Universality and uniqueness in family medicine

One of the consequences of the academic development of family medicine is that medical students in Europe are expected to learn about family medicine as part of their curriculum. The contribution of family medicine to undergraduate education is now well established and in many European countries family medicine is a formal part of the curriculum. When we teach students, we try to convey to them the universal truths of family medicine. We try to make them see that regardless the amazing development of technology, the contact between two persons, the doctor and his patient is still the most important factor in patient care. We teach them about management of common conditions they have not seen in hospital wards. We stress the importance of teamwork. We draw their attention towards prevention and healthy lifestyle. Students encounter typical situations in family medicine. They have a chance to see how we deal with frequent attenders and ‘heartsink’ patients. They see how we struggle with anxious middle-aged businessmen who have for the first time in their life encountered a health problem that may threaten their life. They can talk with patients who are unable to change their unhealthy lifestyle and prefer to lead their own life contrary to their doctor's advice. Quite often, they are able to discuss frail elderly, who live alone. These groups of patients represent the universal problems of family doctors practically worldwide.

If not before, then during family medicine rotation, students soon see that many patients do not fit within the classifications of diseases or symptoms that they were taught in class. They see that classifications of patients in disease categories represent just one layer of expertise needed to be a good family doctor. Sometimes they realize (with the help of their teachers) that categorizing patients into diseases is a result of rationalistic reduction of ‘less important’ in favour of ‘more important’; where variables that are measurable and can be expressed in facts and figures are more important. They see that this simplification is useful in understanding the basics of medicine, but that this approach mostly neglects patient presentations, which are the ‘confounding factor’ in science, education and patient care. If they have a good teacher and a good programme and if they are clever, they realize that if they are going to be good doctors they should not treat arterial hypertension, diabetes or asthma. They should treat patients who have their own attitudes and beliefs because of their upbringing and culture.

If one decides to become a family doctor, one should know that patients need personalized solutions how to manage with the health problems they have. Some of these solutions are in line with disease management protocols, but quite often they are not, because the patient does not fit within the protocol. A family doctor must navigate between science and culture, sometimes balancing one against the other. This requires not only the knowledge of the disease, but also the knowledge about the culture, the skill of communication, empathy and wisdom. This is why medicine is not a science in itself, but a caring profession that uses science as a tool.

This is one of the most important contributions of family medicine to medical education. Students need to understand that patients’ problems are anything but simple; that they are multi-layered and complex, that each patient is unique. We show them how we try to make a comprehensive solution of complex situations in practice, how we manage in situations that are not explained in textbooks and are not easily explicable. Students see how we navigate between the specificities of a country or a culture and the scientific standards of medical care. They see how local specificities affect patient care and why it is important for a doctor to understand them in making practical decisions.

The necessity to address local and specific knowledge creates a practical problem in education because teaching materials must reflect both: the universal principles of family medicine and the local specificities of context in which it is practised. In practical terms, this means that every country must develop its own textbook and that only parts of teaching materials can be simply translated from one language to another. This is not a difficult task for countries with many experts in academic family medicine. However, smaller countries may have a problem with that. Recently, the idea of an international textbook, based on the European definition of family medicine has been developed. The textbook would have its ‘core’ part, describing the principles and the universal problems in family medicine, as well as its ‘application’ part, which would be different for every country. So far, the pilot has been done in two countries (1). The future will show whether this idea will develop further and move beyond the countries of southeast Europe where it was developed.

The issue of local relevance is also important for researchers, who want to publish their work in a scientific paper. Local experiences, however unique, are often not interesting for international journals. If a journal is to have high impact, it should ideally publish themes that will be interesting worldwide and will be quoted by many scientists. This means that disciplines, which produce their research findings in a controlled situation and not in a community context, are at an advantage. This is why average impact factors differ across disciplines. Family medicine research is quite often rooted in a local context and these experiences should be published if they are of adequate quality. When we as editors are faced with such a paper, we usually decide to support it. Quite often, we try to advise the writer how to put the problem and the findings in an international context. We believe that it would not be in line with our role if we were to act differently.

For a practising physician, this issue becomes important when he is asked to treat a patient from a different culture. Immigrants have become a reality for many family physicians in Europe. Communication with a patient through proxy is no longer an exotic situation but a routine that needs to be addressed in training. More than before, students need to learn about different cultures and become tolerant to values of these patients. In this issue, you will be able to read a paper by MacFarlane and colleagues who are describing an ongoing project addressing this issue (2).

Cultural factors also play a role in patient care when the doctor moves to work in another country. In Europe, it is much easier now to move from one country to another as a family physician. We have heard that in some countries, especially the rich ones, the influx of doctors has been considerable. In Norway, for instance, as much as 20% of family doctors are immigrants, as reported by Diaz and co-authors in this issue (3).

Europe is a continent of great diversity, with a long history of cultures fighting against each other. It is only relatively recently that we have found this unacceptable. In today's Europe, we are practising tolerance and acceptance of our differences and trying to find common solutions to complex problems that we are facing. I could not fail to notice the parallel with family medicine: the family physician should be a partner to his patient, trying to understand his personality. Is this attitude one of the reasons why family medicine is so strong in this part of the world?