THE PRINCIPLES OF FAMILY MEDICINE

Family medicine can be described as a body of knowledge about the problems encountered by family physicians. This is, of course, a tautology, but then so are the descriptions of all applied subjects. As in other practical disciplines, the body of kno wledge encompassed by family medicine includes not only factual knowledge but also skills and techniques. Members of a clinical discipline are identifiable not so much by what they know as by what they do. Surgeons, for example, are identifiable more by their skill in diagnosing and treating "surgical" diseases than by any particular knowledge of anatomy, pathology, or clinical medicine. What they do is a matter of their mental set, their values and attitudes, and the principles that govern their actio ns.

In describing family medicine, therefore, it is best to start with the principles that govern our actions. I will describe nine of them. None is unique to family medicine. Not all family physicians exemplify the whole nine. Nevertheless, when take n together, they do represent a distinctive world view - a system of values and an approach to problems - that is identifiably different from that of other disciplines.

1. Family physicians are committed to the person rather than to a particular body of knowledge, group of diseases, or special technique. The commitment is open-ended in two senses. First, it is not limited by the type of health problem. Family physi cians are available for any health problem in a person of either sex and of any age. Their practice is not even limited to strictly defined health problems: the patient defines the problem. This means that a family physician can never say: "I am sorry, but your illness is not in my field." Any health problem in one of our patients is in our field. We may have to refer the patient for specialized treatment, but we are still responsible for the initial assessment and for co-ordination of care. Second, the commitment has no defined end point. It is not terminated by cure of an illness, the end of a course of treatment, or the incurability of an illness. In many cases the commitment is made while the person is healthy, before any problem has developed . In other words, family medicine defines itself in terms of relationships, making it unique among major fields of clinical medicine. The full implications of this difference are discussed on pages 16 and 17.

2. The family physician seeks to understand the context of the illness. "To understand a thing rightly, we need to see it both out of its environment and in it, and to have acquaintance with the whole range of its variations" wrote William James. Man y illnesses cannot be fully understood unless they are seen in their personal, family, and social context. When a patient is admitted to the hospital, much of the context of the illness is removed or obscured. Attention seems to be focused on the foregr ound rather than the background, often resulting in a limited picture of the illness.

3. The family physician sees every contact with his patients as an opportunity for prevention or health education. Since family physicians, on the average, sees each of their patients about four times a year, this is a rich source of opportunities for practicing preventive medicine.

4. The family physician views his practice as a "population at risk". Clinicians think normally in terms of single patients rather than population groups. Family physicians have to think in terms of both. This means that one of their patients who ha s not been immunized, or who has not had his blood pressure checked, should be as much a concern as one who is attending for well-baby care or for the treatment of hypertension. It implies a commitment to maintain health in the members of his practice wh ether or not they happen to be attending the office.

5. The family physician sees himself as part of a community-wide network of supportive and health care agencies. All communities have a network of social supports, official and unofficial, formal and informal. The word network suggests a coordinated system. Unfortunately, this is often not so. Too often, members of the health care and social services - including physicians - work in watertight compartments, without any grasp of the system as a whole. Family physicians can be much more effective if they can deploy all the resources of the community for the benefit of his patients. The kind of network to be found in most communities is described in Chapter 20.

6. Ideally, the family physician should share the same habitat as his patients. In recent years, this has become less common, except in rural areas. Even here, the commuting doctor has made an appearance. In some communities, notably the central are as of large cities, doctors have virtually disappeared. This has all been part of the recent trend toward the separation of life and work. To Wendell Berry (1978) this is the cause of many modern ills: "If we do not live where we work, and when we work ," he writes, "we are wasting our lives, and our work too." The Love Canal disaster in Niagara Falls provides a vivid illustration of what can happen when physicians are remote from the environment of their patients. This abandoned canal had been used b y a local industry for the disposal of toxic waste products. The canal was then covered over and, some years later, houses were built on the site. During the 1960s householders began to notice that chemical sludge was seeping into their basements and ga rdens. Trees and shrubs died, and the atmosphere became polluted by malodorous fumes. About the same time, residents in the neighbourhood began to suffer from illnesses caused by the toxic chemicals. It was not, however, until a local journalist did a health survey in the area that an official health study was done. This showed rates of illness, miscarriage, and birth defects far in excess of the norm (Brown, 1979). How did the cluster of illnesses in an obviously polluted environment escape the noti ce of local physicians? One can only assume that they treated patients without seeing them in their home environment. It is difficult to believe that a neighbourhood family physician, visiting patients in their homes and interested in their environment, would have remained unaware of the problem for so long. To be fully effective, a family physician still needs to be a visible presence in the neighbourhood.

7. The family physician sees patients in their homes. Until modern times, attending physicians in their homes was one of the deepest experiences of family practice. It was in the home that many of the great events of life took place: being born, dyin g, enduring or recovering from serious illness. Being present with the family at these events gave family doctors much of their knowledge of patients and their families. Knowing the home gave us a tacit understanding of the context or ecology of illness . Ecology, derived from the two Greek words oikos (home) and logos, means literally "study of the home".

The rise of the modern hospital removed much of this experience from the home. There were technical advantages and gains in efficiency, but the price was some impoverishment of the experience of family practice. The current redefinition of the hospi tal's role is now changing the balance again and we have the opportunity to restore home care as one of the defining experiences and essential skills of family medicine. The family physician should be a natural ecologist (see Chapter 16).

8. The family physician attaches importance to the subjective aspects of medicine. For most of this century, medicine has been dominated by a strictly objective and positivistic approach to health problems. For family physicians, this has always had to be reconciled with a sensitivity to feelings and an insight into relationships. Insight into relationships requires a knowledge of emotions, including our own emotions. Hence, family medicine should be a self-reflective practice (see pp. 75 and 76).

9. The family physician is a manager of resources. As generalists and first-contact physicians, they have control of large resources and are able, within certain limits, to control admission to hospital, use of investigations, prescription of treatmen t, and referral to specialists. In all parts of the world, resources are limited - sometimes severely limited. It is, therefore, the family physicians' responsibility to manage these resources for the benefit of their patients and for the community as a whole. Since the interests of an individual patient may conflict with those of the community as a whole, this can raise ethical issues.

Implications of the Principles

Defining our discipline in terms of relationships sets it apart from most other fields of medicine. It is more usual to define a field in terms of content: diseases, organ systems, or technologies. Clinicians in other fields form relationships with p atients, but in general practice the relationship is usually prior to content. We know people before we know what their illnesses will be. It is, of course, possible to define a content of general practice, based on the common conditions presenti ng family physicians at a particular time and place. But strictly speaking, the content for a particular doctor is whatever conditions his patients happen to have. Other relationships also define our work. By caring for members of a family, the family doctor may become part of the complex of family relationships, and many of us share with our patients the same community and habitat.

Defining our field in these terms has consequences, both positive and negative. Not to be tied to a particular technology or set of diseases is liberating. It gives general practice a quality of unexpectedness and a flexibility in adapting to change . On the other hand, it is poorly understood in a society that seems to place less and less value on relationships. One major consequence is that we cannot be comfortable with the mechanical metaphor which dominates medicine, or with the mind/body duali sm derived from it. Another is that the value we place on relationships influences our valuation of knowledge. Those who value relationships tend to know the world by experience rather than by what Charles Taylor (1991) calls "instrumental" and "disenga ged" reason. Experience engages our feelings as well as our intellect. The emotions play a very significant part in family practice.

Long term relationships lead to a build up of particular knowledge about patients, much of it at the tacit level. Since caring for patients is about attention to detail, this knowledge of particulars is of great value when it comes to care. On the o ther hand, it can make us somewhat ambivalent about classifying patients into disease categories. "Yes", we might say, "this patient has borderline personality disorder - but he is also John Smith, who I have cared for for 15 years." On the whole, our t endency to think in terms of individual patients more than abstractions is a strength, though it can lead us astray if it diverts us from the appropriate pursuit of diagnostic precision. Our valuation of particular knowledge, however, can make it difficu lt for us to feel comfortable in the modern academic milieu, where diagnosis and management are more usually seen in terms of generalizations than particulars. The risk of living too much in a world of generalizations and abstractions is detachment from the patient's experience and a lack of feeling for his suffering. Abstraction produces accounts of experience which, for all their generalizing power, are stripped of their affective colouring and far removed from the realities of life. The ideal for al l physicians is an integration of the two kinds of knowledge: an ability to see the universal in the particular.

The most significant difference between family medicine and most other clinical disciplines is that it transcents the mind/body division which runs through medicine like a geological fault line. Most clinical disciplines lie on one side or the other: internal medicine, surgery, and paediatrics on one side; psychiatry, child psychiatry, and psychogeriatrics on the other. Separate taxonomies of disease lie on either side: textbooks of medicine and surgery on one, the Diagnostic and Statistical Manual of Mental Disorders on the other. We divide therapies into the physical and the psychological. In clinical practice, internists and surgeons do not normally explore the emotions, psychiatrists do not examine the body. Since family medicine defines itse lf in terms of relationships, it cannot divide in this way.1

One of the legacies of the mind/body division is a clinical method which excludes attention to the emotions as an essential feature of diagnosis and management. Another is the neglect in medical education of the emotional development of physicians. A contemporary writer has referred to the "stunted emotions" of physicians (Price 1994). We may be seeing the consequences of this neglect in the alienation of patients from physicians, the widespread criticism of medical care, and the high levels of emo tional distress among physicians.

Since family medicine transcends the "fault line", the conventional clinical method has never been well suited to family practice. Perhaps this is why the moves to reform the clinical method have often come from family medicine. The most important d ifference about the patient-centred clinical method is that attention to the emotions is a requirement. Family medicine has also emerged as one of the most self-reflective of disciplines.

With developments in cognitive science and psychoneuroimmunology, and the high prevalence of illness which does not lie on one side or the other, the fault line is likely to become increasingly redundant. As medicine strives to achieve a new synthesi s, it could learn much from our experience.

Conflicting Roles

Hidden among the principles are some potential conflicts between the family doctor's roles and responsibilities. The first principle is one of commitment to the individual patient, to respond to any problem the patient may bring. It is the patient wh o defines the problem. According to the third principle (responsibility for prevention) it is usually the doctor who defines the problem, often in situations where the patient has come for an entirely different purpose. It may be argued that anticipator y medicine is part of good clinical practice. Taking the blood pressure is part of the general clinical assessment, and if the diastolic pressure is 120 mm, good preventive and clinical practice requires that the problem be attended to, even if the patie nt has no symptoms related to high blood pressure and has only come for a tension headache.

The issue becomes more complex as one moves along the continuum from the presymptomatic detection of disease to the identification of risk factors arising from a patient's habits and way of life. The number of risk factors increases and the reduction of risk involves behavioural changes which may be very difficult to attain. All this may be successfully integrated with clinical practice, and may actually be demanded by a public who are educated to expect anticipatory care. At some point, however, a n emphasis on anticipatory care may compete for time and resources with care based on responding to problems identified by patients. Striking the right balance may be difficult if physicians are contrained either by requirements of managed care or by fun ding arrangements designed to emphasize anticipatory care.

The fourth principle (the practice as a population at risk) adds another dimension. Here, the focus is switched from the individual to the group. The measure of success is statistical. The motivation may be to extend effective care to all patients in the practice, especially those who may not be aware of its availability. The other extreme, however, is to judge success by the magnitude of compliance in the practice population. If funding is dependent on certain targets, outreach to the practice p opulation may compete for time and resources with other practice services, and there may be pressure on patients to comply. The demand on practice resources may be increased by approaches aimed at identifying unmet needs in the geographic area of the pra ctice, and of conducting audits requiring expensive epidemiological methods. Too much emphasis on the population approach, at the expense of meeting the needs of individual patients, may, as Toon (1994) suggests, have an effect on the orientation and tho ught patterns of the physicians. Rather than thinking about their patients, they may find himself precoccupied with their figures.

The ninth principle (management of resources) may also become the source of conflict if a practice becomes responsible for managing and paying for all the services needed by its enrolled patients. The time necessary for management may reduce the time for patient care, and conflicts of interest may arise when an individual patient's interest conflicts with the interests of the group, or if the doctor stands to gain from economies in expenditure.

Conflicting ideas on the roles of the family physician can make it difficult to agree on criteria of quality, especially at times of rapid social change like the present. Toon (1994) suggests that where there is already a strong tradition of general medical practice there may be an intuitive concept of good general practice which will eventualy lead to a synthesis. The path to a synthesis will be easier if administrators and managers tread lightly in making changes which alter the balance between th e doctors' responsibilities, especially those changes which can divert us from our traditional responsibilities to individual patients.

Continuity of Care

For a discipline that defines itself in terms of relationships, continuity in the sense of an enduring relationship between doctor and patient, is fundamental. Hennen (1975) has described five dimensions of continuity: interpersonal; chronological; ge ographic (continuity between sites: home, hospital, office); interdisciplinary (continuity in meeting a variety of needs, e.g. for obstetric care, surgical procedures); and informational (continuity through the medical records). I use continuity here in the sense of overall, direct, or co-ordinative responsibility for the different medical needs of the patient (Hjortdahl, 1994). The key word here is responsibility. Obviously the physician cannot be available at all times, nor can he carry out al l the care a patient may need. The doctor is responsible for ensuring continuity of service by a competent deputy and for following through when some aspect of care is delegated to a consultant. Responsibility is the key in all important relationships.

Based on a sequence of studies from a number of perspectives, Veale (1996)2 has described four types of general practice utilization. In the first, a consumer visits only one G.P. In the second, all the visits are to one practice. In the third type , the consumer visits a variety of G.P.'s for different purposes. One doctor may be seen because of proximity to place of work, another for proximity to home, or the selection of G.P. may depend on the nature and severity of the problem and the doctor's expertise. This type of utilization appeared to work well for consumers who take responsibility for co-ordinating their own care. In the fourth type of utilization, the consumers decide which doctor they will see on a visit-by-visit basis, with no expec tation that there will be continuity of care from any of them.

There was strong preference, both by consumers and doctors, for the first type of utilization. Three benefits were associated with visits to one G.P.: co-ordination of care, familiarity and openness in the therapeutic relationship, and the opportunit y for monitoring of treatment and mutual agreement about management. However, consumers who had all their visits to one G.P. did not necessarily reap the benefits of continuity. Nor did visits to several G.P.'s in the same practice, or to G.P.'s in diff erent practices preclude continuity.

Brown et al. (1996) have shown that continuity of care can be experienced by patients even in a university group teaching practice with frequent changes of trainees.3 Long term patients of the practice, recruited to focus groups, identified four fac tors contributing to their experience of continuity: the sense of being known as a person by the doctors, nurses, and receptionists; the relationship with a team of doctor-nurse-trainee-receptionist; the sense of responsibility demonstrated by the physici ans, including their openness and honesty in dealing with uncertainty; and the comprehensiveness and availability of the services provided, including a 24-hour on call service and willingness to see patients at home and in the hospital.

Continuity in the doctor-patient relationship is a mutual commitment. Veale concludes that it is best understood, "not as an entity provided by doctors, but rather as an interaction over time, constructed jointly by consumers and their G.P.'s". Cont inuity "cannot be delivered to a passive recipient by the G.P., however skillful." The essential preconditions of continuity were ready access, competence of the doctor, good communication, and a mechanism for bridging from one consultation to the next. There was a tendency for young and healthy people to prefer the visit-by-visit approach, for people with young children to have continuity with a practice, for those with several distinct problems to visit a variety of G.P.'s, and for the elderly and peo ple with serious illness to prefer continuity with one doctor. Attitudes to continuity may therefore change as people grow older and experience different needs (Veale, 1996).

It is difficult for a doctor to feel continuing responsibility for a patient who does not value it. Some experience of a continuing commitment is required for a sense of responsibility to grow. Hjortdahl (1992) found that duration of the relationshi p and frequency of contacts (density) were important in developing the sense of responsibility. After one year, the odds of the doctor feeling this sense doubled, and after five years they increased sixteen fold. If there were four or five contacts over the previous year there was a ten fold increase in the sense of continuing responsibility, compared with only one visit.

Once this mutual commitment has developed, failure to honour the commitment may be seen as a betrayal of trust: if, for example, the doctor terminates the relationship when a patient develops AIDS or is too ill to leave his home.

The value placed on continuity of personal care is reflected in the way a practice is organized. Reception staff can make every effort to book patients with their chosen physician. The practice's philosphy of continuity can be clarified and conveyed to staff and patients. Individual patients' preferences with regard to continuity can be noted, and if possible, accommodated. The on-call system can be organized so that patients see a doctor who communicates with their own doctor, has access to their medical record, and can make a home visit when required. Dying patients, and others with special needs, can be kept out of the on-call system. Continuity can be enhanced by having the patient's record available at all times to those providing care.