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 knowledge encompassed by family medicine includes not only factual knowledge but also skills and techniques. Members of a clinical discipline are identifi - able not so much by what they know as by what they do. Surgeons, for example, are identifi able 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 mind set, their values and attitudes, and the principles that govern their actions. 
In describing family medicine, therefore, it is best to start with the principles that govern our actions. We will describe nine of them. None is unique to family medicine. Not all family physicians exemplify the whole nine. Nevertheless, when taken together, they do represent a distinctive worldview—a system of values and an approach to problems—that is identifi ably 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 physicians are available for any health problem in a person of either sex and of any age. Their practice is not even limited to strictly defi ned health problems: the patient defi nes the problem. This means that a family physician can never say: “I am sorry, but your illness is not in my fi eld.” Any health problem in one of our patients is in our fi eld. We may have to refer the patient for specialized treatment, but we are still responsible for the initial assessment and for coordination and continuity of care. Second, the commitment has no defi ned 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 defi nes itself in terms of relationships, making it unique among major fi elds of clinical medicine. 

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 the American philosopher William James (1958). Many 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
foreground rather than the background, often resulting in a limited picture of the illness.

3. The family physician sees every contact with his or her patients as an opportunity for prevention of disease or promotion of health. Because family physicians, on the average, see 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 or her 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 patients who have not attended for such procedures as immunization, papanicolaou smears, or blood pressure test are as much a concern as those who are attending regularly. Electronic records make it very easy to maintain upto- date attendance records of the whole practice population.

5. The family physician sees himself or herself as part of a communitywide network of supportive and health-care agencies. All communities have a network of social supports, offi cial and unoffi cial, formal and informal. The word network suggests a coordinated system. Up to recently this has often not been the case. Too often, family physicians, hospital doctors, medical offi cers of health, home care nurses, social workers, and others have worked in watertight compartments without a grasp of the system as a whole. At the time of writing, many jurisdictions are in the process of reforming general practice as a key link in the network, which will enable patients to benefi t from whichever provider they require.

6. Ideally, family physicians should share the same habitat as their 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 areas 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 by 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 gardens.

Trees and shrubs died, and the atmosphere became polluted by malodorous fumes. About the same time, residents in the neighborhood 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 offi cial 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 notice 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 neighborhood 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 neighborhood.

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, dying, 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 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 effi ciency, but the price was some impoverishment of the experience of family practice. The current redefi nition of the hospital’s role is now changing the balance again and we have the opportunity to restore home care as one of the defi ning experiences and essential skills of family medicine. The family physician should be a natural ecologist . At the time of writing, a shortage of general practitioners (GPs) has made it diffi cult for practices to visit their patients in their need. At the same time, there are new reasons for attending housebound patients. Hospitals are dangerous for the elderly, from hospital infections and rapid deterioration from the change of environment. Attending patients with short-term illnesses prevents patients spreading or acquiring diseases in emergency rooms, and doctors’ offi ces. Advances in technology have made diagnosis and therapy much  easier than before.

8. The family physician attaches importance to the subjective aspects of medicine. For many years, 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 knowledge of emotions, including our own emotions. Hence, family medicine should be a self-refl ective practice 

9. The family physician is a manager of resources. As generalists and fi rst- contact physicians, they have control of large resources and are able, within certain limits, to control admission to hospital, use of investigations, prescription of treatment, and referral to specialists. In all parts of the world, resources are limited, sometimes severely limited. It is, therefore, the responsibility of family physicians to manage these resources for the benefi t of their patients and for the community as a whole. In certain cases, the interests of an individual patient may conflict with those of the community as a whole, and this can raise ethical issues.

by Umaee
Source: Family Medicine
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