In This Issue: Confronting Constraints on Individual Behavior & Outcomes.

98 This issue of Annals addresses some of the structural and attitudinal boundaries that constrain individual behavior and health outcomes. It is easy to blame individuals for poor choices and to stigmatize groups for bad behavior. Articles in this issue take a more sophisticated and nuanced view to examine the environments, relationships, beliefs, knowledge, and communication approaches that can either restrict or provide new opportunities for health and healthpromoting action. Arthur Kaufman and Leif Solberg address the boundaries of medical practice in a set of Point/ Counterpoint pieces that ask the question: “Should primary care practice take on social determinants of health now?”1,2 Jennifer DeVoe adds a Perspective on integrating the social determinants into health care.3 Their answers are timely in light of recent recommendations by the Institute of Medicine for capturing social and behavioral domains and measures in electronic health records.4,5 Ferrer and colleagues use sophisticated analytic methods to examine how the choices people make depend on the options they have. In a sample of 746 adults visiting 8 large primary care practices in Texas, they find that people’s realistic opportunities for healthy diet and activity affect their intentions, behaviors, and outcomes.6 Mercer et al compare patients’ expectations, their general practitioners’ behaviors in the consultation, and health outcomes in high and low deprivation communities. They find interesting associations with general practitioners’ empathy,7 and interpret their findings in light of the inverse care law, which states that “the availability of good medical care tends to vary inversely with the need for it in the population served.”8 Another novel intervention uses group visits in a geriatrics clinic to help patients consider together their personal values, and to understand how to engage in advanced care planning discussions. After two 90-minute sessions, patients report increases in detailed advance care planning discussions with their doctors.9 The use of an electronic consultation service that fosters communication between primary care clinicians in a community health center and specialty clinicians is tested in a clinical trial by Olayiwola et al.10 They find that a system for secure, asynchronous consultation results in much faster cardiology consultation compared to traditional referral, and lower rates of cardiacrelated emergency department visits. Most electronic consultations do not end up requiring an in-person visit to a cardiologist. An in-depth study by Cabral and colleagues examines the constraints of clinicians’ and patients’ beliefs and communications around antibiotic use for respiratory tract infections. They discover an apparently mutually reinforcing cycle of expectation and discussion that confirms patients’ expectations that antibiotics are needed to treat more severe illness.11 A mixed methods study by Greene et al uses aggregated quantitative patient activation data on a large sample of patients to compare the approaches of physicians with high vs low levels of improvement in their patients’ level of activation. The exemplar physicians are more likely to use 5 strategies to support patient behavior change: emphasizing patient ownership, partnering with patients, identifying small steps, frequent follow-up visits to cheer success and/or problem solve, and showing caring and concern for patients.12 The potential constraints of a don’t ask/don’t tell approach are identified by Metheney and colleagues in an Internet study of men who have sex with men. They find that patients’ disclosure of sexual identity to their clinicians is associated with higher rates of routine HIV testing and hepatitis A and B vaccinations.13 A systematic review by Khanassov et al goes beyond the constraints of an individually focused approach to care to identify the effects of care management in meeting the needs of patients with dementia and their caregivers.14 Rollow proposes a model for achieving value in primary care by focusing on 5 domains that are important to patients.15 EDITORIAL