Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 2. Results: Primary care management and community orientation

Understanding the importance, position, and relevance of this second paper in a series of articles requires a review of the first three references. When placed into the ongoing work of several years, it is a useful report, revealing a hunger for much better knowledge about general practice/family medicine (GP/FM) and also primary care. Of course, primary care and GP/FM) are not the same thing. Primary care is a foundational function to successful, sustainable health care systems, and GP/FM is a medical discipline, long in evolution, undergoing not a tweaking, but a re-make throughout the developed world. The size and scope of the redesign of GP/FM makes the focus on primary care management and community orientation not just relevant, but timely. Studying this paper and some of its references was revealing and provocative of both some general observations and also some very specific reactions.

Three general observations

This serious effort to find relevant literature reveals again the insufficiency of search terms actually to find the ‘right stuff.‘ I suspect that almost every reader is likely to recall un-cited papers she or he would judge as being particularly important research contributions to the topics. The search was made difficult, also, because all problems exist, by definition, in primary care; and all require ‘management.‘ I also wondered how different the results would be if the search method had incorporated ‘quality improvement work.‘ It is possibly time intentionally to blur primary care management research and quality improvement into ‘one thing.‘ In addition, a reader can see in a general way the vast difference between a listing of researchable topics and a listing of researchable questions ready for answering. Some of the results reported contained within them, an implied question. I found that these brought life to the report. After all, the crux of the research enterprise is not the topic, but the formulation of an important, researchable question. What are the burning researchable questions about primary care management? In the US, the care management question of greatest interest at the moment is probably, ‘Can modernized primary care improve quality of care and health, while reducing disparities and containing costs?‘ Moreover, the implications identified for both management and community orientation rather dramatically reveal the need for what many would call BASIC GP/ FM research. Interestingly, this is not a category incorporated onto the web site material cited, and perhaps it should be. Nonetheless, this manuscript does detect and report research about classification and measurement, which I would label basic research, and calls for maturation of methods for particular research designs well suited for GP/FM, e.g. longitudinal cohort studies. Presently in the US, there is an acknowledged dearth of robust measures of key primary care attributes, such as comprehensiveness. How will GP/FM study and master primary care management absent the basic research about measures of comprehensiveness?

Three specific reactions

The documentation of collaborative care as an important research focus is reassuring. There is such urgency in figuring out how to integrate care for people. Integrate means to pull together what often appear to be disparate parts into a coherent whole that has meaning—for patients and health care systems. This function of integration requires ‘co-laboring’ and matters so much now because there are many interventions from various sources that actually help people. Integration, achieved in part by learning how to work together, is possibly the core primary care management challenge, ripe for world-wide research. In addition, the claim that community orientation seems to be a rather new competence does not seem correct. It appears in reports and manuscripts throughout the twentieth century as a key feature of the personal doctor, whether called a general practitioner or a family physician. Furthermore, the search method used seems to have only lightly touched on community-based participatory research, a now well-developed approach to research of great importance to enable not just an orientation toward community, but full participation by community members in research that leads to action. This is an area worthy of much greater exposure and emphasis and inclusion in the reference list.

Additionally, those particularly interested in either primary care management or community orientation are likely to find stimulating and useful a series of manuscripts appearing in Annals of Family Medicine, authored by the editor, Kurt C. Stange. One of particular relevance to this manuscript was published in September of 2009, ‘A Science of Connectedness’ (1). Its formulation and discussion of the holarchy of health care may expand our thinking about studying primary care management and community orientation.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.