Dare to be different! Keynote at the Wonca world conference in Prague, June 2013

ABSTRACT

After decades of developing family medicine, one can see that it has been successful in defining its principles and in proving the importance of its contribution using quantitative measures of quality that are prevailing today. But if family medicine needs to make a real contribution to society, it needs not to forget that using only rationalistic approach is not enough to define its quality and that caring for a fellow being is as important as science.

Our contribution to changing the world for the better should be in constantly reminding that personal care is essential for every doctor regardless the speciality. This largely neglected feature of medicine can be best taught and researched in the context of family medicine, because it represents the very essence of the discipline.

This implies that we must often take a different path from other disciplines when we address the issues of policy, research and education and use every opportunity to stress the importance of personal care.

Keywords::

• Quality
• personal care
• humanism

KEY MESSAGE:

• Personal care can never be fully measured, but it is essential to modern medicine.

• Family medicine is the natural environment where personal care can be taught and studied.

• Keeping the focus on personal care is essential to the survival of family medicine; it is our distinctive feature.

INTRODUCTION

When choosing a profession, my first consideration was that I wanted to help people. Besides, I also wanted to do something meaningful, something that would make the world a better place. My aim was not to be rich or famous, which only shows how naïve and young I was at that time. I decided that for my future career the work of a doctor would suit my characteristics best.

I was successful in applying to medical school, which at that time was a very traditional establishment. Being a student, I learned that medicine is performed in a world of hard realism, where everything is measured and classified. Patient care was based on clinical reasoning, an intellectual exercise, which could be performed well if one knew the facts and the logic. Future doctors were expected to base their decisions on scientific facts, avoiding subjectivity, since that clouds judgement. The process of care was described in a straightforward manner: the patient gets ill, goes to the doctor, is examined, receives treatment, and gets well if the doctor knows what he is doing. The role of the doctor was to be a detective, who discovers the reasons for poorly defined problems and find the correct diagnosis, the correct agent causing the disease and to be a provider of medical services needed to treat the disease

I obediently studied what was taught in the firm belief that by using this logic I would be well prepared for the challenges of the medical profession.

THE ALTERNATIVE REALITY

When I started to work in practice, I saw that professional challenges of a doctor in practice differed from the ones I had been prepared for as a student. You never quite knew who or what to expect. A lot of my patients had signs and symptoms that did not exist in textbooks. A lot of their problems were not biomedical at all and practically all problems had an important ‘non-medical’ component. Some patients could not be cured, some even did not want to be cured, but all of them needed my care.

These challenges were presented every day. The following examples of some patients I encountered during my career, may illustrate this:

• A 82-year-old lady who remained alone after her husband had died. She had many health problems, most of them will never pass. She came to the practice regularly and was very grateful for my time, because she rarely had a chance to have someone listen patiently to her.

  A 75-year-old alcoholic had come for his previous visit two years ago when his wife, who was taking care of him, was still alive. When he arrived, he simply asked for a repeat prescription. He was dirty and smelling of alcohol.

• A 42-year-old lady with low back pain, obesity and hypertension tried to lose weight for many years without success. She had seen many different specialists and had done a lot of tests, most of them several times. She came for another referral to a specialist. I knew this would not help her.

• A 76-year-old patient with disseminated prostate cancer refused to talk about his disease, although I knew he was fully aware of his illness. His family urged me not to tell him he had cancer because they were convinced that if he was spared the awful truth he would live longer.

• A 55-year-old diabetic construction worker could not afford the healthy food I recommended to him based on scientific evidence. On one occasion he found out that his employer did not pay for his health insurance, which meant that I should charge him personally for my consultation.

I soon found out that I needed to achieve other skills if I wanted to become a good family doctor. They included the necessity to communicate with my patients (1), the need to navigate through the maze of the health care system, the attitude to accept patient preferences even if they were different from mine. I needed to focus more on health than on disease; to encourage the patients to look around and discover places where they can smile and laugh, where life can be rewarding and inspirational. I had to master the art of doing nothing (2), and had sometimes the courage to wait and see, to use time both as a diagnostic and as a therapeutic tool. I concluded that these were essential skills for my job.

THE NEW PARADIGM

I also experienced that the paradigm of patient care did not work in general practice. Our aim is not always to cure, but more often to control the disease. As doctors in primary care, we are faced not only with disease, but with prevention as well. Person-to-person contact is not an exclusive form of interaction. We do not work alone, but have to communicate and co-ordinate our work with other professionals.

I was lucky to join an international community of friends who thought the same as I. I got involved in working on defining the specificities of our discipline. Over the years, we developed a new theoretical background of family medicine (3). A lot of time and effort has been put into this exercise, starting from the first Leeuwenhorst group in Europe (4). Overall, family medicine has already been successful in identifying its principles and characteristics.

The exercise of defining the discipline was necessary, but it was not enough. It was needed to prove the importance and usefulness of this in practice (5). This is why the measuring of effects became increasingly important. Fortunately, there is now ample evidence that family medicine works on a policy level, even if we do not always know how. Primary care oriented countries have more equitable resource distributions, are rated as better by their populations and have better health at lower costs (6,7).

In recent years, a series of other indicators were developed to measure the performance of family medicine on a more local or practice-based level. Accessibility of our practices, referral rates, workload, prescribing patterns, vaccination rates and success of achieving all kinds of clinical targets is being measured nowadays. This trend is very appealing, and was quickly adopted by policymakers, who use ‘evidence-based’ indicators in developing increasingly sophisticated payment systems.

Overall, it can safely be said that family doctors perform well under this scrutiny. More than 30 years after my graduation, the situation regarding family medicine is much better. Family medicine as a discipline has proven its importance. Doctors and practices are increasingly working according to measurable quality standards and are regularly achieving goals that are set before them.

In collaboration with other international organizations, family medicine organizations have managed to develop policy suggestions that have been adopted by the WHO and recommended to countries worldwide (8). In the area of education, family medicine has often been a pioneer in developing new and successful methods in teaching and is regularly being taught at undergraduate level. The speciality of family medicine has become a standard, at least in Europe, where vocational training is a requirement for independent work in Europe. Family medicine is increasingly becoming part of the medical establishment.

WHAT NEXT?

If we take the challenge and look to the future, we should address a wider agenda, the problems of medicine and society. The greatest challenge facing contemporary medicine is for it to retain or regain its humanity, its caritas, without losing its essential foundation in science (9). We are experiencing an erosion of medicine's core values. A reflection of that is that new practices are being defined, using new technologies in the hands of naïve rationalists. Rationalistic assumptions perpetuate the myth that, by reducing medicine's complexity to focused questions about populations, interventions, comparisons and outcomes, we will get rid of its uncertainties and ambiguities. This is a mistake. It is impossible to tame complexity without loss of meaning (10).

Using only rationalistic measures is not enough in explaining the quality and contribution of family medicine. By thinking that only the measurable counts, we reduce (family) medicine to a series of simple measurable procedures, which can sometimes be done better by others. By concentrating too much on seeing a lot of patients in a short period of time, ticking boxes according to protocols, spending less money and making patients happy by giving them what they ask for instead of what they need, we miss the true meaning of our discipline. By putting too much focus on measurable standards and by forgetting the personal approach, we are denying our patients our feelings, our wisdom, our caring, our love, the very values that are needed in a modern world dominated by productivity and profit.

To the disappointment of techno-doctors and bureaucratic managers, family medicine cannot be reduced to an industry, producing services according to measurable standards at a low cost. Evidence shows that pay-for-performance schemes stop improving quality when a target is reached (11).

Caring for a fellow being is as important to family medicine as science is. It cannot be measured, but this does not mean that it is not important. It is complicated, because it involves the involvement of the most complex tool: the person of a doctor. It is not enough for a family doctor to be a detective and provider of services. More is needed.

THE NECESSARY ROLES OF A FAMILY DOCTOR

Of course, the role of the family doctor must be the one of a detective discovering the reasons for poorly defined problems, the professional who makes sense of an overabundance of information. Family doctors must remain faithful to the core values of medicine and humanism. They should stay faithful partners to patients throughout their life. Family doctors should care for their patients regardless their problem, gender, or age. This care is always emotional and it unveils patients’ unique personalities. In return, we are greeted with a reciprocal sense of love, a respect, a trust, and an invitation to join our patients as they make their ways in life. We receive gratitude when things go well as well as when they do not.

Family doctors should accept that in encounters with patients, often something inexplicable happens, which cannot be explained by biomedical logic. We have to assist our patients when their lives are not tidy and manageable or predictable, and we are asked sometimes to offer a path amidst the unknown. We should lead patients and their families to feel a sense of competency in the face of life's challenges. We should follow them when they need room to express their fears as well as their strengths. By doing this we play many roles: interpreter, guide, diagnostician, advocate, healer. By doing this, we are supported by what we have learned in training. This is the framework for the play, which has developed into something more whole, more complete, and more authentic—the work of a family doctor (12).

Accepting and mastering these roles is difficult, sometimes dangerous, and often impossible to measure. It is also often rewarding, it is the priceless contribution of family medicine to the society. It is what we are. We do it because it is the most difficult and the most beautiful job in the world, whose beauty is often inexplicable to those who do not practise it.

DARE TO BE DIFFERENT

After decades of developing family medicine as a scientific discipline and a profession, we can conclude that our dreams have been largely fulfilled. Family medicine contributes to people's health. It is an important discipline in medicine. But this is not enough. As a profession we need to work towards improving the world. Our contribution to changing the world for the better is to be a constant reminder that personal care is essential for every doctor regardless the speciality. This largely neglected feature of medicine can be best taught and researched in the context of family medicine, because it represents the very essence of the discipline. By insisting on its importance, we may reduce some of the crisis of modern medicine, driven by technology and money.

We as a discipline must be ambitious and brave. This implies that we must often take a different path from other disciplines when we address the issues of policy, research and education and use every opportunity to stress the importance of personal care. This must be done even if we do very well according to measurable standards of care. By taking a different path, we risk that our positions will not always be understood or accepted. However, the other option is much worse: when we try to be as similar as possible to other disciplines in order to comply with their ways of thinking, we will lose our identity. If we lose our specificities, we are no longer needed as a profession, because we can be replaced by others. And medicine will become even more a commodity that can be purchased and sold, and not a priceless help among fellow beings.

To keep our core values is a difficult task, because it involves a need to be different from other disciplines in medicine. It also involves the need to introduce changes. As a wise man once wrote: ‘It ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things (13).‘

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.