Understanding Variation in Practice
Countries with greater proportions of primary care (and all the content of care variability we know goes with that) have better overall health status, even after controlling for demographics and socioeconomic factors.1 This is true even though there is good evidence that specialists generate better disease-specific process of care measures than generalists.2 This apparent anomaly is not a surprise from a complexity science point of view. The health of a complex adaptive system, such as a human organism, a community, a practice, or an ecological system is always much, much more than the sum of its parts. There are so many interconnections, delayed feedback loops, altered communications, and chance occurrences, and each part of any system has its own peculiar outcomes. This is why standardization, from an evolutionary point of view, always leads to extinction as environmental niches open and close. There is more to health than the control of disease.
We continue to assert that variation in all things is good but that some variations are better than others and some are harmful. Thus, the real challenge for family practice is to establish better systems of ongoing scrutiny of care as it relates to patients, communities, and practices. More than ever, there is a need for all practices to become part of some participatory practice-based research network. This research will need to include measures of system outcomes. Family physicians have always known that there is more than one appropriate way to care for each patient. Our study supports this intuition. Now, it is our responsibility to be sure that the many ways are all good.
William L. Miller, MD, MA
Benjamin F. Crabtree, PhD
Kurt C. Stange, MD, PhD
- Starfield B. Is US health really the best in the world? JAMA 2000; 284:483-5.
- Harrold L, Field T, Gurwitz J. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med 1999; 14:499-511.
