July 2004, Vol 26, No. 7
Discussion Papers

Quality family medicine in a brave new world*

M R Kidd

HK Pract 2004;26:315-318

How do we ensure the quality of our work as family doctors and general practitioners during a time of many changes and challenges? To answer this question I intend to look at the role of our Colleges in quality care, examine some of the essential elements for quality family medicine, and review how we can support quality through medical education.

This oration is named in honour of Dr Sun Yat-Sen who worked as a general practitioner in Hong Kong before world events led him to become one of the great figures of world history and the revered Father of Modern China. Dr Sun Yat-Sen once said, "If you believe in yourself, you can move mountains and fill in the ocean: no matter how difficult the task, you will see the day when you succeed".

So, how do we as family doctors move mountains and fill in the oceans? How do we make a difference in our daily work? How do we ensure the quality of the care we provide to our patients?

One way is through the work of our colleges. Our colleges define the nature of our clinical discipline of family medicine. Our colleges are responsible for setting and maintaining standards for high quality clinical practice, and for education, training and assessment. Our colleges also need to advocate on any issue which affects the ability of our members to deliver a high quality service to the public. Responsibility to our patients and to the public has to be the paramount responsibility for our professional colleges.

In order to ensure quality family practice, we require many things. We require not only a skilled and knowledgeable general practitioner. We require more than just an excellent practice site and systems. We also require attention to the design and resourcing of the whole healthcare system in which we work.

I would like to outline some of these issues which support sustainable quality in family medicine.

Sustainable quality requires a system that:

  • Attracts "the brightest and the best" to join our clinical discipline
  • Supports lifelong learning and encourages continuous improvement
  • Provides excellent practices and infrastructure
  • Enables ready access for our doctors to the best available evidence
  • Values the generalist tradition that is our professional base
  • Cultivates good morale, and a yearning for excellence by our members.

I would like to review each of these points in turn.

Attracting the "brightest and the best"

General practice is an attractive profession. As doctors we are valued by our patients, by the community and by our peers. As professionals we need to be stretched and challenged in our daily work, but that does not mean being unnecessarily stressed in our daily work. With the knowledge that we have, we will perform as best as we can. However we also need recognition and reward for the quality of the work that we do.

We also need to ensure that our medical students receive exposure to high quality general practice. Our students need exposure to high quality general practitioner role-models before leaving university. Our recent medical graduates need exposure to high quality general practice in their early postgraduate years as this will help to inspire them to consider general practice as their future career. We also need to provide general practice training opportunities close to home, especially in countries like mine where distances can be so vast.

Support for lifelong learning

We need to cultivate a yearning for lifelong learning among family doctors. This needs to be part of vocational training. We need to have robust and reliable training arrangements for family doctors, which meet the standards set by our Colleges in our role as the stewards of our professional discipline for the community. Fellowship should be the end-point of vocational training and should certify that our Fellows are competent and able to practice high quality family medicine anywhere.

We need strong programmes of continuing professional development which provide continuing quality improvement through active ongoing learning. Continuous improvement can include cycles of learning and improving, practice-based audit activities and formal research in various forms and of diverse scale. However continuous improvement is challenging because it takes time and requires access to meaningful data.

We also need to provide professional assistance for overseas trained doctors who are joining the ranks of the medical professionals in our countries and support them to acquire knowledge and technical skills and adapt to our local environment.

Providing excellent practices

Our Colleges need to ensure the standards for the general practice locations where we work and for the processes, structures and outcomes of our work as general practitioners. These standards should also apply to other primary medical care services, including after hours services.

In this Brave New World we also need to insist on standards for the information architecture which supports the quality of our clinical work. This includes standards for hardware and software and telecommunications, and standards to ensure the security of personal health information and the maintenance of the personal privacy of our patients.

Ready access to the best available evidence

Quality family doctors need access to the best available evidence to support our clinical decision making. We need to ensure access to excellent international resources such as the Cochrane Library of evidence-based medicine, and national guidelines. The Royal Australian College of General Practitioners produces excellent guidelines to support high quality preventive care in general practice (our Red Book and Green Book) and guidelines to support healthy decision-making by all our patients (our SNAP Guidelines).

Local resources can also support quality family medicine. Australia's Divisions of General Practice produce high quality local resources to support education and the maintenance of standards for general practices across our country.

Valuing the generalist tradition

As family doctors we are specialists in primary medical care. However we need to value our generalist traditions which are based on universal unreferred access, whole person medical care for individuals, families and communities, and comprehensive, coordinated and continuing medical care drawing on biomedical, psychological, social and environmental understandings of health.

Funding structures and workforce arrangements need to support the generalist approach to high quality primary medical care.

Maintaining morale and a yearning for excellence

Finally we need to keep our doctors if we want to maintain high quality. There is no doubt that happy doctors are better doctors. Our communities cannot afford to lose doctors who would otherwise continue working in general practice and provide high quality care to their local population.

I believe it is the context of general practice, rather than its content, that is the key issue in reduced morale among some family doctors.

It can be seen that there are a number of precursors to safe, high quality care in family medicine. Sufficient resources, including workforce, funding, and infrastructure are needed as well as a commitment to quality. Adequate recognition of quality family doctors is needed. And education remains a key to quality.

A quality family doctor can be viewed in many ways. The first family medicine teacher who recorded his thoughts of this subject was, of course, Hippocrates. Hippocrates worked as a family doctor and medical educator in the 400's BC on the Greek Island of Cos. In his oath, Hippocrates outlined a number of principles to guide quality medical practice, including:

  • "I will use my power to help the sick to the best of my ability and judgement; I will abstain from harming or wronging any man by it.
  • Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one".

Sir William Osler is regarded by many as the Father of Modern Medicine. He once wrote:

"Have no higher ambition than to become an all-round family doctor, whose business in life is to know disease and to know how to treat it... that his life is hard and exacting; that his is underpaid and overworked; that he has but little time for study and less for recreation - these are the blows that may give finer temper to his steel, and bring out the nobler elements of his character".

Osler also described a set of principles for quality medical practitioners. He stated that we need to cultivate:

  • the art of equanimity - being able to detach from personal feelings and distractions
  • the virtue of using a systematic method for organised work
  • the quality of thoroughness in assessing symptoms, signs, data and opinions
  • the grace of humility
  • a reverence for responsibility

Many people assert that the Father (or parent) of modern family medicine and general practice is Ian McWhinney. In his landmark publication, "A Textbook of Family Medicine", McWhinney describes his Principles of General Practice:

  1. The general practitioner is committed to the person rather to a particular body of knowledge, group of diseases, or special technique.
  2. The general practitioner seeks to understand the context of the disease.
  3. The general practitioner sees every contact with patients as an opportunity for prevention or health education.
  4. The general practitioner views his or her practice as a population at risk.
  5. The general practitioner sees himself or herself as a part of a community-wide network of supportive health care agencies.
  6. Ideally, general practitioners should share the same habitat as their patients.
  7. The general practitioner sees patients in the clinic, in their homes, and in the hospital.
  8. The general practitioner attaches importance to the subjective aspects of medicine.
  9. The general practitioner is a manager of resources.

McWhinney describes an excellent role model for all family doctors.

Of course there have also been doctors who have done us wrong in the past. Literature and film abounds with doctor-scientists who are depicted as dangerous, unreliable, secretive, authoritarian, impersonal and amoral individuals with the power to heal or destroy. This group includes Dr Faustus, Dr Frankenstein, Dr Jekyll and Dr Strangelove.

Our aim is not to be like any of them.

Voltaire (1694-1778) had a wry view of the medical profession. He once wrote:

"The art of medicine consists of amusing the patient, while nature cures the disease".

If Voltaire was living today, I think he would be working as a journalist.

Mark Twain (1835-1910) also had a warning about health care:

"Be careful about reading health books. You may die of a misprint".

Today the media has a strong influence on the community's perceptions of family doctors. A favourite quote of mine is from Dr Phil Hammond, a general practitioner in the United Kingdom and the presenter of a BBC television show called "Trust Me, I'm a Doctor". Phil said:

"I think all doctors should have piles - it gives them that concerned look when the patient enters the room!"

The World Health Organisation has described the characteristics of the "five star" doctor of the new millennium. The five star doctor will be a care-provider, a decision-maker, an excellent communicator, a community leader and a manager of health resources. Importantly the five star doctor will need to be able to make optimal use of new technologies.

A list of roles like these is one way to look at family doctors. Another way is to look at a list of the qualities which make a great Family Doctor. Each of us will have our own list of such qualities. For me, a great Family Doctor is competent, caring, concerned, responsible, sensitive, trustworthy, honest and behaves with integrity.

We are each of us privileged to be Family Doctors and General Practitioners. We each strive to the best of our abilities to provide a high quality service to the people who trust us for their medical care and advice. We may feel undervalued at times but we receive warm acknowledgement of our contribution from our patients and their families every day.

Each of us makes a positive difference to the lives of our patients.

Through our Colleges we can ensure that the care we deliver remains that of the highest possible quality and that the next generation of doctors is also well trained and experienced.

And through our Colleges we will continue to receive the support of our peers and our mentors and our many friends in General Practice and Family Medicine.

I thank you for the opportunity to share my thoughts with you today.

* This paper was presented as the Dr Sun Yat-Sen Oration on 18 April, 2004.

M R Kidd, MBBS (Melb), MD (Monash), DCCH (Flinders), FRACGP
President of The Royal Australian College of General Practitioners and Head of the Discipline of General Practice at The University of Sydney.

Correspondence to : Professor M R Kidd, House, 1 Palmerston Crescent, South Melbourne VICTORIA 3205, Australia.