Finding safe harbour: reassessing 9 principles of family medicine in difficult times

International impact

Beginning with McWhinney’s An Introduction to Family Medicine in 1981,⁷ what became known as his Textbook of Family Medicine had 4 editions and has been translated into Portuguese, Japanese, and Turkish. His writings have been instrumental in establishing family medicine in Brazil, Japan, Turkey, Nigeria, Argentina, as well as Ethiopia, Guyana, Indonesia and, more recently, Benin and Madagascar.⁸ McWhinney wrote over 150 journal articles, 4 textbooks, and 9 book chapters. His achievements were recognized with numerous awards, visiting lectureships, and 2 honorary degrees. He was made an Officer of the Order of Canada in 2000 and became a Laureate of the Canadian Medical Hall of Fame in 2006.

Why this series of reflections?

Widespread concerns have been expressed about the decline in the number of family physicians in Canada,⁹ as well as the dangers of fragmentation of care as more family physicians focus their practices away from the comprehensive care that characterizes the unique nature of our work.¹⁰ Other health care providers, such as nurse practitioners and pharmacists, are engaged in doing some of the work that was formerly the domain of family practice.¹¹ Team-based care, devised to address the increased complexity of care, threatens to distance family physicians from their patients. New technologies clamour for a place in family practice without making clear what problem they are meant to address, or proof of their effectiveness.¹²

The epidemiology of practice is changing to more multimorbidity of chronic diseases and mental health, even as new infectious agents like the COVID-19 virus emerge.^13,14 Practice patterns are changing, becoming more office-centred, while at the same time family medicine graduates increasingly pursue focused practices as hospitalists or emergency department physicians.¹⁵ The speed of social and professional changes makes it difficult to distinguish signal from noise. At such times, there can be a misalignment between a profession and the people it serves, leading to disenchantment, anomie, and burnout.¹⁶

In this context, family medicine has been described as a profession with an identity in transition.¹⁷ Just as channel markers needed to guide boats to safe harbour require resounding after a major storm, we feel this is a critical time to reflect on the principles—channel markers—that define the nature of family practice. These principles are what make our work impactful in the health care system and, perhaps more importantly, in the lives of our patients.¹⁸

Through an iterative, collaborative process, the authors of this article invited 9 family physicians to contribute a reflection on each of McWhinney’s 9 principles to Canadian Family Physician over the coming year. The goal is to explain how the principles might be considered and applied in the current context of declining interest in family medicine among undergraduate medical students, declining comprehensiveness and continuity among practising family physicians, and a significant shortage of family physicians in Canada. In doing so, we hope to contribute to an ongoing conversation and a revitalization of family medicine in Canada.

Contributors to this series of reflections are Canadian family medicine leaders and thinkers such as Dr Marie-Dominique Beaulieu and Dr Jane Philpott. Reflecting the global reach of McWhinney’s work, participating international family medicine colleagues include Dr Iona Heath from the United Kingdom, Dr Anna Stavdal from Norway, Dr Thiago Trinidade from Brazil, and Dr Sister Monique Bourget from Benin. Each contributor was chosen because they have engaged in work that focuses on the principle about which they will write.

Final thoughts

In 1996, McWhinney delivered the William Pickles Lecture at the spring meeting of the Royal College of General Practitioners in Aberdeen, Scotland. The lecture was later published in the British Journal of General Practice and titled “The importance of being different.”¹⁹ His speaking notes from the lecture contain a passage not found in the published paper that seems as relevant today as when it was written:

These are hard and difficult times for the health services, especially for medicine, and our minds are naturally focused on these immediate troubles. But I am not going to speak of these. I hope you won’t be disappointed. Eventually, these things will pass, and there will still be illness and suffering and the need for healers and healing. If we can remain true to ourselves through these present times, I believe we will find general practice assuming the leadership of medicine as it struggles to meet these human needs in the new century.²⁰