The challenged values of family medicine

After the collapse of global markets and the bankruptcy of financial institutions throughout the world, “crisis” is again a buzzword in the media. A crisis is defined as an inability to know which direction to take. The financial crisis is not the only crisis the world is currently facing. For a long time, experts have agreed that there is also a crisis of contemporary medicine, in the most fundamental sense of the term.

Many concerns are being raised, including concerns about the power of the medical profession. The golden age of medical professionalism is over: doctors now are under enormous pressure to provide quality care at affordable cost. There is a general belief that medicine should be under stricter control. Academic medicine is being challenged that it does not respond to population needs. The best and the brightest do not choose academic medicine as their career pathway, they prefer other, more attractive and more profitable options. The traditional values of medicine are no longer attractive.

Wonca Europe as an international organization should play an important role in promoting the discipline of family medicine. Traditional roles include communicating with different colleges, disseminating knowledge through conferences and other meetings, developing common standards for family medicine in Europe, and establishing a dialogue with policymakers at the international level. Overall, we can claim that we have been relatively successful. In 2008, Wonca Europe together with the Portuguese College of Family Doctors organized a meeting of senior college representatives in Lisbon; we also organized regular meetings of the council, and our website has received considerable attention. Collaboration with network organizations has resulted in the production of a European definition, the Teaching Agenda and the Research Agenda, for general practice. The Vasco da Gama Movement of young doctors is working well. In 2008, we managed to create a structure through which we can incorporate groups with special interests in clinical fields into the structure of Wonca Europe. Our conferences are receiving more and more attendees, and the conference in Istanbul in September 2008 was the biggest ever so far. As an organization, we have been invited to collaborate in the development of international guidelines and have worked together with other international organizations of clinical specialities.

However, there is still a feeling that this is not enough. We have somehow failed to persuade the public about the importance of the discipline and its values, and we need to work harder to find new approaches for promoting our discipline.

The main arguments we use for the importance of family medicine and primary care are that we can offer a large number of services at a low(er) cost and at a reasonable scientific level. Do these arguments reflect the core values of our discipline? Are the volume of work, its cost-effectiveness, and evidence-based standards the only values we should rely on in the face of a crisis? Aren't we missing something?

When looking at the definitions of family medicine, one can see that family physicians are familiar with the concepts of patient-centeredness, humanity, empathy, and compassion. These are the reasons why thousands of bright young people choose medicine every year and why we remain doctors. We all know that science alone is not enough to be a good doctor. Most of us practise family medicine as a caring profession that uses science as a tool and not as a purely scientific discipline. We know that, in order to be able to practise well, we have to connect with our patients on a personal level. We have to understand the storyteller, not only the story. We use this style every day, and we know that this is the way to reduce human suffering and improve health. We know that family medicine cannot be industrialized and reduced to a series of precisely defined procedures that can be standardized and monitored.

There are several problems when one tries to defend humanism in medicine [1]. Humanism is not fashionable, because it is about quality and not quantity. It is very difficult to define and to measure in a traditional scientific manner. Humanism also has its side effects. One of the greatest challenges is being able to respond appropriately to the human suffering of our patients without becoming emotionally overwhelmed by it. By getting emotionally involved with the patient, we lose our “objective detachment” and become vulnerable to error, and risk losing our objectivity. It is easy to be objective and to base one's decisions on evidential data. Such decisions do not bear the same individual responsibility for their outcomes, which more subjective decisions might entail. Humanism is also much more difficult. Interpersonal relationships can be very demanding and stressful. Being a family doctor places demands on the doctor and his/her family as public figures. Drawing the line between personal and professional life is often very difficult. Humanism demands certain attitudes that are not readily taught at medical schools: the need to compromise, humility, tolerance, and acceptance of different values. This is sometimes in sharp contrast with the traditional image of the doctor that is still very much alive in the public's perception.

However, regardless of all these limitations, family doctors know that humanism is important and that it is important to teach it [2], [3]. Although there is no course in being a better person, there are classes in literature, poetry, and art, and courses in communication skills that are aimed at this goal. The most important teaching method, however, is being a good role model [4]. Family medicine is an invaluable provider of excellent tutors in modern medical education [5], [6].

However, if family medicine has managed to persuade the medical schools that teaching humanism is important [7], how can we persuade policymakers that it is important to practise and to invest in it? If humanism in primary care has to do with improving health, then its contribution will be measurable. If not, it will be accepted as the homeopathy of modern medicine. We have not been successful in proving that humanity works, let alone finding out how and why. We know that it is sometimes dangerous and often difficult, but we have no response as to its side effects. How do you measure and standardize the human approach? How does it work? Why does it work? What happens if it is not done? These are difficult research questions we need to answer if we want to defend our position in this world that is dominated by evidence and hard data that would persuade the cynics that rule the world. The alternative is to accept that humanism is not really important and to teach young doctors to get used to human tragedy and to become as objective as possible. This will also be the end of family medicine as we know it.