Please refer to “Principles of Family Medicine” from Textbook of Family Medicine, 2nd edition 1997, Ian McWhinney, Oxford press, and “Four Principles of Family Medicine” found on the College of Family Physicians of Canada website.

FAMILY MEDICINE IS A COMMUNITY-BASED DISCIPLINE

• Family practice is based in the community and is significantly influenced by community factors. As a member of the community, the family physician is able to respond to people’s changing needs, to adapt quickly to changing circumstances and to mobilize appropriate resources to address patients’ needs.

• Clinical problems presenting to a community-based family physician are not pre-selected and are commonly encountered at an undifferentiated stage. Family physicians are skilled at dealing with ambiguity and uncertainty. The family physician will see patients with chronic disease; emotional problems; acute disorders, ranging from those that are minor and self-limiting to those that are life-threatening; and complex biopsychosocial problems. Finally, the family physician may provide palliative care to people with terminal diseases.

• The family physician may care for patients in the office; the hospital, including the emergency department; other health care facilities; or the home. Family physicians see themselves as part of the community network of health care providers and are skilled at collaborating as team members or team leaders. They use referral to specialists and community resources judiciously.

THE FAMILY PHYSICIAN IS A RESOURCE TO A DEFINED PRACTICE POPULATION

• The family physician views his or her practice as a “population at risk”, and organizes the practice to ensure that patients’ health is maintained whether or not they are visiting the office. Such organization requires the ability to evaluate new information and its relevance to practice, knowledge and skills to assess the effectiveness of care provided by the practice and the ability to plan and implement policies that will enhance their patients’ health.

• Family physicians have effective strategies for self-directed, lifelong learning.

• Family physicians have the responsibility to advocate public policy that promotes the health of their patients.

• Family physicians accept their responsibility in the health care system for wise stewardship of scarce resources. They consider the needs of both the individual and the community.

THE PATIENT-PHYSICIAN RELATIONSHIP IS CENTRAL TO THE ROLE OF THE FAMILY PHYSICIAN

• Family physicians have an understanding and appreciation of the human condition, especially the nature of suffering and patients’ response to sickness. Family physicians are aware of their strengths and limitations and recognize when their own personal issues interfere with effective care.

• Family physicians respect the primacy of the person. The relationship has the qualities of a covenant – a promise, by physicians to be faithful to their commitment of well-being of patients, whether or not patients are able to follow through on their commitments. Family physicians are cognizant of the power imbalance between doctors and patients and the potential for abuse of this power.

• Family physicians provide continuing care to their patients. They use repeated contacts with patients to build on their relationship and to promote the healing power of their interactions. Over time, the relationship takes on special importance to patients, their families and the physician. As a result, the family physician becomes an advocate for the patient.

THE FAMILY PHYSICIAN IS A SKILLED CLINICIAN

• Family physicians demonstrate competence in the patient-centered clinical method: they integrate a sensitive, skillful and appropriate search for disease. They demonstrate an understanding of patients’ experience of illness (particularly their ideas, feelings and expectations) and of the impact of illness on patients’ lives.

• Family physicians use their understanding of human development and family and other social systems to develop a comprehensive approach to the management of disease and illness in patients and their families.

• Family physicians are also adept at working with patients to reach common ground on the definition of the problems, goals of treatment and roles of doctor and patient in management. They are skilled at providing information to patients in a manner that respects their autonomy and empowers them to “take charge” of their own health care and make decisions in their best interest.

• Family physicians have an expert knowledge of the wide range of common problems of patients in the community, and of less common but life-threatening and treatable emergencies in patients of all age groups. Their approach to health care is based on the best scientific evidence available.

The Patient-Centered Clinical Method

 Please refer to Chapter One of Patient Centered Medicine: Transforming the Clinical Method, 1995 by J. Brown, M. Stewart, M. Weston, T. Freeman, Sage Publications.

 Introduction

The term “patient-centered care” was introduced in the 1970s within Family Medicine to describe an approach to patient care that went beyond the traditional “disease-centered” or “doctor-centered” method that was (and still is in many situations) expected to be followed by medical school graduates. The traditional history “taking” did not seem to be adequate alone to provide successful primary, continuing, coordinated and comprehensive care to a defined group of patients within a community. Various conceptual frameworks have been elaborated since then culminating in the “patient-centered clinical method” by a group within the department of Family Medicine at the University of Western Ontario. They built on previous ideas to formulate their own conception that was again modified after careful testing into the final form that is described in the book, Patient-Centered Medicine.6 This appendix summarizes the essential components of the method. Students are urged to follow this approach at every patient encounter. Students should not hesitate to discuss their successes and failures with their preceptors.

The SIX essential interactive components of the patient-centred process:

1. Exploring both the disease and the illness experience:

Disease: The traditional approach of history taking, physical examination to produce a differential diagnosis.

Illness: At the same time the physician should respond to “cues” of the patient’s Fears, Ideas, Expectations, and effects on Functioning (FIEF) concerning this “illness” experience. The mnemonic FIEF encapsulates these parameters. Knowledge of past illness experiences and the effect of the family on previous illnesses can be useful to gauge the degree of “disease” the patient is going through.

The physician usually weaves back and forth between the doctor/disease and the patient/illness agendas.

2. Understanding the whole person:

What does the physician, know about the patient’s life in terms of development and experiences, and how does this “illness” impinge on it? It may help to answer the question why does the patient have these symptoms now?  Previous contacts with the patient over the years can provide the physician with valuable insights into the present problem (a mutual investment plan between doctor and patient!).

3. Finding common ground:

An effective management plan requires cooperation between the physician and patient in the areas of a) the nature and priorities of the problems, b) the goals of treatment and c) the roles of the doctor and the patient. Finding common ground rather than bargaining or negotiating requires an understanding of the patient’s ideas, fears and expectations regarding the problems.

4. Incorporating prevention and health promotion:

Health promotion, disease prevention and risk reduction issues should be incorporated into every contact with the patient whenever possible, and not just at “health maintenance” visits. An effective patient-centered relationship enhances the patient’s acceptance of suggestions from the physician for appropriate lifestyle modifications. The provision of optimal continuing and comprehensive care requires this approach and should be supported with a record system (e.g. flow sheets for chronic diseases) and office protocols (such as computer reminder systems) that facilitates this philosophy.

5. Enhancing the doctor-patient relationship:

At every visit the physician should strive to build an effective long-term relationship with the patient so that the patient sees the benefit of this growing “mutual investment plan” between the two. It should be noted that different patients need different approaches, such as the dependent patient in need of extra support versus the assertive, involved patient. The physician should always monitor his/her own feelings regarding the relationship in terms of sharing power and transference/counter transference issues for instance.

6. Being realistic:

Physicians should always manage their time so that they can provide optimal patient care. This requires priority setting, resource management and teamwork. The strategy taken at one consultation may well be tempered by the number of patients still waiting to see the doctor. Physicians should also respect their limits of “emotional energy”.

Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR, Patient-Centred Medicine, Transforming the Clinical Method, Sage Publications, 1995.