"What is general/family practice?" Let us define it

Y T Wun 溫煜讚

TimeTitle

Summary

Internationally, there is no consistent definition of general practice or family medicine. This paper proposes and discusses a simplified definition: a general practitioner (GP) is a physician who personally provides whole-person health care to individuals and families in their living environment. The specialty should define and develop its specific core curriculum of knowledge base and skill, rather than merely sharing those from other specialties. GPs have specific knowledge in diseases managed mainly in the community, in comorbidity, and in family functions. GPs' specific skills include time as a diagnostic tool, selectivity with evidence in examination, investigation and management, and efficient communication. A GP is not just a physician licensed to practice medicine in the community.

摘要

全科醫學或家庭醫學在國際上尚無統一定義。本文提出並討論一個簡化的定義，即全科醫生（GP）是為病人及其家庭在生活環境中提供「全人醫療」。家庭醫學專業應當有自己的核心課程，應該確立和發展特定的知識和技能，而不是借用其他專業的課程。全科醫生須要熟識社區內的疾病和其發病率。他們的特殊技能則包括把時間作為診斷的一種工具，選擇具實證的檢查和治理，及有效的溝通。全科醫生並不僅是一個獲准在社區開業行醫的醫生。

Introduction

In response to a question "What is General Practice?" Dr Choi Kin recently wrote an excellent article to explain what this specialty is and described in detail its development in Hong Kong.¹ I highly commend this article to local physicians interested in our specialty. For several years, I have been looking for a one-sentence definition of our specialty in order to tell other people what kind of a physician I am. There is a lot of misunderstanding and confusion about our specialty, not only among our other colleagues but perhaps even among ourselves. It is the time for us to pool our efforts to define our identity and delineate our role. I hope that this paper will stimulate a fervent and open discussion to arrive at a consistent definition and a clear image of what we are.

For this discussion, I shall use "general practice" and "family medicine" as equivalent. The term "general practice" is more often misunderstood than the other. If we can clarify this term, it will be easier to clarify "family medicine". I use "general practitioner" (GP) in the rest of this discussion because most primary care physicians in Hong Kong either call themselves, or are called, GPs. It is more important to understand or tell other people what a GP is.

Terminology

Up to now, we have not agreed among ourselves what we should be called: "general practitioners" or "family physicians" (FPs). The international organisation to which all GPs/FPs in the world belong has been calling itself "WONCA" (World Organisation of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians). Recently it has also called itself "World Organisation of Family Doctors". "Family doctor" will probably be the future name of the profession.

The confusion of the terminology arises from the failure of distinguishing "medical practitioners" (doctors qualified to practice medicine) or "primary care practitioners" (doctors doing primary care) from "general practitioners" (doctors with a special skill and role in patient care). Because of its nature of integrating knowledge and skill from many disciplines, "general practice" is difficult to define and there is no internationally consistent definition, enforcing the confusion between "medical practitioners" and "general practitioners". The term "family physician" is used in some countries to highlight the discipline as a specialty with training.

In Chinese language, the terms are even more confusing. Both "普通科" and "全科" are used, the former being commoner but also more misleading. In Mainland China, "全科醫生" is used to be equivalent to general practitioners and "通科醫生" to medical practitioners.² "全科醫生" is an appropriate term, as we shall see later in this discussion. However, "全科醫生" in Hong Kong is easily confused with MBBS "全科醫學士".

Definition

The World Organisation of Family Doctors defines general practice as: "a physician who provides personal, primary, and continuing comprehensive health care to individuals and families". The General Practice Strategy Review Group of the Royal Australian College of General Practitioners (RACGP) proposed the definition: "a general practitioner is a doctor who has completed the Fellowship of the RACGP or has an equivalent qualification and who provides primary, continuing, comprehensive whole-person care to individuals, families and the community".³ This definition by means of its first clause is probably the most clear-cut statement but would certainly be the most rejected one if the equivalent is proposed in Hong Kong.

To make the definition short, I propose the version: "a general practitioner is a physician who personally provides whole-person health care to individuals and families in their living environment". (全科醫生是提供全人醫療的醫生) The keywords are "personally", "whole-person care" and "in their living environment". I shall elaborate on these.

Personally

A general practitioner (a person) should be distinguished from a general practice (a clinic). With the increasing commercialisation in modern medical practice, a physician could run a clinic that satisfies the definition of general practice without himself or herself doing much face-to-face doctor-patient care, for instance, as the medical director or manager of a health maintenance organisation. However, personal delivery of care does not exclude the delegation of part of the work to, or involvement of, other members of the primary care team, such as nurses, health educators. Face-to-face encounters over long periods of time are the essence of our practice.

Whole-person care

I distinguish whole-person care from holistic care. The Longman Modern English Dictionary defines holism as: "life as concerned with the making of larger and larger organic wholes, greater than the sum of their parts". The Oxford Companion to Medicine defines holistic medicine as: "a discipline of preventive and therapeutic medicine which emphasises the importance of regarding the individual as a whole being integral with his social, cultural, and environmental context rather than as a patient with isolated malfunction of a particular system or organ". We often divide the holistic care of a patient into physical, psychological, social, spiritual and cultural aspects. This is the cross-sectional view of a person at a certain point in the lifespan. Whole-person care is the accumulation of many instances of holistic care throughout the lifetime of a patient, theoretically from birth to death. In itself, whole-person care is comprehensive and continuous over a lengthy period of time. We care for the young and the elderly.

Another element of whole-person care is the integration of multiple organs and systems. We do not limit our care or skill to any anatomical system. We care for male and female patients with diversified problems of different organs.

Living environment

Our patients are living at their homes and we care for our patients with consideration and emphasis on their living and working environment, not just physical but also social (the interaction of two or more persons). Living environment, to be exact, is part and parcel of whole-person care. Because it is external to a person, living environment is sometimes not recognised as part of a whole-person, and so needs emphasis.

In what do general practitioners specialise? Medical knowledge

Figure 1: The knowledge shared between general practitioner and other specialists GP = general practitioner S = hospital specialists

It has been said, "General practice is a specialty of no specialty". Often, we cannot clearly tell people in what we are specialised. It has been said: we do not have knowledge or skill that is unique to us, unlike the radiologist who reads x-rays, the hepatologist who knows every detail of different types of viral hepatitis, the orthopaedic surgeon who examines the cruciate ligaments of the knee with arthroscope. We derive our medical knowledge from other specialties, stating that our knowledge is in breadth. I depict a GP's knowledge, sharing a proportion of knowledge of each of other specialties, in Figure 1. Unconsciously, we hold this concept very strongly. Over 95% of continuous medical education (CME) activities for GPs involve other specialists as speakers and we are glad that they tell us what we should know even about diseases and treatment in our own setting.

Do we have a knowledge base of our own? Many of us would say that we do not. Indeed, we have not much knowledge base to show, at present and in Hong Kong. But should we have medical knowledge of our own? We always claim that patients (and disease patterns) seen in primary care are different from those seen in hospitals. But we have not the solid knowledge base to show the difference, and we are using other hospital specialists' knowledge. Our pioneers in general practice thought differently. Dr John Fry and Dr Hodgkin described the diseases seen in general practice. Their books ("Common Diseases" and "Towards Earlier Diagnoses in Primary Care")^4,5 are rarely read now by GPs because we rely on other specialists for clinical knowledge. We do not bother to document in detail the diseases we see in our daily practice.

Take an example. Psychiatrists have claimed that GPs usually give antidepressants at such low doses that the medication is no more than placebo.6,7 We, however, have the impression that tricyclic antidepressants at daily doses of 50 or 75mg (in contrast to 125-150mg) do work in our patients with depression. Perhaps our patients suffer from only mild depression and do respond to low doses of antidepressant, or just to our listening and talking with them irrespective of whether a drug or placebo is given. We have not shown which hypothesis is right.

It is not too difficult to name some conditions or diseases mainly seen in general practice but less often in other specialties: an enlarged heart in an otherwise healthy person,⁸ hyperuricaemia without gout as a concurrent condition with controlled hypertension or diabetes mellitus,⁹ chronic hepatitis B infection with negative e-antigen,¹⁰ uninvestigated dyspepsia with helicobacter pylori infection,¹¹ irritable bowel syndrome, chronic fatigue syndrome, obesity.

Knowledge of family cycle and family function (dynamics) is specific and mandatory to all GPs. Perhaps only a few clinical psychologists and psychiatrists would care to understand the positive and negative factors that influence the coping behaviour of a family during crisis or in response to chronic illness in the family. The GP who sees the sick grandmother and grandson together will see more than both the geriatrician and the paediatrician who see the patients separately. In addition there is of course, the saving of resources. Often we have to treat diseases that could not be seen or dealt with by a single specialist. A dermatologist treats chronic eczema. A gynaecologist treats functional uterine bleeding. A GP treats a woman with functional uterine bleeding and chronic eczema (perhaps also with anxiety or depression too). Comorbidity (the concurrent occurrence of two or more diseases) is a disease pattern common and characteristic in general practice¹² and we should be able to treat them effectively. Treating concurrent diseases also makes general practice a large saving to medical resources.

Specific skills

Using time as a diagnostic tool is a skill specific to GPs. This is covered by all general practice textbooks and I will not pursue this further here.

Our next specific skill is selectivity of physical examination and investigation, and prioritisation of which problem(s) to manage first. GPs very seldom do a "complete physical examination", with the usual excuse of pressure of time. In fact, we select examination and investigation according to their effectiveness. We consider (or should have considered) the sensitivity, specificity, and predictive values of a specific test rather than requesting a package of tests. From our experience, we do not often do a certain physical examination because it is not likely give us useful information. When was the last time that we percussed the chest for emphysema? We are seldom aware that our selectivity has scientific basis. It has been shown that, for the clinical diagnosis of obstructive airways disease (OAD) in the general practice setting, smoking 40 pack-years, self-report of past history of OAD, maximum laryngeal height of at least 4 cm, and age of at least 45 years, are the best diagnostic features (when all present, the likelihood of OAD is 220, with the area under the receiver operating characteristic curve of 0.86).¹³ Unfortunately, the development of evidence-based physical examination lags far behind that for diagnostic tests and treatment, and the volume of evidence to support our selectivity in physical examination is still small.

The most important and distinguishing clinical skill of GPs is our consultation and counselling skill. The unique characteristic of our skill is the ability to establish rapport, reveal hidden problems/agenda, and give optimal treatment (even psychotherapy) within the limited time constraint of a consultation.¹⁴ We try, and often achieve, diagnosis, management and prevention in 10 minutes. We encourage our patients to tell their own stories in their own words and at their own pace but without letting them stray from focus. We give them information from evidence so that they can make choices with their individual preference. We respect them as partners of health care, because, while we know physical diseases better, they know their own body better.¹⁵

The future

I have tried to picture what we could or should do, rather than what we are at present doing. We have not yet fully documented our specific knowledge base. We have not yet shown to our patients what we can do for them in addition to the symptomatic relief of minor illnesses. We must define, develop, and demonstrate our own core curriculum of knowledge and skill.

At present, there is the difficulty of distinguishing between a medical practitioner and a general practitioner. For example, a hospital administrator, being licensed to practice medicine (a medical practitioner), may prescribe an antibiotic to a child with tonsillitis. In this act, the administrator would not be considered as practicing paediatrics, but might be wrongly considered as practicing general practice. In future, there must be the difficulty of distinguishing between a general practitioner and a hospital specialist practicing in the community, e.g., the community paediatrician, the community psychiatrist, the community physician. Let us look at Figure 1 again and change the caption to "the work shared between the general practitioner and the other specialists". The shaded areas can be the "shared care" but can also be (wrongly) the work of the general practitioner taken up by the community specialists. In fact many patients in Hong Kong are taking conditions in these areas to the specialists rather than the generalist. That "primary care psychiatry (or any hospital specialty) is not specialist psychiatry in general practice" should be emphasised.¹⁶

I have said earlier that I look for a simple one-sentence definition of general practice. My discussion so far is an elaboration of the traditional thinking about general practice. A new definition was proposed in Year 2000 providing a framework for research, teaching and development: "The general practitioner is a specialist trained to work in the front line of a healthcare system and to take the initial steps to provide care for any health problem(s) that patients may have. The general practitioner takes care of individuals in a society, irrespective of the patient's type of disease or other personal and social characteristics, and organises the resources available in the healthcare system to the best advantage of the patients. The general practitioner engages with autonomous individuals across the fields of prevention, diagnosis, cure, care, and palliation, using and integrating the sciences of biomedicine, medical psychology, and medical sociology."¹⁷ We should find time to read the article and think over the points raised.

A plea

If we are not clear among ourselves what we are and what we are doing, and if we do not have any thing for exchange with other colleagues, we do not have a distinct identity and cannot be regarded as a specialty.

I start this discussion in order to invite and stimulate more input from colleagues. Local GPs are such a mix of physicians with diversified interests that unity for a common goal is difficult to achieve. Most of us are pragmatic rather than theoretic, devoting our time and effort to personal care of individual patients rather than to establishing the scientific ground of our practice. Yes, we have not been aggressive enough. We have not clarified both to the public and the medical profession what we are. We have not systematically documented our core function and scientific core curriculum.

A GP is not a "non-hospital specialist". Every one of us should contribute to the formulation, strengthening, and promotion of our specialty. What are you going to give to this specialty when you claim yourself to be a general/family practitioner, rather than a licensed medical practitioner?