Teaching the essence of family medicine

Out of the ashes built up by highly specialized, dehumanized, and commercialized medical care, family medicine rises like a phoenix, and takes flight, spreading its comprehensive spectrum of light, with the promise of a rainbow.

Margaret Chan, Director-General of WHO¹

With these words, Dr Margaret Chan concluded the opening address of the World Organization of Family Doctors (WONCA) World Conference held in Prague, Czech Republic, in June. A conclusion some might find overly dramatic, but which I found very inspiring, coming as it did just after Dr Chan had given an overview of the challenges facing all health systems and of family medicine’s vital contribution.¹ The WONCA World Conference was a remarkable experience for me, for it gave me an opportunity to talk with family physicians from around the world and made me realize how much our discipline is expanding in nearly every country. Above all, it made me realize that we all share common experiences despite very diverse cultural and educational contexts, from Kazakhstan to Montreal, Que. Even if we go by different titles—family physician, general practitioner, primary care physician—and our practices are different, the nature of our work is essentially the same. The 4 principles of family medicine are universal. This gave rise to a number of questions. Do we ourselves downplay the importance of our contribution? What is unique about our contribution?

In my opinion, our contribution is unique not only because of our qualities as communicators, collaborators, and managers but also and above all because of the scope of our clinical expertise. It is because family physicians are exceptional clinicians that they deserve the quarterback position in the health system. The relationships that we develop with our patients and the continuity of care that we provide make us the clinicians that we are. These relationships allow us to make diagnoses more quickly and with fewer investigations; to choose a specific treatment more quickly; and to understand what resonates with our patients more quickly so that they can take charge of their health.² Relationships and continuity are central to our work but, like Freeman et al,³ I believe that the intimate knowledge of the patient that develops over the years is the result of the scope of our field of practice, making us professionals capable of finding solutions for most of our patients’ health problems.

What is most fascinating is that this all happens in a 15-minute consultation without any of this sophisticated intellectual process being apparent. After the usual greetings, we ask a seemingly ordinary question such as “How have you been since the last time I saw you?” or “What can I do for you today?”—the answers to which provide us with a wealth of information. Then we ask a few focused questions, of which only an informed observer understands the diagnostic or prognostic value—the sensitivity and specificity. We take a furtive look at the patient’s record for the latest test results, and we finish up with a physical examination, where certain gestures sometimes seem to have more to do with shamanism than medical technology. All this information is then analyzed in the light of everything we know about the person’s life history and past episodes of illness. In 15 minutes, we have assessed how the patient’s 2 or 3 chronic health problems are evolving, and judged the seriousness of a new problem or the urgency required for intervention. We have a fair idea not only of the nature of the problem but also of its effect on the person’s life. This clinical approach that characterizes our work has been powerfully illustrated by Swiss filmmaker Sylviane Gindrat, who accompanied 6 family physicians as they went about their daily work. The 3 films, entitled At the Doctor’s Side, were also shown at the WONCA World Conference and are available on the Web (www.atthedoctorsside.ch).

These discussions with family physicians from all types of backgrounds gave rise to some questions for the teacher in me, too. Are we losing sight of what is most important by focusing so much on teaching clinical practice guidelines? Does our way of teaching the art of the doctor-patient relationship and the importance of continuity of care highlight the unique contribution of these 2 fundamental characteristics of family medicine to our daily clinical work? Do we convey a deep understanding of their value to our students? Do we focus enough on teaching the clinical expertise that sets us apart? While we are implementing the Triple C curriculum, it seems to me that it is important to remember that the fundamental role of every teacher is to inspire and to allow students to develop the deeper motivations that will lead them to realize the full potential of their profession.

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