The mission of medicine is to heal the sick. When cure is elusive, it is to relieve distress, and always to comfort. All of us who became physicians had our reasons, but we had to have a genuine interest and ability in science, and an appreciation of people as individuals living in families and societies. We had to be willing to work hard to learn and to keep up with all we needed to know. The profession self-selects its members, usually according to personal proclivities, to the benefit of patients. Those of us who go into technical specialties may have some penchant, those who become psychiatrists some insight.
We who embrace generalism, without attempting to limit ourselves with regard to age, gender, disease, or setting of our patients have the most interesting time of all. We have to remember and revel in this, because the eclectic nature of our specialty and our patients can become a detriment in terms of efficiency and economy of resources. It is much easier to do one thing and do it well, again and again, than to stand ready to do everything and anything. The consolation prize is: we’re never bored. Another plus is that we become the only “real” doctors, in that we can take an undifferentiated patient, and fulfill most of his/her needs, using other specialists as needed.
Generalists themselves come in different forms. The terms primary care and family practice have been fused recently due to pressures outside of medicine, both governmental and commercial. But, although there is overlap, the terms are different.
Family medicine implies a discipline and a philosophy whereby the generalist learns to look at individuals over their life spans and their families’ context. It implies continuity of care over many years and many generations. It is best embodied in the country doctor who lives permanently in a small town or village and cares for a limited population. He/she gets to know nearly all the people, often in and out of the office. But the same concept can apply in large cities, where one doctor stays in one location for many years and carves out a population of patients whom he/she knows and follows.
Ideally, this practitioner is a physician, with the breadth and depth of training sufficient to diagnosis and treat not only common illnesses but to figure out and discover uncommon presentations of common maladies, as well as to think of rarer diseases that are bound to occur among a given population of patients. Managing overlapping and complex multiple illnesses present in a single patient is another skill not easily undertaken by ancillary personnel attempting to do true “primary care.” These functions are unlikely to lend themselves to protocols or algorithms. The ability to know when one does not know implies that one has at least known of the existence and pathology of the gamut of medicine, not just the likeliest presentations of illness.
On the other hand, primary care can mean the person first in line to see the patient. This person may or may not be a physician, nor need to be trained in family medicine. The type of care rendered, say, to an acute sore throat, maybe equal and equivalent according to protocol for that single episode, but the family physician will pick up on other aspects of the patient’s life, using the opportunity of the sore throat to get to the real meat of that person’s future health as well. For example, the obese, smoking patient whose strep throat is treated just fine but whose real problems are ignored. As part of our training, most of us understand that prevention is easier than cure (for those diseases that are preventable) and have incorporated the usual preventive measures into our practices. Some of us could do better at this function, with newer and better “systems” to locate and isolate patients likely to benefit and arrange for group visits or other innovative teaching methods. The truth is that task can be delegated to partially trained or even untrained people. Teachers in schools can take on the task of health education. With the Internet, given proper motivation, patients can educate themselves.
But it is the physician who catches that patient in the “teachable moment,” often when he/she is sick and realizes how illness can affect his/her life.
More recently, we as physicians have been exhorted to have another mission besides healing the sick: to look at our patients as members of a population and to think in terms of the outcomes of disease and death in the aggregate, as our public health colleagues have always done. One problem with that is that rare diseases can be ignored or even discounted. Some of us may think, probably rightly, that if we do an excellent job with each patient, the aggregate will take care of itself. As we master the more common illnesses, we can afford the luxury of seeing well people before they become ill. However, even in the best of societies, where public health outreach has convinced the population to live the healthiest of lives, there will still be sickness and the need for the family physician to evaluate and know when to intervene.
No matter in what country one finds oneself, there are problems. For example, with more basic surroundings, one does not have to worry about being sued in court and one’s life savings taken away. In advanced countries, one is limited by turf battles and certification (other specialists may not want you doing procedures they feel are only their prerogative). If the government or commercial clinic is paying one’s salary, it’s too low. If one is in the marketplace vying for patients, one must worry whether patients can pay.
Some of us find ourselves practicing in settings, not of our choosing and not geared to make the most of our skills. Here, we have the most chance to prove our flexibility and ability to “land on our feet.” Of all the specialties, family medicine prepares us for various roles in the medical spectrum. We have the opportunity to become the “most valuable player” on any medical/health team. Having done more than one job in medicine prepares one for defining what role one really prefers, and one can progress toward one’s goal as chance and circumstance dictate.
The important thing is to have the same sense of purpose that led us into medicine in the first place. It is crucial to remember what a privilege it is to know what we know, understand the body and its illnesses as we do, and be in a position to help our fellow creatures in their worst distress. The day that any one of us wakes up to medicine as “just a job” will be a sad day in the life of an old and glorious profession.
Pepi Granat is a family physician.
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