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ED I T O R I A L S
decisions for nontraumatic complaints of arm, neck,
and shoulder.9
In a poignant essay, Blevins reminds us that
research is a valuable but distant source of knowledge.
When it comes to clinical practice, patients remain our
greatest teachers.10
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/7/5/386.
4. Klein Woolthuis EP, de Grauw WJC, van Gerwen WHEM, et al. Yield
of opportunistic targeted screening for type 2 diabetes in primary
care: the Diabscreen study. Ann Fam Med. 2009;7(5):422-430.
5. Reuland DS, Cherrington A, Watkins GS, Bradford DW, Blanco RA,
Gaynes BN. Diagnostic accuracy of Spanish language depressionscreening instruments. Ann Fam Med. 2009;7(5):455-462.
6. Lin EHB, Heckbert SR, Rutter CM, et al. Depression and increased
mortality in diabetes: unexpected causes of death. Ann Fam Med.
2009;7(5):414-421.
7. Mainous AG III, Everett CJ, Post RE, Diaz VA, Hueston WJ. Availability of antibiotics for purchase without a prescription on the
Internet. Ann Fam Med. 2009;7(5):431-435.
References
8. Barnet B, Liu J, DeVoe M, Dugan AK, Gold MA. Motivational
intervention to reduce rapid subsequent birth of adolescent
mothers: a community-based randomized trial. Ann Fam Med.
2009;7(5):436-445.
1. Glazier RH, Agha MM, Moineddin R, Sibley LM. Universal health
insurance and equity in primary care and specialist office visits:
a population-based study. Ann Fam Med. 2009;7(5):396-405.
9. Feleus A, Bierma-Zeinstra SMA, Bernsen RMD, Miedema HS,
Verhaar JAN, Koes BW. Management decisions in nontraumatic
complaints of arm, neck, and shoulder in general practice. Ann Fam
Med. 2009;7(5):446-454.
2. DeVoe JE, Tillotson CJ, Wallace LS. Children’s receipt of health
care services and family health insurance patterns. Ann Fam Med.
2009;7(5):406-413.
3. Stange KC. A science of connectedness. Ann Fam Med. 2009;7(5):
387-395.
10. Blevins SM. Gazing at the future. Ann Fam Med. 2009;7(5):463-464.
EDITORIAL
A Science of Connectedness
Kurt C. Stange, MD, PhD, Editor
Ann Fam Med 2009;7:387-395. doi:10.1370/afm.990.
H
ow can health care reform approach the holy
trinity of equitable access, controlled costs,
and high value?
How can the sweet spot be found in the midst
of the politically charged and personally wrenching
trade-offs? The sweet spot is where increasing access
to health care creates a sense of commonality rather
than division, where choices about the use of services
are prioritized based on personalized knowledge rather
than crude administrative rationing, and where cost
control happens in ways that add value and diminish
waste.
Previously, this editorial series examined the problem of fragmentation,1 a generalist solution,2 and the
paradox of primary care.3 This fourth piece in the
series explores an integrated way of understanding
how the components of health care can work together
to balance access, cost, and quality. This framework
is not so much a cookbook as a way of making sense
of the current situation and a guidepost for traveling
hopefully to a better future.
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CONNECTING THE PARTS AND THE WHOLES
In the summer of 1968 in the Austrian mountain
hamlet of Alpbach, author Arthur Koestler convened
a scientific symposium intended to challenge “the
insufficient emancipation of the life sciences from the
mechanistic concepts of nineteenth-century physics
and the resulting crudely reductionist philosophy.” 4(p2)
The participants’ task then is highly relevant to health
care today, which is stuck in a similarly old-fashioned
worldview that does not fit the reality of how health
is lost and created, and how the pieces of health care
evolve together to create value.
At the Alpbach Symposium, scientists from a variety of fields, including biologist Paul Weiss, biochemist Holger Hydén, developmental psychologists Jean
Piaget and Bärbell Inhelder, psychopharmacologist Seymour Kety, humanist psychiatrist Viktor Frankl, evolutionary biologist C. H. Waddington, and the father
of general systems theory, Ludwig von Bertalanffy,
presented data from vastly diverse experiments and
observational studies. The common thread—actually
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more of a chain of evidence—was that biological and
social phenomena, like molecular and physical occurrences, evolve as events with many degrees of freedom,
but with “ordering restraints exerted upon them by the
integral activity of the ‘whole’ in its patterned systems
dynamics.” 5(9)
Symposium participants described life in different
ways—observations, scientific experiments, mathematical formulae. But they agreed on the concept that the
phenomena of life (as well the physical world) are best
understood as both parts and wholes. Koestler called
these wholes that simultaneously are parts of other
wholes holons.6 The world, be it atoms, cells, or social
phenomena, is made up of holons.
Holons are arranged in nested hierarchies that
Koestler called holarchies. For example, subatomic
particles are included in atoms, which are subsumed
by molecules, which make up crystals, and so on. Each
higher level transcends and includes the one below.
A decade later, psychiatrist George Engel identified
similar relationships in health care and health. Seeing
that “all of medicine is in crisis” from “adherence to a
model of disease no longer adequate for the scientific
tasks and social responsibilities of either medicine or
psychiatry,” 7(p129) Engel8 articulated a similar hierarchy
to the one proposed at Alpbach. As displayed in Figure 1, each higher level in this holarchy (atom, molecule, organelle, cell, and on) transcends but includes
the level below.
More recently, understanding of complex adaptive
systems has further evolved9-21 in ways that put the useful concepts of holons and holarchies into a richer context for understanding how health care can be improved.
Ken Wilber has synthesized much of this evolved understanding,22,23 including the following principles24:
• Reality is composed “of wholes that are simultaneously parts of other wholes, with no upward or
downward limit.”
• Holons can be understood both horizontally and
vertically. At the horizontal level, they balance selfpreservation and adaptation, conserving themselves
with time, while adjusting to other holons at their
level. Vertically, they balance the possibility of selfdissolution to a lower level, and transcendency—
becoming part of another holon—at a higher level.
Extensive pathologies can appear when these balances are not right.
• Emergent holons transcend but include their predecessors. As they do so, new properties emerge that
are more than the sum of the properties that came
before. Furthermore, each higher level of evolution
produces greater depth (but smaller numbers of
holons). Thus, lower level holons are more fundamental; higher levels are more evolved.
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Figure 1. Systems hierarchy (levels of
organization).
To view this figure, please see the print version of the September/
October Annals of Family Medicine, page 388.
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• Holarchies coevolve with other holons and holarchies in their environment, but each level continues
to depend on a network of relationships with other
holons at the same level.
• Evolution of holons moves toward greater differentiation, variety, complexity, and organization.
How can these concepts help us understand the
provision of high-value health care?
As in any holarchy, there are other levels above and
below. Levels lower than those depicted likely relate
to instrumental factors (such as scheduling and record
keeping) that enable health care. Higher levels likely
relate to spiritual dimensions of care.
The holons of health care in the 4 related levels in
Figure 2 are described below.
Fundamental Health Care
Fundamental health care relates to addressing patient
A HOLARCHY OF HEALTH CARE
concerns, acute and chronic illnesses, prevention, and
The components of health care, much as the phenomena mental health. The reasons patients seek health care
of the natural world, also can be understood as both
services have been empirically classified as desire for
parts and wholes—as holons. The holons of health care, medical information, psychological assistance, therasuch as services, structures, and relationships, are more
peutic listening, general health advice, and biomedical
than isolated commodities to be delivered, bought, and
treatment.25 Addressing the reasons for the visit obvisold. They are related to each other in observable ways
ously is fundamental to meeting patients’ needs.
that include hierarchies of holons, ie, holarchies.
More than one-third of all outpatient visits26 and
Figure 2 depicts 4 levels of health care, ranging
nearly two-thirds of visits to family physicians27 are for
from fundamental to healing and transcendence. The
care of acute illness. In such specialties as dermatollower, more fundamental, holons in this holarchy enable ogy or cardiology, the top 6 diagnosis clusters account
higher-order functions, such as integrating, prioritizing, for 70% to 90% of patient visits.28,29 In primary care,
and personalizing. The higher-order functions of health reasons for visits are so diverse that only one-half can
care transcend but include the lower—adding new
be classified in the top 20 diagnosis clusters.27-29 Many
emergent properties that build on, but are more than,
of these acute illnesses are self-limited and thus require
the sum of those below.
medical care only to the degree to which they cause
patient concern or have symptoms that the patient needs help
Figure 2. Holarchy of health care.
managing. Instrumentally, care
of such conditions may be well
Holarchy of Health Care
managed by allied health professionals or in urgent care settings.
What is not known is the degree
to which providing acute illness
care in a single medical home
Abiding
even when
or with a personal clinician fosHealing and
healing cannot
Transcendence
ters the trust and interpersonal
be fostered
relationships that are needed
Fostering healing
to fully perform higher-order
health care functions.
Balancing individual, family,
community, and system needs
Chronic illnesses account
and opportunities
for
a substantial and growing
Prioritized Care
Iterating between biotechnical
and biographical based on
proportion of health care—37%
deep knowledge of both and
of all outpatient visits in the
connections to others
United States in 2006.26 This
proportion is increasing subIntegrating care across acute and
chronic illness, prevention, and mental health
stantially as the population
Integrated Care
Management of multimorbidity
ages and as behavioral risk factors and obesity increase the
Psychosocial care
prevalence of chronic diseases,
Proactive management of chronic illness and prevention
Fundamental
such as diabetes, hypertension,
Health Care
Care of acute illness
osteoarthritis, and cancer.30 PreManagement of patient concerns
ventive care is the main focus
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its,26 and in primary care, one-third of visits for illness
involve preventive service delivery,31 often tailored to
risk factors32-34 or teachable moments.35,36 Both chronic
illness management and effective delivery of preventive
services require a proactive approach and supportive
systems that go beyond reacting to patient concerns
and providing acute illness care.37 Thus, much current health care systems research and development is
focused on increasing the ability of primary care to
prevent and manage chronic illness.38,39
Recent efforts to control costs and increase quality
by “carving out” mental health care have led to increasingly fragmented care.40,41 There are, however, great
opportunities for both controlling costs and improving care and outcomes by integrating primary medical
and mental health care.40,42-44 Psychosocial care also
involves helping patients manage life events and the
stresses and joys of daily living that do not cross the
threshold to a mental health diagnosis.40,45 An ongoing patient-physician relationship developed over time
can provide a basis for integrating mental and physical
health care.46,47
Integrated Care
Multimorbidity (the co-occurrence of multiple medical conditions) and comorbidity (the co-occurrence of
conditions beyond a particular index condition)48 are
seen in one-half of all outpatient visits.26 Multimorbidity, particularly common in the aging population49,50
is the rule rather than the exception among primary
care patients,48-54 and the typical primary care visit
addresses 3 to 4 problems.51,52 Most scientific evidence
explicitly excludes people with comorbid conditions,
however.49,53 Thus, because of limitations in the current
scientific paradigm, the care of multiple conditions,
particularly the care of whole people with multiple
conditions, is relegated to the art rather than the science of medicine. Evidence-based guidelines are not
helpful; in fact, they are potentially harmful for a large
proportion of patients seen in primary care.49,53-55
Higher-level health care involves not only attending to multiple chronic medical conditions, but also
requires the integration and personalized prioritization
of care across acute and chronic illness, prevention,
and mental health.2,3,56-58
Prioritized Care
The ability to prioritize and integrate care based on
an inclusive view and personal knowledge is a crucial
primary care function that is only beginning to be
recognized. Although recent research has begun to
provide evidence on how preventive services can be
prioritized at the level of the population,59 prioritization of care at the level of the person and across acute
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and chronic illness, prevention, and mental health has
received scant attention in medical science.56 Prioritization and integration of care may help explain the
paradox3 that primary care–based systems result in
better population health and lower costs60,61 and higher
(or similar) quality of care62 at lower cost,63,64 despite
evidence that evidence-based guidelines are followed
at lower rates. At the individual level, prioritization
can involve protecting patients from overuse of tests
with high false-positive rates that begin a cascade of
interventions and procedures of marginal benefit.65 At
the system level, prioritizing care may involve efficient
care of families66,67 and use of equally effective but
lower-cost treatments.68
Primary care benefits the individual and the health
care system by balancing biotechnical and biographical
care.69,70 This balance is a complex function that results
in the personalized application of the best scientific
evidence, tempered by the best evidence from personal
context.71 Limiting resource use at the system level can
only be done crudely, where it is widely seen as rationing. Selective use of resources, however, based on firstcontact access, a comprehensive whole-person family
and community focus, care integration, and continuous
relationships,72,73 results in prioritized care that protects patients from overtreatment.65 Personalized care
that is prioritized based on knowledge of the person,
family, and community rather than crude system-level
rationing is most likely to enhance benefit to the person and the population.
Healing and Transcendence
Healing sometimes involves more than cure. It
involves the transcendence of suffering.74-76 For optimal healing, clinicians must identify and develop
knowledge of opportunities for cure, the values of the
patient, connection with community, and possibilities for transcendence. Sometimes healing cannot be
fostered. A difficult and important aspect of health
care is to stick with the patient and family even when
“success” is not forthcoming. This is a higher, noninstrumental level of caring.
The healing and transcendence level of the holarchy of health care is particularly important during
key moments in the life cycle, such as life-threatening
illness or a major personal or family event. Death and
dying45,77 in particular are poorly handled by the US
health care system, both in terms of cost78 and human
suffering.79,80 High-order healing functions can be fostered by specific short-term approaches to care81 and
by longitudinal relationships and abiding over time.74-76
Patients particularly recognize the value of healing
relationships when they include both going through a
key event together and abiding over time.46,47
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Although much is made of the importance of medical professionalism,82,83 there is a role that surpasses
that of clinician or even healer. This role involves
being a friend, and when it is appropriate, it represents
not a loss of professionalism as much as an expression
of unselfish love that is the mark of the healer.2
APPLYING THE HOLARCHY
OF HEALTH CARE
A previous article in this series2 told the story of a
patient, Jim Bauer. Jim received fundamental care
over time, which enabled moving to the higher level
of an integrated approach to diagnosis and treatment
when he developed a complicated illness. The ongoing relationship helped difficult therapeutic decisions
about treatment for 2 cancers and an aortic aneurysm
to be prioritized in a way that was congruent with
Jim’s values, avoided individual risk, and maximized
value for the system. A temporary break in this relationship diminished the opportunity for healing and
transcendence during the time immediately before
his death. The therapeutic relationship, however, was
resumed with the “hidden patient,” 45 Jim’s wife, Doris,
who received care across the entire continuum of the
holarchy of care.
Understanding the holarchy of health care can help
us organize health care more effectively. For example,
if information systems, which currently function at the
fundamental level, were expanded to include information on patient preferences and individual medical risks, reminder systems would better enable care
integration, personalization, and prioritization across
multiple illnesses and domains. Systems that balance
convenience of access with enhancing access to a personal clinician and health care team during key transitions and life events could change health care from an
isolated commodity into a relationship-centered continuum that maximizes integration, prioritization, and
when needed, healing and transcendence. If we take
seriously the need for time to develop person-focused
relationships that are required for development up the
health care holarchy, we would minimize the unhelpful
distraction of disease-specific coding and incentives for
fundamental primary care,84-86 reimbursing instead for
accessibility, comprehensiveness, integration, and personalization functions that provide the added value of
primary care.58,73,87 A holarchy-informed system would
engage primary care clinicians as a first contact and an
ongoing resource for integrating and prioritizing care,
engaging specialty care selectively when it can be most
effective.62,88-90 An effective system to enable individuals, families, and communities to evolve along the
holarchy would have at least a 50-50 mix of generalists
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and specialists, rather than the current and worsening
imbalance found in the United States.
LIMITATIONS
The holarchy of health care displayed in Figure 2
interacts with other holarchies and evolves with time.
Thus, an accurate depiction of the holarchical system
of health care needs to consider its interactions with
other systems. The biological and social processes that
cause health and illness (some of which are included
in Figure 1) are an important factor in how health care
works, just as economic and environmental systems
affect both health care and health.
In addition, the levels of the holarchy of health care
proceed to both higher and lower levels of development beyond those levels that are shown. Higher levels
likely involve spiritual dimensions. Lower levels likely
involve factors that enable fundamental health care.
A full depiction of these multiple holons, interactions,
and levels defies simple visual representation.
Further, although the holarchy hypothesized here
meets most of Wilber’s tenets,24 it is not clear that
destroying lower holons would obliterate all of the
holons above. It may be possible to provide abiding,
transcendent health care without addressing all of the
lower levels of care. A similar critique has been leveled
against Maslow’s hierarchy of need,91, 92 namely, that
higher levels sometimes are possible without having
achieved the lower levels.93 This limitation likely results
from the coevolution of this holarchy with other
related holons and hierarchies that are not depicted.
Thus, the holarchy of health care depicted here
is a simplification of the true complexity of effective
levels of health care. Recognizing these additional
interactions, however, does not negate the simple
usefulness of understanding that phenomena in health
care and the natural world are both parts and wholes
(holons), and that hierarchies of these holons (holarchies) can be recognized. Recognizing the interaction
of these and other holons and holarchies can help
explain surprises94,95 and reconcile silos of understanding that misrepresent the world in ways that block
advancement. For example, Glass and McAtee recently
have used systems concepts and their evolution to
try to reconcile the fields of sociobehavioral science
and public health.96 Others have called for both vertical and horizontal integration to achieve high-value
health care.97-101
IMPLICATIONS
The holarchy presented here leads to a number of useful implications and hypotheses for understanding the
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nature of health care and for organizing and improving
care.
• Since the phenomena of health care and health are
context dependent, it is helpful to understand their
nature as holons—part/wholes that are simultaneously part of other wholes that coevolve over time.
• Understanding the components of health care as
related holons rather than isolated commodities can
help us to develop systems that foster care which is
more relationship centered, less fragmented, and of
greater value.
• Lower-level tasks, done faithfully over time, can
build relationships that enable higher-level tasks.
• Higher-level tasks in the holarchy provide an
important frame and boundary for lower-level tasks.
Lower-level tasks set the possibilities from which
higher-order health care holons can emerge.65
• Even within levels of the health care holarchy, integration is possible and desirable, eg, at the fundamental level, integrating mental health with other
basic care rather than carving it out.
• With most current crude quality assessment tools
and information systems, we know how to measure
only the fundamental holons of health care.102
• Measuring and incentivizing only the lowest level of
the holarchy may unintentionally disincentivize and
block progression toward higher levels.
• Even though the higher level tasks are less instrumental and therefore less easily specified, they could
be enabled by systems and information technology
(IT). For example, IT could prioritize prompts based
on epidemiological data, thus using the fundamental care level to enable the integrated care level. IT
could prioritize prompts based on information on
patient preferences and societal costs or benefits,
thus enabling the next level of prioritized care. IT
could provide a mechanism for ongoing self-reflection about patients’ evolving preferences, thus moving from our current static approach to living wills to
an evolutionary approach that better reflects the reality of how patient’s preferences work, and preventing
us from getting locked into health care approaches
that push technology in the final days of life way
beyond what people want, and that drain our coffers
with unwanted, unneeded, unhelpful, and sometimes
cruel care that is done to people rather than provided
in partnership with them.
• Care organized to foster development along the holarchy may help to reframe health as more than the
absence of disease,103 but as a foundation for achievement,104 and as relationships and the meaning derived
from them.105,106
• Primary care often is thought to be simple; however, the holarchy of health care reveals increasing
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complexity. Lower-order functions are the building
blocks that develop the relationships necessary to
accomplish higher-order functions. Lower-order
functions relate to managing individual problems
based on various kinds of evidence. Higher-order
functions involve more sophisticated prioritizing,
personalizing, integrating, and abiding.
• Although current incentives and systems often
obstruct development toward the higher levels in the
holarchy of health care, high-quality primary care
need not be limited to fundamental functions; with
support it can incorporate the higher levels of integrating and prioritizing and thereby foster healing.
• Knowing this holarchy can help in the design of flexible, personalized health care delivery systems that
foster the most developed care necessary for a given
situation while providing cost-effective simple care
when appropriate.
• Both specialist and generalist approaches are needed
for effective health care. The broader scope of generalists can help focus the more narrowly construed
work of specialists.
• Ongoing care based on understanding and acting on
this holarchical organization of health care is likely to
lead to lower costs, less waste, greater personalization,
greater effectiveness, and greater value in health care.
• Understanding and acting on this holarchy may lead
to less emphasis on health care and more emphasis
on related holarchies of health and the social determinants of health107 that are not about the health
care industry.
• Understanding and acting on this holarchy is likely
to lead to health care that involves greater caring,
and serves as a force for greater personal development and interpersonal and societal solidarity.
JOIN THE EXCHANGE OF IDEAS
We invite readers from diverse fields to comment on
and provide examples that challenge or support the
concept of holons and the holarchical organization of
physical, biological, and social systems. We encourage
readers to consider and comment on the implications
of this knowledge for understanding and improving
health care and health. Please join the discussion at:
http://www.AnnFamMed.org.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/7/5/387.
Key words: Systems theory; models, theoretical; delivery of health
care; primary health care
Funding support: Dr Stange is supported in part by a Clinical Research
Professorship from the American Cancer Society.
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Acknowledgments: Paul Thomas and William Miller provided substantial input on earlier drafts of this manuscript. I regret that I was not able
to fully incorporate their important ideas on this topic. Robin Gotler,
Robert Phillips, Andrew Bazemore, Martey Dodoo, Frank deGruy, Larry
Green also provided helpful comments.
25. Like R, Zyzanski SJ. Patient requests in family practice: a focal
point for clinical negotiations. Fam Pract. 1986;3(4):216-228.
References
26. Cherry DK, Hing E, Woodwell DA, Rechsteiner EA. National
Ambulatory Medical Care Survey: 2006 Summary. Hyattsville, MD:
National Center for Health Statistics; 2008.
1. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100-103.
24. Wilber K. The pattern that connects. In: Sex, Ecology, Spirituality: The Spirit of Evolution. Boston, MA: Shambala Publications;
1995:40-85.
27. Stange KC, Zyzanski SJ, Jaén CR, et al. Illuminating the ’black box’.
A description of 4454 patient visits to 138 family physicians. J Fam
Pract. 1998;46(5):377-389.
2. Stange KC. The generalist approach. Ann Fam Med. 2009;7(3):
198-203.
28. Schneeweiss R, Cherkin DC, Hart LG, et al. Diagnosis clusters
adapted for ICD-9-CM and ICH-2. J Fam Pract. 1986;22(1):69-72.
3. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med.
2009;7(4):293-299.
29. Schneeweiss R, Rosenblatt RA, Cherkin DC, Kirkwood CR, Hart G.
Diagnosis clusters: a new tool for analyzing the content of ambulatory medical care. Med Care. 1983;21(1):105-122.
4. Koestler A, Smythies JR, eds. Beyond Reductionism: New Perspectives on the Life Sciences. Boston, MA: Houghton Mifflin Co; 1971.
5. Weiss PA. The living system: determinism stratified. In: Koestler A,
Smythies JR, eds. Beyond Reductionism: New Perspectives on the Life
Sciences. New York, NY: Beacon Press; 1969.
6. Koessler A. The Ghost in the Machine. New York, NY: The Macmillan Company; 1967.
7. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136.
8. Engel GL. The clinical application of the biopsychosocial model.
Am J Psychiatry. 1980;137:535-544.
9. Stacey RD. Complexity and Creativity in Organizations. San Francisco,
CA: Berrett-Koehler Publishers; 1996.
10. Goldberger AL. Non-linear dynamics for clinicians: chaos theory,
fractals, and complexity at the bedside. Lancet. 1996;347(9011):
1312-1314.
30. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of
death in the United States, 2000. JAMA. 2004;291(10):1238-1245.
31. Stange KC, Flocke SA, Goodwin MA. Opportunistic preventive
services delivery. Are time limitations and patient satisfaction barriers? J Fam Pract. 1998;46(5):419-424.
32. Jaén CR, Crabtree BF, Zyzanski SJ, Goodwin MA, Stange KC. Making time for tobacco cessation counseling. J Fam Pract. 1998;46(5):
425-428.
33. Podl TR, Goodwin MA, Kikano GE, Stange KC. Direct observation
of exercise counseling in community family practice. Am J Prev
Med. 1999;17:207-210.
34. Eaton CB, Goodwin MA, Stange KC. Direct observation of nutrition counseling in community family practice. Am J Prev Med.
2002;23:174-179.
35. Flocke SA, Stange KC, Goodwin MA. Patient and visit characteristics associated with opportunistic preventive services delivery.
J Fam Pract. 1998;47:202-208.
11. Griffiths F, Byrne D. General practice and the new science emerging from the theories of ’chaos’ and complexity. Br J Gen Pract.
1998;48(435):1697-1699.
36. Lawson PJ, Flocke SA. Teachable moments for health behavior
change: a concept analysis. Patient Educ Couns. 2009;76:25-30.
12. Zimmerman B, Lindberg C, Plsek P. Edgeware: Insights From Complexity Science for Health Care Leaders. Irving, TX: VHA, Inc; 1998.
37. Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model
serve also as a template for improving prevention? Milbank Q.
2001;79:579-612.
13. Miller WL, McDaniel RR, Jr, Crabtree BF, Stange KC. Practice jazz:
Understanding variation in family practices using complexity science. J Fam Pract. 2001;50(10):872-878.
38. Wagner EH, Austin BT, Von Korff M. Organizing care for patients
with chronic illness. Milbank Q. 1996;74:511-544.
14. Sturmberg JP. Systems and complexity thinking in general practice. Part 2: application in primary care research. Aust Fam Physician. 2007;36(4):273-275.
39. Wagner EH, Glasgow RE, Davis C, et al. Quality improvement
in chronic illness care: a collaborative approach. Jt Comm J Qual
Improv. 2001;27:63-80.
15. Sweeney K, Griffiths F, eds. Complexity and Healthcare: An Introduction. Abingdon, UK: Radcliffe Medical Press; 2002.
40. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care:
America’s Health in a New Era. Washington, DC: National Academy
Press; 1996:285-311.
16. Holt TA, ed. Complexity for Clinicians. San Francisco, CA: Radcliffe;
2004.
17. Borrell-Carrio F, Suchman AL, Epstein RM. The biopsychosocial
model 25 years later: principles, practice, and scientific inquiry.
Ann Fam Med. 2004;2(6):576-582.
41. Nease DE, Jr., Aikens JE, Schwenk TL. Mental health disorders and
their descriptive criteria in primary care: clarifying or confounding? Primary Care Companion J Clin Psychiatry. 2005;7:89-90.
18. Berkes F, Colding J, Folke C. Navigating Social-Ecological Systems:
Building Resilience for Complexity And Change. Cambridge, MA:
Cambridge University Press; 2008.
42. Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Collaborative
care for depression in primary care—making sense of a complex
intervention: systematic review and meta-regression. Br J Psychiatry. 2006;189:484-493.
19. Wilson T, Holt T, Greenhalgh T. Complexity science: complexity
and clinical care. BMJ. 2001;323(7314):685-688.
20. Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323(7313):625-628.
21. Sturmberg JP. Systems and complexity thinking in general practice:
part 1—clinical application. Aust Fam Physician. 2007;36(4):170-173.
43. Bower P, Rowland N. Effectiveness and cost effectiveness of
counselling in primary care. Cochrane Database Syst Rev. 2006;3:
CD001025.
22. Wilber K. Sex, Ecology, Spirituality: The Spirit of Evolution. Boston,
MA: Shambhala Publications; 1995.
44. Harkness EF, Bower PJ. On-site mental health workers delivering
psychological therapy and psychosocial interventions to patients in
primary care: effects on the professional practice of primary care
providers. Cochrane Database Sys. Rev. 2009;21(1):CD000532.
23. Wilber K. The Integral Vision. Boston, MA: Shambhala Publications;
2007.
45. Medalie JH. Family Medicine: Principles and Applications. Baltimore,
MD: Williams & Wilkins; 1978.
ANNALS O F FAMILY MED ICINE
✦
WWW.A N N FA MME D.O R G
393
✦
VO L. 7, N O. 5
✦
SE P T E MBE R /O CTO BE R 2009
ED I T O R I A L S
46. Mainous AG, III, Goodwin MA, Stange KC. Patient-physician
shared experiences and value patients place on continuity of care.
Ann Fam Med. 2004;2(5):452-454.
68. Hoffman A, Pearson SD. ‘Marginal medicine’: targeting comparative effectiveness research to reduce waste. Health Aff (Millwood).
2009;28(4):w710-w718.
47. Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Continuity of primary care: to whom does it matter and when? Ann
Fam Med. 2003;1(3):149-155.
69. Gunn J, Naccarella L, Palmer V, Kokanovic R, Pope C, Lathlean J.
What is the Place of Generalism in the 2020 Primary health care
team? Australian Primary Health Care Research Institute. 2008.
http://www.anu.edu.au/aphcri/Domain/Workforce/Perkins_25_
final.pdf. Accessed Jan 12, 2009.
48. Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health
services. Ann Fam Med. 2009;7(4):357-363.
70. Heath I, Sweeney K. Medical generalists: connecting the map and
the territory. BMJ. 2005;331(7530):1462-1464.
49. Tinetti ME, Bogardus ST, Jr., Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N
Eng. J Med. 2004;351(27):2870-2874.
71. Weiner SJ. Contextualizing medical decisions to individualize care:
lessons from the qualitative sciences. J Gen Intern Med. 2004;
19(3):281-285.
50. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence
of multimorbidity among adults seen in family practice. Ann Fam
Med. 2005;3(3):223-228.
72. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. Rev ed. New York, NY: Oxford University Press; 1998.
51. Beasley JW, Hankey TH, Erickson R, et al. How many problems do
family physicians manage at each encounter? A WReN study. Ann
Fam Med. 2004;2(5):405-410.
73. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary
Care: America’s Health in a New Era. Washington, DC: National
Academy Press; 1996.
52. Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in
the family practice office visit. J Fam Pract. 2001;50(30:211-216.
74. Egnew TR. The meaning of healing: transcending suffering. Ann
Fam Med. 2005;3(3):255-262.
53. Fortin M, Dionne J, Pinho G, Gignac J, Almirall J, Lapointe L. Randomized controlled trials: do they have external validity for patients
with multiple comorbidities? Ann Fam Med. 2006;4(2):104-108.
75. Egnew TR. Suffering, meaning, and healing: challenges of contemporary medicine. Ann Fam Med. 2009;7(2):170-175.
54. Nutting PA. Why can’t clinical policies be relevant to practice? J
Fam Pract. 1997;44(4):350-352.
76. Scott JG, Cohen D, Dicicco-Bloom B, Miller WL, Stange KC, Crabtree BF. Understanding healing relationships in primary care. Ann
Fam Med. 2008;6(4):315-322.
55. Schwenk TL. Competing priorities and comorbidities. So much to
do and so little time. Arch Fam Med. 1997;6(3):238-239.
77. Farber SJ, Egnew TR, Herman-Bertsch JL. Defining effective clinician roles in end-of-life care. J Fam Pract. 2002;51(2):153-158.
56. Woolf SH, Stange KC. A sense of priorities for the health care commons. Am J Prev Med. 2006;31(1):99-102.
78. Scitovsky AA. “The high cost of dying”: what do the data show?
1984. Milbank Q. 2005;83(4):825-841.
57. Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care.
2002;14(4):267-268.
79. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder
EL. The implications of regional variations in Medicare spending.
Part 2: health outcomes and satisfaction with care. Ann Intern Med.
2003;138(4):288-298.
58. Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ.
The value of a family physician. J Fam Pract. 1998;46(5):363-368.
80. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder
EL. The implications of regional variations in Medicare spending.
Part 1: the content, quality, and accessibility of care. Ann Intern
Med. 2003;138(4):273-287.
59. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive
services: results of a systematic review and analysis. Am J Prev Med.
2006;31(1):52-61.
81. Epstein RM, Fiscella K, Lesser C, Stange KC. Defining and achieving patient-centered care: the role of clinicians, patients and
healthcare systems. Health Aff (Millwood). In press.
60. Starfield B. Primary care and health: A cross-national comparison.
JAMA. 1991;266(16):2268-2271.
82. McCullough LB. The physician’s virtues and legitimate selfinterest in the patient-physician contract. Mt Sinai J Med. 1993;
60(1):11-14.
61. Starfield B, Shi L, Macinko J. Contribution of primary care to
health systems and health. Milbank Q. 2005;83(3):457-502.
62. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Aff (Millwood).
2004;Suppl Web Exclusives:W184-W197.
83. Sox HC; ABIM Foundation. American Board of Internal Medicine;
ACP-ASIM Foundation. American College of Physicians-American
Society of Internal Medicine; European Federation of Internal
Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.
63. Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource
utilization among medical specialties and systems of care. Results
from the medical outcomes study. JAMA. 1992;267(12):1624-1630.
84. Sandy LG, Schroeder SA. Primary care in a new era: disillusion and
dissolution? Ann Intern Med. 2003;138(3):262-267.
64. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov
AR. Outcomes of patients with hypertension and non-insulindependent diabetes mellitus treated by different systems and
specialties: results from the medical outcomes study. JAMA.
1995;274(18):1436-1444.
85. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953-957.
86. Davis K. Paying for care episodes and care coordination. N Engl J
Med. 2007;356(11):1166-1168.
65. Franks P, Clancy CM, Nutting PA. Gatekeeping revisited—protecting patients from overtreatment. N Engl J Med.
1992;327(6):424-429.
87. Starfield B, Shi LY, Macinko J. Contribution of primary care to
health systems and health. Milbank Q. 2005;83(3):457-502.
66. Flocke SA, Goodwin MA, Stange KC. The effect of a secondary
patient on the family practice visit. J Fam Pract. 1998;46(5):429-434.
88. Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner
JP. Comorbidity: implications for the importance of primary care in
‘case’ management. Ann Fam Med. 2003;1(1):8-14.
67. Orzano AJ, Gregory PM, Nutting PA, Werner JJ, Flocke SA, Stange
KC. Care of the secondary patient in family practice. A report
from the Ambulatory Sentinel Practice Network. J Fam Pract.
2001;50(2):113-116.
ANNALS O F FAMILY MED ICINE
✦
89. Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G.
Comorbidity and the use of primary care and specialist care in the
elderly. Ann Fam Med. 2005;3(3):215-222.
WWW.A N N FA MME D.O R G
394
✦
VO L. 7, N O. 5
✦
SE P T E MBE R /O CTO BE R 2009
ED I T O R I A L S
99. Stange KC. Polyclinics must integrate health care vertically AND
horizontally. Lond J Prim Care. 2008;1:42-44.
90. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist
supply on populations’ health: assessing the evidence. Health Aff
(Millwood). 2005;(Suppl Web Exclusives):W5-97-W95-107.
100. Thomas P, Meads G, Moustafa A, Nazareth I, Stange KC. Combined vertical and horizontal integration of health care—a goal of
practice based commissioning. Qual Prim Care. 2008;16(6):425-432.
91. Maslow A, ed. Motivation and Personality. New York, NY: Harper;
1954.
101. Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M. Alma-Ata
30 years on: revolutionary, relevant, and time to revitalise. Lancet.
2008;372(9642):917-927.
92. Maslow A. The Farther Reaches of Human Nature. New York, NY:
Viking Press; 1971.
93. Wahba A, Bridgewell L. Maslow reconsidered: A review of
research on the need hierarchy theory. Organ Behav Hum Perform.
1976;14:212-240.
102. Stange KC, Nutting PA, Miller WL, et al. Definging and measuring
the patient-centered medical home. J Gen Intern Med. In press.
103. Declaration of Alma-Ata. International conference on primary
health care, Alma-Ata, USSR, 6-12 September 1978. 1978. http://
www.who.int/hpr/NPH/docs/declaration_almaata.pdf, Accessed
Sept 26, 2008.
94. McDaniel RR Jr, Jordan ME, Fleeman BF. Surprise, Surprise, Surprise! A complexity science view of the unexpected. Health Care
Manage Rev. 2003;28(3):266-278.
95. Crabtree BF. Primary care practices are full of surprises! Health
Care Manage Rev. 2003;28(3):279-283, discussion 289-290.
96. Glass TA, McAtee MJ. Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Soc Sci Med.
2006;62(7):1650-1671.
104. Seedhouse D. Health: The Foundations for Achievement. 2nd ed.
New York, NY: Wiley; 2001.
105. Berry W. Life Is a Miracle: An Essay Against Modern Superstition.
Washington, DC: Counterpoint; 2000.
97. Van der Geest S, Speckmann JD, Streefland PH. Primary health
care in a multi-level perspective: towards a research agenda. Soc
Sci Med. 1990;30(9):1025-1034.
106. Fine M, Peters JW. The Nature of Health: How America Lost, and Can
Regain, A Basic Human Value. Abingdon, Oxfordshire: Radcliffe Publishing Limited; 2007.
98. De Maeseneer J, van Weel C, Egilman D, Mfenyana K, Kaufman A,
Sewankambo N. Strengthening primary care: addressing the disparity between vertical and horizontal investment. Br J Gen Pract.
2008;58(546):3-4.
107. World Health Organization. Commission on Social Determinants of
Health—Final Report. 2008. http://www.who.int/social_determinants/final_report/en/index.html. Accessed January 30, 2009.
ANNALS O F FAMILY MED ICINE
✦
WWW.A N N FA MME D.O R G
395
✦
VO L. 7, N O. 5
✦
SE P T E MBE R /O CTO BE R 2009