care enters an era of value-based payment (VBP). New primary care models must reinforce Starfield’s core primary care functions while achieving the quadruple aim. Achieving these objectives requires pragmatic, rapid

It is said that in times of war old people bury young men. As we live in times of peace, and we are old, youngsters will need to bury us. It is said that we become good people after we die. But some of us were good before dying. They were good, generous and honored, wise and tender, effectively human. Some who passed away used to give us a cozy and protective shadow, and their absence leaves us unsheltered, alone with danger. A long time ago, one of our children asked to us: “When an old wise man dies, where does his knowledge and experience go to?”. We were not quite sure about the answer. “When this person has family and friends, they all learn from him. Thus, there will be a lot in their hearts and minds, and his/her kindness, culture, wisdom and accomplishments will be a part of memory, which will pass from generation to generation; it has been this way since the beginning of humanity. If this person diffused activities and work, whether written or illustrated, these will be his/her own words, and this person may be seen and revisited from time to time. Sometimes, words remain and we do not even know to whom they belong to, like Gilgamesh and his poem. Other times, authorship is neglected, even if we know who the author is, like Aristotle. And, other times, memory is alive and recent, like the work of Albert Einstein”. At that time, we did not think about it – but we do now – when a giant dies, we are left without a shadow. Barbara Starfield passed away, a giant in Primary Health Care (PHC), and her protective shadow abandoned us. She was a wise elderly woman, even though she looked young and looked like a student. Barbara Starfield had friends and family members who are capable of passing on her legacy of knowledge, kindness, culture, and wisdom, including many of her deeds and anecdotes. Barbara Starfield also leaves multiple registers, articles, books and presentations, which will serve as a path for others to go further. She was good, even before her death. Now, it is time for tributes, compliments and epitaphs, praised obituaries, and the public memory, which mixes the fear of death that writes its own show, and the desire to forget the mistakes of those who are highly appraised. Now it is time for tributes to death and for the dead. There was time for love, will, friendship, sharing, friendly respect; but many times, there was no time, and it is too late to go back and repair damages and mistakes. “To infinity and beyond”, say the grandchildren to their grandparents, asking them to push the swings harder. Others will come, and within the years, decades, centuries and millenniums, time will fade the memories of a giant, whose shadow no longer protects the dwarves (and this is how we are). Now we are aware of how small we were, exposed to the devastating environment of an arrogant Medicine, which despises everything it ignores, and it ignores almost everything. Now, we are aware of the damage we caused, and that getting a visa was a constant inconvenient for Barbara Starfield in her trips to Brazil. It would have been more worthy, and easier, to name her a Brazilian honorary citizen! We are aware of the damage we caused, and not little damage, when she was turned down at a doctoral examination board in Zaragoza (Spain) for not having a doctorate in medicine. It would have been more worthy, and easier, to name her doctor honoris causa! Now we are aware of her little impact on public health policy in USA, her home. Neither there is a “prophet” in his own land, nor a giant that shadows his close neighbors. It would have been much easier to take her recommendation and establish a strong PHC in her country’s health system, the less developed among the developed ones. Barbara Starfield was a leftist, always sensitive to the suffering of others and an activist against injustices. She met her future husband, who was also a medical student, in an act in favor of the Lincoln Brigade veterans, one of the international brigades that supported the Spanish Republic against the Nazi barbarism. She graduated as a pediatrician, and was a real cosmopolitan. She started her research on the organization of health services with KL White, master and friend, the one from the “medical care ecology” or “it is better to be approximately right than precisely wrong”. This giant accompanied her to the USA, just as other unique giants accompanied her to the United Kingdom, such as John Fry and Julian Tudor Hart. She had a positive critical attitude, pointed out the errors of a sanitary care based on experts, and showed its dangers (especially on her text about the medical practice as a preventable cause of death); with time, she developed an impressive theoretical foundation at the defense of PHC as the best response to excesses in Medicine and prevention. She knew how to analyze the excesses of a weak use of statistics, which was summarized in her article: “Internal elegance, external irrelevance”. She also knew how to compare countries, open paths, and respond to social and technological changes. She never forgot the impact of inequity on health. Many say her name in vain. Many justify barbarian actions on behalf of Barbara Starfield. There are many who confuse PHC with a solution that is exclusive to the poor, low-quality, and based on vertical programs. It is terrifying to think of the manipulation of her ideas by the ones who need them. It is no longer worth it to write things together to mark new paths, to claim for her work and her journey. Now, we have memories, the consolation of prayer in some synagogue, and the goal to follow the path that has been opened “to infinity and beyond”.

Due to changing population demographics and their state of health, the healthcare system in the United States is facing monumental challenges. For example patients suffering from chronic illnesses account for approximately 75 % of the nation’s healthcare-related expenditures. A patient on Medicare with five or more illnesses will visit 13 different outpatient physicians and fill 50 prescriptions per year (Friedman, Jiang, Elixhauser, & Segal, 2006). As the number of a patient’s conditions increases, the risk of hospitalizations grows exponentially (Wolff, Starfield, & Anderson, 2002). While the transitions between providers and settings increase, so does the risk of harm from inadequate information transfer and reconciliation of treatment plans. A third of these costs may be due to inappropriate variation and failure to coordinate and manage care (Wolff et al., 2002). As costs continue to rise, the delivery of care must change to meet these costs.

O Estado como provedor do bem público busca disseminar a saúde entre seus habitantes, sendo uma das principais formas de realizar isso é através da Atenção Primária à Saúde. Esse contexto contribuiu para o escopo deste artigo, cujo objetivo é verificar a eficiência técnica da Atenção Primária à Saúde no âmbito do sudeste brasileiro. Com uma abordagem teórica, tomou-se como base a literatura nacional e internacional sobre o tema, com autores como Mendes, Starfield, Ozcan e Salinas-Jiménez. Para o cumprimento de tal objetivo, utilizou-se uma abordagem quantitativa, através do modelo de Análise Envoltória de Dados (DEA). Os resultados apontaram para escores de eficiência técnica baixos, considerando os inputs e outputs selecionados para a região. O que oferece indícios de eficiência relativa baixa e por consequência, são importantes intervenções e ações pró-ativas na gestão da atenção primária à saúde. The state as provider of public health seeks to disseminate between its inhabitants, one of the main ways to realize this is through Primary Health Care This scenario contributed to scope of this paper, whose purpose is to verify technical efficiency of Primary Health in the Brazilian southeast. With a theoretical approach, was consulted authors such as Mendes, Starfield, Ozcan and Salinas-Jiménez. For compliance of this objective, employed a quantitative approach, using the model of Data envelopment analysis (DEA). Results showed low technique efficiency scores, considering the inputs and outputs selected for the region. What provides signs of relatively low efficiency and consequently are important interventions and proactive actions in the management of primary health care.

The analysis by Barbara Starfield and colleagues has serious methodological and conceptual shortcomings. Despite the reference to “evidence” in the title, there is little evidence to guide the health care community or policymakers. The paper faults specialists for most of the ailments of U.S. medicine and fails to recognize the critical role of specialists in improving Americans’ health status. A variety of factors, including organizational and financing systems, discourage effective use of both primary care and specialty physicians. The nation would be better served by developing an evidence base on the relationship between outcomes and education, training, and specialty.

Barbara Starfield and colleagues present evidence that having more primary care physicians and fewer specialists per capita is associated with lower mortality rates. These analyses stand ...

Two articles in the Ethics Feature of the current issue highlight the growing concerns with the validity of the biomedical literature and recommended guidelines for clinical practice. Genuis[1][1] and Abramson and Starfield[2][2] discuss the influence of commercial funding on clinical practice

Barbara Starfield’s research showed that investing in primary healthcare is the way to a successful health system. So why are these lessons not being heeded, asks Michael Caley, and will general practice commissioning help?

More time and provision of innovative tools to coordinate care may help Patients with multimorbidity often need more frequent general practice consultations, and more complex and structured care, than those with a single condition. Their care is often shared and needs to be coordinated with specialist community and hospital teams. A recent article in this series drew attention to the importance of having one main coordinator of care for patients with multimorbidity,1 and Starfield and colleagues highlighted, almost a decade ago,2 the challenge that primary care practitioners face in managing patients with multimorbidity more effectively. The standard primary care consultation for patients with multiple conditions needs to change, but how? Multimorbidity influences the general practice consultation in three main ways. Firstly, the amount of clinical information that must be collected for an individual patient with many different conditions can be extensive, especially when conditions and their stability change over time.3 Secondly, as conditions progress over time, management priorities and consequently information gathering, plans, and coordination of care must change.4 Thirdly, communication with other services involved in …

Building continuity of care takes work but earns trust Estimates of the prevalence of multimorbidity vary according to how it is measured, but studies agree that prevalence is rising and that it increases precipitously with age.1 By middle age, multimorbidity is the new normal. The first article in this editorial series on multimorbidity highlighted the difficulty of achieving evidence based targets for multiple diseases in a single patient.2 Treating all of a patient’s diseases optimally represents a considerable management burden for the patient and can result in a chaotic experience of care. Barbara Starfield defined relational continuity in primary care as person focused care over time, and such an approach is needed for patients with multimorbidity, rather than the more traditional one of managing diseases.3 But how can continuity of care be achieved for patients with multimorbidity? Continuity of care is most commonly defined as a connected and coherent series of healthcare events, or seamless care.4 For the healthcare professional, this means having all the necessary information about the patient at the point of care (informational continuity) and coordinating actions with other providers to deliver services in a complementary and timely manner along a recommended care pathway (management continuity). Connectedness matters for healthcare professionals because it translates into technical quality of …

The entry point for most people into any healthcare system is primary care. Not surprisingly, primary care–oriented disorders make up the vast majority of all medical conditions seen by healthcare providers. Starfield (1994) pointed out that countries whose health systems are oriented toward primary care achieve better health levels, higher satisfaction with health services among their populations, and lower expenditures in the overall delivery of health care. The American system relies heavily on both physicians as well as nonphysician clinicians to deliver primary care. In the US this cadre of providers includes doctors, PAs and nurse practitioners (NPs).

Barbara Starfield, perhaps the most influential figure in the primary care research community, died unexpectedly at home on June 10 this year while swimming in her pool. She was steadfast in her belief that primary care is central to the delivery of high quality cost-effective health care. Her second passion was as a champion of primary care as the key way to address healthcare inequalities, and she was founding editor of the International Journal for Equity in Health. She was highly critical of health care in her own country, (the US), viewing it as dominated by specialists who provide expensive, inequitable, and sometimes damaging …

I learned of Barbara Starfield’s sudden death from her husband, Neil “Tony” Holtzman. In his e-mail, sent at 2:43 am on Saturday, June, 11, 2011, Tony reported that Barbara’s absence from a simple act of nurturing, generosity, and generativity was the first sign that something was amiss—

Health services utilization has been the object of many books and papers in the literature. Measures associated with utilization are often a function of volume of services. The objective of this paper is to present a comprehensive approach to the evaluation of health services utilization and of associated measures, using databases. Based on the theoretical framework of Starfield (1998), we analyze health services utilization with the help of indicators that are not directly linked to volume but that indirectly provide an estimate, while also documenting the qualitative aspects of utilization. The indicators mark accessibility, continuity, comprehensiveness and productivity of care. Once the concepts have been defined, we propose their operationalization using the databases. We then present the advantages of multidimensional conceptualization of health services utilization through a simultaneous analysis of these indicators. Researchers and decision-makers in public health and health planning have much to gain from this innovative multidimensional approach, which presents a dynamic conceptualization of health services utilization based on health administrative data.This paper was originally published in French, in the journal Pratiques et Organisation des Soins 2011 42(1): 11-18.

This article reviews the hegemonic understanding of health services research in the United States and in the Anglo-Saxon world, taking as a point of reference the recently published PAHO anthology, Health Services Research: An Anthology (which contains the classics in health services research). The author outlines the main characteristics of health services research in the United States, and criticizes the focus on medical care of most health services research literature and the narrow spectrum of positions presented in that literature. He concludes that there is an urgent need for analyses of the socioeconomic and political forces that determine the level of health and the type of health services that exist in any society, analyses that are usually avoided in health services research.

The fact that strong general practice is an essential component of a high quality and cost-effective healthcare system is a message that has never been fully absorbed by successive ministries of health in the UK. (The over-worked and almost meaningless term ‘primary care led’ seems to have been used in the mistaken belief that it just meant cheap.) Ironically, it is a message that has been stated clearly in the US, where Barbara Starfield, the distinguished health services researcher at Johns Hopkins, has published high quality research to make the point1,2 and where Don Berwick, President of the Institute for Healthcare Improvement, wrote in his essay celebrating 60 years of the NHS that, ‘General practice is the jewel in the crown of the NHS. Save it. Build it’.3 We have done neither but instead, with the encouragement of the government, have half-dismantled it and sleep-walked into a time of peril for general practice and for patient care.4 Almost all of the core characteristics of general practice identified by Starfield are in danger of becoming eroded by successive and often poorly-informed lurches in health policy. General practice in the UK was never perfect — there was never an unalloyed golden age …

Background In the article by Starfield and colleagues, it was suggested that the concept of prevention has gone astray. This article aims to extend their ideas. Methods Our methods are to take the Starfield et al article and argue that it is possible and useful to see prevention in a wider context, going beyond prevention in healthcare and viewing prevention as a social good. Results This wider view results in some questioning of the nature of the benefits of prevention. At the same time, it suggests that the values of informed citizens might be more often elicited to help establish the principles underpinning the concept of prevention. Conclusion There is a need for further debate involving various disciplines to examine the concept of prevention in greater depth.

We want to thank Dr. Barbara Starfield for her insightful commentary about our paper in CMAJ May 26. While we agree with the issues she raised, her article contains a misleading statement that the higher rate of visits to emergency departments in capitation was observed only in rural areas. This

It is hard to figure out what motivated the comments on our paper “When There is no Doctor…” (McKinlay and Marceau, 2008), since Timmermans begins by characterizing our thesis as “bleak futurama,” proceeds to generally agree with much of our evidence and arguments and then concludes in almost complete agreement (Timmermans, 2008). He summarizes our essential position when he states, “They envision a world without primary care physicians but not necessarily without primary care.” We outlined seven reasons why primary care doctors are an endangered species, likely to be largely extinct by about 2025. We argue there will a continuing and likely increasing need for effective primary care, especially with a rapidly aging population and increasing co-morbidities, but this is unlikely to be provided by doctors. Social structural influences will drive them from the medical playing field (in contrast to their voluntarily “skipping town”) and they will be replaced by: a) eventually cheaper and equally effective health care workers (especially appropriately trained nurses), b) virtual visits on the internet (web visits), and c) specialists who replace primary care doctors and are part of the “hidden system of primary care” (Timmermans, 2008, PAGE REF NEEDED) (doctors trained as specialists who also provide general primary care to their patients). Admittedly, we gave insufficient emphasis to this phenomenon, even though it supports our general argument. We deliberately offer no judgment as to whether the likely disappearance of primary care doctors is a good or bad development – that requires careful consideration of the demonstrated effectiveness (preferably by randomized controlled trial) of doctors versus other types of delivery, say by nurses, specialists or even a computer. Lacking the requisite data we do not comment on whether the “the retreat of physicians is a loss for primary care.” (Timmermans, 2008, PAGE REF NEEDED) There is excellent observational evidence in support of the importance of primary care for population health, especially the landmark and often quoted work of Starfield and her colleagues (Macinko, Starfield, and Shi, 2007; Shi and Starfield, 2001). Whether doctors are the most effective, cost efficient and socially acceptable medium for the delivery of primary care remains an unanswered question; but it is amenable to resolution by careful evaluation. We acknowledged the ability of the medical profession to resist attempts to conduct trials of their comparative effectiveness and to discredit unfavorable results when they are eventually conducted. But in our view they will eventually be conducted – primary care doctoring vs “doctor nurses,” personal doctoring vs digital or web-based care, and doctoring vs walk-in minute clinics in large retail settings. The results of these studies will likely provide additional justification for the replacement of primary care doctors—nurses and retail clinics may prove as effective, more cost efficient and produce higher levels of customer satisfaction. Time will tell. Rather than focus on minor points in a commentary that generally supports our position, we take this opportunity to place Timmermans’ discussion in the context of more general concerns about current sociological thinking on doctoring and the medical profession. Medical sociologists appear afflicted with five types of blindness: they are 1) blind to the future; 2) blind to alternative theories and paradigms; 3) blind to current facts and recent developments; 4) blind to the magnitude of doctors’ discontent; and 5) blind to the technological advancements in primary care. Let us consider each type of blindness.

Coordination of care factors critically in patient safety and care quality across services and settings (Institute of Medicine 2001). The existing research focuses on coordination of care within a single institution, usually a hospital (Argote 1982; Baggs et al. 1992; Young et al. 1998; Gittell et al. 2000), or alternatively in an outpatient setting either by a single provider (usually a nurse, case manager, or primary care physician [PCPs]) or jointly between PCPs and specialists (Starfield 1998; Stille et al. 2005). This study expands research on care coordination through examination of postsurgical care involving multiple settings and multiple types of care providers. We examine surgical patients' experience of postdischarge coordination as they move from the hospital, often to a rehabilitation facility (RF), and then home. We hypothesize that patients' experiences of coordination problems are significantly associated with clinical outcomes and satisfaction. Increasingly there is an interest in extending coordination beyond the individual organization or care provider to encompass the whole episode of care for a given patient (Provan and Milward 1995; Shortell, Gillies, and Devers 1995; Gittell 2002). Having some form of external coordination between organizations has become an official mandate. Standards from Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and Condition of Participation from the Department of Health and Human Services hold organizations in which a patient receives care responsible for ensuring safe and effective transfers to the next setting (Centers for Medicare and Medicaid Services 2001; Joint Commission on Accreditation of Healthcare Organizations 2005). Despite these mandates, the process of coordination between institutions remains problematic. In a recent study between 15 and 72 percent of physicians reported problems with coordination across settings—lack of treatment follow-up, conflicting information from other care providers, delayed transfer of information following hospital discharge, and unavailability of relevant information during patients' scheduled visits (Audet et al. 2005). Starfield's review of research on coordination in primary care suggests that such communication breakdowns are not new (Starfield 1998). Starfield defines coordination as “the availability of information about prior problems and services and the recognition of that information as it bears on needs for current care” (Starfield 1998, p. 226), thereby distinguishing information transfer and information processing as separate components of coordination. This definition may be extended to specialty care and also to patients and caregivers, who, often serving as the primary conduits of information about their care, require information and must recognize important developments in order to seek and manage their care (Ellers and Walker 1993; Starfield 1998; Coleman, Maloney, and Parry 2005). For patients, coordination breakdowns, between providers or between themselves and providers, threaten continuity. For patients, continuity involves perceptions that providers have enough information about patients and their medical histories to make decisions about care (informational continuity); that providers, whether single or multiple, have a consistent care management plan (management continuity); and that providers who know them will provide care in the future (relational continuity) (Haggerty et al. 2003). Poor care coordination may result in conflicting information to patients and caregivers and lead to a loss of confidence in providers (Gerteis 1993). It may also produce confused, underinformed, or noncompliant patients, a particularly troublesome outcome when successful recovery depends upon patient cooperation (Ellers and Walker 1993). Additionally, coordination failures may produce patient dissatisfaction (Cleary 2003), which may have negative consequences for health care organizations in a competitive environment by reducing repeat business, generating negative word of mouth, or producing low patient care quality ratings.

A continuing patient–doctor relationship has achieved the status of a core value and feature of primary care.1 In this issue of the BJGP , two papers by Salisbury et al 2 and Ridd et al 3 add to the large body of primary care research seeking to improve the definition and measurement of the continuing patient–doctor relationship. The aim is to understand and defend it as a core feature. It has been under pressure as primary health care moves away from autonomous single-handed practices to multidisciplinary group practices with common accountability to central authority. For primary care and family medicine the continuing patient–doctor relationship has been subsumed under the broader concept of continuity of care.4 Clinicians from other health disciplines recognise the importance of the relationship with the patient but use the term ‘continuity of care’ to refer to the delivery of services in a coordinated and timely manner by more than one health professional. Salisbury and colleagues call this coordinated care, as would most primary care clinicians. Both Salisbury et al and Ridd et al use the label ‘longitudinal continuity’ to describe the primary care model of continuity of care, a tribute to Barbara Starfield who proposed this term to distinguish it from that of continuity of care used in other disciplines.5 Ridd et al synthesize what qualitative research tells us about the nature of the patient–doctor relationship, where the regularity of good experiences with the doctor over time leads …

To the Editor. —The recent article by Starfield and Simpson 1 appropriately and eloquently calls for the embodiment of primary health care services as a cornerstone for a reformed US health care delivery system. The authors quite correctly lament the inattentiveness currently paid to primary care. However, in their recommendations to construct a primary care infrastructure, they are inherently self-defeating and exclusionary by implying that only physicians can provide primary care. The reliance on physicians is based on the restrictive interpretation of four characteristics of primary care developed by Starfield and Simpson: first-contact care, coordination, longitudinality, and comprehensiveness. 2 The recognition of other professions as primary care services would extend primary care's scope of patient service and management as well as broaden its base of support for inclusion into the health care delivery system. Dentistry, for one, plays a vital role in the provision of primary health care services and can

To the Editor. —In their discussion of restructuring licensing policies, Starfield and Simpson1essentially state that the government or some other monitoring body should determine whether or not a physician in a given specialty is allowed to go into a practice within a specified area based on statistics of case mix and the like. It is unprecedented, un-American, and probably unconstitutional for the government to direct people where to live. There is no difficulty with the government using incentives to try to direct professionals to an area where it is felt they may be needed and away from areas where it is felt that they are not needed. To deny any American the right to live and attempt to practice their profession where they will is anathema and invalidates the entire program.

To the Editor. —Starfield and Simpson 1 outline some important steps for bolstering the role of primary care physicians in health care reform. But one problem they don't address is that of medical bigotry. By this I mean the prejudice that exists at many of our medical institutions against the specialty of family practice. I single out family practice from the other primary care specialties of general internal medicine and pediatrics because by and large they don't face this problem. But ask just about any medical student interested in family practice, and I think the odds are that they've been subjected to pervasive negative propaganda from attending physicians in other specialties. I interview medical students from all over the country, and the tales they tell are all too familiar to me and my colleagues in family medicine. Here's a sample of what they hear: "Why would you want to go

To the Editor. —The 12-avenue approach of Starfield and Simpson 1 to upgrade primary care in US health services is innovative. Maldistribution of physicians still leads to a significant shortage of primary care physicians across the United States. The role of international medical graduates (IMGs) needs to be emphasized. Their numbers are almost equivalent to the the graduate output of approximately 17 US medical schools, with as many as 58% of these IMGs in 1988 alone being non-US citizens. 2 The bulk of them enter the United States on the exchange visitor's (J-1) program and receive their training at the expense of the United States for periods ranging from 3 to 5 years. They return to their home countries where they often find that their acquired expertise is inappropriate owing to lack of facilities and resources. Hence, the magnanimity of the United States and the well-intended purpose of the J-1

To the Editor. —Starfield and Simpson 1 are to be complimented on their recommendations for strengthening the provision of primary medical services in the United States. However, I would go further and suggest that access to specialist services, except in the case of an emergency, should be only by referral from a primary care provider. Under the reformed health service it would be feasible for everyone to have a primary care provider of record. Only this provider would be granted the discretion to refer a patient for specialist care. In Britain it is unethical for a specialist to see a patient without referral from a general practitioner; penalties could be imposed on specialists accepting patients without referral. This policy would achieve considerable economy by avoiding the costly duplication of services that now occurs and would permit each provider to practice the type of medicine he or she does best. A

Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

Elsewhere in this issue of the Journal, Drs. Fishbane and Starfield offer us some new data comparing the care of children given by general practitioners and by pediatricians in a number of ways.1 T...

Visually induced motion sickness is an unpleasant but common side-effect of many simulations and VR-applications. We investigated whether an earth-fixed reference frame provided in the simulation is able to reduce motion sickness. To do so, we created a moving starfield that did not contain any indicators of the spatial orientation of the observer. The observer wore a head-mounted display (HTC Vive) and was simulated to move through the randomly oscillating starfield, a time-to-contact task had to be carried out. Two colored stars on collision course with each other had to be spotted, then they disappeared and the time of their collision had to be judged. Eye-movements, task performance, and motion sickness were recorded. This condition without visual reference to the observer’s upright was supplemented with three conditions containing either an earth-fixed fixation cross, an earth-fixed horizon line, or a line that was yoked to the head. Results show that only the earth-fixed horizon was able to significantly reduce visually induced motion sickness. Thus, a mere earth-stationary anchor does not suffice, a clear indication of earth horizontal seems necessary to reap a modest benefit.

Like many others, I was somewhat dismayed upon learning of the American Academy of Pediatrics' decision not to endorse the WHO Code of Marketing Breastmilk Substitutes. After reading the commentaries by May,1 Barness,2 and the Ambulatory Pediatric Association Board of Directors,3 I found the matter no less muddled. As long as the can of worms is open, I feel that a few of the statements made deserve additional comment. As the issue was recently discussed at our hospital's Pediatric Department meeting, I would be interested in having May and Starfield elaborate on their apparently contradictory interpretations of the Montreal study on the effects of distribution of free formula samples.4

The paper by Starfield et al.1 presents useful and interesting data about medical care utilization in a sample of Baltimore children, but it fails to address itself to the question posed in its title. The paper examines several important attributes (type of provider, accessibility, and financial requirement) of the patients' regular sources of care. It also includes data about the regularity with which those sources are actually used. However, there are no data or tables which specifically show the relationship between regularity of use and the other attributes studies.