DO WE DARE TO BE
DIFFERENT
Igor Švab
MY AIMS
• At the end of this presentation, you will:
– Remember your dreams
– Understand why you are different
– Value your importance
– Be aware of the challenges we are facing
– Think differently about your competences
– Know how to change the world
CONTENT
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The good old times
The unexpected problems in practice
The concepts we use in family medicine
The scientific evidence of our importance
A short assessment of the current situation
What have we almost forgotten
What are our skills
Conclusion and a proposal
ACKNOWLEDGEMENTS
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Hippocrates
Marcel Proust
Juan Gervas
Chris Dowrick
Larry Green
Richard Horton
Barbara Starfield
Cecil Helman
Moira Stewart
Trish Greenhalgh
James Willis
Iona Heath
Charlie Brown
William Ventres
Niccolo Macchiavelli
•
•
•
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Zalika Klemenc Ketiš
Davorina Petek
Josip Car
Janko Kersnik
THE GOOD OLD DAYS
OUR DREAMS
• To help people
• To be important
• To change the world
for the better
THE HARD REALITY OF MEDICAL
SCHOOL
THE ART AND SCIENCE OF MEDICINE
Correct is to recognize what diseases are and whence they come; which are
long and which are short; which are mortal and which are not; which are
in the process of changing into others; which are increasing and which are
diminishing; which are major and which are minor; to treat the diseases
that can be treated, but to recognize the ones that cannot be, and to know
why they cannot be; by treating patients with the former, to give them the
benefit of treatment as far as it is possible.
Hippocrates
THE PARADIGM
• Medicine is performed in
a world of hard reality.
• Everything can be
measured and classified.
• Patient care is based on
clinical reasoning, which
is an intellectual exercise
one can perform if one
knows the facts and the
logic.
PROCESS OF CARE
•
•
•
•
•
The patient gets ill
Goes to a doctor
Is examined
Receives treatment
Gets well
THE ROLE OF THE DOCTOR
• To be a detective that
discovers the reasons for
poorly defined problems.
• To discover the correct
diagnosis, the correct
agent that is causing the
disease.
11
A SELECTION OF PATIENTS
THE DIFFERENCES IN PRACTICE
FIRST LESSONS
• You never quite know who
or what will walk through
your door next.
• Textbook cases are
exceptions to the rule.
• Some problems are not
biomedical.
A 82-year old lady who has remained
alone after her husband has died.
She has many health problems, most
of them will never been cured.
She comes to practice regulary and is
very grateful for my time,
because she rarely has a chance
to have someone listen patiently
to her.
A 75-year old alcoholic who came for
his last visit two years ago when
his wife, who was taking care of
him, was still alive.
He arrives, asking for a repeat
prescription.
He is dirty and smelling of alcohol.
A 42-year old lady with low back
pain, hypertension and obesity.
It is impossible for her to lose any
weight
She has seen many different
specialists and has done a lot of
tests
She wants another appointment for
a specialist for which I know will
not help her.
A 76-year old patient with terminal
phase of prostate cancer
He refuses to talk about his disease,
but I know he is aware what is
the matter with him
His family is urging me not to tell him
he has cancer because they are
convinced that this will be very
bad for him.
A 55- year old diabetic
construction worker who can
not afford healthy food I am
recommending.
He has found out that he has no
health insurance while coming
for a routine consultation,
which means that I should
charge him my consultation.
DIFFERENCES AND SKILLS WE HAD
TO ACQUIRE
COMMUNICATION
…among the crowd of gestures and speeches
and other little incidents which go to make up
a conversation, it is inevitable that we should
pass (without noticing anything that arouses
our interest) by those that hide a truth for
which our suspicions are blindly searching,
whereas we stop to examine others beneath
which nothing lies concealed.
Marcel Proust: Swann’s world
NAVIGATING THE MAZE
For the doctor
For the patient
ACCEPTING PATIENT PREFERENCES
• Life is not "the supreme good."
• Sometimes life is worse than death.
Gervas J, BMJ listserver discussion, april 2013
FOCUS ON HEALTH
• We have to encourage our patients to look around and
discover places where they can smile and laugh, where life
can be rewarding and inspirational.
Dowrick C: http://wellbecoming.blogspot.com
THE ART OF DOING NOTHING
• Doing nothing, but having the courage sometimes to wait – to
use time as both a diagnostic and and a therapeutic tool – to
see what nature does – to wait and see. These are essential
skills…that are profoundly important if we are not to fall into
the seductive traps of over diagnosis and overtreatment.
Heath I. The art of doing nothing. Eur J Gen Pract 2012; 18: 242-246
AN ADDITIONAL REQUIREMENT
Hippocrates
Charlie Brown
 Correct is to recognize what diseases
are and whence they come; which are
long and which are short; which are
mortal and which are not; which are
in the process of changing into others;
which are increasing and which are
diminishing; which are major and
which are minor; to treat the diseases
that can be treated, but to recognize
the ones that cannot be, and to know
why they cannot be; by treating
patients with the former, to give them
the benefit of treatment as far as it is
possible.
•
Have you been lying awake worrying?
Don't worry...I'm here. The flood
waters will recede, the famine will
end, the sun will shine tomorrow, and
I will always be here to take care of
you.
DIFFERENT CONCEPTS
A DIFFERENT PARADIGM
• The patient gets ill
• Goes to see a doctor
• Not always
(prevention)
• Doctor prescribes a
medication
• Other forms of contact
• Other professionals
• Other treatment
options
• The patient gets well
or dies
• Control of chronic
disease
CONSULTATION
Innes, Campion, Griffiths. Complex consultations and the edge of chaos. BJGP 2005
acute and
chronic health
problems
promotes
health and
wellbeing
early
undifferentiated stages
decision making
based on incidence Specific
and prevalence
problem
Comprehensive
solving skills
approach
responsible for
health of the
community
Community
orientation
care coordination
and advocacy
longitudinal
continuity
centred on
patient and
context
Person-centred
care
Primary care
management
Holistic
approach
first contact,
open access,
all health problems
doctor-patient
relationship
physical, psychological, social, cultural
and existential
European Definition of
Family Medicine:
Core Competencies and
Characteristics
(Wonca 2005)
attitude
science
context
© 2004 Swiss College of Primary Care
Medicine/ U. Grueninger
CONTRIBUTION OF FAMILY
MEDICINE
• In the hands of GPs, I have watched the patients’ confusion,
fear and doubt transform to clarity, relief and assurance….
• With the GP in this role, sick people recover, sick people find
relief from suffering, some sick people fear less, and some sick
people are filled with hope.
Stewart M. Reflections on the doctor-patient relationship: from evidence and
experience. British Journal of General practice 2005; 55: 793-801
CRITICISM
If primary care has anything at all to do with
improving health, then its contribution will be
measurable. If not, it will be accepted as the
homeopathy of modern medicine.
Horton R. Is primary-care research a lost cause? Lancet 2003, 361: 977
MEASURING FAMILY MEDICINE
PRIMARY CARE ORIENTED
COUNTRIES
• Have more equitable
resource distributions
• Are rated as better by
their populations
• Have better health
• Health costs are lower
Starfield and Shi, Policy relevant determinants of health: an international perspective. Health Policy 2002; 60:201-18.
van Doorslaer et al, Explaining income-related inequalities in doctor utilisation in Europe Health Econ 2004; 13:629-47.
OTHER MEASURES
•
•
•
•
Accessibility
Referral rates
Workload
Prescribing
patterns
• Vaccination rates
• Clinical targets
WHERE ARE WE NOW?
SITUATION LOOKS BETTER
• We have proven our
importance
• We are increasingly
working according to
measurable quality
standards and are
regularly achieving goals
• We are increasigly
becoming part of the
establishment
POLICY SUGGESTIONS
World Health Organization. Primary Health Care –Now More than Ever. Geneva, Switzerland, 2008.
TEACHING
 Teaching agenda and other
documents
 Undergraduate teaching of
family medicine as
innovation in teaching
 Vocational training as a
requirement for
independent work in
Europe
RESEARCH
1.
2.
3.
4.
5.
6.
7.
To further develop and evaluate generic
models or strategies
To encourage comparative research
To promote and support longitudinal cohort
studies
To promote and support intervention studies
and randomized controlled trials which take
into account broad issues.
To encourage research focussing on
diagnostic strategies and reasoning
To promote studies assessing effectiveness
and efficiency in everyday care
To develop and validate functional and
generic instruments and outcome measures
for use in GP/FM research and care.
WHAT NEXT?
THE NEXT STEP?
• The greatest challenge
facing contemporary
medicine is for it to retain
… or regain its humanity,
its caritas, without losing
its essential foundation in
science .
Willis, JAR. The sea monster and the whirlpool. Keynote address. Birmingham: Royal
College of General Practitioners; 2002.
CRITICISM OF MEDICINE
• We are experiencing an erosion of medicine’s core values and
defining practices by new technologies in the hands of naive
rationalists.
• Rationalistic assumptions ….perpetuate the myth that, by
reducing medicine’s complexity to focused questions about
populations, interventions, comparisons and outcomes, we
will get rid of its uncertainties and ambiguities.
• In fact, you can’t tame complexity without loss of meaning.
Greenhalgh T. Why do we always end up here? Evidence- based medicine’s conceptual cul-de-sacs and
some off-road alternative routes. J Prim Health Care 2012;4(2):92–97.
REDUCTION OF MEANING IN FAMILY
MEDICINE
• If we concentrate on...
– Seeing a lot of patients in a short period of time
– Ticking boxes according to protocols
– Spending less money
– Making patients happy
• What do we miss?
• By putting too much focus on measurable standards and by
forgetting the personal approach we are denying our patients
our feelings, our wisdom, our caring, our love, the very values
that are needed in a modern world dominated by
productivity profit.
• Using only rationalistic measures is not enough in explaining
quality and contribution of family medicine.
SOME DATA
• Pay for performance schemes stop improving quality when a
target is reached. They also adversely affect continuity of
care*
• There were no significant changes in quality of care for
communication, coordination, and overall satisfaction**.
*Campbell SM,Reeves D, Kontopantelis E,Sibbald B, Roland M. Effects of Pay for Performance on the
Quality of Primary Care in England. NEJM 2009;361:368-78
**Campbell SM, Kontopantelis E, Reeves D, Valderas JM, Gaehl, E, N Small N, Roland M. Changes in
Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007
Ann Fam Med 2010;8:499-506.
THE DANGER OF SIMPLIFICATION
• By thinking that only the measurable counts we reduce family
medicine to a series of simple measurable procedures which
can sometimes be done better by others.
• To the disappointment of techno-doctors and bureaucratic
managers, family medicine can not be reduced to an industry
producing services according to measurable standards at a
low cost.
THE IMPORTANCE OF CARING
• Caring for a fellow being is as important to family medicine as
science is.
• It can not be measured, but this does not mean that it is not
important.
• It is complicated, because it involves the involvement of the
most complex machine: the person of a doctor
• It is not enough for a family doctor to be a detective and
provider of services
• Much more is needed…
WHAT DO WE HAVE TO BE?
Adapted from: Ventres W. The Joy of Family Practice. Ann Fam Med May/June 2012 10:264268;
48
THE DETECTIVE
• The detective that discovers the
reasons for poorly defined
problems, that makes sense of an
overabundance of information.
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THE FAITHFUL PARTNER
• To be a faithful partner to your
patients throughout their life and
your professional career,
regardless their problems.
• To be faithful to the core values
of medicine and humanism.
THE LOVER
• The lover who loves patients
regardless their problem, gender, or
age, because they are sometimes
emotional and because we can
discover their unique personalities.
• In return, we are greeted with a
reciprocal sense of love, a respect, a
trust, and an invitation to join them as
they make their ways in life, with
gratitude when things go well as well
as when they do not.
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THE BELIEVER
• The believer who accepts that in
encounters with patients, often
something inexplicable happens,
which can not be explained by
strictly biomedical logic.
• Who assists when lives are not
tidy and manageable or
predictable
• Who sometimes offers a path
amidst the unknown.
THE DANCER
• The dancer who leads and helps
patients and their families to feel
a sense of competency in the face
of challenge.
• The dancer who follows and
allows them room to express
their fears as well as their
strengths.
THE ACTOR
 The actor who plays the
roles of:
 interpreter,
 guide,
 diagnostician,
 advocate,
 healer
 By doing this, the actor is
supported by what was learned in
training. This is the framework for
the play, which has developed
into something more whole, more
complete, and more authentic —
the work of a family doctor.
CHARACTERISTICS
•
•
•
•
•
•
It is difficult
It is sometimes dangerous
It is often impossible to measure
It is often rewarding
It is priceless
It is what we are
WHY DO WE DO IT?
•
•
•
•
•
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To discover like Sherlock Holmes
To be faithful like Penelope
To love like Romeo and Juliet
To have faith like mother Theresa
To dance like Fred and Ginger
To play like Lawrence Olivier
• It is the most difficult and the most beautiful job in the world.
CONCLUSION AND A PROPOSAL
OUR DREAMS FULFILLED?
• To help people
• To be important
• To change the
world for the better
MISSION (LARGELY)
ACCOMPLISHED
• We contribute to people’s health
• We are an important discipline in medicine
• But this is not enough
THE TASK OF CHANGING THE
WORLD
• Our contribution to changing the world for the better is to be
a constant reminder that personal care is essential for every
doctor regardless the speciality.
• This largely neglected feature of medicine can be best taught
and researched in the context of family medicine, because it
represents the very essence of the discipline.
• By insisting on its importance, we may reduce some of the
crisis of modern medicine, driven by technology and money.
DO WE DARE TO BE DIFFERENT?
• It ought to be remembered that there is nothing more difficult
to take in hand, more perilous to conduct, or more uncertain
in its success, than to take the lead in the introduction of a
new order of things*.
*Macchiavelli N. The Prince, 1505