From the President: The Uneven Climb – Part 2

In the previous issue of WONCA News, I contrasted Family Medicine in Denmark and Romania. Danish family doctors stand tall atop their health care system. Romanian family physicians have a challenging ascent up a very steep slope. In this issue, I reflect on Spain and Brazil – two countries where the national health care systems have been re-built over the past two decades on a foundation of Family Medicine. A fiscal crisis (Spain) and a change in government (Brazil) now threaten the continued climb of Family Medicine in those nations.

Zaragoza en junio

After three flights, two taxi rides, and one high speed train from Madrid, I arrived in early June in Zaragoza, Spain. Built along the Ebro river, Zaragoza is located in a valley between the Pyrenees Mountains to the northeast and the Iberian System to the southwest. It is the fifth largest city in Spain, with a metropolitan population of about 800 000. Zaragoza has a 2,000 year history of diverse rulers. It was founded by Caesar Augustus, captured by the Goths, ruled by Muslim emirs, and governed by the Kingdom of Aragon before becoming part of modern Spain.

My travel to Zaragoza was to attend the annual conference of semFYC (Sociedad Española de Medicina de Familia y Comunitaria). The Spanish Society has just under 10,000 members. There were about 3,000 in attendance at the meeting. The Spanish make a special effort to reach out to medical students through a pre-conference meeting. I participated in a lively panel that discussed the future of Family Medicine in Spain. Several of the professors and deans acknowledged that the Spanish medical school curriculum needed to become more student-centered and relevant to primary care.

During the course of the conference, there was much concern about potential cutbacks because of the government’s financial crisis. Another issue was the effort to create a specialty of Emergency Medicine, which was viewed as a threat to Family Medicine. The relative absence of Family Medicine in academia was also a subject of much discussion.

I spent a portion of one day watching an experienced and skilled family doctor at work in his health center.

Averaging about 5-7 minutes per person, he sees about 40-60 patients each day. His practice was limited to those over age 14, which is the norm for Spanish family physicians. A government established electronic health record provided easy access to information for each patient’s history, lab results, imaging studies, and so on. The range of patient concerns was familiar: musculoskeletal complaints, multi-system problems in the aged, infections of various sorts.

My overall impression is that the family doctor plays an important role in the Spanish health system. A heavy volume of visits (40 per day compared to 25 per day for other specialists) makes it difficult to address the range of problems that patients present, or to know the patient as well as the doctor would like. Part of the solution will be to raise the visibility and status of family doctors in Spanish society in general and medical schools in particular.

Brasília em junho

Several weeks later, I traveled to Brasília for the annual meeting of SBMFC (Sociedade Brasileira de Medicina de Família e Comunidade). Built in the 1950s as a planned capital city to connect the country, Brasília consists of broad boulevards and futuristic government buildings. Growing at a rapid rate, Brasília now has more than 2.5 million inhabitants.

With more than 4,000 registrants, the SBMFC meeting was a reflection of Brazil – big, enthusiastic, and on the rise. I was kept so busy that I did not have the chance to visit a family doctor’s practice in Brasilia, although I have had the pleasure on previous trips to observe family doctors at work across much of Brazil.

One of the most interesting portions of the meeting consisted of sessions with new officials from the Health Ministry. The previous federal government pledged to have all 180 million Brazileiros connected to 90,000 Family Health Units has been slowed by a lack of qualified family doctors. With only 30,000 Units established thus far, the new government had concluded that there was a gap between the promise of the highly touted Family Health Program and the current reality. There is a desperate need for more qualified family doctors. The new government, eager to leave its own imprint on the health system, has begun to talk about allowing more local flexibility, including a reversion back to the old polyclinic model with care provided by specialists or general doctors without primary care expertise.

The wavering by the government generated a great deal of discussion on the part of the SBMFC members who have worked hard to make the Family Health Program successful and to achieve and maintain qualification as experts in Family Medicine and primary care. People lined up at the microphones to confront government representatives and share their concerns that the health system was taking a step backward. The family doctors were quite vocal in expressing their worries about losing many years of effort to build a better Brazilian health system.

On my return home, I thought about what I had learned in Spain and Brazil. These are two countries that had expressed commitment to, and invested heavily in, health systems built on a foundation of family doctors. Yet, when economic times became difficult (Spain) or a new government wanted to be credited with a new system (Brazil), the support for family doctors weakened. These examples reminded me that we need to become more than the friends of any one government – we need to be embedded in the fabric of our cultures. In the end, it is our patients and communities that must be our most dependable allies.

Climbing skills

Leaders of both semFYC and SBMFC asked me for suggestions on how to strengthen the position of Family Medicine in their countries. Following are some of the strategies I offered to both Societies, which are built around three questions they put to me.

How do we respond to proposals by the Health Ministry that do not support Family Medicine?

There are three possible responses: “we do not agree,” “we agree,” or “we agree with some of your concerns and goals, and offer the following better ideas.” Let’s examine each of the three options:

“We do not agree” – outright disagreement with the Ministry is a risky proposition since most family doctors work for the government and the government has very substantial resources and media access to persuade the public of the correctness of its position.

“We agree” – agreement with the Ministry will maintain the important alliances built up between the Ministry and the Society, but puts the Society in the position of endorsing policy proposals that weaken support for family doctors, and risk the loss of confidence of family doctors in the Society.

“We agree with some of your concerns and goals, and offer the following better ideas” – this is the best option. When the Ministry expresses concerns about costs or the need for local flexibility where there are not enough family doctors, the Society should agree with the government about these real concerns. The Society should then show the data it has that total costs will go up and outcomes will worsen if they use other health care workers (nurses, general doctors) or other specialists as the entry point into the health care system. The Society should also develop a proposal to deal with those local situations where there are limited numbers of family doctors, but more workers or specialists of other types. For example, in communities without enough family doctors, their mayors could be brought together in a local summit with family doctors from their areas to discuss better ways to cover all of the population. It can be helpful to look to others to help you make your case for a new and better strategy for access – enlist health services researchers who are sympathetic to your cause and know the data; also ask for help from researchers and others outside the country who can assist.

How do we identify and reach our targeted audiences with our message?

Your target audiences are: governments (federal, state, municipal); influence leaders, media; and patients (the general public).

Governments:

Use the government’s own data, which show that Family Medicine is the best way to provide health care that is lower cost and better quality than traditional basic health units. Many times, public officials look only at the direct costs (a family health unit costs more to set up than a traditional basic health unit), but do not consider all the costs (there are fewer referrals to hospitals or other specialists through a family health unit, which becomes much more expensive overall than the direct costs of the family health unit). In discussions with governments, the Society must speak to the issues and not to political parties or politics. If the Society is seen as linked only to one side of the political spectrum, such as the left, then the Society will be ignored when the other side (the right) comes into power. The focus should be on what’s best for patients and family doctors, not to serve anyone’s specific political agenda. There may be some (or many) Society leaders who had good friends in the old Ministry and who are not good friends with the current Ministry officials. It may therefore be necessary to have other family doctors step into their place when representing Society concerns to the current Ministry.

Influence leaders:

Every community has many influence leaders, some of whom are formal (mayor) and some of whom are informal (TV talk show hosts, business leaders, religious leaders). Ask family doctors to begin to discuss your concerns with the influence leaders they know in their communities. Develop presentations for Rotary, the Chamber of Commerce, church groups, and other organizations that make it easy for family doctors around the country to tell the successful story of Family Medicine and the need for the country to continue to invest in Family Medicine.

Media:

Reach out to the media by offering ideas (even write scripts and suggest actors!) for soap operas (novellas), talk shows, or newspaper articles written by the Society. A story idea: "The secret patient": journalists with a hidden camera pose as patients and go to different specialists and show the different advice, outcomes, and costs they experience.

Patients/public:

Take an active role in the local health councils. Patients who benefit from your services are your best form of advertising. Reach out to all social classes. Even if a wealthy owner of a business gets his care through private insurance and other specialists, show him that his workers will be healthier and miss less work if they get their care from a family doctor.

How do we move forward?

It is crucial that the Society develop a specific action plan with achievable goals and actions to reach those goals.

1 – Set your goals:
What is your dream or vision for family medicine? The Society must set specific goals to achieve. Examples: “We want primary care spending to go up by 20% each year.” “We want qualified family doctors to be paid at 100% of the average pay of all doctors.” “We want the number of new Family Medicine practices to increase by 1000 per year.” Your ultimate focus should be on what is best for the people and for society.

2 – Offer better changes.
The Society is in the difficult position of having to defend the status quo (the current Family Medicine-based strategy), which is associated with the old government. Politicians – and the public – always want a sense that things are changing for the better. Offer them a new and improved strategy that addresses their concerns about the current system.

3 – Promote your position.
Develop good relations with all your stakeholders. Train your members (especially residents and young family doctors) how to develop those relationships and to present well before groups and the media. Create a Speakers Bureau, which identifies, trains, and supports family doctors who are good spokespersons across all of the country.

4 – Network with others.
Activate people who know people. Develop a list of influential people that Society members know – it might be relatives, patients, school mates, and so on. Ask them to help you with your cause. Even other specialists can help you. Many of them support the Family Medicine and can support you in the media and with other influence leaders. John F Kennedy once said, “we have no permanent friends, we have no permanent enemies, we have only mutual and shifting interests.” Understand and appeal to the interests of others that you would like to bring over to your cause.

5 – Re-frame the debate.
Ask yourself: why is the Ministry proposing a change? Is it because of money? (you can show them that Family Medicine is less expensive overall) Is it because of unhappiness with the current program? (for every mayor or patient who expresses unhappiness with the current program, you can bring forward 100 who are very happy) Is it because as a new government, they feel the need to offer change, any change? (you can agree with the need to make the current program better and offer specific recommendations for improvement, thereby allowing the new government to feel like they’ve accomplished something new and good).

6 – Keep the faith.
These kinds of challenges are exhausting and require time, money, and energy. Support each other. Know that you are not alone. When necessary, bring in others from the outside (outside your specialty, outside your community, outside the country) to help you when needed and to boost your energy when needed. The stakes are high. The country should not step back from its ambitious goal to have every person with access to a family doctor. This is more important than any one country – many countries, especially in Latin America, have listened to the excitement and good results of the Family Medicine programs in Spain and Brazil. If either country backs away from Family Medicine now, it will decrease the reputation of the country (Why are you changing directions? Were you wrong before? Are you wrong now?) and it will jeopardize similar reforms in other countries.

Why make the climb?

Much of the world (re)discovered Family Medicine with the new millennium. Intoxicated by these expressions of support, many of us in Family Medicine assumed prematurely that it would just be a matter of time before we climbed to the top of our health care systems. We have learned that the climb can be arduous and is not assured. But then, no one promised us that the climb would be easy, only that it was important.

Professor Richard Roberts