Family Doctor, Researcher, and Former Editor of Annals of Family Medicine
A rural family doctor led astray, an accidental academic, a reluctant editor, he became a garlanded leader of the profession.
Kurt C. Stange, MD, PhD is a family and public health physician. At Case Western Reserve University he is a member of the Center for Community Health Integration (CHI Center), which conducts collaborative Research & Development for Community Health and Integrated, Personalized Care. He is a Distinguished University Professor, and is the Dorothy Jones Weatherhead Professor of Medicine, and Professor of Family Medicine & Community Health, Population & Quantitative Health Sciences, Oncology and Sociology. With Rebecca Etz, PhD, he serves as Co-Director for the Larry A. Green Center for Advancing Primary Health Care for the Public Good. He is interested in how the generalist function and the personal physician make a difference in people’s lives. He is a member of the Academy of Medicine of the US National Academy of Sciences.
Watch the video, listen to the podcast, read the transcript below
“Family physicians are always looking at the parts in their larger context, and moving back and forth between the parts and the whole. There’s a magic in that, that we don’t fully understand.”
Crabtree BF, Miller WL. Doing Qualitative Research. 3rd ed. Sage Publications; 2023
You’ve had a very influential career in family medicine in the US. Tell me where it all began.
Kurt Stange: It began, I think, with Miss Kunzog, my high school biology teacher. When I was a freshman in high school, she said they needed someone to take pictures for the yearbook. And so I did that for four years, joined a new photography business, and that was going to be my career. I was going to be a photographer using film which, in retrospect, looks like a really bad business plan. I did that for a while and thought to myself, ‘I like this, but I can’t imagine doing this when I’m old, like, when I’m 40. What would I really like to do?’ And I thought – well, I like this biology I’m learning from Miss Kunzog, and I want to work for people. Biology and people. I should become a doctor. And a family doctor was my idea of what a doctor was. So that’s where it started for me.
DMacA: Tell me about the progression, university, training in primary care, how did that all work out?
KS: I applied to 17 medical schools and only got into one. I was so happy to be there. I said to myself, I’m not studying for an exam ever again. In every lecture, I would ask – how would a patient present? Biochemistry, epidemiology, whatever it was. So that’s what I did in medical school. And it was clear to me that this is what I was meant to be. And I went from medical school in Albany, to Duke where I did a family medicine residency, and I joined the faculty and a private practice part time while I went down the road to Chapel Hill, University of North Carolina, and did preventive medicine, public health training. And I did that basically to allow my wife to finish her training in pathology. My aim was to be a rural family doctor. And that’s my identity, as a family doctor. And, the fullest way to do that in the US is to do it in a rural area.
But, I had this research training as part of my public health training and, at the time, that was a particularly unique skill. So, I went to Cleveland and joined an academic practice. Mostly I saw patients but I did some teaching to begin with and started doing little studies along the way- looking at questions that came up during practice. And those are still some of my favourite things to do. You don’t need a grant. You get a few of your colleagues to help collect some data, ask questions that are of interest to patients ― questions that come up in the real world. You don’t have to worry about what you’re going to do with it. You’re going to apply it with the next patient that you see. I started doing those small one-off studies and then started doing some bigger things along the way. I was fortunate to work with a lot of wonderful people that I learned a lot from.
DMacA: You did a Ph.D. in epidemiology, how does that fit in with your research?
KS: I was able to do that as part of my preventive medicine training, and I couldn’t believe it, I was getting paid to go to school! I started with a paediatrician and a pathologist colleague and I made fun of them for a whole year for doing a PhD. I said, you should get your MPH, get out, and get on with your lives. And then, literally, one morning after about a year, I woke up and realized that I was taking all these classes, which seemed like remedial work for things I should have been taught in medical school but wasn’t. I was teaching epidemiology to the medical students. My little master’s project had grown because I managed to get some funding for it. Then I realised, I’m actually doing the work for a Ph.D., so I should go and get the degree, which then gave them a whole year to rag on me because of it.
My epidemiology training was part of public health training, and along the way, John Frey who’s a family physician I had lunch with every now and then, said “You’ve got to take a qualitative research methods course if you can. I think there’s something there.” I didn’t know much about it so I went and found one in the course catalogue. It was so complementary to have some narrative to go with the numbers, some stories to go with the statistics.
That got me started, and basically everything I’ve done since that is mixed methods, some quantitative and some qualitative. When I came to Cleveland, I was doing a large study and needed some people who really knew about the qualitative part, I got in contact with Ben Crabtree and Will Miller who were just writing their book on doing qualitative research which, by the way, has just come out in a third edition and which is terrific. That was really, really helpful.
“I was able to do that as part of my preventive medicine training, and I couldn’t believe it, I was getting paid to go to school! …. My little master’s project had grown because I managed to get some funding for it. Then I realised, I’m actually doing the work for a Ph.D., so I should go and get the degree…”
Wheatley M. Leadership and the new science: learning about organization from an orderly universe. San Francisco, Calif: Berrett-Koehler, 1992.
DMacA: You now have the whole toolbox, with clinical practice, epidemiology and the qualitative component. So then how did you bring that into your academic career and career progression?
KS: After the small, one-off clinical studies, we had a group that was interested in improving prevention in practice, and we wanted to do a clinical trial, because that’s the “strongest method.” We were going to do a clinical trial to improve practice but then we realised that we didn’t know how to do that. And any good ideas that we had someone else was in a better position to do it. So we thought, let’s see if we can just see where prevention fits into all the things we’re doing in practice. And we noticed that most people who tried to improve practice looked at one thing at a time, which is fine if you’re only doing one thing at a time, but if you’re a family doctor, if you’re generalists, you’re doing a lot of things. And so we got the idea that perhaps when we’re not doing just the one thing that’s being assessed, we may be doing something that may be even more worthwhile. We started looking at it with the idea of competing demands, thinking, how do we measure prevention and what we’re doing in that context?
And I remember Jason Chao using his fingers to tick off how you can measure things: you can do a medical record review, look at billing data, you could do patient or clinician surveys, or you could observe things… but you can’t do that. And then 10 minutes later, Rob Kelly said, ‘Well, wait a second, why can’t you do that? Why can’t we observe?’ and the response was ‘Well, there’s Hawthorne effect that changes people’s behaviour and who’s going to let you come into the exam room? I mean, patients won’t let you come in and directly observe a visit.’
So we had all these reasons., But I couldn’t sleep that night. I thought, that’s it. That’s what we could do that might be a unique contribution. So we proposed a study called the Direct Observation of Primary Care Study and worked with some of the local clinicians and used that to help develop a practice based research network of the local family doctors in Northeast Ohio.
It took us two years to get funded. It led us to observe directly 4454 visits to 138 family doctors and 84 practices. We classified every 15 seconds of the visit into 20 different behavioural categories, along with a big list of things that were or were not done. We asked the patients about it afterwards, asked the clinicians, and we looked at the medical records and the billing data. At that stage I didn’t know Ben and Will and they just joined us as consultants but ended up doing a lot of extra work on it. We had 2000 pages of ethnographic field notes that eight research nurses collected, and we worked with the clinicians developing a practice-based research network and we had this top down and bottom up approach. It was a two-year study, one year in the field, and we published 70 papers just because there were so many different things you could look at by having these observations from practice.
DMacA: I’m interested in something else you’ve said, because you’re interested in complexity, and I’ve heard you quoted as saying- the world doesn’t fit in to square boxes and straight lines.
KS: It actually started during this practice observation study. Ben and Will were getting together to look at all of these quantitative data and trying to make sense of it. And the linear approach just didn’t work. When Will was visiting Ben he just happened to have a copy of Margaret Wheatley’s book on complexity on the coffee table. And they just read it out loud and said, this is how we need to look at this. The idea that in practice, in health, these are complex systems and if you push on one part, it affects things elsewhere. It doesn’t change in a way that A leads to B leads to C. The initial conditions are important and things emerge that are hard to predict.
We started using complexity science principles as a metaphor for analysing sets of the qualitative data. And we have used that ever since. We got Reuben McDaniel, a business professor at the University of Texas to join the team to help us to use that to make sense, and we continue to use it as a way of understanding things. Along the way, about 10 or 15 years ago, I got a call from a social epidemiologist, George Kaplan, who’s done some large community health studies, and at the last phase of his career he wanted to use complexity science to make sense of these big things affecting health, and particularly equity and inequity. And he brought together people to do computational modelling, agent based models, with people that were doing work on the ground. I was fortunate to be part of this ‘Network of Inequalities, Complexity and Health’ and we started to do some quantitative work as well.
We used complexity research as a way of making sense of the quantitative data, looking at how things emerge, how the whole is often more than the sum of the parts, and more lately doing some things with modelling, often informed by qualitative and quantitative data so that you can do in situ experiments. Before we spend tens of millions of dollars to have a big experiment, what if we looked at a model and looked at what would happen if we changed two or three things across this system, what might be the effects of that?
“… But I couldn’t sleep that night. I thought, that’s it. That’s what we could do that might be a unique contribution. So we proposed a study called the Direct Observation of Primary Care Study and worked with some of the local clinicians and used that to help develop a practice based research network of the local family doctors in Northeast Ohio.”
DMacA: We’ve talked about complexity and we’ve talked about qualitative work, but when we think of Cleveland, we think of highly specialist tertiary care and you’ve been doing work across those boundaries. Tell us about that.
KS: We need people with a narrow view and a broad view, and we go back and forth looking at the balance. But, certainly, in academic centres, we tend to value the specialist more than the generalist. I think that we make sense of things, often in somewhat simplistic ways, that don’t really take into account of the fact that that these are complex systems. That tends to lead us away from understanding how the pieces fit together. Iterating between this big view and the small view, going back and forth, is really important. The prioritising function, which is what we do in primary care is really underappreciated.
Using Barbara Starfields Four C’s, and other ways we have of describing primary care, the idea of prioritizing doesn’t come up, and maybe it’s a little bit threatening to think about that. But if you have the broad view and you’re looking at that broad context of the whole person, you start with what a person comes in with that day and you drill down on that. Maybe that’s the main thing and they go home. But every now and then, we step back and put that in a larger context. And, you do that over time, looking at what’s most important in this moment, in many small moments over time, and there is huge value of this to that. And, in looking at how we measure quality and how we actually support practice improvement, we’re blind to that prioritising function.
[See: Stange KC, Miller WL, Etz RS. The role of primary care in improving population health. Milbank Q. 2023;101(S1):795-840. doi:10.1111/1468-0009.12638]
In Cleveland, I’ve worked with the specialist systems to fund my work. Most available funding is categorical and primarily reductionist., So we use that approach to try to study one thing narrowly, which is what people still value and understand, but around the edges, we look at how the pieces fit together. How that part fits into a larger whole, which is actually what we do as general practitioners. Family physicians are always looking at the parts in their larger context, and moving back and forth between the parts and the whole. There’s a magic in that, that we don’t fully understand.
Understanding that more and trying to figure out how we use that understanding to support some of the things in the system that people need generalists to do. That is what I’m trying to focus on right now.
Kurt and family in more relaxed mode
DMacA: Looking at your work and the breadth of your experience, it’s easy to understand how you brought this all into your work as the editor. You’ve made a tremendous contribution as Editor of the Annals of Family Medicine over 17 years. Tell us about that experience.
KS: Being Editor was the last thing I wanted to do. I was really clear, I wanted to contribute to, but not edit, journals, and it didn’t look like a job that I wanted to do. But, I was the representative for the North American Primary Research Group to the first meeting of the organizations that were sponsoring the Annals. I went to the meeting and, on the flight there, I started thinking about what the journal could be. It was a unique opportunity, before social media, and the initial plan was for a parochial US family medicine journal. And I thought, what if we made it international and multidisciplinary? And what if, rather than the small representative advisory board, we get a broad editorial advisory board? And what if, when we accepted a paper, we talked with the authors about for whom this new knowledge would be relevant and how it could be applied? We could then invite people to comment online and synthesize those insights as an editorial feature and get some discussion about applying it.
So, I went with those ideas and was trying to bring them up the meeting. Finally the chairwoman said, ‘Kurt, those are very nice ideas, but that’s for the editor to decide; we’re here to focus on the business plan.’ I sat quietly for the next half hour until they came to the point on the order of business which was to convene a committee to recruit the editor. I was asked “Would you be willing to chair that committee?” There was this long pause. I looked around the room where a few of the people had encouraged me to apply for Editor, and I’d categorically told them I wasn’t interested. I said, “Well, I think I shouldn’t do that.” She said, “Why not?” I said, “Well, I think I might want to be the editor”. They were just shocked.
You need to have a certain detachment to do a good job at something. So I think the fact that I never really wanted to do it ended up being my ‘superpower’. The real superpowers, of course, were sponsorship by multiple family medicine organizations, and then getting a phenomenal team together. I thought I would do it as a start-up but we had such a great team and were able to have this interaction with the different constituencies affected by the research. And that evolved into different opportunities along the way. And so it was a joyful thing to do and I ended up doing it for a lot longer than I thought I would.
“… I started thinking about what the journal could be… And I thought, what if we made it international and multidisciplinary? And what if, rather than the small representative advisory board, we get a broad editorial advisory board? And what if, when we accepted a paper, we talked with the authors about for whom this new knowledge would be relevant and how it could be applied? We could then invite people to comment online and synthesize those insights as an editorial feature and get some discussion about applying it.”
DMacA: I know you’re doing some really interesting work at the moment. Tell us about your current projects and what you are hoping to do
KS: Well, I’ve been working for about 15 years in community health and equity, and I’m really trying to get back to my roots as a generalist and trying to advance understanding of what this generalist function is in health care. I think those of us that do this kind of work on a day-to-day basis have an intuitive understanding about that but I think, systemically, it’s not really understood. How do we really integrate and personalize and prioritize care for whole people? The way we are trying to improve care is actually very reductionist and increasingly it’s fragmenting care and adding more administrative burden. More and more we’re trying to treat health care as a commodity and that’s a part of the problem.
But a really important part that’s being lost is the relationship aspect. A lot of the things we’re doing in health care to try to improve systems and care are actually making things worse. And I’m really happy that over the last ten years, I’ve been working with a wonderful social anthropologist, Rebecca Etz, and together we co-direct what’s called the Larry A Green Center for the Advancement of Primary Health Care for the Public Good. https://www.green-center.org
We’re working on a whole series of initiatives that are trying to look at the mechanisms by which generalism provides value. As a country, we spend billions of dollars every year to understand the mechanisms for specific diseases, for cancer and heart disease, but nobody tries to understand the mechanisms of the generalist approach to caring for whole people.
So a few years ago, we developed a measure of what matters in primary care. It’s called the Person-Centered Primary Care Measure. https://www.green-center.org/pcpcm And it’s based on asking patients and their primary care clinicians what makes a difference in their lives. We have a whole series of initiatives looking at what happens when you try to focus care on what the patient and their family doctor says are important. We also have some other studies going on trying to understand why people seek care. What is it about the generalist function that provides value? And then, how can we articulate a new vision for generalist care that leads us to do more work, to support what we do on the front lines rather than try to define primary care as a problem that we have to solve to enable people to work on the latest reductionist thing that pops into their heads. So that’s how I want to spend my last years of my professional life.
One last thing I’m doing is that I’m working on a novel. I’m doing a final revision. It tells some of the same stories with the hope that it ties into the heart as well as the head.
DMacA: And finally, let me bring you back full circle, back to family medicine, because you’re doing some work now with disadvantaged populations
KS: Yes, I moved my practice 15 or 16 years ago from the academic center to a community health center. It was at a time where I was thinking, I want to work a little bit more at the interface between health care and community health and public health- and doing that clinically by working at a community health center. And, to try to do more things that are more focused on the health of the community. And one of the big problems we have around the world, frankly, is our inequity. So, to try to do some work in that area.
“… this really is my dream come true. I love this profession…You can become a very dedicated GP in a rural area, or you become a GP that is involved in research as in my case, or you get involved in the political arena and fight for healthcare or primary care. There are so many open roads for you to discover and it is one of the best professions that a young colleague could join.”
DMacA: And, the very final question. You were awarded the Maurice Wood Award. Tell us what that meant to you.
KS: I knew Maurice Wood. He’s a hero to many of us. He was grounded in practice and used that grounding to bring people together, to do research, to generate knowledge that was helpful to support family practice. And the culture he created at the North American Primary Care Research Group meeting (NAPCRG) was supportive and inclusive. To have an award was created to honour him was very meaningful.
I was at a NAPCRG meeting once and trying to meet up with a colleague, Robin Gotler. We’d been trying to talk to each other for a few days and finally linked up. And, she said ‘I see you always talking to people. These are your people here.’ NAPCRG people are people that care about generalism. Family doctors, general practitioners and different disciplines around the world. That really feels like my peer group and I feel like we have a deep understanding about what’s important to integrate, personalize, and provide care for whole people in their family and community context, we’re trying to systematically develop understanding to support that. And people tend to be pretty egoless about it. So, to have that award from that peer group was very meaningful both because it comes from NAPCRG and because it is named after Maurice Wood.
DMacA: I just love that description- NAPCRG people are your people. Thank you very much for chatting to me today. It’s been fascinating. Thank you for all you’ve done in your career and your inspiration to so many others.
Maurice Wood Obituary in the BMJ April 14th 2016
