Public education by an evidence-based butterfly flap

Amy K L Chan 陳潔玲

HK Pract 2007;29:257-258

I often join the crowd to stand in front of the newspaper board erected right in the centre of the university medical library. The bold headlines of "Latest breakthrough in cancer treatment!" or "New scans for check-ups!" attract most attention. The mass media contribute to the perpetuation of over-valuing highly specialized and often expensive therapeutic or diagnostic modalities. Newspapers, magazines, radio broadcasting or TV have never been short of regular disease-focused columns or programmes, while family medicine has been grossly under-represented. Not only do we seldom read or hear about promising advances in family medicine, what have been put up in the media concerning our discipline are often negative: misdiagnosis leading to treatment delay,¹ irresponsible prescription,² malpractice³ and so on. On the one hand, we need to promote access to medical information so as to consolidate a knowledgeable and informed population base in the health system.⁴ On the other hand, the present lopsided situation is undesirable as the health seeking behaviour of the public will all the more be skew towards expensive technology and specialist/sub-specialist care. The portrayal of most, if not all, primary care providers in the media as "incompetent, substandard and of poor quality" should be rectified.

Prof Carol Herbert, visiting professor of our College in 2006, gave a lecture entitled "The Butterfly Flap", and appealed that "we need more stories". Relationship is the most important aspect of the work of family doctors. The goal in building a relationship is to reach a deep sense of agreement with the patient about what is happening. Using all the tools, most primarily our ability to listen deeply, we seek a shared understanding with the patient. From that point, an action plan can be developed involving some short term strategies for symptom relief while considering the longer term issues that have arisen. We tend to think in terms of individual patients, rather than generalized abstractions. Our practice is based on an holistic rather than a reductionist view, and transcends the dualistic division between the mind and the body. This patient-doctor relationship is richly contextual and hence would be best depicted in a narrative framework.

Why the "Butterfly Flap" then? The phrase refers to the idea that a butterfly's wings might create tiny changes in the atmosphere that ultimately cause a tornado to appear (or prevent a tornado from appearing). The flapping wing represents a small change in the initial condition of the system, which causes a chain of events leading to large-scale phenomena. Had the butterfly not flapped its wings, the trajectory of the system might have been vastly different.⁵ Because family doctors collectively undertake literally millions of consultations per year, it is possible for genuine, large scale public health improvements to be achieved through seemingly minor changes in the way we work. The potential to make a real difference is enormous. Our "tiny but meaningful flaps" ought to be documented: and indeed we have! As promoted in the June issue of FP Links, more than fifty stories are captured in a newly launched book on family medicine (家庭醫學手冊之伴我同行). The articles were written by more than a dozen College members, and had been published in a weekly column in the Hong Kong Economic Journal (信報) since October 2005. The wide range of content includes: timely intervention to a frustrated adolescent and her family; saving the life of a depressed single father at the brim of suicide; supporting a frail lady traumatized by an extra-marital affair and presenting for routine pap smear; enabling a retired government servant with terminal cancer to enjoy his beloved family....

Dr Hueston wrote, "The assertion that 'anyone can do primary care' devalues the talents and special knowledge set of primary care doctors. In my opinion, the truth is the converse - i.e. not everyone can do primary care. Not everyone has the intellect or temperament required to deal with the breath of problems that primary care physicians encounter, the complexities of the issues that we deal with, or the uncertainties that permeate our decisions. So, the statement that 'anyone can do primary care' is a myth".⁶ We hope our book can serve to dispel this myth to the public.

In an editorial announcing the establishment of a foundation to spearhead activities in educational outreach and public education, an evidence-based approach has been strongly emphasized: ".... (those) who have served .... were originally selected not only for their knowledge, creativity and commitment, but also for their integrity and the objectivity they brought to their work."⁷ The media have made a tremendous amount of medical information, often unvetted, accessible to the public. Under this context, we should write up stories but at the same time, take advantage of the opportunities to provide the most up-dated, reliable and unbiased information to our interested readers. By doing so, our educational outreach can, in turn, become a self-directed learning exercise, leading to effective continuous professional and personal development. Colleagues who have contributed in the book will echo with me that the experience is both fulfilling and fruitful, and I am sure each one of you will have your stories to tell. To promote our discipline, to reach and touch the public, to re-assure and convince the government who is contemplating to steer slightly towards a primary care-led health system, we need your stories.