Mapping Primary Care: Putting Our Patients in Context

摘要

id="p1">“Stone, kidney disease, strangury, and sciatica are very apt to attack people, and ruptures occur, when they drink water of very many different kinds, or from large rivers, into which other rivers flow, or from a lake fed by many streams of various sorts, and whenever they use foreign waters coming from a great, not a short, distance. […] Such waters then must leave a sediment of mud and sand in the vessels, and drinking them causes the diseases mentioned before. …” —Hippocrates, On Air, Waters, Places (Part 9)id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1 id="p-2">Hippocrates, writing circa 400 class="sc">bc, said that one's health depends on the air one breathes, the water one drinks, and the environment in which one lives. Place matters in health. In several articles in this issue of the Journal of the American Board of Family Medicine, authors explore the ways in which place matters for practicing clinicians, medical educators, and primary care researchers. id="p-3">Knowing a patient's context can make the difference between just treating a child's injury and also calling protective services. Before my present position at the University of Virginia I worked in rural Alaska. I remember being in the emergency department one night when a mother from an Eskimo village brought her toddler in for treatment for burns on his feet. The boy had circumferential, second-degree burns on his feet and ankles and looked as though he had been dipped feet-first into a pot of boiling water. Mom said the child had jumped into a pot of freshly boiled water that had been on the floor. id="p-4">I had flown out to this village and made a number of home visits. I remembered visiting a patient with disseminated tuberculosis, sitting with her on the floor as she butchered a seal and rendered its fat on a camping stove. Stepping into a pot of boiling water on the floor is easy to do under those circumstances. id="p-5">Harder to do is taking my advice to increase your physical activity by walking in your neighborhood for 30 minutes several times a week, as I recently advised a patient of mine. When I asked her several weeks later why she hadn’t started the new exercise, she told me she didn’t feel safe doing it. “Is there a lot of crime in your neighborhood?” I asked. “No, doc,” she said. “There are no sidewalks and no streetlights.” A few minutes of looking at Google Earth before talking to this patient about walking exercise on her neighborhood streets would have made for better advice from the start. id="p-6">Experiences like these make Ethan Berke'sid="xref-ref-2-1" class="xref-bibr" href="#ref-2">2 suggestion that we use place as a vital sign in everyday clinical practice ring true. He explains that understanding a patient's geographic context helps shape clinical decision making and treatment choices. Dr. Berke provides an extremely helpful overview of the importance of geographic information systems (GIS) science and technology to primary care research and practice. Dr. Berke describes early uses of geographic information in disease surveillance and the growing use of GIS in today's public and population health. GIS provide a powerful set of tools for understanding health risks to populations and for planning and evaluating interventions to improve population health. id="p-7">The recent epidemic of the novel H1N1 influenza underscores the importance of disease surveillance to help direct health systems’ resource allocation and to keep communities informed regarding disease risk. In their article, Horst and Cocoid="xref-ref-3-1" class="xref-bibr" href="#ref-3">3 report on a feasibility study they conducted to assess the usefulness of GIS in tracking common illnesses seen in primary care offices and emergency departments. Using data from 26 primary care sites and 1 emergency department in a single health care system, these researchers tracked common respiratory and gastrointestinal syndromes during a 13-month period. Horst and Coco identified clusters of these illnesses during specific time periods and locations within their defined community. Theses authors feel that understanding the temporal and spatial variability of these illnesses may aid in health resource allocation. id="p-8">The usefulness of GIS technology in primary care research and practice is further demonstrated in several other articles in this issue of the JABFM. Dulin et alid="xref-ref-4-1" class="xref-bibr" href="#ref-4">4 report an exciting and innovative use of GIS as a tool for assessing a community's present and future primary care needs. Working in a community-based participatory research framework, these researchers collaborated with community-based physicians (through a practice-based research network), community organizations, and key community leaders to develop a meth