At home and away

If I am to be remembered, I hope it will not be primarily for my specialized scientific work, but as a generalist; one to whom, enlarging Terence’s words, nothing human and nothing in external nature was alien.

Julian Huxley

In this issue we celebrate 2 milestones—the 40th anniversary of the Declaration of Alma-Ata and the 40th anniversary of the Section of Teachers of Family Medicine (SOT) of the College of Family Physicians of Canada.

The Declaration of Alma-Ata was made by the World Health Organization in 1978 at the International Conference on Primary Health Care. It stated that primary health care was the key to attaining health for all by the year 2000. Eight elements were defined as essential to achieving this goal: education, food supply, safe water, maternal and child health (including family planning), immunization, prevention and control of endemic diseases, appropriate treatment of common diseases and injuries, and provision of essential drugs.¹

In the 40 years since Alma-Ata, these elements have been strengthened to varying degrees in different health systems around the world, and there is much to be learned from the experiences of other countries. In this issue, in the first in a series of articles, we begin to describe the successes and challenges of strengthening primary care in Brazil and Canada. As Ponka et al outline in their introductory commentary (page 795),² both countries have a strong common interest in promoting family medicine as a key component of their health care systems. In the first article in the series (page 811), Damji et al outline the 4 essential functions of primary care: first contact, longitudinal care, comprehensiveness, and coordination, and reflect on the Brazilian and Canadian primary care systems’ respective adoption and advancement of these principles.³

In “The times, are they a-changin’?” (page 798), Rainsberry and colleagues celebrate the many achievements of the SOT over the past 4 decades to support and advance the discipline of family medicine, but also enumerate the current and future challenges of defining and training the “expert generalist.”⁴ Ian McWhinney⁵ and Iona Heath⁶ have clearly articulated that “expert generalism” is a combination of a worldview—relationship-based, open-ended, and adaptive to the needs of the patient in front of us—and a skill set—a strong, broad biomedical knowledge base that allows generalists to make diagnoses and effect treatment plans in a way that takes into account the practitioner’s knowledge of the person and that person’s values.

One of the most moving descriptions of an expert generalist is in John Berger’s book A Fortunate Man.⁷ It was published more than 50 years ago and essentially describes a practice in rural, mid-1960s England, long before personal computers, cell phones, e-mail, and social media. Communication was face-to-face, and the community served was well-defined geographically. John Sassall, the subject of the book, lived and worked in the community he served, and the principles of family medicine are well illustrated as Berger describes Sassall’s everyday practice.

This worldview and skill set were previously embodied in one person, like Berger’s protagonist, but powerful social forces have been at work over the past 2 generations that have made this ideal harder to sustain—urbanization; demographic shifts in the medical work force; biomedical advances that have contributed to greater longevity but also higher health care costs; consumerism and rising patient expectations; information technologies and social media that are disrupting traditional face-to-face human exchanges; and neoliberalism and its ideology of market-driven competition as the best driver of progress.⁸

In the face of such powerful forces it is increasingly difficult for one person to embody expert generalism. A recent Nuffield Trust report⁹ makes a case that this worldview and skill set can be embodied within primary care teams. The expert generalist would remain at the heart of such teams, but care might be provided in different ways by different providers depending on patient complexity and need. The SOT will continue to articulate the key role of the expert generalist in the health care system and to advocate for the continued existence and training of such expert generalists now and in the future.

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