Tribute to alvan r. feinsteinBetween iatrotropic stimulus and interiatric referral:: the domain of primary care research
Introduction
The “iatrotropic stimulus” is a typical example of Alvan Feinstein's terminology and of his clinical way of thinking about medical research. He defined this phenomenon as “the particular reason why a person decided to seek medical attention at a particular time.” Feinstein specified “interiatric referral,” including a patient's referral from a family physician to a specialist and from ambulatory status to hospitalization, as an additional important factor affecting “the likelihood that patients will appear at the particular setting in which research is being conducted” 1, 2.
Feinstein discussed the phenomena of iatrotropy and interiatric referral in relation to “cause-effect research,” addressing etiology, pathogenesis, prevention, and therapy, and did not explicitly relate it to diagnostic research [2]. However, Ransohoff and Feinstein [3] made it clear that iatrotropy and interiatric referral, as important determinants of the characteristics of study populations and their morbidity spectra, also have a great impact on the performance of diagnostic tests.
Although the iatrotropic stimulus in itself is a challenging topic for health care research, in clinical epidemiologic research it represents a special case of selection and possible selection bias. In the pursuit of general patterns and concepts, science should be reluctant to attach specific labels at special cases. However, in clinical research, the key role of physicians' involvement justifies a “terminological short cut,” acknowledging the impact of care seeking behavior and patient referral. Recognition of the importance of the iatrotropic stimulus and referral processes has substantially contributed to the development of primary care research.
Section snippets
The basic iatrotropic level
The specific primary care research domain is between the open population survey (directly sampling among subjects in the community) and the referred care study (usually sampling patients from the hospital or outpatient clinic). Primary care represents the basic iatrotropic level, implying
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Health problems are presented to health care workers for the first time because they are not solvable by patients and their social networks without professional medical help.
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Health problems are presented as
Presented health problems
In the presence of a gate-keeping function of primary care, there are characteristic differences between the spectrum of health problems presented to the primary care physician and the spectrum seen by the medical specialist. These can be summarized as follows:
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In principle, problems presented to a primary care physician are undifferentiated (ie, not yet reduced to a specific nosological category). The “problem space” is often large, especially in cases of so-called “vague” or “nonspecific”
Conclusion
More than three decades ago, Feinstein described the concepts “iatrotropic stimulus” and “interiatric referral” as highly relevant for clinical judgment, clinical research, and clinical epidemiology. To a great extent, this has stimulated the realization of original clinical research in international primary medical care. It has helped us to recognize the characteristics of the spectrum of health problems and morbidity patterns presented to primary care physicians and to acknowledge the
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