Many family doctors find patients with psychosomatic disorders "heart-sinkers" because these patients attend frequently but their problems never seem to improve.¹ One way that family doctors can rescue themselves from the "heart-sink" is to look beyond the presenting symptoms to the family for the possible diagnosis and intervention. Minuchin et al have found that families of children with psychosomatic diseases typically tend to be enmeshed, overprotective, rigid and lacking in conflict resolution.² The family doctor may be able to empathise with the patient more if he/she can see the patient's illness and frequent attendance as a necessary way of coping with the family stress.

As Professor Christie-Seely has pointed out, each individual is part of a family system. An individual's illness can be the symptom of a dysfunctional family or can disturb the equilibrium of the family system.³ It is impossible to bring change to a part of the system without changing the other parts and vice versa. Therefore, it is sometimes necessary to treat the whole family for the treatment of an individual's illness to be effective. This is not only applicable to psychosomatic disorders, but also to many chronic diseases such as diabetes mellitus and asthma.² A more family-oriented care may open new management possibilities to the family doctor in solving the health problems of individual patients.

Doherty et al have described five levels of family-centred medical care.⁴ The first and minimal level is the consideration of the family in the diagnosis of genetically related diseases and medical legal situations. The second level is the involvement of the family in the disclosure of diagnosis and management of a patient's illness. The third level is the recognition of the impact of an illness on the family and family problem as a possible causal, precipitating or perpetuating factor of a person's illness. The fourth level involves the conduct of family interviews to assess the family structure, relations and dynamics in order to detect any family dysfunction, and to stimulate the family to find more effective ways of solving their problems. The fifth is the highest level in which specific family therapy is given to change dysfunctional family relationships.

Basic medical education teaches doctors at most up to the second level of family involvement, which is the level required by doctors in most medical disciplines but it is not adequate for family medicine. The family doctor must have the knowledge and skills to provide the third level of family-centred care in order to fulfil the roles of early diagnosis and whole-person care. Like physical diseases, family problems are more likely to have a better outcome if the family doctor can detect them early so that proper management can be given. The family doctor is also in the best position to anticipate and prevent possible family dysfunction in relation to a patient's illnesses, e.g. dementia, or at different stages of a person's life, e.g. newly married.

A family doctor can choose to refer families suspected to be dysfunctional to other experts for further management or move up to the next level of family-oriented medical care. As a matter of fact, the family doctor is in the ideal position to carry out family assessment and counselling through family interviews (fourth level of care) because he/she often knows more than one member of the family, and the family is more motivated to participate when one of its members is ill. Many of the skills of family assessment and counselling such as joining with a person, problem solving, reframing problems, challenging existing ideas and values, and finding alternative solutions are similar to the skills commonly used in a family medicine consultation. Therefore, most family doctors can acquire them through a short course of training and supervision, provided that they rehearse them in their daily practices. This will enable the family doctor to help most psychosomatic families whose dysfunction is often minor. Many family medicine training programmes in North America require trainees to reach this level of skills. This should also be the goal of our College's higher training in Family Medicine as family therapy training courses tailored to the need of family doctors are becoming more available locally.

Specific family therapy (the fifth level of care) is indicated for a small proportion of families whose dysfunction is serious or resistant. The therapy is intense and time-consuming, which is usually beyond the limits of a family doctor. The role of the family doctor in this level of care is mainly co-ordination and facilitation of therapy from an expert family therapist.

The term "family doctor" has gradually replaced the term "general practitioner" in many places including Hong Kong because there is an increasing awareness of the importance of the family in the prevention, diagnosis and management of illnesses of individual patients. We family doctors distinguish ourselves from practitioners in other specialties as experts in family-oriented medical care. We must equip ourselves with the knowledge and skills in order to practise up to the expectation of our name.