PREFACE

There are two kinds of textbook: those that aim to cover a field of knowledge and those that aim to define and conceptualize it. This book is of the second kind. Most textbooks in clinical disciplines are structured in accordance with the conventional system for classifying diseases. A family medicine text that adopts this structure faces two difficulties. Family physicians encounter clinical problems before they have been classified into disease categories. In principle they are available for any type of problem. There is thus no disease, however rare, that may not be encountered in family practice. If a text tries to cover the whole field, it risks becoming a watered down textbook of internal medicine. More seriously, family medicine differs from most other disciplines in such fundamental ways that the conventional structure, though used in family medicine when appropriate, is at variance with the organismic thinking that is natural to our discipline.

The first ten chapters are devoted, as before, to a conceptualization and description of the field. Much new material has been added on the patient-centred clinical method, illness narratives, the biological basis of family medicine, health promotion, the concept of risk and the contribution of evidence-based medicine. Chapter 9 includes an authoritative review of evidence-based preventive strategies.

The five clinical chapters (11 - 15) are there because they exemplify the principles discussed in the first 10 chapters. Three of them are devoted to symptoms (sore throat, headache, and fatigue), one to a conventional disease category (diabetes) and one to a physiological variable/risk factor (hypertension). I have tried to deal with each subject as it appears from the perspective of the family physician. The meaning of the illnesses is addressed from several viewpoints: clinical classification; pathophysiology; the patient's experience as portrayed in illness narratives; the impact of illness on the family and family on the illness; and the doctor as participant/observer. Early diagnosis, how decisions on assessment and management are arrived at, and the management of the illness in the context of the patient and family are emphasized. Prevention is discussed as an integral part of clinical medicine.

In therapeutics, the recommendations are in accordance with authoritative opinion at the time of writing. As time passes, these will inevitably become outdated, and more current recommendations will need to be consulted. It is doubtful nowadays whether any textbook can be considered an appropriate source for information on pharmacotherapy. Drug dosages are not given unless they are of special significance.

The chapters on the practise of family medicine, covering such topics as home care, records, and practice management, reflect the many changes that have occurred since the first edition. A new chapter on alternative (complementary) medicine fills the need for reliable information on this topic.

This is actually the third edition of a book which began life as An Introduction to Family Medicine in 1981. The clinical chapters and the section on the practice of family medicine were added in the edition of 1989. The book and the ideas it presents, have grown with the development of the discipline. Important themes run right through the book. For example, the process of clinical reasoning and narratives of illness emerge in many chapters, with cross-references to other chapters and to case reports. I have visualized the book as a whole, rather than as a series of disconnected chapters, so it is intended to be read as a whole. Since I have tried to anchor it to some fundamental ideas, I hope readers will find it an aid to reflection.

In the use of personal pronouns, I have tried to be fair to both sexes while avoiding he/she and his/her combinations. On the few occasions when it has been necessary I have used the male pronoun for physicians and the female for nurses, while recognizing that many family physicians are female and many nurses are male.