Better Late Than Never – Painting the Big Picture for Learners in Family Medicine

In 2012, not long after his death, I wrote an editorial in Canadian Family Physician, “Reflecting on Dr. Ian McWhinney”, in which I wrote the following words:

“Four days after Dr McWhinney’s death I was in my clinic supervising 2 bright, enthusiastic family medicine residents and a clinical clerk interested in becoming a family physician. At the end of a clinic I like to spend some time reviewing a topic with them in greater detail. That day I just asked, “What can you tell me about the work of Dr Ian McWhinney?” His name was unknown to them. Whether this is true of most family physicians in training I cannot say, but we owe it to family medicine and to Dr McWhinney to keep his enormous contributions alive.”

Since then I have made a consistent effort when working with learners for the first time in the clinic – whether they are elective medical students, clinical clerks, or first-year family medicine residents – to share with them two of the most important papers published in family medicine.

The first is Ian McWhinney’s 1996 William Pickles Lecture published in the British Journal of General Practice entitled “The Importance of Being Different” (2). The second is Iona Heath’s 2011 Harvey Oration entitled “Divided We Fail” (3). Reading them both is mandatory.

In his Pickles Lecture, Ian McWhinney clearly articulates the ways in which general practice differs from specialist practice. We are a discipline at whose core is relationships, not diseases – especially the physician-patient relationship; we tend to think about diseases in terms of individuals in our practices, not abstract entities; we tend to think “organismically”, not “mechanistically” (the biopsychosocial approach); last, we reject mind-body dualism as we see up close in all our patients the interplay of both physical and psychological well-being.

In her Harvey Oration, Iona Heath provides historical context for the split within the medical profession between generalists and specialists. Furthermore, she demonstrates that generalist and specialist physicians are equal, but different, practitioners who share a common basic training each of whose unique skills allow the other to do their work and health care systems to function optimally. Of generalist physicians she argues that our unique skill set is to patrol two boundaries – the boundary between illness (symptoms) and diseases that we generalists can care for, and the boundary between diseases that we can care for and those that require specialist or hospital care.

How has sharing, reading and discussing these papers affected both the learners and the teacher?

First, it has provided important, previously missing context. When I was a medical student most of the teachers I had in the classroom and in clinics were specialists and exposure to family physician teachers occurred only in the final clerkship year. Things have improved somewhat since then, but at no point during undergraduate medical education, for example, is the historical context described by Iona Heath provided (according to the learners I have surveyed). Both undergraduate and post-graduate medical education remain largely ahistorical.

Second, it has provided the opportunity to openly discuss and debias the “hidden curriculum” (4). Learners consistently tell me that they continue to implicitly and explicitly receive the same messages about family medicine as a career choice that I did – that the best and the brightest choose specialty medicine and the rest end up in family medicine. Both Ian McWhinney and Iona Heath show that generalist family physicians, while having common medical school training with specialists, develop a fundamentally different perspective and important set of skills as they go through their post-graduate training – skills that allow them to fulfill their crucial roles in the health care system and in their communities.

For several recent learners, particularly medical students and clinical clerks, the impact has been significant. Some who were interested in choosing family medicine, but hesitant because of hidden curriculum messages from preceptors and even family members, have told me they found reading and discussing these papers empowered them in their decision. Those interested in pursuing specialist careers have been grateful for the opportunity to deepen their understanding of what being a family physician is all about.

As a teacher, I have learned that it is crucial that we teach not only content, but context. It is never too late to paint the big picture – for ourselves and our learners.

Dr. Pimlott is a family physician and teacher in the Department of Family and Community Medicine, Women’s College Hospital and the University of Toronto. He is also the Scientific Editor, Canadian Family Physician.

References

1. Pimlott N. Reflecting on Dr. Ian McWhinney. Can Fam Physician 2012; 58:1187. http://www.cfp.ca/content/58/11/1187

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1239699/

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4952340/

4. http://www.cfp.ca/content/57/9/983