Principles of family medicine and general practice – defining the five core values of the specialty

Traditional values of general practice, reflecting the ethos of the doctors providing general practice care, predate the emergence of the modern speciality of family medicine in the 1960s (Table 1). Consensus on the principles of family medicine emerged in the 1990s from Barbara Starfield’s four pillars of primary care: first contact care, continuity, comprehensiveness, and coordination.⁸ However, primary care is essentially a healthcare delivery model and does not form a complete picture of family medicine. Lack of agreement on core family medicine principles is apparent from other sources.^9–11 Perhaps the clearest exposition in peer-reviewed literature is the 1998 article, ‘Principles of family medicine’ by the general practitioner and academic, Riaz Qureshi.¹² After differentiating family medicine from other specialties, Qureshi outlined 10 core principles that capture the essence of family medicine (Table 1). However, some ideals, such as community-based care, are more aspirational than real.¹³ Consequently, distinct but mostly congruent statements emanated from European, Australian and New Zealand general practice leadership (Table 1).^14–16 There is still a need to distil these efforts into a universal set of core values for primary care doctors worldwide.

Table 1. Evolution of the principles of family medicine/general practice

Five principles of family medicine and general practice are presented here based on a review of prior scholarly work. These core principles are different from practical methods used to operationalize these ideals (Figure 1).

Figure 1. Principles of Family Medicine/General Practice

Compassionate care is a caring attitude towards patients and their families. Expressed as empathy and patient-centred communication, compassionate care is a deep-seated respect for fellow humans.¹⁷ Often the desire to help others attracts aspiring doctors to choose this discipline.¹⁸ Compassion, literally meaning ‘to suffer with,’ is a doctor’s ‘willingness to share the patient’s anguish and to attempt to understand what the sickness means to that person.’¹⁷

Compassion is difficult to measure¹⁹ and thus somewhat neglected in research, perhaps explaining why some academic frameworks of family medicine omit this core value. Yet it is the hallmark of family physicians caring for families over the life cycle. For family physicians in full-time clinical practice, compassionate care is perhaps the principle they relate most to in their day-to-day work: ‘actions that arise out of love and kindness, not duty and fear.’²⁰

A generalist approach focuses on whole people instead of a particular organ or disease. Its field of vision is the context of the illness: the person, their family, and the larger society. A generalist approach weighs subjective factors such as patients’ age, frailty, comorbid illnesses and quality of life, to guide medical decisions. Generalists bring value by enabling a broader worldview that specialists often miss in complex situations and in people with multiple problems. General practitioners writing on the goals of healing have sought to understand patients’ illness experiences within a whole person context.²¹ Developing generalist ways of knowing involves not only a broad base of knowledge but also specific skills, striving to know oneself, one’s patients, and the social milieu, as well as their interconnections.²² Despite the relentless drive towards sub- specialization, the need for generalists who can assume overall management of patients’ care remains.²³ For example, family physicians address women’s health concerns more often during preventive care visits than other specialists,²⁴ and family physicians are essential in caring for patients with mental illnesses.²⁵ Generalists who are experts in the persons and the communities they serve are needed.²⁶

The generalist approach is based on clinical experience with a wide range of illnesses: a broad but not necessarily comprehensive scope of care. The term ‘comprehensive’ implies all possible medical conditions, an incredible demand. When used to describe the scope of conditions treated by family physicians, it raises scepticism among laypeople²⁵ as well as medical students and other health professionals. Furthermore, it perpetuates among patients unfounded perceptions of incompetence in family physicians. Family physicians bring value by their generalist approach and not by a comprehensive scope. Some family physicians’ geriatric focus of practice is an example of social good developed ‘within the value system of family medicine.’²⁷

Continuity of relationships between patients and their family physicians builds trust, responsibility and healing bonds. These interpersonal relationships develop over time with repeated visits to the same doctor. Continuity leads to a rich and rewarding experience for family physicians, enabling them to develop deep knowledge of their patients, along with a sense of connection, trust, enhanced professional competence, personal growth and respect.²⁸ The joy of prenatal care, delivering babies, providing well child care and caring for older adults within the same family is integral to family medicine, and hence the name of the speciality. Continuity of relationship is manifested by family physicians during palliative and hospice care when other specialists have ended their commitment to these patients. Patients trust general practitioners more than other health professionals.²⁹

Care coordination was previously included as a principle of family medicine primarily in academic circles. Care coordination is a complex task that extends beyond administrative coordination to include optimal integration of patients’ needs, preferences and community resources.³⁰ Despite the importance for chronic disease care, care coordination is just one component of family physicians’ long-term commitment to individual people. Coordination by itself is not central enough to be a defining feature of the speciality and can be subsumed within the relationship continuity principle.

Reflective mindfulness refers to doctors’ awareness of personal thoughts and emotions. It is a sense of presence, of curiosity and attentiveness towards self and others. Reflective mindfulness lets doctors listen attentively and act with compassion, technical competence, and insight.³¹ In stress situations, reflection enables a more meaningful response than an emotionally-charged reaction. The benefits of mindfulness extend beyond practicing physicians to their patients, by enabling them to express themselves in an atmosphere of warmth, acceptance and positive regard, leading to higher patient satisfaction.³² Reflective and curious doctors also drive the research domains of family medicine.³⁰ Reflection leads to clinical reasoning that has greater depth and contextual relevance. Reflective practice drives experiential learning.²¹ Peer groups enabling family physicians to reflect on their clinical experiences reduce professional isolation and increase their adaptive reserve.³³ This principle of family medicine is perhaps the most distinctive attribute of the speciality.

Lifelong learning refers to a continuous process of personal and professional development. At the clinical practice level, lifelong learning translates into records reviews and data-driven improvement, and at a personal level into protected time for learning and teaching.³⁴ This quest for knowledge improves clinical skills and professional competence. Well designed continuing medical education programmes can improve patient outcomes.³⁵ Family physicians have led the recent development of practice-based research networks for discovering clinical knowledge relevant to primary care.³⁶ Continuous professional development should include transformational medical education that positively impacts personal and professional skills.³⁷

The five principles of family medicine and general practice collectively form the foundations of the clinical speciality as well as the academic discipline. Each principle is an essential attribute of the speciality and therefore carries weight in teaching and practice. Operationalisation of these principles (second column in Figure 1) will require focus and diligent research from clinicians and academic leaders of family medicine and general practice.

Nothing to declare.