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Refocusing Knowledge Generation, Application, and Education

Raising Our Gaze to Promote Health Across Boundaries
  • Kurt C. Stange
    Correspondence
    Address correspondence to: Kurt C. Stange, MD, PhD, Department of Family Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland OH 44106
    Affiliations
    Case Western Reserve University Departments of Family Medicine, Epidemiology & Biostatistics and Sociology, the Case Comprehensive Cancer Center, the Cleveland Clinical & Translational Science Collaborative, Cleveland, Ohio and the Division of Cancer Control and Population Sciences at the National Cancer Institute, Bethesda, Maryland
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      Those educating healthcare professionals face the undeniable challenge that the current U.S. healthcare system is untenable.
      IOM. Committee on Quality of Health Care in America
      Crossing the quality chasm: a new health system for the 21st century.
      U.S. health care epitomizes low value, spending more than any other country while ranked 37th in the world—between Costa Rica and Slovenia—in its ability to equitably engender health.
      WHO
      Press Release WHO/44: World Health Organization assesses the world's health systems.
      The September 14–15, 2010, conference on Patients and Populations: Public Health in Medical Education, sponsored by the Association of American Medical Colleges (AAMC) and the CDC, provided inspiring examples from those who are trying to show the healthcare professionals of the future a better way.
      With U.S. healthcare spending American business into noncompetitiveness,
      Congress of the United States, Congressional Budget Office
      The Long-Term Outlook for Health Care Spending.
      mortgaging not only our children's but our grandchildren's futures, the task is more than to bring a public health understanding into the mainstream of research and medical education.
      • Maeshiro R.
      • Johnson I.
      • Koo D.
      • et al.
      Medical education for a healthier population: reflections on the Flexner Report from a public health perspective.
      • Maeshiro R.
      Responding to the challenge: population health education for physicians.
      • Maeshiro R.
      Public health practice and academic medicine: promising partnerships regional medicine public health education centers—two cycles.
      The urgent need is to inspire and enable the younger generation to spring over the current dysfunctional medico-industrial complex, to bubble up diverse new streams that together create a torrential delta of change, so that quality health care becomes about both health and caring, accessible to all, while still leaving resources to strengthen the social and environmental determinants of health.
      • Maeshiro R.
      Responding to the challenge: population health education for physicians.
      This daunting task—providing high-value health care for all while spending less and doing more to improve the actual health of the population—requires a different way of understanding health care and health than the current biomedical model. It requires a more inclusive way of framing the generation of new knowledge and of applying that knowledge in education and practice. This reframing involves raising the gaze and spanning boundaries.

      Raising the Gaze

      A reductionist biomedical enterprise has made impressive strides in understanding disease mechanisms and in curing or ameliorating certain diseases.
      • Pauli H.G.
      • White K.L.
      • McWhinney I.R.
      Medical education, research, and scientific thinking in the 21st century (part three of three).
      • Lesko L.J.
      Personalized medicine: elusive dream or imminent reality?.
      • Shaw S.E.
      • Greenhalgh T.
      Best research—for what? Best health—for whom? A critical exploration of primary care research using discourse analysis.
      But as the predominant health problems increasingly relate to chronic more than acute illness
      • Mokdad A.H.
      • Marks J.S.
      • Stroup D.F.
      • Gerberding J.L.
      Actual causes of death in the U.S., 2000.
      ; as multimorbidity becomes the norm in an aging population
      • Fortin M.
      • Bravo G.
      • Hudon C.
      • Vanasse A.
      • Lapointe L.
      Prevalence of multimorbidity among adults seen in family practice.
      • Fortin M.
      • Soubhi H.
      • Hudon C.
      • Bayliss E.A.
      • van den Akker M.
      Multimorbidity's many challenges Time to focus on the needs of this vulnerable and growing population.
      • Valderas J.M.
      • Starfield B.
      • Sibbald B.
      • Salisbury C.
      • Roland M.
      Defining comorbidity: implications for understanding health and health services.
      • Tinetti M.E.
      • Bogardus Jr, S.T.
      • Agostini J.V.
      Potential pitfalls of disease-specific guidelines for patients with multiple conditions.
      ; as health behavior, the education and employment of the population, and other social and environmental determinants become the predominant drivers of health
      WHO
      Commission on Social Determinants of Health—Final Report.
      ; a fragmented approach to understanding and advancing health becomes less and less effective, and the need for a complementary more inclusive approach has become more apparent.
      • Pauli H.G.
      • White K.L.
      • McWhinney I.R.
      Medical education, research, and scientific thinking in the 21st century (part three of three).
      • Bulger R.J.
      Reductionist biology and population medicine—strange bedfellows or a marriage made in heaven?.
      • Sturmberg J.P.
      Systems and complexity thinking in general practice: part 1—clinical application.
      A different lens with which to see the problem becomes vital.
      • Stange K.C.
      Editorial series on integrative approaches to promoting health and personalized, high-value health care: a science of connectedness and the practice of generalism.
      • Stange K.C.
      Ways of knowing, learning, and developing.
      This lens not only focuses on smaller and smaller parts, but also elevates the gaze upward—from molecule to person, from person to system, system to community, community to environment.
      • Stange K.C.
      The problem of fragmentation and the need for integrative solutions.
      Shown in Figure 1 as four circles, a gaze that takes in the broad factors affecting health includes: individuals and families, primary health care, healthcare systems, public health, and communities. This elevated view recognizes that people live in a social context and their health is more than the sum of their diseases.
      WHO
      Declaration of Alma-Ata: International conference on primary health care, Alma-Ata, USSR, 6–12 September 1978.
      It recognizes that healthcare systems based on primary care have better population health, higher-quality health care at lower cost, and less inequality than systems based on more fractured approaches.
      • Starfield B.
      • Shi L.Y.
      • Macinko J.
      Contribution of primary care to health systems and health.
      • Donaldson M.S.
      • Yordy K.D.
      • Lohr K.N.
      • Vanselow N.A.
      Primary care: America's health in a new era.
      • Friedberg M.W.
      • Hussey P.S.
      • Schneider E.C.
      Primary care: a critical review of the evidence on quality and costs of health care.
      It lends a systems perspective to health care, public health, and community.
      As Risa Lavizzo-Mourey and David Williams note in an article in another recent supplement to the American Journal of Preventive Medicine: There is more to health than health care. Where we live, work, learn, and play can affect our health more than what happens in the physician's office. Yet, ask our national leaders, “What determines health?” and you'll hear about access to health care. As vital as health care and healthcare reform are, they are just part of the answer.
      • Lavizzo-Mourey R.
      • Williams D.R.
      Strong medicine for a healthier America: introduction.
      Moving beyond health care to a broader view of health as a state that enables people to do valued life activities can totally reframe our health promotion efforts. Health can be understood as:
      • a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity;
      • a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities
        First International Conference on Health Promotion
        Ottawa Charter for Health Promotion.
        ;
      • conditions that enable a person to work to achieve his or her biological and chosen potential
        • Seedhouse D.
        Health: the foundations for achievement.
        ;
      • membership in community
        • Berry W.
        Health is membership.
        ;
      • the biological, social, and psychological ability that affords an equal opportunity for each individual to function in the relationships appropriate to his or her cultural context at any point in the life cycle
        • Fine M.
        • Peters J.W.
        The nature of health: how America lost, and can regain, a basic human value.
        ;
      • the ability to develop meaningful relationships and pursue a transcendent purpose in a finite life.
        • Stange K.C.
        Power to advocate for health.
      Any of these inclusive, grounded, meaningful definitions of health helps to refocus energy toward solutions to the U.S. health and healthcare crisis, rather than toward more of the same. The enabling importance of focusing on health is indicated in Figure 1 by its centrality.

      Boundary Spanning

      Boundary spanning is reaching across borders to “build relationships, interconnections, and interdependencies”
      • Williams P.T.
      The competent boundary spanner.
      in order to manage complex problems. Boundary-spanning individuals develop partnerships and collaboration by “building sustainable relationships, managing through influence and negotiation, and seeking to understand motives, roles, and responsibilities.”
      • Williams P.T.
      The competent boundary spanner.
      Boundary-spanning organizations
      • Levina N.
      • Vaast E.
      The emergence of boundary spanning competence in practice: implications for information systems' implementation and use.
      create “strategic alliances, joint working arrangements, networks, partnerships, and many other forms of collaboration across organizational boundaries.”
      • Williams P.T.
      The competent boundary spanner.
      Boundary spanning can be a source of innovation and of solving the problems created by working narrowly.
      • Aldrich H.
      • Herker D.
      Boundary spanning roles and organization structure.
      • Miller P.M.
      Examining the work of boundary spanning leaders in community contexts.
      • Weerts D.J.
      • Sandmann L.R.
      Community engagement and boundary-spanning roles at research universities.
      • Hsu S.-H.
      • Wang Y.-C.
      • Tzeng S.F.
      The source of innovation: boundary spanner.
      Transdisciplinary,
      • Warnecke R.B.
      • Oh A.
      • Breen N.
      • et al.
      Approaching health disparities from a population perspective: the National Institutes of Health Centers for Population Health and Health Disparities.
      • Syme S.L.
      The science of team science: assessing the value of transdisciplinary research.
      • Stokols D.
      • Misra S.
      • Moser R.P.
      • Hall K.L.
      • Taylor B.K.
      The ecology of team science: understanding contextual influences on transdisciplinary collaboration.
      • Nash J.M.
      Transdisciplinary training: key components and prerequisites for success.
      • Mabry P.L.
      • Olster D.H.
      • Morgan G.D.
      • Abrams D.B.
      Interdisciplinarity and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research.
      • Klein J.T.
      Evaluation of interdisciplinary and transdisciplinary research: a literature review.
      • Kessel F.
      • Rosenfield P.L.
      Toward transdisciplinary research: historical and contemporary perspectives.
      • Harper G.W.
      • Neubauer L.C.
      • Bangi A.K.
      • Francisco V.T.
      Transdisciplinary research and evaluation for community health initiatives.
      • Emmons K.M.
      • Viswanath K.
      • Colditz G.A.
      The role of transdisciplinary collaboration in translating and disseminating health research: lessons learned and exemplars of success.
      • Croyle R.T.
      The National Cancer Institute's transdisciplinary centers initiatives and the need for building a science of team science.
      • Stokols D.
      Toward a science of transdisciplinary action research.
      multilevel
      • Petermann L.
      • Petz G.
      The E2D2 model: a dynamic approach to cancer prevention interventions.
      • Schensul J.J.
      Community, culture and sustainability in multilevel dynamic systems intervention science.
      • Taplin S.H.
      • Rodgers A.B.
      Toward improving the quality of cancer care: addressing the interfaces of primary and oncology-related subspecialty care.
      research, education, and practice, and boundary-spanning efforts to promote health
      • Richter A.W.
      • West M.A.
      • Dick R.V.
      • Dawson J.F.
      Boundary spanners' identification, intergroup contact, and effective intergroup relations.
      have great potential to build on the strengths of more narrowly focused approaches, while transcending their weaknesses.
      • Burt R.S.
      Structural holes and good ideas.
      Many of these boundaries relate to crossing ideologies, disciplines, cultures, markets, peoples, and entrenched worldviews. As shown in Figure 1 and outlined in the following list, important boundaries to span to advance health relate to (1) personalized health care; (2) healing environments; (3) responsible, evolvable organizations; and (4) healthy environments.
      • 1
        Personalized health care—a relationship between a clinician and care team with the individual and family that includes:
        • Donaldson M.S.
        • Yordy K.D.
        • Lohr K.N.
        • Vanselow N.A.
        Primary care: America's health in a new era.
        • Stange K.C.
        • Nutting P.A.
        • Miller W.L.
        • et al.
        Defining and measuring the patient-centered medical home.
        • accessibility as the first contact with the healthcare system;
        • a comprehensive whole-person approach;
        • coordination of care across settings, and integration of care of acute and chronic illnesses, mental health and prevention;
        • a sustained partnership over time.
      • 2
        Healing environments—restorative settings and conditions, including:
        • trustworthy, invested interpersonal and interorganizational relationships;
        • situations that enable a balance of action and reflection;
        • physical space that provides access to nature, light, privacy, or positive sensory experience;
        • meaningful work or activity.
      • 3
        Responsible organizations move beyond sustaining past successes to continued development based on making sense of a rapidly changing environment—moving from sustainability to evolvability. Such organizations enable health by:
        • following sound environmental procedures;
        • operating with integrity;
        • being accountable to employees, customers, vendors, and the communities in which they operate;
        • recognizing the impact of their actions on the physical, emotional, and social well-being of individuals and communities;
        • developing to meet emerging needs and conditions.
      • 4
        Healthy environments—physical and social surroundings that foster health, including:
        • clean air, water, and sanitation;
        • affordable, accessible, nutritious food, especially fruits and vegetables;
        • safe, affordable, comfortable, and pest-free housing;
        • safe, spacious areas for walking;
        • crime-free neighborhoods and violence-free homes;
        • economic opportunities;
        • affordable and available education.

      Generating and Learning the Relevant Knowledge

      Fortunately, different ways of knowing
      • Stange K.C.
      Ways of knowing, learning, and developing.
      and of generating knowledge
      • Stange K.C.
      A science of connectedness.
      • Stange K.C.
      • Miller W.L.
      • McWhinney I.
      Developing the knowledge base of family practice.
      are emerging. These emergent approaches have great potential to complement the dominant reductionist models of knowledge generation and use
      • Polanyi M.
      Personal knowledge: towards a post-critical philosophy.
      • McWhinney I.R.
      Medical knowledge and the rise of technology.
      • Best A.
      • Hiatt R.A.
      • Norman C.D.
      Knowledge integration: conceptualizing communications in cancer control systems.
      • Wenger E.
      • McDermott R.A.
      • Snyder W.
      Cultivating communities of practice: a guide to managing knowledge.
      to enable boundary spanning that advances health. The new models include participatory
      • Schensul J.J.
      Community, culture and sustainability in multilevel dynamic systems intervention science.
      • Minkler M.
      • Wallerstein N.
      Community-based participatory research for health: from process to outcomes.
      • Green L.W.
      Making research relevant: if it is an evidence-based practice, where's the practice-based evidence?.
      • Cargo M.
      • Mercer S.L.
      The value and challenges of participatory research: strengthening its practice.
      • Israel B.A.
      • Eng E.
      • Schulz A.J.
      • Parker E.A.
      Methods in community-based participatory research for health.
      • Macaulay A.C.
      • Commanda L.E.
      • Freeman W.L.
      • et al.
      Participatory research maximises community and lay involvement North American Primary Care Research Group.
      and practice-based network research,
      • Green L.W.
      Making research relevant: if it is an evidence-based practice, where's the practice-based evidence?.
      Agency for Healthcare Research and Quality
      AHRQ Support for Primary Care Practice-Based Research Networks (PBRNs).
      • Fagnan L.J.
      • Handley M.A.
      • Rollins N.
      • Mold J.
      Voices from left of the dial: reflections of practice-based researchers.
      • Fagan L.J.
      • Davis M.
      • Deyo R.A.
      • Werner J.J.
      • Stange K.C.
      Linking practice-based research networks and Clinical and Transitional Science Awards: new opportunities for community engagement by academic health centers.
      • Westfall J.M.
      • Fagnan L.J.
      • Handley M.
      • et al.
      Practice-based research is community engagement.
      • Baker E.A.
      • Brennan Ramirez L.K.
      • Claus J.M.
      • Land G.
      Translating and disseminating research- and practice-based criteria to support evidence-based intervention planning.
      • Westfall J.M.
      • Mold J.
      • Fagnan L.
      Practice-based research—“Blue Highways” on the NIH roadmap.
      • Westfall J.M.
      • VanVorts R.F.
      • Main D.S.
      • Herbert C.
      Community-based participatory research in practice-based research networks.
      • Macaulay A.C.
      • Nutting P.A.
      Moving the frontiers forward: incorporating community-based participatory research into practice-based research networks.
      • Mold J.W.
      • Peterson K.A.
      Primary care practice-based research networks: working at the interface between research and quality improvement.
      • Nutting P.A.
      • Beasley J.W.
      • Werner J.J.
      Practice-based research networks answer primary care questions.
      • Thomas P.
      • Griffiths F.
      • Kai J.
      • O'Dwyer A.
      Networks for research in primary health care.
      multimethod approaches that integrate quantitative and qualitative methods,
      • Stange K.C.
      • Crabtree B.F.
      • Miller W.L.
      Publishing multimethod research.
      • Stange K.C.
      • Miller W.L.
      • Crabtree B.F.
      • O'Connor P.J.
      • Zyzanski S.J.
      Multimethod research: approaches for integrating qualitative and quantitative methods.
      • Crabtree B.F.
      • Miller W.L.
      • Addison R.B.
      • Gilchrist V.J.
      • Kuzel A.
      Part III: the search for multimethod research.
      • Pawson R.
      • Greenhalgh T.
      • Harvey G.
      • Walshe K.
      Realist review—a new method of systematic review designed for complex policy interventions.
      • Creswell J.W.
      • Fetters M.D.
      • Ivankova N.V.
      Designing a mixed methods study in primary care.
      • Borkan J.M.
      Mixed methods studies: a foundation for primary care research.
      • Creswell J.W.
      Research design: qualitative, quantitative, and mixed methods approaches.
      and theories that recognize the complex adaptive nature of the systems that relate to health and health care.
      • Valderas J.M.
      • Starfield B.
      • Sibbald B.
      • Salisbury C.
      • Roland M.
      Defining comorbidity: implications for understanding health and health services.
      • Pawson R.
      • Greenhalgh T.
      • Harvey G.
      • Walshe K.
      Realist review—a new method of systematic review designed for complex policy interventions.
      • Sturmberg J.P.
      • Martin C.M.
      Complexity and health—yesterday's traditions, tomorrow's future.
      • Peek C.J.
      Integrating care for persons, not only diseases.
      • Miles A.
      Complexity in medicine and healthcare: people and systems, theory and practice.
      • Heath I.
      • Rubinstein A.
      • Stange K.C.
      • van Driel M.L.
      Quality in primary health care: a multidimensional approach to complexity.
      • Leischow S.J.
      • Best A.
      • Trochim W.M.
      • et al.
      Systems thinking to improve the public's health.
      • Berkes F.
      • Colding J.
      • Folke C.
      Navigating social-ecological systems: building resilience for complexity and change.
      • Wilson T.
      • Holt T.
      • Greenhalgh T.
      Complexity science: complexity and clinical care.
      • Plsek P.E.
      • Wilson T.
      Complexity, leadership, and management in healthcare organisations.
      • Plsek P.E.
      • Greenhalgh T.
      Complexity science: the challenge of complexity in health care.
      • Miller W.L.
      • McDaniel Jr, R.R.
      • Crabtree B.F.
      • Stange K.C.
      Practice jazz: understanding variation in family practices using complexity science.
      • Albrecht G.
      • Freeman S.
      • Higginbotham N.
      Complexity and human health: the case for a transdisciplinary paradigm.
      • Campbell M.
      • Fitzpatrick R.
      • Haines A.
      • et al.
      Framework for design and evaluation of complex interventions to improve health.
      Glimmers of support for these more inclusive approaches to research are seen in the NIH Clinical and Translational Science Awards, CDC Prevention Research Centers, and the AAMC–CDC Cooperative Agreement that led to this journal supplement. Even the comparative effectiveness research movement
      • Volpp K.G.
      • Das A.
      Comparative effectiveness—thinking beyond medication A versus medication B.
      • Iglehart J.K.
      Prioritizing comparative-effectiveness research—IOM recommendations.
      • Hoffman A.
      • Pearson S.D.
      “Marginal medicine”: targeting comparative effectiveness research to reduce waste.
      • Conway P.H.
      • Clancy C.
      Comparative-effectiveness research—implications of the Federal Coordinating Council's report.
      has potential to step in a more systemic direction as it struggles to move from a focus on drugs and devices
      • Volpp K.G.
      • Das A.
      Comparative effectiveness—thinking beyond medication A versus medication B.
      to comparing different systems affecting health care and health.
      • Glasgow R.E.
      • Steiner J.S.
      Comparative effectiveness research that translates.
      I invite readers who are interested in the emerging effects of boundary spanning and health to share your own stories or knowledge from other sources at the website of the Promoting Health Across Boundaries initiative (www.PHAB.us).
      Daniel Federman, in his address at the 2007 American Association of Medical Colleges Annual Meeting commented: I believe we should enlist some medical students as agents of change, committed to designing a system of care that is equitable, cost-effective, prevention-oriented, universal, and thus moral. I suggest … an activist focus, and consistent mentoring.
      • Maeshiro R.
      Responding to the challenge: population health education for physicians.
      The 2010 conference on Patients and Populations: Public Health in Medical Education advanced this vision beyond medical students to include multiple disciplines, generations, organizations, and communities that care about health. The hard work of the boundary spanner is needed in research, education, systems development, and practice. Combined with an inclusive view of health and an elevated gaze, there is great cause for hope.
      • Stange K.C.
      Power to advocate for health.
      Mary Ruhe and Heide Aungst helped to develop many of the ideas contained in this manuscript. Dr. Stange's time is supported in part by a Clinical Research Professorship from the American Cancer Society, by the Intergovernmental Personnel Act Mobility Program through the Division of Cancer Control and Population Sciences at the National Cancer Institute, and by the Case Western Reserve University/Cleveland Clinic Clinical and Translational Science Collaborative, Grant Number UL1 RR024989 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health and NIH roadmap for Medical Research. Its contents are solely the responsibility of the author and do not necessarily represent the official view of NCRR, the NIH, or the ACS. The opinions expressed in this article do not necessarily represent those of the National Cancer Institute.
      Publication of this article was supported by the CDC-AAMC ( Association of American Medical Colleges ) Cooperative Agreement number 5U36CD319276 .
      No financial disclosures were reported by the author of this paper.

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