Family Medicine

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World Book of Family Medicine – European Edition 2015 families, communities, work, religion, and other social determinants of health provides important insights into their health. Family doctors appear today to be less likely to live in their patients’ community or remain in a single locale. Critical question: How well do the family doctors know their patients’ context? Comprehensive – Better outcomes and lower costs result when family doctors provide most of the care needed by their patients (4). Fragmenting care across more professionals, even within the primary health care team, diminishes the skills of the family doctors (5). Decisions to delegate tasks or to limit clinical activities to narrow areas of interest shrink the scope of services provided by the family doctors. Critical question: How comprehensive are the services that the family doctors provide? Competence – Patients deserve and expect competence. Particular individuals, both within or outside the primary care team, may perform certain services more skilfully than the family doctor. Yet, the small marginal gain in a specific technical skill may be offset by too limited a perspective of or trust by the patient, with better overall outcomes when that specific service is provided by the family doctor. Moreover, family doctors with inadequate training, time, or motivation often fall victim to a self-fulfilling prophecy: “The less I do, the less I feel confident and skilled to do.” Critical question: How skilled are the family doctors to provide the services needed by their patients? Continuity – One of the most important attributes of primary care is the continuity of the interpersonal relationship between the family doctor and the patient (6). Continuity permits greater knowledge of the patient by the physician and promotes greater trust in the physician by the patient (7). It is possible to extend, but not delegate, the continuity relationship to other members of the care team. In other words, the family doctor must have sufficient direct involvement with the patient for a trusted relationship to develop. Building on that relationship, other members of the care team can then be trusted to provide various services for, and develop their own relationships with, the patient. Critical question: How strong is the relationship between patients and their family doctors? Practices and family doctors that answer “VERY” to all six critical questions provide better primary care. Health care systems that have strong primary health care do better. Thus, the best health care systems are those that respond positively to a single essential question: How well do the family doctors know, foster trust in, and provide services for their patients? Conclusion In essence, good family doctoring comes down to leveraging trusted relationships and providing comprehensive services, thereby achieving better outcomes (8). The risk today is that in our pursuit to measure well against diseaseoriented metrics and to manage growing patient needs and demands, we will give in to the temptation to limit our availability to our patients and fragment their care across more disease-focused professionals. Our challenge is to develop new strategies and technologies to better know and better serve our patients. Family doctors are not valued because of what we think we do or say we do or used to do. We are valued because of what we do. Take Home Messages Health care systems do better when they are built on strong primary care. Strong primary care depends on six key attributes: convenience, coordination, context, competence, comprehensiveness, and continuity. Recent trends suggest that family doctors, and their practices, may not be performing on the six attributes as well as before or as desired. Family doctors must develop improved strategies to better know, foster trust in, and provide more services to their patients, or their relevance will decline. References 1. Primary health care: report of the International Conference 1. on Primary Health Care, Alma-Ata, USSR, 6–12 September, 1978, jointly sponsored by the World Health Organization and the United Nations Children’s Fund. Geneva, World Health Organization, 1978 (Health for All Series No. 1). 2. The world health report 2008: primary health care now more than ever. Geneva, World Health Organization, 2008. 306
World Book of Family Medicine – European Edition 2015 3. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly 2005;83(3):457-502. 4. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. J Fam Pract 1998;47: 105–109. 5. Campbell SM, McDonald R, Lester H. The experience of pay for performance in English family practice: a qualitative study. Ann Fam Med 2008;6:228-34. 6. Starfield B, Horder J. Interpersonal continuity: old and new perspectives. Br J Gen Pract. 2007; 57(540):527-9. 7. Roberts RG. The art of family doctoring: a global view. Eur J Gen Pract. 2013 Mar;19(1):59-61. 307
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Family Medicine

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