Medicine is not only a science, but also an art of letting our own individuality interact with the individuality of the patient. What is spoken of as a “clinical picture” is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, hopes and fears.
The significance of the personal relationship between the family physician and the patient cannot be too strongly emphasized, for in a large number of cases both the diagnosis and treatment are directly dependent on it. The physician must have an interest in humanity, for the secret of the care of the patient is in caring for the patient.
The direct one-to-one patient-physician relationship which traditionally has characterized the practice of medicine is changing, primarily because of the changing setting in which medicine is being practiced. Increasingly, patients are cared by groups of doctors, clinics, hospitals or health maintenance organizations rather than by individual independent practitioners. Although there are potential advantages in the use of such organized medical groups, the chief drawback is the loss of the concept of the physician who is primarily and continuously responsible. With “team management”, a patient can benefit from the collaboration of different doctors and other trained healthcare professionals, but it is the duty of the family physician to guide the patient through his illness.
There are two commonly held misconceptions of family medicine. The first is that the content of family medicine is so vast, so unwieldy, that trying to gain a handle on it is inherently impossible. The second is that family medicine lacks the ferment and dazzling break-throughs so evident in specialties – that in effect, everything worth knowing in family medicine is already known. I believe that the content of family medicine, though undeniably broad, is eminently definable; furthermore that the fundamentals of family medicine can be mastered. I contend that family medicine offers not only intellectual challenges that are truly extraordinary, but also is a treasure trove of research opportunities that we are just beginning to explore.
I have been practicing family medicine for more than 30 years. There have been profound changes in the context of the practice of family medicine in those 30 years. Change must necessarily influence the ways in which family medicine is learnt as a discipline. Evidence-based medicine, the impact of advances in technology, increased emphasis on improved health outcomes and increased consumer knowledge and expectations within a health sector which is under cost constraints have all increased the pressure on the individual physician.
Although I have kept abreast of changes in medicine all these years through conscientiously attending continuing medical events, I have increasingly felt that a formal course of training in Family Medicine is necessary to enpower the family physician in his work.
The Family Medicine Traineeship Programme (Private Practitioners Stream) was introduced in 1995 to provide a parallel stream for the training of doctors in private practice. I have often been asked why I have taken the course. My colleagues reasoned that I cannot be wanting to attract more patients – I have enough patients to keep me very busy already. My patients will not care whether I have a higher degree or not. It cannot be for financial reasons; they do not see my circumstances as exactly impecunious. Then, they ask, why sacrifice 2 ½ years of comfortable living to go into a routine of squeezing time for study and rushing to lectures and tutorials? It is difficult to explain abstracts like challenges. It is all about the challenge to upgrade myself and my organization.
Training is really what counts; that is training to be a family physician with the appropriate full range of clinical and humanistic skills. The public is demanding that physicians act in a responsible manner and that their interpersonal and communication skills at least equal their scientific and technical skills. Practice will facilitate the formation of conclusions and diagnoses, but training is to enable a competent physician to do so with a range of patients presenting with complex problems.
Training is not for passing examinations. Assessment procedures are ideally, to indicate to competent candidates that they have reached a required standard at a particular point in their training and professional careers and are ready to embark upon further training and continuing education. The Master of Medicine (Family Medicine) is about bench-marking – that, hopefully, its acquisition will prevent the doctor, in all aspects of patient-care, from slipping below the mark that has been set for him.
Dr Lim Liang Boon
June 1996