Dr Ian McWhinney Lecture: The Importance of Being Different

I feel grateful, humble and somewhat overawed, to have been invited to deliver this inaugural lecture of the Ian McWhinney Lecture Series, here at Western University, in the presence of members of Ian’s family and so many of his dear friends and colleagues.  Like so many people in family medicine around the world, I knew and admired Ian from a distance, through his influential writing and from the rare privilege of being in the audience when he spoke at a global family medicine conference.

Ian was one of the giants of global family medicine.  Whether he liked the term or not, Ian was often referred to as the "Father of Family Medicine".  Ian influenced the careers and the attitudes of family doctors in all parts of the world, and he led the development of the academic basis of our professional discipline.  As a global community we are indebted to Ian for his many contributions to family medicine and health care, and for the many lessons he shared with us all.  We grieve his passing.

Like many great people, Ian’s legacy lives on through his writing.  I have taken the title of this lecture, The Importance of Being Different, from Ian’s 1996 William Pickles Lecture at the Royal College of General Practitioners in his original homeland, the United Kingdom.  I am going to refer to the four characteristics of family medicine that Ian outlined in that great lecture, and I am also going to share with you some contemporary examples of The Importance of Being Different from family medicine around the world.  I am also going to speak about how Ian made such an impact by being, like so many of us in family medicine, different to other clinicians in the way he thought about clinical medicine, the way he approached medical research, and the way he taught the next generation of young doctors.

There is an extract from the 1996 William Pickles Lecture in Ian’s final book of reflections, A Call to Heal, and the full lecture is available on the Internet thanks to the British Journal of General Practice.  Dr William Pickles, as I am sure many of you know, was a British general practitioner and a pioneer of family medicine research in the early part of the twentieth century.  William Pickles was a keen observer and demonstrated that collecting simple practice information about his patients over many years could lead to important discoveries about health and illness. William Pickles went on to become the first president of the Royal College of General Practitioners, establishing the academic credentials of the UK college right from the outset.

In titling his William Pickles Lecture, The Importance of Being Different, I assume, perhaps wrongly, that Ian was making a playful reference to Oscar Wilde’s comedy, The Importance of Being Earnest.  In the play, there is an important lesson for family medicine when the awful Lady Bracknell says, “Well, I must say, Algernon, that I think it is high time that Mr. Bunbury made up his mind whether he was going to live or to die. This shilly-shallying with the question is absurd. Nor do I in any way approve of the modern sympathy with invalids. I consider it morbid. Illness of any kind is hardly a thing to be encouraged in others. Health is the primary duty of life.”

This lack of compassion by Lady Bracknell for a dying man is abhorrent to those of us dedicated to family medicine, even if Mr Bunbury is the fictitious invalid friend of Algernon whose supposed illness is used as an excuse for Algernon to avoid tedious social engagements.  Unlike Lady Bracknell, Ian was consistent in teaching about the need for doctors to have great empathy for their patients.

My own introduction to Ian’s work was shortly after I joined the Department of General Practice and Community Medicine at Monash University in Melbourne, Australia, as a junior academic family doctor in 1988.  The following year, my boss, Professor Neil Carson, another pioneer leader in academic family medicine, handed me a book he had been sent by a publisher to review to see if it might be suitable for teaching our medical students.  Neil asked me to read the book and let him know what I thought.  The book was the first edition of Ian McWhinney’s Textbook of Family Medicine.  I am sure you all know it well.

first chapter was about the Origins of Family Medicine and I found Ian’s brief history of our discipline very interesting, but it was the next chapter, about the Principles of Family Medicine, that opened my eyes to a new way of looking at my chosen career.  The nine principles of family medicine, outlined by Ian, articulated in clear terms the work that we do as family doctors, no matter where in the world we live and work.  I have shared these nine principles with so many groups of medical students and family medicine residents over the years that I can now recite these nine principles in my sleep. Perhaps you can too, but just in case you can’t, here they are:

1. Family physicians are committed to the person rather than to a particular body of knowledge, group of diseases, or special technique. In this simple sentence, Ian captured the humanity of the work we do and our commitment to person-centred care, long before that term became fashionable.

2. The family physician seeks to understand the context of the illness. Ian asked us to consider how the experience of illness impacts on each individual, again the person-centred focus of our work.

3. The family physician sees every contact with his or her patients as an opportunity for prevention of disease or promotion of health. Prevention has been neglected in recent years in some parts of the world, but its importance is coming back to the fore with the understanding about the global impact of so-called non-communicable diseases and the importance of prevention and health promotion in avoiding or delaying the onset of heart disease, diabetes, and many cancers and other chronic conditions.

4. The family physician views his or her practice as a “population at risk”.  I like this principle because it captures the work we do in primary care to improve population health.  This was the secret to William Pickles’ own work observing the illnesses that affected his population and looking at ways to prevent further morbidity and mortality.

5. The family physicians sees himself or herself as part of a community-wide network of supportive and health-care agencies. In some parts of the world, team-based care and the gatekeeper and referral roles of family doctors, are seen as something newly discovered, but they are of course part of our rich tradition.

6. Ideally, the family physician should share the same habitat as their patients.  This one is my personal favorite, sounding like something from David Attenborough, but also very true.  You can’t truly understand the health needs and concerns of a community, unless you are truly a part of that community. Being a member of a community allows us to understand the social context of our patients’ lives.

7. The family physician sees patients in their homes. Again a very important part of the work we do, and providing both an extraordinary privilege and the opportunity to understand the context of our patients’ lives better and the challenges that they face each day.  Although home visits have become less common in many parts of the world, they are making a resurgence through the development of family health teams in some countries, as I will describe, and even through telehealth, which at least allows us to catch a glimpse of our patients’ home surroundings.

8. The family physician attaches importance to the subjective aspects of medicine. Again one of the important lessons we learn as family doctors.  Trust your instincts.  Listen to your patients.  And especially listen to the carers of your patients.  Never ignore a parent’s concerns about their child.  Or a child’s concerns about their parent.

9. The family physician is a manager of resources.  At the time I thought this final principle was a bit dry, but I now realise it is one of the major contributions family doctors make to our nations.  Through judicious use of expensive investigations and through appropriate management of referrals to other clinicians and services, we ensure that our nations have the finances available to provide health care to all people, rather than just to an entitled subgroup. These are nine seemingly simple principles that encapsulate our role and our contribution as family doctors.  For me, this is part of Ian’s great legacy, his ability to describe with such clarity the important work we do.

A few days later, my boss, Neil Carson, asked me what I thought about the book.  I said we should be using it as part of our teaching.  He said he would think about that.  He then asked if he could have the book back.  I said no, I’m keeping it.  He got the message.

As family doctors, we are all indebted to our teachers; our family doctor colleagues, like Ian, who have taught us how to practise medicine in our communities using a combination of “scientific knowledge and tender loving care”.  Indeed this is the Latin motto of the Royal College of General Practitioners in the UK and my own college, the Royal Australian College of General Practitioners, cum scientia caritas, “with scientific knowledge and tender loving care.”  Our teachers during our medical training and subsequent careers influence the sort of doctors we become. 

This is also part of the mission of WONCA, our World Organization of Family Doctors.

WONCA was started 43 years ago by 18 family medicine colleges and academies, including the College of Family Physicians of Canada, which banded together to create a world body that recognised the importance of strong family medicine in all nations of the world, and which shared an ideal of supporting training and education for family medicine, and high standards for clinical care.

WONCA now has member organisations representing over 500,000 family doctors in 145 countries around the world.  Each year, the 500,000 family doctors represented by WONCA have over 2 and a half billion consultations with our patients.  Two a half billion.  That’s the scope of our current work and our influence.

But we need to do more. We need to strive to ensure that every family doctor, every GP, every primary care doctor, joins us in our commitment to deliver high quality primary care to our patients and communities. We need to expand our commitment to the education and training of family doctors, and quality care, and primary care research, to the 60 nations of the world where WONCA does not yet have a presence, which includes some of the poorest and most troubled nations on earth.  This is one of my personal goals as WONCA president and just this month I was delighted to welcome family doctors from Iran for the first time into our global organisation.

The first of the four key messages from Ian’s William Pickles Lecture was how family medicine is different in that it “is the only discipline to define itself in terms of relationships, especially the doctor-patient relationship.”

One privilege of being WONCA president is that I am invited to visit family doctors in their clinics across the world to gain insights into the challenges that our colleagues face in providing the best possible care to the people of their local communities.  One thing that strikes me is how similar the doctor-patient relationship is in family medicine settings right around the world.  In each country our colleagues value the relationship that they have with each individual patient and with their families.  Ian of course recognized this as well, how despite being different, family doctors are also very alike.  One of the traits of family doctors Ian noticed in his own travels around the world was “the combination of joy and sadness in our daily lives.”

This is family doctor, Katia Medina Matos, who lives in Lechuga Village, a small rural community on the island of Cuba.  Katia works in partnership with a community nurse, Gladys Garnier Martinez, and together Katia and Gladys provide health care to 844 people based in four rural villages. They know everybody in these four communities. Working together they see 40 patients on average each day, including up to 15 in their own homes.  And how do they travel between the four villages?  They walk. 

Katia and our other colleagues in the images I will show you have agreed that I can share their images with you.  The patients you see in these images are other family doctor colleagues role-playing, so that there is no breach of patient confidentiality.

The relationship that Katia and her family medicine colleagues in Cuba establish with each person is the basis of the primary care-based health care system in Cuba.  This is personalized family medicine in action, based on quality and equity, ensuring every member of the community has access to quality primary health care, delivered by well-trained doctors and nurses.

Cuba is a small island nation and it has a health system based on primary care that is the envy of many much more wealthy countries.  In Cuba 36,000 family doctors provide health care to the entire community of 11 million people.  Every person has their own family doctor and primary care nurse team.  And this includes teams based in 3000 clinics in rural areas, like Katia’s, across the country.

Every Cuban, including every person living in rural areas, has free access to their own primary health doctor and nurse team.  These teams of a doctor and a nurse have a list of all people in their community, and they are expected to know the health status of everyone in their community, including the elderly, the disabled and the housebound, and they will go to visit these people, rather than expecting them to come to their clinics.  It is a proactive approach to ensure all people, and especially the most vulnerable, are getting access to the health care they need. 

Cuba offers a model of cost-efficient, effective and equitable primary care that can be adapted by many other countries struggling to provide health care coverage to their entire population.

Cuba demonstrates the potential for family medicine to ensure health coverage for all people in each nation of the world and demonstrates how much we, as family doctors, can achieve by working together.  

This was the message from our very first WONCA president, Australian Dr Monty Kent Hughes, speaking to the first WONCA meeting held in Melbourne in 1972: “the future of our professional discipline will depend on our ability to work together in the service of humanity.” 

And we have been working together ever since.

Where our careers take us as family doctors is often chosen for us as a result of the things that make each of us different.  Our special interests, the patients who seek us out, is related to our diversity. When I finished my own residency training as a family doctor, I needed to decide which community I was going to work in.  For me the choice was clear.  It was the early 1990s and the AIDS epidemic was at its peak.  As a gay man I knew many people affected by HIV and I had lost some of my friends to this awful disease.  I also knew, to our collective professional shame, that many doctors were refusing to treat people with HIV, or were treating people with HIV, or people deemed at potential risk of HIV, poorly.  So I did some further training on the management of HIV, and then joined the staff of the Gay Men’s Health Centre, a community-owned clinic in Melbourne.

It was a very challenging time.  HIV was an inevitably terminal disease and many of our young patients, mostly young gay men in their 20s and 30s and 40s, succumbed to this awful condition.  I worked in a clinic with a multidisciplinary team including doctors, nurses, psychologists, dieticians, massage therapists, acupuncturists and traditional Chinese Medicine practitioners, all doing what we could to relieve the symptoms and support our patients.  And we were supported by a small army of volunteers from the community who worked with us to assist our patients with their daily needs, and when the time came, to die with dignity, in their own homes if they wished. The death toll among our patients was terrible.

And then, in 1995, one of the great miracles of modern medicine occurred, with the introduction of triple therapy.  We suddenly had access to effective treatment for HIV, and an inevitably terminal condition was transformed into a chronic treatable condition.  I now spend most of my time as a family doctor managing HIV as a chronic disease, one of a number of physical and mental health comorbidities affecting members of my, thankfully, ageing patient population.  It has been a rare privilege to work as a family doctor in this field over the past 30 years.  Yet, although my clinical work is different from that of many of my colleagues, the principles that underpin our work are the same.

Ian’s second message in his William Pickles Lecture was how “family medicine is based on an organismic, rather than a mechanistic, metaphor of biology”.  As family doctors, we understand the complexity of human beings, and we well understand the challenges of uncertainty that accompanies treating individuals.  We don’t see the human body as a machine.  We are conscious of the healing powers of nature and understand that medicine works best in supporting natural processes.  Ian described the values of “the traditional regimens of balanced nutrition, rest, sound sleep, exercise, relief of pain and anxiety, and personal support” provided by those we trust and those who love and care for us.

I like the organismic metaphor because I think it also applies to the role of WONCA in supporting our discipline of family medicine.  WONCA provides the global voice of family medicine, advocating for the important work family doctors do every day in meeting the health care needs of our patients and our communities. As family doctor working together we provide the eyes and the ears of global health care observing and listening to our individual patients and our communities and identifying their health care needs.  And we are the head and the heart of global medicine – combining our scientific knowledge with tender loving care.

Why do we do this? 

Because, as Ian understood so well, family medicine is important. 

Because the evidence is clear that health systems based on strong primary care, which includes strong family medicine, are the most efficient, equitable and cost-effective.

Because strong family medicine is the best way to improve the health of individuals, families and communities. 

Because we believe every family in every community in every country in the world should have a family doctor who the members of each family can trust for their medical care and advice. 

Because family doctors and the members of our primary care teams are part of the social fabric of many of our societies and we work together to keep the fabric of health care together.

The family practice team has an important role to play in the life of every family in every community in every nation of the world.

One of the major inequities in global health is the lack of access to health services for people living in rural and remote areas right around the world. There are lessons from Canada that can inform the rest of the world about how to reorient our health systems to better meet the needs of the people of rural communities.  One of my dear friends, from when I was growing up in Melbourne, is Professor Roger Strasser, now dean of the Northern Ontario Medical School here in Canada.  Roger gained his postgraduate experience in family medicine here at Western University, working with Ian and his remarkable colleagues.  One of the measures of leadership is the career trajectories of the junior staff members and students a leader has mentored.  How delighted Ian must have been to see former residents like Roger take the lessons from the work of Ian and his colleagues here at Western University, and adapt them in different contexts to meet the needs of different communities in different parts of the world.

Last year WONCA released our new Rural Medical Education Guidebook, which reinforces our commitment to ensuring we meet the health care needs of the 50% of the world’s population living in rural areas.  I commend it to you.

In one wonderful chapter, Canadian family doctor, Susan Phillips from Queen’s University, writes about the challenges of attracting doctors to work in rural areas and attributes this to images of rural doctors.  Susan challenges the stereotype of the rural doctor as a “rugged male”.  Susan did a search of Google images and described her findings. 

Susan states, “The typical picture of the family physician and, the rural doctor in particular is the rugged male.”  I did a Google search and, sure enough, my Google search brought up the same image.  Susan goes on, “Although hardly scientific, a Google search of why doctors choose rural practice unearthed many images of male physicians hiking across fields and forests (often wearing stethoscopes), riding horses, or roasting pigs on a spit. On those rare occasions when women are pictured, they are at work, smiling at children, and wearing those white lab coats most of us abandoned years ago.”

Susan wrote that “such images can deter young female doctors from rural family practice. If learners do not see themselves in their preceptors or work mentors, they will avoid such practice settings.  Yet while the icon of the rural physician is stereotypically male and not inviting for women, women are drawn to remote practice with the same frequency as men. … Perhaps it is the attraction of the rural setting as ‘a place to make a difference’ that explains why women doctors might choose a career as a rural family doctors.

Susan is reinforcing the importance of being different.  While our clinics may be different from country to country, and from remote and rural areas to the suburbs and the inner cities, what binds us is the way we are the same – through our commitment to comprehensive, continuing, coordinated whole person care. Through care that is person-centred, and family and community-oriented.  Through first-contact care, acute care, chronic disease management, prevention and health promotion.  And, as Ian taught us so well, through our understanding of the interplay between population health and the health of individuals in our communities.

This is another rural family doctor, Dr Yin Shoulong, who practices in Tai Shitun Village in China, two hours drive north of Beijing and a very different world from the densely populated metropolis to the south.

Dr Yin lives in a typical Chinese rural village house built around a central courtyard with his clinic occupying one side of his home.  His patients are from his farming community and many are impoverished and elderly and frail.  

Dr Yin has devoted his career to supporting the health and well being of the people of his village and the surrounding district.  Recently he has become involved in providing experience in rural medicine to young family medicine trainees on rotation from the prestigious Capital Medical University in Beijing.  He is part of the primary care revolution underway across China.

China has embarked on a massive drive to train and recruit up to 400,000 family doctors, called general practitioners in China, in the next seven years in order to reform the country’s health system to meet the current and future needs of the population, especially the 800,000,000 people living in rural areas.

In a speech this month in Beijing at China’s National General Practice Conference, World Health Organization Director-General, Dr Margaret Chan, said, “Having a cadre of well-trained and motivated general practitioners is one of the smartest ways to respond to the unique health challenges of the 21st century, efficiently, effectively, and cost-effectively.”  Dr Chan also emphasised that, “General practice needs to be regarded, and formally recognized, as a specialty in its own right”.  Dr Chan also highlighted the need for general practitioners to receive comparable salaries to hospital-based colleagues. 

The reforms underway in China will have implications for the rest of the world, and especially for those countries where family medicine is not yet well established.  If the challenge of training a family doctor workforce to meet the needs of both urban and rural China can be met with success, then this should provide lessons that will flow to many other parts of the world facing the same challenge of providing universal health coverage.

All around the world governments are waking up to the importance of ensuring health care for all people, and are looking at ways to strengthen primary care through the family practice model.  We are entering a renaissance, a golden age, for family medicine.

I cannot come to Canada and fail to highlight the leadership of Dr Katherine Rouleau and the wonderful work of the Besrour Global Family Medicine Initiative of the College of Family Physicians of Canada, which is linking up family medicine academics from medical schools across Canada with colleagues in low- and middle-income French-speaking nations around the world and especially nations in Africa.  The Besrour Initiative has been funded by a Canadian family doctor, originally from Tunisia, Dr Sadok Besrour, one of the major philanthropists in global health care.

One of the most exciting developments in Africa has been the recent establishment of the first family medicine training program at Addis Ababa University in Ethiopia, developed with support from family medicine educators from the University of Toronto and from the University of Wisconsin.  The potential contribution of family medicine to the Ethiopian health care system is immense. The country is growing at a rapid rate and its population is approaching 90,000,000. Many people still have difficulty accessing anything more than basic care provided by community health workers with one year of training. The country’s doctor-patient ratio is extremely low, roughly one per 20,000 population, well below the World Health Organization’s recommendation of a minimum of one per 10,000. In recent years Ethiopia has opened thirteen new medical schools using an innovative community-based curriculum, similar to the curriculum at my own university, Flinders University, and will soon be graduating 3000 new doctors each year. The community-based curriculum should be an ideal foundation for attracting new graduates to family medicine. The development of family medicine in Ethiopia, supported by family doctors from Canada and the USA, provides another wonderful example of how much we can achieve by working together.

Ian’s third message in his William Pickles lecture was how “family doctors tend to think in terms of individual patients, rather than generalized abstractions.”  It is our commitment to individuals that drives the innovations that are led by family doctors around the world.  And nowhere is this more stark than in situations where the health and well-being of individuals is challenged by natural disaster.

In February last year I was invited by another of Ian’s famous former students, Professor Ryuki Kassai, to travel to the Fukushima Prefecture in Japan to visit communities affected by the terrible 2011 tsunami, which killed thousands of people, and the damaged Fukushima nuclear power plant which exploded releasing radiation into the atmosphere and resulting in over 100,000 people being evacuated from their homes.

I had the privilege to see how Ryuki’s former residents are working with their elderly patients who are still living in temporary accommodation four years later to seek to reduce the impact of the forced relocation and social isolation.

Again I can imagine how proud Ian must have been to see the work of his former student Ryuki in response to this terrible event.  It is in times of community peril that family doctors and the members of their primary care teams often rise to the challenge and do so brilliantly.

One of the greatest health challenges that has faced our world over the past year, has been the impact of the Ebola crisis in West Africa.  As you know many brave front line doctors and nurses and other health workers have been infected while providing treatment and support to their patients with Ebola and this has left the health services in affected countries vulnerable and unable to cope with meeting the continuing health care needs of their communities.

The WHO has reported that the Ebola outbreak in West Africa has taken an unprecedented toll on health care workers, infecting nearly 1000 health care workers and resulting in almost 500 deaths. Nearly ten percent of all deaths from Ebola have occurred among health care workers.  The world hasn’t seen this level of mortality among health workers in modern times.

Many of our family medicine colleagues from across Africa and across the world have been involved with the international response teams, through global organisations like the World Health Organization, Médecins Sans Frontières (Doctors Without Borders) and the International Red Cross/Red Crescent.

I want to share with you a personal face of the Ebola crisis through the story of one remarkable family doctor involved in tackling the Ebola crisis.  This is Dr Atai Omoruto from Uganda.

Atai has long been a strong voice for family medicine in Africa, as a member of our WONCA Africa Regional Council, and as a member of our global working party on women in family medicine.

In July last year, Atai travelled to Liberia as the head of a medical unit of 12 health workers brought from Uganda by the World Health Organisation to fight the Ebola outbreak.  Uganda has experienced a number of outbreaks of Ebola in the past and, through her experience in her own country, Atai, as a family doctor, has become one of the world’s most experienced clinicians in managing cases of Ebola.

Atai said that on arrival in Liberia, “what I saw was dead bodies everywhere; there were more dead bodies than patients, and nobody seemed to know what to do.” Atai and her team got to work, setting up systems to treat those affected by Ebola and supporting the training of local health care workers.

Through their work, Atai and her team made a major contribution towards changing the course of this terrible epidemic.  And it was not without its toll.  At least two Ugandans died while assisting the people of Liberia.  Atai stayed in Liberia for six months, working under very arduous conditions, and not returning home to her family in Kampala until last December.

Atai has since been named one of the most important contributors to tackling the Ebola crisis in Liberia. The world owes a huge debt of gratitude to Atai and to the many other health workers from across Africa and across the world who came to West Africa to provide their support during this dark hour.

Atai has shown us the extraordinary contributions that family doctors can make.  I admired Atai greatly before the Ebola crisis.  She is now one of my all time heroes of family medicine.

Ian’s fourth and final message in his William Pickles Lecture was how “family medicine is the only major field which transcends the dualistic division between mind and body.”  WONCA is committed to the importance of mental health and, in partnership with the World Health Organization, we have been leading global initiatives to integrate mental health into primary care.  Managing both mental health concerns and physical health concerns in family practice is normal in Canada, but it is still unusual in many other parts of the world.  Yet mental health is central to the values and principles of the Alma Ata Declaration; holistic care and universal health coverage will never be achieved until mental health is integrated fully into primary care.

As a family doctor, I often feel I haven’t had a good day unless at least one person has cried in my consulting room.  This doesn’t mean that I am mean to my patients.  Remember I see a lot of people with chronic disease, and depression is a common comorbid condition, so I need to be prepared to pick up on the cues provided by the one person on average each day who comes into my consulting room with undiagnosed depression.  If I ask the right questions, the tears start to flow and we can start to work together on tackling this condition.

I visited Brazil recently to see in action the famous “Family Health Team” model of universal access to health care, and to see how mental health is being integrated into primary care in that country.

At a family medicine clinic in one of the favelas, or shantytowns, of Rio de Janiero, I met young family doctor Euclides Colaço and his colleagues. This is Euclides in one of the bright consulting rooms in his clinic.  Euclides works with a family medicine resident, two nurses and six community agents, or community health workers, providing comprehensive clinic-based and home-based care as a team to a defined population of 4,500 people.

Here is Euclides and one of the community health workers in his team in front of a map showing the geographic area they are responsible for. They are expected to know about the health status of every single person living in that area.

The community health agents in Brazil have a key role to play; they go out into the community and visit everybody and bring those in need of assessment and assistance to the clinic, or the community health agents escort the doctor or one of the nurses on a home visit.

This is the “Family Health Team” model of Brazil in action.   It delivers true comprehensive primary care delivered to an entire community.  And there are nearly 40,000 such teams in operation across the entirety of Brazil providing care to nearly 200,000,000 people.  It is a very impressive model of universal health coverage and I hope many of you will see it in action when you join us for the WONCA 2016 world conference in Rio de Janeiro.

I was keen to hear how psychiatrists link in with their primary care colleagues in Brazil.  I was advised that there had been challenges in Brazil developing collaboration between psychiatrists and family doctors. I was advised that some psychiatrists were afraid that family doctors would take their place in caring for patients with mental health problems.  Yet what they didn’t realise is that in Brazil at least 70% of mental health care was already being provided by family doctors.

So some of our enlightened psychiatry colleagues in Brazil developed "matrix support teams" that work with the Family Health Teams to integrate mental health professionals within the primary care teams of health professionals.  In Rio one psychiatrist and one psychologist are attached to 10 family health teams, covering a population of around 40,000 people, many of them extremely poor. They visit each Family Health Team at least once a month and the Family Health Team members report that they feel better supported by this integration, knowing that if anything happens they can call their own mental health professionals. This has improved access to treatment for the members of these communities and has had a remarkable effect that on continuing education of the members of the family health teams.

We need to build effective partnerships like this between primary care and other specialties. This requires willingness to think differently and to work together to negotiate professional and cultural understandings of serious health problems and how best to manage them.   Brazil shows us universal health coverage in action. Through innovations like these family medicine has the power to transform our world, and how we might finally bring health care to the one billion people around the world currently without access to any health care at all.

Through family medicine we can also tackle the stigma and discrimination, which too often is attached to mental health problems.  Every human being should be treated with dignity and respect.  And as health professionals we should be leading by example. Our common humanity compels us to respect people’s universal aspiration for a better life, and to support their attainment of a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. This is all part of universal health coverage.

2015 is a landmark year in global health as we come to the end of the Millennium Development Goals.  Over the coming week, the United Nation will meet in New York to adopt the new set of 17 Sustainable Development Goals, or SDGs, which will guide the global development agenda from 2015 to 2030.

There is only one health-specific Sustainable Development Goal: “Ensure healthy lives and promote well-being for all at all ages.”  But each of the 17 new SDGs has an impact on global health and the health of individuals.

On Saturday I have been invited by German Chancellor Angela Merkel to be in New York with Bill and Melinda Gates, Margaret Chan, Ban-Ki Moon and many others at the launch of the new global Primary Health Care Performance Initiative.  WONCA has been invited to support the development of this initiative, which is led by the World Bank, the Bill & Melinda Gates Foundation and the World Health Organization, and which encourages all countries to improve their systems of primary health care.

As family doctors we strive each day, along with the other members of our practice teams, to deliver the best quality care to our patients and our community, yet it can be difficult to know exactly how our work as individual doctors is contributing to the health and well-being of our nations as a whole.  And, unless we work in Cuba or Brazil, to know if everyone in our communities is benefiting from the health care services we provide. Are some people missing out, and if so, who and why?

These are among the important questions that the new Primary Health Care Performance Initiative seeks to answer.  The Initiative includes important health system indicators that show how well a nation’s primary health care system is working toward achieving universal health coverage. This initiative will help us “unpack” what happens in primary health care systems across the world, and shine a light on areas that need attention to ensure quality health care is being made available to all people.  Given Ian’s enthusiasm for primary care research, I like to think he would have been as excited about the potential of this initiative as I am.  It is especially encouraging to see the world’s greatest philanthropists, Bill and Melinda Gates, investing in strengthening primary health care in the world’s most disadvantaged communities.

One of the greatest strengths of the people working in family medicine is our diversity, our community leadership, our resilience and our unwavering commitment to our patients and our communities. These are qualities that we need to reinforce and cherish.

The importance of being different applies to each of us as family doctors.  Family doctors, as clinicians, as teachers and researchers, and as members of our global community, should embrace what makes us different from our peers in other branches of medicine, and together aspire to follow the example set by Ian and other leaders of our profession.

As Iona Heath, former president of the Royal College of General Practitioners in the United Kingdom, said a few years ago, “I believe that family medicine/general practice is a force for good throughout the world."

I agree with Iona.  Through my work around the world, I am impressed with the commitment of family doctors and the members of our primary care teams to human rights issues, and I am sure this comes from our daily experience of working with our patients in our communities.  Ian felt that family physicians attain “philia” with our patients, described by Aristotle as the highest form of friendship, and it leads us to think in concrete rather than abstract terms, because so much of our thinking about clinical medicine relates to individual patients we have known. As family doctors, we understand and respect the basic expectations all people have about how we and our families and all people should be treated.

As family doctors we recognise we have social responsibilities. Each of us needs to be an advocate for social justice and human rights.

We need to speak out for what is right, to say “this is not OK”, and in so doing contribute to social change in our communities and our nations.

We need to contribute towards ensuring equity of access to health care – what we call in Australia “a fair go” for everyone.

And we need to care for the health of our planet as well as the health of our patients.  After all, what is good for the environment is also good for the health of our patients and our communities.

Why do I say that family doctors should focus on all these things?  It is because if we, as family doctors, with our privileged position in society, and our access to pretty much the entire population in our communities, don’t stand up for these things, who will?

As family doctors we can be proud of our professional discipline. Each of us has a set of values and principles that determine how we behave as ethical medical practitioners and as decent human beings. Like Ian, each of us has the potential to be a role model for our medical students and our residents, and to contribute our own lasting legacy through the examples that we set in the way that we live our lives and the way we practise medicine.

As Ian reminded us in the concluding sentence of his William Pickles Lecture, “The importance of (family doctors) being different is that we can lead the way.”

Over to you.

Professor Michael Kidd

President, World Organization of Family Doctors (WONCA)

September 23, 2015

 

An extract of this talk is published in the December edition of Canadian Family Physician