INTRODUCTION
It has been my privilege to observe family doctors with their patients, and to meet with their health ministers and other leaders, in more than 50 countries. These observations and meetings, when placed against the backdrop of the scientific literature, make a compelling case for Family Medicine and primary care. This article is a brief attempt to capture some of the differences and commonalities that make family doctors and other primary care professionals such special and valued resources. This commentary provides me an opportunity to share the remarks I had planned to give at the Wonca Europe meeting in Vienna in July 2012, but was unable to present when surgery prevented my travel.
VALUE OF PRIMARY CARE
The World Health Report 2008, entitled Primary Health Care—Now More Than Ever (Citation1), declared that a robust primary health care system is essential for effective and equitable health care systems, in countries rich and poor. Governments, insurance plans, and other purchasers of health care are keen to strengthen primary care. They understand that better primary care is more likely to result in the Triple Aim of better care, better health, and lower costs (Citation2). Yet, primary care comes in many different versions around the world. Why then do people and systems do better when care is built on a foundation of primary health care? Barbara Starfield and colleagues concluded that it comes down to continuity and comprehensiveness (Citation3).
The extra value of family doctors
In developing countries, primary health care is often the domain of nurses or community health workers. As health care systems mature, and outcomes improve, primary care is provided by general doctors, some of whom obtain additional post-graduate training in Family Medicine. This extra training improves the outcomes of primary care systems. For example, in the 1980s Spain planned to replace gradually a primary care system using general doctors with one using family doctors who provided more comprehensive services. Over a few short years, there was a 13.6% decrease in mortality due to hypertension and stroke, compared to a 10.2% decrease in areas that maintained the traditional model of general doctors providing limited care (Citation4). As a result, Spain accelerated its transition to a family doctor-based system.
In some countries, such as the United States, primary care may also be provided by physicians other than family doctors, such as general internists or general paediatricians, or even other specialists. When comparing different types of physicians, family doctors have a more positive impact on mortality risk. For example (Citation5), increasing US physicians by 1 primary care doctor per 10 000 inhabitants reduces mortality by 5%. If the primary care doctor is a family doctor, then the death rate drops 9%. If the doctor is not a primary care physician, but is instead some other specialist, then the mortality rate goes up by 2%. Other studies show similarly impressive improvements for primary care versus specialty care when outcomes less dramatic than death, such as blood pressure control, are considered (Citation6). Overall, when compared to other specialists, family doctors have been shown to decrease health care costs by up to nearly one third while decreasing mortality risk by nearly 20% (Citation7).
These differences in outcomes between a primary care, community-based approach and a specialist, disease-centred approach are not unique to developed countries. In Indonesia, an extraordinary natural experiment played out during the 1990s (Citation8). During the first half of the decade, when the economy was growing robustly, spending on primary care went up relative to specialty care and infant mortality rates dropped in all provinces. After the economic crisis in the mid-1990s, spending on primary care went down, but specialty care spending went up, and infant death rates increased in most provinces. This shift in priorities toward specialty care was felt to be due to the influence of western aid agencies and other donors.
Definitions of family medicine
A review of the definitions of family physician and general practitioner reveals a number of attributes, but several common themes emerge (Appendix). Care should be person-centred, easy to access, comprehensive in scope, and mindful of context (e.g. social determinants such as family and community). In essence, family doctors think about the person first, and that person's disease(s) next.
Family doctors view themselves as the first and last resort when it comes to their patients’ health. They feel a sense of responsibility for all the health care needs of all their patients, even though assistance may be needed at times from other professionals. Cancer is a good example. Cancer prevention and early detection most often occur in the primary care setting. Cancer care by the family doctor can involve monitoring the adverse effects of and providing support during cancer treatment. Finally, when there are no other treatments to offer and the cancer specialists have withdrawn from care, the family doctor provides palliative care to the terminally ill and post-mortem comfort for their loved ones.
TASKS AND TOOLS OF FAMILY DOCTORS
The task of family doctoring is not easy. The practice of the family doctor is more complex and time-pressured than most other medical disciplines. In a typical visit with a family doctor, patients present between 1.5 and 8 separate problems. For other specialists, five diagnoses will capture 90% or more of what they see. For family doctors, the top 25 diagnoses represent only 60% of what they encounter (Citation9). One way to understand this challenge better is to compare the relative complexity of the practice of a family doctor to that of another specialist. Using a complexity score they developed, Katerndahl et al., (Citation10) showed that the relative complexity of a visit to a family doctor was 44, compared to 43 for a cardiologist and 17 for a psychiatrist. When one accounts for the amount of time available at each visit, the complexity density (complexity per unit time) is 167 for family doctor visits, 125 for cardiologists and 31 for psychiatrists.
The trusted relationship is essential
These data give us some insight into the reasons why better health results when care is centred in a trusted relationship with a family doctor. By making themselves easily accessible and by addressing any and all of the patient's concerns, the family doctor develops an effective and special therapeutic relationship. The therapeutic relationship is the cornerstone of the family doctor's success. When patients present to the formal health system, about 75% of their symptoms are self-limited (i.e. they improve and resolve without active intervention). This proportion is 80% for those under 65 years of age and 40% for those over age 65 (Citation3). Consequently, family doctors are able to use time and their therapeutic relationship with patients (‘I will be here for you tomorrow and the day after and so on’), to avoid unnecessary, expensive and potentially harmful interventions while monitoring for more worrisome possibilities.
Leveraging relationships: The four P's as an ecological approach to care. At the same time, preserving or improving the health of the individual is tied intimately to the health of the community. Optimal health requires an understanding of the patient's community and consideration of all the factors that impact health—it must reflect an ecological approach to health and health care. A useful model of an ecological approach in primary care is embodied in the four Ps of care: personal, professional, population, and public. Personal care is the self-care that people take on when they make conscious decisions to engage in prevention (e.g. tobacco avoidance), manage their own conditions (e.g. diet and exercise in diabetes), or seek medical attention. Professional care includes the activities one usually associates with health care professionals: making diagnoses, writing prescriptions, performing surgery, providing therapies, and so on. Population care refers to the increasing need to identify and actively reach out to the growing number of people with chronic or other special and expensive health care conditions. Public care represents efforts to make communities healthier.
Tobacco-related disease offers a useful example for putting the four Ps into action. A family doctor speaks to a class of primary school children about the hazards of tobacco use, causing some of them to avoid smoking (personal care). One of the children pesters her mother about her smoking until the mother presents to her family doctor for tobacco cessation assistance (professional care). A short while later, the mother's father (who is the schoolchild's grandfather and who is an ex-smoker) is prompted by a letter to visit the family doctor for an influenza immunization. The letter is generated from a registry of those in the practice with chronic respiratory disease (population care). During their visit, the family doctor persuades the man, a local political leader, to promote a municipal ordinance that would prohibit smoking in public places (public care). The municipal ordinance makes smoking less visible in public places and discourages some young people from starting to smoke (reinforcing personal care). On and on it goes, each P reinforcing and building on the other.
For the busy family doctor, the tobacco example can seem like another demand added to an already overloaded work day. The tobacco example is drawn from my own busy practice. What the example taught me is that there are others who can help make the healthy choice happen—the school teacher who reinforced the tobacco avoidance message to her students; the pharmacist who counselled the mother about the nicotine substitute that was prescribed; the nurse who monitored the immunization registry in our practice; and the practice receptionist who had a passion for tobacco avoidance and kept after the politicians until the municipal ordinance was adopted.
CHALLENGES FOR FAMILY DOCTORS: TODAY AND TOMORROW
The challenge for family doctors, and for health care systems, will be to provide ready access to care, to prevent and manage chronic diseases, and to prove and improve our performance. For the foreseeable future, it is not possible for every family doctor to be always available to every patient for every problem. To be successful, we will require new tools, technologies, and teams that enable us to pursue enduring goals: therapeutic continuity relationships and comprehensive services. The art of family doctoring resides in our ability to leverage our relationships to achieve better individual and community health. We link our holistic and comprehensive world view with our knowledge of and relationship with the patient. In a way, family doctors are like catalysts—we leverage our relationships with people to set into motion the actions that result in better health. Like all good catalysts, we must be nimble and creative, and not get used up in the process.
APPENDIX
Table A1. Definitions of Family Medicine, family physician, general practice, general practitioner.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES
- The world health report 2008: Primary health care now more than ever. World Health Organization, Geneva, 2008.
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- Simms C, Rowson M. Reassessment of health effects of the Indonesian economic crisis: donors versus the data. Lancet 2003;361: 1382–5.
- Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract. 1998;46:363–8.
- Katerndahl DA, Wood R, Jaen CR. A method for estimating relative complexity of ambulatory care. Ann Fam Med. 2010;8:341–7.