Introduction

My chosen topic is "The core of medicine", the "core" being defined as "the innermost part". Considerable evidence is available to support the view that primary care is the core of medicine and that family practice is, in turn, the core of primary care. Thus, family practice doubly constitutes the core of medicine. Furthermore, more attention needs to be paid to the consultation as it is the core of clinical practice wherever it is carried out. Finally, because of the particular content of family practice and the particular skills of family practitioners, the discipline has a core contribution to make to undergraduate education and research. I intend to highlight those features which make family practice and the consultation the core of medicine.

I have chosen this topic for three reasons. Firstly, it was recently stated that in Hong Kong "... the development of this specialty is still at an early stage" and that "... the benefit of family medicine is still not widely known and appreciated".¹ Secondly, the Hong Kong Government plans to give family practice a higher profile within the local healthcare system, and your College will be required to contribute. Thirdly, my professional interest in the development of family practice and in the primacy of consultation competence initially led to my close personal involvement with your College.

Throughout, I shall use the term "family practitioner" as synonymous with "general practitioner" to represent a physician who has completed a recognised period of postgraduate training in family/general practice. The term "specialist" will represent the equivalent in mainly hospital- based disciplines. For the sake of convenience I shall use the masculine gender throughout.

The crucial role of primary care

Primary care is the setting within a healthcare system in which the first contact with a health professional occurs,² as well as "the locus of responsibility for organising care for (individual) patients and populations over time".³ Primary care thus lies at the interface between self-care and secondary care and fulfils a crucial gatekeeper role. If primary care did not exist, patients would find it very difficult to select the most appropriate source of care to suit their individual needs. Consequently, the most appropriate care may not always be obtained, or it may be delayed, leading to inconvenience or even increased risk to patients. In the most comprehensive study to date of the contribution of primary care involving ten developed countries, Starfield³ concluded that countries which have incorporated a primary care focus within their health services achieve better health indicators and more economical health care delivery.

Nevertheless, as Starfield acknowledged: "There is a universally held belief that the substance of primary care is essentially simple".³ However, Starfield went on to emphatically dismiss this misconception by declaring: "Nothing could be further from the truth".³ By way of reinforcement, McWhinney has frequently emphasised that family practice is the most complex of all the clinical disciplines.⁴

Furthermore, patients' - and governments' - expectations of primary care continue to escalate. Primary care physicians are not only expected to provide high quality medical care, which includes an increasing share of chronic disease monitoring, but also to promote health in areas such as smoking cessation, "safe sex" and substance misuse. They are also expected to collaborate more with other health professionals and to have input to health planning in the community.⁵ All these factors make the task of primary care ever more challenging.

Thus, there is a growing awareness that primary care can not only make a particular contribution to a health care system but also that the efficiency, effectiveness and costs of secondary care are critically dependent on the existence and the quality of primary care. Accordingly, more countries are incorporating a primary care focus in their health services.

The case for generalist based primary care

It is possible to deliver primary care in a wide variety of ways - there is no single blueprint. Nevertheless, within developed countries, there is a general acceptance that the core professional with the responsibility for overseeing all aspects of the very broad spectrum which is primary care, should be medically qualified.

The next issue is whether the physician of first contact should be a "generalist" or a "specialist". In essence, a generalist is someone who is not restricted regarding patients who present themselves, whereas a specialist is. The evidence from Starfield's studies overwhelmingly favours a generalist-based system of primary care, for the following reasons³:

Countries with higher proportions of generalists to specialists working in the community have lower rates of physician contacts, outpatient consultations (including visits to the emergency room) and hospital admissions. Specialists also order twice as many laboratory tests and almost three times as many x-rays as generalists (see Table 1).

Table 1: Comparative rates of ordering investigations by specialists (hospital interns) and generalists (family practitioners)3
Investigation ordered				Proportion ordered per consultation
				Specialists	Generalists
Laboratory tests				73%	34%
X-rays				53%	19%

Furthermore, the overall costs of health care and prescribing are lower, and the costs of consulting a specialist tend to be double those of a generalist. Even with matched samples of case mix and clinical challenges, generalists ask fewer history questions and conduct more focused physical examinations, although there are no differences in the diagnoses reached or levels of patient satisfaction achieved.

It is evident, therefore, that a system of primary care in which specialists see patients directly without referral, is not so cost efficient or effective as one which has a generalist physician at its core performing a gate-keeping role.

The special contribution of family practice

More countries are making family practice the cornerstone of their health services, with the family practitioner as the core generalist physician. Although different styles of family practice have evolved to suit local traditions and needs, there are four core elements which characterise the discipline. These are:

• A particular approach to patient-centredness.
• Particular skills in primary assessment and management of presenting problems.
• Responsibility for delivery of comprehensive care.
• A particular role in health promotion/disease prevention.

Associated with these core elements are some particular competences which the family practitioner needs to acquire. It is the synthesis of all of these which makes the family practitioner different from any other clinician. I will now consider each of these core elements in turn.

Particular approach to patient centredness

Perhaps the most distinctive attribute of the family practitioner is that "his commitment is to people more than to a body of knowledge or a branch of technology".⁶ The meaning of "commitment to people" should not be confused with having an interest in, or being concerned for, people. All clinicians, whether in hospital or primary care, should possess these attributes. Nevertheless, the family practitioner tends to place the highest value on the autonomy of patients and on the consequent need to act in collaboration with patients taking individual circumstances into account.

The family practitioner's responsibilities also tend to be limited to a small population for which he will frequently provide continuing care, involving multiple contacts, over prolonged periods of time. In the United Kingdom, for instance, over 40% of a family practitioner's patients remain with him for 20 years or more⁷ and this phenomenon is replicated in many other countries. Indeed, every United Kingdom resident spends an average of 47 minutes per annum in face-to-face consultations with their family practitioner.⁸ Continuity is a feature of care that patients particularly value, and, the longer the relationship, the greater are a physician's knowledge of the patient, the patient's trust and disclosure to the physician and the level of co-operation in treatment.^5,9

Because of these factors, the family practitioner is more likely to form much closer personal relationships with patients than is normally possible for any other sort of physician. Balint coined the term "mutual investment company"¹⁰ for this relationship, and concluded that both doctor and patient draw interest from their investments! A unique feature of family practice is the frequency with which such relationships are used professionally to benefit the patient. Indeed, studies have shown that "the quality of the physician-patient relationship affects health, recovery from illness and outcomes of chronic diseases".¹¹

Particular skills in the primary assessment and management of presenting problems

The family practitioner operates in a context in which patients have direct access and make the decision whether to consult or not. Patients often present multiple problems in a single consultation, with many symptoms but few clinical signs, and there is frequently a complex mix of physical, psychological and social factors. The family practitioner also deals mainly with common diseases and problems, many presenting at an early stage of development. Although most of these are less serious and have little threat to life, they can be responsible for much disability and great unhappiness. Nevertheless, serious disease does present in the setting of family practice, and family practitioners need to be able to recognise it.

The family practitioner, therefore, needs to develop particular skills as a primary assessor of problems in a situation where few prior suppositions can be made concerning the likely nature of the presenting problems and where it is frequently very difficult to predict their future development. The family practitioner is also the physician who most frequently has to be able to understand patterns of illness behaviour, tolerate uncertainty, and selectively and safely use time as a diagnostic and management tool. He must also be comfortable dealing with patients with "no demonstrable biological aberration"³ and in making decisions on the basis of limited information.

Hospital specialists, on the other hand, deal with patients with the rarer, more life-threatening diseases or atypical versions of the commoner ones. Furthermore, the specialist is usually presented with more organised disease patterns and a routine specialty-specific "work-up" is accorded to virtually all patients irrespective of their particular presenting features. Hospital specialists also tend to be more concerned with "not missing" or "ruling out" diseases of low probability,¹² i.e. they prefer to minimise uncertainty.

Responsibility for delivery of comprehensive care

The family practitioner provides care to individuals, families and a population of potential patients. Care is also comprehensive, since it is given irrespective of the patient's age, sex or type of illness. A specialist, however, has responsibility for specialty related problems only, and may be further restricted by the age of the patient, as in paediatrics, or the sex of the patient, as in gynaecology. The specialist is also limited to episodic responsibility for patients and is rarely, if ever, in a position to provide care for a whole family.

Being in a position to provide care to whole families offers many advantages to both physicians and patients. There is powerful evidence,¹³ gathered over 30 years in family practice in The Netherlands, of "... the striking and continuing relationship between episodes of illness in one member of a family and episodes in another", since " every change in one (family member) causes changes in each of the others and in the family as a whole". Valuable insights concerning individual patients can also be gained in the course of observing family life while making home visits¹³ - an observation which has been replicated by many family practitioners. Family practitioners are the only physicians who make regular professional visits to the homes of their patients, although the extent to which this is done will vary in different health care systems.

To deliver comprehensive care the family practitioner has to develop the competences to:

• Deal with all health and related problems regardless of the age, sex or any other characteristics of the patient.

• Recognise and manage several problems simultaneously in individual patients, even when they are not related in aetiology or pathology.

Particular role in health promotion/disease prevention

Today, clinicians can no longer be satisfied simply to respond to the diseases and problems presented to them by patients. They must be prepared to anticipate undeclared health needs, since many killing and disabling diseases are directly linked to unhealthy lifestyles.

The harmful impact of unhealthy lifestyles can hardly be exaggerated. For example, the UK Department of Health has estimated that "... of every 1,000 young smokers, one will be murdered, six will be killed in a road accident and 250 will die before their time because they smoke".¹⁴

Consequently, the clinician's role is increasingly to assist people to make appropriate changes in their lifestyle to enable them to live healthier and longer lives. In this endeavour, the family practitioner is recognised as "the key to preventive medicine".¹⁵ This is because family practice possesses characteristics which make it the optimum setting for delivering and reinforcing effective preventive care.¹⁶ These include frequent contacts between family practitioner and patient over many years, the influence of the close physician/patient relationship and the contribution of the primary care team.

The core competences the family practitioner needs to develop to discharge his crucial role in prevention include the ability not only to recognise appropriate preventive opportunities, but also to sensitively enlist the cooperation of patients to promote change to healthier lifestyles.

The consultation in clinical medicine

I now want to highlight the core importance of the consultation and the most important consultation competences which all clinicians need to acquire. This is because evidence is emerging that a significant minority of senior medical students and junior clinicians are deficient in such basic consultation skills as taking a history and conducting a physical examination.¹⁷ There are two distinct contributory factors. The first is the advent of high technology medicine, which has induced a tendency to over-rely on readily available, relatively cheap and low risk investigations. This has principally occurred in hospital practice. The other trait is more evident in family practice. Some educators have carried the otherwise laudable notion of a person-centred approach to unsupportable extremes. They have become so keen to see their patients as people that they sometimes forget to treat them as patients - to their potential detriment.¹⁸ In opposing this trend, one British trainer has complained: "Why do our training elite put so little worth on clinical excellence and enforce a politically correct psycho-babble when it is diagnostic accuracy that is the Achilles' heel of family practice?" "We need to back off the Balint and put a bit more value on getting the diagnosis right".¹⁹

Both these traits tend to undermine motivation to value, acquire and utilise the basic consultation competences. What we truly require, of course, are clinicians who are able to exhibit appropriate levels of competence in both the technical and inter-personal aspects of the practice of medicine. This is because both the science and the art of medicine play essential parts in the care of nearly every patient whether in primary care or hospital.

In the past, the consultation was revered as the seminal event in clinical medicine. According to the distinguished paediatrician, Sir James Spence:

"The essential unit of medical practice is the occasion when ... a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it".²⁰

Today, it is essential not to lose sight of what should continue to be the focal point of patient care - the consultation. To achieve consultation competence a clinician needs to acquire inter-personal, reasoning and practical skills. Of all the necessary consultation competences,²¹ history taking lies at the core. The principal task in the consultation is to discover what is wrong with the patient and the key to both diagnosis and subsequent management is the clinical history.²² "Regrettably, the value of the history ... often seems to be neglected in both undergraduate and postgraduate medical education". Accordingly, much greater effort must be expended in convincing clinicians of the over-riding importance of the history. "Students, and postgraduates, should be well trained in taking a good history and in drawing diagnostic conclusions from the history before embarking on the examination. This will encourage the student to seek specific examination findings to confirm or refute the diagnosis based on the history".²²

If all doctors could acquire the skills to take a discriminating history, it would result in a major improvement in the quality and cost efficiency of clinical practice. It would also improve the quality of medical education by providing more appropriate role models for medical students and junior doctors to emulate.

To achieve this, and to reinforce the importance of the consultation, programmes of medical education and training at all levels need to focus far more on the direct observation and assessment of the consultation performance of medical students and clinicians, using validated criteria of consultation competence against which to judge levels of performance.²¹ This needs to be followed by focused and explicit feedback to improve identified weaknesses.²³ Such an approach also needs to be given a much higher profile in all regulatory assessments of clinical competence and to form the focal point of programmes of continuing professional development. We could then place far less reliance on proxy methods of developing and judging clinical competence.²⁴

I am very pleased to acknowledge that your College has placed the assessment of consultation competence by direct observation at the heart of its exit assessment of higher vocational training.²⁵

The family practice contribution to under-graduate education and research

Family practice is increasingly being recognised and utilised as a critically important context in which to educate medical students. This is partly due to the positive advantages which family practice offers and partly to a growing awareness of the drawbacks of the modern hospital from the educational point of view. Family practice provides optimum opportunities for medical students to develop skills in clinical problem solving, because of the frequency with which patients present with undifferentiated problems across the entire spectrum of disease. "This provides students with repeated opportunities to integrate and apply knowledge and skills learned from the basic, behavioural and clinical sciences in a discriminating way".²⁶ Students can also gain unique insights to the true prevalence and nature of disease through exposure to the clinical epidemiology of the community. Family practice is also the context in which anticipatory care, the effects of social and psychological factors on illness and disease and long term and continuing care can best be observed and learned from. All these insights and competences will benefit all future doctors, especially if they opt for a career in hospital.

Another definitive factor in favour of family practice is that it belongs more naturally to a teaching sub-culture, whereas hospital specialists belong more to a research sub-culture.²⁷ This has led family practitioners to recognise that to become a competent teacher requires as thorough a training as is required to become a competent researcher. Within the medical profession, family practitioners have led the way in acquiring and implementing a wide range of teaching techniques.²⁶

Although students can best learn how to recognise and manage serious and acute conditions in the hospital context, this provides them with a misleading picture of a society's medical problems, since they are exposed to highly selected patient populations. They are also exposed to a rather restricted biomedical model, which principally views "the body as a machine, disease as a consequence of breakdown of the machine, and the doctor's task as repairer of the machine".²⁸ These traditional drawbacks of hospital as a suitable context for undergraduate education have been compounded by recent changes in the pattern of health care provision, namely increased throughput of patients combined with shorter patient stays and super specialisation.²⁶

All these factors point to the necessity for an enhanced role for family practice in undergraduate medical education. Indeed, some believe that family practice should become the dominant teaching and learning environment for basic medical education²⁹ and this could be achieved without disadvantaging students.³⁰

Some still believe, however, that family practice can only teach the so called "touchy-feely bits" of clinical medicine. This view persists despite convincing research evidence that basic clinical skills can be taught just as well, or even better, in family practice than in a hospital setting.^31,32 Furthermore, when the two are directly compared, practice-based teaching is often perceived by medical students to be of more value.^33,34

There is overwhelming evidence, therefore, of the advantages of conducting a greater share of undergraduate medical education in the context of family practice.

Family practice has often been criticised for its lack of research productivity compared to hospital disciplines. With a few notable exceptions, it has to be acknowledged that the research potential of family practice has not yet been fully exploited. In an era when we are increasingly encouraged to practise evidence-based medicine,³⁵ the relevant evidence is often lacking because the studies have not been done.

It is our duty as a discipline to undertake the required studies to enable us to better understand, diagnose and manage important diseases such as asthma, depression, hypertension, thyroid disorders, most infections and acute emotional problems.³⁶ This is because "... there are important advantages in studying problems and testing potential solutions in the setting where such problems are most often met".³⁷ Furthermore, family practitioners are often the only professionals with the necessary insights to identify appropriate research priorities in the context of family practice.

Indeed, research opportunities are plentiful as there are many unexplored areas. We are also fortunate in family practice to be able to count on high rates of patient compliance in research studies and collaboration from practitioner colleagues in the collection of data.

Although research output and quality are improving within our discipline, we need to encourage still more of our colleagues to become involved. However, all family practitioners should not be pressurised to become equally active in research. There are three levels of involvement which we should encourage: innovators, collaborators and users. Innovators would be individuals who have the interest and capability to initiate a research project and take responsibility for project design, implementation and write-up. They should comprise 5-10% of family practitioners. Collaborators would be prepared to accurately collect data for other people's research projects, and they should constitute about 25% of all family practitioners. In time, a minority of these may become innovators. Finally, 100% of family practitioners should be prepared to use research findings to inform their clinical practice.

A parallel task is to inform and convince non-practitioner colleagues, grant-giving bodies and health departments of the broader potential and core contribution that family practice could, and must, make to the research endeavour within clinical medicine.

Conclusion

There is no ideal system of health care. The specific format which any single country selects and implements needs to reflect its particular historical, cultural, political and economic circumstances. Nevertheless, I strongly believe that the health and related needs of society are best served through the development of a strong primary care sector, built around a generalist family practitioner acting as the leader of a multi-disciplinary primary care team and with selective referral to specialists. This is entirely in keeping with the growing recognition that "... the expertise of the generalist is complementary to that of the specialist and the two are profoundly interdependent".³⁸ Nevertheless, with the trend towards greater specialisation it is more important than ever to preserve the role of the generalist.

In this Oration, I have highlighted the unique role of the family practitioner, the special skills which the family practitioner needs, the particular contribution that family practice can make to the delivery of health care, undergraduate medical education and research, and the enduring importance of the consultation. In short, I have tried to make the case for family practice and the consultation being "the core of medicine". Finally, I wish to borrow some words from Sir James Mackenzie, perhaps the greatest family practitioner of all time, who used to end a discourse with this sentence: "I would earnestly ask you, not to accept my view, but to enquire whether what I have said is true".³⁹

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* This paper was presented as the Dr Sun Yat-Sen Oration on March 10, 2002.

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