The Context of Simple Rules

Kevin Fiscella, MD, MPH

Fam Med. 2022;54(2):157-157.

DOI: 10.22454/FamMed.2022.139220

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To the Editor:

The special article by Dr Etz et al, “Simple Rules that Guide Generalist and Specialist Care” is a gem.1 It inspired me to reflect in the wee hours this morning on the context of these simple rules. As the authors acknowledge, both sets of rules are used by all clinicians under different contexts, although specialists and generalists often differ in how frequently they adopt each set of rules.

Simple rules, whether those guiding avian or human social behavior, are triggered by context. The frequency and thresholds for threat-based flight and subsequent flocking differ by species and geographical context.2 Similarly, a sprained ankle in a healthy teenager might evoke the first set of rules in contrast to caring for a person with multiple chronic illnesses.

Which set of rules are adopted reflect context related to models of care and training. Specialists are often trained using disease models that adopt a medicotechnical approach based on the first set of rules. Generalists are more often trained to adopt a person-centered model in the context of a long-term, caring relationship. These models and training context shapes each group’s approach to care and the corresponding expectations by patients regarding which set of rules will be applied.

Context enables these rules during patient care. Recognizing, prioritizing, and personalizing are best accomplished in the context of a longitudinal relationship that promotes health, healing, and meaningful interpersonal connection. Patients’ emotions (eg, fear, anxiety, uncertainty), can trigger attachment behavior reflecting long-standing meaningful relationships,3 just as perceived threat by birds elicits flight and refuge in the flock.

Interestingly, the second set of rules are highly contextually dependent. When and how a clinician recognizes, prioritizes, and personalizes care is inherently contingent on the patient, the relationship, the problems, and the context of the visit.

Our health care system undervalues the second set of rules and funds delivery models that favor the first set.4 Yet, the COVID-19 pandemic has reminded us that it is the second set of rules that helps vaccine-hesistant patients make the right choice for themselves, their families, and their communities.5


  1. Etz R, Miller WL, Stange KC. Simple rules that guide generalist and specialist care. Fam Med. 2021;53(8):697-700. doi:10.22454/FamMed.2021.463594
  2. Weston MA, Radkovic A, Kirao L, et al. Differences in flight initiation distances between African and Australian birds. Anim Behav. 2021;179:235-245. doi:10.1016/j.anbehav.2021.07.008
  3. Maunder RG, Hunter JJ. Can patients be ‘attached’ to healthcare providers? An observational study to measure attachment phenomena in patient-provider relationships. BMJ Open. 2016;6(5):e011068. doi:10.1136/bmjopen-2016-011068
  4. Phillips RL Jr, McCauley LA, Koller CF. Implementing high-quality primary care: a report from the National Academies of Sciences, Engineering, and Medicine. JAMA. 2021;325(24):2437-2438. doi:10.1001/jama.2021.7430
  5. Ratzan S, Schneider EC, Hatch H, Cacchione J. Missing the point - how primary care can overcome COVID-19 vaccine “hesitancy”. N Engl J Med. 2021;384(25):e100. doi:10.1056/NEJMp2106137

Lead Author

Kevin Fiscella, MD, MPH

Affiliations: Department of Family Medicine, University of Rochester Medical Center, Rochester, NY

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