New Zealand among global social media initiative leaders for primary care advocacy

What does it mean to be a General Practitioner (GP)? General practice, also referred to as family medicine in many parts of the world, is often difficult to define for both GPs and the broader medical community. The Royal New Zealand College of General Practitioners describes a GP as ‘an appropriately qualified medical graduate who has particular knowledge and skills to provide personal, whanau and community-orientated comprehensive primary medical care that continues over time, is anticipatory as well as responsive, and is not limited by the age, sex, race, religion or social circumstances of patients, nor by their physical or mental states.’¹ In a time of considerable health system change we believe it is timely and important to identify the values and beliefs that underpin the role GPs play in our society. The way our speciality is viewed by politicians, managers, specialists, patients, and ourselves is important to the professional identity and confidence of current and future GPs. In New Zealand the role of GPs could be said to be under siege in the context of: pressure from the extended scope of practice of pharmacists, nurses, paramedics and other ‘mid-level’ providers; the diminishing involvement of GPs in after-hours services; technology advances and more accessible patient self-management and online services; and increasing financial pressures on our health system in the face of rising levels of multi-morbidity and an ageing population.

It is important for New Zealand society to understand not only the role of GPs in the health system, but also the values that underpin that role, so that in the face of inevitable change the core component of our primary care system, doctor–patient relationships, can be protected.

The international #1WordforFamilyMedicine initiative explores the identity of GPs by allowing national general practice and family medicine communities to collaborate in advocating for the discipline via social media. The intent of the #1WordforFamilyMedicine initiative in New Zealand is to provide a vehicle to collaborate with the international Family Medicine community as well as a novel way of investigating the identity of GPs locally.

The #1WorldforFamilyMedicine project was promoted by WONCA (World Organization of Family Doctors) and multiple countries across the globe to help celebrate the 2015 World Family Doctor Day on 19 May 2015. Using the social media platform Twitter, GPs were asked to respond in one word to the question ‘What is your favourite part of Family Medicine/General Practice?’ Responses are used to create an image representing each country with input and suggestions from local colleagues.

To date, over 80 images have been created in 60 different countries on six continents.² These images were viewed more than 6100 times from across 95 countries.

An early colloquial name for New Zealand was Fernland, recognising the dominance of this plant in native bush, its importance in traditional Māori carving, and use as food and medicine. A symbol of a silver fern (a species of tree fern, Cyathea dealbata) was first worn by the New Zealand Natives rugby team that toured Britain in 1888 and is now found on coins, banknotes and in the country’s coat of arms. It has become an unofficial but internationally recognised icon representing New Zealand and is used by commercial interests, the military and by sporting teams.² After a discussion between the authors about different image options, the silver fern was therefore selected as an image that is recognised as representing New Zealand within our borders and around the world.

Between 22 April 2015 and 26 June 2015 a convenience sample of GP trainees and GPs following one author (JSJ) on Twitter were asked the question, ‘What is your favourite thing about family medicine in New Zealand? Participation meant providing single word/phrase responses in English or Māori.

Over a period of 9 weeks, 168 tweets were sent from Twitter account @opotikigp containing the above question and the hashtags ‘#1WordforFamilyMedicine’ ‘#nzversion.’ These tweets were engaged with a total of 663 times by Twitter users. Engagement in this context means tweets were replied to, retweeted, favourited or mentioned in another tweet. Eighty-three responses were received from New Zealand-based doctors, nurses, and other health workers.

The responses were collected into a single list and then turned into a ‘word cloud’ image using Tagul.com by one author (KH). The final image uses the 83 responses repeatedly and in different sizes in order to display the importance of each word as well as to create the silver fern effect. The words in the largest font were selected after discussion with RNZCGP communications staff who also approved the final pictogram from four prototype pictures developed by the authors.

On 29 June 2015 the selected pictogram was uploaded to the initiative’s website at bit.ly/1WordforFamilyMedicine. In little less than two months after online publication the pictogram was viewed in ten countries across the world – most (46%) from New Zealand but some others from countries as diverse as the United States of America, Trinidad and Tobago, Portugal, Finland, Norway, Algeria, Iraq and Indonesia.

In the opposite direction, all-time visitors from New Zealand showed the most interest in the national pictogram but also in the pictograms from 22 other countries, from neighbouring Australia to Tunisia, from Canada to South Africa.³

Afterwards, the responses underwent deductive thematic analysis based on key features of in the European definition of General Practice/Family Medicine.⁴ The responses were given labels (codes) that identified features relevant to answering the research question. Thematic analysis was then done, ie codes were collated and examined in order to identify significant broader patterns of meaning (candidate themes). The latter were checked against the dataset to determine the scope and focus of each theme and whether they answered the research question – one was discarded (Holistic modelling) in order to obtain the final themes. This was a reiterative process involving all three authors (Table 1).

Table 1 Words organised by themes, as per the thematic analysis
¹People, ²Family centric, ³Family, ⁴The people, ⁵Weaving, ⁶Partnership/collaboration, ⁷Love, ⁸Talking, ⁹Understanding, ¹⁰Big love

The pictogram (Figure 1) demonstrates the importance placed upon the relationship between participants and their communities. The central position of ‘kōrero’ (communication), ‘whānau’ (family), ‘aroha’ (love) and number of words that were contributed in Te Reo (Māori language) reflect the importance placed on Māori within New Zealand primary care. Though most participating countries used a single language, Paraguay, Nigeria and South Africa also included indigenous language words in their project contributions. This may reflect the importance of this aspect of population health in these jurisdictions.³ The New Zealand contributions reflect a focus on teamwork, collegiality, an acknowledgment of the complexity of the work, symbolised in ‘whatu’ (weaving) but also the fun, gratitude and optimism of contributors.

Figure 1. #1WordforFamilyMedicine New Zealand: image based on the New Zealand silver fern

We hope that the project picture will be used widely in conference presentations, nationally and internationally and by anyone needing to illustrate the values held by people involved in family medicine in New Zealand. It may be the nidus of a young doctor learning group or other discussion around values. We believe the pictogram, while perhaps inappropriate as an alternative national flag, could become a common emblem used by the RNZCGP to symbolise what it means to be a GP in Aotearoa, New Zealand.

In the international arena, each country’s GPs have a slightly different scope of practice, though we are share a similar core skill and value set. When compared to the published results from other #1WordforFamilyMedicine participating locations such as Portugal, Argentina, and Italy - the New Zealand responses touch on similar themes.^5–7 Examples of these categories include professional competencies like community-orientation, person-centred care, problem solving, primary care management, and a comprehensive approach - all of which are included in the widely known European definition of General Practice /Family Medicine.⁴

This initiative has demonstrated the spirit of collaboration across New Zealand – and our ability to link with the international movement of family practice. The pictogram highlights the importance of General Practice at national, community, whanau (family) and individual levels. The old adage claims that a picture is worth a 1000 words. In this instance, we argue that they are worth even more as these images represent GPs’ love for their profession, the values they hold and the union between General Practice and the community it serves. We hope that this initiative will help inspire current and future GPs.