Family Medicine

The World Book 

of 

Family Medicine 

- 

European Edition 

Published on the occasion of the 20th Anniversary 

of 

WONCA Europe 

Istanbul, October 2015

World Book of Family Medicine – European Edition 2015 

2


First Edition 2015 (published by Stichting WONCA Europe) 

World Organization of Family Doctors - Europe (WONCA Europe) 

Polsjanski Nasip 58, 1000 Ljubljana, Slovenia 

© 2015 Stichting WONCA Europe and the Authors 

Stichting WONCA Europe has asserted its right under the Copyright, Designs and Patents Act 1988 to be identified as 

the author of this work. Every effort has been made to ensure that the information in this book is accurate. This does 

not diminish the requirement to exercise clinical judgement, and neither the publisher nor the authors can accept any 

responsibility for its use in practice. All rights reserved. No part of this publication may be reproduced, stored in a 

retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or 

otherwise, without the prior permission of the copyright owner. Requests for permission to reproduce or translate 

WONCA publications for commercial use or distribution should be addressed to the WONCA Secretariat at 

SecretariatEurope@wonca.net 

The Authors remain the sole copyright owners of their conribution. 

Design: Carl Steylaerts 

Available online at 

http://www.woncaeurope.org/sites/default/files/world book 2015.pdf 

Printed in Turkey on 2000 copies 

Paper copy: 

CIP - Kataložni zapis o publikaciji 

Narodna in univerzitetna knjižnica, Ljubljana 

614.2:316.356.2 

The WORLD book of family medicine. - European ed. - Ljubljana : Stichting WONCA Europe, 2015 

ISBN 978-961-281-983-5 

Electronic copy: 

CIP - Kataložni zapis o publikaciji 

Narodna in univerzitetna knjižnica, Ljubljana 

614.2:316.356.2(0.034.2) 

The WORLD book of family medicine [Elektronski vir]. - European ed. - El. knjiga. - Ljubljana : Stichting WONCA 

Europe, 2015 

Način dostopa (URL): http://www.woncaeurope.org/sites/default/files/42.pdf 

ISBN 978-961-281-984-2 (pdf) 

This book uses British English as the language for carrying thoughts. 

Proofreading was performed by Ms Naomi Uludamar. 

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Table of Contents 

Prologue Mehmet Ungan, Carl Steylaerts 8 

1 Patient Empowerment for Patient Self-Management Andrée Rochfort 10 

2 Communicating with Patients Michael Jones 13 

3 Ethical Problems in Family Medicine Manfred Maier 15 

4 Health Consequences of Emotional, Physical and Sexual 

Abuse 

5 The Role of Family Medicine in Undergraduate Medical 

Education 

6 Developing National Curricula for the Education and 

Training of Family Doctors 

Lucy Candib 18 

Zekeriya Akturk 21 

Jessica Watson 25 

7 Transient Illnesses Ignaas Devisch 28 

8 Cooperation Across the Interface of Primary and 

Secondary Care 

Odd Jarle Kvamme 30 

9 Complexity and Primary Care Joachim Sturmberg 33 

10 Motivational Interviewing in Family Medicine Siggy Rausch 37 

11 Quality Circles Adrian Rohrbasser 40 

12 Pathology and Minor Surgery in Primary Care Pieter Buis 43 

13 Developing Research Capacities in Family Medicine: the 

Croatian Experience 

14 An International Comparison of the Role of the Family 

Doctor in Different Countries 

Mladenka Vrcic 46 

Donatella Sghedoni 49 

15 Tackling Health Inequalities: the Role of Family Medicine William Wong 52 

16 Using the Internet to Answer Clinical Questions Harris Lygidakis 56 

17 Threats to Patient Safety in Primary Care John Sandars 59 

18 Teaching uncertainty Yona Yaphe 61 

19 Home Visits: a Medical Necessity or Simply a Service? Paul Van Royen 64 

20 Promoting the Health and Well-being of Family Doctors Ulrich Busch 67 

21 Prevention and Health Promotion in Clinical Practice Carles Brotons 70 

22 Determinants of Multi-morbidity Marjan van den Akker 73 

23 When Chronic Care Becomes End-of-Life Care: Bridging 

the Gap 

24 What is Universal in Primary Care? Challenges for 

North/South Co-operation. 

Radost Assenova 76 

Matie Obazee 79 

25 The New Consultation: The Doctor in the Electronic Age Theo Schofield 82 

26 How to Deliver a Successful Learning Package for Family 

Medicine Trainees? 

27 The Integration of Mental Health into Primary Care: 

International Perspectives 

Jaime Correia de Sousa 85 

Filippo Zizzo 88 

28 WONCA and the Cochrane Primary Health Care Field Floris A. van de Laar 91 

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29 Do you Understand How Your Health System Works? Sietse Wieringa 94 

30 The Transition from CME to CPD – Fostering Good 

Practice Through Education 

Francine Lemire 97 

31 Factors Associated with Adherence to Drug Therapy Annika Bardel 100 

32 Improving Practice Questionnaire - A Patient Feedback 

Tool 

Michael Greco 103 

33 Health Promotion in European Family Practice Ursula Reichenpfader 105 

34 How the UK Discovered Europe Justin Allen 108 

35 Health Needs Assessment Claire Collins 110 

36 The Balint Experience John Salinsky 113 

37 Environment and Health in Family Medicine Alan Abelsohn 115 

38 Mentoring - a Quality Approach to Professional 

Development 

Karen Bentley 118 

39 Pleasures of Doctoring in Family Medicine Andre Matalon 121 

40 Measuring Effectiveness in Family Medicine Teresa Pawlikowska 124 

41 The International Classification of Primary Care: a 

Success Story 

Jean Karl Soler 127 

42 Physician Heal Thyself and then the World Janet Christie-Seely 129 

43 Competency in Medical Record-Keeping David Bazzo 132 

44 The Health Needs of Hard to Reach Groups: Do We 

Know Enough? 

45 Is There Such a Thing as a Correct Diagnosis in Family 

Medicine? 

46 Family Medicine Facing the New Challenges at a Global 

Scale. 

Erika Zelko 135 

Tor Anvik 138 

Jan De Maeseneer 142 

47 The Educational Agenda Esra Saatchi 145 

48 Continuity in Primary Care Francesco Carelli 148 

49 Where Family Medicine Meets Public Health Francois Schellevis 151 

50 Stages of Behavioural Change – a Helpful Concept for 

Family Doctors? 

Norbert Donner-Banzhoff 154 

51 Future and Innovation in Family Medicine Carl Steylaerts 156 

52 Home Care at the Dawn of the 21st Century Elias Papazissis 160 

53 To Travel With Your Profession Is to Live and Learn Per Kallestrup 163 

54 Am I a Good Doctor? Hrvoje Tiljak 166 

55 Evidence-based Primary Care Through Guidelines Marjukka Makela 169 

56 Developing Skills for the Developed World Christos Lionis 172 

57 Gut Feelings as a Guide in the Diagnostic Reasoning of 

GPs 

Erik Stolper 174 

58 Family Medicine Miles Program Pablo Blasco 178 

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59 Improving the Prescribing of Antimicrobial Drugs in 

Primary Health Care 

Carl Llor 181 

60 Comprehensiveness and Continuity of Care Heinz-Harald Abholz 184 

61 Teaching Cross-Cultural Care Constantinou S. Costas 187 

62 How to Recruit and Select Your Future Colleagues? Monica Lindh 190 

63 Motivate Healthy Habits For Life: Coach Each to Change Rick Botelho 193 

64 An Ideal Training for the Future Career Patterns of 


Mark Rickenbach 197 

65 Burn Out and Family Practice Fatma Goksin Cihan 199 

66 Assessing Patient Satisfaction in Primary Health Care Risto Raivo 202 

67 Risk, Uncertainty and Indeterminacy in Clinical Decisions Roger Strand 205 

68 Do Practice Visits Have a Future? Pieter van den Hombergh 208 

69 Contribution of Drugs and Somnolence to Car Accidents 

with Victims 

Paul Moeremans 211 

70 Involve Patients With Doctors in Safety Improvement Isabelle Dupie 214 

71 The Optimal Practice Size Revisited – a Critical Appraisal 

of a Topical Discussion 

Chris van Weel 217 

72 Revisiting “Home Visits: Your Practice on the Road” Rita Viegas 220 

73 Re-training of Family Doctors: A EURACT Survey Fusun Yaris 223 

74 Primary Care Based Case-management Tobias Freund 226 

75 How Would Citizens Develop the Health Strategy of 

Their Country? 

François Héritier 229 

76 Drafting A Practice Professional Development Plan Alexandre Gouveia 232 

77 European Practice Assessment (EPA) Joachim Szecsenyi 235 

78 The Role of The Royal College of General Practitioners 

(UK) 

Nigel Mathers 239 

79 From Familygram to Personalised Medical Care Tonka Poplas-Susic 241 

80 The Growth of the Guideline Felicity Goodyear-Smith 244 

81 Developing Culturally Sensitive Services in Primary Care Victoria Tkachenko 247 

82 The MRCGP International - Developing a Truly 

Contextual Assessment 

John Howard 250 

83 Do we Practice what we Preach ? Judit Simon 253 

84 Helping Family Physicians in Managing Families With a 

Difficult Child 

Luc Lefebvre 256 

85 Family Systems Medicine Raluca Zoitanu 259 

86 Assessment of the Professional Attitude of Family 

Doctors 

Isabel Santos 262 

87 Family Medicine and Sustainability Giuseppe Maso 265 

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88 How to Build an Ideal Healthcare Information System? Ilkka Kunnamo 268 

89 Making Sense of Chronic Disease Merete Jorgensen 271 

90 A Practical Approach To Teaching Medical Students 

About Community Services 

Karen Flegg 273 

91 New Technologies to Support Family Doctors Berk Geroglu 277 

92 Patients' Rights and the Views of Family Doctors Maria Dolores Perez 280 

93 About Quaternary Prevention: First, do no harm. Marc Jamoulle 283 

94 War – Terrorism – Ethical Challenges and Family 

Physician Education 

Nazan Karaoglu 286 

95 Parents of a New-born Child with Severe Disabilities Anette Hauskov Graungaard 288 

96 Family Doctors' Career Towards Academic Level: Why 

and How 

Igor Svab 292 

97 A European Observatory for Primary Care Development Robert Glendenning 295 

98 New Era for Clinical Research in Primary Care Knut-Arne Wensaas 298 

99 Family Therapy Skills for Medical Practitioners Radkin Honzák 301 

100 What We Do Richard G Roberts 303 

Epilogue as Prologue Michael Kidd, Job Metsemakers 306 

Acknowledgements 307 

20 Years of WONCA Europe - Some History 308 

In close collaboration with our networks 

Vasco da Gama Movement 

7


Mehmet Ungan, MD 

mehmetungan@gmail.com 

Carl Steylaerts, MD 

carl.steylaerts@skynet.be 

Prologue 

Conceiving of a World Book of Family Medicine is easy. Actually making one is a lot harder. 

We started in 1995 and 20 years later, we present you this present in the present. 

It contains a lot of history and the roots for a lot of future plans. 

We leafed through 20 years of abstracts, including those presented at World Conferences, made a long list, selected a 

jury who then made a short list of 100 titles that best represented our job. During this process, it became obvious that 

we had selected mostly European titles, hence, this is the European Edition of the World Book. We do hope that other 

regions will follow, and also hope that a following generation will create The World Book of Family Medicine. Time will 

tell. 

In the process of finding the original authors, some were lost due to natural causes – death, illness, retirement. We 

then went to find body-doubles, and it will be no surprise that a lot of the youngsters of the Vasco da Gama Movement 

are authoring themes that were researched almost before they were born – offering a splendid proof that memory is a 

living organism that is constantly recreated and growing. 

We owe a lot to the 100 authors who finally drafted their 1000 words, selected take home messages and showed us 

the sources of their thoughts, with references. 

They were put under time pressure, some had to redraft, and then everything was being proofread by our outstanding 

Miss Naomi Uludamar. We owe her so much. 

All the authors joined us in a journey towards … a growing body of evidence that WONCA and WONCA Europe inspire, 

teach and learn. 

We show them our eternal gratitude and honour them. Thank you all! 

While editing this World Book, it became also obvious that there is no such thing as one kind of General Practice or 

Family Medicine. There is only a local answer to local needs. And though General Practice/Family medicine is mostly a 

clinical specialty, you will find none of this in this book. For then we should have taken 1000 titles. The chosen titles 

should be regarded as “generic”, applicable in every country – or at least most of them. 

This book is a starting point. 

WONCA (Europe) is the terrific place where knowledge about our field of experience, expertise and interest is 

exchanged. Youngsters come for a try out, PhD students lecture from their research, post docs idem, seasoned 

professors tell us their stories, and key note speakers from various fields come to inspire us. 

Hypes come, hypes go. Some stay, as evidence based medicine – not as a golden bullet, but as an enrichment. The past 

20 years brought us a lot of change and some of that wisdom changed our daily work. 

To be true, this book is about people. The people that we care for, our patients, and the people that we care for, our 

colleagues. The reason why we make the journey to the different places, mostly terrific as well, where the Conferences 

take place. The more you go to a conference, the less you learn, but the more people you get to know. And their 

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stories, which is why every Conference is a rich environment. 

Then bad news arrived. Soon after she finished her contribution, Professor Fusun Yaris died, a lost battle. A few weeks 

later, another author, Professor Janko Kersnik had an appointment with the Great Reaper as well. 

It makes us aware of our mortality. And the legacy that this book bears. 

The myth of Zeus and the birth of Athena comes to mind. A quantum of solace for us, earthlings. 

Fusun and Janko went early, we will follow one day. Theirs and ours and your energy however will not disappear. Our 

genes live in a trans-, inter- and intragenerational environment. 

And as we now know, both Darwin and Wallace were right. So it is important to keep digging for ideas, knowing that 

they will mutate and differentiate as well. 

It is in that great tradition of creating fora for exchanging ideas that we found the inspiration for this World Book. One 

author referred to the famous words of Margaret Mead: 

Never underestimate the power of a few committed people to change the world. Indeed it is the only thing that ever 

has. 

Take home messages 

The proof of the pudding however is in … the reading. 

We hope you enjoy this World Book – European Edition. 

And that we inspire others to follow and do even better. 

Ex Oriente Lux! 

Prof Mehmet Ungan, MD 

Professor of Family Medicine 

Editor 


Hon Treasurer WONCA Europe 

Co-Editor 

Istanbul, October 2015 

9


Andrée Rochfort, MD 

andree.rochfort@icgp.ie 

1 – Patient Empowerment for Patient Self-Management 

Wonca Europe 20th Anniversary Project 2015 

Andrée Rochfort, MD 

Project Leader: Patient 

Empowerment – Wonca Europe, 

Honorary Secretary EQuiP, 

Director of Quality Improvement, 

Irish College of General 

Practitioners, Dublin 

Project Partners: Tina Eriksson 

(DK), Ilkka Kunnamo (FI), Jochen 

Gensichen (DE), Project 

Manager: Claire Collins (IE) 

With thanks to members of the 

EQuiP Wonca Europe Network 

Patient Empowerment Group 

and thanks to Project Special 

Advisers: Ernesto Mola (IT), John 

Litt (AU) and Susan Smith (IE) 

At the European Council meeting of WONCA Europe in Warsaw in 2011, Patient 

Empowerment was adopted as the twelfth characteristic of general practice in the 

European definition of family medicine (FM) by WONCA Europe, and categorised 

within the core competency of person-centred care. Core competencies of the FP 

doctor mean competencies essential to the discipline, irrespective of the health care 

system in which they are applied. 

Fig 1 The WONCA TREE – as produced by the Swiss College of General Practitioners 

(Revised 2011) – Reprinted with permission 

WONCA Europe: The European Definitions of the Key Features of the 

Discipline of General Practice 2011 

The 2011 revision of the definition of FM gives recognition to the new dynamic 

between doctor and patient. As social values and healthcare systems continue to 

change, patients’ expectations are to make choices and decisions in keeping with their 

autonomy. This recent revision of the definition of FM gives the FP in Europe a new 

role to harness this patient autonomy and develop the expertise of patients in 

managing their own health and illnesses. 

Empowering patients is officially acknowledged as a responsibility of family medicine, which provides an appropriate 

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environment to promote patient empowerment for self-management of chronic conditions. 

In 2012 WONCA Europe sought to fund a project with the aim of having a lasting benefit for FM in Europe, and in order 

to prepare its report for the 20 th Anniversary of WONCA Europe in 2015. The successful bid was submitted by EQuiP, 

The European Society for Quality and Safety in family medicine, along with three project partners; the Irish College of 

General Practitioners, the Finnish Medical Society Duodecim, and the Department of Family Medicine at University of 

Jena, Germany. 

The project partners sought to explore one aspect of chronic disease management, namely, patient empowerment in 

self-management of chronic disease. The EQuiP group initially named the project PECC-WE; Patient Empowerment in 

Chronic Conditions - WONCA Europe, and the project was initiated with the definition of “patient empowerment” (PE) 

as defined in the European Journal of General Practice (EJGP) article by Ernesto Mola: 

Patient Empowerment is an educational process to help or support the patient 

to develop knowledge, skills, attitudes and self-awareness, 

and to assume effective responsibility for health-related decisions. 

Definition of Patient Empowerment (E. Mola, EJGP 2008) 

The value of investing in empowering patients to help themselves seems obvious; however the brainstorming sessions 

in our project research group revealed that we still have questions about which specific skills, attitudes and behaviours 

can be taught to primary care clinicians to promote positive patient behaviours and attitudes that improve patient 

outcomes in chronic conditions. The project partners agreed that the best use of project funds would be to explore 

whether the education of clinicians in FM to improve patient empowerment for self-management of chronic 

conditions would improve outcomes for patients compared to patients of clinicians who were not educated in that 

particular skill. 

The WONCA Anniversary Project 2015 

The role of the family physician (FP) has changed over the last twenty years. Patients’ attitudes to health and 

healthcare have also changed. The revision of the European definition of general practice is a response to these 

changes. 

Patients are more informed now and have access to the same sources of information as medical doctors. Patients in 

2015 are less likely to be passive recipients of healthcare and are more likely to have expectations and demands that 

reflect the psychology of consumer-based societies. 21 st century patients expect to receive high quality, safe care. 

However, as all members of society are either patients or potential patients, there is an obligation on all citizens to 

participate in their care and actively manage their own lifestyle factors for optimum health. 

Once established, chronic diseases are by definition not curable. Multimorbidity and polypharmacy are escalating as 

people live longer with chronic conditions. Public services funded by taxpayers and privately funded healthcare 

services, voluntary organisations and charities all contribute finance and other resources towards the management of 

chronic conditions. These challenges of healthcare provision are intensifying as costs, demands and expectations are 

apparently infinite, while resources remain finite. 

Our research shows that one path for assisting patients to improve their health outcomes is through primary care 

health professionals who are educated and trained in the skills of motivation, goal setting and communication skills 

appropriate for change management. 

There are of course many pathways to patient empowerment, and several factors influence patients’ motivation and 

capacity for self-management. We have evidence that patient self-management has a positive impact on health 

outcome, though we must acknowledge that incorporating self-management support in routine healthcare is in itself 

challenging. 

In conclusion 

There are a number of findings of this project which will be formally presented at the WONCA Europe Conference in 

Istanbul, 2015. These include the systematic review report, the online educational tool for health professionals and its 

evaluation, and the launch of an online hub of resources on patient self-management for health professionals, patients 

and those who care for them. 

Our research findings can be regarded as a successful starting point for primary care-based multidisciplinary 

interventions with capacity to implement quality improvement in management of chronic conditions for the benefit of 

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both patients (improved self-efficacy and better outcomes), and for health professionals (improved self-efficacy and 

job satisfaction). 

The future post 2015 

This project will add to the growing evidence-base for integrating patient self-management into routine healthcare. In 

general practice we recognise the need to intervene earlier, even before chronic disease is established, when the 

person has risk factors like smoking, alcohol consumption, obesity, or cardiovascular risk due to a combination of 

several moderate risk factors. 

We hope this will prompt a fresh multifaceted interest in managing lifestyle risk factors for chronic disease in European 

general practice / family medicine, to reappraise our various models of chronic condition management and to ensure 

best practice models are disseminated. 

Exploring this complex topic has highlighted global issues which have an impact at grass roots level in routine general 

practice / family medicine. It would be encouraging to see GP/FP from all WONCA regions collaborate to develop a 

global team player approach in addressing the important role of the patient in determining their own health 

outcomes. 


 

 

 

Patients have capacity to improve their own health through patient self-management. 

Patient empowerment for self-management is a core element of patient-centred care. 

Primary care health professionals with training in patient self-management support can help to empower 

patients for change. 

References 

 

 

 

 

 

THE EUROPEAN DEFINITIONS of The Key Features of the Discipline of General Practice, 

The Role of the General Practitioner and a description of the Core Competencies of the General Practitioner / Family 

Physician. Revised in 2011 by a Commission of the WONCA European Council led by Dr Ernesto Mola and Dr Tina 

Eriksson. http://www.woncaeurope.org/sites/default/files/documents/Definition%203rd%20ed%202011%20with 

%20revised%20wonca%20tree.pdf 

M Battersby et al Twelve Evidence-Based Principles for Implementing Self-Management Support in Primary Care. The 

Joint Commission Journal on Quality and Patient Safety. December 2010 Volume 36 Number 12. 

Mola Ernesto, Judith A De Bonis, Raffaele Giancane, Integrating patient empowerment as an essential characteristic of 

the discipline of general practice/family medicine. European Journal of General Practice. 2008, Vol. 14, No. 2, pp 89-94 

http://informahealthcare.com/doi/full/10.1080/13814780802423463 

An De Sutter, Jan De Maeseneer, Pauline Boeckxstaens. Empowering patients to determine their own health goals. 

Editorial. European Journal of General Practice. 2013; 19: 75–76 

Patient Empowerment in Chronic Conditions, 20th Anniversary project 2015. www.woncaeurope.org 

12


Michael Jones, MB, ChB 

jomijones@netspace.net.au 

2 – Communicating with Patients 

Michael Jones, MB, ChB 

Retired, Darlington, WA – 

Australia 

Patients want: 

 

 

 

 

Factual, authoritative 

information 

Both sides of the story 

Language they can 

understand 

Advice they can follow 

Using the newsletter: 

1. Hand it to patients 

2. Keep it topical 

3. Include personal bits 

and pieces 

This presentation, from Western Australian GP Dr Michael Jones, was aimed at 

encouraging GPs to use a practice newsletter. The talk illustrated the benefits, to both 

patients and doctors, of using this form of communication. The speaker reminded the 

audience that “doctor” used to mean “teacher” and that GPs need to focus on their 

role as educators about health, as well as dealing with the specific issues raised at any 

given consultation. 

In 1991, frustrated by some of his patients making unwise decisions based on what 

they had read in the popular media, or seen on TV, Dr Jones decided to produce a 

newsletter for the patients of his practice. The purpose of the newsletter would be to 

give patients accurate information on topical medical issues, remind them about 

preventative health matters, and give general advice about nutrition and other 

health-related topics. At the same time, the newsletter would keep them informed 

about current activities in the practice, such as details of new doctors, practice 

policies, staff leave, etc. 

He rapidly realised the enormity of this task and hit on the idea of producing a 

‘generic’ newsletter which could then be personalised for individual subscribing 

doctors or practices. As a result, the concept of the practice newsletter ‘Your Doctor’ 

was born. 

With the help of an experienced journalist, Dr Jones 

produced the first edition in February 1992. It is a 

monthly 4 page A4 newsletter (one page of A3 paper 

folded once) with articles of general medical interest, 

plus reminders about preventive health measures 

such as pap smears, mammograms and 

immunisations. One segment – Good Health on the 

Menu – contains nutritional advice plus a recipe 

relevant to that month’s topic. 

Doctors need to: 

Improve their business 

Areas on the front and back pages are left blank in 

the initial print run and then overprinted with information provided by the individual 

subscribing practice. Practices pay a fee which depends upon the number of copies 

required. The practice can change the content of its personalised section each month 

at no extra cost. The concept was promoted to GPs as a useful tool, benefitting both 

patients and doctors. Patients benefit from getting reliable information from a source 

they trust – their family doctor. 

Doctors benefit because in the competitive small-business environment of Australian 

general practice, where patients are free to see GPs from any practice, patient loyalty 

is critical for financial survival. Patients appreciate their doctor doing that little-bitextra 

to keep them informed and healthy. 

The presentation demonstrated the often sensational, out-of-perspective, manner in 

 

 

 

Show that they care 

Tell patients about 

themselves and the 

services they provide 

Make patients feel they 

‘belong’ 

13


which the popular media broadcasts medical information. This may lead to patients making unwise decisions such as 

stopping their medication through fear of highly publicised (although rare) side-effects. 

Dr Jones reported on positive feedback from patients, including a lady in Victoria who had read an article about 

angina, recognised her symptoms, saw the GP and soon after had a triple coronary by-pass operation. She wrote and 

thanked her GP for “writing the article that saved my life”. 

He also emphasised the importance of doctors including some personal information in the practice-specific segment. 

This shows their human side, which patients like. When, in his own practice’s newsletter, he advised readers that he 

would be away for a month, as he was going to the UK for his mother’s 80 th birthday, numerous patients got in touch to 

wish her well, despite never having met her. 

Another tip was for doctors to keep the newsletter on 

their desk and personally hand it to patients saying 

“have you had this month’s newsletter?” or similar, 

rather than leaving it among the piles of other helpyourself 

brochures in the waiting room. Research shows 

that people are more likely to read something when it is 

given to them personally by a doctor. Dr Jones told of a 

patient coming to the reception desk and saying “I don’t 

need to see the doctor, but is this month’s newsletter 

out yet?”. 

In 1994 the Australian government introduced an 

accreditation scheme for general practices. One of the 

criteria for accreditation was that the practice should 

have a patient-information brochure. ‘Your Doctor’ was 

approved as a suitable means of meeting that 

requirement. 

The initiative has proved to be a great success. By the 

end of 2004 it had been used in over 700 Australian 

general practices, plus practices in New Zealand, Hong 

Kong and Fiji. The annual print run was about one 

million copies. 

Original Abstract 

http://www.woncaeurope.org/content/76-pacommunicating-patients 

Figure 1 The first edition of Your Doctor was 

produced in February 1992. My 2004 it had been 

used in more than 700 practices with an annual print 

run of almost one million copies. 

14


Manfred Maier, MD 

manfred.maier@meduniwien.ac.at 

3 – Ethical Dilemmas in Family Medicine - a Workshop 

Manfred Maier, MD 

Professor, Chairman, Dept. 

General Practice, Vienna, 

Austria; Convener of the WONCA 

Working Party on Ethical Issues 

Background 

At the WONCA Europe Conference 2000 in Vienna, Austria, the programme included 

a special symposium entitled “challenges to our professional attitudes- past and 

present”. This full day symposium covered areas and time periods from the past to 

the present where the medical profession in general or individual colleagues have 

been or were involved in developments based on unique political situations: the 

Holocaust in Europe, the Apartheid in South Africa, torture of prisoners in areas of 

war or the death penalty in the United States. Experts and eyewitnesses of these 

developments gave stunning insight into the circumstances whereby physicians could 

get involved and sometimes were even eager to do so. 

This symposium attracted a full auditorium and resulted in the founding of a Special 

Interest Group (SIG) on ethical issues in Family Medicine by WONCA. In 2002 the 

group gathered to formulate the terms of reference: “to attempt to illustrate the 

nature of ethical issues encountered by WONCA and its members and to explore the 

principles, values and beliefs which inform decisions”. Thus, the aims of SIG were 

formulated: 

1. To identify common principles of ethical dilemmas 

2. To consider circumstances which favour the development of ethical dilemmas 

3. To raise awareness about ways to solve some of these ethical dilemmas 

4. To develop an instrument useful to assess professional attitudes 

Since that time, the proceedings of the special symposium from WONCA Europe 

Vienna 2000 have been published (1); a list of interested colleagues has been 

established and the group has tried to identify Family Doctor's working groups on 

ethical issues around the globe. In addition, the group has reviewed the teaching 

situation for professional attitudes worldwide, has introduced a forum for discussion 

on ethical issues and tries to motivate colleagues to initiate similar activities in their 

associations or back in their home country. These activities are promoted at almost 

every WONCA Europe conference and all WONCA World conferences by organizing a 

workshop on “ethical dilemmas in FM” and a special symposium on “challenges to our 

professional attitudes” addressing selected topics such as inequalities in health, 

conflicts of interests, end of life care, electronic health records, etc. 

So far, the activities of the group, which became a Working Party (2) at the WONCA 

World conference 2010, have attracted a very interested crowd - at times it has been 

difficult to accommodate all participants in the room provided! 

The Workshop 

In the workshop, practical situations involving regularly occurring ethical dilemmas in Family Medicine are presented 

15


and their background and possible consequences for the patient, his/her family and the physician are discussed. 

Typically, the group work starts with short presentations by the workshop participants, demonstrating situations 

involving ethical dilemmas. 

The participants then select 3-4 situations out of those presented, split into small groups and discuss the following 

issues: 

1. The patient’s history and other factors, which resulted in the development of the particular ethical problem 

presented 

2. The possible consequences of the situation for the patient and the physician 

3. Possible solutions 

4. What are the basic ethical principles demonstrated and challenged by this situation? 

The aim of this workshop is to increase awareness in ethical standards, attitudes and global differences in the legal 

context of clinical practice applicable to future medical graduates and Family Doctors. Here are a few examples of the 

difficult situations presented: 

 

 

 

 

 

 

Both a woman and her husband are patients with the same family doctor. The woman receives Diazepam for 

anxiety and depression due to metastatic breast cancer; her husband is in early retirement and in a 

consultation with his Family Doctor complains about his sleepiness. Previously, the woman told the Family 

Doctor that in the evening she puts some of her pills into her husband's wine so that he would not sexually 

approach her. 

A patient with a haemoglobin level of 2.4 refuses both diagnostic procedures and therapy suggested by his 

Family Doctor. 

A sixteen year old boy suffers from heavy injuries and tetraplegia after a car accident; it turns out that he had 

too much alcohol in his blood. His father requests the Family Doctor to delete this information from the 

medical record for reasons of disability insurance coverage. 

A 54 year old woman with diabetes and diabetic nephropathy needs kidney transplantation. According to the 

legal situation she is not entitled for a kidney transplant in her country. However, for a large fee, she is offered 

the kidney of a prisoner in China who is facing the death penalty. She approaches her Family Doctor for 

advice. 

An elderly lady first refuses diagnostic clarification and therapy of her hip fracture; a few days later she agrees 

with the suggestion by her Family Doctor to be treated in the hospital and dies there following surgery. The 

Family Doctor feels guilty. 

In a given country, influenza vaccination at the Family Doctor-level is obligatory for every citizen and those 

who refuse are punished with a 400 Euro fine; moreover, Family Doctors are legally obliged to report every 

patient who refuses to comply. 

Among the questions quite often discussed and exchanged among participants are those related to the respective 

health care system, the respective legal framework, the needs and demands of patients in the country concerned, the 

expectations of patients and society, conflicts of interest, options for support and advice in these situations, the need 

for efficient communication, how to react in the particular situation, etc. Finally, the principles and responsibilities of 

medical professionalism (3) such as the principle of respect of patients´ autonomy, priority of patients’ welfare and of 

promoting social justice and equity are identified and their value and possible discrepancies in political or market 

reality are discussed. Despite these principles and guidelines however, the family doctor is more often than not alone 

in his/her decision regarding an individual situation. 

The WP on ethical issues in FM plans to raise awareness of the importance of professional attitudes at every level of 

medical education and training and supports the idea to establish Family Medicine as the leading discipline in teaching 

medical ethics/professional attitudes to students and colleagues. 

This will be accomplished through promoting widespread dialogue within the profession, initiating and supporting 

research and disseminating information throughout the WONCA community, the international academic community, 

healthcare organisations and government agencies. 

Take Home Messages 

16

The WP workshops on Ethics described aims to: 

 

 

 


identify common principles of ethical dilemmas as they occur in daily practice 

discuss circumstances which favour their development 

to raise awareness about ways to solve and prevent some of these ethical dilemmas 


http://www.woncaeurope.org/content/192-ethical-dilemmas-general-practice-workshop 

References 

 

 

 

Kochen M, Rebhandl E, Maier M; Challenges to our Professional Attitudes- past and present. 

Verlag der Österreichischen Ärztekammer, 2001, ISBN 3-901488-22-7 

http://www.globalfamilydoctor.com/groups/WorkingParties/EthicalIssues.aspx 

Medical professionalism in the new millennium: a physicians' charter. 

Medical Professionalism Project; The Lancet 2002, 359, Issue 9305: 520-522 

(DOI: 10.1016/S0140-6736(02)07684-5) 

17


Lucy M. Candib, MD 

lcandib@massmed.org 

4 – Health Consequences of Emotional, Physical, and Sexual Abuse 

Lucy M. Candib, MD 1, 

W. Perry Dickinson, MD 2, 

Pamela McMahon, PhD, MPH 3 

1 Family Health Center of 

Worcester and University of 

Massachusetts Medical School, 

Department of Family and 

Community Medicine, Worcester, 

MA 

2 University Colorado School of 

Medicine, Department of Family 

Medicine, Aurora, CO 

3 Our Lady of the Lake Regional 

Medical Center, Pediatrics 

Residency Program, Baton 

Rouge, LA 

Abuse is widespread across all ethnic, cultural, and socio-economic groups. In the US 

population, 30 - 40% of adults report some type of abuse during childhood. Different 

forms of abuse often co-occur. Rates of abuse in other countries are variable, but 

comparable. Clinicians who believe abuse does not occur in their patients are just not 

looking for it. 

Childhood Abuse – Mental Health Impact 

A history of childhood abuse correlates strongly with mental health symptoms. A 

dose-response effect exists between multiple types and severity of abuse with 

magnitude of symptoms, and number of diagnoses. Post-traumatic stress disorder 

(PTSD) is extremely common in victims of abuse; symptoms may persist for years. 

Complex PTSD in response to multiple severe traumas combines prolonged symptoms 

of PTSD with those of other psychological conditions. Anxiety disorders, various 

eating disorders, and repeated episodes of major depression are common sequelae. 

Survivors also suffer from difficulty with relationships and trust, long-standing shame 

and guilt, poor self-esteem, and anger. Dissociative identity disorder is also a potential 

outcome when a young child experiences multiple severe abusive episodes for which 

adult memories may be elusive. In this condition, a more complex walling off of 

memories of abuse allows the person to develop more normally, free from memories 

of the abuse, although the boundaries between memories often start breaking down 

later in life. While controversial, the syndrome clearly exists and is more common 

than generally recognized. 

Long Term Physical Health Effects of Sexual and Physical Violence 

hepatitis or jaundice (OR=2.4). 

Abuse survivors commonly experience multiple physical symptoms, especially 

abdominal and pelvic pain, genitourinary symptoms, fatigue, and headaches. 

Although medical conditions may explain some symptoms, many remain unexplained 

despite extensive evaluations. Whenever studied, women with unexplained 

symptoms often give a history of childhood and/or adulthood physical and sexual 

abuse, and women with sexual symptoms are likely to have a history of sexual abuse 

or assault. 

The Adverse Childhood Exposure Study found that adverse childhood experiences 

(including physical and sexual abuse and witnessing abuse of a parent) were strongly 

interrelated and that the number of categories of adverse exposures had a graded 

relationship to later adult diseases, including ischaemic heart disease, cancer, chronic 

lung disease, skeletal fractures, and liver disease. Diseases associated with four or 

more categories of exposures included ischaemic heart disease (OR=2.2), cancer 

(OR=1.9), stroke (OR=2.4), COPD (OR=3.9), diabetes (OR=1.6), fracture (OR=1.6), and 

18


Application of the strictly medical model to abuse survivors with chronic abdominal and/or pelvic pain, gastrointestinal 

symptoms, and dyspareunia may lead to multiple investigations and surgeries. Such painful, costly, and often revictimizing 

interventions can lead to complications, including adhesions and more chronic pain. Since previously 

abused women are more likely to be overweight, smoke, drink, use drugs, engage in risky sexual behaviours, and not 

get pap smears, they also are more prone to sexually transmitted disease, HIV/AIDS, unintended pregnancies, and 

various chronic diseases. Violence tends to perpetuate itself with repeating patterns in subsequent generations. 

Mothers with childhood or adult abuse experiences may be less able to protect their daughters from an abuser. 

Helping patients to break such patterns is challenging, and most physicians are not trained, skilled, or comfortable in 

identifying and assisting with survivors of abuse. 

Identification and Management 

Victims of abuse seldom volunteer information about their abuse to clinicians but are generally willing to talk about 

their abuse histories when asked directly. Building trust before asking questions will enable patients to disclose abuse, 

even on a first visit, if asked in an appropriate manner. Using the “generalized other” technique can facilitate the 

inquiry, i.e., “Many of my patients have been threatened or hurt by others, as children or adults. Did anything like this 

ever happen to you?” If the patient answers yes, establishing safety for the patient and any children still vulnerable to 

the abuser is crucial. Another approach is to ask about abuse as part of the standard review of systems or as part of 

family history. Asking about a family history of alcohol and drug abuse can lead easily into questions about physical 

abuse of the patient and family members, followed by a question about sexual abuse. A subsequent question might 

be, “Since then has anyone ever tried to or made you have sex when you didn’t want to?” Another screening strategy 

is to ask the patient about to disrobe, “Is any part of this exam difficult for you?” - enabling disclosure before the 

vulnerability of being undressed. 

Clinicians should ask these questions when they have time to listen and respond appropriately. When adequate time is 

not immediately available, the clinician should schedule early follow-up, indicating the importance of prior abuse to 

the patient’s medical care. Empathy is critical. The clinician must state that the abuse was not the patient’s fault and 

should never have happened. Discussing abuse with a supportive clinician can be very therapeutic, but referral to 

counselling with a therapist skilled with abuse survivors is often the best approach when the patient is ready. In the 

meantime, the clinician should explore how the patient would feel most safe and comfortable receiving medical care. 

Clinicians need to consider the abuse history in the patient’s ongoing management, allowing survivors control over the 

timing and conduct of referrals and investigations. A complex, necessary task is helping survivors make the connection 

between the abuse and their physical and emotional problems, while not implying that symptoms are “all in their 

head.” Another task is acknowledging how ordinary health care can be frightening for abuse survivors; that exams and 

procedures considered part of routine care can easily re-traumatize them. Careful explanations and explicit consent for 

each aspect of disrobing and touch are critical. Because betrayal of trust is often a key source of trauma for abuse 

survivors, clinicians must continuously demonstrate honesty and trustworthiness for these clinical relationships to 

succeed. Giving patients control through attention to safety, and always allowing the patient accompaniment by a 

chosen safe person can facilitate the conduct of necessary and potentially empowering health care. 

Take Home messages 

 

 

 

 

 

Abuse survivors commonly experience physical and psychological symptoms and syndromes. 

The only way to find out if a patient has been abused is to ask. 

Always affirm that the abuse was not the patient’s fault and should never have happened. 

Recognize that ordinary health care can be frightening for abuse survivors. 

Allow patients the maximum possible safety and control. 

Original abstract 

http://www.woncaeurope.org/content/4376-health-consequences-emotional-physical-and-sexual-abuse 

References 

1. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al. The relationship of adult health 

status to childhood abuse and household dysfunction. American Journal of Preventive Medicine. 1998; 14:245-258. 

19


2. Finkelhor D, Browne A. The Traumatic Impact of Child Sexual Abuse: A Conceptualization. American Journal of 

Orthopsychiatry 1985;55:530-41. 

3. Gallo-Silver L, Anderson CM, Romo J. Best clinical practices for male adult survivors of childhood sexual abuse: “Do no 

harm.” Perm J 2014 Summer;18(3):82-7. DOI: http://dx.doi.org/10.7812/TPP/14-009. 

4. Lacelle C, Hebert M, Lavoie F, Vitaro F, & Tremblay RE. (2012). Child sexual abuse and women’s sexual health: The 

contribution of CSA severity and exposure to multiple forms of childhood victimization. Journal of Child Sexual Abuse, 21, 

571–592. 

5. Leeners B, Stiller R, Block E, Görres G, Imthurn B, Rath W. Effect of childhood sexual abuse on gynecologic care as an adult. 

Psychosomatics 2007 Sep-Oct;48(5):385-93. DOI: http://dx.doi.org/10.1176/appi.psy.48.5.385. 

6. Leserman, J, Li, Z, Drossman, DA, & Hu, YJB. (1998). Selected symptoms associated with sexual and physical abuse history 

among female patients with gastrointestinal disorders: The impact on subsequent health care visits. Psychological 

Medicine, 28(2), 417-425. 

7. Raposo SM, Mackenzie CS, Henriksen CA, Afifi, TO. (2014). Time Does Not Heal All Wounds: Older Adults Who 

Experienced Childhood Adversities Have Higher Odds of Mood, Anxiety, and Personality Disorders. Am J Geriatr Psychiatry 

22, 1241-1250. 

8. Sugaya L, Hasin, DS, Olfson M, Lin K-H, Grant BF, & Blanco C. (2012). Child Physical Abuse and Adult Mental Health: A 

National Study. Journal of Traumatic Stress. 25, 384–392. 

© Isha Mehmood on Flickr 

2009 AP Fellow. Location: Kathmandu, Nepal. Partner: IANSA/ SAP-Nepal 

20


Zekeriya Akturk, MD 

zekeriya.akturk@gmail.com 

Education 

5 – The Role of Family Medicine in Undergraduate Medical 

Zekeriya AKTÜRK 1, 

Turan SET 2, Kenan TAŞTAN 1, 

Nezih DAĞDEVİREN 3, 

Erkan Melih ŞAHİN 4, 

Cahit ÖZER 5 

Affiliations - Formerly: 

Trakya University Faculty of 

Medicine, Department of FM 

Currently: 

1 Atatürk University Faculty of 


2 Karadeniz Technical University 

Faculty of Medicine, Department 

of FM 

3 Trakya University Faculty of 


4 Çanakkale 19 Mart University 


of FM 

5 Mustafa Kemal University 


of FM 

Introduction 

General practice / family medicine (GP/FM) is defined as “an academic and scientific 

discipline, with its own educational content, research, evidence base and clinical 

activity, and a clinical speciality orientated to primary care”. Although primary care is 

widely perceived to be the backbone of a rational health services system, medical 

education is widely based on disciplines other than family medicine. There is a 

discrepancy between the place of practice of medical graduates and the place where 

medical education is based: despite nearly 60% of the medical graduates being 

employed there, only less than 10% of the training happens in primary care facilities 

(Figure 1). 

Figure 1: The mismatch in the balance between education and practice platforms. 

Aim 

The aim of this paper is to describe the potential contribution of family 

medicine/general practice to undergraduate medical education (UME). 

The Past: During the early days of the discipline, it was discussed and suggested that 

family medicine should contribute to UME. However, it was not an easy task. There 

were even arguments that general practice is not 'scientific'. In Turkey, we had to wait 

more than another 20 years to see family medicine engaged in UME: in 2001 there 

were only seven actively lecturing family practice departments throughout 47 medical 

faculties (15%). That same year, Trakya University commenced UME of class one 

medical students with objectives such as “to teach the principles of primary 

healthcare, and basic procedures used in medical practice”. 

The Present: Over time, the contribution of family medicine to UME increased 

significantly. The discipline improved in all areas including service provision, 

management, research, and educational content. Today, almost 90% of European 

universities have GP/FM curriculum, the duration of clinical rotations ranging from 1 

to 12 weeks. In Turkey 55/83 medical schools (66%) have a GP/FM curriculum. 

Some of the authors of this article joined a one-day workshop 

(http://www.ktu.edu.tr/dosyalar/17_02_15_769b1.pdf) where participants presented 

21


a literature review on the curricula of different schools. A summary of the suggested family medicine content was 

presented at the end of the workshop. As a result, the authors suggested family medicine should be taught during all 

three years of the pre-clinical phase in the six-year medical education as well as throughout the internship period 

(Table 1). 

Table 1. Topics suggested to teach for undergraduate medical education. 

Lecture name 

Topics 

Basics of family medicine 1 1. Clinical case presentation 1 

2. Primary care medicine 1 

3. Internationalization 

4. Continuous professional development 

5. Time management 

6. The effects of family on health 

7. The family life cycle 

8. Genograms 1 

9. Quality in health care 

10. Basic quality improvement tools 

11. Observation of hospital departments 

12. Effective communication and body language 1 

13. Definition and basic features of family medicine 

14. Oral health 1 

15. Humanities in medicine 

16. Science philosophy 

Basics of family medicine 2 1. Primary care medicine 2 

2. Morbidity patterns in family medicine 

3. Genograms 2 

4. Clinical case presentation 2 

5. Contextual care 

6. Comprehensive care 

7. Continuous care 

8. Coordination of care 

9. Access to care 


11. Patient empowerment 

12. Patient adherence 

13. Medical malpractice 1 

14. Home accidents 

15. Professionalism 

16. Behavioural change 1 

17. First contact with the hospitalized patient 

Clinical family medicine 1. The biopsychosocial approach 

2. Consultation and referral 


4. Patient education 

22


5. Behavioural change 3 

6. Adolescent health 

7. Care of the elderly 

8. Simulation of common health problems 

9. Health life styles counselling 1 

10. Breaking bad news 

11. Periodic health care 

12. Periodic health care guidelines 

13. Integrative medicine 1 

14. Domestic violence 

15. Pre-conceptional care 

16. Pregnancy follow up in family practice 

17. Healthy child follow up in family practice 

18. Social responsibility projects 

19. Care of the disabled person 

20. Equity in health care 

21. Patient interview and clinical examination 

Family practice application 1. Medical records 

2. Medical malpractice 2 

3. Legal responsibilities of the health personnel 

4. Forensic medicine services in family practice 

5. Sick leave in family practice 

6. Low prevalence medicine 

7. Evidence based medicine 

8. Coding in medicine 

9. Health life styles counselling 2 

10. Integrative medicine 2 

11. Management of co-morbid conditions 

12. Polypharmacy 

13. Medical literature review and guidelines 

14. Laboratory use in family practice 

15. Obesity follow up 

16. Home visits and home care 

17. Pregnancy follow up in family practice 

18. Rational prescription 

19. ECG reading in family practice 

20. Direct chest X-rays in family practice 

21. Oral health 2 

22. Rural medicine 

23. Family practice in extraordinary conditions and disaster medicine 

24. Payment systems, insurance organizations and family practice 

25. Community oriented family practice 

26. Community based medical education 

27. Duties of family physicians and family practice management 

23

Conclusion 


UME curriculum should be composed of topics predominantly related to primary and thus preventive health care 

services. However, it takes time for this fact to become a reality in its application within the UME. Over the last 40 

years, there has been an extended gap in the discipline, and the recent developments and improvements are 

promising for the future. We believe that the WONCA working parties 

(http://www.globalfamilydoctor.com/groups.aspx) have contributed much to this success. Of special value are the 

activities of EURACT (www.euract.eu/) and EGPRN (www.egprn.org). Improvements are especially remarkable in the 

number of academic departments and staff. However, most of the contributions so far are via lecturing and interactive 

teaching inside the medical school facilities. Family medicine is a comparatively new medical speciality, but it is 

probably the oldest medical discipline. Hence, there is still a long way to go to involve clinical family practice in UME. 


 

 

 

 

 

Although most medical graduates practice in primary care, most of the training is based in hospital settings. 

Even in the earliest documents of family medicine it was suggested that family medicine should be included in 

undergraduate medical education. 

Today almost 90% of European universities have a GP / FM curriculum, the duration of clinical rotations 

ranging from 1-12 weeks. 

Being a relatively new medical speciality, but probably the oldest medical discipline, family medicine should 

play a much greater part in undergraduate medical education. 

We suggest family medicine play a part in all preclinical phases plus the internship period of the 

undergraduate medical education. 


http://www.woncaeurope.org/content/63-role-family-practice-undergraduate-medical-education-experiences-trakya-university 

References 

Allen J, Gay B, Crebolder H, Heyrman J, Svab I, Ram P. The European Definition of General Practice/Family Medicine. 

Barcelona: 2011. 

Starfield B. Is primary care essential? The Lancet. 1994;344(8930):1129-33. 

Aktürk Z, Dağdeviren N, Şahin EM, Özer C, editors. The Role Of Family Practice in Undergraduate Medical Education - 

Experiences at Trakya University Medical Faculty. The 2001 Conference of the European Society of General Practice/Family 

Medicine; 2001; Tampere. 

Haviland JW. Implementing the Report of the Citizens Commission on Graduate Medical Education. Jama. 1969 Dec 

8;210(10):1902-5. PubMed PMID: 4390945. 

Wright HJ. The contribution of general practice to undergraduate medical education. The Journal of the Royal College of 

General Practitioners. 1973 Aug;23(133):531-8. PubMed PMID: 4785745. Pubmed Central PMCID: 2157174. 

Brekke M, Carelli F, Zarbailov N, Javashvili G, Wilm S, Timonen M, et al. Undergraduate medical education in general 

practice/family medicine throughout Europe - a descriptive study. BMC medical education. 2013;13:157. PubMed PMID: 

24289459. Pubmed Central PMCID: 4220558. 

Ünlüoğlu İ. Aile hekimliği disiplininde akademik yükselmeler ve doçentlik sınavları. Turkish Journal of Family Practice. 

2013;17(3):137-41. 

Saultz J. Around the kitchen table. Family medicine. 2014 Jan;46(1):61-3. PubMed PMID: 24415512. 

24


Jessica Watson, MBChB, DRCOG, DCH, DFSRH 

Jessica.Watson@bristol.ac.uk 

6 – Developing National Curricula for the Education and Training of 

Family Doctors 

Dr Jessica Watson, MBChB, 

DRCOG, DCH, DFSRH 

Academic Clinical Fellow 

School of Social and Community 

Medicine 

University of Bristol 

As a GP trainee, I sometimes feel like an endangered species. Many of my peers from 

medical school have chosen hospital specialties, and non-medical friends find it hard 

to understand that I have chosen to be ‘just a GP’. Across Europe the proportion of 

doctors who train as specialists is rising (1). In the press General Practitioners face 

regular denigration, even from some specialist colleagues in hospital who have 

warned that ‘GPs are part of the NHS’s problem, not the solution’ (2). Yet the evidence 

suggests the opposite, that countries with strong primary care infrastructures have 

healthier populations, reduced health inequalities and greater cost-effectiveness 

(Starfield et al 2005). As a result, in 2008 Iona Health called for ‘A GP for every person 

in the world’ (3, 4). Yet before this can be achieved we need high quality general 

practice training schemes for every country in the world. 

Currently, even in Europe, general practice training varies considerably, and not all 

countries require a qualification in family medicine to work as a family doctor (4). In 

order to achieve improved training in family medicine for all, we should be looking at 

what already works, in countries with well-established training, using an evidencebased 

approach. 

WONCA provides an ideal forum for sharing innovation, knowledge and experience 

and at the annual Vasco da Gama preconference for new and future GPs, the topic of 

training is regularly discussed. Enthusiasts debate the relative merits and 

disadvantages of their countries’ training systems, highlighting areas for 

improvement. How can this shared learning and communal knowledge be captured, 

drawn out and used to benefit training throughout and beyond Europe? 

Various initiatives to compare training schemes in Europe have grown already from 

WONCA conferences. One initiative from EURACT was to develop a dynamic 

interactive database with information enabling comparisons between training 

schemes throughout Europe (2). Another approach which grew from the grassroot 

enthusiasm of trainees themselves was to create a motivation and satisfaction 

questionnaire, with the aim of exploring differences in motivation, satisfaction and 

workload across these very different vocational training schemes of Europe (5). 

Results showed high levels of satisfaction amongst family medicine trainees, and 

demonstrated that ‘positive’ motivators such as ‘challenging medically broad 

discipline’ are the main reasons for a career choice in family medicine. ‘Negative’ 

motivators such as ‘it remained after I ruled out other options’, ‘non availability of 

another specialty training’ and ‘did not get specialty training because of my grades’ 

were chosen by a minority, challenging some negative preconceptions of family 

medicine. 

Other more formal work arising from WONCA Europe has been highly influential in 

the development of family medicine training, such as the European Definition of 

Family Medicine (5), which describes the core competencies of family doctors. This 

25


has been used in negotiations with policymakers, educators, media and physicians, and formed the basis of national 

family practice curricula such as the UK Royal College of General Practitioners GP curriculum. Following on from this, 

more recently the WONCA Working Party on Education has produced WONCA global standards for postgraduate family 

medicine education (6), which will provide further thrust to drive quality improvement, new program development 

and recognition of family medicine training globally. 

However there is a balance and equipoise to be reached in the efforts to develop global standards and curricula, which 

need to be comprehensive enough to be relevant to all family doctors, without producing overly burdensome 

bureaucracy, which may hinder rather than help learning. 

So what about Alternative Blue Sky Thinking, to Help the Development of Family Medicine 

Training? 

A thought experiment by Bernard Lietaer, a professor of economics, might suggest an option (8). The slogan would 

then be “to master your topic, you should teach it”. This means that everybody becomes a student as well as a teacher, 

an apprenticeship model running right through from graduation to retirement. At entry to family medicine specialty 

training (after 6+ years of basic medical education) every doctor would be given a sum of 1000 Sabers. For 1 Saber you 

can buy one hour of teaching or coaching by an elder colleague. The elder colleague can only get Sabers by teaching or 

coaching. After 3 years, the time of getting a Master degree, there is an appraisal by a senior assessor. If you can pass 

this appraisal and demonstrate that you have earned 1000 Saber, you are rewarded with time and money. You get a 

sabbatical leave of 3 months and the money you would normally get in those 3 months. An extra free month a year. 

Every year. 

If it seems hard to imagine how this could be implemented in countries with well established training then imagine 

how this sort of cascade effect might be beneficial in countries without well established family medicine training in 

place. In these countries an educational voucher system could set in motion a ‘learning multiplier’, providing 

educational opportunities despite a lack of available funds for formal teaching. The incentive of extra money and 

sabbaticals could help recruit and retain doctors in countries where family medicine can be seen as ‘low prestige’ and 

where there is often a significant ‘brain drain’ of qualified medical staff to other countries. 

Perhaps another way of thinking of it is that this is just a modified version of the cascade of learning which already 

happens each time a group of family doctors is brought together. As Margaret Mead famously said: 

Never underestimate the power of a few committed people to change the world. 

Indeed it is the only thing that ever has. 

This cascade of learning is hard to quantify but is something which is felt by family doctors each time they attend a 

WONCA or Vasco da Gama conference and meet with a group of committed and inspired family doctors who share 

their visions and goals. The ripples from this learning cascade back as ideas and innovations which are applied in the 

home countries of doctors all over Europe and beyond. 


 

 

 

 

In order to achieve a ‘GP for every person in the world’, we need family medicine training in every country in 

the world. 

WONCA initiatives and collaborations can help drive development of national curricula. 

Thought experiments can help us think outside the box. 

Never underestimate the power of a few committed people. 

Thank You 

The author wishes to thank Marco Roos, MD, academic clinical fellow at the Institute of Primary Care, University of 

Erlangen-Nuremberg, for his helpful suggestions on the article. 


http://www.woncaeurope.org/content/3553-developing-national-curriculum-education-and-training-general-practitioners-united 

References 

26


1. http://www.oecd-ilibrary.org/sites/health_glance-2013-en/03/02/index.html?contentType=&itemId=%2fcontent 

%2fchapter%2fhealth_glance-2013-24-en&mimeType=text%2fhtml&containerItemId=%2fcontent%2fbook 

%2fhealth_glance-2013-en&accessItemIds=%2fcontent%2fbook%2fhealth_glance-2013-en 

2. http://www.dailymail.co.uk/debate/article-2840252/Why-fear-GPs-NHS-s-problem-not-solution-surgeon-J-MEIRION- 

THOMAS.html 

3. Starfield B, Shi L, Macinko J (2005). Contribution of Primary Care to Health Systems and Health. Milbank Quarterly; 

83(3):457-502. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323039/ 

4. Heath I (2008). A general practitioner for every person in the world. BMJ; 336(7649):861. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323039/ 

5. Roos M, Watson JC, Wensing M & Peters-Klimm F (2014). Motivation for career choice and job satisfaction of GP trainees 

and newly qualified GPs across Europe: a seven countries cross-sectional survey. Education for Primary Care; 25: 202-210 

6. http://www.woncaeurope.org/gp-definitions 

7. http://www.globalfamilydoctor.com/site/DefaultSite/filesystem/documents/Groups/Education/WONCA%20ME 

%20stds_edit%20for%20web_250714.pdf 

8. http://www.lietaer.com/2010/01/the-saber/ 

27


Ignaas Devisch, PhD 

Ignaas.Devisch@Ugent.be 

7 – Transient Illnesses 

Prof. Dr. Ignaas Devisch 

PhD Philosophy 

Professor in Philosophy of 

Medicine and Ethics 

Department of Primary Care and 


Ghent University, Belgium 

Within the context of mental illnesses, Ian Hacking talks about ‘transient illnesses’, in 

that certain illnesses are typical for certain eras. (Hacking, 1998). By this, he does not 

state that an era determines its illnesses and therefore illnesses can be reduced to it; 

instead, he analyses why certain illnesses are more prevalent in certain eras than in 

others. ADHD, depression or bipolar disorder for instance, are diseases of our era. 

One can ask why we are limiting ourselves to mental illness? Obesity can also be 

described as a ‘transient illness’: it is a basic characteristic of our era, far more than it 

was before. Obesity is particularly a problem of contemporary society. Everywhere in 

city streets, you can drink coke or eat burgers and all of us are on a daily basis faced 

with a battery of advertisements, influences which can hardly be overestimated. 

Listen to the radio, watch television or walk on the streets: we all are bombarded with 

advertisements appealing us to enjoy our life via the consumption of food and 

beverages. (Minkler, 1999) 

The concept of transient illnesses opens up the forum for discussion on health and 

illness in today’s society. When discussing so called lifestyle diseases, many people 

consider individuals responsible for their health condition and people are even 

blamed for being sick (Wikler, 1987, 2002). Consequently, in many countries the 

pursuit of a healthy lifestyle has or is expected to become a criterion in the allocation 

of healthcare services. One of the crucial questions is what the consequences of this 

evolution would be for health care policy, for individuals and for society in general? If 

we consider individuals as autonomous and regard the way they live as largely a 

matter of their own free choice, it seems ‘logical’ to hold patients personally 

responsible for making (un)healthy life style choices when they try to obtain 

insurance or enter healthcare facilities. And if the individuals are unwilling to change 

their risky behaviour, could they then also be denied health care services? In short, 

the discussion about lifestyle also concerns responsibility and the amount of control 

that others should be allowed to exercise over an individual’s choice for a particular 

way of living. Critics of paternalism talk about control and tyranny, while defenders 

point out the importance of public interest. (Cosner Jr, 2008) 

The idea of transient illness has the potential to make a breakthrough in this debate 

and can be of help to general practitioners in facing patients with lifestyle diseases. It 

explains why people, at the very moment they make autonomous decisions, decide 

for things which are obviously analogous to the main characteristics of society, i.e. 

enjoyment of your personal life, putting your desires first, etc. Despite the fact we are 

often very aware of the possible consequences of our decisions for our health, a lot of 

us keep on making unhealthy choices – it is for instance hard to say we are not 

informed about the dangers of smoking and yet many people continue smoking 

(Devisch I & Dierckx, 2009). 

Can we blame these people for making choices which result in consequences they 

have not opted for? Of course people are responsible, but societies do ‘produce’ illnesses as well. An old ‘Marxist’ 

28


thesis would argue that the ‘system’ is responsible for everything. However, it is not that our choices are determined 

solely by social circumstances; it is not because our particular social context offers us fewer opportunities for physical 

activity that we are destined to live our life as obese. In as much as we should stop ‘blaming the patient’ because of his 

risk behaviour, we cannot simply shift the responsibility of the individual’s lifestyle to society. 

Therefore, we suggest the counter-intuitive thesis: there are aspects of our behaviour for which no one is responsible. 

By this we mean that many of our choices are developed as a strategy for living our lives or – similarly to what Carl 

Elliott writes about in his ‘A Philosophical Disease. Bioethics, Culture and Identity’ – “the result of cultural factors 

beyond our reach”(Elliott, 1999). As long as lifestyle is considered to be based solely on independent, conscious and 

deliberate choices, be they taken individually or collectively, we will never solve the question of why people are 

‘choosing’ one thing or refusing another. 

Beginning with the idea of transient illness, people should be viewed in a societal context which makes their individual 

freedom and choices a relative and not an absolute matter. To be free is more a question of ‘are the terms of the 

choice’ fair? If the available alternatives to a healthy choice are less attractive than they can/should be, maybe the 

terms of the unhealthy choice are unfair. For example, working in a coal mine; you know it is risky, but sometimes, 

there is no alternative. These people need to be protected, not punished. 

Take Home Message 

 

General practitioners should be fully aware of the idea of transient illnesses and make use of it in supporting 

patients struggling with lifestyle diseases. Rather than blaming the victim, people deserve support and 

understanding for the context in which they live and the choices stemming from it. 


http://www.woncaeurope.org/content/36-theory-general-practice-concepts-illness-and-paradigm-general-practice 

References 

Cosner Jr, L. (2008). Lifestyle is an issue. Modern Healthcare, 38(13), 21-21. 

Devisch I, & Dierckx, K. (2009). On idiocy or the plea for an Aristotelian health policy. Public Health, 

doi:10.1016/j.puhe.2009.04.009. 

Elliott, C. (1999). A philosophical disease: bioethics, culture and identity. London and New York: Routledge. 

Hacking, I. (1998). Mad Travellers: Reflections on the Reality of Transient Mental Illnesses. London: Free Association Books. 

Minkler, M. (1999). Personal Responsibility for Health? A Review of the Arguments and the Evidence at Century's End. 

Health Education & Behavior, 26(1), 121-141. 

Wikler, D. (1987). Who should be blamed for being sick? Health Education Quarterly, 14(1), 11-25. 

Wikler, D. (2002). Personal and Social Responsibility for Health. Ethics & International Affairs, 16(2), 47-55. doi: 

10.1111/j.1747-7093.2002.tb00396.x 

29


Odd J Kvamme, MD, PhD 

odd.kvamme@knett.no 

Secondary Care 

8 – Cooperation Across the Interface of Primary and 

Odd Kvamme MD, PhD 

Family doctor at Stord, Norway 

Co-authors 

Frede Olesen (Denmark), 

Marianne Samuelson (France) 

Battle Zone 

Starting with a citation: “cultural interfaces are said to be like battle zones between 

the fronts of two armies facing each other: the situation creates uncertainty and fear, 

there are no rules, the one part trying to impose power to suppress the other part” 

(1). 

The primary secondary care interface is a clearly defined demarcation zone, and it has 

changed very little during the last 20 years. It is similar in different European countries 

(2). The patient seems too often to be caught in a “no mans-land” where they suffer 

from care fragmentation, not knowing what to do, what is to happen next, or who is 

coordinating (3). These days, the patient has become more like a consumer and 

customer, a tendency that is boosted by social media spreading messages about 

which services to demand. Competition is turning health care services into suppliers 

of health care in a market, and the family doctors find themselves often in an 

unexpected role to shop secondary care services for their patients, based on 

expectations or needs. Increase of cost in health care is by many attributed to 

inappropriate use of care at the interface (4). 

Different Cultures 

Primary care and secondary care represent different cultures, and their interface 

represents the biggest hindrance for smooth care processes in modern health care 

systems (5). One important reason is fragmentation of secondary care as result of 

higher professional specialization, technology and focus on pathology, with the risk 

that persons are more often seen as organs or diagnoses than individuals. At the 

same time, family doctors struggle to keep a broad and patient-centred perspective in 

a jungle of new knowledge, patients’ increasing expectations and demands while 

coordinating complex diagnostics and treatment. Iona Heath has described the basis 

for these differences in an eloquent way: “In family medicine, patients stay and 

diseases come and go. In hospitals, diseases stay and patients come and go”. 

Working in separate medical realities may diminish understanding and even respect 

for the concerns of others. To be able to smooth patient journeys, professionals 

themselves must cross the interface to learn about the other side, share perspectives 

and seek mutual understanding and goals. However, little effort has still been devoted 

to bringing professional groups together to enable them to understand that their 

work is complementary with that of others in a single healthcare system. The 

probably best approach so far is a Danish model where family doctors act as advisers 

in hospitals (6). 

Improving interface problems has gradually caught the interest of professionals and 

leaders of health care (7). We all agree that seamless care is an important goal for 

30


quality improvement, but when it comes to broaden our perspectives and changing behaviour, we resist and regress. 

Important Perspectives 

Four important perspectives of the quality of care at the primary/secondary care interface: 

1. The system perspective: A system approach to better co-ordinated care implies that we should understand and 

discuss division of tasks across boundaries within the health care system. This can improve process-flow, reduce 

waste of resources and diminish patient risk. 

2. Perspective of medical quality: Patients must be given an interpretation of symptoms and findings within a 

holistic framework where biological, psychological and social aspects of health care are considered and 

weighted. They have the right to make choices for diagnostics and intervention (8). To achieve this, the 

professionals must cooperate. The alternative is obsolete: fragmented and uncoordinated care resulting in polyinvestigations, 

poly-interventions and poly-pharmacy. 

3. Patient perspective: Patients expect coordinated chains of investigation, treatment and follow up. It is important 

that professionals and leaders use patients’ experiences to improve quality of care on a systematic basis. 

Understanding patient perspective is an assumption for narrowing the “expectation gap”, where needs and 

expectations clash with offers. 

4. Provider perspective: Modern health care systems are complex with multiprofessional providers. There needs to 

be capacity within the system to prevent and settle conflicts between specialities and professions. Competition 

should give way to mutual understanding of roles and skills. 

Targets for Change 

Based on complexity and perspectives, in 2001 the EQuiP listed ten targets for quality improvement of the interface 

(2). They are still valid. 

 

 

 

 

 

 

 

 

 

 

Develop leadership with a defined responsibility for improving the interface 

Develop a shared care approach for patients treated in both primary and secondary care 

Create consensus on explicit task division and job sharing 

Develop guidelines that describe quality problems at the interface and seek solutions to such problems 

Develop an interface that contains the patient perspective 

Develop systems for appropriate information exchange to and from family medicine care 

Reinforce interface improvement through education 

Facilitate team building across the interface 

Establish quality monitoring systems at the interface 

Establish a broad understanding of the need for cost effectiveness at the interface 

The work required in different countries must be based on national needs, resources and priorities. Improvement of 

leadership is probably the most important target. So is bringing family doctors and specialists together to develop 

personal and group relations and understanding. Bridging the expectation gap by informing and empowering patients 

will also be a strong drive to improve communication and cooperation across the interface. The ten targets can help 

redesign health care systems in order to deliver care that is perceived by patients as seamless. 

Working towards these targets can help leaders to make care systems work as a whole. In Norwegian hospitals there is 

a new trend assigning family doctors with public health experience to the leadership. The Danish model for family 

doctors as advisers in hospitals is a multi-potential method to promote cooperation (6). Studies of patients’ 

expectations and experiences can help professionals to act in accordance with guidelines for medical practice and 

cooperation. 

Improving care across the interface is a continuous process that must be based on principles for quality improvement. 

Shared perspectives and common goals can lead to behavioural and system change. Both carrots and sticks are needed 

to accomplish the task. 

31



 

 

 

 

 

The interface primary/secondary care represents major obstacles for seamless care 

The culture gap between primary and secondary care needs closing by sharing perspectives and goals 

The subject must be addressed both by leaders, family doctors and specialists 

Improving care across the interface must be based on principles for quality improvement 

Patient experiences must be monitored and listened to 


http://www.woncaeurope.org/content/24-interface-between-primary-and-secondary-care-continuity-shared-care 

References 

1. Bateson, G. Cultural contacts and Schismogenesis. I: Steps to an ecology of mind. London: Intertextbooks, 1972. 

2. Kvamme OJ, Olesen F, Samuelsson M. Improving the interface between primary and secondary care: a statement from the 

European Working Party on Quality in Family Practice (EQuiP). Qual Health Care 2001;10:33-9. 

3. Preston C, Cheater F, Baker R et al. Left in limbo: patients’ views on care processes across the primary/secondary interface. 

Qual Health Care 1999; 8:16-21. 

4. Improving care at the primary-secondary care interface: a difficult but essential task. Szecsenyi J. Qual Health Care. 

1996;5:191-2. 

5. Kvamme OJ, Eliasson G, Jensen Poul B. Co-operation of care and learning across the interface between primary and 

secondary care. Scand J Prim Health Care. 1998; 16:131-4. 

6. Olesen F. General practitioners as advisors in hospitals. Qual Health Care 1998;7: 42-7 

7. Grimshaw JM, Winkens RA, Shirran L, Cunningham C, Mayhew A, Thomas R, Fraser C. Interventions to improve outpatient 

referrals from primary care to secondary care. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005471. 

8. Berendsen AJ, de Jong GM, Schuling J, Bosveld HE, de Waal MW, Mitchell GK, van der Meer K, Meyboom-de Jong B. 

Patient's need for choice and information across the interface between primary and secondary care: a survey. Int J Integr 

Care. 2004;4:18. 

32


Joachim P Sturmberg, MD, PhD 

jp.sturmberg@gmail.com 

9 – Complexity and Primary Care 

Joachim P Sturmberg MD, PhD 

A/Prof of General Practice, 

Newcastle University, Newcastle 

- Australia 

Complexity comes from the Latin word complexus; com- “together” and plectere “to 

weave” or “braid”. By studying complexity, we aim to understand how things are 

connected, and how these interactions relate to one another. 

Complexity also entails a particular way of thinking, a change in world view, away 

from understanding the whole based on knowledge of its individual parts towards an 

appreciation that the parts exhibit different properties to those they display in the 

context of the whole. In complex science lingo; the whole is different and more than 

the sum of its parts (Fig. 1). Furthermore, the behaviour of system components varies 

depending on context; changing context may result in “unexpected” changes in the 

component’s and therefore the system’s behaviour [1]. 

Fig 1: Gauss and Pareto distributions, the basis that define the key differences 

between simple and complex world views. Note: the long-tail frequency 

distribution and its log-log equivalent are superimposed – modified from West. 

(2010) Homeostasis and Gauss Statistics: barriers to understanding natural 

variability. J Eval Clin Pract. 16(3):403–8) 

Complex systems consist of many different parts (agents) contained within a 

boundary separating it from other systems. Hence every system is part of a suprasystem 

and itself contains many sub-systems. Systems have permeable boundaries, 

providing output and receiving input from their external environment. A system’s 

agents are interconnected, interacting in multiple ways; each agent influencing others and in turn being influenced by 

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their responses resulting in feedback which gives the system its unique non-linear behaviour. Most importantly, 

systems behaviour is non-deterministic, its behaviour will change in major ways with even the smallest change in its 

agents’ initial condition (or starting value) (Fig. 2) [2]. 

Fig 2: Complex systems and their core characteristics: the boundaries of a system and its supra- and sub-system 

context (top left), interconnectedness of agents (top right) resulting in feedback (bottom left), and the impact of 

initial condition (or starting value) on its behaviour (bottom right) 

Primary care exhibits all the characteristics of a complex (adaptive) system [3, 4]. Structurally, primary care is part of 

the wider healthcare system; its agents are members of the community and various health professions. Each agent 

within the primary care system consists of members of its respective craft group. Important agents outside the primary 

care system, like teachers, public services, employers etc., receive outputs and provide inputs to the primary care 

system. Dependent on the size and the number of agents involved, their interactions lead to unique behaviours, and 

the behaviour can vary markedly between various local settings, no more so than in light of the socio-economic 

conditions of the local area. 

How can you implement complexity thinking into problem solving in primary care? The following examples illustrate 

and explain some system and system-dynamic approaches for everyday practice. 

Most frequency distributions in nature show long tail or non-linear (log-log normal, power law, 80:20 split or Pareto) 

distributions. Health in the community has long been known to be distributed that way – most people are healthy 

most of the time, and most people with a health concern have conditions amenable to primary care treatments. Only 

3.2% of the community require secondary and 0.8% tertiary care. Many physiological parameters, like blood pressure, 

cholesterol and BMI, show non-linear distributions. These distributions highlight the gross over-classification of 

patients as abnormal, not only mathematically but also pragmatically. Physiological variables operate within a 

homoeostatic range, i.e. they show threshold behaviour in regards to outcomes, like blood pressure in relation to 

morbidity or income to life-expectancy [5]. 

Multiple cause diagrams provide a means to fully appreciate the dynamic changes underpinning a person’s illness 

trajectory as illustrated by John, a patient with multiple problems known by any primary care provider anywhere in the 

world (Fig. 3). Changing disease-specific parameters more often than not result from influences of factors distant to 

the disease processes (the “real reason” for the deterioration of disease markers). Failing to see the whole picture 

easily results in unnecessary and/or inappropriate management, overlooks the patient’s real needs and results in less 

than the best possible health outcomes [6]. 

In primary care, multiple agents interact with people with usually multiple, less-defined illnesses that typically exhibit 

more unpredictable dynamics and outcomes, i.e. they deal with greater complexity. In situations of high complexity 

health professionals have to rely on improvisation, using multiple different approaches to adapt to seemingly “similar 

problems” in a patient at different points in time, or different patients or patients in different environments. 

Katerndahl demonstrated that primary care physicians deal with far greater complexity and greater uncertainty 

compared to focused physicians like cardiologists and psychiatrists. Not surprisingly working in a more complex 

environment creates greater stress and is associated with a higher error rate, both being outcomes of the system’s 

dynamics [7]. 

34


Fig 3: Multiple cause diagram of patient with multimorbidity – the multiple cause diagram shows that John is part of 

at least three subsystems. John’s central problem is stress. His retrenchment, marital problems and worries about 

his sons all increase his stress and stress response. The causal loops are self explanatory from their physiological and 

pharmacotherapeutic perspective. Of note are the synergistic effects caused by the input of multiple variables, e.g. 

increased alcohol consumption and smoking both cause a decrease in mucosal protection which in turn increase 

ulcer/reflux symptoms and stress (Sturmberg. (2007) Systems and complexity thinking in general practice. Part 1 - 

clinical application. Aust Fam Physician 36(3):170-173) 

The whole health system can be understood by the healthcare vortex metaphor which visualises the 

interconnectedness of all agents at the various organisational levels of health care. The metaphor highlights a core 

feature of complex adaptive systems; its interconnected function depends on sharing a common value or focus that in 

turn generates common simple rules to operationalise each agent’s behaviour. This model creates a space in which 

primary care can lead the discourse for healthcare reform that meets all the various needs for which people require 

the help of a health professionals (Fig 4) [4]. 

To succeed in primary care we have to acknowledge and embrace its underlying complexities and uncertainties. There 

are now a variety of accessible tools that can help us to better cope, learn and act. Using these tools is of paramount 

importance as they help to overcome our brain’s limited capacity to simultaneously process more than a few things (on 

average 7 ± 2) at a time, to easily detect connections between seemingly unconnected objects or facts, and to easily 

anticipate – especially nonlinear – behaviours more than a step or two ahead. Acknowledging our limitations in dealing 

with complexity can easily be compensated for by adopting the science’s foundations and tools; it will make us better 

problem solvers and decision makers [8]. 

Systems and complexity-orientated primary care offers patient-centred, individualised, health-focused healthcare that 

integrates the best solutions with regard to each person’s needs. 

35


Fig 4: The health vortex as a metaphor for the health system. Note the changes between certainty and complexity at 

the various levels within the health vortex. 


 

 

 

 

 

Complexity and uncertainty are core characteristics of primary care 

Variables in “living systems” have non-linear (long-tail) distributions 

Small changes in a single system variable can result in largely divergent system behaviours 

Applying system tools helps to understand complex problems and guides the development of solutions 

Simple rules arising from a shared common focus (value) provide the operating principle for all system agents 


http://www.woncaeurope.org/content/56-complexity-and-primary-care 

References 

1. West BJ. Homeostasis and Gauss Statistics: barriers to understanding natural variability. J Eval Clin Pract. 2010;16(3):403– 

8. 

2. Sturmberg JP, Martin CM. Handbook of Systems and Complexity in Health. New York: Springer; 2013. 

3. Sturmberg JP, O’Halloran DM, Martin CM. People at the centre of complex adaptive health systems reform. Med J Aust. 

2010;193(8):474-8. 

4. Sturmberg JP, O'Halloran DM, Martin CM. Health Care Reform – The Need for a Complex Adaptive Systems Approach. In: 

Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer; 2013. p. 827-53. 

5. Sturmberg JP, West BJ. Fractals in Physiology & Medicine. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and 

Complexity in Health. New York: Springer; 2013. 

6. Sturmberg JP. Systems and complexity thinking in general practice. Part 1 - clinical application. Aust Fam Physician. 

2007;36(3):170-3. 

7. Katerndahl D, Parchman M, Wood R. Trends in the perceived complexity of primary health care: a secondary analysis. J 

Eval Clin Pract. 2010;16(5):1002-8. 

8. Dörner D. The Logic of Failure: recognizing and avoiding error in complex situations. New York: Metropolitan Books; 1996. 

36


Siggy Rausch, MD 

siggyrausch@hotmail.de 

10 – Motivational Interviewing in Family Medicine 

Siggy Rausch, MD 

Lecturer in Medicine University 

of Luxembourg, co-responsible 

for the organization of the 

Specific Training in General 

Medicine at Uni Luxembourg 

Lecturer in Medicine, Free 

University of Brussels (ULB) 

Member SSLMG (Scientific 

Society of General Medicine in 

Luxembourg) 

“People are generally better persuaded by the reasons which they have themselves 

discovered than by those which have come into the minds of others.” 

Blaise Pascal 

When we, as family doctors, have to deal with physical ailments, we can offer 

explanations, good advice and healing treatments and, for the most part, there is a 

successful outcome for the patients. However, we are often faced with more 

challenging situations. When the issue relates to dangerous behaviour, such as 

smoking, alcohol abuse, drug abuse, excessive eating, lack of exercise, not adhering to 

prescribed treatments etc., we can be faced with a resistance to our best efforts at 

advice and treatment - where people continue to behave in self-defeating ways. 

In this situation, our helper role often proves ineffective: when we have given our 

best advice and stressed the importance of a change in behaviour, we are often left 

with the frustrating feeling of failure. 

Patients can react in unexpected ways. They sometimes resist our advice and, indeed, 

argue against it. They can get angry and defensive, thus provoking feelings of 

frustration in us. We may even think that he/she “has bad will or is too silly to follow 

our advice”. 

Motivational Interviewing (MI) was developed more than 30 years ago in the setting 

of alcohol dependence treatments. The approach to counselling advocates is 

particularly relevant in the above context (2). 

We doctors are trained to use what can be called the “Deficit Model” which implies 

that “my patient lacks something (insight, information, understanding) and my role is 

to give him what is missing. The word “docere (to teach)” which is the origin of 

“doctor” is the basis for this “deficit model”. 

In MI the approach is different and has to do with “E-ducere (to draw out)”. That 

means search and draw out what is already present which includes what the patient 

himself may know. With this approach, the doctor and the patient search together, for 

a solution. Instead of focusing on the failings of the patient (which may be important) 

we focus on his/her resources, possibilities, wishes, hopes, strengths and capacity to 

change. 

Our efforts are twofold 

 

 

First, we encourage our patient to find arguments himself/herself, in favour of 

change. 

Second, we listen carefully to every element of “change talk” the patient 

expresses, we support his/her ideas for change and help develop them into a 

strategy that he/she will be able to apply. 

Ambivalence about the problematic behaviour is the starting point for MI 

intervention. Possibly, our first goal is to reveal this ambivalence. To get to understand the specific nature of our 

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patient's ambivalence, we need to avoid a directional and “expert” driven style. Instead, we should adopt an 

empathetic, reflective, listening style in order to communicate understanding of the patient’s inner world of conflicts. 

Reflective listening involves the following skills: 

 

 

 

 

Using Open Questions. 

Making reflections aloud to show empathy and to test whether we have understood what the patient meant. 

Affirming the strengths and qualities of the patient. 

Summarising to check that both doctor and patient have the same understanding of what has been said 

and/or agreed. 

Studies show that these skills are easy to understand, but difficult to use in a fluid and easy manner during a 

consultation. Like the game of tennis - easy to understand, but not so easy to master well! A lot of training and 

supervision is necessary (3). 

The Spirit of MI, is defined essentially by our will to collaborate with the patient and activate his/her own expertise. It 

means Unconditional Acceptance, Empathetic Reflection and support for the patient's Autonomy and this can be 

summed up as: “I’m here to help but it’s up to you to decide where to go and what to do”. 

An important element of Acceptance is affirming the qualities and strengths we can observe in our patient. This is 

linked to Compassion which is another important element of the spirit of MI and implies “I want the best for my 

patient”. 

MI usually starts with Engaging: “Do I understand this person’s perspective and concerns? “How comfortable is this 

person in talking to me?” This is followed by Focusing which is to look for the “goals for change” and questions “Are we 

working together with a common purpose?” “Does this feel more like dancing or wrestling?” 

Next comes Evocation which means: “What are this person’s own reasons for change? Is his/her reluctance more 

about confidence or the importance of change? What change talk am I hearing? Am I steering too far or too fast in a 

particular direction? Is the reflex “to be right” making me the one to be arguing for change?” 

The last element is Planning which takes in: “What would be a reasonable next step toward change? What would help 

this person to move forward? Am I retaining a sense of quiet curiosity about what will work best for this person?” (1 - 

p.311). 

MI is described as a style of being with people, an integration of particular skills to foster motivation for change. It is 

essentially a collaborative partnership that honours the other’s autonomy, seeking to understand the patient’s internal 

frame of reference. Compassion is added to the spirit of MI precisely to emphasise that MI is to be used to promote 

the patient’s welfare and best interests, not one’s own. 

There are currently a lot of studies showing the efficacy of MI (4, 5, 6,7,8). 

The most powerful change catalysts operating in MI include empathic listening, the capacity to strengthen change talk, 

and the therapists ability to refrain from counter therapeutic responses (1 - p.386). 

One last word: there is a benefit for the family doctor himself in MI. My experience in adopting this style of interaction 

with my patients is that, not only is there a greater degree of satisfaction in the doctor/patient relationship, but it is 

also an effective preventative measure for ‘burnout’. 


 

 

 

When patients resist the doctor’s advice, it’s time for MI 

MI gets much better results than blaming or criticizing 

When patients hesitate to consider behaviour change, it’s time for MI. 


http://www.woncaeurope.org/content/ws216-applications-motivational-interviewing-hypertension-treatment 

References 

1. Motivational Interviewing. William R. Miller, Stephen Rollnick, Third edition 2013 New York Guilford Press 

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2. Health Behavior Change. S. Rollnick, P.G.Mason, C.C.Butler Churchill Livingstone 1999 

3. Building Motivational Interviewing Skills. D.B. Rosengren New York Guilford Press 2009 

4. see the ref. in (1) p.435 - 470 especially: Bien,Miller 1993; Brown, Miller 1993; Bohart, Tellman 1999; Hubble &al 1999, 

Miller & al 1993, Project MATCH research group 1998 Hettema & al 2005, Hubble, Duncan, Miller 1999, Sanders L.2011, 

White, Miller 2007) 

5. D’Amico EJ et al, Group Motivational Interviewing for Adolescents. Change Talk and Alcohol and Marijuana Outcomes J 

Consult Clin Psychol 2014 Nov 3 

6. Vesely JM et al.: Obesity: Dietary and Lifestyle Management FP Essent. 2014 Oct; 425: 11-5 

7. Vasilaki EI et al: The Efficacy of Motivational Interviewing as a Brief Intervention for Excessive Drinking: a Meta-analytic 

Review Alcool Alcool 2006 May-Jun; 41 (3) ; 328-35 

8. Keeley R.D. et al Training to Use Motivational Interviewing Techniques for Depression. J Am Board of Family Med 2014; 

27: 621-636 

39


Adrian Rohrbasser, MD, MSc EBHC 

adrian.rohrbasser@bluewin.ch 

11 – Quality Circles 

Adrian Rohrbasser, MD, MSc 

EBHC 

Department of Primary Care 

Health Sciences University of 

Oxford 

Santémed Healthcare Centres 

Switzerland 

Co Author: 

Edith Andres, Dipl.-Psych 

Institute for Applied Quality 

Improvement and Research in 

Health Care GmbH 

The Phenomenon 

Ongoing quality improvement (QI) is fundamental to modern family medicine; it is 

about providing person-centred, safe and effective care, and efficient use of current 

resources in a fast-changing environment. There are diverse methods, tools and 

approaches to QI and structured small group work has been shown to contribute to 

an individual's increase and use of knowledge. The terms peer review group (PRG), 

quality circle (QC), CME/CPD (continuous medical education/continuous professional 

development) group, practice-based small group work (PSGW) and small group work 

(SGW) are used interchangeably in different European countries. 

QCs are groups of 6 to 12 professionals usually working in general practice, who meet 

regularly to consider their standard practice. QCs select the issues they want to deal 

with and decide on their data-gathering method and on ways of finding solutions to 

their problems. Practitioner-participation, certain topics and thematic frameworks 

may be mandatory for accreditations or for reimbursement by health insurance 

companies. The groups provide a social context for reflective practice and allow the 

dissemination of knowledge to the work practices of the participants (1). 

QCs consist of more than one educational step and are best described as a 

multifaceted intervention which uses various predisposing, enabling and reinforcing 

methods (2). They use educational material which is discussed in a workshop-like 

atmosphere, contact with local knowledge experts, audit and feedback with or 

without outreach visits, facilitation and local consensus processes. The groups are led 

through the circle of quality by facilitators who seek to keep the members focused on 

the issue without controlling them, respecting the contribution of each individual and 

taking into consideration the group dynamics. Rhetoric and didactic techniques such 

as debate, consensus discussion, brainstorming, reflective thinking, self-observation 

and role play, among other practice, appear to keep QCs active. 

Origins of the Approach 

QCs are based on two concepts: the framework of Knowledge-To-Action-Cycle (KTA) 

and the social context the group provides for its function. In 1924, Walter Shewart 

created the first table depicting a circle for continuous control of the process and QI. 

The US statistician Deming enhanced this and introduced the Plan Do Check Act 

(PDCA) cycle as a method of QI. QI spread from manufacturing to service industries 

and then to medical service providers. Donabedian introduced the basic aspects of 

quality and QI in health care using the same terms as the manufacturing industry. This 

concept was first implemented in in-patient settings and secondary-care clinics in the 

Netherlands, where Problem Based Learning (PBL) first influenced the health care 

sector. In 1979, PBL was implemented experimentally in Nijmegen, in the 

Netherlands, where small groups of family physicians met voluntarily on a regular basis, using their peers to 

40


continuously and autonomously improve their knowledge. 

Gradually, the learning cycle transformed into a cycle of QI as the focus changed from knowledge gain to QI and 

implementation of knowledge according to the KTA framework (Fig 1)(3). 

PBL added didactic techniques and industrial QCs added communication skills and knowledge about group dynamics to 

these small primary health care groups. QCs spread rapidly to many European countries. A parallel development could 

be observed at Mc Master University in Canada in the Eighties. 

Fig 1: KTA Framework 

Significance of the Phenomenon and its Development 

According to a survey performed by the European Society of Quality and Safety in Family Medicine (EQUiP) presented 

at the WONCA Conference in 2000, of the 26 European countries which participated, QCs had been established in 

Austria, Belgium, Denmark, Germany, Ireland, the Netherlands, Norway, Sweden, Switzerland and the UK. The main 

objectives of QCs in primary health care being QI, CPD and CME (4). 

Numerous Dutch, German and Scandinavian studies conducted in the following years suggest that QCs improve both 

individual and group performance in terms of costs, ordering of tests, prescription habits and adherence to clinical 

practice guidelines, thus resulting in better patient outcomes, measured in changes in performance indicators (5). As 

the QC programme uses several, though varying sequential interventions, it is tempting to judge the programmes 

according to the results each component generates. Several systematic reviews (SR) of high quality show that elements 

of QCs have a positive impact on behaviour (6, 7). 

In the Netherlands and Ireland, QCs have become inherent in QI where family physicians are supported by their 

colleges. In Germany, they are often mandatory as part of integrated or selective contracts in health care. Overall, 

approximately 50% of all family physicians participate regularly in QCs. In Switzerland, currently, 80% of all primary 

health care physicians who answered surveys, regularly attend QCs. QCs have developed rapidly in Scotland and 

England and over 25% of all family physicians in Scotland regularly meet in groups. There are no current data for other 

European countries about how common QCs are and what features they have. However, literature reviews and contact 

with European key stakeholders suggest that QCs also play an important role in Austria, Belgium, Denmark, France and 

Sweden. 

41


Future Prospects 

QCs are assumed to work because they bring people together to identify key issues concerning the quality of health 

care and they involve people in exploring solutions where there is a need for improvement. However, understanding of 

the QC components that act independently and interdependently to optimize the programme has to be improved. The 

influence of the context should be taken into account and studied since it affects both participants and their 

motivation. Basically, it is about unpacking the black box to see what variations of QCs work for whom and under what 

contextual features, by looking at the numerous projects that are being undertaken (8). An EQUiP meeting on this 

subject is planned in Spring 2015 and an updated survey on QCs in European countries will be conducted to discover 

how common they are, what contextual features they display and to identify optimal conditions for their success. 


 

 

 

 

Quality Circles are commonly used in primary health care in Europe to consider and improve standard practice 

over time. 

They represent a complex social intervention that occurs within the fast-changing system of primary health 

care. 

Quality Circles work according to the Knowledge-To-Action Framework 

Numerous controlled trials, reviews and studies have shown small but positive effects on behaviour change. 


http://www.woncaeurope.org/content/20-s-quality-circles 

References 

1. Grol R: Quality improvement by peer review in primary care: a practical guide. Qual Health Care 1994, 3(3):147-152. 

2. Davis DA, Thomson MA, Oxman AD, Haynes RB: Changing physician performance. A systematic review of the effect of 

continuing medical education strategies. JAMA 1995, 274(9):700-705. 

3. Straus SE, Holroyd-Leduc J: Knowledge-to-action cycle. Evidence Based Medicine 2008, 13(4):98-100. 

4. Beyer M, Gerlach FM, Flies U, Grol R, Krol Z, Munck A, Olesen F, O'Riordan M, Seuntjens L, Szecsenyi J: The development 

of quality circles/peer review groups as a method of quality improvement in Europe. Results of a survey in 26 European 

countries. Fam Pract 2003, 20(4):443-451. 

5. Zaher E, Ratnapalan S: Practice-based small group learning programs: systematic review. Can Fam Physician 2012, 

58(6):637-642, e310-636. 

6. Baskerville NB, Liddy C, Hogg W: Systematic Review and Meta-Analysis of Practice Facilitation Within Primary Care 

Settings. The Annals of Family Medicine 2012, 10(1):63-74. 

7. Ivers N, Jamtvedt G, Flottorp S, Young Jane M, Odgaard-Jensen J, French Simon D, O'Brien Mary A, Johansen M, Grimshaw 

J, Oxman Andrew D: Audit and feedback: effects on professional practice and healthcare outcomes. In: Cochrane 

Database of Systematic Reviews. John Wiley & Sons, Ltd; 2012. 

8. Rohrbasser A, Mickan S, Harris J: Exploring why quality circles work in primary health care: a realist review protocol. 

Systematic Reviews 2013, 2(1):110. 

42


Buis, P.A.J., MD, PhD 

pajbuis.huisarts@planet.nl 

12 – Pathology and Minor Surgery in Primary Care 

Buis, P.A.J., MD, PhD 

Former: Department of 

Pathology 

University Medical Centre 

Utrecht Cancer Center Utrecht 

The Netherlands 

Current: Gezondheidcentrum 

Harderwijk, Harderwijk, The 

Netherlands 

Since last century, family doctors have played a varying role in the management of 

skin lesions. While family doctors traditionally played an important role in handling 

skin lesions, this changed in the second half of last century when minor surgery 

performed by family doctors declined as a result of limited funding and the growing 

wish of patients to be treated by specialists. The increasing costs of this led to the 

insight that minor surgery primarily belongs in family medicine, and financial 

incentives were created for family doctors to perform more minor surgery. Since then, 

the role of family doctors in the management of skin lesions has gradually increased, 

illustrated by a significant increase in the volume of minor surgery performed in 

primary care in the UK. This largely involves skin lesions that may be malignant, and 

thus there has been discussion about the appropriateness of clinical management 

decisions in family medicine with several issues of concern: 

 

 

 

 

 

The quality of the clinical diagnosis by family doctors 

The need for histological confirmation of the clinical diagnosis 

The cost-effectiveness of histological confirmation 

The technical quality of the surgical procedures performed by family doctors 

The cost-effectiveness of minor surgery in family medicine 

Pathology applications in Family Medicine can concern cytological or histological 

investigations. Histology is also of great importance in Family Medicine, in terms of 

skin excisions, biopsies and curettings. Skin diseases are a major part of the workload 

of the family doctor, reflecting about 15% of daily consultations. Skin cancer incidence 

rates have increased steadily, leading to a growing demand for healthcare services to 

inspect suspected lesions and treat patients. In The Netherlands, lifetime risk of skin 

cancer is 1:6 and of melanoma is 1:50. In many countries, including The Netherlands, 

family doctors are the portal to healthcare and therefore play an important role in 

handling skin lesions. Nevertheless, the role of family doctors in these matters is not 

without controversy. Family doctors are criticized because of their lack of diagnostic 

accuracy and quality of their surgical technique. 

To have clear insight into this process it is important to know how family doctors 

handle skin lesions in daily practice and to know what the role of histopathological 

investigation is following skin excisions. 

We evaluated the yield of histopathological investigation of a large group of 5105 skin 

excisions performed by family doctors and sent to a family doctors' pathology lab in 

Utrecht (Saltro), with special emphasis on discrepancies between clinical and 

pathology diagnoses of malignancy. The total yield of (pre-)malignancies in this large 

group of skin excisions was about 5%. These (pre-) malignancies were often serious 

and unexpected. 

Table 1. Comparison of clinical and final histological diagnosis in 5105 skin biopsies and excisions by family doctors. 

43


Final histological diagnosis 

benign premalignant malignant unknown total 

Clinical diagnosis benign 4302 (96.6%) 34 (0.8%) 100 (2.2%) 16 (0.4%) 4452 

premalignant 12 (42.9%) 13 (46.4%) 3 (10.7%) 28 

malignant 66 (50%) 11 (8.3%) 54 (40.9%) 1 (0.8%) 132 

unknown 441 (89.5%) 12 (2.4%) 35 (7.1%) 5 (1%) 493 

total 4821 70 192 22 5105 

In the group of benign clinical diagnoses we found 3% (pre-) malignancies. The malignancies occurred over the whole 

spectrum of clinical diagnoses including epidermal/trichilemmal cyst, seborrhoeic keratosis, naevocellular nevus, 

verrucous wart and fibroma. This indicates that clinical assessment of skin lesions by family doctors may be 

insufficiently reliable in allowing some skin excisions to be exempt from histopathological investigation, and that all 

skin excisions by family doctors deserve to be routinely investigated by histopathology in order not to miss serious 

malignancies. 

We compared melanomas excised by family doctors with those excised by dermatologists and surgeons in an academic 

practice to identify the nature of melanomas missed by family doctors, which may be translated into better clinical 

practice for family doctors. Of the family doctor melanomas, 64% were clinically considered to be a benign nevus in 

contrast with 38% of academic melanomas. This does not necessarily mean that family doctors do worse in diagnosing 

melanoma, since family doctors will usually refer patients with highly suspicious lesions anyway, and the low index of 

suspicion lesions will be treated by the family doctors (pre-selection bias). A low index of suspicion will usually lead to 

a narrow primary excision with a higher risk of an incomplete excision. The general consensus is to refer pigmented 

lesions with a high index of suspicion to a dermatologist or surgeon for a slightly wider local excision followed by reexcision 

and sentinel node biopsy if indicated. 

In a study exploring whether the “ugly ducking” (UD) sign is sensitive for melanoma detection it was concluded that 

melanomas are generally apparent as UDs. It is a common observation that, in a given individual, all the nevi tend to 

show a similar pattern. A nevus that stands out, the ugly duckling, is suspicious. Translating this knowledge to Family 

Medicine it seems very important to let patients undress when assessing pigmented skin lesions in order to investigate 

the overall pattern of the skin moles and to detect the “ugly duckling” if present. 

The safest approach to skin lesions is to excise them all and submit them for histopathology. However, this would lead 

to unwanted cosmetic side effects and low cost-effectiveness. Better diagnostic strategies could help family doctors to 

discriminate between benign lesions that can be left alone and high index of suspicion lesions that need to be excised 

properly. Dermatoscopy is widespread in secondary care and has been suggested as a tool to improve the diagnostic 

accuracy and therapeutic management by family doctors as well. 


 

 

 

 

 

The total yield of (pre-)malignancies in skin excisions submitted for pathology is between 5% and 10%, most 

of them unexpected, including serious malignancies. 

Unexpected malignancies in skin excisions performed by family doctors occur across all clinical diagnosis 

categories, and about 2% of clinically 100% benign lesions are malignant. 

Lowering the number of unnecessary excisions is a more fruitful approach to cost-saving than omitting 

histopathology of excised lesions. 

It seems very important to let patients undress when they present with a pigmented skin lesions to 

investigate the overall pattern of the skin and to detect the “ugly duckling” if present. 

Dermatoscopy may be a valuable addition for the diagnostic and management strategy of pigmented skin 

lesions by family doctors. 


http://www.woncaeurope.org/content/27-pa-minor-surgery-primary-care-team 

44

References: 


1. O‘Cathain A, Brazier JE, Milner A, Fall M. The cost-effectiveness of minor surgery in general practice: a prospective 

comparison with hospital practice. Br J Gen Pract 1992;42:13-17. 

2. Lowy A, Brazier J,Fall M, Thomas K, Jones N, Williams B. Quality of minor surgery by general practitioners in 1990 and 

1991. Br J Gen Pract 1994;44:364-365. 

3. Buis PAJ, Chorus R, Van Diest PJ. Value of histopathologic analysis of skin excisions by general practitioners. BJGP 

2005;55:458-460. 

4. Buis PAJ, Verweij W, Van Diest PJ. Value of histopathologic analysis of subcutis excisions by general practitioners. BMC 

Family Practice 2007;8:5. 

5. Buis PAJ, van Kemenade F, Frijling BD, van Diest PJ. Skin melanomas excised by General Practitioners: more often 

unsuspected, of nodular type and less of often radically excised than those excised in an academic setting. Clinical and 

Experimental Dermatology 2011;2:125.doi:104172/2155-9554.1000125 

6. Scope A, Dusza SW, Halpern AC. The “Ugly Duckling” sign. Agreement between observers. Arch Dermatol 2008;144:58-64. 

© Pieter Buis 

45


Mladenka Vrcic Keglevic, MD 

mvrcic@snz.hr 

13 – Developing Research Capacities in General Practice: the 

Croatian Experience 

Mladenka Vrcic Keglevic, MD, 

PhD 

Professor, Department of Family 

Medicine, University of Zagreb 

School of Medicine, Zagreb, 

Croatia 

Co-authors 

Milica Katic, Đurđica Kašuba 

Lazić 

Background 

Vocational training or specialist training (ST) in General Practice / Family Medicine 

(FM) in Croatia started in the school year 1960/61. It was prepared by the 

experienced working general practitioners (GP), supported by the academics, public 

health and clinical teachers from the Zagreb Medical School. The vision was not only 

based on the development of FM as the primary health care discipline, but also on 

the academic development of the discipline, which included the development of 

research capacities. Therefore, ST was organised along three pathways; as a 

postgraduate course, clinical rotations and the FM practical experience under the 

supervision of the trainers. A postgraduate course was equal to other postgraduate 

courses organised by Zagreb Medical School, leading to the obtaining firstly, a Master 

of Science degree followed by a doctoral degree. At the same time, ST trainees in FM 

have had the opportunity to proceed toward doctoral degrees and becoming a 

specialist in FM. Many GPs took advantage of this and obtained Master of Science 

degrees, and several of them doctoral degrees. A doctoral degree is one of the 

prerequisites to becoming a FM teacher, in order to fulfil the same criteria as other 

teachers at the Medical School. It led to the early establishment of the Department of 

FM; in 1980, three prominent GPs with doctoral degrees were elected as a core staff 

of the Department of FM at Zagreb Medical School. The ST curriculum was changed 

several times, with particularly significant changes happening in 2003/04, but the 

vision remains the same; the availability of a postgraduate course with a special 

research module, clinical and FM rotations. The aim of this report is to present our 

experience in the developing research capacities and to evaluate the outcomes in 

terms of published articles written by the ST trainees. 

Developing research capacities 

Over 3 years of ST curriculum, out of a total of 900 teaching hours in the postgraduate 

course, 600 are devoting to direct teaching and 300 hours on individual task-based 

learning. In the research module, out of 100 hours, 40 are devoted to direct teaching 

and 60 to work on small research projects under the supervision of mentors with 

academic degrees. The final requirement is post-graduate diploma work, which 

should be written and defended in front of three members of a jury. The diploma 

work is a prerequisite to obtaining a postgraduate degree. 

Generally, the research module is designed to develop the trainees’ competencies in 

the posing of a research question, collecting data in response to the question, and 

presenting and answering the question (1,2,3). However, the entire educational 

process was divided in smaller modules. Generally the process is initiated with a 

discussion on the general nature of the problem, or rather, its context within the 

46


research framework in Family Medicine. A group discussion is conducted regarding the importance of the research 

problem with relation to the ST trainees’ interests and preferable outcomes from their working experience. Following 

this, a literature review is performed to identify flaws or holes in previous research, which provides justification for the 

study, and is done individually; each trainee undertaking their own literature-search relevant to his/her research 

inquiry. They learn that a gap in the current literature, as identified by them, will lead to the formulation of a research 

question which may be parallel to their hypothesis. In data collecting to test the hypothesis, special attention is paid to 

selection of appropriate research methods, quantitative or qualitative depending on the research question, as well as 

sampling methods. Knowledge and skills on the basic statistical methods, important for data analysis and interpreting, 

are standard content. The education process is organised in an interactive way through a combination of theoretical 

teaching (lectures, small group discussion) and practical work on the defined task, such as data collection. The last 

part of the module is related to the writing of diploma work, and different types of articles, including the rules on 

literature citations and publishing. 

As mentioned previously, the direct outcomes of the research modules are small research projects completed by each 

ST trainees, published and defended as diploma work (4). Some of the projects are also published as research papers 

in different journals and have been presented at the European General Practices Research Network and other 

conferences (5, 6). Another advantage to such education is the further development of the individual’s research 

capacity. Whe some of the ST trainees choose to go on to the doctoral study programme lasting three years, this 

module covers almost one year of the study; and brings him/her 40 ECTS of the 60 ECTS necessary to obtain within 

one year. 

Evaluation 

Two types of pilot evaluation were performed, one related to the post-graduate diploma works and another related to 

the number and content of published articles. We carried out analysis of 420 diploma-works (64.5% of total). 82.1% of 

them are designed as research, 5.2% as literature review, and 12.6% as case presentations. The majority percentage of 

the content are related to clinical themes (27.9%). 17.4% are related to organizational issues and methods of work in 

family practice. In 15.5% of them, specific family medicine themes were surveyed, such as co-morbidity, 

biopsychosocial aspects and palliative care. 10.7% were dealing with patients’ and their health needs. Prior to the start 

of renewed VT in 2003, 42 articles were published in the official Croatian FM journal by the trainees and subsequently, 

71 articles. This accounted for a 69% increase in published articles. 96 articles were published at the Congress 

Proceeding of the Croatian FM Association prior to renewed VT, and 165 subsequently; an increase in 71.9%. Most of 

the articles are related to clinical themes (65%), 21% related to FM issues, and around 14% associated with other 

themes. 

Conclusions 

The results of the pilot evaluation indicated that it was worth the investment of resources in the development of 

research capacities in FM. We presented Croatia’s model in order to share experiences and to improve overall 

development of research capacities in Family Medicine consistent with the “Research Agenda for General Practice / 

Family Medicine and Primary Health Care in Europe” proposed by EGPRN (7). 


 

 

 

 

 

Research capacities are important for the development of FM as a scientific discipline 

It could be undertaken within the ST training 

The research topics should be relevant to the ST trainees’ interest and preferably stem from their working 

experience 

The “active” educational methods are needed 

The effort is a valuable experience and bring success and satisfaction 


http://www.woncaeurope.org/content/research-general-practice-what-and-how-teach 

References 

47


1. Howie FGR. Research Methods in General Practice. Chapman Hall: London, 1989. 

2. Armstrong D, Grace J. Research Methods and Audit in General practice. Third Edition. Oxford University Press: Oxford, 

2000. 

3. Hesse-Biber S, Leavy P. Approaches to Qualitative Research. Oxford University Press: Oxford, 2002. 

4. Katić M, Budak A, Vrcić-Keglević M, Blažeković-Milaković S, Bergman-Marković B, Tiljak H, Lazić Đ, Cerovečki-Nekić V, 

Petriček G, Ožvačić Z. Scientific and research projects of the department of Family medicine: contribution to the identity 

of general practice as scientific discipline [in Croatian]. Liječ Vjesn 2002;124 (Suppl 2):S32-6. 

5. Vrcić Keglević M, Katić M, Tiljak H, Lazić Đ, Cerovečki Nekić V, Petriček G, et al. Specialization in family medicine-has all the 

planned been achieved? [In Croatian] Acta Med Croatica. 2007;61(1):95-100. 

6. Davorka Vrdoljak, Dragomir Petric. A proposal for enhancement of research capacities in Croatian general practice. Acta 

Medica Academica 2013;42(1):71-79. 

7. Hummers-Pradier E, Beyer M, Chevallier P, Eilat-Tsanani S, Lionis C, Peremans L, et al. Research Agenda for General 

Practice/ Family Medicine and Primary Health Care in Europe. Maastricht: European General Practice Research Network 

EGPRN; 2009. 

48


Donatella Sghedoni, MD 

dsghedoni@asl.milano.it 

14 – An International Comparison of the Role of the Family 

Doctor in Different Countries and its Consequences on the National Health 

Outcomes and Expenditures: What has Changed in More than 10 years? 

Donatella Sghedoni, MD 

General Practice Unit, Primary 

Care Services Department , ASL 

(Azienda Sanitaria Locale) of 

Milan, Italy 

Co-authors 

Maria Enrica Bettinelli, MD, 

Alberto Donzelli, MD 

In the 2002 WONCA Congress (London) Alberto Donzelli, Maria Enrica Bettinelli and I 

delivered the presentation “An International Comparison of the Role of the GP in 

Different Countries and its Consequences on the National Health Outcomes and 

Expenditures”. 

The authors are MDs, with clinical and organizational specializations, working for the 

NHS in the continuing education and management of >1000 GPs, in Milan, Italy. 

We addressed some issues about the organization of primary care in industrialized 

countries, looking at the available evidence. 

The GP is the health professional closest to the greatest number of citizens and the 

only professional who can provide personalized/comprehensive care, including 

prevention, at reasonable costs. 

In order to fully accomplish this task, GPs must coordinate and filter the marketdriven 

increasing technological suggestions, be the patients’ advocate in order to 

avoid unnecessary medicalisation, as well as consider the community’s needs and 

attempt to influence the physical/social environment components of the disease. 

The main issues regarding the GPs’ role, how to finance them and organize the health 

service are: 

 

 

 

GPs (mainly) gate-keeper vs. direct provider of services 

GPs paid by capitation vs. fee-for-service 

Public NHS vs Health insurance-based 

We considered the economic point-of-view of the NHS and the community’s wider 

opinion, highlighting the more effective and cost-effective options on the basis of the 

available health and economic indicators. We chose the reliable, updated 

Organization for Economic and Cooperation Development/OECD Health database 

(2001), comparing it now with the 2013 OECD database (1) and others (2). 

To measure the effectiveness and cost-effectiveness in producing health, we chose 

some proxy health and economic available indicators. Health indicators were lifeyears 

lost before 70 years for avoidable mortality; infant mortality; and rates of 

selected surgical interventions. The main economic indicator was the percentage of 

the Gross Domestic Product/GDP spent for health in every country, as total and public 

expenditures. We differentiated the countries according to the different GPs’ role, 

payment and health system model, with special interest for Italy, where the GPs are 

gate-keepers, paid mainly by capitation with some incentives, in a NHS. There is still 

political pressure towards more market and privatization, supposedly more costeffective. 

In 2002, with the exception of Portugal, the USA had the highest quantity of life-years-lost before 70 among the 

49


examined developed countries; in 2013 their life expectancy is still lower than the average of the 34 OECD countries 

(78.7 vs 80.1 years) and much lower than Italy, second-best within the whole evaluation (82.7 years). 

The infant mortality pattern has not changed, with Nordic countries experiencing the lowest rates (2/1000 live births) 

and around 4/1000 in the other Western European countries and 6.1/1000 in the USA. The reduction in infant 

mortality has been slower in the USA than in most other OECD countries, with socio-economic/ethnic inequalities 

playing a significant role. 

In 2002 the rates of some surgical elective procedures showed regional variations not consistent with any 

epidemiological pattern, but strongly correlated with the different method of payment of doctors and with the health 

systems’ organizational structure. This is still valid today. 

We addressed the question whether a GP is more effective and efficient when he/she is mainly a gate-keeper or a 

direct provider of services, even when these functions are compounded in the work of European GPs. 

The Total Health Expenditure was higher in countries without a gate-keeping GP and with direct access to the specialist 

(i.e. USA, Switzerland, France, Belgium…). The countries with gate-keepers (i.e. Italy, UK, Spain…) spent less and 

achieved better health results. Since 2002 the European economic situation has deteriorated and health expenditure 

has abruptly decreased in some countries (Greece), but the main findings seem still valid. 

If the main source of income and gratification comes from the direct provision of services, especially if highly 

technological, this could divert GPs from the fundamental role of gate-keeping. Under these circumstances, they must 

question the appropriateness of many prescriptions or suggestions coming from hospitals or university specialists. The 

gate-keeping task often makes the doctor-patient relationship problematic, especially if it has not been included in the 

education and training and is not seen as important or valued by the health system and community. The public should 

be educated on the value of the gate-keeping function and its ethical significance for a better use of available 

resources. 

The direct provision of additional services is usually linked to fee-for-service payments and where they are used the 

per-person total and public expenditures are higher than where capitation or salary are preferred. Doctors seem to 

provide the best rewarded services, even if they are aware of their questionable health value (3). 

The capitation payment should also be preserved for ethical reasons, being more suitable to comprehensive care, 

prevention included, according to the patient’s needs. It should evolve towards an age-weighted capitation formula 

with a progression by age, weighted more towards the elderly (and infants) than the young (4). It could be integrated 

by incentives based on results/levels-of-result, especially in crucial areas such as the anti-smoking and breast-feeding 

counselling in Italy. 

The General Medical Contract/GMS for GPs with its related Quality Outcome Framework/QOF, introduced in 2004 in 

the UK and continually readjusted, showed that the P4P was more expensive than expected because most GPs have 

reached the fixed goals, concentrating their efforts on the targeted areas only. Our model with a strongly age-weighted 

capitation is more comprehensive and should avoid the latter. 

The role of GPs is also preventative; increased financial reward for older patients should encourage every evidencebased 

preventative efforts to ensure a healthy old age for their patients, avoiding unnecessary diagnostics and 

treatment, recently defined as “quaternary prevention” (5). To sum up: “A system that pays for health and not for 

disease”. 

Comparing Insurance–based and NH services, the total health expenditures are obviously not contained by the former, 

and such systems are not able to contain the public expenditure, both in the non-profit version (“mutuel”, 

“Krankenkassen”…) and in the profit ones (private insurance companies) which also have the worst health outcomes. 


 

 

 

 

National health services are still the more effective and efficient health systems 

Within them, GPs should have a strong role as gate-keeper 

GPs should be paid by a weighted capitation system, integrated by outcome-based incentives 

Fee-for-service payments and other systems paying for disease (disease management…) and for processes 

(pay-for-performance/P4P…) should be dismissed in favour of a system paying for health (and for a long 

healthy life of the citizens) 

50



http://www.woncaeurope.org/content/419-international-comparison-role-general-practitioner-gp-different-countries-and-its 

References 

1. http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf 

2. http://www.euro.who.int/en/about-us/partners/observatory 

3. Brotons C, Bjorkelund C, Bulc M et al. Prevention and health promotion in clinical practice: the views of general 

practitioners in Europe. Prev Med 2005; 40: 595–601. 

4. Donzelli A, Carelli F, Ronchi L et al. A Reform of Rewarding Systems of the Providers and Other Players in Health Care 

Arena: a Structural Way to Prevent Overdiagnosis and Disease Mongering. Response July, 5, 2012 to: Moynihan R, Doust J, 

and Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012; 344:19-23 

5. Kuehlein T, Sghedoni D, Visentin G et al., Quaternary Prevention: a task of the General Practitioner - Primary Care 2010;10: 

Nr. 18 (translated also in German, Italian, French, Spanish, Portuguese and Croatian) 

http://www.primary-care.ch/docs/primarycare/archiv/de/2010/2010-18/2010-18-368_ELPS_engl.pdf 

51


William Wong MD (Edin) MPH (CUHK) FRACGP (Aus) 

FRCGP (UK) 

wongwcw@hku.hk 

15 – Tackling Health Inequalities: the Role of Family Medicine 

Dr. William Wong MD (Edin) 

MPH (CUHK) FRACGP (Aus) 

FRCGP (UK), 

Specialist in Family Medicine, 

Clinical Associate Professor & 

Chief of Research, Department of 

Family Medicine and Primary 

Care, The University of Hong 

Kong, Hong Kong, China 

Co-authors: 

E Shadmi, Karen Kinder, Iona 

Heath, Michael Kidd 

The late Barbara Starfield left us her wisdom, “Inequity is built into health systemsespecially 

health systems that are based on a view of health needs disease by disease. 

Therefore, the benefits of primary care, which is in person- and population- rather than 

disease-focused, are under-appreciated. Data provide evidence not only of its benefit to 

populations but also of its preferential benefit to the socially disadvantaged.” (1) 

Introduction 

Health inequities occur in different socio-economic classes (2), and span across a wide 

range of socio-cultural characteristics (2-3). Health inequity refers to differences in 

health that are not only unnecessary and avoidable, but are also unfair and unjust (4). 

Research consistently shows that gaps in health and health care persist, and are even 

widening (5). Research has repeatedly shown the strength of a country’s primary 

health care system and its primary care attributes significantly improves populations' 

health and reduces inequity (6-7). Starfield et al identified the primary care attributes 

that contribute to population health, including first contact access, greater focus on 

prevention, provision of person-focused comprehensive care, with greater continuity 

and coordination (7). Such attributes are of special importance to inequity reduction 

as the socially disadvantaged have a greater likelihood of occurrence, severity, and 

adverse effects in multiple illnesses for which a comprehensive, coordinated, personfocused 

primary care (rather than a speciality driven, disease-focused) view of 

morbidity can be more effective (1). 

Recent evidence also supports the above conclusions showing that primary care can 

reduce inequity in developed as well as in low and middle-income countries. A review 

that assessed the contribution of large primary care initiatives to a broad range of 

health system goals in low and middle-income countries concluded that primary carefocused 

health initiatives had improved access to health care, including among the 

poor, at reasonably low cost and primary care programs had reduced child mortality 

and, in some cases, wealth-based inequity in mortality (8). 

Current Health Inequity Issues Faced by Primary Care Practitioners 

(PCP) 

As a foundation step for the establishment of WONCA's first Health Equity Special 

Interest Group, The World WONCA held a workshop on health equity during its biannual 

meeting in Prague on 26-30 June 2013 with the aim of exploring how a better 

understanding of health inequities could enable PCP to adopt strategies that could 

improve health outcomes through the delivery of primary health care. It was 

attended by 120 delegates from across the globe, including developed as well as low 

and middle-income countries. Following the presentations, workshop attendees were 

asked to participate in small group discussions and were asked to rate on thirteen possible inequity reduction activities 

52


on a 1-5 Likert scale in an anonymous survey. 

In the small group discussions, they recognized in their own setting how uneven distribution of social determinants of 

health could have affected poor health outcomes such as life expectancies and risk behaviours, and how health 

systems that had operated in different countries could have systematically affected people’s affordability as well as 

access to healthcare services and fundamental rights to good health. They identified health workforce shortage, lack of 

communications between primary & secondary care, low political incentive and priority for marginalized populations 

as well as low health literacy and expectation of the patients as contributions in meeting the health equity agenda. 

They believed signposting for how to navigate the healthcare system and training should be provided to leaders of 

vulnerable groups since community awareness should be provided to the public as well as the patients. Furthermore, 

they believed that training in inequity should be provided to medical students as well as PCP on how to improve health 

equity through primary care. 

Overall, the participants rated the degree to which their country currently had utilized the various mechanisms to 

reduce health inequity as “moderate” (mean: 2.85, standard deviation (SD): 1.12). The results indicated that the types 

of mechanisms most commonly utilized included: promoting access to primary care (mean: 3.63, SD: 1.24); initiation of 

public health programs to promote health equity (mean: 3.17, SD: 1.01); and, promoting access to care by increasing 

coverage (mean: 3.12, SD: 1.36). The activities least practised were: engagement in cross-national collaborations to 

promote health equity (mean: 2.12, SD: 0.99); promoting research on health equity (mean: 2.40, SD: 1.04); and, 

reforming medical education to incorporate health equity and cultural competency training (mean: 2.44, SD: 0.96). 

On average, participants rated the degree to which they had believed the items representing priority areas which 

countries should be engaged in as “high” (average: 3.85, SD: 0.88). Practices most commonly viewed as useful were: 

promoting the availability of primary care services (mean: 4.68, SD: 0.63); and, initiation of primary care programs to 

promote health equity (mean: 4.42, SD: 0.76). 

How Could PCP Help in this Movement? 

In view of these findings and enthusiasm within the profession, the Health Equity Special interest group (SIG) was 

proposed and approved by the WONCA Executive in early 2014 bringing the essential experience, skills and perspective 

of interested PCP around the world to address the differences in healthcare that are unfair, unjust, unnecessary but 

avoidable. It is hoped this group will use WONCA as a platform for exchange of ideas, advice, support and advocate for 

better equity in health. 

The WONCA Health Equity SIG plans to contact and work with existing centres on health equity; to provide news 

updates and events related to health equity; to conduct/facilitate literature review on research gaps; to 

collaborate/identify/set up a resource centre on health equity; to organise regional/international workshops/ seminars 

to keep up with the health equity agenda; and, to formulate a framework within a medical curriculum on health 

equity. Interested parties should visit: 

http://www.globalfamilydoctor.com/groups/SpecialInterestGroups/HealthEquity.aspx for further information. 


 

 

 

 

 

Despite evidence of the contribution of the core attributes of primary care to populations’ health and 

reduction of inequity, inconsistencies are found in implementation of primary care features in different 

countries, with greater emphasis on the provision of easily accessible primary care and less investment in 

promoting programmes to improve continuity or coordination. 

Health equity workshop participants expressed similar assessments regarding their countries’ priorities, 

indicating that promoting access (availability and coverage) of primary care services was more often 

performed than initiating tailored primary care interventions (mean score: 3.04-3.63, compared to 2.96, 

respectively). 

Importantly, survey respondents identified “promoting access to primary care services” as the most important 

priority that countries should engage in. 

Activities that have been previously cited as important for promoting equity in health i.e., reform in medical 

education, promoting research, and fostering cross-national collaborations, were identified by survey 

respondents as low current priorities in their own countries. 

Assessment of the gaps between current and preferred priorities showed that to bridge expectations and 

53


actual performance, countries should engage in forming cross-national collaborations; incorporate health 

equity and cultural competency training in medical education; and, engage in initiation of advocacy programs 

that involve major stakeholders in equity promotion policy making as well as promoting research on health 

equity. 

This article is a modified version of the manuscript published at the International Journal of Health in Equity 

(http://www.equityhealthj.com/content/13/1/104). 


http://www.woncaeurope.org/content/28-tackling-health-inequalities-role-general-practice 

References 

1. Starfield B. The hidden inequity in health care. International journal for equity in health. 2011;10:15. 

2. WHO. Closing the gap in a generation: Health equity through action on the social determinants of health. 2011; 

www.who.int/social_determinants/final_report. Accessed November 20, 2013. 

3. Marmot M, Allen J, Goldblatt P, et al. Fair Society, Healthy Lives. The Marmot Review. 2010. 

4. Whitehead M. The concepts and principles of equity and health. International journal of health services : planning, 

administration, evaluation. 1992;22(3):429-445. 

5. Bleich SN, Jarlenski MP, Bell CN, LaVeist TA. Health inequalities: trends, progress, and policy. Annual review of public 

health. Apr 2012;33:7-40. 

6. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for 

Economic Cooperation and Development (OECD) countries, 1970-1998. Health services research. Jun 2003;38(3):831-865. 

7. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. The Milbank quarterly. 

2005;83(3):457-502. 

8. Kruk ME, Porignon D, Rockers PC, Van Lerberghe W. The contribution of primary care to health and health systems in lowand 

middle-income countries: a critical review of major primary care initiatives. Social science & medicine (1982). Mar 

2010;70(6):904-911. 

54


The level to which this 

activity is currently part 

of respondent's 

countries' key priority 

issues (1-5) * , M±SD 

The level to which this activity 

SHOULD be part of 

respondent's countries' key 

priority issues (1-5) ** , M±SD 

Initiation of advocacy programmes to involve major 

stakeholders in equity promotion policy making 

Reform of medical education to incorporate health 

equity and cultural competency training 

2.71±1.08 4.35±0.75 

2.44±0.96 4.19±0.83 

Promote research on health equity 2.40±1.04 3.96±0.85 

Initiate public health programmes to promote health 

equity 

Initiate primary care programmes to promote health 

equity 

Promote access to care – availability of primary care 

services 

Promote access to care- increased coverage of 

services / health insurance 

3.17±1.01 4.22±0.89 

2.96±1.04 4.42±0.76 

3.63±1.24 4.68±0.63 

3.12±1.36 4.20±1.12 

Promote access to care- point-of- service free care 3.04±1.06 4.08±1.08 

Promote the collection of socio-demographic data on 

patients in a routine and standardized way 

Write guidelines for physicians for health equity 

promotion 

Promote the development and implementation of 

tools to measure and monitor inequity in health 

3.07±1.46 3.82±1.31 

2.70±1.23 3.74±1.13 

2.73±1.12 4.11±0.70 

Promote diversity in medical workforce 2.96±1.19 4.04±0.84 

Engage in cross-national collaborations to promote 

health equity 

2.12±0.99 4.08±0.91 

* 

1=Currently not a priority; 5=Currently a top priority. 

** 

1=SHOULD not be a priority; 5=SHOULD be a top priority 

55


Harris Lygidakis, MD 

lygidakis@gmail.com 

16 – Using the Internet to Answer Clinical Questions 

Harris Lygidakis, MD 

Vasco da Gama Movement - 

Immediate Past Chair, 

Bologna 

“Medicine has built on a long history of innovation […] 

Doctors have embraced each new technology to advance patient care. 

But nothing has changed clinical practice more fundamentally 

than one recent innovation: the Internet.” 

- Pamela Hartzband and Jerome Groopman (1) 

Evidence-based Medicine became widely accepted at the same time that the World 

Wide Web was rapidly expanding and the development of online databases was 

making information easily available. Nowadays, healthcare professionals are 

increasingly using the Internet to obtain current health and medical information, and 

access journal articles and synthesis of evidence-based information. 

However, there is relatively limited research on the healthcare professionals’ online 

searching methods and behaviour, especially in real-world settings, beyond the 

academia’s strict models (2). The plethora of information readily available on the 

Internet has gradually shifted the focus to how well we are able to search, filter and 

appraise the most relevant, accurate and reliable information and how efficiently and 

appropriately we are able to handle and apply it in clinical practice. 

Retrieving information from the Internet necessitates specific skills and the outcome 

depends on the user’s ability to access catalogues and databases, and employ an 

effective search strategy. Besides the essential digital literacy which is considered to 

be commonplace among young physicians, healthcare professionals are also required 

to be trained in order to translate their need for information into a properly 

structured and “answerable” query (3). Systems using natural language and semantic 

tagging are under development and promise to change the way we seek and obtain 

information. 

Although almost three out of four physicians who seek out medical information on 

the Internet state that they begin their research with a generic search engine, such as 

Google (4), other research suggests that healthcare professionals prefer more specific 

resources, like Pubmed and WebMD (5). 

There are still a significant number of online resources that require paid subscriptions, 

restricting the fair dissemination of medical knowledge. 

Time also represents a major constraint: healthcare professionals have very little 

amount of time available to search the Internet for the current best information. With 

medical knowledge and literature expanding rapidly, there is a negative impact on 

how healthcare professionals are seeking and managing information, leading to 

misinterpretation of the evidence, acceptance of lower-quality information and 

resignation (3). 

Social Networks 

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Despite the exponential growth of medical information available on the Internet, many healthcare professionals still 

turn to colleagues and trusted experts as their first resource (2). With the advent of the 2.0 era, these resources are 

being replaced by global networks, where information-seeking and appraisal can be crowd-sourced. 

Although social networking should function as a companion in the search for the best available evidence, by investing 

in the development of a trustworthy network, healthcare professionals can reach out to the world and have 

information at their fingertips. Besides employing generic-purpose social networks, they can also use those relevant to 

the medical sector, such as Doximity, Sermo and doc2doc, which offer more controlled and possibly safer 

environments. What is more, in this era of brewing participatory culture they are also given the opportunity to curate 

content themselves and open up to a dialogue not only with their peers, but also with professionals from various 

settings and with different backgrounds and expertise. 

Information Seeking and Healthcare Users 

As health information is becoming widely accessible and growingly reliable, patients are increasingly interested in 

learning about their conditions, their prevention and treatments, and sharing their experiences. They seek online 

health information, connect and collaborate with the others and take advantage of the Internet not only for decisionmaking 

and management of their own condition, but also for education and advocacy purposes. In fact, according to 

the Pew Research Centre, 7 out of 10 Internet users in the United States searched for health-related information in the 

span of a year and one in three adults looked online to diagnose a condition (6). Remarkably, 30% of the older people 

sought health-related information as well. 

For the first time, as Eric Topol mentions, the medical world is getting democratized (7) and the flow of information is 

leading to a paradigm shift of the patient and healthcare professional roles. 

As patients face the overwhelming and often conflicting body of available information, it is becoming common practice 

for them to bring such information to consultations in a quest to analyse and comprehend it. Patients in fact, are 

increasingly relying on their physicians for the interpretation of the online information (5). It is therefore becoming 

increasingly essential that not only should healthcare professionals embrace this need and accept this behaviour, but 

they should also guide their patients and refer them to reliable online resources. 


 

 

 

Healthcare professionals are increasingly using the Internet to obtain current medical information and are 

gradually focusing on how well they are able to search, filter and appraise the most relevant, accurate and 

reliable information and how efficiently and appropriately they are able to handle and apply it in clinical 

practice. 

Information-seeking and appraisal can be crowd-sourced with the use of social networks, where physicians 

can also curate content and converse with professionals around the globe. 

As patients seek online health information, and connect and collaborate with others on the Internet, 

healthcare professionals should be able to help them interpret such information and guide them to reliable 

online resources. 


http://www.woncaeurope.org/content/3550-using-internet-answer-clinical-questions 

References 

1. Hartzband P, Groopman J. Untangling the Web--patients, doctors, and the Internet. N Engl J Med. 2010;362(12):1063-6. 

doi: 10.1056/NEJMp0911938. PubMed PMID: 20335581. 

2. Younger P. Internet-based information-seeking behaviour amongst doctors and nurses: a short review of the literature. 

Health Info Libr J. 2010;27(1):2-10. doi: 10.1111/j.1471-1842.2010.00883.x. PubMed PMID: 20402799. 

3. Clarke MA, Belden JL, Koopman RJ, Steege LM, Moore JL, Canfield SM, et al. Information needs and information-seeking 

behaviour analysis of primary care physicians and nurses: a literature review. Health Info Libr J. 2013;30(3):178-90. doi: 

10.1111/hir.12036. PubMed PMID: 23981019. 

4. Lewis Dolan P. 86% of physicians use Internet to access health information. Am Med News [Internet]. 2010. Available 

from: http://www.amednews.com/article/20100104/business/301049966/7/. 

5. Higgins O, Barry M, Dmegan C. A literature review on health information seeking behaviour on the web: a health 

consumer and health professional perspective. European Centre for Disease Control, 2011. 

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6. Susannah F, Maeve D. Health Online 2013. Pew Research Center’s Internet & American Life Project, 2013. 

7. Topol E. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic 

Books; 2012. 

58


John Sandars 

j.e.sandars@sheffield.ac.uk 

17 – Threats to Patient Safety in Primary Care: A Review of the 

Research into the Frequency and Nature of Errors in Primary Care 

John Sandars MD 

Professor, Academic Unit of 

Medical Education, The Medical 

School 

The University of Sheffield 

This WONCA Conference presentation was based on a literature review that had been 

sponsored in 2001 by the Department of Health in the UK. Several databases were 

systematically reviewed, the key findings of which showed that medical error 

occurred between five and 80 times per 100,000 consultations, and these errors were 

mainly related to the processes involved in diagnosis and treatment (1). Prescribing 

and prescription errors were identified to occur in up to 11% of all prescriptions, and 

these were mainly related to errors in dose. 

An important aspect of this review was to highlight firstly, the wide variety of 

definitions of the various threats to patient safety that were used to identify the 

frequency and nature of these threats and secondly, the different methods used to 

identify threats to patient safety. These findings are of great importance if a 

comprehensive understanding of the frequency and possible causes of threats to 

patient safety is to be obtained. This understanding is essential for making 

appropriate interventions, including policies and protocols, to reduce threats to 

patient safety, with the ultimate aim of improving patient care. 

The main approaches to identifying threats to patient safety are incident reporting, 

systematic identification (such as by observing clinical practice), and medico-legal and 

patient complaint databases and qualitative interviews. All of these approaches reveal 

different aspects since some of the events may, or may not, have caused actual harm 

and the identification may only be through mandatory reporting, with greater 

emphasis on the less common but more serious events. Overall, the variety in the 

reported frequency and type of threat to patient safety depends on the different 

perspectives obtained from family physicians, primary health care workers and 

patients. A recent study has confirmed these findings, noting that patient surveys 

identified the highest number of events and pharmacist reports for the lowest 

number (2). Many of these events reported by patients are likely to have caused 

minimal harm but can be regarded as an indicator of potential causes of more serious 

threats to patient safety. 

The causes of threats to patient safety are usually a combination of inter-dependent 

factors (3). A study in primary care found that about half of the threats to patient 

safety were due to “situational” factors and that these events were often linked to 

serious potential consequences. The most frequent contributing factor was the 

organisation of work in primary care, including the excessive demands of working in a 

complex clinical environment, as well as the fragmentation of healthcare across the 

variety of different health care providers in primary care (4). 

Dealing with complexity is typical of the work of primary care and it is not surprising 

that this factor is a major contributory cause of threats to patient safety. A recent 

59


study in the UK found that there was a risk of eight adverse events per 10 000 consultations, and that the highest risk 

were in patients aged 65–84 years, in patients who frequently consulted, patients who had five or more emergency 

admissions and in those patients who had the most diseases recorded (5). It is also interesting to note the findings of a 

review of international malpractice claims (6) .The most common reason for a claim was associated with failure to, or 

delay, in diagnosis, especially missed or delayed diagnoses included cancer and myocardial infarction in adults and 

meningitis in children. Medication error was the second most common reason for a claim. 

Threats to patient safety continue to be a priority for all healthcare systems, including primary care. The increasing 

recognition over the last 20 years that these threats are associated, and probably to some extent inevitable, when 

working in a complex clinical environment should turn attention of all stakeholders to the important “situational” 

factors. The approach should be to minimise the impact of these factors on the process of healthcare, such as ensuring 

doctors recognise when they feel under stress, developing clinical decision-support systems and empowering patients 

to speak out during the process of their care. 


 

 

 

 

 

Estimates of the frequency and nature of threats to patient safety in primary care vary widely due to 

differences in definition and method of identification, with patient surveys identifying the highest number of 

threats to patient safety 

The most common causes of threats to patient safety in primary care are related to making a diagnosis and 

using medication. 

Recent research highlights the importance of factors associated with the complexity of providing primary 

care, such as elderly patients with co-morbidities and early diagnosis of serious diseases, to threats to patient 

safety in primary care. 

The importance of “situational” factors, such as work-load stress and fragmentation of care across different 

healthcare providers, is increasingly recognised as contributing to threats to patient safety in primary care. 

Reducing threats to patient safety in primary care requires an awareness of the different inter-related factors 

that occur with the complexity of the provision of primary care and requires a variety of appropriate 

interventions, including empowering patients to speak out during the process of their care. 


http://www.woncaeurope.org/content/53-threats-patient-safety-primary-care-review-research-frequency-and-nature-errorsprimary 

References 

1. Sandars , J., Esmail, A., (2003). The frequency and nature of medical error in primary care: understanding the diversity 

across studies. Family Practice, 20(3), 231-236. 

2. Wetzels, R., Wolters, R., van Weel, C., & Wensing, M. (2008). Mix of methods is needed to identify adverse events in 

general practice: a prospective observational study. BMC family practice, 9(1), 35. doi:10.1186/1471-2296-9-35 

3. Sandars, J., & Cook, G. (Eds.). (2009). ABC of patient safety. John Wiley & Sons. 

4. Kostopoulou, O., & Delaney, B. (2007). Confidential reporting of patient safety events in primary care: results from a 

multilevel classification of cognitive and system factors. Quality and Safety in Health Care, 16(2), 95-100. 

doi:10.1136/qshc.2006.020909 

5. Tsang C1, Bottle A, Majeed A, Aylin P. Adverse events recorded in English primary care: observational study using the 

General Practice Research Database Br J Gen Pract. 2013 Aug;63(613):e534-42. doi: 10.3399/bjgp13X670660. 

6. Wallace, E., Lowry, J., Smith, S. M., & Fahey, T. (2013). The epidemiology of malpractice claims in primary care: a 

systematic review. BMJ Open 2013;3:e002929 doi:10.1136/bmjopen-2013-002929 

60


John Yaphe MD 

yonahyaphe@hotmail.com 

18 – Teaching and Learning about Uncertainty in Family Medicine 

John Yaphe MD 

Associate Professor, Community 

Health, University of Minho, 

Portugal 

Uncertainty is a fact of life. We face many kinds of uncertainty in medicine: 

uncertainty about diagnosis, tests, treatments, and outcomes. There is financial, 

political, and organizational uncertainty in health services. All this is in addition to 

uncertainty in our daily lives. 

Acceptance of uncertainty can help us develop coping strategies in the low-tech, hightouch 

world of Family Medicine. We can teach this to our students and trainees and 

hone this throughout our careers. Does uncertainty make us ask more questions, 

order more tests, prescribe more treatments, make more referrals, and do more 

surgery? Does it lead us to take time for personal reflection and discussion with 

colleagues, patients and their families? It is worth exploring this field and considering 

new directions for research. 

Attitudes to uncertainty have shifted from attempts to master or diminish uncertainty 

to efforts to cope with it. Many accept and celebrate that things remain uncertain. 

Uncertainty can be tolerated (1). By sharing responsibility with the patient we can 

make it easier on ourselves. Long-term relationships in family medicine and close 

follow-up allow us to use time as a diagnostic and therapeutic tool. This may reduce 

anxiety in both doctor and patient from the initial visit. 

Uncertainty arises in primary care at the point of first contact with the medical care 

system (2). Patients appear with undifferentiated symptoms. A patient-centred 

approach, focusing on understanding the patient’s reasons for consulting, may help. 

The doctor-patient relationship is an important tool for managing uncertainty. 

Shared decision-making affects doctors’ feelings of uncertainty and their willingness 

to disclose this to patients (3). Anxiety may be related to gender and be more 

prevalent among younger doctors. Willingness to learn about shared decision-making 

increases comfort through sharing uncertainty with patients. Training can help people 

to cope with the inevitable uncertainty of practice. 

Consider a 30 year-old man who comes to the family doctor with low back pain of 

three days’ duration, after heavy lifting at home. The neurological examination is 

normal. When doctors are asked how certain they are of their diagnosis and that their 

usual treatment would help the patient in this scenario, figures are high on both 

counts. When they subsequently learn that this patient had a history of successful 

treatment with radiotherapy and chemotherapy for Hodgkin’s disease ten years 

earlier, assessments of certainty fall. Context is everything. 

Uncertainty also plagues our patients. Patients with chronic obstructive lung disease 

face ambiguity, defined as a lack of understanding of symptoms, and complexity, 

defined as lack of understanding of treatment (4). Criticism from family members 

increases uncertainty while participation in patient support groups helps patients by 

decreasing uncertainty. Research into patient self-help groups and their effects on 

uncertainty and self-efficacy might be useful. 

Uncertainty may represent hope to patients. We need to recognize and validate uncertainty in our patients concerning 

61


breast self-examination (BSE) (5). BSE increases anxiety without decreasing morbidity or mortality from breast cancer. 

Teachers also feel uncertain (6). They may ask: how much do my students know and understand, how effective is my 

teaching, how can I best use the limited time I have with students and what intellectual and social authority do I have 

to teach? Too much uncertainty in the classroom can lead to anarchy while too little uncertainty can lead to 

dogmatism. 

Medical students appreciate that we can’t know it all, we don’t know everything, and we can’t even agree on what we 

think we know. We help our students by listening to their concerns, helping them to ask questions, strengthening their 

healthy coping mechanisms, providing information they need, and simply by being there for them. 

Are evidence-based medicine and computers sufficient to lift the smog of uncertainty (7)? Technology and data are not 

enough. We work in complex systems on the edge of chaos (8). Strategies for coping with uncertainty may include 

shared reflection of narratives in Balint groups. 

Research may tell us how much uncertainty plays a role in our clinical encounters and describe the ways patients and 

doctors cope. We should assess the consequences of uncertainty, including costs. We need to understand the meaning 

of uncertainty in the unique context of family medicine. The results of research in this field will certainly be helpful to 

us. 


 

 

 

 

 

Uncertainty is a fact of life in Family Medicine. 

We can tolerate, accept, manage, and even celebrate uncertainty. 

A patient-centred approach and long-term relationships can help us cope with uncertainty. 

Patients may value uncertainty because it gives them hope. 

Research will help us understand how we cope with uncertainty and what this means to medical care. 


http://www.woncaeurope.org/content/73-teaching-uncertainty 

Conflict of interest: 

None reported 

This essay first appeared in another format in The Portuguese Journal of Family Medicine in 2014. It is reprinted with 

permission. 

Dedication 

It is dedicated to the memory of Dr. Ivar Ostergaard, the original co-author of the workshop on uncertainty presented 

at the WONCA 2001 conference in Tampere. 

References 

1. Thomson GH. Tolerating uncertainty in family medicine. J R Coll Gen Pract. 1978 Jun;28(191):343-6. 

2. Biehn J. Managing uncertainty in family practice. Can Med Assoc J. 1982 Apr 15;126(8):915-7. 

3. Politi MC, Légaré F. Physicians' reactions to uncertainty in the context of shared decision making. Patient Educ Couns. 2010 

Aug;80(2):155-7. doi: 10.1016/j.pec.2009.10.030. Epub 2009 Nov 30. 

4. Hoth KF, Wamboldt FS, Ford DW, Sandhaus RA, Strange C, Bekelman DB, Holm KE. The Social Environment and Illness 

Uncertainty in Chronic Obstructive Pulmonary Disease. Int J Behav Med. 2014 Jul 10. [Epub ahead of print] 

5. Babrow AS, Kline KN From "reducing" to "coping with" uncertainty: reconceptualizing the central challenge in breast selfexams. 

Soc Sci Med 2000 Dec;51(12):1805-16 

6. Floden, RE, Buchmann, M. Between Routines and Anarchy: Preparing Teachers for Uncertainty. Occasional Paper No. 138. 

1992 The Institute for Research on Teaching, Colege of Education, Michigan State University, East Lansing, Michigan 4824- 

1034 

7. Djubekovic B. Lifting the fog of uncertainty from the practice of medicine. BMJ. 2004 Dec 18;329(7480):1419-20. 

8. Tudela M, Amado Lobo F, Ramos V. Desafios da complexidade em medicina geral e familiar. (Challenges of complexity in 

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general practice) Rev Port Clin Geral, 2007, Vol. 23, Nº 6, 715-725. 

63


Paul Van Royen, MD, PhD 

paul.vanroyen@uantwerpen.be 

19 – Home Visits: are they Useful or Necessary in Family Medicine? 


Professor of General Practice, 

Department of Primary and 

Interdisciplinary Care, University 

of Antwerp, Belgium 

Introduction 

In most European countries home visits form part of the family doctors’ (FD) normal 

routine. However, the chance of receiving a home visit by a family doctor varies 

widely across Europe. In the Nineties, the percentage of home visits was high in 

several European countries, such as Belgium, Germany and France (1). But also in East 

European countries, such as Moldavia, the percentage of home visits varied from 35 

to 40 %, taking up the majority of the doctor’s time (2). However in health care 

systems with a patient list system and payment by capitation, there were fewer home 

visits. Especially in Scandinavian and Mediterranean countries, family doctors had a 

low frequency of home visiting (1). 

Necessity of Home Visits – Their Added Value, Disadvantage and/or 

Benefit Versus an Office Encounter 

There is a debate about the value of home visits and the appropriate rate. 

Patients seemed to like home visits more than family doctors did, and it is likely that 

this is often the deciding factor , as stated by several authors (1, 2). There is little 

debate about the family doctor's role in performing a home visit when patients are 

restricted in their mobility, especially for the elderly and very ill patients. But there 

are constraints. Home visits are time-consuming (double time compared to office 

consultation), less efficient (because of less favourable clinical situations for 

diagnostic and therapeutic interventions) and not always safe to realise, especially in 

the evening and night. 

Quantitative research revealed that doctor-related factors, the organisation of the 

healthcare system and to a lesser extent, patient characteristics were explanatory 

factors for the high number of home visits (3). 

In Belgium, qualitative focus group research was conducted with family doctors, 

patients and representatives of health insurance companies, in order to list all added 

values, disadvantages of home visits by family doctors – and to explore the factors in 

determining the request and performance of home visits (4). In total, 77 items were 

identified, classified into 8 categories of a theoretical framework. Besides different 

patient groups/illnesses, health care organisation and doctor-related factors, other 

factors were also revealed – such as patient related factors (convenience for the 

patient), practice organisation (waiting times, appointment systems), context and 

intimacy (closer relationship), medical/technical factors and economic factors (cost of 

a home visit). The additional value of home visits was reported as the understanding 

gained from meeting the patients on their own territory and the observation of the 

home situation. 

64


Decreasing Rate of Home Visiting by Family Doctors 

In order to change the rate of home visits, an analysis of the necessity of home visits in countries such as Moldavia and 

Belgium was a first step. This stimulated intervention at the level of practice organisation, for example, in providing an 

easily accessible appointment system, repeatedly asking patients to come to the surgery and reduction in waiting 

times. In addition, both patients and health care providers need to alter their view of home visits. 

There has been a clear decline in family doctor home visits over the past two decades. The decrease of the number 

home visits performed was remarkable, for instance in Moldavia from 30 % in 2003 to 12 % in 2005 (2). Especially 

urgent house calls are increasingly delegated to the emergency services, whereas home visits to nursing homes are 

often characterised as emotionally stressful (5). The question arises whether these changes have really had a positive 

influence on the quality of medical services. 

When asking family doctors, they are convinced that they have to ensure quality home care but they are unable to 

suggest how this might be achieved (5). 

Home Visits in the After-hours of Primary Medical Care 

Furthermore, the organization of after-hours primary medical care services in many European countries is changing. 

The development of out-of hours cooperatives combined with telephone triage seem to decrease the home visiting 

rates (6), while deputizing services seem to increase home visiting rates. The circumstances of after-hours primary 

medical care could possibly give inspiration to daily primary care. 

Other Professionals 

Since family doctors are increasingly working within multidisciplinary teams, home visits are not just performed by 

family doctors but are increasingly redistributed from the family doctor to other qualified members of the healthcare 

team such as nurse practitioners or specially trained nurses (7). Their role is important in improving, for instance, the 

safety of medication management among older persons- but also in (tele) monitoring for different chronic diseases. 

Multiple programmes have shown to be effective. Informal caregivers are also taking up roles, which were previously 

undertaken by health care professionals and/or family doctors. They look after and provide help and support to family 

members, friends and neighbours because of their long-term physical or mental ill health/disability or problems 

related to old age. Collaborative approaches and redistribution of tasks could probably be the response to the 

challenging demand for ensuring quality home care in future. 

Conclusion 

Despite the increase of chronically ill and elderly patients, the home visiting rate by family doctors is declining in all 

European countries. Home visits remain a central element of primary care, especially for the increasing vulnerable 

patient group. Primary care should reflect on how to ensure this essential service, regarding changing contexts. 


 

 

 

 

 

Although the home visits rate has declined over the past two decades, home visits remain an important 

component of family doctors’ routine and workload. 

Many factors influence the request and performance of home visits by family doctors: doctor- related factors, 

practice organisation, contextual information and patient-related factors are the most important reasons to 

perform home visits. 

Family doctors have an important role in performing a home visit when patients are restricted in their 

mobility, especially in relation to the elderly and the very ill. 

Other healthcare professionals and informal caregivers have to take up roles in home care for and home 

visiting to the disabled and elderly, in order to ensure quality home care in future primary care. 

Collaborative approaches and redistribution of tasks are good answers to the challenging demand for 

ensuring quality home care in future. 


65


http://www.woncaeurope.org/content/cf73-home-visits-medical-necessity-or-simply-service 

References 

1. Boerma W, Groenewegen P. GP home visiting in 18 European countries. Eur J Gen Pract. 2001;7:132-7. 

2. Nemerenco A. Home Visits- A medical necessity or simply a service? 12th Regional Conference of Wonca Europe ESGP/FM; 

Firenze: Abstract book 2006. p. 56. 

3. De Maeseneer J, De Prins L, Heyerick J. Home visits in Belgium: a multivariate analysis. Eur J Gen Pract. 1999;5(1):11-4. 

4. Van Royen P, De Lepeleire J, Maes R. Home visits in general practice: an exploration by focus groups. Arch Public Health. 

2002;60:371-84. 

5. Theile G, Kruschinski C, Buck M, Müller C, Hummers-Pradier E. Home visits - central to primary care, tradition or an 

obligation? A qualitative study. BMC Family Practice. 2011;12:24. 

6. Philips H, Remmen R, Van Royen P, Teblick M, Geudens L, Bronckaers M, et al. What's the effect of the implementation of 

general practitioner cooperatives on caseload? Prospective intervention study on primary and secondary care. BMC 

Health Serv Res. 2010;10:222. 

7. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. 

Cochrane Database Syst Rev. 2005;18(2):CD001271. 

66


Ulrich Busch, MD 

buschdoctor@mnp.at 

20 – Promoting the Health and Well-being of Family Doctors 

-Guerilla Tactics for Family Doctors 

Ulrich Busch, MD 

MU Vienna Lect., 

Grosskrut, Austria 

Co-author 


Physicians are well known to be very reluctant to have a family doctor –but every GP 

needs a GP! They don't feel the need to have a competent medical “second opinion” 

or just a routine monitoring of their health. They know it all – and who would trust 

another doctor?! 

We decided to tackle this issue as a Military Operation –the doctor as his own enemy 

and feeling surrounded by enemy colleagues. 

Sometimes when your day was fully packed fighting infectious and non-infectious 

diseases, fighting against insurance companies’ bureaucracy, struggling with technical 

problems in your computerized office, never finding the right specialist at the right 

time when you need him/her, then one can feel forsaken from the protecting crowd 

of medical doctors. 

In your Forward Command Post, with limited low cost armaments, as near as possible 

to your entrusted patients, that´s where your graduate and postgraduate Training 

someday comes to an End. Once you realize that the people are the key to be secured 

and defended rather than the conquest of new Scientific Territory, you will seek new 

strategies to carry on. 

Guerilla Tactics for Family Doctors focuses on low-cost strategies to guarantee one’s 

own healthy survival. These Guerilla Tactics were surely never taught at any medical 

College, or at the University… 

Strategies for Survival 

Acquire Dogs & Training 

Since scientists left their Offices and followed Timber Wolves to the woods, we begin 

to understand why dogs are the most successful companions of Mankind. They 

developed a rich Body Language or “Calming Signals“, easily understood by any Dog 

worldwide, and by humans! If you want something to be done by a dog, it´s mostly a 

question of motivation! Dogs immediately show their Feelings and Emotions to the 

pack and seem to balance Signs of Stress and Discomfort very quickly in order to 

avoid stress (Turid Rugaas). A Dog wants to get out no matter what the weather and 

enjoys your sporty companionship very much. Communicating with this species 

focuses on the understanding of Body Language and a few Words. And by looking at 

the dog, you know who’s boss (‘What the Dog Saw’, Malcolm Gladwell). 

Photography 

A doctor should have fundamental knowledge of taking a picture. As doctors, we are 

obliged to focus on Light, to help People out of their unknown Darkness of their 

Complaints: The more you see, the more you learn, the more you learn, the more you see (Aldous Huxley). Go buy a 

good Camera! Reframe your Picture of yourself as a GP on a regular base. Be aware that you only get the inside-out 

67


view. Once in a while, you should also practice the art of looking outside-in (Kahneman). 

Try to relax and condense a moment of time, freeze a movement, a notion, catch an emotion with your lens. Then 

store it and refresh every bit of these pictures. You might try some photoshopping once in a while. Delete what you 

don't like, sharpen the edges, give a little more contrast when it's lacking, be the director. 

Dancing 

Dancing offers Family Doctors a whole new world of a worldwide fully accepted Concept of Interaction with our 

Patients and Fellow Colleagues of other Disciplines. 

The Euract “Bled” Courses in Slovenia offer Family Doctors dancing lessons! 

In our daily consultations we mostly perform a Pas de Deux. Compliance and Adherence are about Leading and 

Following, and getting into ones Stride. It´s a fine School of humour in our attempts to follow the Rhythms of Life. 

Sometimes you're invited for a Quickstep, the next patient is in for a Tango, the next one likes to Waltz you around and 

a day without a Rumba is a day not lived. All this dancing can exhaust you, and at the end of the day all you want is to 

skip along Fandango on a Whiter Shade of Pale with your life partner. 

Haute Cuisine 

Some Principles in Cooking are compatible with our prescriptions /interventions: please take a close Look at the local 

Food Traditions. Exchange Recipes! Ask your patients in which season and how to prepare the Fresh Food when you 

are rewarded with it at your Office. 

Train your Nose and your Senses of Taste for the Joy of Life not only for the cure of illnesses. 

Lucky you when your dog is under-the-table to protect you from: Medicus Medico Lupus est! 

Sailing 

Some principles of sailing are also very useful. 

If the wind is coming straight from behind, just go straight out – if that is the direction you want to go. 

If the wind is from one of the sides, you can still go straight out without manoeuvring a lot. 

If the wind is opposite to you, and you decide not to go with the flow, then you need to tack. 

If the wind is changing a lot, you need to adjust your course and tacking. 

Always know your goal. Tides and winds are just as easy to play with as coping with life and its doings. 

In your Network it’s the knots not the mesh! Sail fast and live slow in the seas of Love! 

Symphonic 

Symphonic thinking is an art that is very useful in your daily life as well as in your daily practice. 

A symptom or a complaint might be a note, it might be a tune, it might also contain a whole song or harmony. Train 

your ears in discerning what you hear – or don't. 

Think of remedies or solutions as of symphonies: there is more than one music player at work, although the solo of an 

instrument can do wonders – if it is well timed and perfectly orchestrated. 

All players are equal, as equal as the slowest or worst or atonal player. See to it that you know what you are directing – 

and to what it should lead: a wonderful piece of Bach or Beatles. Engage yourself in the way of lateral thinking and 

listening what´s between the lines due to celestial strings! 

Conclusion 

Lucky you living in the countryside, if you´ve found a wonderful Partner for Dancing, a Dog as your Personal Fitness 

Trainer, and a friendly Photographer/ friend who takes your picture and lets you look outside in. Lucky you if you can 

sail on symphonic thoughts. 

The Art of practising these touches of Guerilla Tactics in Dog Training, Cooking, Dancing, Sailing and Taking Pictures 

while playing music is taught in the University of Life, and patients, partners and students help us in developing skills, 

motivation, feedback and in maturing together. 


 

 

Try to be in a good physical condition / shape. 

Learn from other species how to teach on the basis of motivation rather than of paternalistic, maternalistic, 

pillistic ways. 

68


 

 

Reflect your Life with Friends and professionally with Balint Groups. 

Be sure that your partner supports your wish to become a real good (rural) GP 


http://www.woncaeurope.org/content/37-pa-education-promote-health-and-well-being-family-doctors 

References 

E. Paul Cherniack and Ariella R. Cherniack, The Benefit of Pets and Animal-Assisted Therapy to the Health of Older 

Individuals. Arch Gerontol Geriatr. 2006 Mar-Apr;42(2):207-16. Epub 2005 Sep 26. 

Maskarinec GG, Look M, Tolentino K, Trask-Batti M, Seto T, de Silva M, Kaholokula JK. Patient Perspectives on the Hula 

Empowering Lifestyle Adaptation Study: Benefits of Dancing Hula for Cardiac Rehabilitation. Health Promot Pract. 2014 

Mar 27. [Epub ahead of print] PMID: 24677383 

Zhang J, Li C, Smithson A, Spann E, Ruan F. Culture and importance of backgrounds: a cross-cultural study of photograph 

taking. Psychol Rep. 2010 Oct;107(2):603-6. PMID:21117488 [PubMed - indexed for MEDLINE] 

Flego A1, Herbert J1, Waters E2, Gibbs L2, Swinburn B3, Reynolds J4, Moodie M1. Jamie's Ministry of Food: Quasi- 

Experimental Evaluation of Immediate and Sustained Impacts of a Cooking SkillsProgram in Australia. PLoS One. 2014 Dec 

16;9(12):e114673. doi: 10.1371/journal.pone.0114673. eCollection 2014. 

Gladwell Malcolm, What the Dog Saw, Penguin Books, 2009 

Turid Rugaas, Calming Signals, Dogwise Publishing, 2006 

69


Carlos Brotons MD, PhD 

cbrotons@eapsardenya.cat 

21 – Prevention and Health Promotion in Clinical Practice 

Carlos Brotons MD, PhD, on 

behalf of EUROPREV (European 

network for prevention and 

health promotion in GP/FM) 

Primary health care is a suitable setting for interventions to identify and reduce 

behavioural risks factors and recommend preventive activities (including 

immunisations, screening for cardiovascular risk factors and cancer, and counselling). 

A survey carried out in the year 2000 among 2082 GPs from eleven European 

countries showed that significant gaps persist between GPs' knowledge and their 

practice in the use of evidence-based recommendations for health promotion and 

disease prevention in primary care (1). To complement this GPs’ survey, and in order 

to explore patients’ views and beliefs on the importance of lifestyle and preventive 

interventions, another survey was carried out in the year 2008-2009, involving 7947 

patients from 22 European countries (2). 

The results of this survey showed that alcohol drinkers do not see, or fail to admit, 

that alcohol use is a risky habit that needs to be modified. Less than one third of risky 

drinkers would like to receive advice concerning alcohol intake from their GPs. It 

seems that patients are much more conscious about the risk of tobacco, unhealthy 

diet or sedentary lifestyle than the risk of alcohol. Also, patients reported that they 

had received less advice (in a discussion initiated by GPs) for alcohol than for tobacco, 

diet and physical exercise. In another study done in Sweden, only 18% of patients 

reported that they had received advice at least in one area, with a four-fold variation 

between the most common type of advice (exercise in 16%) and the rarest type 

(alcohol in 5%) (3). 

The view of patients that GPs initiated a discussion on smoking in 63% of cases, eating 

habits (59% of cases), and physical activity (55%) shows some correlation with the 

views of GPs in Europe as surveyed in 2000 (1). At that time, GPs declared that they 

advised smokers to quit in 61 – 71% of cases, and counselled overweight and 

sedentary patients in 59 – 62% and 54 – 57% of cases respectively. However, in this 

study patients identified as risky drinkers said that their GPs had only initiated a 

discussion regarding their alcohol use in 42% while the 2082 doctors participating said 

they would advise heavy drinkers to reduce consumption in 57 – 64% of cases. Thus 

while patients and doctors seem to agree regarding the frequency of their discussions 

on smoking, healthy eating/weight and physical activity, patients seem to have a 

more negative viewpoint on how often doctors give advice on alcohol use. Table 

shows the views of patients regarding optimal interval for screening for cardiovascular 

risk factors and cancer and for vaccination. 

More than 80% of women think they should be checked for cervical cancer yearly or 

every two years. However, revised guidelines recommend Pap test screening every 

three years for women age 30 and older (4). These findings reflect overuse of Pap test 

screening, which is expensive for the health care system and may result in 

unnecessary follow-up testing and increased risk for colposcopy-associated illnesses 

and adverse birth outcomes, as well as distress for patients (5). 

The survey also showed that 43% of women aged 30-49 thought that screening for breast cancer should be done 

70


yearly or more often and that 30% felt that screening should take place every two years. This recommendation is a 

direct challenge to the strong message from massive campaigns aimed at women in some countries over the last two 

decades advising they undergo yearly screening starting at age 40, and this is also reflected in the results of our study. 

Other studies have also found that opportunistic mammography screening in excess of the recommendation is 

common and persists despite explicit advice about recommended screening frequency (6). 

Health professionals should be conversant with the recommended testing intervals for cardiovascular risk factors and 

for cancer screening in order to better educate patients in the judicious use of such tests. 

Table. Views of patients regarding the optimal interval for screening for cardiovascular risks factors and cancer, and 

for vaccination. 

How often do you think 

it would be appropriate 

to have…,% (95% CI) 

Not at all I don't know Yearly or 

more often 

Every 2 

years 

Every 3 

years 

Less often 

than every 3 

years 

Blood pressure check 

(n=5085) 1 

1.2% 

(0.8-1.7) 

15.5% 

(13.7-19.7) 

75.1% 

(72.0-78.0) 

5.2% 

(4.3-6.3) 

1.1% 

(0.7-1.7) 

0.9% 

(0.5-1.6) 

Blood sugar check 

(n=6865) 2 

1.1% 

(0.8-1.6) 

16.7% 

(14.5-19.3) 

66.0% 

(63.3-68.7) 

12.4% 

(10.9-13.9) 

2.3% 

(1.7-3.0) 

1.5% 

(1.1-2.2) 

Blood cholesterol check 

(n=5805) 3 

1.3% 

(0.9-1.8) 

17.5% 

(14.8-20.5) 

62.6% 

(59.6-65.5) 

14.3% 

(12.5-16.3) 

2.7% 

(2.1-3.4) 

1.7% 

(1.2-2.5) 

Flu vaccination (65 

years old and over) 

(n=928) 

14.4% 

(10.9-18.7) 

15.2% 

(11.7-19.5) 

67.6% 

(61.1-73.5) 

2.0% 

(1.0-3.7) 

0.6% 

(0.2-2.4) 

0.2% 

(0.0-1.1) 

Cervical smear test 

(only women) (n=4007) 

4 

1.9% 

(1.2-2.8) 

8.5% 

(7.1-10.3) 

58.2% 

(54.9-61.5) 

23.3% 

(20.8-26.0) 

5.9% 

(4.6-7.6) 

2.2% 

(1.6-2.9) 

Mammogram (only women) (n=3650) 5 

30-49 years (n=1919) 

1.4% 

(0.7-2.8) 

14.4% 

(12.0-17.1) 

43.1% 

(38.9-47.4) 

29.7% 

(26.5-33.3) 

6.6% 

(5.0-8.7) 

4.8% 

(3.5-6.5) 

50 years or more 

(n=1731) 

2.8% 

(1.7-4.5) 

8.2% 

(6.2-10.6) 

41.7% 

(38.3-45.2) 

40.6% 

(37.1-44.2) 

4.5% 

(3.2-6.1) 

2.3% 

(1.5-3.6) 

1 Excluding patients diagnosed with high blood pressure 

2 Excluding patients diagnosed with high blood glucose 

3 Excluding patients diagnosed with high blood cholesterol 

4 Excluding women diagnosed with cervical cancer 

5 Excluding women diagnosed with breast cancer 


 

 

 

 

 

A high proportion of patients attending primary care with unhealthy lifestyles 

(especially risky drinkers) do not perceive the need to change their habits. 

Half the patients reported not having had any discussion on healthy lifestyles with their GPs. 

Patients overestimate their need to be screened for cardiovascular risk factors and for cancer. 

Further studies are needed to investigate the reasons behind these perceptions so that suitable strategies 

may be devised to tackle them. 

Health professionals should be conversant with the recommended testing intervals for cardiovascular risk 

factors and for screening for cancer in order to better educate patients in the judicious use of such tests. 

71



http://www.woncaeurope.org/content/3851-prevention-and-health-promotion-clinical-practice-views-general-practitionerseurope 

References 

1. Brotons C , Björkelund C, Bulc M, Ciurana R, Godycki-Cwirko M, Jurgova E, et al. on behalf of the EUROPREV network. 

Prevention and health promotion in clinical practice: the views of general practitioners in Europe. Prev Med 2005; 40:595- 

601. 

2. Brotons C, Bulc M, Sammut M , Sheehan M, da Silva Martins C M, Björkelund C, et al. Attitudes toward preventive services 

and lifestyle: the views of primary care patients in Europe. The EUROPREVIEW patient study. Family practice 2012; 29 

(suppl. 1): i168-i176. 

3. Johansson K, Bendtsen P, Akerlind I. Advice to patients in Swedish primary care regarding alcohol and other lifestyle 

habits: how patients report the actions of GPs in relation to their own expectations and satisfaction with the consultation. 

Eur J Public Health 2005; 15: 615-20. 

4. Cervical Cytology Screening. The American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 2009; 109: 

1-12. 

5. Yabroff KR, Saraiya M, Meissner HI, Haggstrom DA, Wideroff L, Yuan G, et al. Specialty Differences in Primary Care 

Physician Reports of Papanicolaou Test Screening Practices: A National Survey, 2006 to 2007. Ann Int Med 2009; 151: 602- 

11. 

6. Chamot E, Charvet A, Perneger TV. Overuse of mammography during the first round of an organized breast cancer 

screening programme. J Eval Clin Pract 2009; 15: 620-5. 

72


Marjan van den Akker, MD, PhD 

marjan.vandenakker@maastrichtuniversity.nl 

22 – Determinants of Multimorbidity 

Marjan van den Akker, MD, PhD 

Maastricht University, School 

CAPHRI, dept of Family Medicine, 

KU Leuven,dept of General 

Practice 

Co-authors 

Christiane Muth, Job FM 

Metsemakers, J André 

Knottnerus, Frank Buntinx 

Introduction 

Multimorbidity, often defined as the co-occurrence of two or more (chronic) diseases 

within a patient, without an index disease being specified (1), is the rule rather than 

the exception in daily clinical practice. In Western countries the prevalence of 

multimorbidity in the general population ranges around 20-30% when the whole 

population was considered, and ranges between 55-98% when only older persons 

were included (2), with Asian studies showing similar results. 

Risk Factors Associated for Multimorbidity 

The main risk factor for multimorbidity seems to be age: in older populations the 

prevalence of the most common diseases, such as heart failure and dementia, is 

much higher than among younger patients, resulting in frequent co-occurrence of 

diseases. Multimorbidity is therefore often positioned as a condition of older 

patients. This is confirmed when looking at relative numbers, but increasingly it is 

recognized, that in absolute numbers the majority of patients suffering from 

multimorbidity is less than 65 years of age, with Barnett et al (3) reporting just over 

half of the people with multimorbidity to be 65 years of age or less. 

Secondly, women and persons from low social classes consistently appeared to be 

more prone to multimorbidity across Western and Asian studies (2, 4). In a Brazilian 

study, Andrade et al (5) reported that somatic and mental disorders also frequently 

co-occur in a population sample of a developing country. The results suggest that 

substantial proportions of both chronic medical and psychiatric morbidities are not 

attributable to disorder-specific risks but rather to a few generic liability factors 

associated with many disorders, like lifestyle and distress. This supports the notion of 

general disease susceptibility (6). 

Thirdly, ethnic, educational and cultural differences seem to play an important role: 

Black Americans had significantly higher initial levels of multimorbidity relative to 

white Americans in a national representative sample of US adults (7). The same study 

by Quinones et al. showed that higher education is associated with fewer reported 

diseases. 

Methodological Influences on Prevalence Estimates 

Already in the late 1990s it was recognized that many of the choices related to design 

of the study, definition and operationalisation of multimorbidity strongly influence 

the reported prevalence and incidence of multimorbidity (8). The influence of 

methodological decisions on the reported amount of multimorbidity is considerable. 

Starting with the various definitions of multimorbidity, where the minimum numbers 

of diseases differ (two vs three or more chronic conditions), or where multimorbidity 

is defined as the simultaneous presence of diseases/symptoms, cognitive and physical functional limitations, or the 

73


unit of counting is organ systems instead of diseases. Furthermore, the number of conditions studied is of major 

importance for prevalence estimates: the higher the number, the higher the occurrence of multimorbidity. 

Apart from a disease count there are a number of validated indices, such as the Charlson Index and the Cumulative 

Index Rating Scale. Although some indices cover only a limited number of diseases, they all aim to weigh the presumed 

impact according to illness burden. As chronic conditions widely differ in terms if severity and effects on survival and 

functioning, the mere number of chronic conditions do not necessarily have a major impact on outcomes. We can 

reasonably hypothesize that disease severity, disease duration and interactions between acute and chronic conditions 

are probably much more important than the mere count of chronic morbidities in increasing mortality risk. On the 

other hand, all studies agree on the fact that persons with multiple diseases have significant medical needs, which 

raises issues of resource allocation, equality and prioritization (2). 

There is a serious distinction between data collection based on physician-diagnosed diseases (chart, paper files, EMR), 

administrative data, or patient self-reported diseases (questionnaires, interviews). The agreement between physiciandiagnosed 

and patient-reported diseases is limited. Based on availability / feasibility, data choices made should be 

optimally adjusted to the research question. 

In general, it can be stated that the more specialized the care setting the higher the prevalence of multimorbidity. 

Going from the general population to people in the waiting room in primary care, to a hospitalized population, the 

prevalence of multimorbidity is likely to increase gradually. 

Future Research 

It has been argued that future studies must begin to investigate multimorbidity across life course, to enable the 

distinction between real longitudinal changes and cohort effects. Furthermore, overlooking the field, knowledge on 

determinants of multimorbidity is still lacking for the greater part. 

Key Points 

Population prevalence of multimorbidity is 20-30%; with a sharp increase above 55 years; in absolute numbers of all 

patients with multimorbidity, more than half are over 65 years of age. 

Older age, female sex and lower level of education are apparent determinants of multimorbidity. 

Different definitions of multimorbidity and other methodological decisions have an influence on the reported 

multimorbidity. 


 

 

 

Population prevalence of multimorbidity is 20-30%; with a sharp increase above 55 years; in absolute 

numbers of all patients with multimorbidity more than half are older than 65 years. 

Older age, female sex and lower level of education are apparent determinants of multimorbidity. 

Different definitions of multimorbidity and other methodological decisions have an influence on the reported 

multimorbidity. 


http://www.woncaeurope.org/content/determinants-multi-morbidity 

References 

Full list of references is available on request from the first author. 

1. Van den Akker M, Buntinx F, Knottnerus JA. Co-morbidity or multimorbidity: what's in a name? A review of literature. Eur J 

Gen Pract. 1996;2:65-70. 

2. Marengoni A, Angelman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: a systematic 

review of the literature. Ageing Res Rev. 2011;10:430-9. 

3. Barnett K, Mercer S, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health 

care, research, and medical education: a cross-sectional study. Lancet. 2012;379. 

4. Khanam M, Streatfield P, Kabir Z, Qiu C, Cornelius C, Wahlin A. Prevalence and patterns of multimorbidity among elderly 

people in rural Bangladesh: a cross-sectional study. J Health Popul Nutr. 2011;29(4):406-14. 

5. Andrade L, Bensenor I, Viana M, Andreoni S, Wang Y. Clustering of psychiatric and somatic illness in the general 

74


population: multimorbidity and socioeconomic correlates. Braz J Med Biolog Res. 2010;43(5):483-91. 

6. Van den Akker M, Vos R, Knottnerus J. In an exploratory prospective study on multimorbidity general and disease related 

susceptibility could be distinguished. J Clin Epidemiol. 2006;59(9):934-9. 

7. Quinones A, Liang J, Bennett J, Xu X, Ye W. How does the trajectory of multimorbidity vary across black, white, and 

Mexican Americans in middle and old age? Journals of Gerontology, Series B, Psychological Sciences and Social Sciences. 

2011;66(6):739-49. 

8. Van den Akker M, Buntinx F, Roos S, Knottnerus J. Problems in determining occurrence rates of multimorbidity. J Clin 

Epidemiol. 2001;54(7):675-9. 

75


Radost Assenova, MD, PhD 

r_assenova@yahoo.com 

Gap 

23 – When Chronic Care Becomes End-of-Life Care: Bridging the 

Radost Asenova, MD, PhD 

Assoc Professor, Dept. General 

Practice, Public Health Faculty 

Medical University of Plovdiv, 

Plovdiv, Bulgaria 

National representative of 

EGPRN 

Chairperson of Bulgarian 

General Practice Society for 

Research and Education 

Population ageing remains a global phenomenon and it is not only a triumph for 

society but a huge challenge for health care systems. 

Advances in health care have transformed our society and as a result fewer people 

today die of infectious diseases, and more people live longer. In addition however, 

more people are living longer with serious and chronic illnesses characterised by 

fluctuations in trajectory, uncertainty in prognoses, extended disease timelines and 

stress. 

Helping someone that is living with a chronic condition can be challenging and 

sometimes the transition to end-of-life care is introduced too late to be fully effective. 

The Key Question Is “When Does End-of-life Care Begin?” 

The point at which end-of-life care begins depends on patients’ needs. End-of-life care 

may last a few days, or for months, or years, beginning and ending when the patient 

needs it. 

Often doctors focus on curing the disease but few have the time to explore all the 

wide-ranging solutions that can address symptoms and restore people to normal life 

as far as possible. 

The current evidence suggests various gaps in care, as reported by patients, their 

families, GPs and other health care providers. 

Identified gaps in the end-of-life care include problems in areas such as: 

 

 

 

 

patient’s quality of life 

quality of care 

physical or psychological distress of caregivers 

cost-effectiveness of care. 

Quality of care incorporates a great variety of aspects related to structure and process 

of care such as: 

 

 

 

 

 

 

physical aspects of care which hide many underwater stones in the management 

of pain, other symptoms and side-effects of treatment 

psychological and psychiatric aspects of care which involve trained professionals 

working as a team and special attention given to delivering bad news 

social needs, spiritual, religious and existential aspects of care which are often 

underestimated 

not respecting cultural preferences of patients and family 

disregard for the end-of-life concerns, hopes, fears, and expectations of the 

imminently dying patients 

and finally, key ethical and legal issues for terminal patients 

76


A great variety of initiatives are needed to bridge the gaps in the current practices of care and achieve a better quality 

of life. Providers who care for chronically ill patients should be supported with evidence-based guidelines, specialty 

expertise, and information systems. 

This vast subject would require a much more comprehensive approach beyond the health care system as it concerns 

other areas such as employment and the environment - “health in all policies”. Another consideration is “What are the 

patient’s desires and wishes?” 

There is a need for an approach that focuses on the individual who has specific needs related to provision of prolonged 

and continuous care. These needs can be: 

 

 

 

 

medical; with regard to pain control and prevention of complications, etc. 

psychological; associated with the need for information or emotional support 

social aid in patients’ daily life and involvement in the community 

spiritual; searching for a meaning. 

All these needs relate to the organisation of healthcare, accessibility of services, and coordination between care 

settings. 

The key being “Patient gets the right care at the right time in the right setting by the right health care providers.” 

In the search for effective and efficient solutions for the management of long term care, scientists are developing 

different programs. 

The Chronic Care Model by Ed Wagner describes the necessary components for a delivery system that encourages and 

sustains productive interactions between patients and providers. 

Improving Chronic Illness Care’s Chronic Care Model brings together the best in research and practice for chronic 

illness care interventions. 

The KCE report from Belgium in 2012 proposed a draft of an optimal-idealised-system, with the characteristics for the 

optimal management of chronic diseases that is needs-based, personalized, goal-oriented, planned and services are 

provided in a high quality, efficient, sustainable, accessible, culturally competent and patient empowering manner in 

the least complex environment that is clinically appropriate. 

Palliative care offers an alternative perspective. Palliative care is a new, supportive, compassionate and integrative 

approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening 

illness, through the prevention and relief of suffering by means of early identification and impeccable 

assessment and treatment of pain, and other problems. Palliative care can be provided in hospitals, nursing homes, 

outpatient palliative care clinics, other specialized clinics, or at home. Palliative care teams help patients manage their 

new circumstances and relieve some of the physical and mental stress of internal illness. Ultimately, palliative care 

helps individuals live as well as possible for as long as possible. It is focused on timely identification of patients in need 

of palliative and end-of life care, assessing and agreeing how to meet people’s needs and preferences, timely referral 

to palliative care experts, collaboration between patients, family and the medical team, the use of guidelines and 

appropriate working procedures, and knowledge of palliative care and symptom management on the clinical wards 

using advanced care planning, and delivering high quality services. 

The end of a person’s life can be one of the most important moments in that life. Meeting end-of-life care gives rise to 

ethical issues. Voluntary euthanasia and physician-assisted suicide bring about many ethical issues regarding a 

patient’s death and have been the focus of great controversy in recent years. Some physicians claim that euthanasia is 

a rational choice for competent patients who wish to die to escape unbearable suffering. Others feel that aiding in the 

patient’s death goes against a physician’s duty to preserve life that is morally unacceptable. Some forms of voluntary 

euthanasia are legal in Belgium, Luxembourg, the Netherlands, Switzerland, and some states in the USA. 

Primary health care, provided by GPs, is to a great extent the cornerstone of eliminating some of the gaps previously 

mentioned. High quality training for family doctors is vital to ensure the delivery of quality chronic disease 

management and a smooth transition to palliative care. 

Patient-centred care is an option to help patients and families in various ways. Good doctor–patient communication 

leads to various positive aspects both for patients as increased satisfaction, better health outcomes, improved 

understanding, increased adherence to treatment and for doctors - decreased job distress and less emotional stress 

and burnout. 

77


 

 

 

 

 

Proactive and holistic thinking 


Attention to patient and family as unit of care; patient-centred approach 

Education and support for the patient and family, and continuing medical education for care providers 

Effective communication 

Interdisciplinary team approach 


http://www.woncaeurope.org/content/4325-when-chronic-care-becomes-end-life-care-bridging-gap 

Reference 

Ambigga KS, Ramli AS,Suthahar A,Tauhid N,Clearihan L, Browning C. Bridging the gap in ageing: Translating policies into 

practice in Malaysian Primary Care. Asia Pac Fam Med 2011;10(1):2. 

Effiong A, Effiong AI. Palliative care for the management of chronic illness: a systematic review study protocol. BMJ Open 

2012;2:e000899 doi:10.1136/bmjopen-2012-000899 

Foreva G, Asenova R, Semergjieva M. Follow-up of patients needing palliative care in general practice. Progress in 

Palliative Care 2014, DOI: http://dx.doi.org/10.1179/1743291X13Y.0000000072. 

Foreva G, Assenova R. Hidden Patients: The Relatives of Patients in Need of Palliative Care. Journal of Palliative Medicine 

2014,17(1):56-61. doi:10.1089/jpm.2013.0333. 

http://www.goldstandardsframework.org.uk 

http://www.improvingchroniccare.org/; available 2014 

https://kce.fgov.be/; KCE Report 109C 2012. Health Services Research. Organisation of Care for Chronic Patient in Belgium: 

Development of a position paper; available 2014 

O'Grady EL, VanGraafeiland B. Bridging the Gap in Care for Children Through the Clinical Nurse Leader. Pediatr Nurs. 

2012;38(3):155-158, 167. 

78


Matie Obazee, FWACP(GP), FMCGP, MBA 

matieobazee77@gmail.com 

24 – What is Universal in Primary Care? Challenges for 

North/South Co-operation. 

Ehimatie M. Obazee 

FWACP(GP); FMCGP; MBA. 

Medical Director Echos Hospital 

Ltd, Benin City, Nigeria. 

Visiting Consultant, Department 

of. Family Medicine, University of 

Benin Teaching Hospital, Benin 

City. Nigeria 

Co-author 

Michael Kidd AM 

Executive Dean Faculty of 

Medicine, Nursing and Health 

Sciences, Flinders University, 

Australia 

President World Organization of 

Family Doctors (WONCA) 

Introduction 

A cursory examination of the way Primary Care is practised in the Northern and the 

Southern hemispheres gives the impression of vast differences in orientation, settings 

and operations. With the advent of the global focus on Primary Health Care heralded 

by the Alma Mata declaration of 1978, the focus of Primary Health Care in the South 

was predominantly Community oriented. Emphasis was on disease prevention 

through immunization, provision of water and environmental hygiene (1). 

The operation was driven by Community Health Extension Workers and other 

Physician assistant personnel. On the other hand, in the North, the orientation has 

traditionally been based on physician-led individual person-centred care often with 

strong Private Public Partnership. 

Over the years, there has been a convergence in the approach to Primary Care with 

more integration of both models to varying degrees. However, differences still exists 

in broad terms. The apparent differences often give the impression that there is 

nothing in common in Primary Care between the North and South. 

The impression is further accentuated by the vast array of ethnic, cultural, social, 

economic and technological diversity in which Primary Care operates in both settings. 

The apparent differences give the impression of a parallel paradigm with no meeting 

point, nothing in common and nothing to learn from each other. This is misleading. 

What is Universal? 

Within the midst of the array of ethnic, cultural, social and economic diversity is the 

universal cord that ties us all together – the humanity in us. At the most basic level, 

man’s needs are the same irrespective of the circumstances, location or situation of 

our birth – the need for self-preservation, safety and security, love and self esteem. 

Primary Care is at the heart of the most basic of these needs - the instinct for self 

preservation. Forging alliances with people and their families to promote optimum 

health, prevent disease, and when necessary make prompt accurate diagnosis and 

implement /coordinate effective care to our patients in the most dignified manner 

possible. The basic elements of Primary Care - accessibility, comprehensiveness, 

continuity and coordination apply universally (3). The attributes of good primary care 

- compassion, patience, love of people, love of communication and care are 

universally demanded and appreciated(4). 

Perhaps the strongest articulation of the universality of the quest for Primary Care is 

that of Margaret Chan, the Director General of WHO in her introductory remarks to 

the World Health Assembly 2008 World Health Report: 

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"A primary care approach is the most efficient, fair, and cost effective way to organise 

a health system. It can prevent much of the disease burden, and it can also prevent people with minor complaints from 

flooding the emergency wards of hospitals. Decades of experience tell us that primary health care produces better 

outcomes, at lower costs and with higher user satisfaction" (5) 

The entire report titled "Primary Care; Now More Than Ever" underscores the urgency of concerted universal efforts to 

give thought to rekindling attention to the development and sustenance of Primary Care (6). 

However, Primary Care has many different faces, depending on the context and geographical location where it is 

practised. Whereas in one location it may be normal to perform a surgical procedure for appendicitis on the kitchen 

table, it is highly irregular to perform the same procedure in another place. Though both doctors work in Primary Care, 

their task description is very different – modified by several factors. 

The moderating factors include the economic environment, the level of social and technological development and the 

effectiveness of the Health Systems in place. Even within Regions, there are differences. Health Systems in the United 

States and Canada for example are quite different from those in Brazil or Cuba. These factors are dynamic and 

undergoing continuous evolution. This has resulted in evolutionary continuum with the North predominantly at one 

end and the South at the other in different fronts. 

These factors of socio-economic and cultural realities impart on how Primary Care is implemented. The 

implementation of Primary Care is in the context and place where it is practised. Therefore, there is no such thing as a 

unique form of Family Doctor. 

North/South Co-operation 

The peculiarity of the circumstances and situations under which Primary Care is practised from North to South offers 

unique challenges to the practitioner. The mastery of these challenges builds valuable experience for the practitioner 

whether practising in the North or the South. The experiences in a geopolitical zone at a point in time are potential 

sources for learning for others. The examples of Brazil and Cuba's models of Primary care are veritable examples which 

offer lessons for Countries in both the North and South. 

Most of the time, North-South co-operation is seen as a one – directional way of assistance. But as described above, 

the time and place of delivering Primary Care are so different, that there is no real mirror of the circumstances. 

Therefore, bi-directional co-operation in which experience are shared between the North and South is what is needed. 

The vital questions should be: What can each of us contribute to each other? What can the North learn from the South 

and vice versa? There is a lot we can learn from each other - From National Health Systems, how Primary Care is 

delivered at practice level to epidemiological disease prevalence, pattern and treatment. 

Challenges 

Implementing such bi-directional co-operation has its challenges: 

Living in a world where Malaria and Ebola are prevalent is quite different from a world with largely lifestyle problems 

as challenges. Hypertension is a Northern problem, Dengue and Malaria are Southern problems. 

Cancer and Diabetes Type 2 are ubiquitous; but one has to live long enough to get them. To add to the complexity, in 

the dynamic societal evolution and globalization, what was exclusively a Northern problem yesterday is gradually 

becoming a universal problem today and vice versa. This is why co-operation is inevitable. 


 

 

 

 

Primary care offers the opportunity to forge an alliance with people and their families to promote optimum 

health, prevent disease, and when necessary make prompt accurate diagnosis and ensure effective care to 

our patients in the most dignified manner possible. 

The peculiarity of the circumstances and situations under which primary care is practised in both the North 

and in the South offers unique challenges to the health care practitioner. 

We need bi-directional approaches and co-operation, in which experiences are shared between the South and 

the North. 

The best way to co-operate is to learn from one another – and that is why WONCA is so important. It offers 

the opportunity through its Conferences and other activities to exchange experience and ideas. 

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http://www.woncaeurope.org/content/291-what-universal-primary-care-challenges-northsouth-co-operation 

References 

1. World Health Organisation: Declaration of Alma-Ata International Conference on Primary Health Care. 

www.who.int/publications/almaata_declaration-en.pdf 

2. World Health Organization: Main Terminology - Primary Health Care. Http:// www.euro.who.int/en/what-we-do/healthssytems/primary-health-care/main-terms-used. 

3. WHO: The World Health Report 2008: Primary Care, Now More Than Ever. http//www.who.int.whr08-en.pdf. 

4. WHO: Director-General's Speeches. Primary Care :Now More Than Ever. who.int/dg/speeches/2008/30081014. 

5. Molly Edmonds: Health Systems Around the World. People.howstuffworks.com/10-health-care-systems.htm. 

6. Wonca in brief. Global Family Doctor. globalfamilydoctor.com/aboutwonca/brief.aspx. 

81


Theo Schofield, OBE FRCP FRCGP 

dolphin.farm@which.net 

25 – The New Consultation: The Doctor in the Electronic Age 

Theo Schofield OBE FRCP FRCGP, 

retired Lecturer and Fellow of 

ETHOX, Department of Primary 

Care University of Oxford. 

Co-author 

Peter Havelock, retired Associate 

Advisor in General Practice, 

Oxford Deanery. 

The New Consultation: developing doctor-patient communication, (Pendleton et al 

2003), and it’s predecessor The Consultation: an approach to learning and teaching 

(Pendleton et al 1984) both described: 

 

 

 

 

the current literature on Doctor Patient communication 

the ideas, concerns and expectations that patients bring to their consultation 

the opportunity that each consultation has to develop the patient’s 

understanding 

the potential to develop the relationship between the doctor and patient over 

time. 

Based on this “Cycle of Care” we were able to describe Tasks to be achieved in 

the consultation, which in summary are: 

Understanding the patient’s problem 

Understanding the patient 

Sharing understanding 

Sharing decisions 

Sharing responsibility, and 

Developing a relationship that helps to achieve the other tasks. 

Are these still relevant in “The Electronic Age” characterized by the emphasis on 

Evidence Based Medicine and Shared Decision Making, by new technologies, and by 

developments in health care systems? 

Evidence based medicine aims to improve the quality of the evidence on which 

clinical decisions can be based. However most evidence is derived from populations, 

while the clinician is dealing with an individual patient, and that the approach can 

generate a “right” answer, with which the clinician, and in turn the patient, is 

encouraged to comply. 

Shared decision making, or Evidence Based Patient Choice (Elwyn et al 1999), 

responds to these criticisms by an approach where clinicians and patients make 

decisions together using the best possible evidence. This involves presenting the 

evidence about diagnosis, options for treatment and it’s benefits and harms and 

uncertainties, in ways that are fully comprehensible to patients, and encourages and 

enables patients to make choices about their own care. 

There is evidence that shared decision making can produce better informed patients 

who are less passive, who adhere better to treatment, and who sometimes make 

more conservative decisions about treatment. There is strong professional and 

institutional support for the implementation of shared decision making. (The Salzburg 

Declaration 2010). 

Another major technological change is the almost universal presence of the Computer in the Consulting Room. This 

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has transformed record keeping, particularly in primary care. They can provide structured records and templates for 

the management of chronic conditions, for results and for screening and prevention. The patient’s record can be 

shared with other team members, and across sites, and in some settings patients can access their own records, and 

become more involved in their own care. 

Computerization of the consultation can also bring problems. It can interfere with maintaining eye contact with the 

patient, and can influence the doctor’s agenda to be more structured and task orientated in response to the templates 

and prompts of the computer. Bensing et al in 2006 found that in two sets of recorded consultations with patients with 

hypertension separated by 10 years, the technical quality of care by the doctors improved, while the patients spoke 

less, asked fewer questions, and expressed fewer concerns and worries. She speculated that this reflected the shift 

towards more evidence based protocol driven care, as well as the influence of the computer in the room. 

Computers also allow doctors and patients to access information, guidelines and decision aids either in the 

consultation, or for patients to consider afterwards. This can also include examples of patient experiences on sites such 

as Healthtalk (Ziebland et al 2013). 

The telephone is being used increasingly as a means of communication with patients in many settings. It can improve 

access and follow up, it can be convenient for patients, and can be a more efficient use of doctors’ time. On the other 

hand a telephone consultation does not involve face to face contact, omits visual cues and physical examination, and 

both the doctor and the patient may feel that it was a “second best” and riskier encounter. 

Other modes of communication such as Email, Web sites and Social Media are less well established but offer 

opportunities for innovation, as does self-recording and monitoring using smart phones. All have the potential to help 

patients become better informed and more in control of their own health care. However it is face to face contact that 

builds mutual understanding and trust between doctor and patient. 

Continuity of Personal Care is valued by many patients, particularly those that are older, have long term medical 

conditions or psychological conditions. Supporters of personal continuity argue that personal continuity leads to 

increased patient satisfaction, more trust, and better care (Gray DP et al 2013). However, in the United Kingdom the 

health care system has recently given greater weight to accessibility, which is also valued by patients. Changes in the 

contract with general practitioners, and increased shift working in hospitals, have made the delivery of personal 

continuity more difficult. 

Per Fugelli in his James Mackenzie Lecture in 2001 defined Trust as the individual’s belief that the sincerity, 

benevolence and truthfulness of others can be relied on, and that trust often implies a transfer of power to a person, 

or to a system, to act on one’s behalf, in one’s best interest. He described personal trust as the trust you have in an 

individual, such as your doctor, and social trust as trust in societal institutions such as the government or health care 

institution. He went on to describe the influence that trust, or the lack of it, has on the process of the consultation. 


 

 

 

 

Understanding the patient, their problems and their perspective remains an essential task in an effective 

consultation. 

Shared Decision Making can enable patients and improve their care. 

New technologies offer new opportunities for communication, but should not be a substitute for face to face 

contact. 

It is essential that we maintain the trust of patients in their doctor, the medical profession and the health care 

system. 


http://www.woncaeurope.org/content/466-new-consultation-doctor-electronic-age 

References 

 

 

 

Pendleton D, Schofield T, Tate P and Havelock P. 2003. The New Consultation. OUP .Oxford. 

Pendleton D, Schofield T, Tate P and Havelock P. 1984. The Consultation: an approach to learning and teaching OUP. 

Oxford. 

Elwyn G, Edwards A and Kinnersley P. Shared decision making in primary care: the neglected second half of the 

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consultation. BJGP 1999; 49 :477-482. 

The Salzburg statement on shared decision making BMJ 2011;342: d1745. 

Ziebland, S Coulter A Calabrese J Locock L (Eds) (2013) Understanding and Using Health Experiences: improving patient 

care. OUP. Oxford 

Bensing JM et al. Shifts in Doctor-patient communication between 1986 and 2002: a study of videotaped general practice 

consultations with hypertension patients. BMC Family Practice 2006; 7: 62 

Gray DP, White E and Evans P. The importance of continuity of care. BJGP 201464:446. 

Fugelli P. Trust - in general practice. BJGP 2001;51: 575-579. 

84


Jaime Correia de Sousa, MD, PhD 

jaimecsousa@gmail.com 

26 – How to Deliver a Successful Learning Package for Family 

Medicine Trainees? 

Jaime Correia de Sousa, MD, PhD 

Community Health, School of 

Health Sciences, University of 

Minho, Portugal 

Like most learners, FM trainees are eager to learn to become competent 

professionals. It is the task of tutors and course organisers to guarantee the quality of 

learning. In order to be successful, learning programmes require a certain number of 

features. Family Medicine has been in the front line of innovation in designing 

learning and teaching programmes to fit the objectives and learning needs of trainees 

(1). Furthermore, it has published guidance and developed several courses to allow 

the development of teaching skills of tutors and teachers in family medicine (2,3). 

What Makes a Teaching Programme Successful? 

This text will review some of the characteristics of a teaching package that can include 

in-person learning, such as small group work modules combined with distance 

learning, mostly using problem based learning and integrating practical work in a real 

primary care setting. 

Learning objectives and content can be adapted to work with small groups, individual 

learning or one-to-one teaching in a residency programme. We will consider the six 

key features that make such a comprehensive programme effective. 

Content 

In most countries, there is already a good syllabus defining the content of learning 

and teaching in the training phase (4). In the planning stage of each learning package, 

teachers have to define very clearly the purpose of the module that should be based 

in the assessment of the training needs, the skills and knowledge deficits of students 

and the learning objectives (5). The objectives have to be written in a clear way as 

measurable statements of what participants should know or be able to do. Ideally, the 

specific training needs of each trainee or group of trainees should be evaluated 

previously to the design of the programme, so that the teaching and learning package 

is tailored to the participants’ knowledge or skills gaps (5,6). 

The Human Factor 

Training involves different people who agree to participate and need to be aware of 

their roles and tasks. Trainer and trainee have to be capable to build and maintain a 

continuing relationship. They should also be able to involve the practice nurses and 

staff and to obtain the consent from patients, who should be clearly informed of their 

rights and assured that their voluntary participation is important for the teaching 

programme and that any inconvenience should be minimised. 

The Environment 

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Teaching and learning is facilitated by an adequate environment. Premises for group work should allow a distribution 

of seats so that all participants and the speaker can face each other. If a group sits in a circle without a table, 

communication is likely to be easier. Designing web based teaching requires certain skills and the support of a good 

technical team. In a teaching practice, the premises have to meet certain requirements such as a minimum number of 

consulting rooms and areas for meetings and presentations. Besides the normal clinical tools there should be 

equipment specifically dedicated for teaching, such as a fast internet access, data-show and screen, flip charts, and 

video cameras. 

Types of Learning 

Other important features that need attention are the types of learning required with relation to different aspects of 

education. Types of learning fall into three categories. The first one consists of the knowledge of specific facts, 

patterns, and concepts. The second category includes the skills that require practical abilities, manual skills measured 

in speed and / or precision, clinical reasoning and problem solving aptitudes. The third one contains the attitudes, 

realising feelings, values, and motivation (5). 

Learning also requires adaptation of the program to individual trainees as people have different individual learning 

styles. Some persons learn quickly by listening, some others need to complete listening by reading and memorising; 

others have to repeat and correct the skill until they know it. This requires the tutor to take into account the trainee's 

preferred learning style and to consider the trainee’s learning needs. 

Communication 

Good communication is essential for effective teaching and learning. Tutor and trainee should develop an adequate 

communication mode. This requires frequent interaction aimed at clarification, problem solving and course correction. 

Adult learning though, is a process that requires independent learning and the role of the tutor is more of a facilitator 

and organiser coaching the trainee through the learning process. Qualities such as openness, networking, and 

proactive communication are important ingredients in the process of personal and organisational change (7). 

Assessment 

Assessment is important because it drives learning, allows measures of individual and programmatic progress and 

assures the public that providers are competent. It is fundamental to outcomes or competency-based education (8). 

Assessment methods have to be adapted to the type of learning. Common methods of assessment such as multiple 

choice questions, simulation tests, and objective structured clinical examinations (OSCEs) target the lowest levels of 

the learning pyramid (7,8), while work based methods of assessment target the highest level of the pyramid and 

collect information about doctors’ performance in their normal practice and should be preferred in a more 

comprehensive teaching program. 

Conclusion 

Miller’s Pyramid of Competence. (8) 

Delivering a successful learning package for FM trainees requires a certain number of skills. Family Medicine teachers 

and tutors should be aware of this and undergo some of the available training programmes in order to master the 

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basic features of adult education. This will be a key element in assuring the quality of future family physicians. 


 

 

Learning is a process that you have to learn. 

Teaching is a skill that you have to learn and train. 


http://www.woncaeurope.org/content/11-w-teaching-science-learning-care-how-deliver-effective-learning-package-gp-trainees 

References 

1. Heyrman J: EURACT Educational Agenda. Leuven: European Academy of Teachers in General Practice EURACT; 2005. 

2. Guldal D, Windak A, Maagaard R, Allen J, Kjaer NK. Educational expectations of GP trainers. A EURACT needs analysis. Eur 

J Gen Pract. 2012 Dec;18(4):233-7. doi: 10.3109/13814788.2012.712958. Epub 2012 Aug 31. 

3. Bulc M, Švab I, Radi S, Correia de Sousa J, Yaphe J. Faculty development for teachers of family medicine in Europe: 

reflections on 16 years' experience with the international Bled course'. Eur J Gen Pract 2009; 15: 69–73. 

4. General Medical Council The Trainee Doctor. Foundation and specialty, including GP training. General Medical Council, 

London; 2011. 

5. Northwest Center for Public Health Practice at the University of Washington School of Public Health. Effective Adult 

Learning. A Toolkit for Teaching Adults. University of Washington; 2014. 

6. Tomasik T, Windak A, Domagala A, Dubas K, Sumskas L, Rosinski J. An evaluation of family physicians' educational needs 

and experiences in health promotion and disease prevention in Poland and Lithuania--a qualitative study. BMC Fam Pract. 

2011 Mar 25;12:13. doi: 10.1186/1471-2296-12-13. 

7. ABC of Learning and Teaching in Medicine. Peter Cantillon, Linda Hutchinson, Diana Wood Editors. London, BMJ Publishing 

Group, 2003. 

8. Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990 Sep;65(9 Suppl):S63-7. 

87


Filippo Zizzo MD, Psych. 

zizzofil@tin.it 

27 – The Integration of Mental Health into Primary Care: 

International Perspectives 

Filippo Zizzo MD, Psych. 

Psychiatry lecturer at the 

General Practice Training School, 

Milan Bicocca University, 

Head of Scientific Medical 

Society SIICP 

According to an evaluation in 2012, approximately 38% (1) of the European 

population suffer from a mental disorder at some time in their life. The WHO predicts 

that by 2020, significant psychiatric disorders will make a major contribution to the 

burden of disability and suicide (2)(3). This is even more pertinent with regard to the 

current economic crisis and the consequent reduction in resources and services. The 

message delivered to European nations at the Helsinki Conference of 2005 was that 

there is no health without mental health (3). Nine years later, one wonders if 

European states have kept their commitment to promote mental health policies with 

respect to public health, adoption of a life course approach targeting all age groups, 

making structural changes, community transformation and respect for human and 

civil rights of people with mental disabilities. If they had, perhaps today’s outcomes 

may have been different. In recent years, the international economic crisis has had an 

important psychosocial impact on individuals and families through the reduction of 

available resources. It has resulted in increasing social marginalization, 

unemployment and higher risk of exposure of the individual to stressful life situations, 

with negative repercussions through the increased risk of developing psychiatric 

disorders and by making treatment and recovery more difficult. 

In high income countries there remains a lack of social inclusion for those people with 

mental health problems including a fragmentation of family and social structures, 

poor housing, lack of employment opportunities and loss of spiritual framework. 

Against this background; 

 

 

Family Physicians are in a position to provide leadership in the health care system 

(5) 

it is important that this role is supported by national governments. 

Family Physicians should be carefully consulted before the development and 

implementation of new policies and processes in order to achieve the goal of health 

care cost containment and improvement in the management of mild and moderate 

psychiatric disorders, in order to avoid the stigmatization of mental health patients 

with all the negative consequences that this may carry. Family Physicians must have 

leadership roles in managing the delivery of health services because the Family 

Physician is one of the medical professionals best placed to demonstrate the full 

range of qualities necessary to drive change including; (6) trust and doctor-patient 

relationship, expertise in diagnosis and prognosis, expertise in complex decisionmaking 

process, the beginnings of a multidisciplinary approach to health care, 

professionalism, leadership and management skills in delivering comprehensive 

primary health care to large populations and skills in the training of medical students 

and doctors. 

In the early 2000s, care delivery to patients with mental health difficulties was driven 

through a lens of ethics and morals (7). Today the choice is not only based on these ideals but also on the wise use of 

88


limited economic resources to deliver quality interventions with a reduction in health care costs. 

The vision that I’m proposing, could be interpreted as reductionist but it is better at maintaining quality of care and 

treatment interventions ethically whilst reducing costs. To achieve this goal, Family Physicians need to become more 

skilled in the foundations of psychiatric diagnosis and therapy, not to become pseudo-psychiatrists but to play a pivotal 

function in delivering mental health services to a broader range of the primary care population. 

By adopting this suggested approach, the role of the Family Physician becomes the constant filter and support at the 

primary/secondary care intersection. We might say that there is nothing new under the sun. From my point of view 

there is a great difference between the former vision and the current situation. In the 1980s there was a simple 

proposal designed to streamline the psychiatrist’s work, making him/her responsible for interventions for the most 

severe and high-risk cases. The current economic stagnation dictates that there should be less waste and demands 

that the majority of interventions are delivered in primary care (8). Moreover, it has broadened the horizon to a world 

of "emerging needs" of mental health for primary care including adolescents and young people who require early 

intervention, the elderly, people suffering from common emotional disorders or with complex co-morbid somatic 

conditions and a whole population who attend family practice as the first port of call when faced with medical needs. 

Alongside the responsibility of delivering more treatment for newly presenting mental health problems, Family 

Physicians are also expected to sustain the goal of a more inclusive society by supporting the reintegration of patients 

with severe mental disorders. Family Physicians are called upon to promote societies’ ability to understand and 

tolerate the complexity of individuals and the variety of different ways of being in the world. They are also expected to 

avoid the temptation to make superficial changes by evading the right but difficult decisions and ignore the evidence 

base for political expediency and ‘short-termism’ or by merely attending to the risk associated with mental suffering 

and disorder. 

I would like to propose the following goals: 

Mid- term goals: 

A reduction in the numbers of people with mental health problems followed up by secondary care mental health 

services 

An increase in the number of patients with mental health problems managed by Family Physicians 

More appropriate use of the resources offered by psychiatrists in Secondary Care 

More rational use of nursing resources to address mental health problems 

Long- term goals: 

An improvement in the quality of interventions offered in mental distress 

Evidence based and appropriate consultations 

Evidence based clinical and therapeutic interventions 

Evidence based nursing interventions 

A decrease in hospital admissions 

A decrease in relapse rates 

Efficient management of resources 

In my view this is the future challenge for the Family Physician who, as a result of the nature of the role, deliver 

assessment and treatment to large numbers of the population within a defined geographical area, and in a broader 

social context, informed by the Family Physician’s depth of knowledge of the family and social contexts of his/her 

individual patients. Therefore, the Family Physician remains the pivotal figure of future health systems. 


 

 

 

 

 

Family Physicians encounter covert and sub-clinical psychiatric disorders 

Family Physicians manage psychiatric disorders with reduced costs 

The stigma related to mental disorder is decreased in the general practice context 

Family Physicians are in a unique position to provide comprehensive management of the patient's mental and 

physical disorders 

Family Physicians also implement social interventions for their patients 


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http://www.woncaeurope.org/content/cw18-integration-mental-health-primary-care-international-perspectives 

References 

1. Wittchen, H.-U. The size and burden of mental health in Europe. Israel Journal of Psychiatry and Related Sciences, 49(1), 6- 

6. 2012. 

2. McBain R., Salhi C, Morris JE, Salomon JA, Betancourt TS. Disease burden and mental health system capacity: WHO Atlas 

study of 117 low- and middle-income countries. Br J Psychiatry. 2012 Dec;201(6):444-50. 

3. Joseph G.Froerera, Michael Penneb, Michael Pembertonb, Ralph Folsomb. Substance abuse treatment need among older 

adults in 2020: the impact of the aging baby-boom cohort. Drug and Alcohol Dependence Volume 69, Issue 2, 1 March 

2003, Pages 127・135. 

4. http://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdf. 

5. https://ama.com.au/media/unique-pivotal-role-doctors-australian-health-system 

6. Charles Watters. Emerging paradigms in the mental health care of refugees Social Science & Medicine, Volume 52, Issue 

11, Pages 1709-1718.2013. 

7. Gabriel, M.D. Ivbijaro (Editor) - Companion to Primary Care Mental Health Paperback ・August 12, 2012. 

8. Weinstein and al.-Cost-effectiveness in Health and Medicine. Jama October 1996, vol.276,n.15. 

90


Floris A. van de Laar, MD, PhD 

Floris.vandeLaar@radboudumc.nl 

28 – WONCA and the Cochrane Primary Health Care Field: 

opportunities for a synergetic collaboration 

Floris A. van de Laar, MD, PhD 

Dept. of Primary and 

Community Care, Radboud 

University Nijmegen Medical 

Centre, Nijmegen, The 

Netherlands. 

Co-authors 

Caroline Roos, MA, 

Tom Fahey, MD 

Bruce Arroll MBChB, PhD, 

FRNZCGP 

Elaine Gurr Chair of General 

Practice and Primary Health Care 

Director of the Goodfellow Unit, 

Department of General Practice 

and Primary Health Care, 

University of Auckland 

The Cochrane Collaboration is a global independent network of more than 31,000 

dedicated people from over 120 countries. It constitutes an equal partnership 

between health practitioners, researchers, health care providers and patient 

advocates. Its mission is to promote evidence-informed health decision-making by 

preparing, updating, and promoting the accessibility of Cochrane Reviews, published 

online in the Cochrane Database of Systematic Reviews, part of The Cochrane Library 

(www.thecochranelibrary.com ). 

Cochrane Reviews are systematic reviews of primary research in human health care 

and health policy, and are the highest standard in evidence-based health care. The 

abstracts and plain language summaries of all Cochrane Reviews are also freely 

available on Cochrane Summaries (http://summaries.cochrane.org/ ), thus ensuring 

equal accessibility to anyone interested in evidence informed health care. 

In January 2011, the World Health Organization (WHO) awarded Cochrane a seat on 

the World Health Assembly, the decision-making body of the WHO. This provides 

Cochrane an opportunity to promote evidence-based health care at the highest levels 

of international health care policy-setting. 

The Cochrane Primary Health Care Field (CPHCF) and its 

Achievements 

The Cochrane Collaboration (www.cochrane.org ) is organised by ‘entities’ called 

‘groups’ or ‘fields’. Primary Health Care became the first registered field in October 

1993. While the Cochrane Review Groups focus on production and promotion of 

Cochrane Reviews, Fields advocate the representation of certain interests in the 

Cochrane Reviews (for example a focus on setting, e.g. primary care, or patient 

groups, e.g. children). Furthermore, fields promote and enhance dissemination and 

implementation of evidence from systematic reviews in the area they represent. 

Thus, the CPHCF aims to ensure that the primary care perspectives are adequately 

represented within the Cochrane Collaboration. Moreover, the field promotes and 

stimulates the development of Cochrane reviews which are more relevant and 

accessible to primary care (Van de Laar 2007). 

Means to achieve these goals are, for example: introducing, supporting or linking 

primary care peer reviewers, or authors with Field-relevant expertise to Review 

Groups editors. In addition, the CPHCF tags existing reviews and review-protocols 

with ICPC-codes in order to make them more accessible to workers in primary care. 

This enables the products of the Collaboration to be accepted and adopted into 

practice. 

We have developed two important ‘tools’ to assist us achieve our goals. Firstly, we 

have created the concept of PEARLS (Practical Evidence About Real Life Situations) which are very concise summaries 

91


of (Cochrane) reviews focusing on one Clinical question for direct implementation in practice (Arroll 2011). PEARLS are 

disseminated through the CPHCF website and Newsletter, The Cochrane Library, the WONCA website and the website 

of the New Zealand Guidelines Group. PEARLS have also been published in the Dutch Journals of Huisarts en 

Wetenschap and Modern Medicine and also at conference presentations. 

Furthermore, we have developed the website www.cochranegetinvolved.org in which we welcome new collaborators 

in primary care research. Accordingly, this network is integrated into the formal Cochrane (‘Archie) network and 

enhances (future) collaboration with primary care research and practice. The current focus is to expand this network 

and link it to the activities of the various Cochrane Review Groups. 

Another spearhead of the CPHCF is the development of a register of studies on the development, validation and 

impact of Clinical Predication Rules in primary care. This project is coordinated by the Dublin branch of the CPHCF and 

is supported by the HRB Centre for Primary Care Research (www.hrbcentreprimarycare.ie ). So far, a register of over 

700 CPRs have been identified. A reproducible search strategy to identify relevant CPRs has been developed that is 

enabling regular updating of the register. A searchable, web-based register is being developed and would form part of 

the Cochrane Primary Health Care Field activity. Other developments include assessment of CPRs in relation to their 

use in clinical practice guidelines, and a systematic review of randomized trials that assess the impact of CPRs in clinical 

practice in primary care. 

Global Family Medicine and PHCF 

WONCA and the Cochrane Collaboration share many important objectives. Both WONCA and the CPHCF aim to foster 

high standards of care in general practice. With this in mind, the Cochrane Collaboration produces high quality and 

accessible systematic reviews for the promotion of evidence –informed health decision making. Both organizations aim 

to promote health equity. Cochrane strives to achieve this by making the vast amounts of evidence generated through 

research useful and available to everyone (both practitioners and patients) interested in human health care. In 

addition, both WONCA and the CPHCF are academic initiatives which aim to collect, collate and disseminate 

information concerning the research aspects of general practice. And finally, both WONCA and Cochrane provide a 

forum for exchange of knowledge in the field of health and medical care. 

WONCA has already important, established links with the Cochrane Collaboration. Cochrane output such as the 

Cochrane Library and PEARLS from the CPHCF are incorporated at the WONCA World website as important resources 

for general practitioners. Cochrane is also represented in WONCA through many individual members. We sincerely 

hope that Cochrane and WONCA will continue to collaborate in the promotion of evidence-based primary care. 

Is Cochrane Helpful in Everyday Practice? 

For some colleagues The Cochrane Collaboration may seem an academic initiative with only a distant association to 

every day practice. We believe that the opposite is true (Fahey 2013). Firstly, an efficient way in applying Evidencebased 

principles for your patients is searching, reading and using systematic reviews. Compared to primary studies, the 

information-density that comes from systematic reviews is enormous. The Cochrane systematic review aims to reduce 

publication bias. Moreover, the latter’s structured format makes them easily accessible for readers whore are 

interested in part of the information only. And for those who like to cherry pick, there are many easy-to-read 

structured summaries available through the Cochrane summaries website, in particular for those primary care people 

who wish to receive the PEARLS that are distributed through the Primary Care Field. So do not hesitate and subscribe 

for the Field on www.cochraneprimarycare.org . 


 

 

 

 

The Cochrane Collaboration publishes Systematic Reviews in order to support evidence based decision making 

in Health Care 

The Primary Care Health Care Field is the entity within Cochrane that represents family medicine and primary 

care in the Collaboration and vice versa 

The Field produces PEARLS which are concise and easy-to-read abstracts of Cochrane reviews aiming at 

specific clinical questions 

WONCA and Cochrane share many important values and further future cooperation between the primary 

care field and WONCA seems promising 

92



http://www.woncaeurope.org/content/cochrane-primary-health-care-field-introduction-systematic-reviews-and-cochrane-primary 

References 

Arroll, B. (2011). "Getting clinical answers in 1 sentence." Ann.Fam.Med. 9(1): 86. 

Fahey, T., Smith SM, van de Laar, F., Kenealy, T, Arroll, B. (2013). "Cochrane reviews: relevant more than ever." British 

Journal of General Practice 63(606): 10. 

Van de Laar, F. A., T. Kenealy, et al. (2007). "Cochrane Primary Health Care Field. About The Cochrane Collaboration 

(Fields)." Cochrane Database Syst Rev(3): CE000051. 

93


Sietse Wieringa, MD 

sietse.wieringa@nhs.net 

29 – Do you Understand how Your Health System Works? From Beveridge to 

Bismarck; a Whistle-stop Tour of European Health Systems 

Sietse Wieringa, GP, MSc 

Co-authors 

Luisa Pettigrew, MB ChB, 

MRCGP, MSc 

Stephanie Kumpunen, MSc 

Greg Irving, BMedSci, BMBS, 

MSc, MPH, MRCGP 

As family doctors we should be thinking about how our healthcare system works and 

how we can shape it. We share responsibility for the distribution of limited resources 

not only as healthcare professionals, but also as patients and taxpaying citizens. But 

how much do we know about how the system works, and in particular how it is 

financed? 

Healthcare Systems’ Goals 

In order to understand a healthcare system the first requirement is to think about its 

policy goals. The ‘final’ goals ultimately are; to improve the health of the population; 

to be responsive to the needs of healthcare service users and citizens; and to ensure 

protection among citizens from the burden of financial hardship due to healthcare 

payments. 

There are also ‘instrumental’ goals; to be transparent and accountable; to deliver high 

quality healthcare services; to be efficient; and to ensure equity across the healthcare 

system. Equity exists in several forms, such as equity in access or use of the service, 

equity in coverage of the type of services provided to the local population, and equity 

in how financial risk is redistributed. 

With the final and instrumental goals of a health system in mind, there are three key 

questions that help to determine the financing structure of a health system; (1) 

Where does the money come from? (2) Who collects the money? (3) How is the 

money spent? 

Where Does the Money Come From? 

There are several ways to collect funds for healthcare. Options include taxation, 

compulsory social health insurance, voluntary private health insurance, individual 

medical savings accounts or out-of-pocket payments. In the case of lower income 

countries, funding can also come from international donations. 

The archetypical European models to collect funds for healthcare are the tax model, named after the English 

94


economist William Beveridge (1879-1963), and the social health insurance model more commonly known as the 

Bismarck model, named after German Chancellor Otto von Bismarck (1815-1898). In 1942 Beveridge laid the 

foundations of the National Health Service (NHS) in the United Kingdom in which free healthcare at the point of 

delivery was paid through taxation collected by the government. Bismarck passed the sickness insurance law in 1883 in 

an effort to improve economic growth through employees’ well-being in Germany. In his model employers contributed 

one-third and workers two-thirds into locally managed funds that paid for medical treatment and sick pay. 

In general terms, taxation and social health insurance are considered the most ‘progressive’ methods of paying for 

healthcare, in other words, they enable the most equitable forms of collecting and pooling funds. On the other hand 

out of pocket payments are ‘regressive’ or the least equitable, hitting the sickest and poorest the hardest. Every 

method has of course its own variants, advantages and disadvantages, as well as its ethical, moral and ideological 

arguments. Thinking about taxes, for example, differences can arise in whether taxes are collected directly (e.g. income 

tax) or indirectly (e.g. tobacco tax) or whether those who earn more should contribute a higher proportion of their 

earnings. 

Who Collects and Redistributes the Money? 

The second question points to how the money is pooled and (re-)distributed. Fund pooling is the accumulation of 

prepaid healthcare revenues on behalf of a population and facilitates the pooling of financial risk across the 

population. Collection agents can either be public or private, for profit or not-for-profit. The size of pools can vary (e.g. 

national versus regional). If multiple pools are available a risk-adjusted re-distribution of funds according to the risk 

profile of the population (e.g. age, sex, etc.) covered by each pool is preferable. This, in addition to regulation, is 

important to prevent cherry picking of patients in competitive health insurance systems, as well as to reduce the risk of 

healthcare funding bodies becoming insolvent. 

How Is the Money Spent? 

The third question explores how money is used to purchase healthcare. The range or package of services can be 

agreed upon in several ways, for instance by decree in the Netherlands or by negotiation in Germany. A single 

organisation can undertake both the purchasing and provision functions, or these may be divided up between different 

organisations. In the English NHS in the 1990s for example, a purchaser–provider ‘split’ was introduced to encourage 

provider competition in healthcare markets. 

95


How healthcare professionals are paid can vary and this can affect the healthcare system’s ability to contain costs and 

deliver high quality care. Thinking specifically about primary care, for example, family doctors can be salaried, paid 

through fee-for-service or by capitation – or a blend of all three payment methods. In the most basic sense, salary and 

capitation payments are often less costly than fee-for-service and in particular in the case of capitation may promote 

preventive work. However they can lead to doctors over-delegating and under-providing services. Meanwhile fee-forservice 

places the financial risk on the payer and may potentially increase ‘unnecessary’ activities. 

Performance-based pay is also often used, which involves paying doctors or groups of doctors for achieving targets on 

quality indicators. This may lead to improved attention to quality domains, but can also lead to surrogate end points, 

neglect of non-quality indicators and may disturb the doctor-patient relationship. There are, of course, more incentives 

than just money. Providers can be incentivised by professional development, clinical guidelines, utilisation reviews, 

targets, public disclosure, ethics and of course an intrinsic desire to do good! Payments can modify behaviour, but 

mechanisms to create more incentives generally have greater administrative costs. Their merits depend on the context 

in which they are made. 

Take Home Messages – Finding the Right ‘Blend’ 

 

 

Archetypal models and methods generally ignore the complexity of healthcare system financing and conceal 

similarities and differences. It is unlikely to find a system that, for example, uses tax contributions solely to 

fund healthcare and reimburses providers using solely capitation-based payments. Most systems in Europe 

now blend methods to collect, pool and spend healthcare funds. 

In order to achieve the policy goals of any healthcare system blended methods of financing are needed to 

balance the drawbacks of purist methodologies and to align incentives. The input of family doctors as 

advocates for their patients and as front-line health professionals is important to help find the right blend in 

each context to meet the desired goals of their healthcare system. 


www.woncaeurope.org/content/ws07-do-you-understand-how-your-health-system-works-beveridge-bismarck-whistle-stop-tour-2 

WONCA Europe Vienna 2012 

In a packed room during the 2012 WONCA Europe conference in Vienna, this workshop set out to provide participants 

with a framework to compare their own healthcare systems. It was picked up in a column by RCGP chair at the time, 

Prof Claire Gerada (1), reported in a blog for the London School of Economics and Political Science (2), and the full 

presentation (available on Prezi) has over 3000 views (3). 

References 

1. http://email.rcgp.org.uk/rp/440/process.clsp? 

EmailId=139125&Token=29A76D1D621057493A98ECFE1394744DC&utm_campaign=RCGP_Update_| 

_4_November_2011&utm_medium=Email&utm_source=CM_RCGP 

2. http://blogs.lse.ac.uk/healthandsocialcare/2012/07/10/how-does-your-health-system-work-a-workshop-at-the-woncaeurope-conference-2012/ 

3. https://prezi.com/ba6bcwlco-ge/from-beveridge-to-bismarck-a-whistle-stop-tour-of-european-health-systems/ 

96


Francine Lemire, MD CM, CCFP, FCFP 

fl@cfpc.ca 

30 – The Transition from CME to CPD - Fostering Good Practice Through Education 

Francine Lemire, MD CM, CCFP, 

FCFP 

Co-authors 

Marlow, Bernard; Rock, Susan; 

Meuser, Jamie 

Introduction 

The College of Family Physicians of Canada is a voluntary organization of Family 

Physicians, which makes CME/CPD mandatory. Over ninety percent of its members 

have obtained Certification, which is an indicator of special competence in the 

discipline of Family Medicine. In 1997, the CFPC introduced Mainpro-C activities, 

which aim to have more of an impact on practice than traditional CME, by 

encouraging physicians to reflect on the impact of the learning on their practice. It is 

well recognized that the determinants of good practice go far beyond disease 

management and the role of clinical expert. We utilized eight identified physician 

roles: 

 

 

 

 

 

 

 

 

medical expert, 

communicator, 

collaborator, 

health advocate, 

learner, 

manager (gatekeeper), 

scholar, 

and "physician as person", 

as a model consistent with good practice and meeting societal needs. Currently, 

Medical Regulatory authorities in Canada are reviewing the integration of a 

physician's CPD/CME portfolio as a component of revalidation of licensure. In this 

study, we will review the past Mainpro-C activities of our members based on the 

identified physician roles. 

From CME to CPD in a Regulatory Context of Physician Practice 

Improvement 

The College of Family Physicians of Canada is responsible for the accreditation of 

postgraduate residency programmes in family medicine in each of Canada’s 17 

faculties of medicine. It is responsible for the creation and administration of 

examinations leading to Certification in Family Medicine and a Certificate of Special 

Competence in Emergency Medicine. It is also responsible for setting the criteria for 

Maintenance of Certification, and for supporting all family physicians in their 

commitment to lifelong learning. Since 2007, most medical regulatory authorities are 

mandating that physicians demonstrate such commitment through participation in an 

accredited programme of continuing Professional Development (CPD) by either the 

CFPC or the Royal College of Physicians and Surgeons of Canada (RCPSC) for 

specialties other than family medicine. 

97

Context 


Several factors have stimulated reflection and evolution regarding CFPC’s maintenance of certification programme: 1. 

Team based care; 2. Greater importance of work-based learning; 3. The need for reflection about impact of learning on 

practice, given the evidence to support the importance of this step to support practice improvement; 4. Regulatory 

context in which increasingly physicians will need to demonstrate maintenance of competence and a commitment to 

practice improvement. 

Action 

The CFPC will be introducing an enhanced programme of maintenance of Certification, Mainpro+, in July 2015. It aims 

to support family physicians better in assessing their learning needs, to help them to capture the many ways in which 

they further their learning in all spheres of practice, and to reflect on the impact of each learning activity on their 

practice. Mainpro+ has three categories of CPD activities: Group Learning, Self Learning, and Assessment, with subcategories 

(Certified and Non-Certified) within each group. There will continue to be a yearly minimum requirement of 

credits for each five year Mainpro cycle. CPD activities that stimulate learning in all the roles expected of physicians 

(Collaborator, Communicator, Manager/Leader, Professional, Scholar, Health Advocate, Medical Expert-Definitions 

based upon CanMeds-FM) will be encouraged and incentivised, and recognition of the learning needed to excel at 

teaching, research, and administration as well as clinical work. All participants will be encouraged to develop a learning 

plan at the beginning of their cycle. For those family physicians who have acquired enhanced credentials in a focused 

area of practice, there will be a minimum number of credits required to address that practice domain. 

The CFPC, along with several other medical professional organizations, will build upon the Future of Medical Education 

in Canada (FMEC) project, to be part of a consortium working towards a CPD system that can consistently address 

evolving needs and priorities. The 3-year planning phase will be co-chaired by CFPC and the Royal College of Physicians 

and Surgeons of Canada. Describing and bringing these future directions to life will be accomplished through 

commissioning a series of collaborative projects to address important questions that will have a bearing on the future 

of CPD and the role(s) of a future Consortium (e.g. How will CPD activities be funded? What will be the role of patients 

and the public in setting priorities? How will team-based care be reflected in the setting of learning? etc.). The FMEC- 

CPD project will leverage the high degree of collaboration and conjunction of interest that already exists across the 

many organizations involved in CPD to construct a future pan-Canadian system with an appropriate governance 

structure that can respond more completely to the diversity of physician, provider, and societal health care needs. 

We have good evidence that clinicians who commit to lifelong learning perform better in practice. Mainpro+ aims to 

facilitate such engagement. The FMEC-CPD project will include a robust evaluation agenda to confirm collaborative 

priority-setting to support this learning. 


 

 

The context of practice is evolving: team based care, workplace based learning, and increased accountability 

expected of our profession. Our CPD system needs to evolve to support physicians in their engagement in 

lifelong learning 

CFPC’s new Mainpro+ programme will better support physicians in assessing their learning needs, developing 

a plan, and measuring the impact of learning on all aspects of their practice. The CFPC is part of a consortium 

to build upon the Future of Medical Education in Canada (FMEC) project, to build a Pan-Canadian Planning 

Consortium for CPD. The initial phase of this work will unfold in 2015-2017 


http://www.woncaeurope.org/content/4488-transition-cme-cpd-fostering-good-practice-through-education 

References: 

 

 

Meuser J, Hill L, Outschoorn A: Learning to change: Coming updates to the CFPC Mainpro program; Can Fam Physician 

September 2013 59:913-914 

The Future of Medical Education in Canada (FMEC) Continuing Professional Development (CPD): A Strategy for the 

Development of a Pan-Canadian FMEC CPD Consortium (unpublished)-Development coordinated by the Association of 

Faculties of Medicine of Canada-last revision August 2014 

98


 

 

 

Goulet F, and all: Effects of Continuing Professional Development on Clinical Performance: Results of a study involving 

family practitioners in Quebec; Can Fam Physician May 2013 59: 518-525 

Lemire F: Mainpro: From improvement of knowledge to improvement of performance; Can Fam Physician September 

2013 59: 1020 

CanMEDS-Family Medicine: A Framework of Competencies in Family Medicine - See more at: 

http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=3031#sthash.FsnHuFaW.dpuf 

99


Annika Bardel, GP, PhD 

annika.bardel@pubcare.uu.se 

31 – Factors Associated With Adherence to Drug Therapy 

Annika Bardel, GP, PhD 

R&D Center/Center for Clinical 

Research, Sörmland, Uppsala 

University, Eskilstuna, Sweden 

Department of Public Health and 

Caring Sciences, Family Medicine 

and Preventive Medicine Section, 

Uppsala, Sweden 

Co-authors 

Mari-Ann Wallander PhD, Kurt 

Svärdsudd MD, PhD 

Uppsala University, Department 

of Public Health and Caring 

Sciences, Family Medicine and 

Preventive Medicine Section, 

Uppsala, Sweden 

It is well known that lack of patient adherence is of major importance in the success 

of a prescribed medical treatment. Lack of adherence may result from patient-related 

factors, or be related to the provider. Various measures to promote adherence have 

been proposed, ranging from pill counts and use of trace elements to interviews and 

questionnaire-based methods. 

Adherence varies with diseases and across methods used. It has for instance, been 

found that following an acute coronary syndrome, 8–20% of patients discontinue 

their medication within 6 months. In many chronic diseases, 40–50% of patients do 

not adhere to the initial treatment beyond 12 months and in women given hormone 

replacement therapy, as few as 50% still adhere to their medication after one year. 

Most adherence studies focus on one drug or one type of disease and are typically 

run only in patient groups. Few have taken a wider perspective. To this end, we 

carried out a study on medication adherence, defined as persistence of medication or 

stopped as prescribed, and some of its determinants in middle-aged women in the 

general Swedish population. 

The study was carried out in the Uppsala-Örebro Health Care Region in mid-Sweden 

with a population of approximately 2 million. The study was performed by means of a 

postal questionnaire and comprised 2991 women willing to participate. The age 

distribution of respondents and non- respondents was similar. The questionnaire had 

two parts, the first containing questions on marital, occupational and educational 

status, tobacco use, and height and weight. The second part of the questionnaire 

contained questions on drugs prescribed during the past year. For each prescription, 

information was sought on drug trade name, dosage, duration of medication and 

whether the drug was currently being taken as prescribed, was ceased as prescribed, 

was ceased by the woman against prescription, whether the prescription was filled 

but the medication not started or whether the prescription was not filled at all. If 

more than five prescriptions were received during the study period, information on 

drug number six and onwards was given in a free format, but with the same type of 

information as for the first five. 

The study population constituted 1406 women who reported having received at least 

one prescription . Adherence was considered to be satisfactory if the medication was 

taken or stopped as prescribed; in all other cases it was considered to be 

unsatisfactory, since the purpose of the study was to study general adherence to 

prescribed medication, not the occasional loss of individual drug doses. 

Information was also sought on scheduled check-ups, perceived necessity of the 

medication (coded from low (=1) to very high (=7)), concerns about medication safety 

(yes/no) and prescribing physician’s sex and type (general practitioner, hospital 

physician, private practitioner or occupational health physician). 

Mean age was 51 years, mean BMI was 25, 27% had a college or university education. 79% were married or cohabiting, 

100


68% were gainfully employed, 26% were smokers. 

The number of prescriptions per women ranged from 1 to 15 drugs, with a median of 1.5. 

Based on 3067 prescriptions among the 1406 women, 85.6% reported satisfactory adherence, with 78% of the 

medication being currently taken and 7.6% being stopped as prescribed. In 10.7% medication was stopped 

prematurely, in 1.8% it was never taken and in 1.9% it was not filled at the pharmacy. A total of 207 (14.7%) women 

reported mixed adherence, satisfactory for some medications and unsatisfactory for others. With relation to 62% of 

the prescriptions a follow-up appointment with the prescribing physician was given. In 68% the women regarded the 

medication as important to their health. Seventeen per cent of the women had concerns about the safety of a 

particular medication. The majority of the prescriptions were for one dose per day or less, 66.6% were issued by a 

male prescribing physician, in 71% of the prescriptions the confidence in the prescribing physician was reported as 

high. Most of the prescriptions were issued either by general practitioners (41%) or by hospital physicians (38%). 

Patient age, a scheduled follow-up appointment, perceived importance of medication, concerns about medication 

safety, taking respiratory disease medication and taking cardiovascular disease medication remained significantly 

related to adherence as was seen in a multivariate analysis (Table 1). Among other drug groups the best adherence 

was found in the groups taking hormonal medications, such as insulin and thyroid hormones, not including hormone 

replacement therapy or contraceptives. The lowest adherence was found in the women taking musculoskeletal 

medications, such as non-steroidal anti-inflammatory drugs. 

Table 1. Factors associated with adherence to medication in multivariate logistic regression with backward 

elimination of non-significant factors, listed in order of importance. Odds ratios greater than 1.0 indicate that 

presence of the factor increases adherence, and odds ratios less than 1.0 that adherence decreases. (1) odds ratio, 

(2) 95% confidence interval 

Factor OR (1) 95%CI (2) 

Age, years 1.04 1.02-1.06 

Check-up appointment scheduled, yes/no 2.51 1.85-3.40 

Importance of medication score, 1-7 1.94 1.77-2.12 

Concerns about medication safety, yes/no 0.50 0.35-0.73 

Respiratory disease medication, yes/no 2.16 1.13-4.14 

Cardiovascular disease medication, yes/no 1.80 1.05-3.10 

Adherence also varied with various combinations of significant factors in the multivariate analysis. An example is given 

in Figure 1. Among women 35 years old, who regarded their medication as unimportant and who had no follow-up 

appointment scheduled, adherence was approximately 15% while among women 65 years old it was 35%. A scheduled 

follow-up appointment increased adherence by 15–20% units. The change in perceived importance of a medication 

from unimportant to moderately important increased adherence by 40% units. The best adherence, 95% or more, was 

found among those who regarded their medication as important and who had a follow-up appointment scheduled, 

almost regardless of age. 

Compliance is associated with information giving and positive talk. Patient-centred consultations, when the patient’s 

points of view are sought by the physician result in higher reported compliance rates. Our findings of high adherence 

in the group of women with a follow-up appointment is supported by prior findings, where following patients in care is 

seen as one of the most important adherence interventions. 

It seems that the patient-provider relationship, when communicative and concordant aspects are developed, may 

further improve adherence. One way to optimize this relationship is to train the medical providers and students in 

101


communication skills, in order to improve their abilities in creating an optimal consultation within the given time 

constraints. 

100 

90 

80 

70 

60 

50 

40 

Compliance, % 

30 

20 

10 

Important medication, check-up 

scheduled 

Important medication, no checkup 

scheduled 

Moderately important 

medication, check-up scheduled 

Moderately important 

medication, no check-up 

scheduled 

Unimportant medication, checkup 

scheduled 

Unimportant medication, no 

check-up scheduled 

0 

35 40 45 50 55 60 65 

Patient age, years 

Figure 1 Adherence (%) according to patient age, perceived importance of medication, and given scheduled checkup 

appointment. 


 

 

 

 

 


Arrange for scheduled follow-up appointments to assess the effects of the medication. 

Discuss the medication and the importance of taking it as prescribed during the consultation. 

Ask about the patient´s concerns with the medication. 

Explain disease severity to the patient. 

Provide training opportunities for medical students and practitioners to improve communication skills. 

http://www.woncaeurope.org/content/bp18-factors-associated-adherence-drug-therapy-population-based-study 

Reference 

 

Bardel A, Wallander MA, Svärdsudd K. Factors associated with adherence to drug therapy: a population-based study. Eur J 

Clin Pharmacol. 2007 Mar;63(3):307-14. 

102


Michael Greco 

Michael.Greco@cfepsurveys.com.au 

32 – Improving Practice Questionnaire - A Patient Feedback Tool for Clinical 

Governance, Practice Accreditation and Recertification: Where Are We Now? 

Michael Greco PhD; BTheol; 

Grad.Dip.Teach (Sec); GAICD 

Chief Executive, CFEP Surveys 

Introduction 

The voice of the patient is becoming increasingly recognized as a significant indicator 

of quality. The patient is envisaged as an important part of developing new services, 

and ensuring quality improvement across the various levels of the health care system. 

A recent systematic review published in the BMJ showed that patient experience is 

linked to clinical effectiveness and patient safety (1). 

So how can practices gather robust, valid and reliable data on patient experience? 

And how can this data be helpful in supporting the practice to improve its quality? 

The Improving Practice Questionnaire (IPQ) is a patient feedback instrument that 

combines both the general issues around primary care, such as access, availability of 

information, preventive care and health promotion, as well as the patient’s 

experience of the clinician’s interpersonal skills in the consultation (2). 

Spread 

The IPQ was extensively used across UK primary care practices (over 4,000) as part of 

the evidence required for the Quality Outcomes Framework (QOF) (3). In Australia, 

the IPQ is called the Practice Accreditation and Improvement Survey (or PAIS) and has 

been approved by the RACGP as part of its 4th Edition Quality Standards 

(commencing 2011) for practice accreditation (4). Over 3,500 Australian practices are 

involved in using the tool. Several other countries have adopted the tool including 

New Zealand and the Republic of Ireland. 

However, just undertaking a valid and reliable patient survey is not enough. The real 

challenge begins when healthcare organisations receive their results and reflect on 

their significance. Research evidence shows that these organisations do better when 

they build action plans around their results of patient feedback, and even more so, 

when patients are involved in the proposed improvement strategies. This process has 

been referred to as ‘Critical Friends Groups’ (5). 

At the individual level, clinicians can receive feedback on their interpersonal skills. In 

the UK, doctors are using this evidence as part of their requirements for Revalidation 

(6). In Australia, where revalidation does not yet exist, the IPQ is being utilised by 

doctors for their CPD requirements. Increasingly, the tool is being linked to Multi- 

Source Feedback (MSF) which is becoming more widely adopted across health 

practitioner recertification/revalidation (7). 

So What Next? 

Although several countries are now embedding systematic patient feedback into their 

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quality requirements, there is still little known about how practices reflect and respond to their feedback. More 

research is needed in the area of what actions, based on patient feedback, lead to improved outcomes. 

Another issue is that systematic patient feedback has been largely adopted by medical organisations because of quality 

requirements. However, there seems to be little uptake among other primary care providers such as dentists, 

pharmacists, physiotherapists and other allied health professionals. This apparent neglect of patient feedback is 

beginning to change. For example, the Pharmacy Guild of Australia has recently engaged their pharmacies in patient 

feedback as part of their Quality Care Pharmacy Program (8). However, to ensure further uptake by allied health 

professionals, more needs to be done to incentivise them in not only measuring patient experience, but also 

embedding such feedback into their quality review processes. 


 

 

 

 

 

Patient experience and its measurement is key for providing evidence of quality and safety across healthcare 

organisations. 

The Improving Practice Questionnaire has been extensively used in the UK, Australia, Ireland and NZ. 

It provides feedback at both the organisational and individual levels of performance to help provide evidence 

for practice accreditation and practitioner recertification/revalidation. 

Approximately 4 million questionnaires have been analysed across 10,000 organisations, however more needs 

to done in other allied-health professions. 

More research is needed on the impact of the tool in terms of improving quality at both organisational and 

individual levels. 


http://www.woncaeurope.org/content/221-improving-practice-questionnaire-patient-feedback-tool-clinical-governance-practice 

References 

1. Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570 

2. Greco, M.; Powell, R. and Sweeney, K. 2003. The Improving Practice Questionnaire (IPQ): a practical tool for general 

practices seeking patient views. Education for Primary Care. Vol.14: 440-448. 

3. Powell RJ, Powell, HJ and Greco MJ (2008) The impact of patient survey feedback in general practice: the influence of 

practice size. Journal of Management & Marketing in Healthcare, Vol 1, No.2, 202-213. 

4. Greco, M.; Sweeney, K.; Brownlea, A. and McGovern, J. 2001. The Practice Accreditation and Improvement Survey (PAIS) – 

what patients think. Australian Family Physician. Vol.30, No.11, 1096-1100. 

5. Greco, M.; Carter, M.; Powell, R.; Sweeney, K.; Jolliffe, J. and Stead, J. 2006. Impact of patient involvement in general 

practice. Education for Primary Care. Vol.17: 486-95. 

6. Narayanan, A. and Greco, M. 2007. What distinguishes general practitioners from consultants, according to colleagues? 

Journal of Healthcare Management and Marketing. Vol.1 No.1: 80-87 

7. Campbell, J., Narayanan, A., Burford, B. and Greco, M. 2010. Validation of a multi-source feedback tool for use in general 

practice. Education for Primary Care. Vol.21, 165-179. 

8. Narayanan, A., Greco, M. Reeves, P. et al. 2014. “Community pharmacy performance evaluation: Reliability and validity of 

the Pharmacy Patient Questionnaire (PPQ)”. International Journal of Healthcare Management. Vol.27, 103-119. 

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Ursula Reichenpfader, MD, MPH 

ureichenpfader@hotmail.com 

33 – Health Promotion In European General Practice – Opportunities and 

Challenges from a Research Perspective 

Ursula Reichenpfader, MD, MPH 

Department of Medical and 

Health Sciences - Division of 

Community Medicine, Linköping 

University, Sweden 

Co-authors 

Petra Plunger, Institute for 

Palliative Care & Organisational 

Ethics/IFF/Alpen Adria University 

Klagenfurt – Wien – Graz, 

Austria 

Karl Krajic, FORBA Working Life 

Research Centre, Vienna; 

University of Vienna, Austria 

Background - Health Promotion in General Practice: the Project 

The project "Health Promotion in Primary Health Care - General Practice and 

Community Pharmacy", commissioned by the European Commission, brought 

together professional associations of general practice/family medicine (GP/FM) and 

community pharmacy from all participating EU member states. Conceptually 

developed and coordinated by the Ludwig Boltzmann Institute for the Sociology of 

Health and Medicine in Vienna, WHO Collaborating Centre for Health Promotion in 

Hospitals and Health Care, and supported by a European expert group, this project 

aimed to contribute to the development of quality assured patient-/user-oriented 

health promotion in GP/FM and community pharmacy in the - then - 15 member 

states of the European Union (http://www.univie.ac.at/phc/e/tx_1020_85.htm ). 

The main objectives were to strengthen health promotion perspectives in 

professional health care settings, and to further European exchange and mutual 

learning. Based on a systematic literature search, consultations with project 

participants, and country reports, we provided an overview of the state of health 

promotion in these two settings. In a further step, the partners of the project 

formulated proposals as to how the European Commission could support the further 

development of health promotion in both settings. 

Our literature review revealed that health promotion in GP/FM was an underresearched 

topic. However, health promotion was explicitly recognized as an integral 

part of the professional role of the GP in several policy statements both at the 

European and the national level. Nevertheless, health promotion and relevant skills 

and competencies did not figure very prominently in professional education and 

training. As to reported health promotion activities, we identified several models and 

initiatives, albeit with only very few systematically designed and evaluated 

intervention studies; research on interventions and their effectiveness mostly referred 

to risk-factors and disease-oriented interventions. Health promotion and prevention 

activities provided in routine GP/FM had an emphasis on individually oriented 

interventions, including health-checks, opportunistic screening, and lifestyle 

counselling, vaccinations and participation in national cancer screening programs. 

Opportunities 

General practitioners (GPs) are considered well positioned to provide health 

promotion and preventive interventions. GP/FM is usually the point of first and low 

threshold contact for a large segment of the population and deals with a wide range 

of health issues. Given the nature of problems presented in GP/FM consultations, Gps 

are responsible for longitudinal continuity of care, often have established trusting relationships with their patients over 

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time, and develop a person-centred approach (1). Furthermore, patient attitudes towards lifestyle advice by GPs are 

positive, specifically regarding advice on dietary habits, physical exercise and smoking (2). 

Research suggests that brief lifestyle advice by primary care physicians can be effective, such as advice to promote 

smoking cessation, reduce harmful drinking, or improve nutrition behaviour, especially when offered to patients at risk 

of chronic conditions rather than to an unselected healthy primary care population. Interestingly, evidence also shows 

that more intensive interventions do not result in additional health benefits (3-5). 

Challenges 

Despite all these opportunities, wide-ranging implementation of health promotion, especially of more communicationintensive 

interventions, as well as prevention in routine GP/FM practice still seems to remain low. Patients report low 

rates of lifestyle advice and counselling by physicians in primary health care and often perceive their GPs not 

sufficiently interested in delivering such interventions. Research exploring barriers to provide health promotion as 

perceived by primary health care physicians identified the following factors: perceived lack of time or competing work 

load, insufficient reimbursement, doubts about patients’ acceptance and willingness to receive lifestyle counselling, 

low self-efficacy, insufficient skills and training, doubts about effectiveness of interventions, and health promotion 

perceived as outside professional role (6). 

As these perceived barriers may differ, ranging from factors associated with the individual practitioner to factors 

dependent on organizational or systems’ context (7), strategies to address these barriers and to influence professional 

practice will also vary. They include interventions to enhance professional competencies (i.e. professional education, 

audit and feedback, or quality assurance projects), financial incentives and improved regulatory contexts, or 

organizational measures for physicians (explicit inclusion in occupational roles, skill mix changes, integration of GP/FM 

in multidisciplinary teams, integration of different providers/services). 

Current and Future Perspectives 

While we were unable to carry out an update of our review, we found indications that the aim to better integrate 

health promotion in today’s GP/FM has not been fully achieved. Thus, how can evidence-based effective health 

promotion interventions successfully be implemented in routine GP/FM? Results from implementation research call 

for a structured and multi-faceted approach: so-called tailored implementation interventions, i.e. strategies designed 

to achieve desired changes in professional practice based on an assessment of relevant determinants, are needed. 

There is evidence that efforts to change professional practice have a higher likelihood of success when relevant 

barriers are identified in advance and taken into account (8). So far a majority of the tailored interventions 

investigated has been oriented at the individual provider, predominantly as educational interventions, while other 

strategies, like skill-mix development or multidisciplinary teams, have not been equally explored. 

Future activities as to how health promotion interventions can be better integrated in GP/FM should move beyond the 

traditional linear “from research-to-practice” approaches to more collaborative and flexible ones. More consideration 

should be given to actively involve patients and health care practitioners in designing research interventions and, 

research designs should more carefully address local and socio-cultural contextual factors in order to increase 

acceptability and sustainability. Before transferred into routine practice, such innovative strategies should then be 

tested using an appropriate methodological framework. 


 

 

 

 

General practitioners are considered well positioned to provide health promotion and preventive 

interventions. 

Implementation of health promotion and preventive interventions in routine GP/FM practice still remains low. 

Multiple barriers to health promotion implementation in GP/FM have been identified. 

Tailored implementation strategies with collaborative and flexible approaches should be explored to better 

integrate health promotion interventions in GP/FM. 


http://www.woncaeurope.org/content/279-health-promotion-european-general-practice-%E2%80%93-overview 

106

References 


1. Nutting PA. Health promotion in primary medical care: problems and potential. Preventive medicine. 1986;15(5):537-48. 

2. Brotons C, Drenthen AJ, Durrer D, Moral I. Beliefs and attitudes to lifestyle, nutrition and physical activity: the views of 

patients in Europe. Family practice. 2012;29 Suppl 1:i49-i55. 

3. Kaner EF, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, et al. Effectiveness of brief alcohol interventions in 

primary care populations. The Cochrane database of systematic reviews. 2007(2). 

4. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. The 

Cochrane database of systematic reviews. 2013;5. 

5. Ball L, Johnson C, Desbrow B, Leveritt M. General practitioners can offer effective nutrition care to patients with lifestylerelated 

chronic disease. Journal of primary health care. 2013;5(1):59-69. 

6. Geense WW, van de Glind IM, Visscher TL, van Achterberg T. Barriers, facilitators and attitudes influencing health 

promotion activities in general practice: an explorative pilot study. BMC family practice. 2013;14:20. 

7. Rubio-Valera M, Pons-Vigués M, Martínez-Andrés M, Moreno-Peral P, Berenguera A, Fernández A. Barriers and Facilitators 

for the Implementation of Primary Prevention and Health Promotion Activities in Primary Care: A Synthesis through Meta- 

Ethnography. PLoS ONE. 2014;9(2):e89554. 

8. Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, et al. Tailored interventions to overcome identified 

barriers to change: effects on professional practice and health care outcomes. The Cochrane database of systematic 

reviews. 2010(3). 

107


Justin Allen FRCGP 

justinallen@btinternet.com 

34 – How the UK Discovered Europe 

Justin Allen FRCGP 

President of EURACT 2001 - 2005 

Background 

In the United Kingdom over the last 15 years arrangements for the provision of 

specialty training for general practice and its supervision have undergone several 

reorganisations, and one of the major changes has been the development of a 

general practice curriculum. Specialty training for general practice lasted for three 

years, in six month training posts, two years in hospital and one year in an approved 

general practice placement. 

It may surprise you to know that until 2005 there was no comprehensive GP 

curriculum in the UK. Although there was high quality practice-based teaching, the 

governance and supervision arrangements were fragmented and inconsistent. The 

approval of hospital posts for GP training was vested in Royal College of the specialty 

concerned rather than the general practice college. The Joint Committee on 

Postgraduate Training for General Practice (JCPTGP), a statutory committee of the 

RCGP and the GP Committee of the British Medical Association (BMA) was 

responsible for approving general practice trainers, training placements and the issue 

of certificates of satisfactory completion of the training programme. 

The Joint Committee on Postgraduate Training for General Practice (JCPTGP), a 

statutory committee of the RCGP and the GP Committee of the British Medical 

Association; this committee was responsible for approving general practice trainers, 

training placements and the issue of certificates of satisfactory completion of training, 

given by an approved trainer. To add to this chaotic mix, the supervision of hospital 

training for GPs rested with the specialty college concerned. All medical colleges 

except general practice were supervised by a different national body, the Specialty 

Training Authority (STA). All these bodies were responsible to the overarching 

supervisory body in the UK, the General Medical Council (GMC). The GMC was also 

separately responsible for the undergraduate curriculum and performance matters of 

working doctors. 

As a result of some major governance issues in the UK involving patient harm (for 

example Harold Shipman) the government decided that the whole governance 

process was in need of reform, to avoid duplication and possible confusion of roles 

and responsibilities, not helped by the number of acronyms! The STA and JCPTGP 

were to be abolished and replaced by a single body, the Postgraduate Medical 

Education and Training Board. 

One of the strangest anomalies of the former system was that the RCGP had a very 

good final assessment exam but this was not approved for use as the national 

outcome assessment and a different system of assessment ran in parallel. 

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My Input 

In 2005 the RCGP was given the responsibility for developing a national curriculum for GP training, including 

assessment. It is at this point that I joined in the fun, having been invited to join the RCGP curriculum group, as I had 

some knowledge of work going on in Europe on curriculum development. 

The curriculum group was running a symposium on curriculum development at a WONCA conference entitled: 

“Developing a National Curriculum for the Education and Training 

of General Practitioners in the United Kingdom” 

This symposium looked at the process the Royal College curriculum group were undertaking in designing a new GP 

curriculum. The RCGP prides itself on the quality of its work and set about its task with its customary academic rigour 

and energy; it had already started this process when I joined, having started a programme of focus groups, trainee and 

educator surveys, presentations and workshops at national and international meetings. It had commissioned a 

literature review and was starting a process of considering other general practice curriculum models that had been 

developed elsewhere – one from the Oxford region in the UK, and nine from other countries: Australia, Canada, 

Denmark, Ireland, the Netherlands, Norway, Portugal, Spain and the USA. 

The observant will have noticed that four of the countries are native English speakers and that the remainder are from 

the WONCA European region (Ireland fits both categories). Even so the RCGP group were having difficulties in finding 

a good match for a comprehensive training curriculum for GPs in the National Health Service. 

As a newcomer to the group I was puzzled (I was often puzzled anyway). The Royal College of General Practitioners was 

an active member of WONCA Europe and its network organisations which had produced the 2005 European Definition 

(1) which contained a list of the core competences required to be a GP. EURACT had worked further and developed the 

European Definition into its Education Agenda (2). This document developed the list of competences into a full blown 

curriculum statement for European general practice ready for adaptation to the needs of individual countries. But the 

College did not appear to have considered the European Definition or the Educational Agenda. As we are part of the 

European Union and as a college have worked hard with our WONCA Europe colleagues, I suggested to the group that 

we should consider these models. This they did and discovered that with some modifications these documents would 

be a good basis for the new UK curriculum. With very little dissent, which was possibly related to the fact that the 

British only speak one language (and that rather badly) the WONCA definition, with its six core competences and three 

essential features became the basis for the UK curriculum in 2005, and remains so today. The EURACT Educational 

Agenda is the basis of the core curriculum statement “Being A GP”, and all of the RCGP curriculum statements use the 

six core competences and three essential features - see for yourself on the RCGP curriculum web site: 

http://www.rcgp.org.uk/training-exams/gp-curriculum-overview.aspx . 

Take Home messages 

 

 

 

Until 2005 there was no comprehensive national GP curriculum in the UK. 

Governance of GP training was by a number of bodies, with overlapping roles. GP and hospital training were 

supervised by different organisations. 

The national GP curriculum in the UK has now been developed, and is based on the WONCA Definition of 

General Practice and the EURACT Educational Agenda. 


http://www.woncaeurope.org/content/3553-developing-national-curriculum-education-and-training-general-practitioners-united 

References 

1. The European Definition of General Practice/Family Medicine 2005 Edition 

http://www.woncaeurope.org/sites/default/files/documents/Definition%202nd%20ed%202005.pdf (accessed 19/12/14) 

2. The Educational Agenda 2006 ed. J.Heyrman, Leuven, 

http://www.euract.eu/official-documents/finish/3-official-documents/93-euract-educational-agenda (accessed 

19/12/14) 

109


Claire Collins, PhD, MSocSc, BSocSc, Dip Stat 

claire.collins@icgp.ie 

35 – Health Needs Assessment 

Claire Collins, PhD, MSocSc, 

BSocSc, Dip Stats 

Irish College of General 

Practitioners, Dublin, Ireland 

What is a HNA? 

“Health needs assessment (HNA) is a systematic method for reviewing the health 

issues facing a population, leading to agreed priorities and resource allocation that 

will improve health and reduce inequalities” (NICE, 2005). It is not only the process of 

identifying the health needs in the community but also an exploration of all the 

resources involved - how they are used and how they could better be used - and 

where they are lacking. It is used to inform decision making and should lead to 

change which benefits the health of the target population, usually within finite 

resources – it is therefore necessary to be realistic about what you are capable of 

achieving from a practical, clinical and economic position. It is important to consider 

that many factors influence health and therefore numerous individuals, groups and 

institutions/bodies have a role to play in the health arena. 

It is accepted that a HNA will produce benefits on multiple levels; these may include: 

 

 

 

 

 

 

 

 

 

strengthening community involvement in decision making 

improved public/patient participation in planning services 

improved team and partnership working 

professional development of skills and experience 

increased understanding of local health issues 

improved patient care/improved health of people in your 

community/practice 

improved communication with other agencies and the public 

demonstrate the reasons for decisions about health care 

better use of resources, services and people. 

What Does a HNA Involve? 

The steps involved in a HNA are outlined in many toolkits – Figure 1 outlines the five 

key steps from one of these (NICE, 2005). 

In brief, data collection in a HNA in primary care will likely include existing practice 

data, routinely available local statistics, a patient/public consultation exercise, and a 

mechanism to obtain public and professional perspectives on need. The latter two 

may include such activities as questionnaire surveys, interviews, focus groups, 

casework information and observations. 

It will most likely be necessary to determine need priorities in consultation; questions 

which may help this process relate to the numbers affected (absolute or 

comparatively), equity, impact, changeability, availability of effective and appropriate 

interventions, the provision of adequate services, the existence of expertise, local and 

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national priorities/strategies, acceptability and resource feasibility. 

Planning and implementing actions is the most important part of a HNA and involves setting clear aim(s) and 

objectives, agreeing a shortlist of potentially effective interventions or actions and specifying the resources required 

(people, space, time and equipment). 

Evaluating successes and failures and continuous monitoring are part of the process. Effective outcome evaluation 

requires setting indicators (measures against which to monitor progress) and targets (the level of outcome you want to 

achieve, for whom and by when). 

Guiding Principles and Notes for Primary Care 

The many authors who have written on the subject take different theoretical perspectives and propose diverse 

approaches. Furthermore, a HNA may be conducted at different levels (European, national, local, individual etc). 

However, the guiding principles when conducting a HNA are: 

 

 

 

 

 

 

 

 

 

Be clear about your aim(s) from the very start as this will determine your approach. 

The negotiations leading up to a needs assessment are important to determine what sort of evidence of 

'neediness' you will have to demonstrate to convince decision makers. 

There are many different concepts of ‘need’ e.g. felt need, expressed need etc. 

Different information sources and methods of investigation tell you about different aspects of ‘need’ – a mix 

of sources/methods will build a broader picture of need. 

The way you undertake a needs assessment is important and ideally you should use a method that allows you 

to start to work on the solution to a problem while you are assessing it. 

The needs assessment should be owned by the people who will have to implement the actions. 

Health needs assessment should fit in with the appropriate decision making/planning system e.g. team, local, 

regional etc. 

Health needs assessment is not an end in itself but a means to help plan the future. 

Health needs assessment is a part of a cyclical process and should include an evaluation of how the needs 

have been met and not met by the actions taken. 

Kilduff et al (1998) highlight the need for primary health care teams (PHCTs) to understand their stage of development 

and how this will directly affect any health needs assessment, and discusses the place of health needs assessment 

within the general processes and systems of the PHCT. A diagnostic and development tool, which links together the 

intimate relationships between five stages of development needed for effective primary care-oriented health needs 

assessment work, is outlined. The BMJ has produced a series of six articles on HNA which give a useful overview and 

direction, and contain many useful references for further and directed reading. Of particular interest for primary care is 

the first of these articles which points to the importance of distinguishing between individual needs and the wider 

needs of the community in the planning and provision of local health services; ignoring these needs can lead to a topdown 

approach to providing health services, which relies too heavily on what a few people perceive to be the needs of 

the population rather than what they actually are. The third article moves HNA from theory to practice; it notes that 

the assessment of individual's needs may form part of the assessment of a population's needs and outlines the 

circumstances favouring individual needs assessment for planning purposes. The fourth article in the series focuses on 

HNA in primary care (albeit in the UK) and identifies the different levels at which a HNA might be conducted and the 

related approaches and methods. The fifth article in the series highlights the importance of and scope for greater 

consultation with the general public and with current users about needs and priorities. It points to a need to 

acknowledge limitations to professional knowledge as well as to respond to inequalities in health (BMJ, 1998). 

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Step 1 

Getting started 

What population? 

What are you trying to achieve? 

Who needs to be involved? 

What resources are required? 

What are the risks? 

Step 2 

Identifying health priorities 

Population profiling 

Gathering data 

Perceptions of needs 

Identifying and assessing health 

conditions and determinant factors 

Step 5 

Moving on/review 

Learning from the project 

Measuring impact 

Choosing the next priority 

Step 4 

Planning for change 

Clarifying aims of intervention 

Action planning 

Monitoring and evaluation strategy 

Risk-management strategy 

Step 3 

Assessing a health priority for action 

Choosing health conditions and 

determinant factors with the most 

significant size and severity impact 

Determining effective and acceptable 

interventions and actions 


 

 

 

 

 

Figure 1: The five steps of health needs assessment 

HNA is an approach that helps plan services that tackle ‘needs’ rather than just reacting to demands. 

HNA is a multidisciplinary and multisectoral activity and consultation is a key component. 

HNA is not only about assessment but also about taking action to improve the health of the population. 

Aim for small, achievable, measurable goals; this increases the chance of success. 

HNA is not an end in itself. 


http://www.woncaeurope.org/content/theme-b-needs-assessment-general-practice-family-medicine 

References 

BMJ. Series of articles on ‘Health needs assessment’ online: BMJ 1998; 316 (April to June 1998): 

http://www.bmj.com/content/316/ 

Gillam, S. & Murray, S. (1996). Needs assessment in general practice. London: RCGP occasional paper. 

Harris A. (1997) (ed). Needs to Know: a guide to needs assessment for primary care London: Churchill Livingstone. 

Hooper J, Longworth F (1997). Health needs assessment in primary care. A workbook for primary health care teams. 

Calderdale and Kirklees Health Authority. 

Kilduff A, McKeown K, Crowther A. Health needs assessment in primary care: the evolution of a practical public health 

approach. Public Health. 1998 May;112(3):175-81.PMID:9629025. 

NICE (2005) Health Needs Assessment: a Practical Guide. 

http://www.gserve.nice.org.uk/nicemedia/documents/Health_Needs_Assessment_A_Practical_Guide.pdf 

Scottish Needs Assessment Programme (1998) Needs Assessment in Primary Care: A Rough Guide. Glasgow. 

WHO Community health needs assessment (2001) An introductory guide for the family health nurse in Europe. 

http://www.euro.who.int/__data/assets/pdf_file/0018/102249/E73494.pdf 

112


John Salinsky, MD, FRCGP 

jvsalinsky@aol.com 

36 – The Balint Experience 

John Salinsky, FRCGP 

General Practitioner and Training 

Programme Director 

Whittington GP Education and 

Training, London, UK. 

The Early Days of Balint 

Balint groups are named after the psychoanalyst Michael Balint (1896-1970). In the 

late 1950s, Michael and his wife Enid began holding psychological training seminars 

for GPs in London. This work was first described in the book The Doctor, his Patient 

and the Illness (1957). There were no lectures and the doctors’ education was based 

on case presentation and discussion in a small group of nine or ten with a 

psychoanalyst leader. To begin with, Balint encouraged the group members to hold 

‘long interviews’ with their problem patients. This helped the doctors to concentrate 

on becoming good listeners. Subsequently the focus changed to studying the 

relationship between doctor and patient in the context of every day ordinary-length 

consultations. The groups met once a week for a number of years so that patients and 

their progress could be followed up. The continuity also enabled group members to 

feel at ease with other. Since those early days, Balint groups have spread across the 

world and in 20 countries there are national Balint Societies whose aim is to foster 

and develop the Balint approach. 

Balint Groups Today: What Happens? 

The group members and the leader sit in a circle and the leader (or one of the leaders 

if there are two) asks ‘who has a case?’ Someone volunteers to talk about a patient 

who has been on her mind. The problem may be that the patient has been 

emotionally disturbing or just difficult to understand or to engage in treatment. The 

group listens to the story without interrupting. When the presenter has finished, the 

leader invites the group to respond to what they have heard. Responses take various 

forms. There may be questions, advice to the doctor, emotional reactions induced by 

the patient’s story and speculations about what else might be going on. The group 

leader will gently discourage too much interrogation of the presenter, as the aim is to 

get the group members themselves to work on the case. In a variation of the group 

process, the leader asks the presenter to ‘sit back’ i.e. to push his chair back a little 

and to remain silent for the next 20-30 minutes. 

This effectively prevents the group from asking any more questions and throws them 

back on their own resources. The presenter is allowed to have her say and respond to 

what she has heard when she is invited to join in again later. 

The Role of the Leaders 

The leaders’ first aim is to make the group a safe place, where confidentiality is 

observed and members feel free to talk about their feelings and their work (including 

their mistakes). The leaders will discourage unwanted and intrusive questions about 

the presenting doctor’s personal life and history. Personal anecdotes are sometimes 

volunteered and can be helpful. The leaders will allow this provided there is no pressure. The group is not a therapy 

113

group although its effects can be therapeutic. 


The leaders’ second aim is to keep the discussion focused on the doctor patient relationship. They may ask how the 

patient has made everyone feel. Do we feel angry or sad? Do we like the patient and want to help him? Or would we 

prefer to keep him at a distance? The group may be invited to consider how the patient is feeling or what sort of 

doctor he wants his doctor to be. A group that dislikes or fears the patient may be unwilling to engage and will try to 

‘escape’ by talking about generalities: ‘these patients are always untreatable’ or recommending referral to an expert 

whom somebody knows. In this situation the leaders will try to bring the group back to the work, perhaps by 

representing the patient (‘If I were this patient I would be feeling terribly alone and abandoned right now…’) 

If there are two leaders, they will be trying to work in sympathy, picking up cues from each other. One may steer the 

discussion while the other watches for people trying to get a word in. Often, the presenting doctor finds herself 

behaving like the patient, while the group members mirror her own reaction in the consultation. 

Ending the Session 

The session ends, like a therapy session, when time has run out. At least one leader will be keeping a discreet eye on 

the clock. There may be one or two presentations (including follow-ups) in a ninety-minute session. The leaders may 

ask for a follow up and thank everyone. They do not attempt to tie the loose ends or give a reassuring summary. 

Benefits of Balint 

What does participation in a Balint group do for a group member? 

The first and most easily obtained benefit is to have a safe place where you can talk about interpersonal aspects of 

your work with your patients. The group will be sympathetic and they will all have been in similar situations 

themselves. This is a great relief and usually means that when a dreaded patient turns up again he or she will cause 

less anxiety. We believe that the Balint group experience helps to avoid professional ‘burnout’. Are older Balint doctors 

still enjoying their work? Try asking them! 

Secondly, the Balint group encourages doctor to see their patients as human beings who have a life and relationships 

outside the consulting room. They become more interesting to listen to and easier to help. 

Thirdly, the group members may gradually reach a deeper level of understanding of their patients’ feelings and their 

own. They may realise that certain patients or emotions may resonate with what is going on in their own inner and 

outer lives. This may be causing problems which the doctor can learn to avoid or even to turn to therapeutic 

advantage. 


Taking part in a Balint group can help a doctor to: 

 

 

 

find a safe place to discuss doctor-patient issues 

see patients as human beings 

reach a deeper level of understanding of the feelings of both patient and doctor 


http://www.woncaeurope.org/content/25-balint-group-experience 

References 

 

 

Balint, M. (1957) The Doctor, his Patient and the Illness. London: Pitman. Millennium edition 2000. Edinburgh: Churchill 

Livingston. 

Kjeldmand, D, Jablonski, H and Salinsky, J (2013). Balint Groups and peer supervision. In L Sommers & J Launer (Eds.) 

Clinical Uncertainty in Primary Care. The challenge of collaborative engagement. New York, Springer. 

114


Alan Abelsohn MBChB, CCFP, FCFP 

alan.abelsohn@utoronto.ca 

37 – Environment and Health in Family Medicine 

Alan Abelsohn MBChB, CCFP, 

FCFP 

Associate Professor, Department 

of Family and Community 

Medicine and the Dalla Lana 

School of Public Health, 

University of Toronto. 

How is the environment that my patient lives in, affecting her health? It is an 

interesting question, and one most family doctors seldom consider. I will discuss this 

question from a number of perspectives. 

Is it important, i.e. how big is the burden on health as a result of environmental 

factors? There have been a number of estimates of the burden of environmental 

impacts on health, noting that these impacts are preventable. However, the scope of 

the definition of environmental health and the methods used vary from study to 

study, making interpretation difficult. Table 1 lists a selection of the studies. It is clear 

that the morbidity and mortality from environmental factors is significant. 

Study Jurisdiction Scope of Study Health costs 

WHO 

(1) 

Globally 

A broad scope of factors, 

including chemical and 

biological pollution in 

air, water and soil, UV 

and ionizing radiation, 

noise and 

electromagnetic fields, 

occupational risks, 

climate and ecosystem 

change and the effects 

of the built 

environment. 

24% of DALYs (Disability 

Adjusted Life Years) 

23% of all deaths 

36% of deaths in children aged 

0-14 

WHO 

(1) 

Developed 

countries 

As above 

16% of DALYs 

Boyd 

(2) 

Canada 

Restricted to 

environmental burden of 

disease from respiratory 

disease, cardiovascular 

disease, cancer and 

congenital affliction 

Annually: 10,000–25,000 

deaths, 78,000–194,000 

hospitalizations, 8000–24,000 

new cases of cancer; and 500– 

2500 low birth weight babies, 

costing between $3.6 billion 

and $9.1 billion 

Developed countries are less affected, as the burden in developing countries includes 

water contamination, and the large numbers affected by indoor burning of coal and 

biomass for home heating and cooking, which is responsible for 1.6 million premature 

deaths and nearly 3% of the global burden of disease in 2000 (3), as well as the 

suffocating outdoor air pollution of cities like Beijing and Delhi. 

So let’s consider a case. A 14 year-old girl presents in the emergency department with an exacerbation of her asthma. 

115


She had been previously well controlled, on a LABA and Inhaled Corticosteroid combination. What might have 

precipitated this exacerbation? It could be due to a viral upper respiratory infection, or non-compliance. But to 

consider possible environmental factors, we suggest taking an “exposure history” using the CHP mnemonic (4). She 

might be exposed in the following environments. (Table 2) 

CHOP Location Examples 

C Community Outdoor air pollution from traffic, industry, wood-smoke from a 

fire, crop burning or home heating/cooking 

H Home Second-hand smoke; a new pet; cockroaches; House dust mites; 

water damage and mould; smoke from wood-burning or kerosene 

stoves or fireplaces; Outdoor air pollution infiltrating inside 

H Hobbies Clay dust or glazes from pottery/ceramics; paint fumes; solvents; 

chemicals; baking flour 

O Occupation/ School Exposures at work or in the school building 

P Personal Smoking 

So asking, or if a house-call is carried out, observation, might reveal the “upstream” provocative factors, which might 

otherwise not be recognised. And the treatment would be two-fold: treating the asthma exacerbation medically, but 

also intervening if possible in the environment. For example, community air pollution was increased that day, and the 

corresponding Air Quality Index was elevated. The family could be counselled that strenuous outdoor activity increases 

the intake of air pollutants into the airways, and should be reduced when pollution levels are high; and that she should 

exercise away from traffic as much as possible, because exercising near traffic increases pollutant exposure and 

reduces FEV1 (5). 

Environmental health is by definition multidisciplinary, and many of these issues might overlap with Public Health, or 

other disciplines. For example, a 2 year-old child is found to have a high serum lead level. The source (H in the CHOP 

mnemonic) is hand to mouth activity so that house dust is ingested; and the dust is contaminated by deteriorating old 

lead-based paint around the windows. Lead was removed from paint in Canada in 1978. The intervention is to remove 

the child from the environment, and remediate the house dust/paint situation. Other sources of lead might have been 

from 

 

 

 

(H-Home) children’s toys or jewellery, lead-soldered pots or glazed pottery; 

(H-hobbies) stained glass or pottery and 

(P-personal) folk remedies, Ayurvedic products or Asian eye-cosmetics. 

But there is another aspect of the environment that, although less immediately clinically relevant, is important to 

family doctors; namely the health of the planet. Climate change is not just a physical issue; it is very much a health 

issue. Dr Margaret Chan, director-general of the WHO, called climate change “the defining issue for public health in the 

21 st century”. The broader perspective of planetary sustainability (6) is being discussed more and more urgently in 

medical circles. 

The health effects of climate change are described as direct (heat extremes; severe storms and floods) and indirect, 

which spans a number of pathways; increased range of vector-borne diseases (Lyme disease in Canada; Chikungunya in 

Europe and the Caribbean); food insecurity secondary to drought, with resulting malnutrition, water insecurity, and 

sea level rise which will all lead to the displacement of climate change refugees and the potential for international 

conflict. 

What is the role of family doctors? 

We should be checking and taking steps to reduce our own and our family’s Carbon footprints: 

http://www.nature.org/greenliving/carboncalculator/ . 

In our clinics and hospitals, we should be leading by example, and doing our best to make them ecologically 

sustainable: “greening” our workplaces. 

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We are also teachers, and need to impress on the next generations of health care professionals the urgency of tackling 

these global health threats. 

Finally, we could be advocates for our planet, advocates for the urgent transformations required by our societies, to 

gain control of carbon emissions, and reduce over-consumption and inequity. Family doctors are well-respected 

community based scientists. There is one of us in almost every community around the globe. We are uniquely placed 

to be effective actors (7). My hope is that we exert our well-deserved influence and credibility, as individuals, and also 

as medical organizations, in the name of redirecting our planet towards health and sustainability. 


 

 

 

 

 

Environmental factors are responsible for a significant burden of illness. 

Environmental causes of illness are “upstream”, and often not recognized. 

An exposure history, using the CHP mnemonic, is a useful clinical tool. 

Climate change and planetary sustainability are pressing global issues. 

Family doctors have a role in greening their clinics and hospitals, educating the next generation of doctors, 

and advocating individually and in our organizations, for planetary health. 

Original Abstact 

http://www.woncaeurope.org/content/ws-013-environmental-medicine-family-practice 

References 

1. Pruss-Ustun A. Corvalan C. How much disease burden can be prevented by environmental interventions. Epidemiology. 

2007;18(1):167-78. 

2. Boyd DR, Genuis SJ. The environmental burden of disease in Canada: Respiratory disease, cardiovascular disease, cancer, 

and congenital affliction. Environmental Research. 2008; 106(2):240-249. 

3. Ezzati M. Indoor air pollution and health in developing countries. Lancet. 2005; 366(9480):104-106. 

4. Marshall L, Weir E, Abelsohn A, Sanborn MD. Identifying and managing adverse environmental health effects: 1. Taking an 

exposure history. CMAJ 2002;166(8):1049-55. Available at: http://www.cmaj.ca/cgi/content/full/166/8/1049 

5. McCreanor J, Cullinan P, Nieuwenhuijsen MJ, Stewart-Evans J, Malliarou E, Jarup L, et al. Respiratory effects of exposure 

to diesel traffic in persons with asthma. N Engl J Med 2007;357(23):2348-58. 

6. Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S. From public to planetary health: A manifesto. The Lancet. 

2014; 383:847-847. 

7. Blashki G, Abelsohn A, Woollard R, Arya N, Parkes WM, Kendal P, Bell E, Bell RW. General Practitioners' responses to 

global climate change - lessons from clinical experience and the clinical method. Asia Pacific Family Medicine. 2012,11:6 

117


Karen Bentley, BM 

karen.bentley1001@ntlworld.com 

38 – Mentoring – a Quality Approach to Professional Development 

Karen Bentley. BM DRCOG DGM 

MRCGP PGCME 

GP trainer, appraiser, Associate 

Dean. Wessex Deanery. 

Hampshire . UK 

The term 'mentoring' is derived from the character 'Mentor' in Homers Odyssey. In 

the story, Mentor was an old friend of Odysseus and was the respected advisor to 

Telemachus, the son of Odysseus and Penelope. Odysseus entrusted his Son and 

household to Mentor when he sailed against Troy. The goddess Athena took on the 

appearance of Mentor in order to guide young Telemachus in his time of difficulty, 

giving him prudent counsel. Since then, wise and trusted advisers have been called 

"mentors". 

Appraisal is now an annual requirement of every doctor registered with the GMC in 

the UK in order to continue to demonstrate their ongoing fitness to practice. 

Revalidation occurs in a five yearly cycle enabling a doctor to continue the practice of 

medicine. Although the process of Mentoring has been around for a long time the 

advent of annual appraisal has meant that appraisers have identified 'doctors in 

difficulty' who need the advice and guidance of a mentor with increasing frequency. 

So what is Mentoring? 

"Mentoring is to support and encourage people to manage their own learning in 

order that they may maximise their potential, develop their skills, improve their 

performance and become the person they want to be.” (Eric Parsloe) 

Mentoring is a powerful personal development and empowerment tool. It is an 

effective way of helping people to progress in their careers and is becoming 

increasingly popular as its potential is realised. It is a partnership between two 

people. The MENTOR (the person doing the mentoring) and the MENTEE (the person 

receiving the mentoring) normally work in a similar field or share similar experiences. 

It is a helpful relationship based upon mutual trust and respect and is different to 

coaching an individual. It is for the mentee to find their own path rather than being 

told what to do. 

A mentor is a guide who can help the mentee to find the right direction and who can 

help them to develop solutions to career issues. Mentors rely upon having had similar 

experiences to gain an empathy with the mentee and an understanding of their 

issues. Mentoring provides the mentee with an opportunity to think about career 

options, personal difficulties life hurdles and helps them to progress. 

A mentor should help the mentee to believe in themselves and boost their confidence 

and above all do no harm in this relationship. 

A mentor should ask questions and challenge, while providing guidance and 

encouragement. Mentoring allows the mentee to explore new ideas in confidence. It 

is a chance to look more closely at themselves, their issues, opportunities and what 

they want in life. Mentoring is about becoming more self aware, taking responsibility 

for your life and directing your life in the direction you decide, rather than leaving it to 

chance. 

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How is it achieved? 

Usually there is an agreement between the mentee and the mentor for a number of sessions over a period of time. 

The session length and the number of sessions are predetermined so that dependence on the mentor does not occur. 

The mentor should have a proven track record of helping others and of continuing self development and continuing 

professional and personal development. 

The sessions may consist of whatever the Mentee may bring but the premise of the Mentor is to get the Mentee to 

'solve' the problems themselves through the use of powerful questioning and putting the mentee in the driving seat to 

re-frame the problem and approach it from a different point of view. Powerful questioning should take into account 

the learning styles of the mentee i.e. Honey and Mumford - Theorists, Activists, Reflectors and Pragmatists. The 

powerful questioning can then be tailored on these styles so that they are even more relevant to the mentee. This 

process often begins with the mentee producing a time line and looking at significant life changing events that have 

occurred that may influence behaviour, to get the mentee to understand why they behave as they do. 

At the end of the sessions it is implied that the Mentee will have been on a journey of self discovery and been 

empowered to change their behaviour. 

This process can be divided into the' five phase' approach to mentoring: 

Phase One: Contracting and building the relationship: the mentor and mentee build an initial relationship, getting to 

know one another and building rapport. They establish what the mentee hope to gain from the mentoring and confirm 

what the mentor has to offer. They jointly agree the mentoring contract. 

Phase Two: Understanding the Mentee: the mentee describes their current situation and how they would like things to 

be in the future. This looks at the mentees strengths and weaknesses, skills and experience. 

Phase three: Analysis: the mentee and mentor work together to apply appropriate frameworks to help the mentee 

gain awareness and understanding, recognising the patterns of behaviour that are relevant. 

Phase four: Action Planning: the mentor and mentee identify the options that will extend the range of possibilities for 

the mentee. This involves looking at problems in different ways and the possibility of acting as 'devil's advocate', to 

challenge the mentee to change and take a different perspective. This involves considering and comparing the options 

and helping the mentee to understand the implications of each option in order to work out the best option and create 

a detailed action plan. 

Phase five: Implementation and review: this is where the mentee puts their action plan into practice. This is the result 

of the mentoring process. 

The elements of this process are 

Awareness - understanding what's going on in the here and now, not reacting in ways that are historical and 

redundant. 

Alternatives- being able to identify and develop choices for any given situation and not having one way of responding. 

Authenticity - being able to build genuine relationships with others. 

Key to the success of mentoring is the relationship established between mentor and mentee, the formulation of a 

'contract' between the two parties to reach a successful end point involving a changed behaviour to enable the 

individual to progress and continue in their career. 


 

 

 

 

 

The need for Mentoring is increasing. 

A contract is needed between mentor and mentee. 

The premise is 'Do no harm'. 

The mentee should be empowered. 

Effective change should be an action plan outcome. 


http://www.woncaeurope.org/content/mentoring-quality-approach-professional-development 

119

References 


GMC 'Good medical Practice' (2013) www.gmc-uk.org/guidance/good_medical_practice.asp 

mentoring.londondeanery.ac.uk/ 

NHS Thames Valley and Wessex Leadership Academy Mentoring scheme: Resource Pack 2012 Published by the Thames 

Valley and Wessex Leadership Academy 

Clutterbuck, D & Megginson, D, Mentoring Executives and Directors (1999) 

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Andre Matalon, MD 

matalon@netvision.net.il 

39 – Pleasures of Doctoring in Family Medicine 

Andre Matalon MD 

Dept. of Family Medicine, Rabin 

Medical Centre, Belinson 

Campus, and the Dept. of Family 

Medicine, Tel-Aviv University, 

Israel 

Co-authors 

Martine Granek-Catarivas MD 

(2) & Stanley Rabin PhD (3) 

(2) Dept. of Family Medicine, Tel- 

Aviv University and Clalit Health 

Services, Sharon-Shomron 

District 

(3) Dept. of Psychiatry, Soroka 

University Medical Centre, and 

Division of Psychiatry, Faculty for 

Health Sciences, Ben Gurion 

University of the Negev, 

Beersheba, Israel. 

Every day family physicians deal with difficult patients and difficult diseases, with 

disability and death. In many parts of the world, they face crowded waiting rooms, 

little time for each patient, disrupting telephone calls and financial and administrative 

pressures (1). Other pressures are those related to the doctors' own personalities 

such as perfectionism, self criticism, fear of failure or making mistakes or discomfort 

about uncertainty (2) (3). Feelings of helplessness or guilt are common among them 

(4). Doctors often feel overworked and under-supported and feelings of loneliness are 

also common (5). When family medicine is practised in a hostile environment with the 

threat of malpractice, doctors adopt a defensive position where their personal and 

professional well being is jeopardized, nibbling at their ability to enjoy their 

profession. 

But, in every simple day of work of any family physician, there are plenty of 

pleasurable moments, laughter, intimacy and closeness, moments of trust, 

compassion, love and warmth. 

Based on a qualitative review of Balint groups with residents (6) and on focus groups 

of tutors and specialists in family medicine, three themes could be identified 

regarding the pleasures of doctoring: the professional, emotional and contextual 

gratifications. 

Professional Gratification 

Family physicians expressed their enjoyment in practising holistic medicine, their 

ability to deal with almost all aspects of medicine, from cardiology through infectious 

diseases and psychiatry. This diversity guaranteed a continuous interest in their work. 

Some of the doctors expressed feelings of accomplishment when performing simple 

surgical procedures or actions that brought immediate relief from pain or disease. 

They described sharing the joy and prompt relief obtained after opening an abscess, 

excising an infected ingrown toenail or reducing a dislocated elbow. They expressed 

that there was no greater gratification than when the patient left the office without 

pain. 

Gratification was also felt in making a precise diagnosis, at the right time. This would 

happen especially when a diagnosis led to a dramatic change in the patient’s health, 

which further on, would also lead to a better doctor-patient relationship, recognition, 

respect and trust. To decide to treat difficult problems alone and succeed was also 

stated as immensely rewarding. The courage to treat difficult issues on one’s own, 

with the cooperation and full participation of the patient in the decision-making 

process was another source of much joy. 

Emotional Gratification 

We found a second group of expressions of emotional gratification that brought comfort and pleasure. 

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One doctor described how good he felt when he examined a child who did not cry, even after forcing a wooden tongue 

depressor into his throat. He felt special pleasure in conquering his trust, and the trust of the child's parents accepting 

his explanations about him having "just" a viral infection. 

Other doctors described their satisfaction in caring for their dying patients and their families, discovering the real 

meaning of assistance when easing the physical pain of the body, or the emotional anguish in a cancer patient. They 

felt at their best in their ability to break bad news and to handle the anxiety and depression that followed. The 

emotional price paid by the doctor in his involvement gave him a feeling of spiritual uplifting. They felt that this was 

family medicine at its best. 

Many doctors shared the pleasure obtained through continuity of care, so characteristic of the profession, and the 

simple joy of knowing their patients. Powerful sources of pleasure were going out into the waiting room of the clinic, 

welcoming a patient-friend, calling him by his/her name, giving a strong and affectionate handshake, or a gentle touch 

on the shoulders while leading the patient from the waiting room to the examination room. Knowing precisely the 

appropriate opening phrase for each patient, from their last vacation to football, or directly addressing the patient’s 

suffering were also pointed out to be most satisfying. 

Physicians related to their feelings of affection that grew with time, while accompanying the personal, familial or 

health crises of their patients: “It’s the mutual respect, trust and friendship that develop over time that I especially 

enjoy.” 

The awareness that one has the ability to care and feel positive feelings, like a mother who discovers her ability to 

parent and love, was, in itself, gratifying to the participants. 

Contextual Gratification 

Many rural doctors live and work in the same community as their patients, or have personal friends as patients. 

Although this situation may cause problems, most of the doctors reported more satisfaction than problems. Some 

doctors reported their joy and pride at being invited to the weddings of their patients or being treated with a special 

respect by the community grocer or by the car mechanic. These satisfactions may have been unwarranted, yet the 

pride and respect doctors felt from their special status in the community were sources of special joy to them. 

With regard to the issue of professional status, the doctors, mainly the residents, reported that family doctors 

sometimes enter into competition with other profession specialists, wishing to win their collaboration and approval. 

While the disrespect some residents felt from hospital doctors was translated into indignation, earning the respect of 

colleagues was reported as a source of satisfaction. Hospital-based colleagues regarded the decision to become a 

family doctor as going down the easy path. Yet, most of the residents opted positively for a career in family medicine. 

Identifying and understanding the rewards and gratifications of their professional choice helped these family doctors 

overcome any insinuation that they took the easy option. 

Conclusion 

The joy we experience with our work radiates to the entire environment and to the patients in particular, fostering 

their well being and the well-being of the doctors as well. Pleasurable insights achieved in Balint groups or in 

workshops on the pleasures of doctoring can serve as another source of gratification and can help in preventing burnout. 


 

 

 

 

 

Family physicians often deal with difficult patients, crowded waiting rooms, little time with patients and 

administrative pressures. 

Other pressures are related to the doctors' own personalities such as perfectionism, self criticism or fear of 

making mistakes. 

But, in every day of work of any family physician, there are plenty of pleasurable moments, laughter and 

intimacy. 

Three themes were identified regarding the pleasures of doctoring: professional, emotional and contextual 

gratifications. 

Pleasure in doctoring radiates to the entire environment, fostering both patients' and doctors' well-being. 

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http://www.woncaeurope.org/content/451-pleasures-doctoring-family-medicine 

References 

Williams ES, Linzer M, Pathman DE, McMurray JE, Konrad TR. What do physicians want in their ideal job? J Med Pract 

Manage. 2003 Jan-Feb; 18(4):175-6. 

Brock CD, Johnson AH. Balint group observations: the white knight and other heroic physician roles. Fam Med. 1999 Jun; 

31(6):404-8. 

Edwards N, Kornacki M J, Silversin J. Unhappy doctors: what are the causes and what can be done? BMJ 2002; 324:835- 

838 

Balint M. The doctor, his patient and the illness. London, Pitman, 1957. 

Smith R. Why are doctors so unhappy? BMJ 2001; 322:1073-1074 

Matalon A. The pleasures of doctoring as seen through reflections in Balint groups. Psychodinamische Psychotherapie 

2010; 9: 176-182 (Ger) 

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Teresa Pawlikowska BSc MB BS MSc PhD DRCOG 

MRCP 

tpawlikowska@rcsi.ie 


40 – Measuring Effectiveness in General Practice / Family 

Teresa Pawlikowska BSc MB BS 

MSc PhD DRCOG MRCP 

Professor and Director Health 

Professions Education Centre, 

RCSI, Dublin, Ireland. 

Context 

Increasing patient involvement in their own care, and its evaluation, is an important 

feature of health service development. Donabedian has conceptualised effectiveness 

into technical and interpersonal aspects: the latter is explored here. 

McWhinney defined general practice as working with undifferentiated problems, 

patient -focused, and stressed the importance of the doctor-patient relationship. All 

definitions of the role of general practitioner (The Leeuwenhorst Group 1974, the 

European Academy of Teachers in General Practice, EURACT in 2005) focus on a 

biopsychosocial perspective. 

So core values in primary care include a holistic patient-centred approach. There has 

been much debate over the definition of patient-centredness and its measurement, 

but Stewart defines essential components as: exploring the patient’s reason for the 

visit, including their information needs and concerns, seeking an integrated 

understanding of the patient’s world, finding common ground on defining the 

problem and how to manage it, attending to health promotion and prevention, and 

enhancing the on-going patient-doctor relationship. This paradigm change from 

biomedical and disease-centred, is embodied in ‘the patient-centred clinical 

approach’. Patient-centredness, although a widely recognized concept, is difficult to 

define, and measure. 

The importance of communication 

The consultation is the pivotal exchange in health care delivery. Silverman reports 

that during their working life doctors perform 200,000 consultations. Striving for 

quality in such a fundamental area is therefore a professional imperative. Research 

continues to show that doctors fail to determine why their patients really consult. 

Studies have shown how quickly doctors interrupt patients, how they fail to elicit half 

of their concerns and how important unvoiced agendas are. Doctors often consult in a 

directive doctor-centred style. Patients crave information and want to be involved in 

decisions regarding their care. Problematic communication has led to malpractice 

claims and dissatisfaction. 

Pragmatic process and outcome measures 

Time is used as a crude measure of consultation quality and studies have shown that 

longer consultations are associated with improved problem recognition. Studies have 

also shown that a “patient –centred” approach to the medical consultation does not 

always take longer -it is the interplay of factors that is important. Mechanic has 

pointed out the complexity of potential “active ingredients” in consultations which 

impact on time and quality (variability in problems, patients, doctors, the system). 

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Our understanding of effectiveness needs to be further developed. 

Patient satisfaction surveys have flourished and many are now available. Baker defined satisfaction as “the patient’s 

judgement of the quality of care”. Both Ware (in the US) and Baker (UK) found that technical and interpersonal aspects 

of care are important for satisfaction. Patient satisfaction studies confirmed that remarkably few patients express 

dissatisfaction, which may be because satisfaction becomes a composite of overall attitude to health care and specific 

feelings. Framing may be influenced by methodological approaches. 

In satisfaction studies there was downward drift over time, which could be linked to increasing patient expectations 

and staff demoralisation, so repeated surveys could become problematic. Calnan has investigated patient satisfaction 

with general practice in the UK (95%), Greece (87%), Yugoslavia (85%) and Russia (62%): all nominated the doctorpatient 

relationship, and professional skills as important. Another of his surveys reported that despite patient 

satisfaction being high, 38% of respondents felt unable to discuss personal problems with their GP, which casts doubt 

on satisfaction denoting quality of care. Satisfaction surveys have limitations as patients seem inclined to report 

satisfaction and the results of such surveys fail to provide detail needed for assessment of individual consultation 

quality. Patients may report satisfaction with their consultation, but have they been helped? 

The Patient Enablement Instrument 

The development of the Patient Enablement Instrument (PEI) aims to operationalise patient-centred consulting in 

terms of a patient-reported outcome. It represents over 20 years work by Howie (1) and was developed from literature 

review and patient focus groups: six questions were discriminatory (Figure 1). 

The Patient Enablement Instrument 

As a result of your visit to the doctor, do you feel you are ... 

Much Better Same Not 

better or less applicable 

able to cope with life ⃝ ⃝ ⃝ ⃝ 

able to understand your illness ⃝ ⃝ ⃝ ⃝ 

able to cope with your illness ⃝ ⃝ ⃝ ⃝ 

able to keep yourself healthy ⃝ ⃝ ⃝ ⃝ 

Much More Same Not 

more or less applicable 

confident about your health ⃝ ⃝ ⃝ ⃝ 

able to help yourself ⃝ ⃝ ⃝ ⃝ 

Scoring: much better/more: 2; Better/more: 1; Same or less: 0; 

Total score: max 12, min 0, per consultation 

Figure 1: The Patient Enablement Instrument (PEI) 

Enablement builds on theories that adjustment and coping are important modifiers of patient outcome, and predictors 

of how patients feel and perceive life. Although enablement correlates with satisfaction measures, it represents a 

distinct concept. GPs who were more enabling were those who had longer consultation times, so both were regarded 

as useful measures of consultation quality. 

It is known that continuity (how well the patient knows their GP) improves enablement (and is under attack by 

contemporary service development). Studies relate enablement and empathy (2) , and an analysis of verbal 

interactions in consultations (3) showed that socio-emotional interactions support enablement. Receiving a 

prescription when one is expected (4,5) is also associated with enablement. Mead et al studied a modified PEI (part of 

the General Practice Assessment Questionnaire (GPAQ 12) in the UK, with 190,038 consultations, 1031 practices) and 

found patients’ evaluation of communication skills was associated with enablement. Patients with chronic illness and 

frequent attenders report lower enablement, and patients consulting in other languages report higher enablement (5). 

The PEI has been validated in Poland (5) Croatia, Thailand, Japan, China and Sweden with similar results. Howie’s study 

reported PEI as independent of case-mix (4), but Mercer and Pawlikowska (5) have found that those with psychological 

problems are more difficult to enable. 

A wide variety of issues impact on the consultation, given the influence of case-mix, the individuality of patients, 

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doctors and their relationships, it is clear that any quantitative measure of effectiveness based on the analysis of small 

numbers of consultations, will be unlikely to yield a reliable measure. Large numbers of unselected consultations are 

needed for the effect of influences to accumulate. PEI requires such conditions, which is both its strength and its 

possible limitation. 

Patient enablement (the PEI) provides us with a way to investigate effectiveness in general practice, which is sensitive 

to patient, doctors and consultations. It encapsulates general practice core values and a patient-centred approach. 


 

 

 

 

Increasing patient involvement in the assessment of their own care is a 21st Century imperative. 

The medical consultation is pivotal to health care delivery, and the pursuit of excellence in consultations 

enables practitioners to activate their knowledge in the service of patients. 

There are many ways to approach the assessment of effectiveness, and patient centred outcomes are valued, 

but sometimes difficult to define and operationalise. 

The Patient Enablement Instrument (PEI): Patient offers an approach to investigate effectiveness in family 

practice, which is sensitive to patient, doctors and consultations. 


http://www.woncaeurope.org/content/theme-c-measuring-effectiveness-general-practice-family-medicine 

References 

1. Howie J, Heaney D, Maxwell M. Measuring quality in general practice. Occas Pap R Coll Gen Pract. 1997; 75:32. 

2. Mercer S, Reilly D, Watt G. The importance of empathy in the enablement of patients attending the Glasgow 

Homoeopathic Hospital. Br J Gen Pract. 2002; 52(484): 901-5. 

3. Pawlikowska T, Zhang W, Griffiths F, van Dalen J, van der Vleuten C. Verbal and non-verbal behavior of doctors and patients 

in primary care consultations - how this relates to patient enablement. Patient Educ Couns. 2012 Jan; 86(1): 70-6. 

4. Howie J, Heaney D, Maxwell M, Walker J, Freeman G, Rai H. Quality at general practice consultations: cross-sectional 

survey. BMJ. 1999; 319: 738-43. 

5. Pawlikowska T, Nowak P, Szumilo-Grzesik W, Walker J. Primary care reform: a pilot study to test the evaluative potential of 

the Patient Enablement Instrument in Poland. Fam Pract. 2002; 19(2): 197-201. 

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Jean Karl Soler, MD, PhD 

info@thefamilypractice.com.mt 

Success Story 

41 – The International Classification of Primary Care: a 

Jean Karl Soler, MD, PhD 

Wonca International 

Classification Committee (WICC) 

Wonca Informatics Working Party 

(WIWP) 

Co-authors 

Marc Jamoulle 1,2, Peter 

Schattner 2 

1. Wonca International 

Classification Committee (WICC) 

2. Wonca Informatics Working 

Party (WIWP) 

(°) The first WICC working group 

consisted of Charles Bridges- 

Webb (Australia), Robert 

Westbury (Canada), Philip Sive 

(Israel), Derek Callagher (New 

Zealand), Donald Crombie 

(United Kingdom) and Jack 

Froom (United States). ICPC was 

first developed by Henk 

Lamberts, Maurice Wood and 

Sue Meads. 

The Forty Year Story of ICPC 

The WONCA International Classification Committee (WICC) was set up by the WONCA 

Council in Melbourne in 1972 on the occasion of the Fifth World Conference (1). 

WONCA recognized the need for classifying and analysing data derived from clinical 

encounters with patients that was quite unique to family medicine. This would 

become increasingly important with the advent of electronic health records. 

From an initial small group led by Henk Lamberts and Maurice Wood (°), a tool which 

would become the ICPC was progressively developed and in 1987, the three existing 

classification systems, the International Classification of Health Problems in Primary 

Care (ICHPPC-2), ICPC-Process and Reason for Encounter - were merged into a single 

one; the ICPC. ICPC-2 was published in 1998 by the WONCA International 

Classification Committee, after several years of revision and cross-mapping with the 

International Classification of Diseases (ICD) – 10 (2). 

ICPC-2 is maintained by WICC and an updated version is edited on the site of the 

Norwegian Centre for Informatics in Health and Social Care. WICC members meet 

each year in a different country and communicate through a very active mailing list. 

ICPC and its Role in Primary Care 

ICPC is a coding and classification system that reflects the distribution and content of 

the domain of family medicine, and also acts as its ordering principle. It was designed 

as an epidemiological tool to classify and analyse data about three important 

elements of the health care encounter: the reasons for encounter (RFE), the diagnosis 

or problem, and the process of care in family medicine. Novel features are the 

inclusion of patients’ symptoms and complaints which allows the patient's reasons for 

encounter to enter a system of routine clinical data collection, the structuring of data 

into episodes of care, and the incorporation of the symptom as a diagnosis (3). 

The collation and analysis can occur at the level of an individual patient for clinical 

care, and at the practice level for recall, clinical audit and activity analysis for health 

services research. Maps are maintained from other classifications such as ICD-10 so 

that ICPC may also be used as an organizing principle for data collected in other 

systems such as the clinical terminology, SNOMED-CT. Linkage of elements permits 

categorization from the beginning of the encounter with a health problem to its 

conclusion, as well as a dynamic arrangement of encounters into episodes. 

ICPC-2 is available in more than 25 languages. It is compact, and the entire 

classification can fit onto two A4 pages. It is compatible with problem-oriented clinical 

records. In Norway, FDs are obliged to label all fee-for-service bills, sick-leave 

certificates and social security forms with an ICPC-diagnosis in order for them to be 

accepted by the health authorities. It is also used in referrals, e-Prescriptions and the 

127

ICPC Use in Family Medicine Research 


electronic ordering of laboratory tests (4). 

ICPC has been used extensively for research in family medicine. In Australia, a version of ICPC is used in the BEACH 

database which contains more than 1,400,000 FD-patient encounter records (5). In the Netherlands and Malta, 

researchers are able to create reports from TransHis (6), an ICPC-based electronic health record, and the data have 

been used to develop the first public domain database of the predictive power of symptoms in making a diagnosis, for 

all relevant primary care diagnoses. ICPC is used by Danes conducting research in rural practice (7), as well as FDs who 

enter data into the Danish General Practice Research Database (8). 

The Future of ICPC 

A workshop on ICPC and other classification systems was conducted at the 2010 WONCA Europe conference in Malaga, 

Spain between WICC and the WONCA Informatics Working Party (WIWP). WIWP is primarily concerned with education 

in the field of family medicine informatics. 

Meanwhile, WICC is developing the third version of ICPC. ICPC-3 has been in development for many years, using data 

collected with ICPC and other coding systems to allow expansion and modernisation of the classification without losing 

its core characteristics and values. Further information is available at www.ph3c.org , including the ICPC training 

module and an extended bibliography. 


 

 

 

Structured data in electronic health records are important not only for education but also for research and 

audit purposes 

Several classification systems are available, including the International Classification of Primary Care (ICPC) 

produced by WONCA 

Revising ICPC and getting more family physicians skilled in its use remain ongoing challenges 


http://www.woncaeurope.org/content/ws-17-international-classification-primary-care-icpc-and-hows-and-whys-classification 

References 

1. Westbury RC. A classification for family medicine. Can Med Assoc J. 1976 Aug 7;115(3):202. PubMed PMID: 20312758; 

PubMed Central PMCID: PMC1878637. 

2. Okkes I, Jamoulle M, Lamberts H, Bentzen N. ICPC-2-E: the electronic version of ICPC-2. Differences from the printed 

version and the consequences. Fam Pract. 2000 Apr;17(2):101-7. Erratum in: Fam Pract 2000 un;17(3):275. PubMed 

PMID:10758069. 

3. Bentsen BG, Hjortdahl P. Why do people contact physicians? The development of the core classification of primary health 

care. Tidsskr Nor Laegeforen. 1991 Sep 30;111(23):2867-70. Norwegian. PubMed PMID: 1948889. 

4. Karlstad O, Nafstad P, Tverdal A, Skurtveit S, Furu K. Comorbidities in an asthma population 8-29 years old: a study from 

the Norwegian Prescription Database. Pharmacoepidemiol Drug Saf. 2011. Available at: 

http://www.ncbi.nlm.nih.gov/pubmed/21953881. 

5. Harrison C, Britt H, Miller G, Henderson J. Prevalence of chronic conditions in Australia. PLoS One. 2013;8(7):e67494. 

doi:10.1371/journal.pone.0067494. 

6. Jean K Soler; Inge Okkes; Sibo Oskam; Kees van Boven; Predrag Zivotic; Milan Jevtic; Frank Dobbs; Henk Lamberts; The 

Transition Project. An international comparative family medicine study of the Transition Project data from the 

Netherlands, Malta and Serbia. Is family medicine an international discipline? Comparing diagnostic odds ratios across 

populations. Family Practice 2012; doi: 10.1093/fampra/cmr099. 

7. Klinis S, Markaki A, Kounalakis D, Symvoulakis EK. Monitoring Reasons for Encounter via an Electronic Patient Record 

System: the Case of a Rural Practice Initiative. Int J Med Sci 2012; 9(8):704-707. doi:10.7150/ijms.4999. Available from 

http://www.medsci.org/v09p0704.htm 

8. Thomsen, R. W., Friborg, S., Nielsen, J. S., Schroll, H., & Johnsen, S. P. (2012). The Danish Centre for Strategic Research in 

Type 2 Diabetes (DD2): organization of diabetes care in Denmark and supplementary data sources for data collection 

among DD2 study participants. Clinical epidemiology, 4(Suppl 1), 15. 

128


Janet Christie-Seely, MD 

jcseely@uottawa.ca 

42 – Physician Heal Thyself and then the World: Workaholism, 

Helpaholism and other Physician Conditions (Fraud Syndrome, 

Empathopoenia, Email-Overdose, MDeity Syndrome, Cell-phone-Otitis, etc) – 

Playful but Effective Medications for Serious Symptoms 

Janet Christie-Seely, MD, FCFP, 

Professor of Family Medicine, 

University of Ottawa, Ontario, 

Canada. Family Therapist 

Most docs are workaholics or helpaholics -- especially Family Docs (1)! I am both. I still 

run workshops and a psychotherapy practice at 75. I love what I do, that’s the 

problem! 

I’m getting better! I read Barbara Killinger’s “Workaholics: the Respectable Addicts; a 

Family Survival Guide” (2), often worse in its impact than alcoholism. Take the 

Workaholic Quiz at: www.cnn.com/interactive/2011/05/living/workaholic.test/ 

and find out if your case is serious! 

I was fortunate to train with Virginia Satir, the “Columbus of Family Therapy”, an 

enlightened lady way ahead of her time. Stone deaf for two years from mastoiditis at 

six, she noticed people looked very different when communicating, and planned to 

become a detective on parents when she grew up. Her mother, a Placator never 

spoke her own feelings, hid anger deep inside, never saying “No!”– like many family 

docs. Her father was a Blamer, hiding his helplessness and shame of alcoholism. 

Others looked like computers, the Super-Reasonables –- maybe she met some 

doctors (specialists particularly) -- hiding discomfort about feelings (“Just give me the 

facts. Don’t bother me with this emotional stuff!”), quoting N.E.J.M or the Bible. 

Others were always joking or changing the subject, the clowns hiding despair, the 

Distracters. She later understood these four came from AND increase Low Self- 

Esteem (3). So one medication that helps stop the Performance-Based Self-Esteem of 

most physicians is the prescription of: 

Congruence! 

I remember being told to be congruent with patients in Med School, but nobody 

explained how! Congruence is being respectful, considerate and honest. Non-verbal 

signals match verbal content. If you’re angry you may look and sound angry, but you 

don’t blame or accuse, you try to understand the other’s position. 

HIGH SELF-ESTEEM 

129


Every communication has three components: Self - one’s thoughts, feelings and opinions, Other’s thoughts, feeling and 

opinions, and the Context or situation. Picture a peace sign, without the bottom bar, and you have congruence - all 

three are expressed. When feeling safe and confident (high Self-Esteem), it’s easy to be congruent AND it adds to the 

self-esteem of both parties. For example; “Mrs Smith. I see you are fed up with the side-effects, and I’m getting 

frustrated with you ‘forgetting’ the pills, because you really need them. Can we discuss this situation so we get 

unstuck?” 

When you feel insecure or defensive you move to one of those Stances, which make you feel a victim, a jerk, a cold fish 

or a clown respectively, i.e. you feel even worse about yourself underneath the anger, apologies, quoting of studies or 

joking. They are “survival stances” as that’s how you learned to survive in your family growing up. 

Each coping stance ignores part of the picture: 

Stance: PLACATING BLAMING SUPER-REASONABLE DISTRACTING 

OR COMPUTER 

OR IRRELEVANT 

Each hides (ANGER ) (HELPLESSNESS) (FEAR OF FEELINGS) (DESPAIR) 

Feelings: 

Icebergs 

LOW SELF-ESTEEM 

Virginia often said: “The problem’s not the problem, it’s the coping”. What are we coping with? The insecure feelings 

the problem generates. 

Behaviour is the tip of an iceberg (4) - the only part seen. It pays, especially for physicians to know the other layers. 

Humans, like icebergs are all unique and beautiful, but the layers under the waterline can be dangerous. 

Below Behaviour, determining it, are the Coping Stances described above. Fuelling them are Feelings, especially feeling 

about ourselves – our Self-Esteem. We developed that from Perceptions of ourselves from childhood experiences. If 

we came to expect criticism and punishment, that’s what we continue to dole out to ourselves -- what we in the 

Ottawa Satir Learning Centre call our Gremlin (from a wonderful little book: ”Taming Your Gremlin:” (5)). The Gremlin 

loves Negative Self-Talk, and lives in the Expectation or “Should-ing” layer. 

First homework: Draw your Gremlin (did he or she just say: “But you can’t draw!” – a scowly-face or a cut out tiger 

from a magazine will do, but it should be visual on a piece of paper). Carry this around for several days, recording 

anything it says, like: “You’re lazy / a fraud / way behind in your journals / etc”. Beware; doctors’ Gremlins are louder 

than most! Then, for another week, try elastic band therapy - wear one on your wrist - every time you hear the little 

fellow give it a flick – not too hard, this is NOT self-punishment! Under the Expectation layer is “Yearnings” – what we 

really want and need in life –to love and be loved, to be heard, to contribute. How often do you listen to yourself 

rather than patients? Have you ever talked to the kid inside you who longs to play, paint, dance or research 

something? 

Second homework: dialogue with him or her, with a pen or a pencil in your non-dominant hand for the child. (When I 

tried I was startled at what I heard – from a three year old whom I’d told was not good enough! She loves painting! 

www.christie-seely-art.ca ). Diving into Yearnings propels you into the Self or “I AM”, your spiritual core. Good news! 

Here, your self-esteem is always high, and you can readily say: “The world is a better place because I am in it!” Try 

saying that to yourself now – without thinking in terms of your work contributions. 

You can also get to Self through meditation, music, art, running – but if you go through the Iceberg you can learn to live 

there. It will improve your ability to heal the world! 

130


Good luck! 


 

 

 

 

True self-esteem is independent of performance. 

Congruence raises self-esteem of all concerned. 

Listen to your inner kid, don’t berate him / her. 

Satisfy YOUR real needs, THEN help the world. 


http://www.woncaeurope.org/content/3798-physician-heal-thyself-and-then-world-workshop-workaholism-helpaholism-andother 

References 

1. Janet Christie Seely, author-editor.: Working with the Family in Primary Care: A Systems Approach to Health and Illness. 

Chapter 31: The Physician’s Family. Praegar. 1984 

2. Barbara Killinger: Workaholics; the Respectable Addicts. A Family Survival Guide. Key Porter books Ltd. 1991 

3. Virginia Satir, The New Peoplemaking, Palo Alto, CA:Science and Behaviour Books, Inc. 1988 

4. Virginia Satir, John Banmen, Jane Gerber, Maria Gomori: The Satir Model: Family Therapy and Beyond. Palo Alto. CA. 

Science and Behaviour Books Inc. 1991 

5. Richard Carson: Taming Your Gremlin, A Guide to Enjoying Yourself. Dallas, Texas. The Family Resource, Inc. 1983 

131


David E.J. Bazzo, M.D., FAAFP, CAQSM 

dbazzo@mail.ucsd.edu 

43 – Competency in Medical Record-Keeping: Development of a 

Scale and Assessing CME (CPD) Impact 

David E.J. Bazzo, MD, FAAFP, 

CAQSM 

Clinical Professor of Family 

Medicine, University of 

California, San Diego, School of 


Director, Fitness for Duty 

Program, UCSD PACE Program 

Co-Director, Primary Care Core 

Clerkship 

Co-authors: 

William J. Sieber, PhD, William A. 

Norcross, MD , Sara Fernandes- 

Taylor, BA, University of 

California, San Diego Physician 

Assessment and Clinical 

Education (PACE) Program 

Poor medical record keeping is a commonly encountered deficiency when evaluating 

physician quality. Medical records that do not adequately or accurately capture what 

transpired between the provider and patient at the time of an interaction lead to 

poor communication, medical errors and lawsuits. The University of California, San 

Diego, Physician Assessment and Clinical Education (PACE) Program has been offering 

assessment and remediation of physicians in all specialties since 1996. Early in the 

course of our assessment program, it became clear that deficient medical records 

were a common theme for many referred participants. Further needs assessment 

work revealed that only a small minority of physicians ever received formal training in 

medical record keeping. A surprising finding since a medical record entry must be 

made for every patient interaction. PACE therefore developed the Medical Records 

Keeping Course (MRKC) and initially offered it in 1999. Similarly, PACE offers 

continuing education courses in prescribing, physician-patient communications, 

professional boundaries, anger management and customized courses. 

A number of the ACGME/ABMS Core Competencies (Patient Care, Medical 

Knowledge, Practice-Based Learning and Improvement, Interpersonal and 

Communication Skills, Professionalism and Systems Based Practice) particularly 

interpersonal and communication skills, and professionalism address medical record 

keeping. It is an integral and necessary part of the practice of medicine. The medical 

record serves as a source of communication, is used to help determine the quality of 

patient care, is used to confirm proper reimbursement and is the key source of 

evidence in medical risk management matters. 

The PACE MRKC content covers: an introduction to medical records and a brief history 

of the modern day record; the legal requirements and aspects of the medical record; 

coding, billing and compliance regulations; computer hardware and software 

information related to the record; information retrieval, information security, privacy 

and HIPAA ; and, the electronic health record. Acquisition of knowledge, skills or 

attitudes is the goal of any educational endeavour. To measure the success of 

knowledge acquisition, the PACE MRKC course has pre-tests and post-tests. 

Knowledge (competence) must be achieved prior to incorporating items into practice 

(performance). Knowledge, the precursor to practice, is easier to assess and became 

our initial objective. 

The participants of the PACE MRKC were generally mandated to attend the course by 

a state regulatory board, hospital or medical group based on a disciplinary action. In 

the sample, one hundred seventy-two participants took the pre- and post-test. A 

comparison group/convenience sample of thirty-two non-disciplined UCSD Family 

Medicine residents and faculty were recruited. A thirty item multiple-choice test was 

devised covering the content areas of “legal/ethical, electronic health record and 

coding.” Principle components factor analysis demonstrated a strong one factor 

132


solution. An independent three factor solution was tested but there was weak statistical support for the three factor 

structure. Cronbach’s alpha was 0.72, with 30 items indicating internal consistency. 

The MRKC participants scored 21.2 on the pre-test and 24.7 on the post-test. The UCSD faculty scored 24.3 on the pretest 

and 25.3 on the post-test and the UCSD residents scored 23.1 on the pre-test and 24.0 on the post-test (figure 1). 

There was significance difference between comparison groups with the MRKC physicians scoring significantly lower 

than the UCSD groups on the pre-test (p


 

Knowledge in MRKC participants was statistically significantly less on the pre-test when compared to a 

university faculty and resident cohort confirming that the participants, almost exclusively referred to the 

course for disciplinary reasons, had a pre-course deficient knowledge base in medical record keeping. 


http://www.woncaeurope.org/content/4305-competency-medical-record-keeping-development-scale-and-assessing-cme-impact 

References 

Greene J. Risk management becoming crucial focus of CME study. American Medical News. July 2, 2001;Professional 

Issues. 

McCready LA. Guidebook to the Laws Governing the Practice of Medicine. Sacramento, CA: Medical Board of California, 

Department of Consumer Affairs; 1998. 

Minkin MJ. Protect yourself from malpractice suits. Fertil Steril. Mar 2004;81 Suppl 2:41-44. 

Sullivan GH. Does your charting measure up? RN. Mar 2004;67(3):61-65. 

Roberts RG. Seven reasons family doctors get sued and how to reduce your risk. Fam Pract Manag. Mar 2003;10(3):29- 

34. 

Allen J, Burkin A. How plaintiffs' lawyers pick their targets. Med Econ. Apr 24 2000;77(8):94-96, 99, 103-104 passim. 

Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical records and patient questionnaires for physician profiling 

and health services research? A comparison with direct observation of patients visits. Med Care. Jun 1998;36(6):851-867. 

Soto CM, Kleinman KP, Simon SR. Quality and correlates of medical record documentation in the ambulatory care setting. 

BMC Health Serv Res. Dec 10 2002;2(1):22. 

134


Erika ZelkoMD, MSc 

erikazelko@gmail.com 

Enough? 

44 – The Health Needs of Hard to Reach Groups: Do We Know 

Erika Zelko, MD, MSc 

University of Maribor, Medical 

Faculty, Department of Family 

Medicine, Maribor, Slovenia 

One of the most representative minority groups in almost every country in Europe are 

the Roma. The Roma (Gypsies) are a special ethnic community with multiple 

homelands, abundant cultural heritage, and a certain way of life. They are a special 

ethnic group of people who predominantly live in Central or Eastern Europe (CEE) 

(approximately 5.2 million of Roma live in CEE countries). It is estimated that about 

10,000 Roma live in Slovenia, of which 3,000 live in Prekmurje. In Slovenia, the Roma 

are legally considered to be a minority at risk, and their status is partly regulated by 

the Slovenian Constitution. Their integration into the community primarily involves 

jobs and schooling (Roma children attend the same schools as non-Roma). The 

Majority of Roma in Prekmurje have built good relations with the non-Roma 

population. They are also very active in protecting and developing their cultural and 

ethnic specificity. They have their own radio and TV programme, publications in the 

Roma language, and they take part in investigating the needs and specificity of the 

Roma population. 

Due to the problems researchers face when carrying out studies in Roma settlements, 

there is a lack of data on how public healthcare measures should be appropriately 

developed and implemented for this minority group. These problems arise because of 

the mistrust the Roma hold for the non-Roma researchers; they are afraid of being 

discriminated against and exploited, they have problems talking to researchers, and 

they are afraid of any consequences they might face within and outside their 

community if they participate or do not participate in these studies. Time-related and 

financial obstacles represent an additional burden in carrying out such studies. 

The Roma have their specific material and spiritual culture, including health culture 

which determines their attitudes towards health, diseases and death. In the past, 

their strong superstitious beliefs led them to prefer visiting domestic healers rather 

than doctors and conventional medicine. The decision by Roma to seek medical care 

is affected by their culture. They equate health with happiness. They believed that 

certain diseases were outside the realm of their perception of health so they visited 

special Romani practitioners, and used herbal home-made medicines. However, most 

of those Roma beliefs have been abandoned over the past few decades. They have 

developed an increased trust in conventional medical methods but a lack of 

confidence in health-care workers and institutions. Since they are mostly poorly 

educated, and sometimes do not trust the non-Roma population, this often results in 

communication difficulties with healthcare workers. In addition, their low education 

level, poor mastery of the language of the non-Roma population, and cultural and 

ethnic differences contribute to poor health literacy. They often do not understand 

medical protocols, and have problems comprehending information material they are 

given in health centres. Due to the poor health literacy of the Roma, their difficulties 

understanding medical terminology or misinterpreting it, few publications deal with 

135


the issue of healthcare in the Roma communities. In some cases, their culture still 

contains beliefs about health and healthcare with which health workers may not be familiar. Vivian and Dundes 

emphasized that health care workers frequently make the mistake of assuming that all Roma patients have basic 

medical knowledge and accept the standards of the country’s medical system. The hierarchy of the Roma family and 

gender distinction in seeking out medical assistance plays a vital role in the communication with medical workers. 

Usually, the family elder makes conversation, decides on family decisions, and ensures that younger family members 

co-operate with doctors and other medical workers. An understanding of the culture, traditions, and values of the 

Roma is of great importance if health professionals wish to understand and assist these people. The general health of 

the Roma people is substantially worse than that of the majority population, with poor compliance with preventive 

activities and vaccinations. Different Studies show that the Roma have a high prevalence of a variety of diseases, for 

example: smoking, metabolic syndrome with type 2 diabetes, respiratory diseases, mental health problems and 

increased cardiovascular mortality compared with the general population. The health of the Roma is strongly related 

to their socio-economic situation, associated inadequate living conditions and infrastructure of their homes. Their 

health problems are also linked to inadequate hygiene conditions and poverty, which in turn leads to decreased 

lifespan, increased risk of illness, and chronic diseases. A Hungarian study that compared the health status of the 

general population with that of the Roma community and a Serbian study that examined sexually transmitted diseases 

identified the need for a specific public healthcare approach in the Roma community that includes health education 

and promotion of a healthy lifestyle. Similar findings have been established by Croatian researchers, who concluded 

their study by recommending the planning of a public healthcare approach in socially marginalized and economically 

disadvantaged communities such as the Roma. 

However, overall life quality of the Roma has improved over the last few decades. Today the remaining problems of the 

Roma (including in Slovenia) include: socio-economic conditions (mainly affected by education and employment), 

social exclusion, and in some cases, misunderstanding with the local people. While health care is largely free in 

Slovenia, obstacles for the Roma population relate more to certain special medications and hospital-related fees, 

especially for those Roma who do not hold compulsory health insurance. As with any ethnic minority, the Roma need 

special consideration from the social and healthcare systems. It is important that the healthcare system recognises and 

deals with the requirements of this population. This is, however, difficult if the Roma attitudes and beliefs towards 

healthcare are not taken into account. Numerous studies have taken into account ethnicity and culture as important 

variables in the exploration of marginalized ethnic communities’ relationship to health and healthcare. Considering 

inequalities and the special needs of the population, this variable is important in analysing attitudes of ethnic and 

ethnic minorities towards the health and healthcare services. Over the last few decades, numerous qualitative and 

quantitative studies have raised the issue of the Roma population and their attitudes towards health and healthcare 

services in the US, some West European countries, CEE countries, and the former Yugoslav republics including 

Slovenia. 


 

 

Culture, customs and socio-economic situations affect minority groups' relationship towards health and 

healthcare services 

Only with knowledge and improved communication, we can together develop the health for marginalized 

populations 


http://www.woncaeurope.org/content/40-pa-assessing-health-needs-hard-reach-groups 

References 

Van Cleemput P, Parry G, Thomas K, Peters J, Cooper C. Health-related beliefs and experiences of Gypsies and travellers: a 

qualitative study. J Epidemiol Community Health. 2007; 61:205–10. 

Koupilová I, Epstein H, Holcík J, Haijoff S, McKee M. Health needs of the Roma population in the Czech and Slovak 

republics. Soc Sci Med. 2001; 53:1191–1204. 

Zeman CL, Depken DE, Senchina DS. Roma health issues: a review of the literature and discussion. Ethnicity and Health. 

2003; 8(3):223–49. 

Niksić D, Kurspahić-Mujcić A. The presence of health-risk behaviour in Roma families. Bosn J Basic Med. Sci. 2007; 7:144–9. 

136


Vivian C, Dundes L. The crossroads of culture and health among the Roma (Gypsies). J Nurs Scholarsh. 2004; 36(1):86–91. 

Pavlič D, Zelko E, Kersnik J, Lolić V. Health beliefs and practices among Slovenian Roma and their response to febrile 

illnesses: a qualitative study. Zdrav Var. 2011; 503:169–74. 

Kósa Z, Széles G, Kardos L, Kosa K, Nemeth R, Orszagh S. A comparative health survey of the inhabitants of Roma 

settlements in Hungary. Am J Public Health. 2007; 97(5):853–9. 

Serrano Rodriguez N, Rodriguez Derecho N. Health and the Roma community, analysis of its situation in Europe: Bulgaria, 

Czech Republic, Greece, Portugal, Romania, Slovakia, Spain. Madrid: Efixini Poli. Available from: 

http://ec.europa.eu/justice/discrimination/files/roma_health_en.pdf 

137


Tor Anvik, MD, Ass. professor 

tor.anvik@uit.no 

45 – Is There Such a Thing as a Correct Diagnosis in Family 

Medicine? Learning Points from the Use of Consensus in Validating Diagnoses 

in Family Practice 

Tor Anvik, MD, Ass. Professor 

Department of Community 

Medicine, Faculty of Health 

Sciences, University of Tromsø, 

Norway 

Background 

A correct diagnosis is the basis for therapy in clinical medicine. Research in validation 

of medical diagnoses has however demonstrated disappointing results. Different 

doctors have been shown to make different diagnoses when presented with the same 

case history, and the same doctor makes different diagnoses when the same history is 

presented several times. 

The author wanted to study the ability of experienced family doctors to make a 

diagnosis based upon a video recording of real life consultations in family practice, 

and to test the impact of subsequent information about the long-term outcome as 

well as a small group discussion on agreement or disagreement about correct 

diagnosis. 

Setting and Methods 

244 consecutive patients over the age of 15 presenting for consultations with the 

author in a group practice in northern Norway, were asked for informed consent to 

video recording of their meeting with the doctor. Immediately following each 

consultation the doctor decided whether the patient had presented a new problem 

that had not been discussed before. The doctor made a note of the new diagnoses 

that he had made by the end of the consultations. The patients were interviewed by 

telephone 3-6 months later. Three years later the medical records of the patients 

were scrutinised and the doctor made a final diagnosis. 

Altogether, 69 video recorded consultations where the patients presented 90 new 

problems were included. In 20 problems a specialist had made the final diagnosis 

after referral. Among the remaining 70 problems, 20 were selected at random for 

validation by experienced FDs. Four patients did not consent to their video being 

shown to other FDs, which allowed the remaining 16 video recorded consultations 

with 16 new problems to be analysed further. 

Five experienced family doctors were invited and each of them met three times in 

groups of three. The video recordings and the medical history of the patients were 

presented according to a step-by-step procedure: 

1. The doctors were given a short written summary of the patient's previous history 

and presented with one new problem which they were expected to diagnose. They 

then watched the video recording of the whole consultation. After the video, the 

author answered clarifying questions and elaborated on his clinical findings during the 

consultation. The author then left the room. Each doctor was asked individually to 

write down the most likely diagnosis of this single problem (Diagnosis 1), without 

138


discussing this with the other doctors in the group. 

139


2. The doctors were then presented with a summary of results of subsequent tests, further examinations and the longterm 

outcome after three years. Each doctor then wrote down the most likely diagnosis at this point (Diagnosis 2), still 

with no discussion within the group. 

3. The doctors were then presented with the final diagnoses that the author - who had performed the consultations - 

had made after three years, and they were asked to score whether they agreed or disagreed with these diagnoses. 

4. Finally, the participating doctors were asked to compare their diagnoses and engage in a discussion in the group of 

three to try and reach consensus about the most likely diagnosis (Final diagnosis) in each case. The participants were 

asked to indicate the certainty of each diagnosis on a scale from 1 (most unlikely, but possible) to 5 (certain). 

Results 

For each of the 16 videos there were three doctors making individual diagnoses of the new problem, yielding 48 

individual diagnoses altogether. The participating doctors reached consensus on the most likely final diagnoses for all 

16 problems. For one problem the final diagnosis was that of a symptom (T 08 Loss of weight), whereas the diagnoses 

for the remaining 15 problems were clinical diagnoses (ICPC-code 70+). Details of diagnoses of the 16 new problems 

are presented in table 1. The results of the doctors’ self-assessed feeling of confidence with his or her own diagnoses 

at each step are shown in table 2. 

There was no major disagreement between the final diagnoses made by the author and those made by consensus 

between the FDs. However, two cases deserve commenting upon: 

 

 

Discussion 

In case no. nine the author stated R 78 acute bronchitis as the most likely diagnosis, whereas consensus 

among the other doctors as their first choice was R96 COPD. In view of the long-term outcome, the author did 

agree. 

In case no. three the author - having made an unexpected clinical finding - maintained a rare diagnosis for his 

first choice even following validation: 

Case 3: A 65-year-old married woman presented with upper gastric pain. The pain gradually subsided 

spontaneously over three weeks and when palpating the epigastric area one month later the author had 

noticed a tender subcutaneous lump in the area where she had located her pain. He concluded that the most 

probable reason for her pain was acute necrosis in a subcutaneous lipoma with a probability score of 4. The 

participating doctors individually gave a probability score of two (“unlikely”) on the 1-5 scale for this 

diagnosis, and found consensus that the most probable reason was biliary dyskinesia. 

The fact that all the FDs were able to find a diagnosis is in agreement with earlier findings that doctors are able to 

make a correct diagnosis in more than 90% of cases after taking medical history only. 

The finding that the FDs initially had less confidence in their own individual diagnoses than the author is hardly 

surprising. What is surprising is that the doctors did not feel more confident with their diagnoses after having been 

presented with the long-term outcome. 

Only after having discussed the case with other colleagues did they feel as confident with their own diagnoses as the 

doctor who had seen the patient in the flesh. This may be taken as an illustration of the strong normative power of 

consensus in professional judgement. 


 

 

 

Experienced FDs are able to find consensus about a correct diagnosis when given all relevant information and 

watching a video recording of the consultation. 

Only after having discussed the case with other colleagues will they feel as confident with their own 

diagnoses as the doctor who has seen the patient in the flesh. 

Unexpected clinical findings made by the doctor during the consultation may be decisive for the doctor to 

insist on a different or rare diagnosis. 


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http://www.woncaeurope.org/content/there-such-thing-correct-diagnosis-general-practice 

References 

Christensen-Szalanski JJJ, Busyhead JB: Physicians' Use of Probablistic Information in a real clinical Setting. J Exp Psychol 

1981;7:928 

Dowie J, Elstein A ed.: Professional judgment. A Reader in Clinical Decisionmaking. Cambridge University Press, Cambridge 

1988. 

Goldman L, Sayson R, Robbins S et al: The Value of the Autopsy in Three Medical Eras. New Engl J Med: 1983:308;1000-5 

Hampton JR, Harrison MJG, Mitchell JRA, Prichard JS, Seymour C: Relative Contributions of History-taking, Physical 

Examination, and Laboratory Investigation to Diagnosis and Management of Medical Outpatients. BMJ 1975,2; 486-9 

Melbye H, Straume B, Aasebø U, Brox J: The Diagnosis of Adult Pneumonia in General Practice. The Diagnostic value of 

History, Physical Examination and Some Blood Tests. Scand J Prim Health Care 1988;6:111-7 

Rudebeck CE: Symptoms and symptom presentation. Scand J Prim Health Care Suppl 1;1991:48-60. 

Marieke de Vries, Cilia L. M. Witteman, Rob W. Holland and Ap Dijksterhuis: The Unconscious Thought Effect in Clinical 

Decision Making: An Example in Diagnosis. Med Decis Making 2010 30: 578 

Kienle GS1, Kiene H. Clinical judgement and the medical profession. J Eval Clin Pract. 2011 Aug;17(4):621-7 

Table 2: Participating doctors‘ self-assessed feeling of confidence in own diagnoses 

Mean score and 95% confidence intervals on scoring on a scale from 1 (most unlikely, but possible) to 5 (certain). 

Diagnoses 1 Diagnoses 2 Final diagnoses 

Author (n=1) 

Mean 

95% CI 

4.13 

3.92-4.35 

4.06 

3.90-4.22 

4.06 

3.90-4.22 

Participating 

doctors (n=5) 

Mean 

95% CI 

3.52 

3.29-3.75 

3.75 

3.56-3.94 

3.94 

3.71-4.14 

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Table 1: Diagnoses based on viewing video recordings of 16 consultations in family practice. 

Problems presented by the patient, the author’s diagnoses before validation, and consensus by experienced FD’s. 

Most likely diagnosis first. 

Case 

no. 

New problem 

presented by the 

patient 

ICPC 

Author’s diagnoses before 

validation 

ICPC 

Consensus by participating 

doctors 

ICPC 

1 Lump in the groin S04 Lipoma 

S78 

Lipoma 

S78 

Atheroma 

S93 

2 Pain in the left hand L11 Tendinitis L93 Tendinitis L93 

3 Pain in the stomach D02 Necrosis in lipoma 

S78 

Biliary bladder colic 

D98 

Biliary stones 

D98 

4 Loss of weight T08 Depression 

P76 

Depression 

P76 

Cerebral infarction 

K89 

Encephalitis 

N71 

5 Pain under the right 

heel 

L17 

Pressure ulcer 

Fasciitis 

S97 

L93 

Osteotendinitis 

L93 

6 Pain in right side of 

the neck 

L01 Shoulder myalgia L92 Myalgia of the neck L83 

7 Pain on micturition U01 Cystitis U71 Cystitis U71 

8 Reduction of 

medication 

R50 Reduction of medication R50 Reduction of medication R50 

9 Cough R05 Acute bronchitis 

R78 

Asthma 

R96 

Chronic obstructive 

pulmonary disease 

R96 

Chronic obstructive 

pulmonary disease 

R95 

10 Difficulties in 

swallowing 

D21 

Functional problems with 

swallowing 

P75 

Functional problems with 

swallowing 

D21 

Thrush 

D83 

11 Pain in the right 

shoulder 

L08 

Tendinitis 

Problems with sick child 

L92 

Z18 

Shoulder tendinitis 

L92 

Problems at work 

Z05 

12 Loss of weight T08 No disease A97 Loss of weight T08 

13 Pain in the chest L04 Myalgia 

L99 

Intercostal myalgia 

L99 

Angina pectoris 

K74 

14 Pain in the head, neck, 

back and chest 

L01 

Myalgia 

Fibroadenomatosis of breasts 

L84 

X88 

Myalgia of neck and back 

L84 

15 Pain in both shoulders 

and hands 

L08 Arthritis L91 Arthritis L91 

16 Sore throat R21 Upper respiratory infection 

(viral) 

R74 

Upper respiratory infection 

(viral) 

R74 

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Jan De Maeseneer, MD, PhD 

Jan.DeMaeseneer@UGent.be 

46 – Family Medicine Facing New Challenges on a Global Scale. 

Jan De Maeseneer, MD, PhD, 

Family Physician (part-time), 

Community Health Centre 

Botermarkt, Ledeberg – Belgium; 

Head of Department of Family 

Medicine and Primary Health 

Care, Ghent University; Director 

International Centre for Primary 

Health Care and Family Medicine 

– Ghent University, WHO 

Collaborating Centre on PHC; 

Chair European Forum for 

Primary Care; Promoter 

Primafamed-Africa-Network. 

Co-authors: 

An De Sutter, MD, PhD, Family 

Physician (part-time), 

Community Health Centre Rabot. 

Gent – Belgium. Associate 

Professor Family Medicine and 

Primary Health Care, Ghent 

University. 

Sara Willems, MA, PhD Assistant 

Professor, Equity in Health Care, 

Ghent University. 

Introduction 

In the second half of the 20 th century, family medicine developed considerably, 

starting with the exploration of the different dimensions of the patient-centred 

approach, developing the bio-psycho-socio-ecological model, training appropriate 

consultation-models, underpinning clinical decision-making in the epidemiological 

context of primary care, front running in the development of Evidence Based 

Medicine, framing the profession in the broader concept of the primary health careteam, 

and serving patients and populations throughout their lives. Increasingly, the 

"experience" of family physicians became underpinned with results from both 

quantitative and qualitative research, strengthening the evidence base of the 

discipline. 

Presently, the health of populations is facing two important challenges. The first is the 

worldwide epidemiological and demographical transition leading to the fact that 

multi-morbidity is becoming more and more the rule, rather than the exception in 

patient populations (1) while in the meantime, there are the new challenges of 

emerging infectious diseases (e.g. Ebola). 

The second challenge has to do with the increasing social gradient in life expectancy, 

both within and between countries. In Belgium, the gap in healthy life expectancy for 

men at the age of 25 is more than 18 years between those having received only basic 

education and those with a university degree. How can family medicine and primary 

health care respond in order to face both these challenges? 

The Epidemiological Transition and the Need for a Paradigm-shift. 

Nowadays, 50% of those aged over 65 have at least 3 chronic conditions and 20% of 

those aged over 65 have at least 5 chronic conditions. 

In recent years, not only Western countries, but also developing countries, have 

started "Chronic Disease Management Programmes". A recent survey of "Chronic 

Disease Management" in 10 European countries illustrated that disease-management 

programmes are mostly organized around a single chronic condition, e.g. diabetes, 

sometimes even focusing on sub-groups within a specific chronic disease, e.g. disease 

management programmes that only include people with type 2 diabetes. Although 

this approach has led to more providers adhering to guidelines, to task-shifting from 

physicians to nurses, dieticians and health educators, and to improved knowledge and 

skills of patients in dealing with their chronic condition, we actually face the growing 

mismatch between the needs of people living with multi-morbidity and the resources 

offered by a health system that increasingly focuses on disease-defined care. Vertical 

disease-oriented programmes produce gaps in the care of patients with multimorbidity 

and cause inequity for patients who do not have the "right" disease (2) 

leading to "inequity by disease". There is a need to explore new generic ways and 

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paradigms. A goal-oriented approach that encourages each individual to achieve the highest possible level of health, 

which is defined by the individual instead of the health system (3). Family Physicians can be involved in the facilitation 

of "goal definition" by the patients and are well-placed to integrate these goals in clinical decision-making for multimorbidity 

and build an individual care plan together with the patient. Continuity of care enables the family physician to 

be attentive to the fact that goals of patients can alter over time as the context changes. Such an approach will require 

more focus on the individual patient-provider interaction and on appropriate communication skills to facilitate goal 

definition and patient empowerment. It is obvious that this can only take place in the framework of an interprofessional 

team including other primary care providers (see: www.euprimarycare.org ). Shared decision-making, 

starting from the patient’s goals and involving the patient and other care providers, will avoid gaps in the process and 

encourage empowerment of the patient (4). 

The Contribution of Family Medicine and Primary Health Care to More Health Equity. 

In figure 1, we formulate a hypothesis about how family medicine, in the framework of a primary health care team can 

be a strategy for promoting health equity and intersectoral action (5). A first prerequisite is a high level of accessibility 

of the primary health care team (6). A second is: the team should deliver high quality care. Moreover, the team should 

interact with different networks (education, work, economy, housing,…) that are related to important sectors. Apart 

from an approach to individuals and families, the primary health care team should also address the community, 

utilizing the Community Oriented Primary Care Strategy (COPC) (7). The COPC, the direct action of the primary health 

care team and the intersectoral networking will enhance the social cohesion in the community. The actions of the 

primary health care team (preventive, curative, rehabilitative, health promotion,…) together with the increased social 

cohesion in the community will lead to empowerment of the people. This empowerment will decrease the 

vulnerability to factors that may contribute to health inequity. Moreover, as the COPC-action will address the living 

conditions of the local population, the exposure of the people to factors that may be a threat to their health will 

diminish and the differential vulnerability will decrease. Finally, a better education, improved working conditions, 

decreased unemployment, better housing conditions, and access to safe food and water will improve the structure of 

determinants that influences social stratification. In summary, the inter-professional primary health care team 

operating in a network with other sectors will promote health equity through increased social cohesion and 

empowerment. This is in line with Starfield et al who find a rationale for the benefits of primary healthcare in (1) 

greater access to needed services, better quality of care, (2) a greater focus on prevention, (3) early management of 

health problems, (4) the cumulative effect of the main primary care delivery characteristics, and (5) the role of primary 

care in reducing unnecessary and potentially harmful specialist care. 

Examples of this kind of inter-sectoral action for health can be found in the International Federation of Community 

Health Centres (http://www.ifchc2013.org). 

Family Medicine on a Global Scale. 

Nowadays family medicine is operating in the context of primary health care all over the world. Recent developments 

of the profession of family medicine in Asia, Latin America, Africa, have illustrated the ubiquitous need for this 

discipline in order to build strong health systems. Important in this development is the continuous integration of 

personal and community health care. Interestingly, there is a two-directional evolution in the current developments: in 

Western countries practices that were mostly focusing on care for patients are becoming more and more "populationoriented", 

and in countries like Latin America, Africa, the challenge is to integrate the (vertical) population health 

programmes in a comprehensive primary care system (8). 

Family Medicine and WONCA have an important role to play in the further development of an inter-professional 

learning community of primary health care practice. 

Take Home Messages: 

 

 

In order to address the challenge of multi-morbidity a paradigm-shift from problem- to goal-oriented care is 

needed 

Accessible family medicine practices may contribute to health equity 

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Fig. 1: Primary health care as a strategy for promoting health equity and intersectoral action. 


http://www.woncaeurope.org/content/478-equity-human-rights-and-primary-care-national-and-international-perspectives-human 

References 

1. Barnett K, Mercer SW, Norbury M, et al: Epidemiology of multi-morbidity and implications for health care, research and 

medical education: a cross-sectional study. Lancet 2012;380:37-43. 

2. De Maeseneer J, Roberts RG, Demarzo M, et al: Tackling NCDs: a different approach is needed: Lancet 2012;379:1860- 

1861. 

3. Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Family medicine 1991;23(1):46-51 

4. Boeckxstaens P, De Maeseneer J, De Sutter A. The role of general practitioners and family physicians in the management 

of multi-morbidity. In: Sartorius N, Holt RIG, Mai M (eds): Comorbidity of mental and physical disorders. Key Issues Ment 

Health. Basel, Karger, 2015, Vol.179, pp.129-136. 

5. De Maeseneer J, Willems S, De Sutter A et el. Primary Health Care as a strategy for achieving equitable care. Available at: 

http://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf?ua=1 

6. EXPH (Expert Panel on Effective ways of investing in Health). Report on Definition of a frame of reference in relation to 

primary care with a special emphasis on financing systems and referral systems, 10 July 2014. Available at: 

http://ec.europa.eu/health/expert_panel/opinions/docs/004_definitionprimarycare_en.pdf 

7. Rhyne R, Bogue R, Kukulka G, Fulmer H, editors. Community-oriented primary care: health care for the 21st century. 

Washington, DC: American Public Health Association, 1998. 

8. Anonymous. Primary health care, including health system strengthening. Resolution WHA 62.12. Geneva, World Health 

Organisation, 22 May 2009. Available at: http://www.personcenteredmedicine.org/docs/wha2009.pdf 

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Esra Saatci, MD 

esra.saatci@gmail.com 

47 – The EURACT Educational Agenda 

Esra Saatci, MD, Specialist in 

Family Medicine, 

Professor Cukurova University 

Faculty of Medicine, Dep of 

Family Medicine, Adana, Turkey 

Co-author 

Janko Kersnik, MD, MSc, PhD, 

Head of Family Medicine Dpt, 

Medical School University 

Maribor, 

Chair of Research Dep at Family 

Medicine Dep, Medical School 

University Ljubljana, 

Chair of Scientific Board at 

Slovenian Family Medicine 

Society 

President of EURACT 

Honorary Secretary WONCA 

Europe 

Introduction 

“General practice is the easiest job in the world to do badly, 

but the most difficult to do well.” 

Professor Sir Denis Pereira Gray 

The discipline of general practice/family medicine (GP/FM) should move away from 

time- and institution-based curriculum set-up to competence- and outcome-based 

learning. A relevant education programme that is mainly competence driven should 

be produced. GP/FM is best learned in a GP-setting, although specific competences 

and skills can be learned in environments of other disciplines. It should also be 

remembered that learning is a lifelong issue. 

Specifically the discipline needs to establish: 

• How family medicine is learnt best? 

• Where should it be taught? 

• When should it be taught? 

• What should be taught? 

• What should GP/FM be teaching learners from other disciplines? 

Harmonization in Europe at the level of competency aims and 

learning outcomes 

The European Union stresses harmonization of the content and level of the training in 

all areas. Since 1993 the European Directive on mutual recognition of medical 

qualifications (Directive, 1993) has been trying to complement the quality of GP/FM 

by harmonizing the length of specialist training, the setting where it takes place, and 

the national supervising authority. The Directive contains no descriptions of content 

or competence issues and is regarded as unsatisfactory in this regard. 

EURACT Educational Agenda (EEA) (Heyrman, 2005) is a dynamic document, derived 

from the core competencies accepted by all European GP/FM academies during the 

WONCA Europe meeting in London 2002, (updated in 2005 and 2011) and presented 

at the WONCA Europe meeting in KOS-Greece 2005. 

Its aim is to contribute to the harmonization of the learning outcomes of the different 

educational programmes all over Europe. It explores six core competencies and how 

the acquisition of these competencies can be converted into abilities to perform. In 

each of eight chapters the specific educational objectives, appropriate learning and 

assessment methods and the specific options for the setting and the time frame 

within the curriculum are identified. Six core competencies lead to the definition of 

25 first level and 80 second level educational objectives. The implications of the EEA 

on education and research in family medicine have been profound. In this document the complexity of the real 

146


practice was accepted as the main focus and complexity learning as the educational paradigm. Learning is seen as a 

process, highly dependent on pre-knowledge and on the learning context (Innes, 2004). Rather than the acquisition of 

a list of defined knowledge and skills, “Action in wisdom” (Harris, 1993) is the final aim. 

The EEA involves the use of specialized knowledge, but central to this is judgement in specific situations with 

conflicting values regarding which problems need to be solved and how to solve them. It involves knowing-in-action, 

reflection-in-action, and reflection-about-action, using repertories of examples, images, and understandings learned 

through experience. It involves using prototypes in memory of frequently encountered situations to construct 

interpretations of related situations. That is why “the tree of wisdom” became the final logo of the EEA. 

The legacy of EEA? 

EEA is a living document serving as a foundation for General Practice/Family Medicine teaching in general with a set of 

offspring documents necessary for the development of the discipline. For those involved in delivering general 

practice/family medicine education and in developing programmes of teaching in general practice, it is designed to 

provide a framework to teach the core competencies. Several countries have adopted the EEA framework and built it 

in their specialty training programmes. For those who learn the discipline, it aims to offer an educational framework 

for setting the learning aims, and monitoring their achievement. A Performance agenda developed on the foundations 

of EEA provides an opportunity for self-assessment on how the learning objectives have been used in everyday 

practice (Wilm, 2014). For those involved in curriculum building, it should be used to determine priorities in teaching 

and learning general practice/family medicine. A Framework for continuing educational development of trainers in 

general practice in Europe (CEDinGP) sets standards for teachers in general practice based on EEA (Alen et al., 2012). 

For healthcare developers, it is meant to contribute to national policy development. 

With regard to the whole medical profession, it is conceived to define which specific competencies can be expected 

from the particular discipline called General Practice/Family Medicine as a crucial contribution to healthcare. 

For the researchers, it defines the mile stones for the Research agenda related to these competencies (Hummers- 

Pradier, et al., 2009). 

The EEA and future generations 

What the future will bring to health care industry is almost impossible to foresee. The future of European General 

Practice/Family Medicine is set in stone in The European Definition of General Practice and supported by a series of 

documents based on it. Fortunately, the position of General Practice/Family Medicine and the level of incorporation of 

General Practice/Family Medicine in health care provision varied at the times when these documents were produced, 

meaning they are so generic that they will survive any turmoil of local health policy decisions. Through very well 

developed education and research in the majority of European countries, quality of General Practice/Family Medicine 

services has risen and can no longer be overlooked. A large number of recently qualified General Practice/Family 

Medicine physicians have been trained in the spirit of EEA and they are the best prophecy for future success. However, 

the leaders of the discipline at national and international level shall further strive for the implementation of the EEA in 

specialist as well undergraduate education. The General Practice/Family Medicine Agenda for undergraduate 

education is still one of the tasks remaining for future generations along with regular updating with regard to content 

and methods.. 


 

 

 

 

 

The definition of the discipline of general practice/family medicine and of the specialist family doctor must 

lead directly to the core competencies of the general practitioner/family doctor. 

The interrelation of core competencies, and essential application features characterizes the discipline and 

underlines the complexity of the specialty. 

There is a need for harmony, equal quality standards and exchangeability in teaching general practice/family 

medicine. 

Rather than the acquisition of a list of defined knowledge and skills, “Action in wisdom” is the final aim. 

General practice/family medicine is best learned in a GP-setting, although specific competences and skills can 

be learned in environments of other disciplines. 

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http://www.woncaeurope.org/content/313-wo-educational-change-users-perspective-educational-agenda-gpfm 

References 

1. Council Directive 93/16/EEC to facilitate the free movement of doctors and the mutual recognition of their diplomas, 

certificates and other evidence of formal qualifications. Official Journal of the European Community. 1993;165:7/7/93. 

2. Innes RB. Reconstructing undergraduate education. Using Learning Science to Design Effective Courses. Larence Erlbaum, 

New Jersey London, 2004. 

3. Harris IB. Educating Professionals, Responding to New Expectations for Competence and Accountability. In: “New 

Expectations for Professional Competence”. Curry L, Wergin JF and ass. Jossey-Bass, 1993. 

4. Heyrman,J. ed., EURACT Educational Agenda, European Academy of Teachers in General Practice EURACT, Leuven 2005. 

5. Wilm S, ed., Assessment of General Practitioners’ Performance in Daily Practice: The EURACT Performance Agenda of 

General Practice /Family Medicine (EUPA). Düsseldorf university press, Duseldorf 2014. http://www.euract.eu/officialdocuments/finish/3-official-documents/307-euract-performance-agenda-eupa-2014 

6. Allen J, Price E, Svab I, Windak A. Framework for Continuing Educational Development of Trainers in General Practice in 

Europe (CEDinGP). ZiZ Centrum Edukacji Ltd., Krakow 2012. http://www.euract.eu/official-documents/finish/3-officialdocuments/241-framework-for-continuing-educational-development-of-trainers-in-general-practice-in-europe-cedingp 

7. Hummers-Pradier E, et al., Research Agenda for General Practice / Family Medicine and Primary Health Care in Europe, 

EGPRN, Maastricht 2009 http://www.egprn.org/files/userfiles/file/egprn%20research%20agenda%20summary.pdf 

148


Francesco Carelli 

francesco.carelli@alice.it 

48 – Continuity of Care 

Francesco Carelli 

Professor, EURACT Council 

Executive Board, 

BME Committee Chair, LJPC 

International Editor 

Continuity of care is a cornerstone of family medicine and a key point for patients. 

It has been included by EURACT (European Academy of Teachers in General Practice 

and Family Medicine), in “Person-centred care”, and one of the “Core competences of 

GP/FM”(1), as the ability “to provide longitudinal continuity of care as determined by 

the needs of the patient, referring to continuing and co-ordinated care management”. 

It can be interpreted as following the patient from birth (sometimes also before) until 

death (sometimes even after), throughout their whole life. 

Continuity of care, also described as ‘the ability to manage in continuity of time, in 

the individual, a series of multiple complaints and pathologies, both acute and 

chronic health problems’ (3), enables doctors to promote health and well-being by 

applying health care and disease prevention strategies appropriately, as described in 

another core competence, the “Comprehensive Approach”. 

It is firmly bound to other core competencies, in the “Holistic Approach” (considering 

a biopsychosocial model taking into account cultural and existential dimensions), and 

“Community Orientation” (also taking into account the community in which the 

individual patient lives and trying to reconcile health needs of both individual patient 

and community in balance with available resources). 

With continuity of care, it is possible to adequately handle risk factors by promoting 

self-care and empowering patients. 

The family doctor knows the community's potential and limitations, health needs, 

epidemiological characteristics, interrelationships between health and social care, 

impact of poverty, ethnicity, and inequalities in health care. He also needs to have an 

understanding of the structure of the health care system, with its economical 

limitations, the correct use of its services by patient and doctor (referral procedure, 

co-payments, sick leave, legal issues etc.) in their own context. All this is possible 

through provision of continuity of care by GP/Family Doctor. 

The multiple dimensions of continuity 

Fletcher et al. (3) distinguish between “coordination” as “the degree to which various 

components of care bear a useful relation to each other”, and “continuity” as “the 

existence of some thread - individual, practitioner, group, or medical record - that 

bind together episodes of care”. But the term ‘continuity of care’ has been used to 

describe a great variety of relationships between patients and the delivery of health 

care. (4) 

Record Continuity refers to availability of all the information about a patient's history, 

visits, tests, allergies, medications, and preferences, in a medical record or clinical 

database, easily shared by all the clinicians caring for the patient, whether in the 

same institution, between institutions, or between care settings. This can improve 

quality of care in the presence of increasing mobility of patients, increasing numbers of people involved in their care, 

149


and increasing amount of information to remember. 

Clinician Continuity, highly appreciated by patients, refers to maintaining a relationship with the same doctor over time 

(5). In medical education literature, this use appears in family practice, general internal medicine, and paediatric 

journals. 

Both record and clinician continuity are used in the definition of primary care that describe it as accessible, continuous, 

comprehensive, family centred, coordinated, and compassionate, delivered or directed by well-trained physicians, both 

able to manage or facilitate essentially all aspects of care and linked to the patient and family in a relationship of 

mutual responsibility and trust with them. Of course nobody can be available 24 hours/day, but a GP/FD can usually 

manage the care of a patient with occasional intervention of nurses or other colleagues, ward or emergency doctors, 

or specialists, when not present. In various surveys, patients showed a preference for single doctor practices, or multipractice 

where they can see their own FD, even in limited hours, than for “Polyclinics” with rotas of doctors and 24/7 

visiting hours. 

Clinician continuity is thought to be important, in that not all information is included in the medical records, and a 

clinician who knows a patient can recognize significant changes, with a period of reference to go by (the patient as 

his/her own control). Behaviour and body language compared to patients’ previous visits may be as important as 

clinical findings in identifying a significant event. 

A continuous relationship can promote trust, a core part of the clinician-patient relationship and possible part of the 

healing process. Trust and mutual respect facilitate patients divulging private information, or posing questions 

otherwise. This relationship is important not only to patients, but also to the clinicians, representing a valued part of 

medical practice. 

Site Continuity means that patients have a "usual source of care" as opposed, for example, to unrelated emergency 

departments. 

Continuity also appears in the literature as synonymous with accessibility or availability or even with compliance, such 

as following post-hospital discharge instructions or follow-up appointment keeping. 

The Continuum of Care. In long-term care literature, continuity is used as a synonym for the continuum of care (7) 

which is defined as a client-oriented system composed of both services and integrating mechanisms that guides and 

tracks patients over time through a comprehensive array of health, mental health, and social services spanning all 

levels of intensity of care. 

Continuity as an Attitudinal Contract. Finally, continuity has been described as a "contract of attitudes” (8). There is a 

“cornerstone caregiver” who is in charge of the patient's care and is the sole responsible for decisions and for 

communicating information to the patient and his or her family. If the previous uses of the term “continuity” could be 

considered retrospective (to what extent has it occurred), the attitudinal contract - whether called coordination, 

integration, or continuity - could be considered concurrent and prospective. 

Continuity and Improved Outcomes of Care 

Linking the degree of continuity, however defined, with improved clinical outcomes (e.g., for chronic problems, 

preventive care) has been reviewed by Starfield , concluding that continuity of care is “associated with more indicated 

preventive care, better identification of patients’ psychosocial problems, fewer hospitalizations (in emergency and in 

general), shorter lengths of stay, better compliance with appointments and taking of medications, and more timely 

care for problems”. 


 

 

 

 

Cornerstone of family medicine and key point for the patients. 

Present in core competences ( person-centred; comprehensiveness, community orientation; holistic 

approach. 

Promotes health, well-being , empowering patients. 

Relationship with the same doctor over the time. 


http://www.woncaeurope.org/content/bp21-continuity-general-practice 

150

References 


1. EURACT Educational Agenda, www.euract.eu 

2. Starfield, B. Primary Care: Concept, Evaluation, and Policy. New York: Oxford University Press, 1992. 

3. Fletcher, R.H., O'Malley, M.S., Fletcher, S.W., et al., Measuring Continuity and Coordination of Medical Care in a System 

Involving Multiple Providers. Med Care 22:403-411, 1984. 

4. Kristjansson et al. Predictors of relational continuity in primary care: patient, provider and practice factors 

5. Rivo, M.L., Saultz, J.W., Wartman, S. et al. Defining the Generalist Physician's Training. JAMA 271:1499-1504,1994. 

6. Hayward, R.A. Regular Source of Ambulatory Care and Access to Health Services AJPH 81:434- 438,1991. 

7. Evashwick, C.J. The Continuum of Long-Term Care: An Integrated Systems Approach. New York: Delmar, 1996. 

8. Banahan, B.F., Jr. and Banahan, B.F., III. Continuity as an Attitudinal Contract. J Fam Prac 12:767-768, 1981. 

151


François Schellevis MD, PhD 

F.Schellevis@nivel.nl 

49 – Where General Practice Meets Public Health: Surveillance and 

Prevention as Examples 

François G. Schellevis MD PhD 

Head research department 

NIVEL (Netherlands Institute for 

Health Services Research), 

Utrecht 

and Department of General 

Practice & Elderly Care 

Medicine / EMGO Institute for 

Health and Care Research VU 

University Medical Centre, 

Amsterdam, the Netherlands 

Co-author 

Douglas Fleming, MD, PhD 

Emeritus director of the 

Birmingham Research and 

Surveillance Unit of the Royal 

College of General Practitioners, 

United Kingdom 

Introduction 

Traditionally, general practice deals with individual patient care for people with 

illnesses and diseases or who are worried about their health. Public health deals with 

the threats potentially affecting the health of populations, e.g. through vaccination 

programs, sanitation, surveillance, or health education at population level. Public 

health is organized and financed as a governmental service. 

Health systems vary with respect to the integration of general practice and public 

health from almost complete overlap (e.g. in Central and Eastern European countries) 

to complete segregation (e.g. in Belgium and in The Netherlands). However, the level 

of integration does not affect the potential contribution of general practice to public 

health. We argue here that the setting of general practice and the information 

available in general practices is very valuable for public health purposes. We illustrate 

this for two domains of public health: surveillance of common infectious diseases, 

notably influenza, and the prevention of chronic diseases. 

Surveillance of influenza and other common infectious diseases 

The importance of general practice in signalling the emergence and the course of 

influenza epidemics over the last 60 years is well recognized and sentinel practice 

networks have been established in numerous countries [Deckers et al, 2006]. 

Historically these networks were established to monitor various common infectious 

diseases (e.g. measles, mumps, rubella) many of which are now prevented through 

vaccination. In these practices, data on the number of patients presenting for each 

illness is collected and reported on a daily or weekly basis to public health authorities. 

This ‘early warning’ information provides insight into the periodicity, age specificity 

and severity of epidemics. In the example of influenza, virological surveillance has 

been integrated as part of clinical surveillance in many countries enhancing the 

interpretation of clinical surveillance data and providing virological determination at 

the earliest opportunity [Hannoun et al, 1989]. The virus strain-specific information 

obtained from general practice supports the choice of vaccine strain types to be 

included in the WHO recommendations for influenza vaccine manufacture. Associated 

patient-specific vaccination uptake information has also facilitated studies of influenza 

vaccine effectiveness [Hardelid et al, 2012]. 

Influenza is the best example of an illness with a significant public health impact 

which is predominantly managed in general practice. There are many other illnesses 

(e.g. chickenpox/herpes zoster, skin infections) for which data from primary care is 

essential for the evaluation of optimum and cost effective management strategies. In 

most countries sick persons usually visit a general practitioner as the first point of 

contact when they have significant symptoms, which makes general practice- based medical records a valuable source 

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of information on population health trends. 

Over the last 20 years general practices participating in the surveillance networks have converted from a paper to an 

electronic record-based reporting system, opening up new opportunities for disease surveillance and its management; 

in particular therapeutic management such as antibiotic prescribing, which is, as a result of its association with 

antimicrobial resistance, an issue of particular importance for public health. More than ninety per cent of antibiotic 

prescriptions are issued in general practice and it is essential if we are to achieve more appropriate use of antibiotics 

that patient-specific antibiotic data are collected routinely on a continuous basis [Woodhead et al, 2004]. 

Prevention of chronic diseases 

According to the Institute of Medicine’s categorization of prevention, universal prevention is the domain of public 

health, and indicative and care-related prevention is the domain of health care, including general practice. However, 

selective prevention (identification of people at high risk and interventions aimed at reducing their risk) has no natural 

embedding, neither in public health, nor in general practice. Selective prevention is at the interface of public health 

and general practice: it addresses the general population without symptoms or diseases and it addresses general 

practice for individualized risk-reducing interventions. As general practitioners keep a medical record of their patients, 

information about their risk profile is available. This facilitates the identification of persons whose risk profile is not 

available or incomplete, and these persons can be invited selectively. This increases the efficiency of selective 

prevention when compared to a mass screening prevention programme. 

Prevention of chronic diseases such as cardiovascular diseases, diabetes mellitus or chronic respiratory diseases often 

means intervening in the lifestyle of people (physical exercise, smoking, diet). This includes interventions on the 

individual level, but also at the level of their household and the community they live in. General practitioners are in the 

ideal position to tailor risk-reducing interventions to individuals, with regard to their social and physical environment. 

Therefore, close collaboration between public health professionals and general practitioners in the field of prevention 

of chronic diseases is warranted and will increase the effectiveness of preventive interventions. 

Where family practice meets public health: the importance of linked information 

The examples of influenza surveillance and prevention of chronic diseases illustrate the interface between general 

practice and public health. An effective link between the two is established through the use of individual patient data 

which is collected routinely in general practice. Exploitation of this link requires the collection of the raw data from 

primary care and its storage as coded data according to an agreed classification system. Ideally, the same classification 

system should be used in all healthcare domains thus maximizing opportunities for linking information from different 

sources. There is also a need for longitudinal linkage over time which is readily achieved in patient-specific medical 

records. However, reliable linkage of individual patient data across different health care providers requires the use of 

unique patient identifiers. Information stored in (electronic) medical records is primarily recorded for individual patient 

care purposes but it has an economic value for public health services, e.g. for determining the disease burden in 

populations [Fleming et al, 2004]. There is also a political perspective: aggregated information from medical records 

provides critical information about groups of people who are otherwise marginalized such as persons with minor 

mental illness, immigrants, and homeless persons. 


 

 

 

 

 

Information available in general practices is very valuable for public health purposes 

General practice is the ideal setting for real-time surveillance of common diseases 

Patient-specific data needs to be recorded and stored according to an agreed classification system 

Patient-specific information from medical records facilitates tailored prevention of chronic diseases 

Aggregated data from general practices provide insight into population health 


http://www.woncaeurope.org/content/sentinel-practice-networks-contribution-general-practice-public-health-europe 

References 

153


Deckers JGM, Paget WJ, Schellevis FG, Fleming DM. European primary care surveillance networks: their structure and 

operation. Fam Pract 2006;23:151-8. 

Fleming DM, Schellevis FG, Casteren V van. The prevalence of known diabetes in eight European countries. Eur J Publ 

Health 2004;14:10-14. 

Hannoun C, Dab W, Cohen JM. A new influenza surveillance system in France, the Ile-de-France GROG. I. Principles and 

methodology. Eur J Epidemiol 1989; 5: 285-93. 

Hardelid P, Fleming DM, Andrews N, Barley M, Durnall H, Mangtani P, Pebody R. Effectiveness of trivalent and pandemic 

influenza vaccines in England and Wales 2008-2010: results from a cohort study in general practice. Vaccine 

2012;30:1371-8. 

Woodhead M, Fleming D, Wise R. Antibiotics, resistance, and clinical outcomes. Br Med J 2004;328:1270-1. 

154


Norbert Donner-Banzhoff, MD, MHSc 

Norbert@staff.uni-marburg.de 

50 – Stages of Behavioural Change – a Helpful Concept for GPs? 

Norbert Donner-Banzhoff, MD, 

MHSc 

Prof. Department of General 

Practice, University of Marburg, 

Germany 

also the lack thereof. 

Stages of change originated from the field of counselling for addiction disorders. 

Instead of treating every patient in a one-size-fits-all fashion, a motivational diagnosis 

is made before doctor and patient embark on a treatment plan. A patient may have 

tried to stop smoking or drinking several times. Subsequently, a person probably does 

not have to be informed about the fact that smoking or drinking is bad for his health 

and perhaps even the health of others. There are others, however, who initially need 

to be informed that their weekly alcohol consumption is above safe levels. While the 

former may benefit from a precise plan for when to stop and how to manage the 

transition, the latter would be forced into resistance when confronted with a 

prescription of this kind. Instead, patient-communication should roll with resistance. 

Clinicians should only propose to the patient what he can realistically achieve at his 

current motivational stage (1). Stages of change implies that humans go through a 

sequence of defined stages of contemplation, preparation and observable action. For 

each stage, tailored interventions are available to help the patient move on to the 

next and, finally, to the aspired behaviour. Since they drew upon previous models, 

Prochaska and DiClemente coined the notion of a Transtheoretical Model (2). 

Twenty years ago this approach became almost orthodox in the treatment of 

behavioural problems related to health. This happened despite the empirical 

evidence supporting the model being somewhat contradictory (3). Moreover, Stages 

of Change came under the attack from scientists proposing different models of 

behavioural change (4,5). 

Despite this, Stages of Change has had a long-lasting appeal with General 

Practitioners (GPs) (6). While the scientific debate centred on the descriptive and 

analytical validity of the model, clinicians embraced it for its pragmatic utility. The 

model may not apply to all human beings in the process of changing their minds and 

their behaviours. But GPs find the model useful for distinguishing between those in 

which immediate intervention makes sense and those in which friendly waiting is to 

be preferred. 

Counsellors in specialised clinics usually see those who have decided to seek help, 

their clients are at least ambivalent and perhaps even ready for change. GPs, on the 

other hand, see smokers not because they want to stop their smoking habit but 

because of their cough or other manifested illness. In primary care we are thus 

confronted with a much broader range of motivational stages than the specialist 

counsellor. While in a specialised clinic the stages of contemplation and preparation 

are more frequent, primary care more closely reflects the distribution in the general 

population. The latter is U-shaped with most people having no intention at all or 

being past the sequence of changes (maintenance). 

GPs thus need a tool to decide where to invest their time and energy. The “Stages of 

Change“ model provides exactly that. It helps identify opportunities for change but 

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Nowadays, clinicians are under pressure by their governments and the public to motivate their patients to adopt 

healthy behaviours. Their professional leaders may even stress the suitability of the setting for prevention by getting 

patients to change. Among busy clinicians already struggling with the narrow curative task this often results in feelings 

of guilt. 

The simple question ‘Have you ever tried to [give up smoking, stop drinking, exercise more, take your tablets regularly 

etc.]?’ is often sufficient to understand where the patient is in the process (hopefully) of leading to healthier 

behaviour. There is no need to use lengthy questionnaires although standardised instruments have been developed for 

research purposes. The practical steps of taking a history and suggesting the next move are easy to learn. The longer 

one tries, the more one realises that “Stages of Change“ is an attitude rather than a cookbook-like prescription. Ideally, 

the patient is given room to identify opportunities and barriers himself and to suggest the next step. In primary care, 

occasions are plentiful, they range from the most obvious addictive behaviours to lack of exercise and poor diet. 

Discussions regarding taking medicines regularly or attending for chronic disease monitoring may also benefit from this 

approach. 

Against this background the “Stages of Change“ approach can be likened to an internal gatekeeper. It can ease the 

tension between practice resources, with time being the most valuable, and the needs of the patient. “Stages of 

Change” has also been of tremendous benefit in implementing patient centred communication strategies in primary 

care. 

Perhaps the most important and damaging risk factors for chronic diseases are behavioural. The moral overtones 

arising from this knowledge have often put a heavy strain on the doctor-patient relationship. Payment being linked to 

behavioural outcomes of care has only made matters worse. “Stages of Change” has helped GPs prioritise their tasks, 

avoid unnecessary guilt and maintain their feelings of respect for their patients. 


 

 

 

Before you suggest behavioural change to your patient, stop and ask whether he / she has already tried [to 

stop smoking, have more exercise, take his / her tablets regularly etc.]. 

The answer will help you decide whether the patient is ready or not. 

Ideally, the patients formulates him / herself what the next step should be. Waiting is perfectly OK, but try to 

address the issue later. 


http://www.woncaeurope.org/content/7-pa-stages-behavioural-change-helpful-concept-gps 

References 

1. Miller WR. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guildford; 1991. 

2. Prochaska, JO; Butterworth, S; Redding, CA; Burden, V; Perrin, N; Leo, M; Flaherty-Robb, M; Prochaska, JM. Initial efficacy 

of MI, TTM tailoring and HRI's with multiple behaviors for employee health promotion. Prev Med 2008 Mar;46(3):226–31. 

3. Riemsma, RP; Pattenden, J; Bridle, C; Sowden, AJ; Mather, L; Watt, IS; Walker, A. Systematic review of the effectiveness of 

stage based interventions to promote smoking cessation. BMJ 2003 May 31;326(7400):1175–7. 

4. West R, Sohal T. "Catastrophic" pathways to smoking cessation: findings from a national survey. BMJ. 2006 Feb 

25;332(7539):458-60. 

5. Littell, JH; Girvin, H. Stages of change. A critique. Behav Modif 2002 Apr;26(2):223–73 

6. Rollnick S et al. Health Behavior Change. A Guide for Practitioners. Edinburgh: Churchill Livingstone; 1999 

156



carl.steylaerts@skynet.be 

51 – Future and Innovations in Family Medicine – in 2065 


Honorary Treasurer WONCA 

Europe 

Family Doctor, Belgium 

Dr Monty Kent Hughes, the very first WONCA president, said in 1972: “the future of 

our professional discipline will depend on our ability to work together in the service of 

humanity.” (1) 

Fast forward to 2065 

Who would have thought that the apparently least developed specialization, family 

medicine, would eventually end up as the only one? Cardiologists? There are still 

three in Europe. Emeriti, they are no longer active. Gynaecologists? None. No longer 

necessary since the breakthrough in cloning. Paediatricians? All retrained to 

avatarologues. Surgeons? Obsolete after the introduction of growing graphene and 

nanobots which turn every cancer cell in apoptosis. Falls and accidents have been 

eradicated: we use superconductivity to move now. What bliss! 

Graphene, delineating and replacing the vessel wall, causing no more obstructions or 

bleeding, was a fine piece of nanotechnology. Extended life span by at least 200 years. 

Moreover, everything that is somewhat based on medical technology is obsolete 

today. Technique killed technique. But family medicine has remained. Because of 

demand. 

And thanks to symphonic thinking, our trade has survived. We were already strong 

through our holistic thinking, but this additional thinking step turned out to be the 

right one. 

General Practice, General Practitioner, Family Medicine, Family 

Physicians ... 

With the putting in motion of a quality train entitled "Validation of increase", the 

formerly flat and uninspiring trail of a GP career was transformed into an inspiring 

one. From GP to Personal Doctor to Family Doctor. 

A first master after six years, second master after 9 years, third master after 12 years, 

and so on every 3 years, the family physician trained in the complex game of families, 

relationships and interactions with the new technology and unhealthy environment, 

proved to be just what the future needed: not more technology, but doctors trained 

in the inclusive approach of more or less healthy people and their relationships. 

Because despite all the technological advances, 80% of people remained just that - 

people with their facts and failures, their joys and wishes and their hopes still to make 

it (2). 

Family Doctor Art has remained a versatile specialty, with an eye for the totality, 

continuity, quality, and equality. As demanded. 

How did family medicine become so successful? 

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Through Genius Forecasting a properly balanced accreditation system was developed along with the establishment of 

a WONCA Europe observatory. They turned out to be the strategic moves that kept the discipline up to date. 

Accreditation became validation, mainly inspired by the British. Credere or validere? Belief or evidence based? The 

British knew for sure: evidence based. Confidence or control? Control and confidence! 

Core values 

A literature search on the website of WONCA Europe came up with the following titles: 

1. Community-Oriented Patient-Centred Primary Care 

2. Continuity and Comprehensiveness 

3. Teaching Cross-Cultural Care 

4. The Transition from CME to CPD - Fostering Good Practice Through Education 

5. Physician Heal Thyself and then the World: on Workaholism, Helpaholism and other Physician Conditions - 

Playful but Effective Medication for Serious Symptoms 

6. The Role of the College of General Practitioners in Developing Research Capacity and Capability in Primary 

Care 

7. About quaternary prevention 

All wonderful titles. 

Let us zoom in on two phenomena the researchers unanimously selected as the first to start with: 

 

 

The Role of the College of General Practitioners in Developing Research Capacity and Capability in Primary 

Care 

The Transition from CME to CPD - Fostering Good Practice Through Education 

They had also read other books 

1. Michio Kaku, Journey to the Future, 2011 

2. Michael Kidd, The Contribution of Family Medicine to Improving Health Systems, 2013 

3. John Cleese, How to Survive your Family? 1983 

4. Wilkinson, Pickett, The Spirit Level, 2009 

5. Daniel Kahneman, Thinking Fast and Slow, 2011 

6. Daron Acemoglu, Why Nations Fail, 2012 

7. Jeremy Rifkin, The Empathic Society, 2009 

8. Malcolm Gladwell, Outliers, 

9. Leo Bormans, The World Book of Happiness, 2010 

10. Michio Kaku, The Future of the Mind, 2014 

From this additional literature they took a surprisingly simple principle: (s)he who knows his/her business is in the best 

position to teach it. To know your topic best you have to teach it. So everyone became both student and teacher 

concurrently. 

Then WONCA got an Observatory 

GPs measured, and therefore increased their knowledge-base. They started simple. Weight and height of each patient, 

at every consultation. The data entered into the Electronic Health Record were sent to the Observatory in real time. 

The aggregated data were sent to several city squares, where a local information display flashed the current average 

BMI of the city, updated by the hour. This followed a campaign launched under the title "Your BMI minus one!" Actions 

were developed in conjunction with several advertising agencies. Thus, even more people were encouraged to 

participate, and in no time the target was achieved: BMI – 1. 

The yield was calculated as being 1000 million Euro per year, along with an increase in happiness. 

And many more health benefits. For Europe alone. 

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Another added value: the general practitioners at that time asked their patients to join them in conducting research – 

inclusive policy, you know - through a kind of Galaxy Zoo project. All that now seems obvious, but then it was anything 

but: http://www.galaxyzoo.org/ . 

Next, slightly more advanced parameters were recorded, and all the general practitioners of the scientific society 

participated, also encouraged by the success and a few incentives of course. 

You know those historical targets, but I will repeat them, even though they are obsolete now. 

From Wilkinson and Pickett: The Spirit Level 

 

 

 

 

 

 

 

 

 

Level of trust 

Mental health and drug use 

Physical health and life expectancy, child mortality 

Obesity: wider income gaps, wider waists 

Educational performance 

Teenage births: recycling deprivation 

Homicides 

Imprisonment and punishment 

Social mobility 

When cloning became a trend, teenage pregnancies in particular disappeared. With the first rough version of the 

amnesia pill, addictions were treated successfully. They just forgot that they were hooked. But in the beginning they 

also forgot who they were, tabula rasa, and that decreased the pill’s success. 

Murder and suicide have been decimated, as there are hardly any drugs in circulation and those that exist have been 

legalized. The amnesia pill was truly an asset. Social mobility was simply no longer needed. 

Next Came Educational Reform 

CPD starts early today, about the 7th year of life, and this commenced in 2015. 

Subsequently, in 2020, it was announced that anyone who wanted to study medicine with a specialization in family 

medicine (this really was its name) needed to have undergone at least 4000 hours of music lessons. 

Indeed, it was scientifically proven that music education positively influenced language competence. And of course, 

the symphonic thinking. The 10,000 hour rule to form experts subsequently evolved. 

Then the Bologna model was enriched and expanded. Your first Master was an MD, purely out of nostalgia, then 

became a Master of Arts, MA. The second master was a Master of Family Arts, the third master - here is where the 

divergence may have begun - was either a Master BioNanotechnology, BioCloning, Singularity, Symphonic Thinking or 

Photosynthesis, for those who wanted to keep themselves busy while repairing energy modules. 

The sequential achievement of various Masters titles was a wonderful incentive. Not only lifelong learning, but the 

introduction of innovations could also be faster now. 

But ’fine-tuning’ was necessary – and they finally came up with 100 Master's degrees. 

Change is not so simple. Especially when you are coming up for 450 years old. 

I hope we will soon find the right flexibility with the switching of connectomes through reverse engineering. In order 

that the once pruned dendrites can redevelop and search, find and reconnect with new experiences. 

And since the decimation of agriculture, much time is freed up to do the really important things: create beauty, and 

provide clean water universally. Still needed, because we have inherited quite a mess from our ancestors. But it must 

be said that our family doctor forefathers surely propagated this with insight. 

Singularity 

Years later the step to singularity became a fact. Gone is osteoarthritis, cancer, diabetes and pain. What is left is 

stainless steel, carbon fibre and an energy module based on photosynthesis. Food is not needed anymore. Pity. 

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A rising equality gave rise to fewer thefts and that along with fewer killers led to decreased numbers of prisoners and 

punishments. Inclusive policies, it can be a blessing. 

The most difficult one to improve was the level of trust and confidence, because fear has always been an evolutionary 

advantage. The brave were trampled, the fearful in their dens survived and procreated. 

Confidence was difficult to measure because of its variability with age and prone to bias and confounding. But family 

physicians found a solution, and the Edelman Trust Barometer has simply been washed away by means of a daily 

representative measurement. Exhibited daily in the town squares. Boosting trust. 

What will the future bring next? 

The achievement of the stages of Kardasjev’s predictions. 

People becoming gods, in the depths of their mind, it's something absolutely new. So they say. 


 

 

 

 

Symphonic thinking as a selection criterion 

Validation of increase 

In order to learn you have to teach 

WONCA enriched with an Observatory 


http://www.woncaeurope.org/content/436-future-and-innovation-family-medicine-active-workshop-perspectives-discipline 

References 

In the text and 

1. AM Michael Kidd. Challenges for Healthcare in the 21st Century: How Family Medicine Can Help. J Family Med Prim Care. 

2013 Jul-Sep; 2(3): 211–214. 

2. Credo of Family Medicine by André Raes. Antwerpen, 1981 

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Elias Papazissis, MD, MSc 

homed.medical@gmail.com 

52 – Home Care at the Dawn of the 21st Century. Electronic 

Devices and Telemedicine Facilitate Safe Home Care for Acutely Ill Patients. 

Elias Papazissis, MD, MSc 

President, hoMed Co. 

Introduction 

The current status of technology, which is available and affordable for widespread 

use, is already sufficient to permit advanced home care to acutely ill patients (1). 

However, ongoing technological evolution is even more promising and highlights a big 

change in healthcare provision (2). It seems that soon, the concept “hospital” will not 

continue to be considered so much related to the venue itself, but to an overall 

organization where sophisticated treatment and enhanced patient monitoring can be 

provided with safety regardless of the place, whether hospital ward or patient’s 

residence, neutralizing distance barriers (3). 

Continually increasing bandwidth in telecommunications, which permits fast and 

smooth video and data transmission, tablets, smartphones, portable analysers, 

imaging systems and other diagnostic devices, apparatuses such as electronic infusion 

pumps and ambulatory monitoring systems including high-tech sensors incorporated 

into “smart clothes”, are the main contributors in this evolution. 

Point of care diagnostic devices. 

Portable palm-size analysers can perform a wide range of important measurements 

including blood gas analysis, basic chemistry, troponin, BNP and PT-INR, at the point 

of care, within just 2 minutes. There are also portable, small and lightweight 

automated 5-part WBC haematology analysers, which provide quantitative results in 3 

minutes. 

Ultrasound portable scanners are equivalent to the stand-alone ones in terms of 

capability, reliability and accuracy. There are also quite reliable pocket size scanners 

for prompt emergency testing. 

Portable x-ray systems produce high-resolution images in seconds. We use fully 

equipped vehicles. Digital x-rays, which are performed in a patient’s home, are 

subsequently developed in the vehicle outside the home. Images are transmitted to 

radiologists for diagnosis and, concurrently, to other physicians involved in the 

patient’s treatment. 

Telemedicine state of the art. 

Digital sound archives which are captured by electronic stethoscopes and transmitted 

by means of Bluetooth protocol, can undergo frequency and waveform analysis. For 

example, when an additional tone is heard, graphs can show it’s frequency, duration, 

time-distance from the 1st to 2nd tone and it’s variation with respiration. This 

information, which otherwise would need a very experienced cardiologist’s ear, can 

be recorded with accuracy through us of an electronic stethoscope and subsequently transmitted for remote 

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interpretation by a specialist. 

Flexible cameras can capture images from inside the ear, nose, throat and vagina for evaluation by specialists through 

remote consultation. Teledermatology has been reported as being practised in various settings (4,5). Fundoscopy can 

now be carried out by professionals who are not expert cardiologists, with the use of an amazing digital 

ophthalmoscope. 

Videoconference is now becoming progressively more available with the support of 3D, 4D and Wi-Fi technology . With 

the widespread use of tablets and smart phones, a team of health professionals including nurses, primary care 

physicians and specialists can virtually “team up” at any time regardless of distance and with considerable reduction in 

manpower cost. 

Inspection is an essential part of physical examination. As a result, videoconference is very important for the remote 

specialists in order to gain a complete impression of a patient’s condition. With the aid of the visiting health 

professional’s hands and his or her cooperation, a remote specialist can also recognize abdomen guarding, tenderness, 

stiffness of joints, tendon reflexes and other signs, which are classified under “palpation”. Percussion sounds can also 

be heard and evaluated by the remote specialist. 

We use Ethernet cameras with pan, tilt and zoom functions to achieve 7/24 observation of very ill patients at home. 

This not only assists in the continuous monitoring of a patients’ breathing and alertness, but also to monitor the 

carers’ adherence to given instructions. 

Infusion pumps. 

In order to guarantee accuracy, safety and nurses’ compliance to regulations, we use multi-functional infusion pumps. 

Multi-dose function allows administration of medicines in doses, even when a nurse is not present at the time of 

infusion. Often, a nurse stays with the patient and monitors vital signs, urine output and other parameters. He/she is 

able to change the pump’s settings, either according to a given protocol, or after a remote specialist’s consultation. 

A view into the future. 

Flexible technologies and smart clothing are highlighting a new era in the field of telemonitoring. There is ongoing 

evolution towards the development of miniature, soft and flexible non-invasive sensors, which are incorporated to 

clothes (6). 

Many important parameters regarding metabolism, thermal comfort, skin blood flow, skin hydration, skin thermal 

conductance, skin infection, muscle activity, autonomic nervous system activity, respiration rate and amplitude, heart 

rate, blood pressure, position, circadian rhythm, pressure sore detection, heart point detection, etc., can be measured 

from skin, using non-invasive sensors. A personal area network (7) connects the distributed intelligence of all the items 

of smart clothing, transmitting data to a computer and a specialist monitoring station, where vital parameters are 

analysed (8). 

Conclusion 

Point of care diagnostic capabilities and telemedicine are essential parameters towards a safe shift of the care of 

acutely ill patients from hospital to home. Yet the treatment of an acutely ill patient also requires uninterrupted 

responsibility by a clinical team, regular clinical measurements including vital signs, bio-signals and water 

intake/output balance, frequent and rapid acquisition of testing results, prompt interpretation of the entire clinical 

information and decision making and high degree of alertness to effectively react in the case of any unforeseen 

complication or deterioration. Consequently, safe home care for acutely ill patients, apart from the availability of 

ambulatory testing equipment and telemedicine, also requires special and smoothly operating organizational 

structures. 


 

 

“Hospital” should not continue to be regarded as a venue, but as an organization, which combines concerted 

teamwork of health professionals, enhanced patient monitoring and sophisticated treatment. 

Point-of-care portable diagnostic apparatuses enable most of the frequently required diagnostic tests to be 

rapidly and reliably performed at the patient’s home. 

162


 

 

A team of doctors, nurses and other health professionals can be at any time virtually near the patient 

regardless of distance barriers, with the support of information and communication technology. 

Ongoing technological evolution highlights a new era in the field of telemedicine, which promises to allow 

safer advanced home medical care in the near future. 


http://www.woncaeurope.org/content/4478-home-care-dawn-21st-century-whats-difference-electronic-devices-and-telemedicine 

References 

1. E.Papazissis, Advanced Technology Permits the Provision of Advanced Hospital Care in the Patients' Homes, Studies in 

Health Technology and Informatics 100 (2004), 190-199. 

2. A.Junais, Telemonitoring, COPD and cough counting, Journal of Telemedicine and Telecare 2012; 18: 301-302. 

3. S.Martin, J.Augusto, P.McCullagh, W.Carswell, H.Zheng, H.Wang, J.Wallace, M.Mulvenna, Participatory Research to Design 

a Novel Telehealth System to Support the Night-Time Needs of People with Dementia: NOCTURNAL, Int J Environ Res 

Public Health. 2013 Dec 4; 10(12):6764-82. doi: 10.3390/ijerph10126764. 

4. J.Frühauf, G.Schwantzer, C.Ambros-Rudolph, W.Weger, V.Ahlgrimm-Siess, W.Salmhofer, R.Hofmann-Wellenhof, Pilot study 

on the acceptance of mobile teledermatology for the home monitoring of high-need patients with psoriasis, Australas J 

Dermatol. 2012 Feb;53(1):41-6. doi: 10.1111/j.1440-0960.2011.00852.x. Epub 2012 Jan 6. 

5. C.Chanussot-Deprez, J.Conteras-Ruiz, Telemedicine in Wound Care: A Review, Adv Skin Wound Care. 2013 Feb;26(2):78-82. 

doi:10.1097/01. ASW.0000426717.59326.5f. 

6. F.Axisa, P.Schmitt. C.Gehin, G.Delhomme, E.McAdams, A.Dittmar, Flexible Technologies and Smart Clothing for Citizen 

Medicine, Home Healthcare, and Disease Prevention, IEEE Trans Inf Technol Biomed. 2005 Sep; 9(3): 325-36. 

7. Yu-Fang Chung, Chia-Hui Liu, Design of a Wireless Sensor Network Platform for Tele-Homecare, Sensors (Basel). 2013 Dec 

12;13(12):17156-75. doi: 10.3390/s131217156. 

8. Jia-Li Ma, Yuan-Lian Cui, Ming-Chui Dong, An Effective Low-Complexity Multi-Fital-Signs Compression Technique for 

Embedded-Link e-Home Healthcare, Engineering in Medicine and Biology Society (EMBC), 2013 35th Annual International 

Conference of the IEEE. doi: 10.1109/EMBC.2013.6609716 

163


Per Kallestrup, MD, PhD 

kallestrup@dadlnet.dk 

53 – “To Travel With Your Profession Is to Live and Learn”*: Educational Exchanges 

in Family Medicine Training - the Hippokrates Exchange Programme 

Per Kallestrup, MD, PhD 

Specialist of Family Medicine, 

Skødstrup Lægepraksis and 

Associate Professor, Centre for 

Global Health, Aarhus University 

(GloHAU) 

Co-author 

Sara Rigon, MD, Specialist of 

Family Medicine. 

Since the beginning of western civilization travel has always been an essential part of 

the education of future generations. At first, there was the legendary Grand Tour, a 

rite of passage, which brought young British aristocrats in contact with the cultural 

legacy of classical antiquity and the Renaissance. Today, in times of standardized and 

mandatory schooling the Grand Tour is safer, often shorter, but equally valuable and 

enlightening; it takes the form of an exchange and it covers all stages of education, 

from lower and upper schooling to higher and post-graduate education (1). 

In recent years, interest in international rotations has increased among students, at all 

levels and in every field of education. Correspondingly, many Universities around the 

world have acknowledged such a need and are now promoting exchanges and the 

internationalization of school curricula in the aim of preparing (their) students to a 

globalised world as well as work environment (2-4). 

Exchange in General Practice/Family Medicine (GP/FM): The 

Hippokrates Exchange Programme 

Hippokrates is an exchange programme for medical doctors specialising in GP/FM and 

junior GPs/FPs within five years of completing specialty training. It offers the 

possibility of undertaking an inspiring journey to discover different primary care 

systems and educational environments. 

Now thriving and well structured, the programme was first presented at the 6th 

European Conference on GP/FM (WONCA Europe) in Vienna in 2000, under the 

auspices of the European Academy of Teachers in GP/FM (EURACT), which has always 

had an important role in shaping and enhancing medical education in Family 

Medicine throughout Europe. In 2008 the programme was entrusted to the then 

established Vasco da Gama Movement (VdGM) which reviewed the scheme two years 

later and established a database along with a standardised framework to guarantee a 

beneficial and verifiable educational outcome for every exchange. 

The Aims of Hippokrates 

The main objective of the Hippokrates Programme is to provide an enriched learning 

experience that promotes the acquisition of academic and clinical knowledge of 

another health system and encourages mobility among junior doctors. Thus it offers a 

broader perspective to the concepts of GP/FM at both professional and personal 

levels for future GPs/FPs. 

* One of the earlier restless Danes, the famous Poet and Fairy-tale-writer Hans Christian Andersen said: “To travel is to live” and he described the 

enhanced sensitivity that characterises you when you are on unfamiliar territory. Now if you travel with your profession you are up for a double 

bonus – living and learning. 

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Through these experiences, participants, visitors as well as GP/FP hosts, gain new perspectives that inspire them to 

undertake an active part in the development of GP/FM in their own country. In fact, the programme also contributes to 

enhance collaboration among national colleges of GP/FM and recruitment of young professionals to these important 

associations (5). 

At the individual level, the benefits are numerous; some are open to any kind of exchange, while others are particular 

for an international clinical experience in a vocational setting. Most exchanges offer the opportunity to improve foreign 

language skills, challenge one’s ability to adapt to new situations, developing an intercultural identity and establish 

friendships that are most likely to inspire throughout life (4). Moreover, the exposure to a different health system and 

GP/FM environment enhances professional skills, as well as improving academic knowledge and increase opportunities 

for subsequent employment (5). 

The Hippokrates framework 

Aimed at ensuring high quality educational content, the programme is set on a distinctive and standardised framework 

which entails a pre-exchange and post-exchange section. 

Pre-exchange: 

Before embarking on an exchange, participants must reflect on the potential educational benefits. 

 

 

Learning objectives should be guided by the Visitor's own learning needs, respect their national vocational 

training curriculum and comply with the WONCA Definition of General Practice (6). Such educational goals 

need to be realistically achievable within the Educational Programme that the Host is able to offer and 

therefore shared and agreed on by both parties. 

Educational programme: Hippokrates exchanges are normally 2 weeks long. During this time the visitor will be 

introduced to many aspects of the local Primary Care system, mainly by shadowing all the host practice 

activities such as consultations, house visits, practice nurse clinics, and collaboration with other caregivers as 

well as special services. The exchange should ideally also entail visiting local Family Medicine training and 

research departments to meet and exchange views with homeland trainees. Where applicable, visitors will be 

encouraged to gain insight into local resources and quality improvement activities as well as local healthcare 

structures, such as the management of emergencies in primary care by attending an out-of-hours service run 

by GPs/FPs. 

Post-exchange: 

Once back home the participant is asked to reflect on the experience and the professional and personal gains. 

 

 

Learning outcomes: participants are requested to reconsider the original learning objectives and discuss with 

the host the overall outcomes of the international experience. 

Final report: The participants are requested to make a comparison between their own country and that of 

their destination, considering different aspects of primary care and GP/FM, including the contextual, 

attitudinal and scientific ones. All participants are also encouraged to strive to present and publish their 

experiences locally, nationally and internationally (7). 

Hippokrates in numbers 

Over the years, the programme has grown extensively, from an initial pilot phase of five participating countries, the 

Hippokrates Programme today counts an extended network of hundreds of host practices in 26 European countries. 

The numbers of participants and completed exchanges has also increased consistently from 13 in 2010 to 83 in 2013. 

Prospects 

Further research on the impact of exchange programmes during GP/FM vocational training is needed to determine the 

actual educational value and outcomes of international rotations. However, the potential contribution of such schemes 

targeting future European FDs/GPs not only for personal development of individual participants but also to a greater 

collective professional identity of our profession is undoubtedly substantial. The authors believe that the Hippokrates 

Programme has contributed considerably to the formation of the VdGM and consequently to the vitalisation of 

WONCA Europe. It has also been the inspiration for similar programmes of vocational exchange like the FM360 and 

thus has created resonance throughout the global GP/FM community. 

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Hippokrates is very much alive and all European trainees/GPs/FDs are encouraged to participate. 


 

 

 

 

In a world of international travel and migration, educational institutions have been acknowledging the need 

for the internationalization of school curricula and the promotion of educational exchanges. 

Hippokrates is an exchange programme for medical doctors specialising in GP/FM and junior GPs/FPs within 

five years of completing specialty training. 

The Hippokrates Exchange Programme offers a standardised framework that helps deliver structured 

professional development to new and future GPs/FPs through international exchanges. 

Benefits are numerous at many levels for all participants, trainees as well as GP/FD Hosts. 


http://www.woncaeurope.org/content/388-hippokrates-european-exchange-programme-medical-doctors-specializing-general 

References 

1. BALLATORE M, FEREDE MK. The Erasmus Programme in France, Italy and the United Kingdom: student mobility as a signal 

of distinction and privilege. Eur Educ Res J [Internet]. 2013 [cited 2015 Jan 21];12(4):525. Available from: 

http://www.scopus.com/inward/record.url?eid=2-s2.0-84890542873&partnerID=tZOtx3y1 

2. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: a call for cooperation and 

consortium. World J Surg [Internet]. 2011 Dec [cited 2015 Jan 21];35(12):2617–24. Available from: 

http://www.ncbi.nlm.nih.gov/pubmed/21989647 

3. Klemenc-Ketiš Z, Kersnik J. Importance of international networking in academic family medicine. Acta Med Acad 

[Internet]. 2014 Jan [cited 2015 Jan 21];43(1):63–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24893640 

4. Jha V, Mclean M, Gibbs TJ, Sandars J. Medical professionalism across cultures: A challenge for medicine and medical 

education. Med Teach [Internet]. Informa UK Ltd. London; 2014 Jul 30 [cited 2014 Dec 21];1–7. Available from: 

http://informahealthcare.com.ez.statsbiblioteket.dk:2048/doi/abs/10.3109/0142159X.2014.920492 

5. Rotar-Pavlič D. Erasmus exchange in the field of family medicine in Slovenia. Acta Med Acad [Internet]. 2012 Jan [cited 

2015 Jan 21];41(1):47–51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23311484 

6. The European Definition of General Practice/Family Medicine, Wonca Europe Edition 2011 - Available from: 

http://www.woncaeurope.org/sites/default/files/documents/Definition%203rd%20ed%202011%20with%20revised 

%20wonca%20tree.pdf. 

7. Willoughby H, Welsh V, Attridge M, Ramsay R. The Leonardo Grant: an opportunity to undertake a Hippokrates Exchange 

Programme. Br J Gen Pract [Internet]. 2012 Sep [cited 2015 Jan 21];62(602):486. Available from: 

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3426587&tool=pmcentrez&rendertype=abstract 

“To move, to breathe, to fly, to float, 

To gain all while you give, 

To roam the roads of lands remote, 

To travel is to live.” 

Hans Christian Andersen, The Fairy Tale of my Life: An Autobiography 

166


Hrvoje Tiljak, PhD, MD, GP 

tiljak@gmail.com 

54 – Am I a good doctor? Education about Quality Assurance in 

Family Medicine in Croatia 15 Years On 

Hrvoje Tiljak, PhD, MD, GP 

Associated Professor, 

Department for Family Medicine, 

University of Zagreb Medical 

School 

Co-authors 

Zlata Ožvaćić Adžić , Venija 

Cerovečki 

At the turn of the century, education on quality assurance (QA) in family medicine 

(FM) in Croatia was organized through several minor local projects. It was a time of 

primary health care (PHC) reorganization involving the privatisation of FM service. FDs 

who had worked in an already established network of FM teams were offered to run 

private practices as long as they remained under contract to the national health 

insurance fund (CHIF). This process was gradually introduced to eventually establish 

over 1000 privately run FM practices all over Croatia. During the process, several 

flaws appeared. One of the most prominent was the omission to define FM’s 

vocational education financing framework. This problem resulted in delays and a 

diminishing number of FDs vocational training posts lasting for longer than 5 year 

periods. 

Practising FM teams felt the need for additional education and under these 

circumstances, local educational projects started to expand in response. The “Am I a 

good doctor” educational programme for QA in FM was organized by local PHC 

centres supervised by experts from the Department of Family Medicine, University of 

Zagreb Medical School. The programme consisted of six to ten one-day workshops 

held monthly in the cities of Čakovec, Karlovac and Slavonski Brod. Topics of 

workshops were audit methodology, data gathering and registration, quality 

improvement options, malpractice prevention and sanction, etc. The programmes 

were well accepted by participating FDs and were certainly effective in raising 

awareness on the importance of QA in PHC. 

Many changes have occurred since then. The most significant positive movement was 

reanimation of the FDs vocational training framework. The national project 

“Harmonisation of Family Medicine according to EU standards through introduction 

of Family Medicine Specialization” was introduced in 2003. The project offered inservice 

and regular vocational training and attracted almost 300 FDs to join 

specialised educational programmes in the first two years of its existence. One part of 

the educational programme consisted of a theoretical course organized by the 

Department of Family Medicine, University of Zagreb Medical School. The content 

and format of this course has changed over the last 10 years, but it has become a 

permanent component of specialization in FM. Topics for QA were incorporated into 

this course and by this time, the specific subject “Improving quality in FP” had been 

introduced as one of the mandatory subjects for FD trainees within the educational 

programme offered at the University of Zagreb Medical School. Based on previous 

experience, the educational programme consisted of basic information on QA and 

practising audit and peer review. Each student had to perform an audit of his/her 

practice and present it to his peers. This format allowed practical training in QA 

procedures. Aside from this, it also offered a broad database of Croatian FDs’ practice 

due to the obligation of students to submit written audit reports. “Improving quality 

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in FP” was welcomed by trainees and resulted in the publication of many articles in national medical journals as well as 

two doctorate theses by FDs. 

The next positive step was to establish a National Agency for Accreditation and Quality in Health Care in 2007. The 

Agency defined quality indicators (QI) for FM offering a variety of indicators covering common chronic diseases and 

prevention procedures. QI promoted by the Agency were largely based on international standards rather than on 

experience and research results produced in Croatian FM. The Agency has not yet succeeded in establishing any kind 

of accreditation scheme for FM and therefore weak affirmation of the Agency still exists among Croatian FDs. 

Based on the mutual interest of FDs and the Croatian Health Insurance Fund (CHIF), a new movement was launched in 

2012. The CHIF substantially changed its contract with FM teams by the introduction of a combined remuneration 

system which included performance payment and stimulation for practice quality improvement. In this way, quality of 

care became rewarded or related to contract obligations and payment systems as laid out by the UEMO statement in 

2010. In the beginning, CHIF introduced Key Performance Indicators (KPI) and a ‘five-star practice scheme’ in an annual 

contract with FM teams. KPI comprised issues of “created care” resulting from the FD’s gate-keeping role: total 

prescription costs, sick-leave rate, referring rate etc. Five-star practice scheme comprised of the FDs’ service offer 

profile: electronic and telephone communication friendly approach, possibility of taking blood samples in practice etc. 

It was evident that both innovations in the CHIF contract were not main-stream of quality improvement in FM. KPI 

aimed for optimization of CHIF costs and five-star practice scheme did not go further than proposal – did not concern 

performance quality. In the 2013 contract, CHIF introduced Quality Indicators (QI) composed of well-known QIs in the 

British Quality and Outcome Framework (QOF). Newly introduced QI by CHIF consist of a target population and values 

for defined health problems as well as stimulus for target achievement. Health problems covered by QI are arterial 

hypertension, diabetes mellitus, COPD and cardiovascular prevention. This aside, CHIF also recognised peer-review as 

part of the quality improvement process in FM. Peer-review performed monthly in groups of not less than three FDs 

and related to specific patient problems can be registered in monthly reports and rewarded by CHIF. At the same time, 

such peer-review is awarded continuous medical education (CME) points within the accreditation scheme covered by 

CME. It is important to note that CHIF did not support FDs in performing any kind of CME activity until 2013 and such a 

movement represents a small but important step in promoting QA and CME in FM. 

Although the described process is not ideal, does not represent epic movements and needs refining, there are reasons 

to be satisfied when looking back on the last 15 years. In 2014, Croatian FM has a well-established structured 

education for QA as a mandatory subject in the specialization of FM, numerous QA activities throughout Croatia and 

the support of CHIF in performing QA activities and improving quality of PHC. Currently, Croatia is suffering from 

economic recession and achievements are expected to improve in the future. 


 

 

 

 

 

Family Doctors themselves feel a need for quality improvement. 

Family Doctors have a capacity to promote quality assurance. 

Basic educational package on quality of care is imperative for every FD early in their career. 

Quality assurance activities should be related to everyday work of FDs. 

Quality assurance activities should be rewarded and stimulated by health policy stakeholders. 


http://www.woncaeurope.org/content/am-i-good-doctor-teaching-qa-general-practice 

References 

1. Hebrang A, Henigsberg N, Erdeljic V, Foro S, Vidjak V, Grga A, Macek T. Privatization in the health care system of Croatia: 

effects on general practice accessibility. Health Policy Plan. 2003 Dec;18(4):421-8. 

2. Vrcić-Keglević M, Katić M, Tiljak H, Lazić D, Nekić VC, Petricek G, Ozvacić Z, Soldo D. [Specialization in family medicine--has 

all the planned been achieved?]. Acta Med Croatica. 2007 Feb;61(1):95-100. Croatian. 

3. Towards transparency on quality in general practice. UEMO statement UEMO document 2010/065 

http://www.uemo.eu/images/stories/publicdocs/2010-065Towardstransparencyonqualityofcareingeneralpractice.pdf 

4. National Institute for Health and Care Excellence. About the Quality and Outcomes Framework (QOF). 

https://www.nice.org.uk/proxy/?sourceUrl=http%3A%2F%2Fwww.nice.org.uk%2Faboutnice%2Fqof%2Fqof.jsp) 

5. Tiljak H, Đaković S, Katić M, Ožvačić-Adžić Z. [Quality Indicators in Family Medicine – comparison between United Kingdom 

168


and Croatia] Medix 2011; 94/94: 241-254.Croatian 

6. Hrvatska agencija za kvalitetu i akreditaciju u zdravstvu i socijalnoj skrbi. O agenciji. [Croatian Agency for accreditation and Quality in Health and Social 

Care] http://aaz.hr/o-agenciji 

7. HZZO vodič kroz ponudu novog modela prihodovanja PZZ OM. [CHIF guide for new contract model in PHC- Family Medicine] 

http://www.hzzo.hr/wp-content/uploads/2014/01/HZZO_Vodic_kroz_ponudu_NM_za_OM_v31012013.pdf 

169


Marjukka Mäkelä, MD, PhD, MSc. 

marjukka.makela@thl.fi 

55 – Evidence-based Primary Care Through Guidelines 

Marjukka Mäkelä, MD, PhD, 

MSc. 

Research Professor, Finnish 

Office for HTA (FINOHTA) at THL 

(National Institute for Health and 

Welfare) 

Helsinki, Finland 

Co-authors 

Jukkapekka Jousimaa, MD, PhD, 

and Ilkka Kunnamo, MD, PhD 

Sound knowledge about effectiveness and safety of diagnostic and treatment 

methods should form the basis of decisions in all health care. Finding such knowledge 

is particularly challenging for doctors in primary care, because they treat people of all 

age groups and with any illness. Guidelines can answer their information needs if they 

are appropriate to their working environment, easy to access and use, and up to date. 

Modern guidelines can also provide reminders and active decision support. Here, we 

describe the national guideline structure and their use in Finland as an example. 

Guideline quality 

High-quality guidelines are produced in a systematic and transparent manner. This 

means that best available evidence is searched for, evaluated and synthesized. 

Guidelines should be produced by content experts and presented clearly in a userfriendly 

format (1). With the AGREE instrument, guideline developers and users can 

assess the methodological quality of guidelines (2). 

Not all well-produced guidelines, however, are useful in primary care. Those written 

by subspecialists may focus on patients in secondary care – a selected group – and 

may be irrelevant or misleading if applied to patients in primary health care. Not only 

are our patients different from those referred to hospitals; we also have different 

diagnostic and treatment resources. 

Recommendations in quality guidelines are often based on systematic reviews of 

trials, most of which study patients with a single disease. FDs see patients who often 

have several diseases and key decisions may affect more than one of these. We apply 

the evidence while discussing with each patient what their own preferences are. 

General practitioners may need to check several guidelines in one consultation. The 

necessary information must be found quickly and in a clear format: How helpful is this 

treatment for these patients in achieving better health outcomes? 

Best guidelines also offer links to supporting material, such as pictures, flow charts, 

references, evidence summaries, and materials for patients. The level of evidence and 

strength of recommendations is presented clearly and in a methodical fashion: Is this 

information likely to change with new research or not? 

Using guidelines 

Bringing guidelines to practice is a challenge. Doctors’ habits change slowly and only 

to a small extent. Grimshaw and colleagues have reviewed the effects of guideline 

implementation strategies (3) and found improvements in performance from 6 % 

when using multifaceted interventions to 14 % for reminders. 

Likewise, the MIKSTRA project in Finland produced evidence-based guidelines for six 

common infections and implemented these in a randomized trial (4). Patient versions 

of guidelines were edited and distributed. Primary care units received training and other support to change their care 

170


pathways toward more evidence-based practices. The use of diagnostic tools became somewhat more systematic, and 

antibacterial prescriptions were 2 – 16 % better targeted. The study demonstrated that not only doctors but also 

patients need to change their attitudes regarding drug prescriptions. 

For the busy general practitioner, the threshold for looking up information during a consultation is quite high. If 

guidelines are available in a compact source, covering many diseases, the task becomes easier. Guideline collections 

are preferable to single guidelines. Searching medical databases or googling for an answer to a patient problem during 

consultation is seldom feasible. 

When a guideline collection for general practitioners was introduced in Finland, we studied how our colleagues 

consulted these guidelines (5). They made at best up to ten searches and on average three searches each working day, 

and found sufficient information in 71% of the searches. Another study found that general practitioners’ compliance 

with guidelines was high: over 80% for use of laboratory, radiology, physical examinations, and referrals (6). 

Any guideline starts getting outdated the minute it’s published. Users should know how well guideline producers are 

able to keep the guidelines up-to-date. Medical Society Duodecim houses the national guideline organization in 

Finland, providing a stable framework for guideline production. This includes regular updates every two or three years: 

new searches are made on key questions in the guidelines and authors evaluate new publications, updating the 

information. If important new information (e.g. on new side effects of treatments) appear between regular updates, a 

partial rapid addition can be included in the guidelines. 

Next step: Decision support 

Good guideline collections are useful, but even better support is on its way. Linking guideline information to actual 

patient data can be used to create clever systems that provide guidance without request. Electronic decision support 

brings evidence into practice by means of context-sensitive guidance at the point of care. The national guidelines in 

Finland were used as the basis for creating a set of evidence-based, patient-specific reminders for 59 different health 

conditions embedded into the Electronic Patient Record (EPR) system (7). These reminders were shown to healthcare 

professionals when they opened and used the EPR during consultation. Typically, a reminder suggested timely action 

(e.g. “Long-term glucocorticoids—add calcium and vitamin D?”) or gave a warning (e.g. “Serum potassium is 

dangerously out of range”). In addition, links to guidelines were shown in accordance with the patient’s diagnosis list, 

and drug alerts were triggered on prescribing a medication that for example created a risk for interaction with existing 

medication. 

The trial in primary care included more than 13000 patients randomized to trigger or not to trigger reminders during 

consultations (7). We had expected the number of reminders to decrease over one year, however, both in the 

intervention and control group, numbers of reminders increased. One possible explanation is that recording of disease 

codes improved during the trial. Implementing computer-based decision support is still problematic, but it is possible 

to build such systems based on sound guidelines. In this way, guidelines can fulfil their aim of improving quality of care 

and, ultimately, improving health (8). 

Take-home messages 

 

 

 

 

 

Evidence based guidelines are essential for high quality primary care. 

Guideline collections are preferable to single guidelines. 

Patient versions of guidelines should be produced alongside full professional versions. 

Guidelines do not make decisions; patients and doctors decide together. 

Linking guideline recommendations to individual patient data can make GPs’ work easier in the future. 


http://www.woncaeurope.org/content/37-evidence-based-primary-care-through-guidelines 

References 

1. The AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of 

clinical practice guidelines: the AGREE project. Qual Saf Health Care 2003;12:18–23. 

2. Brouwers M, Kho ME, Browman GP, Cluzeau F, feder G, Fervers B, Hanna S, Makarski J on behalf of the AGREE Next Steps 

171


Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J. Dec 

2010, 182:E839-842; doi: 10.1503/cmaj.090449. http://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II- 

Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf , accessed 4.11.2014. 

3. Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, Vale L. Toward evidence-based quality improvement. 

Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998. 

Gen Intern Med. 2006 Feb;21 Suppl 2:S14-20. 

4. Rautakorpi U, Nyberg S, Honkanen P, Klaukka T, Liira H, Mäkelä M et al. Management of Infection Patients in health 

Centres. Final Report of the MIKSTRA programme. THL Report 36/2010. THL (National Institute for Health and Welfare), 

Yliopistopaino, Helsinki 2010. Available at http://www.thl.fi/thl-client/pdfs/564bad56-e25c-46af-b178-fa0b7e3642da , 

accessed 4.11.2014. 

5. Jousimaa J, Kunnamo I, Mäkelä M. Physicians' patterns of using a computerized collection of guidelines for primary care. 

Int J Technol Assess Health Care. 1998;14:484-93. 

6. Jousimaa J, Mäkelä M, Kunnamo I, MacLennan G, Grimshaw JM. Primary care guidelines on consultation practices: the 

effectiveness of computerized versus paper-based versions. A cluster randomized controlled trial among newly qualified 

primary care physicians. Int J Technol Assess Health Care 2002;18:586-96. 

7. Kortteisto T, Raitanen J, Komulainen J, Kunnamo I, Mäkelä M, Rissanen P, Kaila M for the EBMeDS (Evidence-Based 

Medicine electronic Decision Support) Study Group. Patient-specific computer-based decision support in primary 

healthcare--a randomized trial. Implement Sci 2014 Jan 20;9:15. 

8. Burgers J. Quality of clinical practice guidelines. Dissertation, Universities of Nijmegen and Maastricht. Ponsen & Looijen, 

Wageningen 2002. 

172


Christos Lionis, MD, PhD 

lionis@galinos.med.uoc.gr 

56 – Developing Skills for the Developed World 

Christos Lionis, MD, PhD, 

HonFRCGP 

Professor of General Practice 

and Primary Health Care 

Head of Clinic of Social and 


Faculty of Medicine 

University of Crete, Greece 

Co-authors 

C. Lamprinea, Ε. Symvoulakis, A. 

Saridaki, C. Vardavas 

Undoubtedly, technological advances have improved health outcomes and quality of 

life. On the other hand, lifestyles have been significantly altered by this developing 

era. The purpose of this opinion piece is to identify potentials and skills, especially 

within family medicine that more traditional societies in the developed world use. 

Thus, it will be interesting to observe how primary health care physicians cope and 

manage to overcome obstacles and challenges encountered due to either the slow 

pace of or no development in isolated rural areas around the world, where certain 

hidden secrets may still prevail. 

Life expectancy has increased in industrialized countries mostly as a result of 

reduction in childhood mortality and improved medical treatment, due to advances in 

medicine. Developing regions have poorer mortality rates due to limited biomedical 

and technological resources, although they may have skills and remedies to offer in 

complementary and alternative medicine through services provided by traditional 

practitioners and healers. Transcultural health care or indigenous healthcare may 

include, among others; acupuncture, herbal medicine, homoeopathy, yoga, 

meditation exercise training, and music and art therapy. It is always challenging to test 

alternative remedies within primary care in order to more flexibly manage several 

medical conditions such as chronic health problems, cardiovascular, respiratory, 

allergies, infections and other disorders. 

Another approach is the concept of religiosity and spirituality that may also offer 

efficient ways for handling patients’ problems, since they are well-integrated in the 

cultural identity of the world communities and can act as preventive or ‘healing’ 

mechanisms against a range of health problems. The appropriate use of indigenous 

knowledge available in traditional societies may also be a major source for developing 

natural products in improving health and curing illnesses. An example of the 

traditional ‘secret’ that has diminished in the fast pace modern world and can prolong 

life expectancy with higher quality of life is the so-called midday nap (siesta), and the 

well-known Mediterranean diet. 

Due to the geographic isolation, emergency cases and workforce shortages, general 

practitioners serving rural and remote areas are often called upon to maintain a 

greater variety of skills, to provide a more integrated and patient-centred care 

approach for conditions due to limited resources. On the other hand, general 

practitioners serving urban areas often perform more advanced duties in improved 

conditions with regard to available facilities and special resources. Learning the 

indigenous healthcare practices is also an essential resource at the hands of GPs that 

it is expected to enhance their capacity in promoting self-management. 

Another useful primary care practice ‘tool’ adapted by GPs in underdeveloped regions 

that is lacking in the developed world is their comprehensive role with the family and 

community caregivers, as their orientation towards the patient in the context of the 

family and local community may enhance their health outcomes. The role of family 

support in decision making and in caring in a more traditional structure, may be critical to manage different illnesses as 

173


it promotes compassion and the sense of belonging. The involvement of the family in the decision-making process is 

also critical since such processes take into consideration not only the family’s socio-cultural values but also the family 

roles and dynamics in the process of delivering a more holistic approach towards the patient. 

Among special qualities that seem to have almost diminished in urban settings and developed societies is the cultural 

difference of the social interactions. Interpersonal relationships shaped within rural areas are more enduring and they 

are based on loyalty, not only to friends and relatives, but to the community and its members. On the contrary, 

relationships in urban settings are usually based on self-interest as they are forged in extremely competitive 

environments. Furthermore, social roles and function in rural settings are more likely to be connected to traditional 

and religious beliefs. 

All these cultural habits influence GPs while also illuminating another great asset that can be of use in regions under 

development and that is the value of compassion, meaning the awareness of someone else's suffering and the will, 

effort and action to help and relieve it. Compassion is the fundamental element of the bond connecting a family 

especially in rural areas as urbanization and excessive technological development have altered the structures of the 

traditional pattern of families resulting in the loss of compassion and cohesion. Compassion in treatment served in 

rural and remote primary health care can strengthen the doctor-patient relationship, increasing trust, confidence and 

effectiveness, when traditional and cultural aspects or beliefs of health are taken into account. With this in mind, a 

recently published systematic review provides initial support for the discussion that doctors’ empathy can be enhanced 

through targeted interventions. 


 

 

 

Developing societies can contribute to find effective solutions of health care for the developed world 

communities combining the ‘wisdom’ from the first and the scientific knowledge from the second. 

Community-based interventions and innovative strategies with regard to the socio-cultural differences 

mentioned could prove helpful in managing developed-society healthcare challenges. 

All lost 'ingredients’ found in a complex web of social relations, cultural history and socio-political networks of 

the developing world, helping a general practitioner overcome barriers in the delivery of health care, should 

be revived and integrated into the modern primary health care services, especially now that society and 

humanity has to overcome many crises and challenges. 

Globalization always claims service cost reduction and communication flexibility. By learning the 'secrets' that 

have been embedded in underdeveloped societies, we can test and build additional skills for GPs with the aim 

of investing more efforts in the health and happiness of the people that they serve. 


http://www.woncaeurope.org/content/14-namibia-shetland-developing-skills-developed-world 

References 

P. Carrera-Bastos, M. Fontes-Villalba, J. H O’Keefe et al. The western diet and lifestyle and diseases of civilization, Research 

Reports in Clinical Cardiology 2011 1:2 15-35. 

Anyfantakis, E. K. Symvoulakis, D. B. Panagiotakos et al. Impact of religiosity/spirituality on biological and preclinical 

markers related to cardiovascular disease. Results from the SPILI III study. Hormones 2013; 12(3):386-396. 

D.B. Panagiotakos, C. Chryshohoou, G. Siasos et al. Sociodemographic and Lifestyle Statistics of Oldest Old People (>80 

Years) Living in Ikaria Island: The Ikaria Study, Cardiology Research and Practice 2011; 

RM. Glazebrook, SL. Harrison Obstacles and solutions to maintenance of advanced procedural skills for rural and remote 

medical practitioners in Australia. Rural and Remote Health 2006; 6: 502. 

R. Strasser. Rural health around the world: challenges and solutions Family Practice 2003; 20:4. 

S. Shea, C. Lionis Restoring humanity in health care through the art of compassion: an issue for the teaching and research 

agenda in rural health care. Rural Remote Health. 2010; 10(4):1679 . 

Z. Kelm, J. Worner, JK. Walter et al. Interventions to cultivate physician empathy: a systematic review. BMC Medical 

Education 2014; 14:219. 

S.B Syed, V. Dadwal, P. Rutter et al. Developed-developing country partnerships: Benefits to developed countries? 

Globalization and Health 2012; 8:17. 

174


C.F. Stolper, MD, PhD 

cf.stolper@maastrichtuniversity.nl 

57 – Gut Feelings as a Guide in the Diagnostic Reasoning of GPs 

C.F. Stolper, MD, PhD 

Department of Family Practice, 

Maastricht, the Netherlands. 

University of Antwerp, Faculty of 

Medicine and Health Sciences, 


Interdisciplinary Care, Belgium. 

Co-author 


Introduction 

General practitioners (GPs) all over Europe sometimes experience the feeling that 

something is wrong with a patient during a consultation, although they do not know 

exactly what(1, 2). This so-called ‘sense of alarm’ is a feeling of sudden heightened 

awareness alerting a GP and causing them to worry about the patient’s health status. 

It is often accompanied by physical sensations in the abdomen (hence ‘gut feelings’) 

or the heart. Remarkably, the decisions of Dutch medical disciplinary tribunals 

indicate that the timely manifestation of this sense of alarm should be part of the 

professional standard for doctors(3). However, in the era of evidence based medicine 

(EBM), gut feelings sound slightly old-fashioned, and the question may arise as to how 

much gut feelings really contribute to a GP’s decision making process. Ten years ago, 

an international group of GP-researchers started a study on the topic. This chapter 

reports on their findings. 

COGITA European Network 

Focus Groups and a Delphi Consensus Procedure 

We explored the meaning and significance that GPs attach to gut feelings using a 

focus group method. Most of the participating GPs considered gut feelings to be a 

valuable instrument that they could rely on (4). They emphasized that besides the 

sense of alarm, the sense of reassurance also played a substantial role in general 

practice, i.e. when a GP is sure about the prognosis and therapy, even in the absence 

of a definitive diagnosis. The basis of gut feelings is a GP’s knowledge, including 

medical knowledge, experiential knowledge and contextual knowledge, the latter 

defined as everything a GP knows about the patient apart from the symptoms and 

signs. Various determinants influence the process of arousing gut feelings, such as the 

doctor’s personality, factors that fit the general picture, alerting triggers and 

interfering factors. 

In order to find valid definitions of gut feelings, we conducted a Delphi consensus 

procedure and achieved consensus on precise descriptions of the sense of alarm and 

sense of reassurance(5) (See Text box 1). 

Gut Feelings Questionnaire 

Based on the consensus statements, we then composed a short questionnaire to 

determine the presence of gut feelings in the context of GPs’ diagnostic reasoning. 

The gut feelings questionnaire (GFQ) was validated after a construct validation 

procedure(6). Consequently, we are now able to study the diagnostic value of gut 

feelings. We produced a linguistically validated English-language version, and the GFQ 

is now also available in French, Polish and German. 

175


The European General Practice Research Network (EGPRN) gave us the opportunity to present the results of our study 

at several conferences, which led to the establishment of a network of FD researchers interested in the topic, called 

COGITA (www.gutfeelingsingeneralpractice.eu). Its aim is to share research findings and to prepare proposals for crossborder 

research projects. At yearly meetings, European researchers discuss research findings and advise on the 

implementation of new studies. A glossary of diagnostic reasoning terms related to the topic of our research was 

composed by the group and published on the COGITA website. 

1. Statement 1: A ‘sense of alarm’ means that a GP perceives an uneasy feeling as he/she is 

concerned about a possible adverse outcome. 

2. Statement 2: A ‘sense of alarm’ implies that a GP worries about a patient’s health status, 

even though he/she has found no specific indications yet; it is a sense of ‘there’s something 

wrong here’. 

3. Statement 3: A ‘sense of alarm’ activates the diagnostic process by stimulating a GP to 

formulate and weigh up working hypotheses that might involve a serious outcome. 

4. Statement 4: A ‘sense of alarm’ means that, if possible, the GP needs to initiate specific 

management to prevent serious health problems 

5. Statement 5: A ‘sense of alarm’ will decrease as the diagnosis and the right management 

become clearer. 

6. Statement 6: A ‘sense of reassurance’ means that a GP feels secure about the further 

management and course of a patient’s problem, even though he/she may not be certain 

about the diagnosis: everything fits in. 

7. Statement 7: The ‘sense of reassurance’ and the ‘sense of alarm’ constitute a dynamic 

element in a GP’s diagnostic process. 

Theoretical Framing 

Text box 1. Consensus statements 

To explain how gut feelings arise and function in GPs’ diagnostic reasoning, we reviewed the literature from medical, 

psychological and neuroscientific perspectives(7). Gut feelings are based on the interaction between patient 

information and a GP’s knowledge and experience. We visualized this in a knowledge-based model integrating the two 

well-known reasoning tracks of medical decision-making and medical problem-solving, adding gut feelings as a third 

track. (See Figure 1) These three tracks fit well in dual-process theories, where analytical and non-analytical reasoning 

continually interact as two modes of knowing and thinking. The interaction enables GPs to use elements of all three 

tracks, depending on the task and situation. The role of affect as a heuristic within the physician’s knowledge network 

explains how gut feelings may support GPs in navigating efficiently in often complex and uncertain diagnostic 

situations. 

Skilled Intuition 

Intuitive thoughts come to mind without apparent effort but their value is the topic of many scientific debates(8). 

Some researchers showed that intuitive judgements based on simplifying heuristics are often flawed. Others believe 

that intuition defined as the process of pattern recognition is trustworthy in some domains such as nursing, medicine, 

fire-fighting and accountancy. It is based on experience that recognises valid cues. E.g. medicine provides a highvalidity 

environment where cues are stable and regular and can rather easily be recognized. In such domains prolonged 

practice and rapid feedback may enable students to develop a so-called skilled intuition which can be trusted. Gut 

feelings are based on skilled intuition and form a substantial part of the diagnostic reasoning process. 

176


Evidence Based Medicine 

Figure 1. Knowledge-based model of GPs' diagnostic reasoning. 

Although evidence and skilled intuition may sometimes appear as irreconcilable opposites, the combination fits in very 

well with the EBM concept that is based on the integration of scientific knowledge, patients’ preferences and 

physicians’ expertise and skills. Doctors have to weigh up these three elements in their decision-making process, but it 

is remarkable that the literature offers no studies on how this integration process must be achieved or taught. 

Future 

We may conclude that the gut feelings concept exists and that they substantially contribute to GPs’ diagnostic 

reasoning process. In the future, we will study them in greater depth, i.e. by investigating the predictive value of gut 

feelings, the influence of the determinants of experience and contextual knowledge, and the significance of gut 

feelings in the learning process for diagnostic reasoning in workplace settings. We welcome any researchers who 

would like to participate in our research. 

For more information and contact please visit www.gutfeelingsingeneralpractice.eu . 


 

 

 

 

 

Gut feelings , i.e. a sense of alarm and a sense of reassurance, play a substantial role in the diagnostic 

reasoning of general practitioners. 

The sense of alarm stimulates a GP to formulate and weigh up working hypotheses that might involve a 

serious outcome. 

The sense of reassurance means that a GP feels secure about the further management and course of a 

patient’s problem, even though he/she may not be certain about the diagnosis. 

Gut feelings can be considered a third track in general practitioners’ diagnostic reasoning next to medical 

decision-making and medical problem-solving. 

Gut feelings are a kind of skilled intuition and fit well in EBM. 

177



http://www.woncaeurope.org/content/ws-061-gut-feelings-guide-diagnostic-reasoning-gps 

References 

1. Stolper CF, Van Royen P, Dinant GJ. The 'sense of alarm' ('gut feeling') in clinical practice. A survey among European 

general practitioners on recognition and expression. Eur J Gen Pract. 2010(2):72-4. 

2. Le Reste JY, Coppens M, Barais M, Nabbe P, Le FB, Chiron B, et al. The transculturality of 'gut feelings'. Results from a 

French Delphi consensus survey. Eur J Gen Pract. 2013;19:237-43. 

3. Stolper CF, Legemaate J, Dinant GJ. How do disciplinary tribunals judge the 'gut feelings' of doctors? An analysis of Dutch 

tribunal decisions 2000-2008. J Law and Medicine. 2010;18(1):68-75. 

4. Stolper CF, Van Bokhoven MA, Houben PHH, Van Royen P, Van de Wiel MWJ, Van der Weijden T, et al. The diagnostic role 

of gut feelings in general practice. A focus group study of the concept and its determinants. BMC Fam Pract. 2009;10(17). 

5. Stolper CF, Van Royen P, Van Bokhoven MA, Houben PHH, Van de Wiel MWJ, Van der Weijden T, et al. Consensus on gut 

feelings in general practice. BMC Family Practice 2009, 10:66. 2009. 

6. Stolper CF, Van de Wiel MWJ, De Vet HCW, Rutten ALB, Van Royen P, Van Bokhoven MA, et al. Family physicians' diagnostic 

gut feelings are measurable: validation of a questionnaire. BMC Family Practice. 2013;14(1). 

7. Stolper CF, Van de Wiel MWJ, Van Royen P, Van Bokhoven MA, Van der Weijden T, Dinant GJ. Gut feelings as a third track in 

general practitioners' diagnostic reasoning. J Gen Intern Med. 2011;26(2):197-203. 

8. Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009;64(6):515-26. 

178


Pablo Blasco, MD, PhD, FACP 

pablogb@sobramfa.com.br 

58 – Family Medicine Miles Programme: Getting Students 

Involved Where There is No Family Medicine in Medical School 

Pablo González Blasco, MD, PhD 

Scientific Director at SOBRAMFA. 

- (Brazilian Society of Family 

Medicine) 

São Paulo, SP. Brazil 

Co-authors 

Graziela Moreto, MD 

Marcelo R. Levites, MD 

Marco Aurelio Janaudis, MD, 

PhD 

Brazilian Background on Family Medicine. 

Since 1988, Brazil’s public health system has tried to build a national health system 

that responds to the needs and expectations of Brazil’s population. In 1994, the 

government created the Family Health Programme to help carry out this goal. 

However, the shortage of family physicians in Brazil—the central figures of this 

programme—limits the programme’s effectiveness. 

The lack of family physicians can be traced primarily to the medical schools in which 

medical training favours specialists and discourages generalists. Medical students 

seldom have family physicians acting as role models. If the academic knowledge of 

primary care is absent as a model in the undergraduate curriculum it will be difficult 

to promote family doctors among the students and to encourage them to choose 

family medicine as their future career (1,2,3). 

SOBRAMFA Working with Medical Students 

In 1992, a group of physicians (most of them specialist and some faculty from medical 

schools), inspired by other countries’ associations of family medicine teachers, 

founded SOBRAMFA- Brazilian Society for Family Medicine, in São Paulo, Brazil. 

SOBRAMFA is an academic society established with the purpose of promoting the 

humanistic dimensions of doctoring and establishing the proper basis and scientific 

methodology for family medicine. 

SOBRAMFA has developed a variety of initiatives involving more than 4,000 medical 

students in family medicine over the last 22 years. Thus: 1) The Annual Family 

Medicine Academic Meeting (up to the 18th). 2) Family Medicine Interested Groups 

3) The Family Medicine Day bringing students from several medical schools along to 

share educational experiences. 4) The Young Doctor Monthly Meetings, where an 

innovative learning model is set (student-teaching-student) as continuous medical 

education course. 5 ) Participation in International Meetings and Conferences(STFM- 

Society of Teachers of Family Medicine Conferences and WONCA) where students 

present their academic work. 

Students´ interest in family medicine has been increasing over these years through a 

continuous preparation process of a non-curricular nature, as a result of the 

realisation that they need these values to become better doctors. Besides seeing 

family medicine as their future specialty choice, family medicine provides students 

with tools to improve doctoring (4). 

The Mini Fellowship in FM (MF2) and the Family Medicine Miles Programme 

179


One of the most effective family practice exposures for medical students occurs in the Mini-Fellowship in Family 

Medicine (MF2) programme; an elective clerkship over one to two weeks (40 or 80 hours). Students see patients under 

supervision of SOBRAMFA’s faculty and residents in a broad range of family doctors’ private practices. 

The MF2 started in 2004 and to date, 162 students from 46 different medical schools have participated in the 

programme. Students learn how to develop communication skills understanding the whole person and the family 

context; they also learn about continuity of care, solving complicated problems with inpatients, dealing with other 

physicians and facilitating health professional teams in order to provide better care. Finally, they address selfknowledge 

as a surprising outcome of the programme. The students gain respect for the specialty and spread this 

“discovery” to their colleagues. 

The Family Medicine Miles Programme (5) was created to measure students´ participation in SOBRAMFA activities and 

in which students are rewarded with grades (miles). The Miles Programme allows an individual assessment of each 

student, offers balance between theory and practice, provides tutorial guides, and fosters leadership among the 

students. This “continuous medical education programme” fosters students´ interest in family medicine, and 

encourages those who will be able to apply for the residency programme currently under development by SOBRAMFA. 

The Family Medicine Miles Programme is managed by the SOBRAMFA web site, and students can track their own 

performance, as well as monitor specific guidance in order to improve their training. 

Training Young Doctors through the Pacemaker Agenda 

There is a growing diversity of opportunities for family doctors in private practice supported by Insurance Health 

Companies in São Paulo, Brazil. Patient’s satisfaction, problem-solving while keeping costs low are the real basket of 

services companies ask for. The practising scenarios in private practice include: Geriatric Care, Managing Complicated 

Patients with co-morbidities in Hospitals, Palliative Care, Family Medicine Clinics and Ambulatory, Home Visits, Nursing 

homes and Hospices. 

For a proper training of young doctors in such variety of practices, in a city with a population of 14 million people (São 

Paulo), SOBRAMFA has developed an innovative agenda in which several components are incorporated for pursuing 

excellence and expanding opportunities. This Agenda, required for all trainees and faculty members, has been ongoing 

for more than a decade and includes: 

1. Scientific “pacemaker” - Weekly Scientific Meeting. A two-hour meeting. Case-based discussion, update with 

articles from the most relevant publications, case-decisions for specific patients supported by Evidence Based 

Medicine. 

2. Construction “pacemaker”- Monthly Meeting, conducted as workshops and to include topics to promote 

reflective practice: professionalism, medical education, humanism, family medicine core values, personal 

development, teamwork, and leadership. 

3. Cultural monthly Meetings - at dinner time and displayed as a familiar get-together and targeting an openmind 

scenario, with acknowledged leaders in several fields (Philosophers, Journalists, Educators, Lawyers, 

Artist and Musicians, Entrepreneurs). 

4. Young Doctor Monthly Meeting- case-based discussions lead by medical students and young doctors acting as 

facilitators, fine-tuning their teaching skills. 

5. Mentoring and Evaluation- trainees are evaluated and giving feedback by their respective preceptors. 

The Main Outcomes of the Pacemaker Agenda Are: 

1. Effective Training- Clinical Competence - Trainees develop expertise in doctoring, skills in managing 

complicated patients and leading health teams. 

2. Mastering Communication with patients, families and their peers. 

3. Respect, Credibility and Happiness - They are recognized as good physicians by the patients they are caring 

for, by their peers in the clinical setting, and by the owners of the Insurance Companies. 


180


 

 

 

 

Family doctors as role models in the academic undergraduate curriculum are needed to promote FM among 

medical students. 

Students exposed to the real practice of a family doctor realize they need family medicine core values to 

improve their future doctoring. 

The Mini Fellowship in FM (MF2) and the Family Medicine Miles Programme are two successful initiatives 

which involve medical students in family medicine through a non-curricular process, allowing for concurrent 

involvement for students from different medical schools.. 

The Pacemaker agenda is set for training young family doctors for the wide basket of services and the growing 

diversity of opportunities in private practice. 


http://www.woncaeurope.org/content/3434-family-medicine-miles-program-getting-students-involved-where-there-no-familymedicine 

References 

1. Freeman J, Kelly P, Blasco PG, Levites MR. Attitudes about Family Medicine among Brazilian medical students. O Mundo 

da saúde. 2010;34(3): 336-340. 

2. Blasco, PG; Rodnick, JE. Family Medicine in Brazil: Establishing the Specialty. Family Medicine. 2005, 37(9): 668-668 

3. Blasco, PG; Levites, MR; Freeman, J; Haq, C. Educating Physicians for the Health of Brazil: The Role of Family Medicine. 

Wonca News.2004, 30( 3): 13-15. 

4. Blasco, PG; Roncoletta AFT; Moreto, G; Benedetto, MAC; Levites, MR; Janaudis MA. SOBRAMFA has promoted family 

medicine education in Brazil since 1992. Medical Education. 2008, 42:115. 

5. Blasco, PG; Levites, MR; Janaudis, MA; Moreto, G; Roncoletta, AFT; Benedetto, MA. ; Pinhero, TRP. Family Medicine 

Education in Brazil: Challenges, Opportunities, and innovations. Academic Medicine, 2008. 83(7): 684-689 

6. Blasco, PG; Roncoletta AFT; Moreto G; Levites, MR; Janaudis MA. Accompanying Physicians in Their Family Practice: A 

Primary Care Model for Medical Students’ Learning in Brazil. Family Medicine.2006, 38(9): 619-621. 

7. Janaudis MA, Levites MR, Roncoletta AFT, Garcia DSO, Moreto G, Benedetto MAC, Pinheiro TRP, Blasco PG. Academic 

Family Medicine in Brazil. GP-Miles: the Brazilian approach to make medical students enthusiastic for Family Medicine. 

Primary Care. 2009. v.9, p.280 – 281. 

181


Carl Llor, MD 

carles.llor@gmail.com 

59 – Improving the Prescribing of Antimicrobial Drugs in Primary 

Health Care: the Effect of Being Members of a Scientific Society 

Carl Llor, MD 

Catalan Society of Family 


Co-authors 

Ana Moragas, Josep M. Cots, 

Silvia Hernández, Carolina 

Bayona 

Introduction 

Unnecessary use of antibiotics plays an important role in increasing bacterial 

resistance and medical costs as well as in the risk of drug-related adverse events [1]. 

The most frequent indication for antibiotic prescription in Europe is respiratory tract 

infections (RTI) [2]. Clinical signs and symptoms are unreliable for distinguishing viral 

from bacterial RTI [3]. Diagnostic uncertainty increases the likelihood of inappropriate 

antibiotic prescription and, when in doubt, general practitioners (GP) opt for 

antibiotic prescription. Compared to other European countries, Spain has historically 

had a high outpatient antimicrobial consumption rate [4]. We presented an abstract 

in WONCA 2000 aimed at knowing if GPs who are members of task force groups on 

the rational use of antibiotics prescribe antibiotics more appropriately than GPs who 

are not involved in these study groups. The overall consumption of antibacterial drugs 

in 1997 was lower among the six GPs who were members of a task force compared 

with the mean prescription of all the GPs in Catalonia (10.1 DID vs. 14.8 DID, 

respectively). In addition, the former GPs prescribed more penicillins and fewer 

macrolides and quinolones than their counterparts. A prospective non-randomised 

controlled before-after study was performed in primary care clinics in 2008 and 2009. 

This study constituted part of the Happy Audit project, a study financed by the 

European Commission [5]. A total of 281 FDs throughout Spain participated in this 

study, with the inclusion of FDs in nine Autonomous Communities. Some of these GPs 

were members of study groups on the rational use of antibiotics in each of these 

areas, belonging to the Societies of Family Medicine. We wished to know if the 

antibiotic prescription of these GPs significantly varies from the remaining GPs in 

terms of the total amount of antibiotics prescribed for RTIs and the type of antibiotics 

used. 

Methods 

All the participants were instructed to fill out a template with all the patients with 

RTIs during a 3-week period in the winter months of 2008 (first registry) and 2009 

after the intervention (second registry), covering a total of 15 working days in both 

periods. On this sheet the physician attending the patient noted different specific 

parameters of medical care, including the age and gender of the patient, the number 

of days of symptoms, presenting signs, diagnosis, performance of chest X-ray, rapid 

antigen detection tests (RADT) and C-reactive protein (CRP), and antibiotic treatment 

or not. The intervention consisted of discussion sessions of the results of the first 

registry, courses for GPs, guidelines, patient information leaflets, workshops on RADT 

and CRP and use of both rapid tests. A descriptive statistical analysis was performed 

and significant differences were considered if the p value was


Results 

Out of the 281 GPs, 42 were members of study groups on the rational use of antibiotics (14.9%). As shown in the table, 

the percentage of antibiotic prescribing was lower among the members of these groups than in the remaining GPs 

before the intervention (25.2% vs. 28.2%; p


the inclusion of GPs in taskforces that promote a more rational use of antibiotics. The fact that these GPs are more 

motivated to prescribe fewer antibiotics than other GPs seems logical since they are more aware of the threat of 

antimicrobial resistance. 

Take-Home Messages 

 

 

 

 

 

GPs involved in study groups on the rational use of antibiotics are more aware of antimicrobial resistance. 

These primary care physicians prescribe fewer antibiotics and use more narrow-spectrum antibacterials than 

GPs not particularly interested in the rational use of antibiotics. 

These clinicians also use more rapid tests that can help GPs to better distinguish viral from the bacterial 

respiratory tract infections. 

An intervention aimed at promoting more prudent use of antibiotics for respiratory tract infections is able to 

improve the prescribing of antibiotics. 

However, strategies to improve the use of antibiotics seem to be less effective among GPs involved in study 

groups than in the general population of primary care physicians, mainly because the baseline prescription of 

antibiotics is much lower. 


http://www.woncaeurope.org/content/133-improving-prescribing-antimicrobial-drugs-primary-health-care 

References 

1. Michael CA, Dominey-Howes D, Labbate M. The antimicrobial resistance crisis: causes, consequences, and management. 

Front Public Health 2014;2:145. 

2. Mizgerd JP. Acute lower respiratory tract infection. N Engl J Med 2008;358:716–27. 

3. Hopstaken RM, Stobberingh EE, Knottnerus JA, Muris JW, Nelemans P, Rinkens PE, et al. Clinical items not helpful in 

differentiating viral from bacterial lower respiratory tract infections in general practice. J Clin Epidemiol 2005;58:175–83. 

4. Versporten A, Bolokhovets G, Ghazaryan L, Abilova V, Pyshnik G, Spasojevic T, et al; WHO/Europe-ESAC Project Group., 

Antibiotic use in eastern Europe: a cross-national database study in coordination with the WHO Regional Office for 

Europe. Lancet Infect Dis 2014;14:3817. 

5. Bjerrum L, Munck A, Gahrn-Hansen B, Hansen MP, Jarbol DE, Cordoba G, et al. Health Alliance for prudent antibiotic 

prescribing in patients with respiratory tract infections (HAPPY AUDIT) – impact of a non randomised multifaceted 

intervention programme. BMC Fam Pract 2011;12:52. 

6. Lervy B, Wareham K, Cheung WY. Practice characteristics associated with audit activity: a medical audit advisory group 

survey. Br J Gen Pract 1994;44:311–4. 

7. Dallas A, van Driel M, van de Mortel T, Magin P. Antibiotic prescribing for the future: exploring the attitudes of trainees in 

general practice. Br J Gen Pract 2014;64:e561–7. 

184


Heinz-Harald Abholz, MD 

abholz@med.uni-duesseldorf.de 

60 – Comprehensiveness and Continuity of Care - Core values 

Necessary for the Survival of General Practice 

Heinz-Harald Abholz, MD 

Emeritus Professor, Institut für 

Allgemeinmedizin, Universität 

Duesseldorf 

Germany 

Frankly spoken, General Practice is especially appreciated by politicians because it is 

cheap and effective. And providing good care for little expense truly is a value - 

especially in poorer countries. But it is also true for richer countries where specialized 

care is becoming rapidly more expensive because of the sophisticated developments 

in diagnostics, treatments and pharmaceutics – even if this progress involves only 

very small steps of being “better” in diagnosing or treating. In other words, specialists 

are making care more and more cost-ineffective. 

General practice can still be cost-effective because not all the possible diagnosing and 

treating is actually carried out in all “cases”. General practitioners (GP) decide on the 

“individual patient” and not on the “case”, e.g. they are not doing the same in all 

patients with a similar problem. This is basically different from the specialist, who 

usually does not know the patient well and therefore follows, more or less, a 

guideline, i.e. is doing more or less the same in each similar consultation. 

If one is not doing all that is possible, one is at risk to make mistakes, miss a diagnosis 

etc. There are two things reducing this risk: first of all, one has to reflect on all the 

possible things which can be done, but then decide on what can also be left out by 

following Bayes' theorem. This process needs sound medical knowledge as all 

possibilities must be known to become part of this reflection. 

Secondly, there has to be good knowledge of the patient and his/her lifecircumstances, 

his/her preferences and values and, last but not least, his/her way of 

handling/coping when being ill. Combining all these factors, a decision is a complex 

process and is made for just this patient in that particular situation and with these 

special findings – and often by discussing it with the patient. 

This way of decision-making saves money – otherwise often spent on futile diagnostic 

or therapeutic procedures. And it decreases stress for the patient by reducing the 

proportion of false-positive results (Bayes theorem) and by reducing over-treatment. 

What allows GPs to know their patients well? The GP is the only doctor seeing his/her 

patient over several years and under different circumstances of health and illness. 

Additionally, an emotional relationship between doctor and patient is established 

through the length of their association which allows them to understand one another 

instead of simply knowing the facts about him/her. With this background, GPs are at 

an advantage in noticing even subtle differences in his/her patient - in the way of 

behaving, moaning, talking, looking and expressing him or herself. This knowledge can 

be employed in “interpreting” the patient and his problems and wishes – and hence 

finding an appropriate decision for a certain situation. 

All this can only work if the doctor can see his/her patient often and under different 

circumstances. In other words, GPs have to provide comprehensiveness and 

continuity in care – and society has to guarantee this. This makes continuity and comprehensiveness not only popular 

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with patients, but also an “essential” in the special way GPs work; as shown above. 

If this is no longer possible or the number of contacts between GP and patient are reduced considerably (e.g. by shift 

work, special services for extramural care etc.), GPs would not know enough about patient's life-circumstances, values, 

and their coping ways of handling symptoms – and by this also lose their abilities to engage patients in shared 

decision-making based on understanding the patient. 

If continuity of care and comprehensiveness are reduced considerably, as is happening in some countries, General 

Practice will lose its allure for society and the patient - due to a loss in the described special ability of General practice 

to provide cost-effective care as well as reducing overtreatment. 

Should it be “personal continuity” or “institutional continuity”? Personal continuity is the only guarantor for obtaining 

optimal knowledge of a patient and a joint experience with each other, which is absolutely essential for a solid doctorpatient-relationship. 

Institutional continuity is only a second-best substitute because joint experiences of patient and 

doctor cannot be “transported” from one doctor to the next through writing notes. In most developed countries today, 

these core values of comprehensiveness and continuity of care are under pressure due to the developments in 

medicine bringing in sophisticated technical and analytical skills and knowledge on the one hand, and young doctors 

insisting on a limited number of working hours (including half-time work) on the other hand. Group practices and, 

within these, a division of functions also undermine these core values. “Emergency services” and “hotlines for health”, 

supported by the health care system, are additional institutions reducing the number of contacts with the GP. 

In some rich countries, like Germany, without a) a gate-keeper function of General practice and b) a work force of 

specialists as large as that of GPs, working full-time outside the hospital, the core values of continuity and 

comprehensiveness are seriously threatened. Additionally, patients are more and more attracted by the modern 

developments of technical medicine - which they expect to receive from specialists. 

In countries with fewer specialists and less funding on health care, General practice has to face another threat: 

contacts to one GP are massively reduced by installation of shift-work in health care, hospital ambulances for 

immediate care, and several different paramedic professions doing some of the work previously undertaken by GPs. 

Without the core values of comprehensiveness and continuity of care as well as an underlying solid patient-doctorrelationship, 

General Practice will, in the long run, lose any justification for its existence: Under such circumstances, 

specialists- with little information about the patient - would perform better because they are better educated for 

medicine of the “details”. But knowing that often these “details” are not the real problem, and that the patient's 

complaints have to be interpreted in the context of the whole person, the time and circumstances of developing a 

symptom or illness, we have to fear about the quality of care in a future without GPs. 


 

 

 

 

 

General Practice is a very cost-effective way of caring. 

For this it is absolutely necessary to have detailed knowledge of and experience with the patient. 

Only a system allowing GPs to care comprehensively and in continuity makes this possible. 

Without these two core values General Practice will lose its base. 

And society its cost-effective health care. 


http://www.woncaeurope.org/content/155-comprehensiveness-and-continuity-care-core-values-necessary-survival-germangeneral 

References 

Boulton M, Tarrant C, Windridge K, et al. How are different types of continuity achieved? A mixed methods longitudinal 

study, British Journal of General Practice 2006,56:749-755 

Boyd CM, Darer J, Bould C. et al. Clinical practice guidelines and the quality of care for older patients with multiple 

comorbid diseases. JAMA 2005; 294:716-24 

Freeman G, Hughes J. Continuity of care and the patient experience. The Kings Fund, London 2010 

Haggerty JL, Roberge D, Freeman GK, et al. Experienced continuity of care when patients see multiple clinicians: A 

Qualitative Metasummary. Annals of Family Medicine 2013,11: 262-271 

186


Miles A. Complexity in medicine and healthcare: people and systems, theory and practice. Journal of Evaluation in Clinical 

Practice 2009; 15: 409–410 

Reeve J. Interpretive medicine – Supporting generalism in a changing primary care world. Royal College of General 

Practitioners, Occasional Paper 88, London 2010 

Starfield B, Lemke, KW, Herbert R. et al. Comorbidity and the use of primary care and specialist care in the elderly. Annals 

of Family Medicine 2005; 3: 215-222 

Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly 2005, 83 

(3):457–502 

187


Costas S. Constantinou, PhD 

constantinou.c@unic.ac.cy 

61 – Teaching Cross-Cultural Care 

Constantinou S. Costas PhD, 

Assistant Professor 

Medical Sociology Lead | 

Community Placements Lead | 

SSC Assistant Lead & 

Co-author 

George Samoutis MD, CCT, PhD 

Associate Professor 

Academic Lead for Clinical 

Placements CS&T year 

General Practice Curriculum 

Lead, National Institute for 

Health and Care Excellence 

(NICE, UK) Int Associate 

St George's, University of London 

medical programme 

Delivered in Cyprus by the 

University of Nicosia Medical 

School, Centre for Primary Care 

and Population Health 

Nicosia, Cyprus 

The need for cross-cultural care and cultural competence 

The need for cross-cultural care derives from the fact that modern societies are 

increasingly becoming multi-cultural and the observation that many cultural groups 

are not satisfied with health care, while medical practitioners say that some cultural 

groups are difficult to work with (Waxler-Morrison et al., 2005). On this note, Waxler- 

Morrison et al. (2005, p.6) argued that we need to adopt a cross-cultural care 

approach in order to deal with such “problems with health care”. These problems 

with health care relate to the different philosophies and knowledge that medical 

practitioners and lay people have with regard to health, illness and the management 

of diseases. Waxler-Morrison et al. (2005) explained that when a medical practitioner 

and a patient do not share the same culture they may not understand each other and 

lead to what they authors called “clash of cultures” (p.2). Such a clash should be 

avoided when medical practitioners communicate with and treat their patients. But 

how can they avoid it? To answer this question, we should first look into the main 

source of the different understanding between medical practitioners and lay people. 

This difference is attributable to the distance between the biomedical model and 

social knowledge. 

The biomedical model, which medical practitioners are trained to adopt, makes a 

distinction between the body and mind, and focuses on measurable characteristics of 

the body and identifiable symptoms, which represent distinct medical conditions 

(Helman, 2007). Furthermore, the biomedical model is concerned with causes of 

health conditions which can be observed in the physical world or inside the body, 

while it tends to attribute the development of certain diseases (i.e. heart diseases) to 

human behaviour, such as diet and lifestyle choices (Helman, 2007). Interestingly, 

biomedicine tends to underplay influential social forces, such as socio-economic 

status, occupation, migration and so forth. On the other hand, lay people rely heavily 

on socio-cultural knowledge to understand the causes and management of diseases. 

Such socio-cultural knowledge can result from cultural and religious values, such as 

the belief in the spiritual world or the evil eye. Moreover, lay people pay particular 

attention to the importance of social relations and the stress they experience in daily 

life (Helman, 2007). In other words, while medical practitioners are looking into the 

individual to find out the causes of diseases, lay people look at the outside world. To 

reduce the distance between these two regimes of knowledge we should not expect 

patients to acquire medical knowledge but medical practitioners should become 

“culturally competent” (Betancourt et al., 2005). 

Cultural competence is increasingly considered an important skill for medical 

practitioners. Betancourt et al. (2003, p.297) explained that cultural competence 

refers to “understanding the importance of social and cultural influences on patients’ 

health beliefs and behaviours”. These social and cultural influences may relate to services, language barriers, belief 

systems, habits and so forth. If medical practitioners manage to understand the rationale of their patients’ beliefs and 

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behaviour they can then develop their skills in how to work with their patients more effectively. But how can we make 

medical practitioners culturally competent? A multi-layered long-standing training may be very effective. 

Methodology of teaching cross-cultural care 

The Cultural Competence Train-the-Trainer Manual (2011) outlines a series of teaching methodologies in cultural 

competence. Drawing from this manual we propose a more simplified teaching methodology of cross-cultural care and 

cultural competence which should rely on situated learning and constructivism. Situated learning refers to 

contextualising learning by using examples or cases (Kaufman and Mann, 2010). Constructivism refers to the role the 

learners play in their own learning and to the process of constructing their learning by being active participants (Davis 

and Forrest, 2008). Both situated learning and constructivism have been used in modern medical education through 

adopting Problem-Based Learning (PBL) as the main method of teaching. 

Based on situated learning and constructivism, we propose a pyramid of building competence in cross-cultural care 

(figure 1), which is a modification of Mehay’s (2012, p.358) pyramid of clinical assessment. The proposed pyramid 

consists of three layers in order to train medical practitioners and students more effectively. The first layer is called 

“acquiring knowledge” and focuses on transferring knowledge to the learners through lectures. The second layer, 

“applying knowledge” could be enhanced by making the lectures case-based. Therefore, the learners learn the basic 

information in the social and cultural background of specific cultural groups and then they apply their knowledge to 

real life cases. The third layer, “practising knowledge” would train learners in how to perform their knowledge. In other 

words, the learners would be trained in the ways that they could use their knowledge in medical practice. To achieve 

this, teachers of cross-cultural care could construct cases and tasks for the learners to undertake based on these cases. 

For example, a scenario could describe a female migrant who cannot accept the medical diagnosis by her doctor and 

prefers attributing her condition to the act of the evil eye. The learners should then be taught how they should handle 

this patient. This third layer of practising knowledge could take the form of small-group role play sessions and 

reflection on work-based experience. Through the pyramid of building competence in cross-cultural care, medical 

practitioners can acquire knowledge, skills and attitudes to communicate with and treat their patients more effectively. 

Conclusion 

The need for cross-cultural care has increasingly been acknowledged as an important element in medical practice. 

Based on situated learning and constructivism, a three-layered pyramid of building competence in cross-cultural care 

can be implemented to help medical practitioners acquire knowledge, skills and attitudes to become more competent 

and effective in communicating with and treating their patients. Better cross-cultural care would thus mean better 

health care in general and improved medical practice. 

Figure 1: Pyramid of building competence in cross-cultural care. Modified from Mehay’s (2012, p. 358) pyramid of 

clinical competence. Mehay based his approach on Miller’s prism of clinical competence published in 1990 at 

Academic Medicine, 65(9): 63-67. 


189


 

 

 

Medical practitioners need to be trained in how to become competent in cross cultural care. 

To improve their communication with and treatment of patients, medical practitioners should be trained on 

the basis of the pyramid of building competence in cross-cultural care in order to acquire, apply and practise 

their knowledge. 

Better cross-cultural care means better medical practice. 


http://www.woncaeurope.org/content/1014-wo-teaching-cross-cultural-care 

References 

 

 

 

 

 

 

 

 

Betancourt J., Green A.R., Carrillo J.E. and Ananeh-Firempong O. (2003)‘Defining cultural competence: a practical 

framework for addressing racial / ethnic disparities in health and health care’,Public Health report, 118, pp. 293-302. 

Betancourt J., Green A.R., Carrillo J.E. and Park E.R. (2005)‘Cultural competence and health care disparities: key 

perspectives and trends’, Health Affairs, 24(2), pp. 499-505. 

Cultural Competence.Train-the-Trainer Manual. (2011) Available at: https://www.sickkids.ca/culturalcompetence/37976- 

NISN%20-%20Train-the-Trainer%20Manual%20-%202011.pdf 

Davis M, Forrest K. (2008)How to teach continuing medical education. Oxford: Wiley-Blackwell. 

Helman C. (2007)Culture, health and illness.5 th edn. London: Hodder Arnold. 

Kaufman DM, Mann KV. (2010)‘Teaching and learning in medical education: how theory can inform practice’, in Swanwick, 

T.(ed.) Understanding medical education: evidence, theory and practice. Chichester: Wiley-Blackwell, pp. 16-36. 

Mehay, R. (2012) The Essential Handbook for GP Training & Education. 1 st edn. Oxford: Radcliffe Publishing Ltd. 

Waxler-Morrison N., Anderson J.M., Richardson E. and Chambers N.A. 2005. Cross-cultural caring: a handbook for health 

professionals. 2 nd edn. Vancouver: UBC Press. 

190


Monica Lindh 

monica.lindh@telia.com 

62 – How to Recruit and Select Your Future Colleagues? 

Monica Lindh, specialist in 

GP/FM, Hofors Health Centre, 

Region Gävleborg, Sweden. 

Swedish EURACT Councilrepresentative 

(2004-2010). 

Co-authors 

Fergus O’Kelly, Prof, Ireland 

Margus Lember, Prof, Univ of 

Tartu, Estonia 

Roar Maagaard, GP & Ass Prof, 

Univ of Aarhus, Denmark 

Bernhard Rindlisbacher, 

Specialist in GP/FM, Switzerland 

Dolores Forés, GP, Spain 

Roger Price, MB BS, FRCGP. Ass 

Postgrad Dean in Health 

Education East Midlands, UK 

Recruitment of new colleagues to general practice/family medicine is essential for the 

viability of the specialty. Selection of “the right” colleagues for training in general 

practice/family medicine is also essential in order to give the trainees a satisfying 

professional life and their patients excellent GPs/family doctors! 

A survey conducted in 2004 by EURACT, the European Academy of Teacher´s in 

General Practice/Family Medicine, on specific selection processes for GP trainees in 

28 European countries indicated different processes, even within the same country in 

50% of the countries. The selection was done by course organizers in 75% and by 

universities in 25%, usually using interview and university scores. Training 

Programmes in other specialties sometimes gave credit in general practice 

programmes. The future trend was predicted to involve “more control by GPs in the 

process”. 

This issue was further explored at an interactive workshop at the WONCA Europe 

conference 2005 in Kos organized by EURACT. The aim was to strive to produce 

European recommendations for recruiting and selecting GP trainees. 

Introductory presentations by EURACT-Council members (Table 1) gave insight into a 

very diverse situation in different countries in Europe, ranging from nearly no 

selection “who is volunteering for GP ?” to very elaborate selection processes. In 

some places non-GP-specialists were doing the selection – in other places GPs were 

leading the process. A clinical testing period and references on collaborative 

competences were sometimes included. 

Table 1 

Dr Monica Lindh 

Prof Fergus O’Kelly 

Prof Llukan Rrumbullaku 

Prof Margus Lember 

Dr Roar Maagaard 

Dr Bernhard Rindlisbacher 

Dr Dolores Forés 

Dr Roger Price 

Sweden 

Ireland 

Albania 

Estonia 

Denmark 

Switzerland 

Spain 

United Kingdom 

According to the literature review presentation, selection practices are relatively 

unsystematic (1) and also ineffective, uneconomical and unfair (2). The most 

important factors in selecting applicants have been reported as the personal 

interview and earlier performance on clinical rotations (3). Knowledge tests at the 

entrance are not suitable (4). Personal attributes need to be considered rather than 

academic and clinical competence alone (5,6). In addition, it is recommended to 

target on six competences essential for family medicine: empathy and sensitivity; 

communication skills; clinical expertise; problem solving; professional integrity and 

coping with pressure (1). 

The UK was in the process of introducing a new application procedure: firstly a 

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“technical/formal” procedure, secondly a knowledge test, and if successfully short-listed in this part, the process 

continued to the third step: direct observation of behavioural competencies, a simulated consultation, and a group 

problem-solving exercise. 

The Kos-workshop was successful with intense discussions. Many participants were very inspired by the elaborate 

system being used in certain areas of the UK. It became clear that different national settings have to influence the 

method of selection. It was also obvious that we might learn from each other and we should try to generate some 

general principles and recommendations. 

Some unanswered questions were: Where should training start? (in general practice or in hospital). Introductory 

period? (to try out the GP-speciality). Who should undertake the selection? Written application? Standard criteria? Use 

of references? Personal interview? Who should be the interviewers? 

Selection and recruitment relate closely to other aspects. EURACT has conducted further work, accessible on its 

website, on various issues believed to be useful to trainees, trainers, course organizers and also to policy-makers. Some 

examples are: 

 

 

 

http://www.euract.eu/resources/specialist-training: 

A database with information on “the European GP-training landscape” 

http://www.euract.eu/scientific-papers/finish/2-scientific-papers/96-funding-of-vocational-trainingprogrammes-for-general-practicefamily-medicine-in-europe: 

How is GP-training funded? How are GP-trainees salaried? Overview and recommendations. 

http://www.euract.eu/resources/educational-research-presentations/finish/5-educational-researchpresentations/226-selection-and-reaccreditation-of-st-trainers-in-general-practice-in-europe-brendan-osheafor-euract-specialist-training-committee-11nov2011: 

On selection and re-accreditation of ST-trainers in GP in Europe 

Since 2006 the UK has implemented a very elaborate and systematic selection process nationwide, which has been 

well researched, evaluated and published (7). Focus remains on assessed competencies - Communication, Empathy, 

Professionalism and context-based Problem solving, with no interview at all! There is a 3-stage process: a single Person 

Specification for entry to all Specialty training; a Machine Marked Test (8) with papers on Clinical Problem Solving and 

Situational Judgement; and a Selection centre including Written test and Simulations. It is an expensive but reliable 

process with evidence that the various elements are predictive of progress in training. 

Other countries were also inspired by the workshop and the ongoing discussion within EURACT. For example, Denmark 

- where Multiple Mini Interviews are used, and in the near future, also simulated patients. Ireland is moving towards 

national selection with interviews looking at 6 competencies, assuming minimum criteria are met. GP teachers are 

central to this process which attracts the best candidates. 

However the situation is still diverse. In Switzerland the GP-trainee has no clearly structured program, but many 

options and selection notably depend on the (hospital) posts found. Spain has an exam, consisting of the same 

Multiple Choice Questionnaire for all specialties. The best student is the first to choose specialty and place, usually a 

hospital. In Sweden some areas have too few applicants minimizing selection. Sometimes the trainee starts a 

supervised trial-period. 

The recruitment agenda in GP/FM is a big and increasing problem in many countries and in some may even present a 

threat to the specialty. 


 

 

 

 

 

Selection of trainees to be done by GPs/FPs. 

Target competencies essential in GP/FM (empathy and sensitivity; communication skills; clinical expertise; 

problem solving; professional integrity and coping with pressure) to be evaluated. 

Systematic approach and selection process should be adapted to conditions within the country taking into 

account e.g. credits, funding issues, re-training. 

Selection of trainers. 

Recruitment of trainees in GP/FM of importance to the specialty, but also to other disciplines and the ability 

to meet the challenges of our changing world. 

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http://www.woncaeurope.org/content/275-wo-how-recruit-and-select-your-future-colleagues 

References 

1. Patterson F et al BMJ 2005; 330:711-714 

2. Spiegel W et al, Acad Med 2004; 79:703-10 

3. Galazka SS et al, Acad Med 1994; 69: 304-6 

4. Van Leeuwen YD et al 1997 Nr J Gen Pract 47: 359-362 

5. Patterson F et al Br J Gen Pract 2000; 50: 188-93 

6. Fergusson E et al BMJ 2003; 326:429-32 

7. The GP National Recruitment Office in UK 

http://gprecruitment.hee.nhs.uk/Recruitment/Selection-System-Research-Evaluation 

8. Patterson F, Irish B, Plint S, Gregory S. Validation of a Machine Marked Test to select trainees into UK General Practice; A 

model for the future. 2008; http://gprecruitment.hee.nhs.uk/LinkClick.aspx?fileticket=uv7eXWEpJLo%3d&portalid=8 

193


Rick Botelho, MD 

rbotelho@me.com 

63 – Motivate Healthy Habits For Life: Coach Each to Change 

Before Helping Patients and Families 

Rick Botelho, MD 


(1985-2009) 

University of Rochester 

http://www.linkedin.com/in/ 

rickbotelho 

Systems are perfectly designed to get the results that they get. Our toxic cultures have 

created epidemics of unhealthy habits. These epidemics have mass-produced 

premature deaths and diseases on unprecedented scales in the history of humankind. 

We are killing ourselves with unhealthy habits beyond all acts of war and terrorism 

combined. One billion people, or 1-in-8 persons, will die from smoking in the 21st 

century: never mind the impact of obesity, poor nutrition, alcohol abuse and 

sedentary lifestyles (1-3). Unhealthy habits shorten life expectancy by 10 years (4). 

Our “disease” care systems face overwhelming demands, unmet needs, finite 

resources, regulatory reforms and time-pressured, short-term demands. There will 

never be enough practitioners and coaches to reverse these epidemics and reduce 

the mounting burdens of chronic diseases (5). . These constraints combined with the 

dominance of the medical model stymie innovation for where population health 

improvement needs to go (6). 

There are no saviours to solve these problems. We can only save ourselves. Closed 

mindsets are the greatest barriers to innovation and change. We must expand our 

closed professional systems constrained by finite resources to include peer coaching 

systems with exponential capacities and capabilities (See figure 1). 

Our greatness lies not in remaking the world … but in being able to remake ourselves. 

Gandhi 

To do this, we must open, expand and align our mindsets to design health movements 

(6). Health movements are for the people and led by the people. To build such 

movements, we need catalytic innovations: scalable, sustainable and self-organizing 

solutions to: 

 

 

 

 

Go beyond the limitations of (1-to-1) clinical encounters and (1-to-n) group visits 

(8) 

Overcome the limitations of evidence-based guidelines and static brief 

interventions that address surface change 

Engage people in dynamic peer coaching activities to explore, make and sustain 

deep change 

Mobilize communities to help healthcare organizations break through the ceiling 

of their organizational performance 

Catalytic innovations are inexpensive, convenient and accessible learning processes 

that radically change how we improve our health (7). Everyone can develop some 

level of health coaching skills. Taking turns, we can coach each other to improve our 

health. Social media and online courses can make these innovations widely available: 

anytime, anyplace and anywhere. Crowd-sourcing strategies using catalytic 

innovations can unleash the positive power (n-to-n) of our social networks. 

194


Figure 1: Transformational Leadership: 

Re-designing Systems 

Figure 2: Design Exponential Health Movements 

The Health Coaching Buddies (HCB) learning system helps people coach each other to motivate healthy habits for life. 

In other words, we develop health coaching skills for everyday life and create our own circles of health coaching 

buddies. To initiate this process, we invite our healthcare teams, staff and students to: 

 

 

 

Lead Together 

Become Health Coaching Buddies (HCB) together 

Break the taboo and talk about deep change 

Develop healthier habits before helping our patients and families do the same 

To create leadership, professional social movements, our leaders can implement the HCB learning system at all levels. 

Together, we can follow the seven simple “C” rules to lead exponential health movements (see figure 2). 

 

 

 

Connect to Care 

Be Curious, Creative and Courageous 

Collaborate to Coach each other 

Become Health Coaching Buddies 

"You must be the change that you wish to see in the world." 

Gandhi 

Working together to go beyond surface change (increasing knowledge, setting goals with good intentions and making 

action plans), you can learn how to talk about deep change. 

A. Explore Deep Change 

 

 

 

 

Clarify your issues for and against deep change 

Understand why you maximize your reasons to stay the same 

Understand why you minimize your reasons to change 

Identify gaps in your values between what you do and say 

B. Make Deep Change 

 

Address gaps in your values between what you do and say 

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Shift your perceptions in favour of healthy change 

Lower your emotional resistance 

Increase your motivation 

Enhance your confidence and ability to change 

Create commitment and passion to live a healthy life 

C. Sustain Deep Change 

 

 

 

 

 

 

 

 

Develop the discipline to maintain deep change 

Become accountable to yourself and others 

Stay on track with the right motives 

Manage negative feelings and impulses effectively 

Overcome roadblocks to change and stop getting side tracked 

Keep focused on achieving your goals 

Learn from failures to prevent lapses and relapses 

Celebrate successes 

The ten online modules (See Table 1) enable you and your health coaching buddies explore, make and sustain deep 

change. 

Learn More 

Table 1. Learning Modules 

1—Inspire Healthy Choices 

2—Navigate Deep Change 

3—Explore Goal-setting 

4—Enhance Your Prospects of Deep Change 

5—Get to the Heart of Deep Change 

6—Lower Your Resistance 

7—Increase Your Motivation 

8—Enhance Your Skills 

9—Use a Circular Process for Effective Action 

10—Sustain Your Healthy Habits 

Experience this learning process for yourself. Go to www.HealthCoachingBuddies.com. Look over a decision balance of 

a woman who has unprotected sex with her HIV positive partner and understand why she sacrifices her health. Then 

use a decision on yourself to discuss your resistance and motivation to change with your health coaching buddy. 

Host Your Own Webinar or Workshop: Lead the Next Health Movement for your organization and 

community 

 

 

Download the free e-book www.HealthCoachingBuddiesMovement.com for group discussion 

Access free online course to hear leaders, scholars, researchers and practitioners reviewing this e-book 


Mission 

 

 

Vision 

 

 

 

Implement the Health Coaching Buddies learning system at all levels. 

Create ever-growing social networks of Health Coaching Buddies 

Align leadership, professional and social movements 

Build exponential health movements 

Reverse the epidemics of unhealthy habits 


196


http://www.woncaeurope.org/content/4044-online-learning-motivating-healthy-habits-change-yourself-helping-others 

References 

1. Collin J. Global health, equity and the WHO Framework Convention on Tobacco Control. Global health promotion. 

2010;17(1 Suppl):73-75. 

2. James WP. WHO recognition of the global obesity epidemic. Int. J. Obes.(Lond). 2008;32 Suppl 7:S120-S126. 

3. Kimokoti RW, Millen BE. Diet, the global obesity epidemic, and prevention. J Am Diet Assoc. 2011;111(8):1137-1140. 

4. Tamakoshi A, Kawado M, Ozasa K, et al. Impact of smoking and other lifestyle factors on life expectancy among Japanese: 

findings from the Japan Collaborative Cohort (JACC) Study. Journal of epidemiology / Japan Epidemiological Association. 

2010;20(5):370-376. 

5. Wolever RQ, Simmons LA, Sforzo GA, et al. A Systematic Review of the Literature on Health and Wellness Coaching: 

Defining a Key Behavioral intervention in Healthcare. Global advances in health and medicine: improving healthcare 

outcomes worldwide. 2013;2(4):38-57. 

6. Botelho R. Handbook of Systems and Complexity in Health, Chapter 42: Reverse the Epidemic Tides of Unhealthy Habits: 

Personal, Professional and Leadership Challenges. New York: Spinger; 2012. 

7. Christensen CM, Baumann H, Ruggles R, Sadtler TM. Disruptive innovation for social change. Harv Bus Rev. 

2006;84(12):94-101, 163. 

197


Mark Rickenbach FRCGP FRCP PhD FHEA 

Mark.rickenbach@nhs.net 


64 – An Ideal Training for the Future Career Patterns of Family 

Mark Rickenbach FRCGP FRCP 

PhD FHEA 

Professor Healthcare and 

Education Quality, Winchester 

University 

General Practitioner, Park 

Surgery, Hampshire England 

It has been fourteen years since the presentation of innovative training posts in the 

UK combining clinical experience in primary and secondary care education within the 

same working week (1). This chapter considers how far we have come since then in 

achieving the ideal education for family medicine. It uses the NHS in the UK as an 

example, but the principles apply worldwide. 

What is the ideal educational environment? One in which the learner feels fully 

supported and encouraged to achieve their maximum potential. An apprenticeship, 

described by Dreyfus, in which they move through advanced beginner, to proficient 

and possibly expert in their future career choice; in this case, family medicine. A 

learning environment where they achieve Mintzberg’s “shortcut to the acquisition of 

experience”, on a daily basis in their future career choice. Learning from both formal 

education and informal education in the workplace environment, whilst caring for 

patients. 

The vision outlined in the 2013 RCGP report “Enhanced GP training” is for a focus on 

community approaches and integration of care (2). To have primary care experience 

early on in training, to move to 24 months in primary care, with more child health and 

mental health experience, for all trainees. 

The report describes a “spiral curriculum model where expertise in generalist medical 

care is built up incrementally over time” (2). Five educational themes are identified 

for the four year curriculum. These are relating to others, applying clinical knowledge, 

managing complex care, working in systems of care, and caring for the whole person. 

Opinion in the UK is moving towards more generalist training with capacity to adapt 

to future pluri-potential integrated care posts spanning across secondary, primary and 

community care (3, 4). 

However the current reality of today is similar to the 1980s. Doctors training for UK 

family medicine still rotate through a range of separate specialties where the focus is 

predominantly on learning related to the secondary care specialty setting. There is 

considerable value and insights that continue to be derived from secondary care 

experience for doctors with careers in family medicine, but it does not appear that 

the full potential of GP training is being recognised. 

In the GMC national training survey these secondary care posts were consistently 

rated lower by general practice trainees than their secondary care colleagues and also 

lower in comparison to training posts in the primary care setting (5). Part of this is the 

context of education, and the relevance of education to future career, but part of this 

may be due to the quality of education. Factors such as the ratio of learners to 

educational supervisors, the professional recognition of educators, the demands of 

service pressures, the lack of protected time and shift systems all play a part in the 

secondary care setting. Educators, as professionals, need the time to supervise, teach, 

review and improve their own practice. 

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Until now the focus for change has been on the proportion of time spent in primary 

care. Moving towards 18 out of 36 months, with regular one day primary care focused education once a month during 

hospital based posts. Change is happening around the basic structure of GP training rather than to the core of GP 

training. 

Attempts to integrate secondary and primary care education in 2002 did move on from this current model by 

combining primary and secondary care experience each week in the same post (1). Satisfaction was high (1). Trainees 

gained insight into both sectors and had the opportunity to follow patients from primary to secondary care and back. 

Their learning was more focused on future career needs, even though doctors still experienced two distinctly separate 

learning environments. Looking back it is evident there is still room for yet greater integration of education with 

contributions to be made not only from secondary care specialist knowledge, but social care, community care and 

voluntary care as well as primary care. 

However, the support for these basic initiatives to flourish was not present. For most of the UK the basic model of 

siloed secondary care education for the primary care doctor continues. It is possible that healthcare itself needs to 

integrate more effectively before education for healthcare becomes more integrated. 

One current example of future integrated models related to future career needs is the rural medicine course in 

Scotland, which has a placement in a developing country. The course makes use of video-conferencing for both service 

delivery and education. There are rural attachments and additional training in medical retrieval, intubation and 

roadside care. 

Since 2000 there have also been a selection of ST4 and clinical fellow posts across the UK emerging as optional add-ons 

to help get trainees up to speed for real general practice, following their core training. This gives them skills in a range 

of settings including management, research, leadership and integrated healthcare. 

In addition, external factors such as technology are bringing about developments. Websites, apps, YouTube, podcasts, 

wikis, discussion rooms, twitter, and Facebook are moving on line education into the workplace and the learners’ 

pocket. The difficulty is picking out what is really needed and retrieving it quickly, when required, within the 

consultation. 

Simulation has also evolved. Examples now exist of manikin simulation running from the road side, through the 

emergency department to the wards and into intensive care, involving a range of multi-professional teams in the real 

life workplace, providing learning that is immediately relevant. Actors and actual patients, including children, now take 

on the simulated patient role. Trainees take exams with simulated patients, but there are, as yet, no simulations of the 

real life pressures of full-on, busy primary care. 

In conclusion, education for family medicine has evolved by having proportionally more time in the primary care 

setting. However, there is a long way to go before we attain a shared NHS vision and plan to create the ideal integrated 

care education for future family medicine in the 21 st century. 


 

 

 

 

Education for family medicine continues to be predominantly in the secondary care setting 

Education in secondary care is consistently rated less favourably than in primary care by trainees 

Technology is opening a range of new educational approaches 

The full potential of integrated care education for family medicine has yet to be recognised 


http://www.woncaeurope.org/content/1-ideal-training-future-career-patterns-family-medicine 

References 

1. Rickenbach M.A, Mullee M, Smith F and Scallan S. (2006) Innovative Training posts: trust attached general practice 

registrars. Education for Primary Care 17:130-137. 

2. RCGP (2014) Enhanced GP Training: an integrated four year curriculum, assessment and quality improvement training 

programme for General Practice. London: Royal College of General Practitioners 

3. Tooke,J. (2013) Postgraduate medical education and training in the UK. BMJ 347:f7604 

4. Greenaway, D. (2013) Shape of training: securing the future of excellent patient care. Final report of the independent 

review led by professor David Greenaway. London: General Medical Council. 

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5. GMC (2014) National Training Survey 2014 Key findings. London: General Medical Council. 

200


Fatma Goksin Cihan 

goksincihan@yahoo.com 

65 – ‘Burnout’ and Family Practice 

Fatma Goksin Cihan, MD 

Assistant Professor, Necmettin 

Erbakan University Meram 

Medical Faculty 

Family Medicine Department, 

Konya, Turkey 

Co-author 

Hakan Yaman, MD, MS 

Professor, Convener of the 

WONCA SIG Elderly Care, 

Chairman, Dept. 

Medicine, Akdeniz University, 

Faculty of Medicine, Antalya, 

Turkey 

Occupational stress has been recognized as a problem for family physicians. Relations 

with patients, colleagues, managers, satisfaction or dissatisfaction with the work, 

possible conflict situations in the workplace, insufficient education to perform workrelated 

tasks, work overload, and lack of promotion opportunities at work are 

considered to be the most common causes of workplace stress. Many countries in 

Europe have been trying to transform their health care systems and implement health 

care reforms in recent years. Working with system changes, responsibility for the 

registration of citizens, financial responsibility, and other changes within the reforms 

are the most important reasons for the high prevalence of burnout syndrome among 

family medicine physicians. Burnout syndrome is defined as chronic work-related 

stress which includes three dimensions: 

 

 

 

feeling of emotional exhaustion, 

negative approach to the service provided (depersonalization) 

reduced sense of satisfaction and lack of professionalism (sense of reduced 

personal accomplishment)(1, 2). 

These symptoms tend to be seen frequently among personalities which are 

characterised by the setting of unrealistic high performance goals, or unrealistic goals 

altogether, and ignoring warning signals from family and friends. 

The Maslach Burnout Inventory Test is a validated diagnostic instrument. 

One of the major research projects on the presence of burnout syndrome among 

physicians in primary health care was conducted by the EGPRN (European General 

Practice Research Network Burnout Study Group) in 12 European countries: Bulgaria, 

Croatia, France, Greece, Hungary, Italy, Malta, Poland, Spain, Sweden, Turkey and the 

United Kingdom (3). The research results were published in 2008 showing that 43% of 

the respondents had a high level of emotional exhaustion, 35% had a high level of 

depersonalization, and 32% had a low level of personal satisfaction/accomplishment. 

Burnout syndrome is seen as a common problem among family medicine physicians 

throughout Europe and it is followed with personal and work overloads, tendency to 

change jobs, and use/abuse of alcohol, tobacco and drugs. High burnout was found to 

be more likely in association with several of the variables examined, especially those 

relative to respondents’ country of residence and European region, job satisfaction, 

intention to change job, sick leave utilization, the use/abuse of alcohol, tobacco and 

psychotropic medication, younger age and male sex. The strong relationships found in 

this study between low job satisfaction and burnout support the notion of focusing 

future research on improving job satisfaction rather than addressing burnout directly. 

Surprisingly, little research has been conducted into interventions for burnout. 

Although research indicates that it is the organizational attributes that seem to have 

stronger associations with burnout, most interventions have in the past ironically 

been centred on changing individuals (4,5). 

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Paperwork; feeling undervalued; long waits for accessing specialists, diagnostic tests, and community resources; 

difficult patients; obligation to undertake night shifts at the emergency departments of hospitals and medico legal 

issues are well known stressors of family practice. Unfortunately, workplace violence caused by patients and their 

relatives are increasing and this is another demotivating factor for the physicians. 

Measures to be taken 

 

 

 

 

 

 

 

 

improving skills and knowledge, 

improving conditions for work and rest, 

improvement of facilities and working conditions, 

increase in work motivation, 

changes in reward system, 

implementation of social programmes for self-protection, 

introduction of the system for psychosocial draining and stress relief after working day; 

improving organizational psychosocial atmosphere and recommendations to stop the development of 

burnout syndrome: 

◦ introduction and implementation of new projects without waiting for the manager’s consent, 

◦ maintenance of good health habits including provision for adequate sleep and nutrition, 

◦ acquiring meditation skills, 

◦ developing a satisfying social life, 

◦ establishing contacts with some friends possibly from other professions, 

◦ desire to achieve results without expecting to be always the best, 

◦ ability to lose without the feeling of self-underestimation and aggressiveness, 

◦ ability of self-assessment without thinking about the opinion of others, 

◦ openness to new experiences, 

◦ ability to provide sufficient time to achieve positive results in business and personal life, 

◦ ability to take responsibility, 

◦ to read literature not related to the profession, 

◦ participation in seminars and conferences where there is a chance to meet new people and share 

experience with colleagues, 

◦ occasionally working together with colleagues with whom you disagree in professional and/or private life, 

◦ participation in the work of professional groups and thus have the opportunity to discuss personal 

problems connected with recommendations on the work, 

◦ nurturing hobbies which bring joy and satisfaction (2). 

The American Association of Internist's proposed five basic measures which should be applied by every physician to 

prevent the development of burnout syndrome: 

1. Care of yourself; first consider your own safety programme. Include fun or some other distraction in your 

work. When you are under stress, it is important to be with your family more than usual, and find time for 

your hobbies. 

2. Define the boundaries/limits of your work, consider your practice and see where it is necessary to draw the 

line. Saying “no” to the patient and thus risk him leaving you and going to another doctor is healthier than 

constantly appeasing and satisfying unreasonable patient demands. 

3. Determine methods for coping with stress. Select the person who you can confide in. If you don’t want to 

discuss your problems with your colleagues, contact old classmates, former professors or mentors. 

4. Analyse yourself, figure out what your values and desires are, what your skills are and what you like doing and 

what you do not like or hate doing. Burning often results from the imbalance between desires, assessments 

and interest on the one hand and job requirements on the other. 

5. Overcome the complex that others are always better than you and that this happens only to you. The 

physician’s job is very demanding and subject to constant changes. However, this happens in other 

professions as well. In order to be protected from the development of burnout syndrome the physician must 

develop skills which will help him/her to cope with constant change and to create the necessary defence 

mechanisms (6). 

202


 

 

 


Burnout syndrome is characterized by mental or emotional exhaustion, fatigue and depression, with a greater 

emphasis on psychological rather than physical symptoms 

Job satisfaction is an important element; it should be seen as an action point for further research and 

intervention 

Not only individual but also organizational interventions should be developed to overcome the problem 


http://www.woncaeurope.org/content/or1337-burn-out-and-job-satisfaction-among-turkish-family-physicians 

References 

1. Lee FJ, Stewart M, Brown JB. Stress, burnout, and strategies for reducing them. What’s the situation among Canadian 

family physicians? Can Fam Physician 2008;54:234-5.e1-5 

2. Stanetıć K, Tešanovıć G. Influence of age and length of service on the level of stress and burnout syndrome. Med Pregl 

2013; 66(3-4): 153-162. 

3. Soler JK, Yaman H, Esteva M, Dobbs F, Assenova RS, Katic M, et al. Burnout in European family doctors: the EGPRN study, 

Fam Pract 2008;25:245-65. 

4. Maslach C, Goldberg J. Prevention of burnout: new perspectives. Appl Prev Psychol. 1998; 7: 63–74. 

5. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001; 52: 397–422. 

6. Zellars KL, Perrewé PL. Affective personality and the content of emotional social support: coping in organizations. J Appl 

Psychol 2001;86:459-67 

203


Risto Raivio 

Risto.Raivio@phsotey.fi 

66 – Assessing Patient Satisfaction in Primary Health Care – Reliable 

Information and Benchmarking 

Risto Raivio MD, Chief Physician, 

Head of the Unit, GP, Family 

Doctor, Qualification in 

Administration and 

Management. 

Primary Care Unit, Joint 

Authority for Päijät-Häme Social 

and Health Care Group, Lahti, 

Finland 

Co-authors 

Juhani Jääskeläinen, Kari 

Mattila, 

School of Medicine, Department 

of General Practice, University of 

Tampere, Tampere, Finland 

Doris Holmberg-Marttila 

Centre for General Practice, 

Pirkanmaa Hospital District, 

Tampere, Finland 

Background 

Health policy declarations emphasize the importance of patients' views and opinions 

in providing and developing health services (1-3). Patients´ opinions should be 

assessed regularly and used systematically as an indicator of the quality of health care 

(4, 5). We studied the feasibility and reliability of a questionnaire for data collection 

and as a benchmarking instrument in evaluating the opinions of Finnish primary 

health care patients. The aim was also to explore trends in patient satisfaction within 

primary health care. 

Methods 

A 15-year follow-up questionnaire survey was conducted among patients attending 

health care centres in the Tampere University Hospital catchment area during 1998- 

2013. The questions were based on international study findings (6) and adapted to 

the special characteristics of Finnish primary health care. There were originally 65 

health care centres in this area, the total population being 1.2 million. Basic 

demographic data such as gender and age of participants were collected. 

Data were always collected during the same calendar week in September. The 

reception staff distributed the questionnaire to patients visiting physicians and nurses 

due to illness from Monday to Friday between 8 a.m. and 4 p.m. Patients returned the 

anonymously filled questionnaires to a box in the waiting room after their 

consultation. The health care centres collected the questionnaires and sent them to 

the Department of General Practice at the University of Tampere where the data were 

recorded and analysed. 

Patient satisfaction was assessed with the statement: “The service in the health care 

centre was so good that I can recommend it to my family and friends”. The response 

alternatives were: “I totally agree”, “I agree”, “I disagree” and “I totally disagree”. 

Since the objective in health service is complete satisfaction, we sought particularly to 

ascertain the proportion of respondents who gave the answer “I totally agree”, this 

being considered to represent unreserved satisfaction with care. 

In statistical analysis we used frequencies, percentages and cross-tabulation. The 

analyses were carried out with SPSS predictive analytics software. 

Results 

A total of 157 549 patients responded out of a sample of 363 464. The response rate 

varied yearly from 39% to 53%. Forty out of 65 primary health care centres 

participated in the study at least six times and 61 at least four times. Each health care 

centre was informed of its own results and also the combined results from the other centres. 

204


The general patient satisfaction varied considerably among the centres (Figure 1). 

There was a notable decreasing trend in patient satisfaction with care in Finnish health care centres from 1998 to 2013 

(Figure 2). 

Figure 1. The variation of unreserved patient satisfaction (%) according to health care centre. 

Figure 2. Linear trend line of unreserved patient satisfaction (%) by year. 

There were no differences between genders in patient satisfaction. Sixty-year-olds or older were more satisfied (75% 

vs. 58%) than those under 60 years of age. On the other hand, satisfaction decreased most in the age group 60 years or 

older. Those patients who had a family doctor specifically appointed to them were more satisfied (63% vs. 57%) than 

those who had no specific doctor appointed by the health care centre for consultation. 

Conclusions 

The findings underline the importance of the patient in assessing primary care services in giving new and useful 

information on patient-related satisfaction within Finnish primary care. 

205


We developed a feasible, reliable and comprehensive process for assessing patients' opinions in Finland. This process 

also provides a benchmarking instrument for primary health care centres. 

Despite efforts by the authorities, in the past 15 years patient-reported satisfaction with primary health care has 

declined in Finland (7). In addition to a decreasing satisfaction, fewer patients have reported good access to and 

continuity of care. This fall-off in satisfaction is a matter for concern. 

Finnish health care centres have undergone a number of changes during the study years. This may partly explain the 

falling trend in patient satisfaction with the services. Some of the changes in question were influenced by societal 

change, financial austerity and a lack of experienced primary care professionals (7). 

The implemented and planned national health care programmes and legislation in Finland between 2000 and 2010 

were designed to improve the health services. However the general strategic reforms with weak implementation 

methods might not have been able to resist the strong pressures within the service provision system (7). 

The findings indicate that new means of coordinating and developing care in Finland are still necessary in order to 

improve satisfaction with primary health care. The authors also suggest that, at least those patients who need care 

most should be able to consult with a specific family doctor to enhance their satisfaction with and continuity of their 

care (8). 


 

 

 

Patients´ opinions can be assessed regularly and used systematically as a quality and benchmarking 

instrument in primary health care. 

Despite efforts by the authorities, in the past 15 years patient-reported satisfaction with primary health care 

has declined in Finland. 

Patients who need care most should be able to consult with a specific family doctor appointed to them to 

enhance their satisfaction with and the continuity of their care. 


http://www.woncaeurope.org/content/op-183-assessing-patient-satisfaction-primary-health-care-reliable-information-and 

References 

1. Starfield B, Shi L: Policy relevant determinants of health: an international perspective. Health Policy 2002, 60(3):201–218. 

Jun. 

2. Dionne S Kringos, Wienke GW Boerma, Allen Hutchinson, Jouke van der Zee, and Peter P Groenewegen 1NIVEL- 

Netherlands Institute for Health Services Research, Otterstraat 114-118, 3500 BN Utrecht, the Netherlands The breadth of 

primary care: a systematic literature review of its core dimensions. BMC Health Serv Res. 2010; 10: 65. 

3. World Health Organisation. Developing the new European policy for health - Health 2020./07 110419. World Health 

Organisation; 2011. http://www.opsoms.org.pa/drupal/SCMDSS/3%20Case%20studies%20and%20key 

%20documents/WHO%20Regional%20Office%20of%20Europe/EURO_Health2020_2011.pdf 

4. Vedstedt P, Mainz J, Lauritzen T, Olesen F: Patient and GP agreement on aspects of general practice care. Fam Pract 2002, 

19:339–343. 

5. Haggerty JL, Pineault R, Beaulieu M-D, et al. Practice features associated with patient-reported accessibility, continuity, 

and coordination of primary health care. Ann Fam Med 2008; 6(2): 116–123. 

6. Grol R, Wensing M, Mainz J, et al. Patients’ priorities with respect to general practice care: an international comparison. 

European Task Force on Patient Evaluations of General Practice (EUROPEP). Fam Pract 1999; 16(1): 4–11. 

7. Raivio R, Jääskeläinen J, Holmberg-Marttila D, Mattila KJ. Decreasing trends in patient satisfaction, accessibility and 

continuity of care in Finnish primary health care - a 14-year follow-up questionnaire study. BMC Fam Pract. 2014 

May;15;15(1):98. doi: 10.1186/1471-2296-15-98. 

8. Raivio R, Holmberg-Marttila D, Mattila KJ. Patients’ assessments of the continuity of primary care in Finland: a 15-year 

follow-up questionnaire survey. Br J Gen Pract. 2014 Oct;64(627):e657-63. doi: 10.3399/bjgp14X68184. 

206


Roger Strand 

roger.strand@svt.uib.no 

Decisions 

67 – Risk, Uncertainty and Indeterminacy in Clinical 

Roger Strand 

Centre for Cancer Biomarkers 

and Centre for the Study of the 

Sciences and the Humanities, 

University of Bergen, Bergen, 

Norway 

Guri Rortveit*¤, Yngvild S. 

Hannestad¤ & Edvin Schei¤ 

* Research Unit for General 

Practice, Uni Research Health, 

Bergen, Norway 

¤ Dept of Global Public Health 

and Primary Care, University of 


Rationality, Science and the Legitimacy of Clinical Decisions 

We present a typology of scientific uncertainty and discuss how uncertainty can 

inform patient-centred clinical decision-making. 

The emergence of modern states in 18th and 19th century Europe came with a 

particular model of policy-making, the modern model (Funtowicz and Strand 2007). 

Within this model, the legitimacy of decisions is rooted in being based on scientific 

facts. The modern model captures the economic concept of rationality. Rational 

actors choose those policy options that, given the scientific facts, best meet their 

preferences. 

Accordingly, if a patient can only survive if surgery is performed and he “prefers” 

survival, surgery is the unique rational choice. Rationality in this model has two 

distinctive features: The relevant facts are known with certainty (by science), and the 

preferences are also known (by the patient). 

Gradually, the concept of objective probability replaced certainty in empirical science. 

Rationality and legitimacy were also claimed in the absence of certainty as long as 

probabilities could be quantified objectively in terms of frequencies, a procedure 

requiring formalization in risk-cost-benefit-analysis. Below we discuss several other 

forms of uncertainty. How can physicians and patients make rational decisions in the 

absence of quantifiable knowledge? 

Risk, Uncertainty, Ignorance and Indeterminacy 

“Risk” has many definitions. According to Knight (1921) uncertainty is reduced to risk 

when the frequencies of the outcomes are known. There is strict uncertainty when 

frequencies remain unknown. Ignorance is the lack of knowledge of relevant 

outcomes (incomplete knowledge of the event space). 

The rationality of the modern model hinges upon the possibility of reducing 

uncertainty and ignorance to risk. Without probability estimates there is no unique 

rational choice. Bayesian concepts and methods cannot solve this problem because 

their subjective component compromises the original legitimizing force of the 

probabilities. 

Finally, there is indeterminacy: no unique way of defining the system (Wynne 1992). 

Causal chains and networks are open and any choice of system boundaries has an 

arbitrary component (the neck, the person, the person and his colleagues, the person 

and his family). Moreover, any definition of system boundaries introduces its own 

sources of risk, uncertainty and ignorance. 

207


Sources of Risk, Uncertainty, Ignorance and Indeterminacy in Clinical Contexts 

There are numerous sources of incomplete knowledge in clinical contexts (Rørtveit & Strand 2001). The following 

questions may elicit some of them: 

Risks: What frequencies are known for the prognosis of patients similar to mine, given this or that treatment? 

Strict uncertainty: Is my patient representative for the group(s) for which I have risk information, or is he too different? 

Of which relevant peculiarities of my patient am I ignorant? 

Ignorance: Which non-medical (or hitherto unknown) consequences of the clinical decision will feed back into health? 

Indeterminacy: How did we define the clinical problem and system? If we had defined it differently, what would the 

relevant options and outcomes be, and which sources of risk, uncertainty and ignorance would they entail? 

Jane, 71 Years, Slightly Overweight 

The following hypothetical example is adapted from Rørtveit & Strand (2001): Jane (71) goes to her GP, allegedly for a 

“check-up”. She is somewhat overweight, does not smoke and feels quite well. She walks the dog every day. On 

request she tells that her father died suddenly at age 55 “because of the heart”, and her mother’s brother “has 

angina”. Blood pressure is 140/90 mm Hg. Clinical tests are normal except the cholesterol, being 8.5 mmol/l. Three 

months later, following changes to her diet, she presents with a cholesterol of 8.3 mmol/l. HDL 1.3 mmol/l and 

triglycerides 1.0 mmol/l. The GP is in doubt about what to do and whether medication should be prescribed. 

Our point is not to indicate the correct decision. Indeed, there are several ways ahead. We shall begin by eliciting 

sources of risk, uncertainty, ignorance and indeterminacy. 

Risk can be assessed by risk charts and risk calculators, also for this patient. Strict uncertainty is present, however, 

notably because the patient does not fit into the groups well characterized by existing epidemiology: she is a 

Norwegian woman >65 years without established disease, with unclear familial risk and living in a different country 

than those of most relevant studies (Selmer et al 2008, Cooper et al 2008, Petursson et al 2010). Although it is always 

possible to base the clinical decision upon the risk charts it is not necessarily legitimate, since the assumptions of the 

modern model are violated. Therefore, there might be other rational options. 

Other options can be found by eliciting sources of ignorance and indeterminacy. This requires more knowledge about 

the patient, some of it quite reliable, some of it not. Will she continue to walk her dog if she is on medication? Will she 

think of herself as ill and will this have a (positive or negative) health effect? Did she only want a “check-up” and had 

nothing else on her mind (for example a small lump in her groin)? Why is she overweight, and is it a problem? What is 

important for this woman to be able to do in her remaining healthy years, and how can the GP help her accomplish her 

objectives? Such questions may clarify (a) other sources of uncertainty and ignorance with respect to the decision to 

medicate or not; (b) other options for action; (c) that the decision on whether or not to medicate, loses importance. 

Perhaps the GP should just give the medication to her without further ado and then concentrate his/her effort on 

Jane’s other health aspects. 

Conclusion: Creative Efforts May Be Rational 

Knowledge is essential. We do not encourage unaccountable forms of judgement. However, when scientific 

uncertainty prevails, an approach where doctor and patient co-produce relevant knowledge about the patient may 

strengthen the knowledge base and the legitimacy of clinical decisions. Sometimes, this leads to a re-framing of the 

clinical problem in which uncertainties are less critical. Sometimes, uncertainties remain unresolved, actually giving GP 

and patient more autonomy to develop their own path ahead. 


 

 

 

Clinical decisions often have to be made in the presence of scientific uncertainty about premises and possible 

outcomes 

A model of rationality based on probabilities can be restrictive in clinical settings 

We present a typology of uncertainty and its application in a clinical example: risk (probability), strict 

uncertainty, ignorance and indeterminacy 


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http://www.woncaeurope.org/content/ws-036-risk-uncertainty-and-indeterminacy-clinical-decisions 

References 

 

 

 

 

 

 

 

Cooper A, O’Flynn N. Risk assessment and lipid modification for primary and secondary prevention of cardiovascular 

disease: summary of NICE guidance. BMJ 2008;336:1246-8. 

Funtowicz S, Strand R (2007) “Models of Science and Policy”, in Traavik, T. and Lim, L.C. (eds.) Biosafety First: Holistic 

Approaches to Risk and Uncertainty in Genetic Engineering and Genetically Modified Organisms, Trondheim: Tapir, pp 

263-278. 

Knight F (1921) Risk, uncertainty, and profit, Boston, MA: Hart, Schaffner & Marx; Houghton Mifflin Co. 

To be found at http://www.econlib.org/library/Knight/knRUP.html 

Petursson H, Sigurdsson JA, Bengtsson C, Nilsen TIL, Getz L. is the use of cholesterol in mortality risk algorithms in clinical 

guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study. J Eval Clin Pract 2012;18:159-68. 

Rørtveit G & Strand R (2001) “Risiko, usikkerhet og uvitenhet i medisinen [Risk, uncertainty and ignorance in medicine],” 

Tidsskrift for Den Norske Lægeforening, 121:1382-1386. 

Selmer R, Lindman AS, Tverdal A, Pedersen JI, Njølstad I, Veierød MB (2008) “Modell for estimering av kardiovaskulær 

risiko i Norge” [Model for estimation of cardiovascular risk in Norway], ” Tidsskrift for Den Norske Lægeforening, 128:286- 

290. 

Wynne B (1992) Uncertainty and environmental learning: reconceiving science and policy in the preventive paradigm. 

Global Environmental Change 2:111-127. 

209


Pieter van den Hombergh, MD, PhD 

p.hombergh@gmail.com 

68 – Do Practice Visits Have a Future? 

Pieter van den Hombergh, MD, 

PhD. 

Research fellow & policy advisor; 

Radboud University Medical 

Center, Scientific Institute for 

Quality in Health care (IQhealth 

care), Nijmegen, The 

Netherlands 

Teacher in the FM-Training 

Institute, University of 

Amsterdam (UvA), Amsterdam 

Medical Centre (AMC) 

Co-author 

Stephen Buetow 

Associate Professor in the 

Department of General Practice 

and Primary Health Care at the 

University of Auckland, in 

Auckland, New Zealand. 

Assessment in visits in the various countries 

Many countries have initiated some sort of visit programme depending on the level of 

commitment from the profession and on external pressure. In an individualistic 

culture of general practice more resistance to the introduction of practice visits can 

be expected. Practice visits require a culture of valuing feedback and reflection. 

Donabedian puts it succinctly with: “every defect is a treasure”. 

The UK had a first with the “What sort of Doctor” programme assessing GP 

performance, which included an extensive visit by three GPs as a requirement to 

become a “fellow” of the RCGP. It developed into a portfolio system requesting data 

to be entered in order to qualify for “revalidation” and re-registration. 

The Netherlands’ Practice Accreditation program was set up in 2001 by the Dutch 

College based on the validated VIP (Visit Instrument Practice management) to 

improve the quality of care in general practices. Each practice can voluntarily 

participate in the programme by meeting conditions regarding hygiene, telephone 

accessibility in emergency situations, use of electronic medical records and safety 

report incidents. The programme tests the practice on three aspects: practice 

organization, medical care and patient experiences. 

European Practice Assessment (EPA) 

The successful development with the help of EQUIP (European Quality Improvement 

Party, WONCA) of a European patient questionnaire (EUROPEP) led to much insight 

into the variation between countries. The next step was an attempt by Germany, 

Holland, The UK, Switzerland, France and Belgium to develop the Dutch VIP-method 

into a European approach. Practice organization/management was defined as: 

‘systems, structures and processes aimed to enable the delivery of good quality 

patient care’, excluding clinical processes and clinical outcomes. 171 indicators within 

five domains of practice organization were identified, organized into 202 questions 

and allocated to specific questionnaires for the principal GP or practice manager, all 

GPs and all staff respectively. In addition, 30 patients completed the EUROPEP patient 

questionnaire. During a practice visit, an external visitor used an observer check-list 

and interview schedule for the principal GP or PM, and all data were entered into the 

computer. Thus the EPA-system was able to generate real-time practice feedback 

(provided by the AQUA-institute, Göttingen, Germany) to be discussed with the 

practice team. Developed in English the EPA visit-instrument was translated into 

relevant languages and adapted by each country. 

Development worldwide 

Many other countries started in the nineties to develop their own standards of care 

and practices were assessed against these standards. For example in Australia, Canada and New Zealand, practices 

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could increasingly provide their own data (internal auditing) to make independent, external visits more feasible. 

Meanwhile, Scandinavian countries have continued to value personal, formative mutual practice visits including 

observation of consultations using straightforward check-lists. The different countries and their respective colleges all 

appear happy with their approach to practice visits and agree it deserves a place in their CME-system and/or 

(re)registration. Almost no research, however, compares the methods on their effectiveness or uses the data for 

benchmarking. Also problematic is that the more selective the instrument becomes, the more local its use for 

research. Most methods appear to result in an improvement process using the quality or the Deming circle, but few of 

the methods provide benchmarking data. 

Effectiveness of practice visits and accreditation or certification in Family practice 

Practice visits mostly form part of accreditation programmes for healthcare providers (3). Accreditation affects the 

institution or practice and is more or less voluntary, while certification focuses on a specific norm that individuals or 

particular services should reach. In hospitals, accreditation and certification have proven more effective than ‘no 

intervention’, with accreditation scoring slightly better; but the results have to be interpreted cautiously (4). 

A Cochrane review suggested that an audit and feedback system has a small positive effect on quality of care overall 

(5), but the added value of accreditation was not considered. In another systematic review Greenfield and Braithwaite 

found that accreditation can promote change, for example through the opportunity to reflect on organizational 

performance, and influence professional development. However, they reported inconsistent findings regarding 

quantifiable effects of accreditation on measures of clinical processes and outcomes. 

Few rigorous evaluations of effectiveness of accreditation are available, particularly in primary care. This conclusion 

emerges from the review by O’Beirne et al. (6) on accreditation in primary care. Nevertheless, Szecsenyi et al. 

examined an accreditation programme (The EPA-program, adapted to Germany and Switzerland called Topaz) that 

focuses on practice management; they found improvements on several quality and safety measures regarding 

complaint management, analysis of critical incidents and quality development (7). A study with two cohorts including 

138 Dutch family practices showed improvement of the quality of primary care for patients with chronic diseases, but 

few could be attributed to the accreditation programme (8). We conclude that there is growing evidence that 

accreditation has an effect, but we do not know at what costs and how much patients benefit. 

Personal view on the coming of age of practice visits 

Collins, an American anthropologist who visited 60 British practices in 1950, published a blistering report in the JAMA 

which was a turnaround for General practice. But visits can be a major, cumbersome enterprise. The profession has an 

obligation to make the procedure as “lean and mean” as necessary. 

Practice visits were the first step towards accountability and transparency and ICT has increased the possibilities to 

make the visit more virtual and lean. Dutch practice visits shifted from internal audit and feedback to meeting 

standards. Consequently accreditation shifted more to certification and has become quite bureaucratic. Often GPs 

delegate required activities to their staff, which make you wonder whether visits may become more of a ritual to get 

protocols in place and to be able to tick them off rather than making an effort to change the culture of the practice. 

After 15 years, Dutch GPs are proud to have been assessed, feel safe to do so and take time to reflect in 

assessment/peer groups or quality circles. Ultimately visits could become obsolete, with mere data and patient 

feedback followed by reflection becoming sufficient to produce quality improvement and innovation. The future may 

be that practices have their own dashboard with data serving an ongoing improvement process. 

Figure 1 Practice visit with auditors and FP 

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Feedback and taking action on feedback have become an ethical imperative for a practice 

Practice visits with a validated tool can provide the necessary feedback on quality of care and patient safety 

and are complementary to self-assessments 

Consensus on framework and indicators for quality of care assist in benchmarking and comparison between 

practices, population/ regions and countries 

Practice visits / generating feedback should be lean and mean 

All GPs and staff always have to be engaged in the feedback and improvement 


http://www.woncaeurope.org/content/175-practice-visits-controlling-doctors-or-improving-practice 

References 

1. Wensing M. A standardised instrument for patient evaluations of general practice care in Europe. Eur J Gen Pract 

2000;6:82-7. 

2. Buetow S, Wensing M. What might European general practice learn from New Zealand experience of practice 

accreditation? Eur J Gen Pract. 2008;14(1):40-4 

3. Jaafaripooyan E, Agrizzi D, Akbari-Haghighi F: Healthcare accreditation systems: further perspectives on performance 

measures. Int J Qual Health Care 2011, 23:645–656 

4. Shaw C, Groene O, Mora N, Sunol R: Accreditation and ISO certification: do they explain differences in quality 

management in European hospitals? Int J Qual Health Care 2010, 22:445–451. 

5. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD: 

Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012, 

6:CD000259 

6. O'Beirne M, Zwicker K, Sterling PD, Lait J, Lee Robertson H, Oelke ND: The status of accreditation in primary care. Qual 

Prim Care 2013, 21:23-31. 

7. Szecsenyi J, Campbell S, Broge B, Laux G, Willms S, Wensing M, Goetz K: Effectiveness of a quality-improvement program 

in improving management of primary care practices. CMAJ 2011, 183:E1326–E1333 

8. van Doorn – Klomberg et al. BMC Family Practice 2014, 15:179 http://www.biomedcentral.com/1471-2296/15/179 

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Paul Moeremans, MD 

pp_rd@skynet.be 

69 – Contribution of Drugs and Somnolence to Car Accidents 

with Victims: A Family Practice Study 

Paul Moeremans, MD 

GP, Mechelen, Belgium 

Somnolence at the wheel 

 

 

 

 

is a major cause of severe car-accidents 

is in most cases preventable 

Family practitioners can detect and prevent most cases 

therapy is expensive but cost effective. 

In 2004 and 2010, the UN General Assembly and World Health Organisation (WHO) 

(1) reviewed the costs of traffic accidents, and unanimously approved a policy 

statement urging that in the years 2011 to 2020, increased attention be given to the 

issue of road safety. The road traffic injury fatality rates per 10.000 population were 

16,6 in South-East Asia; 32,2 in Africa; 32,2 in Eastern Mediterranean; 15,8 in the 

Americas; 13,4 in Europe and 15,6 in Western Pacific. In Australia it has been shown 

that driver fatigue is responsible for 17% of all accidents, 30% of which resulted in 

deaths. In 2010, 41% of a sample of US drivers who responded to a telephone survey 

admitted to having “fallen asleep or nodded of” at the wheel. Road transport causes 

over 95% of travel accidents and 90% of travel fatalities in Europe (2). Obstructive 

sleep apnoea, excessive workload and lack of physical and mental rest are 

preventable causes of sleep restriction, driver fatigue, sleep attacks and falling asleep 

at the wheel. Run-off-the-road single car collisions and head-on collisions by failure to 

brake make up 16% to 20% of serious highway accidents (3). Drivers aged 18-22, 

nurses, medical residents, medical doctors and police officers are especially at risk. Of 

the medical residents who drove after a night shift, 29% reported falling asleep at 

least once while driving and 14% reported a motor vehicle accident (4). 61% of 

accidents and injuries and 36% of fatalities occur between 00 and 08 hours, most of 

these between 03 and 06 hours. Benzodiazepine hypnotics and zopiclone significantly 

impair next morning driving performance. Less than 6 hours nocturnal sleep is 

associated with increased risk of rear-end collisions and single-car accidents (5). 

Maggie’s Law in the state of New Jersey, US, is the toughest and most detailed law 

regarding driver fatigue. A driver who causes a fatal accident after being awake for 

more than 24 consecutive hours can be convicted of second-degree homicide, and 

sentenced up to 10 years in prison. People in the state of heavy tiredness drive 

emergency vehicles and take “controlled” risks (6). Doctors far too often turn a blind 

eye to impaired driving ability of young attention deficit hyperactivity disorder 

patients, and of patients with a severe depression or mania (no reference). Different 

studies performed in many countries show a remarkable similarity of 8% to 10% of 

psychotropic substances in the blood of injured drivers: benzodiazepines, Z-drugs, 

antidepressants, antipsychotics, Parkinson drugs, antiepileptics, sedative antihistamines, 

antidepressants and thymo-regulators in people who were not warned at 

all of the well known vigilance deficits they create, especially in combination with alcohol and illicit drugs such as 

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cocaine, cannabis, designer drugs. 

The Driving under the Influence of Drugs, Alcohol and Medicines project has the acronym DRUID. 

Sleep apnoea syndrome has been identified as the major cause of habitual drowsy driving with a relative risk op six 

than can be reduced five times with continuous positive airway pressure and a major increase in health care expenses. 

Restless legs syndrome, periodic limb movement in sleep, acute and chronic insomnia are preventable causes which 

cause dozing and micro-sleep at the wheel. 

Focusing on these illnesses in primary care could reduce the toll of often very severe vehicle accidents up to 20 to 30%. 

The EQUINOX cross-sectional study was carried out by primary care physicians across ten countries. It highlighted the 

link between insomnia and domestic accidents, work accidents and car accidents. Karolinska Drowsiness Score and 

Karolinska Sleepiness score correlate well with on-board expert driving instructor’s judgement of prematurely 

terminated night drive as a result of sleep-related imminent danger. 

Open window or loud music have little effect. Two or three cups of coffee, about 200 mg caffeine, can delay 

drowsiness for half an hour after nil sleep and up to two hours following sleep restriction. Prophylactic naps are 

effective, especially during night work. 

JOSE 2013, Vol. 19, No. 2 p.303 

An additional but until now never published caveat: many countries introduce a driving licence with points. The 

younger generation who have caused a single car accident while intoxicated with cocaine, cannabis, designer drugs, 

alcohol and most often a cocktail of these can press elderly to declare they were drowsy drivers. 


 

 

 

 

 

Family Doctors, surgeons, and police-officers are especially at risk; 

Not all single car accidents are suicide attempts; 

Sometimes, elderly drivers declare having fallen asleep at the wheel to hide alcohol and drug use of 

youngsters; 

As obesity increases, sleep apnoea increases accordingly; 

Family practitioners should motivate people to use CPAP. 


http://www.woncaeurope.org/content/293-contribution-drugs-and-somnolence-car-accidents-victims-family-practice-study 

214

References 


De Mello, MT., Narciso, FV., Tufik, S.,Paiva, T., Spence, DW. e a. (Mar 2003) Sleep Disorders as a Cause of Motor Vehicle 

Collisions. Int J Prev Med. 4(3):246-257 

Jamroz, K., Smolarek, L. (2013) Driver Fatigue and Road Safety on Poland’s National Roads. Int J of Occupational Safety and 

Ergonomics (JOSE) 19(2):297-309 

Radun, I., Ohisalo, J., Radun, J., Kecklund, G. (2011) Night Work, Fatigued Driving and Traffic Law: The case of Police 

Officers. Industrial Health 49:389-392 

Frchtman, Y., Moser, AM., Perry, ZH. (2011) Fatigue in medical residents: lessons to be learned. Med Lav 102(5):455-463 

WHO Global Plan for the Decade of Action for Road Safety 2011-2020 Consulted on August 21,2014 

http://www.roadsafetyfund.org/UnDecadeOfAction/Documents/global_plan_en.pdf 

ROSPA (June 2011) Driver Fatigue and Road Accidents Consulted on August 21, 2014 

http://www.rospa.com/roadsafety/info/driver_fatigue_2011.pdf 

© imnewtryme on Flickr 

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Isabelle Dupie, MD 

isabelle.dupie@orange.fr 

70 – Talking about Medical Errors: the Bigger Picture 

Isabelle Dupie, MD 

EQuiP delegate 

SFTG - Société Française de 

Thérapeutique du Généraliste 

Paris - France 

Healthcare professionals involved in quality improvement focus more and more on 

active patient participation in the care process. The point is not patient satisfaction, 

but to get the patient involved as the central actor to improve outcomes in all quality 

dimensions, especially in safety. 

The patient has a key-role in hospitals and even more so in primary care: When will 

he call and whom? How does he express and understand his illness? Will he/she 

observe the prescriptions? 

These questions appear essential when dealing with the risk issue. Previous studies 

focused on adverse events (AEs) in primary care showed that some risks can be 

reduced if the patient is well listened to, informed and guided by the surrounding 

professionals. 

At the 2014 Lisbon conference, we presented a French epidemiological study ESPRIT 

(1) collecting AEs in general practice and drawing up a typology. This study showed 

that AEs are frequent in primary care (1 every 2 days, detected by a GP in his 

practice), fortunately with no resulting consequence to the patient in 3/4 cases. 

Some AEs’ examples from this study suggest that the physician-patient interaction 

and the information given to the patient are important to the risk management in the 

outpatient health care system: 

A 78 year-old patient, treated for glaucoma, consults her GP for a prescription 

renewal. By the end of the consultation, he proposes to substitute benzodiazepine for 

an anticholinergic drug. The glaucoma is listed in the patient's history but the 

software alarm does not work when writing the prescription. 

This error resulted in no adverse consequence because the patient, being aware of 

frequent drug contraindications with glaucoma, read the notice and decided not to 

take it. 

The key here was the patient’s health literacy, her ability to draw a conclusion, and 

the relationship’s quality enabling the patient to speak with her doctor about it. 

While electronically composing a prescription, a doctor makes a slip in the 

alphabetical medication list and validates Temesta* instead of Temerit* just above on 

the list. Reading the prescription together, the patient observes she does not 

recognize this drug. 

Joint reading of the newly-issued prescription is a secured practice and signals a good 

doctor-patient relationship. 

Such good practices could be more widespread: a 2013 report from the WHO (2) gives 

the results of a Polish study exploring the knowledge and information the patients 

have at hand about their treatments: only 39% of the patients with chronic diseases knew the name and dosage of the 

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prescribed drugs, 2/3 had a talk about it during the consultation - mostly (93%) at their own initiative; only 6% 

reported that the physician mentioned or discussed the possible drug interactions. 

Diagnostic procedures and investigations also require some information exchange at the right time with the right 

actors: 

A 70 year-old patient consults his GP for diarrhoea associated with poor general condition. The physician orders a 

colonoscopy for his patient as soon as possible. An appointment is organized but two days prior to the exam, the 

endoscopy centre finds out that the patient had not seen the anaesthetist, and postpones the exam for a month. 

The patient was neither aware of the need for an anaesthetist consultation, nor that he had to make the appointment 

himself. 

This was a near-miss: the patient informed the GP, who obtained the anaesthetist consultation in time for the initial 

endoscopy date. 

Mr Y, 80 years old, consults for his anti-hypertensive treatment renewal. Some hours later, the pharmacist calls, 

wondering about the double treatment, duplicating the nephrologists', ordered two weeks before. The GP had not 

received any mail and the patient did not mention it. 

Here, the pharmacist’s mediation averted any harmful consequence. The communication between physicians is an 

issue; however the patient did not provide the link between them. What exactly did he know and understand about 

the treatment change? 

Sometimes, the patient situation is awkward to explain, and tricky to understand: 

A teenager, 14 years old, comes with her mother for a delayed period. In front of her mother, the girl declares she 

never had intercourse. The physician does not order a BHcg level. Some weeks later, the patient comes again and the 

diagnosis of pregnancy is made. 

Communication between patient and physician is a key issue in this diagnosis delay, an incident most feared among 

GPs. However, one cannot assume that a face-to-face interview would have helped the teenager to speak out. 

Obviously patients could significantly contribute to their own safety with better information and understanding of their 

disease and treatment. 

The studies quoted suggest enhancing this new role for the patient, already applied in chronic disease management. 

However, practitioners often regret the constraints of time in training and educating their patients (3). 

But patient safety, transparent communication and mutual patient-doctor trust, are not always easy to conciliate, 

when it comes to the inherent risks linked to care activities. A Danish qualitative study (2013) shows that in oncology, 

patients and physicians talk little about safety (4). Exchanges are limited to medication adherence and some drug side 

effects. According to the physicians, talking about risks, would add unnecessary anxiety. 

With regard to the patients,, there is a large array of feedback, from the continuous demanding of information to 

keeping to the strictly necessary: not everybody “wants to know” … 

Threats to the doctor-patient relationship become more obvious in the case of more direct involvement of patients in 

safety management such as error reports. Patients do not feel comfortable challenging a professional they trust. They 

may fear coming across as “difficult patients” and decreased quality and outcome of care. 

Today general practitioners seem open to the idea of giving a larger and more central place to the patient (5), provided 

that such involvement does not detract y responsibility away from doctors (6). 

Building a comprehensive action to facilitate AE reporting and their analyses in quality circles or other QI programs 

could promote real cultural change and good practices, improving patient-physician communication regarding medical 

errors and risks as well as preventing harm to the patient. 


217


 

 

 

Adverse events are frequent in primary care, mostly with no harm to the patient. 

Better informed and educated patients could significantly contribute to safety improvement. 

Let us get familiarized with preventing, reporting and analysing medical errors. 


http://www.woncaeurope.org/content/333-system-medical-error-disclosure-promoting-quality-care-through-partnership-between 

References 

Michel P. Mosnier A. Kret M. Chanelière M. Dupie I. ESPRIT 2013: a French epidemiological Survey on medical errors 

associated to primary care beh 2014_24-25_1 

World Health Organization 2013 Exploring patient participation in reducing health-care-related safety risks. 

Chapitre V: “Patient safety, rights and medication safety in primary care in Poland” 

Rachel E. Davis MSc. Patient involvement in patient safety: what factors influence patient participation and engagement? 

Health Expectations 2007;10, issue 3 pp.259-267 

Martin HM, Navne LE, Lipzak H. Involvement of patients with cancer in patient safety: a qualitative study of currents 

practices, potentials and barriers. BMJ Qual Saf 2013;22:836-84 

Longtin Y. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc. 2010 January; 85(1): 

53–62 

Lawton R. Armitage G. The role of the patient in clinical safety. The Health Foundation 2012 

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Chris van Weel, MD PhD 

chris.vanweel@radboudumc.nl 

71 – The Optimal Practice Size Revisited – a 

Critical Appraisal of a Topical Discussion in the Light of Academic Leadership 

in Primary Care 

Chris van Weel, MD PhD 

Emeritus Professor of Family 

Medicine/General Practice 

Radboud University Nijmegen, 

the Netherlands 

Professor of Primary Health Care 

Research, Australian National 

University, Canberra, Australia 

Past President of Wonca 


Community Care 

Radboud University Nijmegen 

Medical Centre 

The Netherlands 

Practice size has been an issue in general practice for as long as most of us can 

remember. Although the discussion apparently hinges on the provision of quality of 

care and maintaining clinical experience, more mundane conditions like the number 

of general doctors (GP) in relation to the population, or the GPs’ ability to generate an 

income are never far away from the argumentation. There remain substantial 

differences in the numbers of GPs, proportional to the population [1], and this is also 

true for the performance of GPs in (primary) health care [2]. But there is no 

correlation between GP density and actual performance and never has been: in no 

way are the smaller or larger numbers of patients to be cared for a determinant of the 

care provided [3]. 

Against this background, a Workshop was run at the Kos WONCA Europe conference 

in 2005 on Optimal Practice Size. What To Preserve Of Single Handed Care? [4].The 

workshop reviewed the available literature and then moved to explore the personal 

experiences of participants in their own practice setting. The discussions amongst the 

universally proud GPs were animated, and yielded a diversity of views. And needless 

to say, that the exchanges were highly valued. But with full respect to the workshop 

instigators and participants, one might question the value of the exercise: posing the 

same question over and over again seldom leads to a new answer. 

The occasion of this World Book of Family Medicine offers an opportunity to revisit 

this and explore alternatives to approach the core values of primary care. In this, four 

angles come forward from which to develop these alternatives. 

Variation and value 

Variation is a powerful input to examine practitioners’ performance, trigger discussion 

on alternatives and effectuate change [5]. Variation appears to install feelings of 

unease, differing from one’s peers is seen as a sign of underperformance. Yet, the 

very core of primary health care and general practice is in tuning to the needs of the 

individuals and the community that is served [6]. As communities’ and individual 

needs differ, therefore general practice should differ in approaching these needs. 

Numbers of (general) practitioners per population is part of the variation in the 

context in which primary care operates. Not ‘practice size’ but how apt the practice is 

tuned to the needs of its patients and population should be the core of the 

discussion. 

The lone ranger versus the leader of the pack 

Single handed practice in the community has been the starting point of general 

practice, but for decades there has been an evolution in primary care from the 

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general practitioners to the general practice, from an individual to an institutional level. This is in line with the motor 

car replacing the horse and carriage as the practitioner’s transportation, or the telephone with the knock on the 

doctor’s door to invoke care in the middle of the night. Rather than redoing discussions of old, it might have been 

more appropriate to explore the innovation of practice organisation: how GPs can shape and lead the development of 

their practice to be able to respond to the challenges in nature and volume their practice environment poses. 

General practice or primary health care 

This orientation is the more important in the current development in which mono-disciplinary general practice is 

replaced by an integrated multi-disciplinary primary health care structure. Interconnectedness within primary health 

care, with hospitals, public health and with other sectors in society is required to fulfil the contemporary mission of 

promoting and securing health of individuals and populations [7]. This is a generic principle that has to be translated to 

the conditions on the ground in which GP and practice work and the numbers to consider have to be related to the 

multi-disciplinary team. 

Experience and performance 

A returning argument in the opinions about practice size has been the building and maintaining of clinical experience. 

It goes without saying that hands-on exposure to patients and their health problems are important in developing and 

shaping clinical reasoning. But exposure in itself does little to generate skills. For this, a process of critical reflection is 

required, and it is in the quality, not the quantity of these reflections that GPs’ professionalisation comes about. This is 

the more decisive, as the most important clinical decisions may concern the most infrequent health problems. For this, 

no practice size will ever cater, and exposure alone can never secure the adequacy of clinical decisions. This presents in 

my view the most compelling reason to get away from the ‘ideal’ practice size, recognise the vast importance of 

building skills from clinical exposure and turn to more sophisticated methods to do so. Attributing critical decisions to 

experience or intuition [8] is mystifying, unhelpful and potentially dangerous. It is exactly in this line of thinking that 

discussions on practice size have focused. The engagement of experienced GPs in the workshop in 2005 might have 

made better use of their intellectual skills, by getting to the heart of decision-making in uncertain situations and with 

few available data – better than fixating on a number for the size of their practice. 

Conclusions 

Looking back objectively, the workshop in 2005 might have been better directed at the leadership role of GPs – in 

transforming the context of their practice setting from single-handed, mono-disciplinary to integrated multidisciplinary 

teams; in exploring the nature of functional differences between practices; and in focusing on the innermind 

processes of how their decisions under real life circumstances come about – rather than fixating on an ideal 

number criterion. But GPs work with and in time to solve problems, and this makes 2015 the first opportunity to 

address these issues after all. 


 

 

 

 

Single-handed general practice is a feature of the profession’s past, as a consequence of its ever more 

prominent role in health care. 

Size and disciplinary composition have to be determined by the needs of the practice community. 

It is not possible to build expertise and knowledge simply on experience from exposure to primary care health 

problems. 

As primary care has to direct and adopt the local needs and conditions, practice variation can be an indicator 

of quality as much as lack of quality. 


http://www.woncaeurope.org/content/777-wo-optimal-practice-size-what-preserve-single-handed-care 

References 

World Health Organization Europe, European health for all Database, Copenhagen: WHO-regional Office for Europe, 2002. 

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http://data.euro.who.int/hfadb/ (accessed 27 October 2014). 

Kringos DS. The Strength of Primary Care in Europe. Utrecht: NIVEL, 2012. 

http://www.nivel.nl/sites/default/files/bestanden/Proefschrift-Dionne-Kringos-The-strength-of-primary-care.pdf 

(accessed 27 October 2014) 

van der Zee J, Kroneman M, Boerma W. De Nederlandse huisarts in Europees perspectief. [The Dutch GP in a European 

context.]Huisarts Wet 2004;47:266-73. Abstract in English. http://www.henw.org/archief/volledig/id2956-denederlandse-huisarts-in-europees-perspectief.html 

(accessed 27 October 2014). 

Hombergh P van den, Weel C van, Seuntjes L, Isar C. Optimal Practice Size. What To Preserve Of Single Handed Care? 

Abstract 777 (Wo). Wonca Europe Conference, Kos, 2005. 

Wensing M, Broge B, Kaufmann-Kolle P, Andres E, Szecsenyi J. Quality circles to improve prescribing patterns in primary 

medical care: what is their actual impact? Journal of Evaluation in Clinical Practice 2004; 10: 457–466 

Wonca Europe. The European Definition of General Practice/Family medicine. 2011 revision. 

http://www.woncaeurope.org/sites/default/files/documents/Definition%203rd%20ed%202011%20with%20revised 

%20wonca%20tree.pdf (accessed 27 October 2014). 

De Maeseneer J, Roberts RG, Demarzo M, et al Tackling NCDs: a different approach is needed. Lancet 2012; 379: 1860- 

1861http://hdl.handle.net/1854/LU-2111512 (accessed 27 October 2014) 

van Weel C Primary health care and family medicine at the core of health care: challenges and priorities in how to further 

strengthen their potential. Front. Med. 2014 1:37. doi: 10.3389/fmed.2014.00037 

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Rita Viegas, MD 

ritapaviegas@gmail.com 

72 – Revisiting “Home Visits: Your Practice on the Road” 

Rita Viegas, MD 

Family Doctor, Unidade de Saúde 

Familiar da Cova da Piedade, 

Portugal 

Co-authors 

Teresa Peneda, Marta Fragoeiro 

Home visits have been a central part of medical practice and were once a standard of 

practice (1). The number of home visits made by physicians has consistently declined, 

being today less than 1% of all patient-physician encounters, with the average doctor 

conducting fewer than one house call per week in the United States (2). In most 

European countries, home visits are increasingly becoming an exception and common 

reasons cited for this decline are inadequate compensation, the time required, 

limitations of technological support and poor physician training and exposure in this 

area. 

Today there are 174 million people aged 65 years or older, in Europe and North 

America. A further increase of about 93 million people is expected within the next 20 

years; a fact that illustrates the acceleration of an ageing population (3) and that a 

considerable number of persons will live home-bound, reinforcing the need for home 

visits. 

This reality requires a thoughtful definition of the rationale for home visits in order to 

improve efficiency of care and optimization of physician’s time and community 

resources, as the effective use of home care services has become a core competency 

for family physicians (1). 

Home visits: who and how? 

The major types of home visits reflecting patient-related situations viewed as a 

priority by the general practitioner (1): 

 

 

 

 

 

patient assessment: polypharmacy, comorbidity, immobility, social isolation, 

frailty, suspected neglect; 

illness management: emergency, acute and/or chronic conditions; 

dying patients: palliative/terminal care, grief support; 

post hospitalization follow-up; 

and preventive house visits. 

A cross sectional study (4) which meant to evaluate which older people benefit most 

from a comprehensive geriatric assessment, concluded that general practitioners 

should, at least, target older people with ≥ two chronic conditions, using ≥ five 

medications, being female of an older age, living alone and less educated. 

An effective home visit implies developing a systematic approach that includes 

advanced planning, minimal interference with daily practice, establishing the reason 

and type of home visit, gathering the necessary equipment and establishing a formal 

hour for the visit. 

The INHOMESSS mnemonic (1) still reflects the components of a holistic house call 

and helps the physician remember some items to consider in a possible check-list: 

Impairments/ Immobility, Nutrition, Home environment, Other people, Medication, Examination, Safety, Spiritual 

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health and Services. In the majority of house visits only specific elements will be addressed, allowing the conciliation 

between patient needs and the physician´s agenda. 

The equipment recommended for a house call should include: map, mobile phone, physical exam instruments and 

documentation as dictated by the patient and type of home visit. The technological evolution has made computers 

easily portable and internet connection widespread. This previously considered “optional medical equipment” has 

become fundamental for daily practice, allowing accurate record-keeping and access of important patient information 

and clinical tools for evidence-based decision making. 

Overcoming barriers 

Scheduling visits in geographic clusters and choosing a specific day/hour for home visits allows time optimization. The 

restricted diagnostic options available in the domestic setting are being overcome by the use of easily accessible 

technology, as the ever-expanding contents of the modern-day “black bag”, which can include everything from a 

Blackberry to portable IV medications, keeps evolving. Concern about personal safety is reduced if the physician knows 

the community, makes daytime visits, carries a mobile phone or is accompanied by other health professionals. 

The establishment of a “home visits curriculum” should be considered during medical training. The use of role models 

as well as mandatory and longitudinal clinical time provision of home visits and residential care will produce both 

challenges and opportunities. This will allow family physicians to become more confident when providing home care. 

What does the evidence tell us today? 

The number of home visits is continuously declining while the primary target group, older people with multimorbidity, 

is growing. These contradictory findings are sustained by several studies published in the last two decades, which have 

analysed the number of home visits from either quantitative surveys or practice data (5). 

Since 2000, five English language systematic reviews have been published with conflicting results. Some reported that 

home visits and primary care programmes did not affect mortality, physical and psychosocial function, health status or 

health care use and costs; others concluded that these programmes reduced mortality, admissions to long-term care 

facilities and functional decline (6). Home visits were not consistently associated with differences in mortality or 

independent living; investigations of heterogeneity did not identify any programmes that were associated with 

consistent benefits, although the poor reporting of intervention components and delivery, did not allow for the 

possibility that some programmes may be effective (7). 

Looking to the future 

Quality of primary health care must be maintained while improving the quality of home visits. This modernisation 

implies designing effective and scalable programmes, developing education and training skills of general practitioners 

and their vocational trainees, investing in research and in continuous evaluation of the implemented programmes 

(5,6). Learning and adapting from specifically designed home-based primary care programmes can considerably affect 

patient, caregiver and systems outcomes; high-quality evidence from the Veterans Affairs System in the United States 

shows that these programmes can substantially reduce emergency department visits, hospitalizations, and long-term 

care admissions (8). Making theses outcomes reproducible would be critical to maintain the quality of life and function 

of the elderly and home-bound population, as well as to allow the sustainability of the health care system worldwide. 


 

 

 

 

The ageing population make home visits increasingly necessary and their rebirth must be seen as an essential 

part of a community integrated care programme. 

There are suggested economic benefits by eliminating unnecessary emergency room visits and by ensuring 

adequate health care for housebound elderly, although these presumed advantages must be critically 

addressed by further research. 

The challenge concerning home visits is making them cost and time effective, attractive, unthreatening and 

rewarding for family doctors. 

Continual medical education and resident training programmes are fundamental for providing physicians with 

the attitudes, knowledge and skills to conduct home visits effectively. 

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Home visits may provide benefits to patients and physicians, with their potential to re-establish a more 

intimate doctor-patient relationship. The opportunity of taking care of patients in their own home allows the 

perception of their living environment, support system and overall safety which gives the family doctor an 

insight that cannot be gleaned from office or hospital visits. 


http://www.woncaeurope.org/content/926-po-home-visits-your-practice-road 

References 

1. Brian K. Unwin; Paul E. Tatum III. House Calls. Am Fam Physician. 2011; 83(8): 925-931. 

2. American Academy of Family Physicians. Table 6: Average Number of Family Physician Patient Encounters Per Week by 

Setting, December 2013.http://www.aafp.org/about/the-aafp/family-medicine-facts/table-6.html. Accessed Nov 15, 2014. 

3. Rodrigues, R., Huber, M. & Lamura, G. (eds.) (2012). Facts and Figures on Healthy Ageing and Long-term Care. European 

Centre for Social Welfare Policy and Research: Vienna. 

4. Stijnen MM, Van Hoof MS, Wijnands-Hoekstra IY, Guldemond-Hecker Y, Duimel-Peeters IG, Vrijhoef HJ, Jansen MW. 

Detected health and well-being problems following comprehensive geriatric assessment during a home visit among 

community-dwelling older people: who benefits most? Fam Pract. 2014 Jun;31(3):333-40. doi: 10.1093/fampra/cmu015. 

Epub 2014 Apr 15. 

5. Theile G, Kruschinski C, Buck M, Muller CA, Hummers-Pradier E. Home Visits - Central to Primary Care, Traditionor an 

Obligatin? A Qualitative Study. BMC Fam Pract. 2011;12. 

6. Stall N, Nowaczynski M, Sinha SK. Back to the future: home-based primary care for older homebound Canadians. Part 1: 

where we are now. Can Fam Physician 2013;59:237-40. 

7. Mayo-Wilson E, Grant S, Burton J, Parsons A, Underhill K, et al. (2014) Preventive Home Visits for Mortality, Morbidity, and 

Institutionalization in Older Adults: A Systematic Review and Meta-Analysis. PLoS ONE 9(3): e89257. 

doi:10.1371/journal.pone.0089257. 

8. Stall N, Nowaczynski M, Sinha SK. Back to the future: home-based primary care for older homebound Canadians. Part 2: 

where we are going. Can Fam Physician 2013;59:243-5. 

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Fusun Yaris MD, PhD 

fyaris@omu.edu.tr 

73 – Re-training of GPs: A EURACT Survey 

Fusun Yaris MD, PhD. Professor 

Ondokuzmayis University School 

of Medicine, Department of 

Family Medicine Samsun – 

Turkey 

Co-author 

Mustafa Fevzi Dikici, MD 

Professor 

Medical education’s ultimate aim is to supply society with knowledgeable, skilled and 

updated professionals who put patient care above self-interest, and undertake to 

maintain and develop their expertise over the course of a lifelong career (1). Many 

areas of education and training bring together both functions within a learning 

experience. The two may be differentiated by thinking of: education as being about 

doing better, training as being about taking on new tasks (2). In recent years, major 

components of healthcare have been transferred out of the hospital and are now only 

found in the community. Chronic diseases are managed primarily in community. This 

experience is unique for the trainees (3). 

At the postgraduate level, lectures are of even less value than at the undergraduate 

level, yet they are used just as frequently. Trainees gain far more from small group 

teaching sessions and on-the-job training than from, for instance, revision courses for 

passing membership exams. In the UK, primary care has tended to lead the way with 

its long-established one-to-one training relationship and regular group-based release 

courses, but effective education and training is also possible in secondary care and 

the training need not be one to one. It is common practice to train senior doctors, 

junior doctors and medical students concurrently (1) and training requires a multiprofessional 

approach in primary care (2). Flexible training often has low priority in 

general practice departments (4). Doctors are eligible for flexible training if they have 

well-founded reasons such as young children or disability (4). 

Educational needs assessment 

Educational needs assessment tools have been developed to help primary care 

practitioners identify their learning needs (2). Comprehensive check-lists or 

organizational development tools can help any organization to identify its learning 

needs from individual practitioners’ or the organizational perspective. The outcome 

should be to evolve learning culture while addressing these needs. Local coordination 

of the training programmes helps to reduce duplication of resources. In Turkey, during 

the first phase recertification programmes of primary care doctors, needs assessment 

was used for the planning of the second phase retraining programme (5). 

Evidence based training 

Best evidence medical education has been defined as the implementation by teachers 

in their practice, of methods and approaches based on the best evidence available 

(2). Guidelines can be used for this purpose and impact of training on the practice, 

prescriptions, and cost-effectiveness can be evaluated (6). 

Educational Plans and Monitoring 

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Assessment of your training needs as a teacher, or other health professionals must take account of the differing 

priority areas of the government, your health organization as well as the influences on public. We need to decide how 

to balance the priorities (2). A supervisor works with the learner to develop and facilitate an educational plan that 

addresses their educational needs and monitors following training (2). 

Teacher in primary care 

A teacher does not only need sufficient knowledge, skills, but also the right attitude and understanding of the overall 

context and cultural environment to be able to make the teaching relevant to the learner’s needs (2). 

Assessment of learning in General Practice 

Assessment is a measurement of achievement of progress towards meeting defined educational objectives. Formative 

assessment to give feedback to learners in order to guide progress may be used. Summative assessment can also be 

used. Programme evaluation and in-training assessment are necessary to be flexible in the primary care. Validity, 

reliability, educational impact, acceptability, feasibility, and efficiency are the characteristics of good assessment for 

general practitioners. Check-lists, rating scales, and portfolio may also be integrated. General Practice requires 

proficient team work, therefore team and the patients should assess the trainee (7). Objective structured clinical 

examinations can be used with simulated/standardized patients (8). Continuing professional development (CPD) 

The aim of continuous medical education is to sustain the professional development of general practitioners and help 

them to provide high-quality patient care and to keep up to date with developments in general practice (4). The 

accredited professional development programme is designed as a new approach to CPD in order to offer ongoing 

support as general practitioners continue their professional development as part of their everyday practice (4). The 

process is a semi-structured process that will help general practitioners to collect all information and evidence that will 

be required for annual appraisals and revalidation over a five year period (4). 

Lifelong learning 

The structure of the programme is to encourage learning for the individual’s needs. It is well focused on the day to day 

work of the average GP. This programme allows GPs to plan their learning and also provides evidence and 

documentation which will be useful for appraisals and revalidation in the future (4). 

Turkey 

In Turkey, physicians who choose to specialize in family medicine or other specialties have to pass a standard exam, 

which allocates them to a residency programme according to their score. The physicians who do not pass the specialty 

exam are also granted a certified family doctor position with a smaller salary than specialists in the National Primary 

Health Care System. Both family medicine specialists and certified family doctors work in primary care in rural and 

urban areas. In Turkey, family medicine is a relatively new specialty having been established through legislation in 

1983. The first vocational training programme was started in 1985. Retraining is mandatory for certified family doctors, 

but not for family medicine specialists. Starting with pilot provinces, retraining of the 25 thousand certified family 

doctors has been ongoing since 2004 all over Turkey, based on needs assessment and guidelines for primary care (5). 


 

 

 

 

 

Training requires a multi-professional approach in primary care. 

Trainees gain more from small group teaching sessions. 

Educational needs assessment tools have been developed to help those in primary care identify their learning 

needs. 

Guidelines can be used for evidence based training. 

The aim of continuous professional development is to sustain the professional development of GP’s and to 

keep up to date with developments in general practice. 


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http://www.woncaeurope.org/content/ws-027-re-training-gps-%E2%80%93-euract-survey 

References: 

1. Swanwick T, Buckley G. Introduction: Understanding medical education. McCrorie P. Teaching and leading small groups. In: 

Understanding medical education. Evidence, theory and practice. Ed. Swanwick T. Wiley& Blackwell Publications. 2010, NJ, 

USA. PP: 15-16 and 124-39.. 

2. Mohanna K, Wall D, Chambers R. Chapters: Healthcare teaching in context. Providing supervision and support. In: 

Teaching made easy. A manual for health professionals. Second ed. 2004. Radcliffe Medical Publications, Oxon, UK. PP: 12- 

28, 169- 87. 

3. Stephenson A. Learning in General Practice: Why and How? In: A textbook of general practice. 3rd Ed. Hodder Arnold 

Company. 2011, Kent, UK. PP: 1-7. 

4. Hastie A. Flexible training for general practice. Jenkins P, Finlay K. Accredited professional development. In: The General 

Practice Journey. The future of educational management in primary care. Swanwick T, Jackson N (Eds). 2003. Radcliffe 

Medical Publications, Oxon, UK. PP: 67- 70 and 103- 6. 

5. Dikici MF, Gorpelioglu S, Ersoy F, Yaris F, Filiz TM, Topsever P, Gurel S, Cubukcu M, Akturk Z. First results of Second Phase 

Needs Assessment in the pilot cities of Turkey. Family Medicine Actual and Scientific Journal. 2007; 1 (5- 6), 12- 13 (In 

Turkish). 

6. Dikici MF, Yaris F, Artiran Igde F, Yarar F, Altuntas O, Alper Gurz A. Effect of a workshop in rational pharmacotherapy for 

interns during family medicine clerkship in Samsun- Turkey. Pak J Med Sci. 2014 Mar; 30 (2):305-9. 

7. Hays R. Assessment of learning in general practice. In: Teaching and learning in primary care. Radcliffe Publishing, 2006, 

Oxon, UK. PP: 25- 36. 

8. Muller E, Mehay R, Seigel S, Lamb I. A smorgasbord of educational methods. In: The essential handbook for GP training 

and education. Mehay R. (Ed). Radcliffe Publishing, London, UK. PP: 45-68. 

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Tobias Freund, MD 

Tobias.Freund@med.uni-heidelberg.de 

74 – Primary Care Based Case Management – Current Research 

and Implications for Daily Practice 

Tobias Freund, MD 

Dep. of General Practice and 

Health Services Research 

University Hospital Heidelberg, 

Germany 

Co-authors 

Peters-Klimm F, van Lieshout J 

Disease, case or care management? A history of terms 

What is meant by disease, case or care management? A variety of definitions behind 

these terms often hinders a cross-national or even a national comparison of effects of 

these care models on patient outcomes. We do not want to aggravate this problem by 

providing new definitions for these terms. In contrast, a short overview of the history 

of these terms and the concepts behind them will help to clarify things. 

Historically, “case management” is the oldest of these terms first used during the deinstitutionalization 

movement in psychiatric care in the 1970’s. With shifting the focus 

from in-hospital psychiatric care to community based psychiatric care, concepts were 

needed that actively approach “complex”, “critical” or “high-risk” patients in order to 

monitor their health status continuously. During the 1980’s, case management was 

introduced nationwide in the USA, resulting in the foundation of the Case 

Management Society of America (CMSA) in 1990. The CMSA defines case 

management as a “collaborative process of assessment, planning, facilitation, care 

coordination, evaluation, and advocacy for options and services to meet an 

individual’s and family’s comprehensive health needs through communication and 

available resources to promote quality, cost-effective outcomes” [1] including social 

services and health services. 

The term “Disease management”, however, was invented and implemented by US 

pharmaceutical companies in the 1990’s to foster evidence-based care (mainly 

medication) for specific chronic diseases. Besides its focus of single diseases, disease 

management programmes vary enormously by both intention and intervention. 

Bodenheimer and colleagues [2] defined the term “care management” in contrast to 

“case management” to distinguish concepts focusing on patient (health) care from 

those focusing on social care. However, case management and care management 

share the same generic process of assessment, care planning, action/intervention and 

monitoring. 

Case management – basic concept 

The basic concept of case management (see figure 1) comprises of 5 steps: 

a) Case finding 

Evidently, the highly resource-intensive process of case management cannot be 

offered to all patients. Therefore, identification of patients most likely to benefit from 

case management, a process called “case finding” is crucial for the success of a case 

management intervention. The most common case finding methods are referral, 

patient survey/health assessment or predictive modelling of future adverse events (e.g. hospitalizations). 

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b) Assessment 

A structured assessment of patients’ needs and resources is the first step of case management. It is often performed 

by nurses or other non-physician health professionals. 

c) Planning 

Once needs and resources of a patient are evident, comprehensive care planning together with patients and caregivers 

is essential to focus case management on problems which could be addressed by the intervention. Long term goals 

and short term actions plans should be laid out explicitly. Planning often includes supervision by physicians, 

particularly if medication regimes have to be changed. 

d) Action 

In every case, specific actions have to be undertaken by patients, caregivers or health professionals (e.g. selfmonitoring 

of symptoms by patients, modified medication regime etc.) 

e) Monitoring 

Ongoing pro-active monitoring of patients` symptoms, health status and progress in achieving his or her goals is crucial 

for case management. Monitoring is often performed by nurses via telephone on a monthly or bi-monthly basis. 

Thereby, clinical deterioration of patients can be detected early. 

Figure 1: Basic concept of case management (3) 

(Freund et al. BMC Health Services Research 2010 10:112 doi:10.1186/1472-6963-10-11). 

Case management should be primary-care based. 

The basic principle of patient-centred, comprehensive care for the most vulnerable patients meets the core ideas of 

family medicine as defined by WONCA [4]. Therefore, case management is and should be part of primary care 

management of complex patients. 

Case management can easily be provided by specially trained non-physician health professionals. Nurses are the most 

common profession providing case management in the US, the UK and in many other countries. But as case 

management is mainly focused on complex, high risk patients, health insurance companies have special interest in 

offering these programmes in order to improve health and to reduce costs. This has led to the development of vendorsupported, 

external case management programmes offered by a number of health maintenance organizations (HMOs) 

in the USA. However, patients’ acceptance of these programmes is much lower when compared to case management 

programmes offered by “their” primary care clinics [2]. 

What does research say? 

In 1998 the first literature review on primary care-based case management concluded that none of the programmes 

supervised by generalists showed a positive effect on resource use [5]. Since then, evidence on primary care-based 

case management has been expanded by a large number of studies. First results of an ongoing systematic review show 

positive outcomes of primary care-based case management particularly in high risk patients [3]. Core features 

common to many of the more successful models, include: systematic identification and intensive care management 

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(including frequent face-to-face contact) of high-risk patients; primary care physicians collaborating with on-site 

registered nurses and other staff (all working in redefined roles “at the tops of their licenses”); health information 

technology that facilitates coordinated care; engagement of patients and their family; 

caregivers in evidence-based health education and self-management; easy 24/7/365 access to primary care for 

emerging problems; well-coordinated transitional care following hospital discharges; comprehensive medication 

management; and the integration of community-based support services into health care [6]. 

Future developments may include primary care based case management supervised by nurses [7] as well as more 

sophisticated ways of case finding including both prediction of patients’ risk of adverse outcomes and their ability and 

willingness to participate in case management – a concept called “care sensitivity” [8]. 


 

 

 

 

Person-centred, comprehensive management of vulnerable patients (i.e. “case management”) is a core 

element of primary care. 

Primary care-based rather than vendor-supported case management is well accepted by patients and 

physicians. 

Case management should focus on high risk patients with sufficient “care sensitivity” (i.e. willingness and 

ability to participate). 

Case management is a multi-professional approach that engages non-physician primary care team members 

to work “at the top of their license”. 


http://www.woncaeurope.org/content/ws-03-primary-care-based-case-management-%E2%80%93-current-research-andimplications-daily-practice 

References 

1. CMSA 2014. Definition of case management. URL: 

http://www.cmsa.org/Home/CMSA/WhatisaCaseManager/tabid/224/Default.aspx. 

Accessed Oct 3 1st 2014 

2. Bodenheimer T. Berry-Millett R. Care Management of patients with complex health care needs. Robert Wood Johnson 

Foundation. Research Synthesis Report No. 19 December 2009. 

http://selfmanagementsupport.health.org.uk/media_manager/public/179/SMS_resourcecentre_publications/Bodenheimer%20Care%20Mgt%20RWJreport.pdf 


3. Freund T, Kayling F, Miksch A, Szecsenyi J, Wensing M. Effectiveness and efficiency of primary care based case 

management for chronic diseases: rationale and design of a systematic review and meta-analysis of randomized and nonrandomized 

trials [CRD32009100316]. BMC Health Serv Res 2010; 10: 112 

4. The European definition of General Practice / Family Medicine 2011. http://www.woncaeurope.org/gp-definitions. 


5. Ferguson JA, Weinberger M. Case management programs in primary care. J Gen Intern Med. 1998 Feb;13(2):123-6 

6. Boult C, Leff B, Boyd CM, Wolff JL, Marsteller JA, Frick KD, Wegener S, Reider L, Frey K, Mroz TM, Karm L, Scharfstein DO. A 

matched-pair cluster-randomized trial of guided care for high-risk older patients. J Gen Intern Med. 2013 May;28(5):612- 

21 

7. Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. 

Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010 Dec 30;363(27):2611-20. 

8. Freund T, Wensing M, Geissler S, Peters-Klimm F, Mahler C, Boyd CM, Szecsenyi J. Primary care physicians' experiences 

with case finding for practice-based care management. Am J Manag Care. 2012 Apr 1;18(4):e155-61. 

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François Héritier, MD 

heritier.vf@vtxnet.ch 

Country? 

François Héritier, MD 

Swiss Association of GP’s 

Co-author 


75 - How Would Citizens Develop the Health Strategy of Their 

Introduction 

Answering this question could give more importance to a bottom-up health strategy, 

allowing citizens the right to choose and decide the most appropriate health care 

system adapted to their needs. Is it possible in a health world dominated by 

centralized and top-down policies under the pressure of economics, which forget that 

Health is a value and not only cost-factor? Are there successful examples? 

Individual behaviour 

First of all we can assume that individual changes in lifestyle will improve health 

outcomes. It is not really «strategy» but it certainly does have an impact. An 

individual is able to do a lot to improve his well-being starting early in life. The health 

behaviour of a pregnant woman may influence the lifelong mental and physical 

conditions of her baby. Early, adapted and repeated interventions at school (1) 

regarding better nutrition and physical activities can improve the health status of 

children. Self responsibility at any age moving towards healthier behaviour (e.g. 

stopping tobacco) contributes to better health outcomes of a nation. 

By interfering with the mode of urbanization, demanding a reduction in car exhaust 

emissions, decreasing air pollution, protesting against fracking, and other 

environmental acts, citizens can prevent ill health-related measures. 

Actions against global warming, such as bringing fossil fuel consumption to an end 

and investment in alternative energy, are an emergency according to the latest report 

of the Intergovernmental Panel on Climate Change in March 2014 (2). Such actions 

are necessary to prevent increasing illnesses from food-, water- and vector-borne 

diseases. Citizens can thus individually and indirectly weigh on health policies. 

Democracy and peoples’ input 

At national level, with a direct democracy system like in Switzerland, a group of 

citizens can modify a law or the direction of a policy. Facing an increasing shortage of 

primary care physicians and a loss of consideration in comparison to specialists, the 

Swiss Association of Family Doctors put forward a popular Initiative with 200,000 

signatures in 2010 to change the Constitution, defining primary care as essential for 

the Swiss health system and demanding that the State assure better education and 

financial support for family medicine. When a minimum of 100,000 Swiss citizens put 

forward such a petition it obligates the Government and the Parliament to propose 

new laws or to apply the petition. Finally, all citizens have to vote on it. This took 

place on May 18 th , 2014 in Switzerland and the new constitution was approved by the 

people with a majority of 88%. Nowadays, there is a directive in the Swiss health 

system clearly based on primary care and obliging the Authorities to legislate on 

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better education and financial incentives for family doctors. The first concrete achievement occurred in October 2014, 

with the provision of around 150 Million Euros from specialists’ budget allocated to family doctors. Such an example 

proves that the mobilization of citizens can influence a national health strategy. Could the Swiss example inspire other 

countries? Every situation is different… 

In England in 1996, randomly selected groups of citizens were questioned about their views on the current state of 

their country’s health strategy and on their ideas for its development compared with the government’s 1995 plan. In 

conclusion, citizens «should contribute to but not determine health strategy». Citizens may produce fresh ideas but 

perceive as inadequate the existing arrangements to screen certain types of cancer, although such screening is 

evidence based (3). This proves that individual points of view without a global perspective do not define a strategy. 

The increasing complexity of health care organizations combined with the pressure of costs seems to anaesthetize 

individual initiatives. Or are the health care systems still comfortable enough not to mobilize the population? 

In Canada in 2002 (4), dialogue sessions with members of the public were used to help define a new health policy. 

Twelve sessions of a full day of dialogue were held across the country, each with about 40 citizen participants aged 18 

years and over, randomly selected to provide a representative cross section of the Canadian population. People 

working in the healthcare system were excluded. Combining their roles as patients, taxpayers and members of the 

community, participants reframed the healthcare contract, redefining both individual and collective responsibilities. 

This had an important impact on the ensuing debate, giving for example a stronger direction for primary care. In 

conclusion, such engagement of the public may be costly but an essential requirement when opinions are unstable and 

difficult decisions must be made. 

An article published in 2004 by De Vos and colleagues (5) analyses the evolution of the European health systems. The 

authors demonstrate how, since the 1990s, the European Union has built a strict financial and political straitjacket, 

forcing these systems to carry out privatization and cutbacks. Reform measures can be divided into three 

interdependent categories: 1) the increasing influence of governments on health care organization, to enable 

restructuring; 2) measures aimed at reducing public expenses, including higher financial contributions by patients and 

restrictions on the range of services provided; and, 3) measures that establish competition and hide or open 

privatization of services and insurance systems. 

The De Vos et al publication is already 10 years old, during which time the economical crisis of 2008 has taken place , 

with no change whatsoever to this trend. 

Is this not a contradiction with the growing collective needs? Is it not a threat to health and social security? The 

defence of the European welfare state is one of today’s most important challenges. Are citizens aware of the dangers 

and able to mobilize? Finally as voters, we all have a responsibility to elect or change our authorities if we do not agree 

with their strategies. 

Future involvement 

In a time when social media is creating new ground, can we imagine someone inventing an even more direct 

democracy than the Swiss model? Groups like Avaaz (6) gather clicks but also voices to get their opinion heard. 

All forms are probably necessary bearing in mind that humanity has always used both the pioneers and the 

conservative power brokers in order to maintain the equilibrium in society. 


 

 

 

Individual changes of lifestyle improve health outcomes and can thus indirectly weigh on health policies. 

A direct democracy system or randomly selected groups of citizens can contribute to health strategy when 

difficult decisions need to be made. 

In a moving and increasingly connected world, new ways of mobilization are appearing, from citizen to 

netizen. For a better humanity? 


http://www.woncaeurope.org/content/6-s-health-their-nation-how-would-citizens-develop-englands-health-strategy 

References 

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1. Summerbell CD1, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ. Interventions for preventing obesity in children. 

Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001871. http://www.ncbi.nlm.nih.gov/pubmed/16034868 

2. IPCC - Intergovernmental Panel on Climate Change www.ipcc.ch 

3. Bradley N, Sweeney K, Waterfield M. The health of their nation: how would citizens develop England's health strategy? Br 

J Gen Pract. 1999 Oct;49(447):801-5. http://www.ncbi.nlm.nih.gov/pubmed/10885084 

4. Maxwell J, Rosell S, Forest PG. Giving citizens a voice in healthcare policy in Canada. BMJ. 2003 May 10;326(7397):1031-3. 


5. De Vos P1, Dewitte H, Van der Stuyft P. Unhealthy European health policy. Int J Health Serv. 2004;34(2):255-69. 


6. The Avaaz community http://www.avaaz.org/en/ 

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Alexandre Gouveia, MD, GP 

alexandre.gouveia@me.com 

76 – Drafting A Practice Professional Development Plan: A 

Learning Exercise Using A Continuous Quality Improvement Approach 

Alexandre Gouveia, MD, GP 

Department of Ambulatory Care 

and Community Medicine, 

Polyclinique Médicale 

Universitaire, Lausanne, 

Switzerland 

Primary health care services are still provided in many GP single-handed practices 

around the world. However, primary health care is increasingly being delivered by 

practices with multidisciplinary teams that include doctors, nurses, health care 

assistants, receptionists, physiotherapists, psychologists, and social workers, among 

many others. 

A team is, by definition, a group of people that have complementary skills and 

generate synergy through a coordinated effort, which allows each member to 

maximize their strengths and minimize their weaknesses. However, each team 

member has a specific set of knowledge, skills and attitudes, as well as personal 

values, experiences and ambitions. Teams are a highly challenging and enthusiastic 

environment to work in and to work with. 

To be able to face the daily requests of patients and challenges posed by health 

administrations and primary care organisations, teams need to be open to change, to 

be innovative, multi-skilled and efficient, well managed and popular while respected 

in the community. Team members can only reach this high level of performance if 

they concentrate efforts while being coordinated by a leading member. 

Leadership is nowadays recognized as an increasingly fundamental skill that needs to 

be developed and trained by every primary care doctor. However, only some will 

master the five skills defined by the Clinical Leadership Competency Framework: 

 

 

 

 

 

Demonstrating Personal Qualities 

Working with Others 

Managing Services 

Improving Services 

Setting Direction 

The Working Party on Quality Improvement from the World Organization of Family 

Doctors (WONCA) defined quality in primary care as being “the best health outcomes 

that are possible, given available resources, and that are consistent with patient 

values and preferences”. To achieve higher quality in primary care, leadership is seen 

as a crucial skill to help the entire team to understand the value of adopting a quality 

improvement approach. 

One of the quality improvement strategies that teams can apply is the Practice 

professional development plan, or PPDP, defined as follows: 

A Practice Professional Development Plan describes the developments planned, and 

the specific educational actions for individuals, groups and the whole team to enable 

the Practice to improve care, and which is reviewed annually. 

The PPDP is a team-based approach for quality improvement that relies on the 

assessment of needs, together with planning and implementation of a collectively owned project, which should be 

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meaningful for the team, evidence-based and centred in patient care. The main purpose of the PPDP is to enable the 

primary health care team to focus on the objectives and priorities for future years and to identify continuing needs. 

Through effective leadership, teams might allocate directed efforts and protected time for the development and 

implementation of their PPDP. Evidence shows that PPDPs can improve patient care, although results are sometimes 

only seen at a later stage. 

Each PPDP should be structured according to the team’s needs and goals, to be owned by the team and to be 

perceived as a collective effort. The following draft and its components can be used as a starting point for more 

complex and ambitious plans. 

Topic Goal Strategy for 

improvement 

Assessment methodology 

Team members 

involved 

Deadline 

Colorectal cancer 

screening rates 

To audit and 

improve 

colorectal 

screening rates in 

our practice 

population 

Local protocol to be 

produced and 

implemented in 

January 2015 after 

team discussion 

Screening rates are 

assessed yearly and 

published in the annual 

practice report in each 

January 

AG, SL July – 

December 

2014 

Internal 

communication 

To develop and 

improve 

communication 

between team 

members 

Outdoor team-work 

activities and interprofessional 

collaboration 

workshops 

Working conditions 

appraisal by team 

members to be done at 

the end of each year 

JMC, FA January – 

December 

2014 

Prescription 

errors 

To avoid harmful 

drug interactions 

in medical 

prescriptions 

Learning activities 

and practical 

workshops 

One week audit of 

medical prescriptions 

AO July 2014 

The Plan-do-study-act cycle is one of the approaches available for quality improvement. It’s a feasible strategy to be 

used in the implementation of the PPDP, although its effectiveness is quite variable. In the ‘plan’ stage a change aimed 

at improvement is identified, the ‘do’ stage sees this change tested, the ‘study’ stage examines the success of the 

change and the ‘act’ stage identifies adaptations and next steps to inform a new cycle. 

Although a PPDP represents an efficient and simple tool for organisational quality improvement, it has considerable 

obstacles in its implementation and success. Teams need to be aware that PPDPs require protected time for its design, 

an enduring commitment for its implementation and a rigorous assessment of the proposed outcomes. Even if the 

achievement of the desired objectives might not be reached, this does not represent a defeat. In sum, it’s the process 

itself of developing and implementing a PPDP that matters the most. 


 

 

 

 

Primary care teams are made of professionals that have complementary skills and generate synergy through a 

coordinated effort in order to provide high quality care for their local population. 

Leadership is an essential skill for family doctors and fundamental in quality improvement among primary 

care teams. 

A practice professional development plan is a team-based approach for quality improvement in 

consensualized topics identified by all team members, through structured collective efforts that are focused 

on accepted outcomes. 

The implementation process of the practice profession development plan is by itself an important strategy for 

the development of better relationships among team members and will lead in the long-term to better results 

of the primary care team. 


http://www.woncaeurope.org/content/1003-drafting-practice-professional-development-plan-learning-exercise-using-continuous 

235

References 


http://en.wikipedia.org/wiki/Team 

Wilcock P, Campion-Smith C, Elston S. Practice Professional Development Planning - A guide for primary care. Oxon: 

Radclife Medical Press; 2003. 

Attwood M, Curtis A, Pitts J, While R. Professional Development: A Guide for Primary Care. Oxford: Blackwell Publishing; 

2005. 

NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges. Medical Leadership Competency 

Framework, 3rd edition. Coventry: NHS Institute for Innovation and Improvement; 2010. 

Makela M, Booth B, Roberts R, eds. Family Doctors’ Journey to Quality. Helsinki: Stakes National Research and 

Development Centre for Welfare and Health; 2001. 

Elwyn G. Professional and practice development plans for primary care. Editorial. BMJ 1998, 316:1619-20. 

Elwyn G, Hocking P: Organisational development in general practice: lessons from practice and professional development 

plans (PPDPs). BMC Family Practice 2000, 1:2-. 

Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act 

method to improve quality in healthcare. BMJ Quality & Safety 2014, 23(4): 290–298. 

236


Joachim Szecsenyi, MD MSc 

Joachim.Szecsenyi@med.uni-heidelberg.de 

77 – European Practice Assessment (EPA): Practice Assessment 

and Quality Management With Indicators That Matter 

Joachim Szecsenyi, MD, MSc 

Professor of General Practice 

University of Heidelberg Hospital 

Dept. of General Practice and 

Health Services Research 

Heidelberg, Germany 

Quality management systems within healthcare aim to improve health outcomes, 

patient experiences, accessibility and efficiency of service delivery as well as the job 

satisfaction of all staff involved. EPA is an easy to use and self-explanatory system 

which can be used without specific training in quality management. With its educative 

and reflective approach, it has a high impact on the change of performance. 

Objectives 

The main objective of EPA is to develop an internationally validated tool for quality 

management for healthcare providers. It aims at enabling healthcare providers to 

assess and improve the quality of care they provide. 

Quality indicators 

Quality indicators play an important role in achieving these objectives. They are 

measurable elements of performance that can be used to assess the quality of care. 

Their development is based on evidence or consensus and they close the gap 

between expert knowledge and routine daily practice. Based on indicators, quality 

improvement starts with measurement according to the principle that you cannot 

change what you cannot measure. In order to assess the quality of care, indicators 

need to be well defined. They should be smart (specific, measurable, achievable, 

relevant and time-bound), valid, objective, and sensitive. 

To assess the quality of care in general practice, indicators were developed that are 

comprehensive and relevant to general practice; to assure this, general practitioners 

and experienced researchers were closely involved in the development process. The 

current EPA version contains more than 200 quality indicators covering a wide range 

of quality issues relevant for practice management across Europe. Quality indicators 

are arranged thematically in 34 dimensions and 5 overarching domains covering all 

important aspects of practice management, like quality and safety, people, 

infrastructure, information and finances. 

International development 

The indicators used within EPA for general practice were developed in an 

international study in Germany funded by the Bertelsmann Foundation, Germany. 

Various countries like Switzerland, Austria, France, Great Britain, Italy, Slovenia and 

Israel took part in the project. The set of indicators was piloted in 50 general practices 

for each participating country. National implementation of EPA nowadays lies with the 

responsibility of the individual countries. 

Methodology 

237


The set of indicators used within EPA was developed with science-based methods and instruments. A modified 

RAND/UCLA appropriateness method was used as the scientific basis. An expert panel consisting of international 

scientists and experts from daily practice rated the indicators according to clarity and relevance to generate a usable 

set of indicators. Expert knowledge as well as patients’ perspectives were included to generate practical indicators. 

Assessment process 

The process of EPA is based on an assessment where indicators are measured and results are presented to the 

participating healthcare provider. There are five steps covering the whole process of assessment with EPA. In a first, 

initial step of the assessment, all staff involved are informed about EPA and the assessment process. As a second step, 

the situation of the healthcare provider is analysed to evaluate performance using a self assessment questionnaire, a 

patient survey and a staff survey. All three instruments are based on the indicators defined previously. In a third step, 

the healthcare provider is visited by an expert facilitator who collects more data using a check-list and an interview 

guide. In a subsequent team meeting, the facilitator presents the result from the assessment to the whole team. The 

team thus gets feedback for every indicator of the assessment of the healthcare provider and can also benchmark its 

result against all participating providers. As a last step, the team of the healthcare provider itself plans activities and 

measures to improve the quality of care provided. 

By working with quality indicators, improvements can be recognized exactly where they are necessary and useful. 

Figure 1 shows the overall structure of EPA and the results of an assessment as seen by the healthcare provider during 

the feedback session. Our unique software Visotool® visualizes the results of the assessment via a pentagraph and 

allows benchmarking against all other participating providers. 

Figure 1: Pentagraph representing the results of the individual healthcare provider compared to the mean value of 

other participating providers in the five domains 

The pentagraph shows; 

• results of all indicators/data collected for an individual provider (continuous red line) 

• mean value of all facilities which have so far taken part in the EPA process (dashed blue line) 

• potentially best value to be reached by a provider and the benchmark group for this provider (black external line) 

The closer the lines are to the edges of the five domains (the black external line), the better the results in each of these 

domains, dimensions and indicators. Each indicator is measured via items which are part of the instruments used 

during the assessment. To generate these lines, all indicators and items are transferred into degrees of goal 

achievement between 0% and 100% (e.g. yes = 100% and no = 0% goal achievement for a specific item). 

Table 1: The overall structure of EPA shown with an example of the domain Quality and Safety 

Domain 

Dimension 

Indicator 

Item 

Quality and Safety 

Critical Incident Reporting 

There is a critical incident register 

Does the facility have a critical incident register? 

Instrument: Interview 

Results 

EPA has been successfully implemented in various European countries and is currently being tested in an international 

context. So far, the results have been encouraging. They show; 

 

 

 

improved quality of care and higher standards of service delivery 

increased transparency and competition among healthcare providers 

increased job satisfaction by staff 

238


 

 

improved confidence and experiences by clients/ patients 

motivation for practice teams for measurable change and improvement 

Further perspectives 

The strength of the EPA approach lies in the transparency it generates. A direct and detailed feedback and the 

possibility to benchmark against participating healthcare providers can be used in various settings and healthcare 

systems. It can be used to focus healthcare services provided by healthcare specialists or be tailored to illuminate 

health system aspects such as health financing, leadership, drugs, human resources as well as clinical areas. It may, 

furthermore, be adapted to special fields of interest. 


 

 

 

 

 

Improvement starts with measuring (indicators). 

Motivates healthcare providers for measurable change and improvement. 

Shows strengths and weaknesses to providers. 

Initiates quality improvement activities where they are necessary and useful. 

Has a high and scientifically well proven impact on change of performance. 


http://www.woncaeurope.org/content/ws-56-european-practice-assessment-epa-practice-assessment-and-quality-managementindicators 

References 

Engels Y, Campbell St, Dautzenberg M, Hombergh P, Brinkmann H, SzecsenyiJ, Falcoff H, Seuntjens L, Kuenzi B, Grol R. 

Developing a framework of, and quality indicators for, general practice management in Europe. Fam Pract 2005; 22: 215- 

222 

Engels Y, Dautzenberg M, Campbell S, Broge B, Boffin N, Marshall M, Elwyn G, Vodopivec-Jamsek V, Gerlach F, Samuelson 

M and Grol, R. Testing a European set of indicators for the evaluation of the management of primary care practices. Fam 

Pract 2006; 23: 137-147 

Goetz K, Campbell S, Broge B, Brodowski M, Steinhaeuser J, Wensing M, Szecsenyi J. Job satisfaction of practice assistants 

in general practice in Germany: an observational study. Fam Pract 2013, 30:411-417 

Grol R, Dautzenberg M, Brinkmann H. (Eds). 2004: Quality Management in Primary Care. European Practice Assessment. 

Publisher: Bertelsmann Foundation 

Szecsenyi J, Broge B, Eckhardt J, Heller G, Kaufmann-Kolle P and Wensing M. Tearing down walls: opening the border 

between hospital and ambulatory care for quality improvement in Germany. Int J Quality Health Care 2012; 24:101-104 

Szecsenyi J, Campbell S, Broge B, Laux G, Willms S, Wensing M, Goetz K. Effectiveness of a quality-improvement program 

in improving management of primary care practices, CMAJ 2011; 183: 1326-1333 

Szecsenyi J, Götz K, Campbell S, Broge B, Reuschenbach B, Wensing M. Is the job satisfaction of primary care team 

members associated with patient satisfaction? BMJ Qual Saf 2011; 20: 508-514 

239


240


Nigel Mathers, MD, FRCGP, PhD 

n.mathers@sheffield.ac.uk 

78 – The Role of The Royal College of General Practitioners (UK) 

in Developing Research Capacity and Capability in Primary Care 

Nigel Mathers, BSc. MB ChB. 

DCH, MD. FRCGP. PhD. DipEd. , 

Honorary Secretary of the Royal 

College of General Practitioners, 

Professor of Primary Medical 

Care, University of Sheffield, UK 

Co-author 

Imran Rafi, BSc(Hons) MRCGP 

FRCP MSc PhD DFMS 

Chair of RCGP Clinical Innovation 

and Research 

Royal College of General 

Practitioners, London, UK 

The Royal College of General Practitioners (RCGP) in the UK is the largest professional 

organisation of General Practitioners (GPs) in the world with over 50,000 members. 

The RCGP has an important role in facilitating research by its members, building 

primary care research capacity and capability and collaborating with the academic 

community, particularly on its key strategic and clinical priorities. The RCGP 

recognises that there are potential benefits of undertaking research in General 

Practice, not only for patients themselves but also for the individual members of 

primary health care teams, the academic community and the wider NHS. 

The benefits to GPs themselves in participating in research projects include the 

acquisition of new knowledge and skills which can lead to more satisfaction in their 

professional lives and create opportunities for career progression. The majority of 

GPs, of course, wish to be primarily the users of the results of research. However, a 

substantial minority of GPs do wish to collaborate in the conduct of research, 

although it is only a small minority who wish or have the opportunity to initiate 

research in General Practice. The growing emphasis on translational research and 

getting evidence into clinical practice have also contributed to many development and 

opportunities for GP research. 

Professional bodies such as the RCGP have become increasingly involved in recent 

years in supporting the training of GPs to do research. The importance of research is 

clearly stated in the RCGP curriculum which sets out what is required to practise as an 

independent General Practitioner in the UK NHS (http://www.rcgp.org.uk/gp-trainingand-exams/gp-curriculum-overview.aspx). 

In addition, the RCGP, through its 

charitable funding body, the Scientific Foundation Board (SFB) 

(http://www.rcgp.org.uk/clinical-and-research/research-opportunities-andawards/scientific-foundation-board-sfb.aspx) 

provides annual “pump-priming” 

funding opportunities of up to £20,000 for individual GPs to get started on research 

projects with support from the local university departments. The SFB has been 

established since 1976 and has been responsible for nurturing the early research 

careers of general practitioners and primary care scientists who have gone on to 

develop key roles in academia (including one of the authors of this article, NM). 

The College, of course, does not work in a vacuum and there are many other schemes 

which support GP research. These include the National Institute for Health Research 

(NIHR) in the UK which provides In-Practice Academic Fellowships in the form of entry 

level funding for GPs who wish to experience a “taster” of the GP academic life before 

deciding whether or not to embark on an academic career. 

The RCGP is also keen to offer support to practices. The attraction of general practice 

based research includes both the geographical and demographic diversity of GP 

practices. The RCGP offers a scheme that provides the quality assurance of practices 

taking part in research. For example, the College provides a set of quality standards for the accreditation of “Research 

241


Ready” (RR) practices (http://www.rcgp.org.uk/clinical-and-research/research-opportunities-and-awards/researchready-self-accreditation.aspx). 

The scheme was initially commissioned by the Department of Health and developed in 

conjunction with the NIHR Clinical Research Network (NIHR CRN). The RR programme comprises five core 

competencies that cover the essential knowledge needed to safely and effectively undertake research in primary care. 

More than 1,000 practices in the UK have already been successful in achieving RCGP accreditation to undertake 

research by measurement against core competencies of the scheme which includes providing evidence of good clinical 

practice in research. 

General Practice, of course, is “where the patients are” and GP electronic patient records offer an unparalleled 

opportunity for high-quality epidemiological and clinical research. This is exemplified by RCGP Research and 

Surveillance Centre (http://www.rcgp.org.uk/clinical-and-research/research-and-surveillance-centre.aspx). The 

incidence data provided through consultation data from over 100 practices in England and Wales provides the early 

warning of changes in the incidence of common illnesses such as influenza like-illness and incidence rates for acute 

illnesses, as detailed in the RCGP’s weekly Communicable and Respiratory Disease Report for England and Wales. 

The RCGP also provides recognition to an individual or group of researchers who have undertaken and published an 

exceptional piece of research relating to general practice or primary care, through its Research Paper of the Year 

award, now in its 18th year. There is a formal presentation of the winning paper at the annual RCGP Conference and an 

award of £1,000 to the authors. The most recent award was presented at the 2014 RCGP annual conference to Dr Joe 

Gallagher on behalf of the authors of the winning paper (*). 

Exceptional individuals involved in research are recognised by the RCGP through other awards. The RCGP Discovery 

prize for the most sustained contribution to GP research have included such luminaries as Julian Tudor-Hart of “Inverse 

Care Law” fame. More recently the Yvonne Carter award, in memory of Professor Yvonne Carter, is presented jointly by 

the RCGP and the Society for Academic Primary Care (SAPC) and aims to support the career developments of a 

promising new researcher in primary care, particularly by facilitating international research links. The most recent 

recipient is a primary care scientist, Dr Helen Atherton. In terms of potential new awards, an appeal has recently been 

launched by the RCGP to support primary care mental health researchers through the Helen Lester Appeal for Mental 

Health Research. Helen Lester was a GP champion of patients with mental health problems. 

Finally the academic hub of the RCGP, the Clinical Innovation and Research Centre (CIRC, currently chaired by Dr Imran 

Rafi) provides a link with external organisations to develop joint collaborative working. An example of this is the 

submission of research topics by key RCGP clinical champions to the NIHR designed to lead onto ‘fully developed’ 

research funding opportunities. A further example is a recent RCGP-NIHR Multimorbidity workshop which brought 

together key academics in Multimorbidity research with representatives from key organisations such as the National 

Institute for Health and Care Excellence to reflect the importance of translatable research. 


 

 

General Practitioners organisations have important roles in facilitating research by their members, building 

primary care research capacity and capability, and working closely with the academic community. 

There are considerable benefits to GPs themselves in engaging in research. 


http://www.woncaeurope.org/content/3505-role-royal-college-general-practitioners-developing-research-capacity-and-capability 

References: 

Ledwidge M, Gallagher J, Conlon C, Tallon E, O'Connell E, Dawkins I, Watson C, O'Hanlon R, Bermingham M, Patle A, 

Badabhagni MR, Murtagh G, Voon V, Tilson L, Barry M, McDonald L, Maurer B, McDonald K. Natriuretic peptide-based 

screening and collaborative care for heart failure: the STOP-HF randomised trial. JAMA. 2013. 310(1):66-74. DOI: 

10.1001/jama.2013.7588 

242


Tonka Poplas Susič, MD, PhD 

tonka.poplas-susic@mf.uni-lj.si 

Care 

79 – From Familygram to Personalised Medical 

Tonka Poplas Susič, MD, PhD 

Assist. Prof. Health Centre 

Ljubljana, Ljubljana, Slovenia 

WONCA Europe 5 Star Doctor 

2014 

Familygram 

As a profession, family medicine has a myriad of specific tools designed for assessing 

every single patient in the context of his/her family and its psycho-sociological and 

health circumstances. Even though many modern techniques have been introduced 

into clinical care, family physicians continue to use tools deeply rooted in simple 

family assessment techniques, considering them a unique privilege of the profession. 

Patient/family assessment is provided by the Family Apgar, Family profile and Family 

history. Through analysis, a family tree and family genogram can be established. 

Connection and assessment is made of all obtained data results in a familygram 

profile, which is recognised as an integral presentation of the entire family and its 

social and health record, including personal comments. 

Family Apgar is designed to test five areas of family function (Adaptability, 

Partnership, Growth, Affection, Resolve). Every question is scored as 2 (almost 

always), 1 (sometimes) and 0 (hardly ever). A total score of 7-10 presents a highly 

functional family and 0-3 a severely dysfunctional family. 

Family profile comprises of different assessments. Family structure and family form 

show a large variety of different, nationally or regionally specific patterns, often 

strongly connected to different cultural backgrounds or family policy models. Some 

new types of families represent different environments that affect family members 

and their attitude to social and health-related behaviour. 

Family history (FH) has become evident as the gateway to medical genetics 

(recognizing inherited disorders). Creating a FH involves several steps, the family 

medical history questionnaire often being the first step in this process. Patients may 

be encouraged to contact relatives to obtain or confirm information. The face-to-face 

interview is a critical part of eliciting family history, with the ultimate goal to obtain a 

pedigree that includes at least 3 generations (age or year of birth, age and cause of 

death, ethnic background of each grandparent, relevant health information -e.g., 

height and weight-, illnesses and age at diagnosis, information regarding prior genetic 

testing and information regarding pregnancies). 

Family history plays an important role in identifying patients who may benefit from 

predictive genetic testing. A positive FH has been recognized as a risk factor for the 

development of cardiovascular diseases (CVD), diabetes (DM) and various cancers, 

moreover, it has been identified as an independent risk factor for the development of 

CVD and DM. It is known that family history of common chronic disease is associated 

with a 2- to 5-fold relative risk of developing the condition, and this increases with the 

number of affected relatives. 

IT supporting systems (ITSS) 

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Several IT supporting systems (ITSS) have been developed to integrate all elements of familygram. Some of them are 

oriented to pedigree profiling and offer a standardized system for pedigree storage. Other pedigree oriented ITSS are 

particularly intended for epidemiologists in the sense that they allow customized automatic drawing of large numbers 

of pedigrees and remote and distributed consultation of pedigrees. Some other pedigree ITSS fully integrate risk 

analysis and support for industry standard databases and are designed for genetic counsellors and work with genetic 

marker data, enable haplotyping and allow exports to a range of linking analysis packages. 

Family tree programmes enable construction of family trees, offering an ability to import data from other genealogy 

programmes. Attractive charts and reports in a variety of formats can be drawn and the photos, audio, and video files 

can be added to the tree. 

Graphical genotyping package ITSS combines genetic map data and locus data to display graphical genotypes. Data can 

be viewed by individual or by linkage group, and sorted on markers. Statistics are calculated, and simultaneous 

filtering/selection on multiple linkage groups are made possible. 

However, gathering, filtering and inputting data is always a doctor’s task, while ITSS only manages inputted data. If the 

inputted data are more complete, the output and suggested course is more comprehensive. 

Future challenge: a personalized medicine 

In the future, medicine will become more and more focused on personalized approach to the patient. Personalized 

health care (PHC) is a strategic approach to medicine that is individualized, predictive, preventive, and is based on an 

individual’s specific profile. People subject to increased risk because of their family history are among the most 

appropriate candidates for genetic profiling to find possible new biomarkers. Biomarkers can help in better 

understanding of the disease, prediction of its onset and development. Such genomic approach can help to evaluate 

co-morbidity of selected chronic diseases horizontally and connect them with family history. This shall help to reveal 

new horizons of genomics in chronic diseases. 

Such processes should be supported by an IT centralised vendor-neutral clinical data repository with support for realtime 

transactional health data storage, query, retrieval and exchange. This is structured data set for the validation of 

the decision support model, efficiency calculations and bio-informatic studies. 

Views on personalized medicine can vary according to standpoint: for patients, it offers access to life or better quality 

of life; researchers see potential in their own areas of specialization; for pharmaceutical industry it offers the hope of 

developing more effective medicines as understanding of specific diseases advances; a physician sees a new way of 

treating a patient; for society, it may be perceived as offering scope for an overall improvement in healthcare – or a 

new cost. 

It will be possible for patients and professionals to discuss options only if a common language and conceptual 

understanding of genetic and protein signatures and pathophysiology of the disease are available for both – taking 

account of the individual patient’s psychological make-up (educational level, mental state, and attitudes to risk). 

Additionally, ethical standards must be evaluated taking into account the specifics of PM and creating an infrastructure 

in which genetic information is available in a regulated context. 

To conclude, familygram opens the pathway to PM which is entering medical care. However no one, not even ITSS, can 

replace the family physician and its fundamental role in assessing the health of each individual within the context of 

family, society and socio-economic aspects and to communicate with the patient on his/her personal level. 


 

 

 

 

 

Familygram is an important tool for assessing every patient in the content of his/her family. 

Family history enables detection of risk factors and presents a gateway to medical genetics. 

IT supporting systems (ITSS) have been developed to integrate all elements of familygram. 

Medicine is becoming focused on a personalized approach to patient in the near future. 

Nobody can replace the family physician and its fundamental role in assessing the health of each individual. 


http://www.woncaeurope.org/content/295-family-profile-and-familygram-99 

244

References 


Yoon PW, Scheuner MT, Peterson-Oehlke KL, Gwinn M, Faucett A et al. (2002) Can family history be used as a tool for 

public health and preventive medicine? Genet Med 4: 304-310. doi:10.1097/00125817-200207000-00009. PubMed: 

12172397 

Klemenc-Ketis Z, Peterlin B (2013) Family History as a Predictor for Disease Risk in Healthy Individuals: A Cross-Sectional 

Study in Slovenia. PLoS ONE 8(11): e80333. doi:10.1371/journal.pone.0080333 

McCarthy, J. J. (2014), Driving personalized medicine forward: the who, what, when, and how of educating the health-care 

workforce. Molecular Genetics & Genomic Medicine. doi: 10.1002/mgg3.113 

Burnette R, Simmons LA, Snyderman R. Personalized Health Care as a Pathway for the Adoption of Genomic Medicine. J. 

Pers. Med. 2012, 2, 232-240; doi:10.3390/jpm2040232 

Cesuroglu T, van Ommen B, Malats N, Sudbrak R, Lehrach H, Brand A. Public health perspective: from personalized 

medicine to personal health. Pers Med 2012; 9(2): 115-119). 

Rich EC, Burke W, Heaton CJ et al. Reconsidering the Family History in Primary Care. J Gen Intern Med 2004;19:273–280. 

Wonca Europe. An Anthology of Useful Family Assessment Tools 

http://www.woncaeurope.org/content/anthology-useful-family-assessment-tools 

European Alliance for Personalised Medicine. Integrating Personalised Medicine into EU strategy. EAPM Annual 

Conference Report Bibliotheque Solvay and the European Parliament; Brussels, 2014. 

245


Felicity Goodyear-Smith, MBChB, MD, FRNZCGP 

f.goodyear-smith@auckland.ac.nz 

80 – The Growth of the Guideline – Provision of Evidence-based 

Care with Unintended Consequences 

Felicity Goodyear-Smith, MBChB, 

MD, FRNZCGP 

Professor 

Head of Department of General 

Practice and Primary Health 

Care. University of Auckland, 

New Zealand 

Member of Executive Board & 

Chair of the International 

Committee, North American 

Primary Care Research Group 

Member of WONCA Working 

Party on Research Executive 

Editor-in-Chief, Journal of 

Primary Health Care 

The rise of evidence-based medicine 

In the 1980s David Sackett, a professor of medicine at McMaster University, Canada, 

published a series of articles on how to critically appraise medical research to inform 

safe and effective clinical practice (1). This work was extended by his colleague 

Gordon Guyatt in the 1990s, who coined the term evidence-based medicine - clinical 

practice based on what has been scientifically shown to work for patient management 

of different conditions (2). There followed a series of papers in JAMA on ‘Users Guides 

to the Medical Literature’ with a particular focus on interpreting the results of clinical 

studies, and on deciding how to apply these in patient care (3). 

At the same time Scottish doctor Archibald Cochrane was advocating for the use of 

randomised controlled trials (RCTs) to improve the effectiveness and efficiency of 

medical practice. The Cochrane Centre was established in Oxford, England in 1992 

under the leadership of a health services researcher, Iain Chalmers. The aim of the 

Centre was to review and assess the entire body of literature on all interventions. This 

led to the establishment of the international Cochrane Collaboration in 1993, 

producing up-to-date systematic reviews and meta-analyses of relevant RCTs of 

healthcare, and subsequently the Cochrane Library database (4). 

Chalmers and Muir Gray, a public health physician, established the Centre for 

Evidence-Based Medicine in Oxford in 1995, with David Sackett as director. This 

facilitated the spread of evidence-based medicine to the United Kingdom, Europe and 

beyond (5). Clinical practice now could be based on examination of the current 

evidence rather than tradition or authority. 

Practice by Guideline 

By the turn of the century this evidence was being incorporated into clinical 

guidelines, directing decisions regarding diagnosis and management in specific areas 

of healthcare. Guidelines usually include consensus statements of what is considered 

to be best practice, and often algorithms to aid decision-making. There was a rapid 

proliferation of guidelines for a huge variety of conditions, produced regionally, 

nationally and internationally by professional bodies, healthcare organisations, 

governments and international collaborations to help standardise and improve the 

quality of care. Guidelines rapidly became commonplace. 

However guidelines themselves could be variable in their scientific validity, reliability 

and usability. In 2002 an international group of researchers from 13 countries (the 

Appraisal of Guidelines, REsearch and Evaluation [AGREE] Collaboration) developed 

and validated a generic tool to appraise the quality of clinical guidelines (6). This led in 

turn to the establishment of the Guidelines International Network, with member 

organisations such as the UK National Institute for Health and Clinical Excellence (NICE) and the US National Guideline 

246


Clearinghouse, applying the AGREE standardised methods to produce quality guidelines. 

There has been an exponential increase in the publication of RCTs, of systematic reviews distilling the accumulating 

evidence, and guidelines to inform best practice. Increasingly general practitioners (GPs) are expected to use 

guidelines to direct their clinical decision-making. In 2004 the Quality and Outcomes Framework (QOF) was introduced 

in the UK as a pay-for-performance scheme, covering a wide range of clinical and organisational outcomes, with 

financial rewards for meeting determined targets for these QOF indicators. 

As the stack of guideline books accumulated on the consultation room floor, increased effort went into the 

implementation of guidelines, now a research topic in its own right. Approaches include educational sessions, making 

summaries available on GPs’ computer desktops, and algorithms electronically incorporated into clinical pathways. 

Benefits and unintended consequences 

There is no doubt that understanding and applying robust scientific evidence from well-conducted trials can improve 

patient care and health outcomes. For example, achieving quality targets may result in significant health gains among 

patients with cardiovascular disease . 

However there is also the danger that guidelines can lead to cookbook medicine, with less of a holistic, biopsychosocial 

approach to patient care. Many guidelines synthesise hospital-based studies of homogeneous patient groups. This may 

lead to fragmentation and consequent poor coordination of care. Applying single disease guidelines to a patient with 

multi-morbidity may lead to polypharmacy and adverse medication interactions. Insufficient resources for all GPs to 

implement the evidence may increase health disparities. The QOF tick-box approach focuses on what is easy to 

measure, rather than the less tangible clinical elements such as the nature of the doctor-patient relationship. 

Population health objectives may conflict with a patient-centred approach to individual care. Consultations have a 

finite capacity, and the quality of care may reduce for conditions not included in the incentive framework. 

Sackett himself warned that scientific evidence can inform but never replace clinical expertise 7. Clinical decisions must 

always involve our patients within the complex and uncertain reality of their lives. Decisions must take into account a 

large array of factors, including patient preferences, social, moral and legal issues and resource constraints. Best 

practice requires the synthesis of scientific knowledge, the context in which it is applied and phronesis - the 

accumulated wisdom of the practitioner 8. Empirical evidence contributes to management decisions made by doctors 

and their patients, but must not supplant the contextual knowledge that both contribute. 


 

 

 

 

 

Evidence-based medicine led to systematic reviews and meta-analyses of studies to assess the effectiveness 

and efficiency of medical interventions. 

Clinical guidelines use distilled evidence to direct clinical decision-making. 

Best practice is incentivised by achieving specified quality indicator targets. 

Unintended consequences include fragmentation of care, polypharmacy, health disparities, and neglect of 

conditions excluded from the quality framework. 

Best practice requires the synthesis of scientific knowledge, the context in which it is applied, and phronesis. 


http://www.woncaeurope.org/content/what-are-general-practitioners-obstacles-implementing-guidelines 

References 

1. Sackett DL. How to read clinical journals. CMAJ 1982; 126(12): 1373. 

2. Guyatt GH. Evidence-based medicine. ACP Journal Club 1991; 114: A16. 

3. Guyatt GH, Rennie D. Users' guides to the medical literature. JAMA 1993; 270(17): 2096-7. 

4. Starr M, Chalmers I, Clarke M, Oxman AD. The origins, evolution, and future of The Cochrane Database of Systematic 

Reviews. International Journal of Technology Assessment in Health Care 2009; 25 Suppl 1: 182-95. 

5. Smith R, Rennie D. Evidence-based medicine--an oral history. JAMA 2014; 311(4): 365-7. 

6. Collaboration A. Development and validation of an international appraisal instrument for assessing the quality of clinical 

practice guidelines: the AGREE project. Qual Saf Health Care 2003; 12(1): 18-23. 

7. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 

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1996; 312(7023): 71-2. 

8. Goodyear-Smith F. Practising alchemy: the transmutation of evidence into best health care. Fam Pract 2011; 28(2): 123-7. 

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Tkachenko Victoria, MD, PhD 

witk@ukr.net 

81 – Developing Culturally Sensitive Services in Primary Care 

Tkachenko Victoria, MD, PhD 

Associate Professor 

P.L. Shupyk National Medical 

Academy of Postgraduate 

Education, Kiev, Ukraine 

The capacity for migration has increased in the 21st century due to the expansion of 

international relations, opening of borders, and the development of democratization 

processes in modern society. The reasons for migration differ with every case and 

may include; international expansion or work abroad, family reunion, return to the 

native land, looking for better quality of life, education, economic reasons or simply, a 

more peaceful life. The process of migration results in a population that has a variety 

of religious and cultural characteristics that must be considered during the provision 

of medical care. 

The importance of cultural sensitivity was initially emphasized in providing services to 

members of ethnic minority groups, especially given the language and cultural 

barriers faced by non-English-speaking immigrants and the ethnic and economic 

barriers (8). Patients may not understand a prescription or general health 

recommendations correctly which may lead to low adherence to treatment (3). 

Patients may be prevented from discussing their problems as a result of language 

barriers or religious prohibitions. 

The family doctor should start with the principles of individual liberty, human ethics 

and deontology, respect for beliefs, feelings and rights of patients, be aware of the 

cultural religious characteristics of its population, know manners, rituals and norms of 

behaviour, and consider them when providing medical care (1-3, 7). For example, the 

various cultures and religions have different attitudes to abortion, vaccination, 

euthanasia, blood transfusion, organ transplantation, resuscitation, autopsy, artificial 

insemination, sterilization, etc. Euthanasia and abortion are rejected by most 

religions, including Catholicism, Judaism, Buddhism, Christianity and Islam. Abortion 

is prohibited in most religions, but Muslims believe that the soul of the foetus appears 

in the first week of the fourth month of pregnancy, so abortion is allowed within that 

time frame. Artificial insemination is not recognized in Buddhism, but allowed by the 

Orthodox. In Buddhism and Islam, organ transplants and blood transfusions are only 

allowed from a living donor of the same religion and with his consent. The Jewish 

faith is against autopsy and organ transplantation, unless permission was given by 

the patient and his family before death. Buddhism and Judaism also deny artificial 

continuation of life, when medical equipment and intensive therapy prevent natural 

death, however, the physician should make every effort to preserve and save human 

life according to the Hippocratic Oath. 

In daily life, there are also many occasions when it is necessary to be aware of 

religious and cultural diversity in the provision of health services, such as religious 

restriction diet, fasting, hygiene, possibility of examination etc (7-8). For example, 

religious restriction of food (fasting, restriction of meat) may lead to deficiency 

disease and decreased immunity. Also, religious diet restriction can influence 

prescribing therapy. Thus, Islam forbids the use of any products derived from pork. In 

India the cow is sacred, so medications based on bovine serum (some vaccines, 

regenerating drugs etc.) cannot be used. In Judaism, only kosher products are allowed to be ingested, and accordingly, 

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all drugs employed should be kosher. 

The family physician must also consider that the need to perform religious rites and duties can lead to physical torture 

and psychological disorders, including depression (4). Some religious rituals can contribute to the development of 

certain syndromes and diseases, and lead to the spread of infections. Ignorance of them causes difficulties in 

diagnosis, false diagnosis and ineffective treatment. For example, eating traditional dishes from certain kinds of raw or 

insufficiently processed meats or fish, offal or animal brain can lead to the development of prion, helminthic diseases 

and different infections. Such lifestyle habits are transmitted from generation to generation without suspicion that it 

may cause harm to health. 

On the other hand, the violation of religious and cultural features can lead to extremely negative consequences not 

only to patient, but also to doctor, leading to criminal liability. For example, blood transfusion without consent of the 

patient or his relatives is a crime in some Muslims countries and African states. In Muslim countries, male doctors, 

especially non-Muslim, may examine women and deliver babies in the absence of her family. 

Nevertheless, the family doctor should remain patient, observe human ethics, compassion and empathy, do no harm 

and try to find a way to provide the necessary medical care as outlined in the Hippocratic Oath (1-3, 7). 

It is clear that the education of family doctors should pay attention to the development of religious and culturally 

sensitive care to avoid mistakes and problems such as misdiagnosis, misunderstanding, non-adherence, and recidivism 

(1-3). In 1996, the Society of Teachers of Family Medicine published curriculum guidelines for teaching culturally 

sensitive and culturally competent health care to family medicine residents and other health professions students. 

Cultural Sensitivity permits us to respond with respect and empathy to people of all nationalities, classes, ethnicities, 

religions, ethnic backgrounds and other groups in a manner that recognizes, affirms, and values their worth (4-7). As a 

result, it is necessary to form culture competence in the family doctor, which is measurable as an important quality 

indicator of care. Quality indicators must incorporate principles and measures of cultural competence focusing on the 

policies, procedures, and resources needed to provide linguistically appropriate and culturally relevant services at all 

points of client contact within a system (1-3, 8). Several existing quality improvement tools have the potential to 

incorporate dimensions of cultural competence and can be used to define and track outcomes of interest for 

populations at risk (3). 


 

 

 

The patient's religion, their cultural and personal features need to be taken into account in health care as 

much as possible. This will avoid confusion, medical errors, misdiagnosis, misunderstanding, non-adherence 

and recidivism. 

The family doctor should be aware of cultural religious characteristics of his population, know manners, 

rituals and norms of behaviour, and consider them when providing medical care, observing human ethics and 

compassionate empathy. 

Cultural competence training should focus on empathic listening and development of communication skills 

that work across cultures and have to be monitored with special tools. 


http://www.woncaeurope.org/content/43-developing-culturally-sensitive-services-primary-care 

References 

1. Colliver JA, Conlee MJ, Verhulst SJ, Dorsery JK. Reports of the decline of empathy during medical education are greatly 

exaggerated: A reexamination of the research. Acad Med. 2010; 85(4) : 588–93. 

2. Helen Riess, John M. Kelley, Robert W. Bailey, Emily J. Dunn & Margot Phillips. Empathy Training for Resident Physicians: A 

Randomized Controlled Trial of a Neuroscience-Informed Curriculum. JGIM, Published online 02 may 2012. 

3. Jean Lau Chin. Culturally Competent Health Care. Public Health Reports, January /February 2000, Vоlume 1, 15, p 25-33 

4. Karina Lovell, Jonathan Lamb, Linda Gask, Pete Bower, Waquas Waheed et al. Development and evaluation of culturally 

sensitive psychosocial interventions for under-served people in primary care. BMC Psychiatry 2014; 14 : 217 

http://www.biomedcentral.com/1471-244X/14/217 

5. Michael S. Krasner, Ronald M. Epstein, Howard Beckman, Anthony L. Suchman, Benjamin Chapman, Christopher J. 

Mooney, Timothy E. Quill. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and 

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Attitudes Among Primary Care Physicians. JAMA. 2009; 302(12):1284-1293 

6. National health service corps educational program for clinical and community issues in primary care. Developed by Robert 

T. Trotter II, Northern Arizona University, October 1, 1994, Revised by National center for cultural healing, Reston, Virginia, 

June 30, 1999, 67 p 

7. Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: A systematic review of studies with medical 

students and residents. Acad Med. 2011; 86(8) : 996–1009. 

8. Stephanie Marshal A Cultural Competence Guide for Primary Health Care Professionals in Nova Scotia, 2005, 50 p. 

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John V Howard FRCGP, FRCP 

jvhoward129@gmail.com 

82 – The MRCGP International - Developing a Truly Contextual 

Assessment 

John V Howard FRCGP, FRCP 

Former Medical Director 

MRCGP[INT] Programme 

Co-authors 

Caird GR, Evans PR, Haslam D, 

Heath I, Neighbour R & 

Southgate L 

It is 13 years since the Royal College of General Practitioners (RCGP) of the UK 

presented the framework and process for accrediting local developed postgraduate 

assessments of Family Doctor/General Practitioner competence at the WONCA World 

Conference in Tampere, known as the MRCGP[INT] programme. This is a brief 

progress report including the perspectives of colleagues and an external programme 

evaluation. 

The purpose for developing this programme followed a 1996 survey of international 

colleagues and academic departments who were communicating with the RCGP. They 

expressed a wish to develop an internationally recognised postgraduate assessment 

of competence and qualification for FM/GP at a national or regional level, tailored to 

local needs, educational systems and practice; it was important that such assessment 

be equivalent in status to those in hospital-based specialist disciplines. The 

development of MRCGP[INT] has been undertaken on the premise that it is 

inappropriate to export the UK MRCGP exam, which is the exit assessment of the 

RCGP training curriculum towards the Certificate of Completion of Training required 

to practice as a GP in the UK (RCGP, 2013). 

The MRCGP[INT] programme recognises that there is a generic core to the FM 

specialty, but there are important differences between countries in patient’s 

expectations of their doctor, communication styles, cultural and ethical issues, such as 

consent and confidentiality, epidemiology, training and the legislative and resource 

framework of health and social care. 

The programme forms part of the RCGP strategy to improve the quality of education 

and delivery of FM/GP internationally (RCGP, 2011). The RCGP collaborates with local 

examination boards to develop an assessment of competence of their FM curricula, 

which is then accredited as being of equal academic rigour to the MRCGP UK 

examination. The assessment design is based upon current best practice principles 

but incorporates, sometimes transitionally, test methods appropriate for local 

educational needs (van der Vleuten & Schuwirth, 2005) (Wass, et al., 2001). Then 

there follows an ongoing quality assurance re-accreditation cycle, to monitor, refine 

and raise standards. Rather than being a generic international examination, each 

MRCGP[INT] assessment is set locally to reflect that context. The aim is to assist that 

country in strengthening both the role of family medicine and local postgraduate 

education institutions. Successful candidates become International members of the 

RCGP, but this is not a passport to work in the UK or any other country. 

There are now seven accredited MRCGP[INT] assessments. The purpose differs 

between countries; for Oman, Brunei, Dubai, Kuwait, Egypt and Malta it conjointly 

accredits the end point assessment of vocational training. Additionally, in Brunei the 

examination may be taken by candidates who have either worked or trained in family 

medicine elsewhere; in Dubai where many family medicine doctors are graduates 

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from countries without postgraduate training schemes in family medicine, it offers an opportunity to demonstrate the 

quality of their work and further their career (Ahmed, et al., 2010). The South Asia MRCGP[INT] is a consortium 

representing India, Pakistan, Sri Lanka and Bangladesh; again, for FDs who have had no structured training 

opportunities, as well as expatriate South Asian doctors working in neighbouring countries who intend to return to 

work in the South Asia region (RCGP, 2014). It is intended that Kosovo and Cyprus will have similar accreditation and 

provide a focus for quality competence assessment in those regions. 

The challenge of taking the assessment in regions where family medicine is undeveloped, where there is little provision 

of speciality training or continuing medical education, is also an opportunity. For many candidates the MRCGP[INT] 

examination has acted as a stimulus for learning where one did not exist before. Success often comes after a long 

period of self-directed preparation and RCGP International membership enables the College to help support these 

outstanding colleagues in their continuing professional development. 

A commissioned external evaluation of the MRCGP[INT] (Capacity Development International, 2014) conducted in 

March 2014 interviewed internal and external stakeholders, particularly colleagues representing accredited sites; 

reporting on: 

Relevance: positively affirming congruence to RCGP strategy, WHO policy and the WONCA WHO publication. The 

MRCGP[INT] model is aligned with current thinking in good development practice: meeting country needs, building 

institutional capacity and promoting local ownership. 

Effectiveness: MRCGP[INT] is based on partnership working and local empowerment, with long term collaborative and 

QA commitment. Problems of recognition by national regulatory bodies are a potential risk. Joint working on test 

writing, examining and standard setting should be further encouraged between sites to improve calibration. 

Impact: The evidence is clear for developing robust primary care health systems with strong FM (Starfield, 2011). 

MRCGP[INT] has demonstrated that it is possible to provide a contextualised exam to rigorous assessment standards 

that strengthens countries own assessment expertise, rather than exporting its UK exam. There is, however, a need to 

address the paucity of both quantitative and qualitative research that demonstrates the impact of the MRCGP[INT]. 

Advocacy to focus political will to influence national and global policy is key to increasing the potential uptake and 

impact of the MRCGP[INT] Programme, with increasing recognition for FM/GP as central to primary healthcare. 

Efficiency: MRCGP[INT] site hosts were extremely positive about the quality of academic support received. However, 

accreditation fee increases are a concern to sites, although the programme provided value for money. 

Sustainability: There is significant commitment to continue the MRCGP[INT] programme. The programme is mutually 

valued. The RCGP should continue to tailor CPD support more to the needs of International members. The RCGP must 

remain mindful that MRCGP[INT] cost effectiveness is designed for the long term, and the resources available to 

current and future sites. 


 

 

 

 

 

FM/GP curricula and their assessment are context specific, with perhaps two thirds recognisable globally. 

FD/GP assessments of competence require rigour to be credible with all stakeholders, but it is inappropriate 

to export FM/GP competency assessments to other contexts. 

Collaborative working to build institutional capacity and promote local ownership works well. 

Recognition by national regulatory bodies and political support is necessary for sustainability. 

Opportunities can be made for FDs who have no postgraduate training to demonstrate their quality. 


http://www.woncaeurope.org/content/301-mrcgp-international-membership-royal-college-general-practitioners-internationalnew 

References 

 

 

Ahmed, A., Jeffries, M. & Swidan, H., 2010. Enhancing career opportunities through MRCGP. Education for Primary Care, 

21(July). 

Capacity Development International, 2014. 2014 MRCGP[INT] Review - Highlight Report, s.l.: Capacity Development 

International: www.capacity‐development.com. 

253


 

 

 

 

 

 

RCGP, 2011. Transforming our approach to international affairs - a 10 year strategy, London: RCGP. 

RCGP, 2014. GP Training and Examinations. [Online] 

Available at: http://www.rcgp.org.uk/gp-training-and-exams/gp-curriculum-overview.aspx 

[Accessed October 2014]. 

RCGP, 2014. MRCGP[INT] Accredited Sites and Eligibility. [Online] 

Available at: www.rcgp.org.uk/rcgp-near-you/rcgp-international/mrcgp-int-countries-and-eligibility.aspx 

[Accessed 6 November 2014]. 

Starfield, B., 2011. The Barbara Starfield collection. [Online] 

Available at: http://www.globalfamilydoctor.com/InternationalIssues/BarbaraStarfield.aspx 

[Accessed 30 March 2014]. 

van der Vleuten, C. & Schuwirth, L., 2005. Assessing professional competence: from methods to programmes. Medical 

Education, 3(March), pp. 309-317. 

Wass, V., van der Vleuten, C., Shatzer, J. & Jones, R., 2001. Assessment of clinical competence. Lancet, Volume 357, pp. 

945-9. 

254


Judit Simon, MD 

simon.judit@t-online.hu 

83 – Do we Practice what we Preach? 

Judit Simon MD 

Semmelweis Medical University 

of Budapest, Hungary 

Doctors and especially general practitioners play an important role in health 

education and devote huge efforts to improve their patients’ nutritional habits. This 

study has been performed in order to assess doctors’ nutritional habits and to find 

out whether they follow good advice or not. I am convinced that patients take our 

advice more favourably if they observe that we practice what we preach. 

In 2000, one hundred general practitioners from Budapest (67 women and 33 men) 

were asked to fill out a questionnaire containing 16 questions with regard to their 

nutritional habits. As a consequence of their life style, the majority of their food 

consumption is at dinner, with very little food eaten throughout the day. 

Diagram 1: The distribution of the daily nutriment intake (self estimate on a scale 

from 1 to 5) 

Source: Author’s diagram based on the 2000 questionnaires 

According to the questionnaires, general practitioners in Budapest generally eat the 

minimal amount of food and liquid during daytime. 

Consistently, their daily fluid consumption is only 1.2 litres per day in, as can be seen 

in diagram 2. 

Diagram 2: Distribution of daily fluid consumption (dL) 

Source: Author’s diagram based on the 2000 questionnaires 

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While men generally eat hot dishes at least once a day every day, women only do so 4 times a week. More than one 

third of women do not have lunch at all. This ratio is only 13% in the case of men. 50% of men eat lunch in the comfort 

of their home but only 29% of women do the same. 26% of women eat a cold meal for lunch on the go, which is not as 

popular among men. 39% of the women questioned do not have any lunch at all on weekdays, while the percentage 

among men is only 11%. 81% of men questioned have three-course lunches weekends with their families. One quarter 

of physicians follow a special diet. 48% of the women who are on a diet want to lose weight; the percentage among 

men is 18%. The ratio of vegetarians was the same among the two genders. One fifth of the women and men were 

vegetarians. This is a relatively high number when compared to the general population. 

Almost half of the respondents take some kind of vitamin product regularly. Furthermore, half of the doctors snack 

throughout day. According to the study, a general practitioner drinks an average of two cups of coffee daily. When it 

comes to selecting food, men are more likely than women to choose the tastiest foods. Women prefer ingredients 

which can be prepared easily. Cost appears to be a negligible factor in their food choice. For women the second most 

important factor is that the food they choose should be healthy. For men this is the second least important factor. 

General practitioners eat dairy products, fruits and vegetables almost every day, but they consume meat only 4 times a 

week. Doctors evaluated their own nutritional habit as medium level. 

General practitioners play a distinguished role in health education even if they are not able to comply with these 

principles fully (probably because of their running life style and pressure of circumstances). 

There are several new studies on the health condition of doctors. The biggest studies have been made in the USA (1) 

and in the UK (2). In Hungary in 2004, Drs Rubik and Kalabay (3) conducted a study among the doctors who graduated 

from Semmelweis University 25 years ago. The questionnaire contained demographic, somatic and morbidity data. The 

doctors participating in the study had to classify their own health status and lifestyle. They found that both BMI (Body 

Mass Index) and bodyweight had increased among both genders. The most remarkable bodyweight increase was 

detected among men working in primary health care (average 14.3 kg) and among women working in sedentary 

specialties. The men who work in primary health care had the highest BMI (average 27.4). Most of the smokers worked 

as surgeons and in primary health care (in this case, mostly women). Another, similar study compared 454 medical 

workers’ health condition, lifestyle and health attitude in Szeged (Hungary) and Szabadka (Serbia) (4). Most of the 

nurses from both cities (roughly half of them) did not smoke (among the Serbian nurses there were more nonsmokers). 

Nevertheless, the doctors in Szabadka smoked 20 cigarettes more a day than their counterparts in Szeged. 

41.4 % of the doctors from Szeged did not drink alcohol, In Szabadka this ratio was a bit higher (44.7 %). There were 

some non-coffee drinkers in Szeged (19.2%) and Szabadka (21, 7%) as well. The most common amount consumed was 

1-2 cups of coffee a day but there were many participants who drank 3-4 cups daily. Coffee addiction, meaning six cups 

a day or more was only observed among the Hungarian doctors (2.5%). It is alarming that most of the medical workers, 

including the Hungarians and Serbians, have at least one addiction! 

In another study by the Medical University of Debrecen (Hungary) (5), 188 medical workers aged over 35 from 9 clinics 

were investigated. They had to rate their own health condition on a 1-5 scale. The average score was 3.99. 39% of the 

nurses were smokers and on average they smoked 13.2 cigarettes per day. 89% of the nurses attended screening 

examinations voluntarily on a regular basis. 

Consequently, neither doctors nor medical workers pay enough attention to their own health (6). The rates of 

consuming non-essential nutrition, smoking and alcoholism among doctors and medical workers are not lower than 

the general population either in Hungary or throughout neighbouring countries. We should be taking better care of 

each other! 

If we make a positive precedent, then our patients will take our advice more seriously (5). 


 

 

 

Our personal nutritional habits and the professional focus of doctors and medical staff are not balanced – we 

don’t practice what we preach. 

We should pay more attention to our and also our colleagues’ health! 

We should make some positive precedents if we want our patients to take our advice more seriously. 


http://www.woncaeurope.org/content/465-do-we-practice-what-we-preach 

256

References 


1. Ajani, U.A., Lotufo,P.A., Gaziano, J.M. et al.: Body mass index and mortality among US male physicians. Ann. Epidemiol, 

2004, 14, 731-739 

2. McMurray, J.E.,Linzer M., Konrad, T.R. és mtsai for the Society of General Internal Medicine Satisfaction Study Group: The 

work lives of women physicians: results from the Physician Work Life Study. J. Gen. Intern. Med., 2000, 15, 372-380 

3. Rurik,I., Kalabay,L., : Morbidity, demography, life style, and self-perceived health of Hungarian medical doctors 25 years 

after graduation, Med.sci Monit, 2008, 14, SR1-8 

4. Markovic Marija SZTE BTK Szociológia Tanszék, Pikó Bettina, Szeged; SZTE ÁOK Pszichiátriai Klinika, Magatartástudományi 

Csoport, Szeged, Piczil Márta,SZTE EFK Szociális munka és Szociálpolitika Tanszék, Szeged, Kasza Bálint, Háziorvosi 

Szolgálat, Szabadka: Egészségi állapot, életmód és egészségmagatartás az ápolók körében Szegeden és Szabadkán, 

http://www.eski.hu/new3/kiadv/nover/2006/200603/2006_03.htm 

5. Fodor Babett: Nővérek egészségi állapotának felmérése és értékelése, 2010/2011 TDK 

Téma vezető: Dr Rurik Imre 

6. Dr Boros Miklós, 2010, Ki foglalkozik az orvosok egészségével! http://www.drportal.hu/hir.php? 

szid=88&tema=7&hid=3159 

257


Luc Lefevbre MD 

l.lefebvre@skynet.be 

84 – Helping Family Physicians in Managing Families With a 

Difficult Child 

Luc Lefebvre, MD 

family doctor, Chair of the 

Belgian Society of GP/FP, 

Brussels. 

Co-author 

Véronique Delvenne MD 

Professor of Child and 

Adolescent Psychiatry, Hôpital 

Universitaire Reine Fabiola, 

Université Libre de Bruxelles. 

Prevention is one important task of family physicians. In the context of child and 

family difficulties, he is the closest professional in detecting primary signs of 

dysfunction. However, he needs to acquire abilities to recognize and manage parents’ 

difficulties with their children. It may not be a frequent consultation complaint but 

when it does occur, the physician often does not have much idea on how to deal with 

the situation. 

Opposition, temper, violence, school difficulties; what distinguishes a 

difficult child? How can one identify a family or a child at risk? 

The management of the consultation 

Aggressive or oppositional behaviour are not necessarily pathological. They might 

have different significance depending on the context, the environment or the age of 

the children. Symptoms displayed by the difficult child are variable: lies, stealing, 

aggressive or disrespectful behaviour which are not pathological if occasional. All 

children lie and it is between 6 and 8 years old that they can differentiate between 

real and false. After 8 years old, lies become intentional. Stealing is the most frequent 

conduct disorder but consistent with lying, it is not intentional prior to 8 years of age. 

Aggressiveness or temper may be the expression of unhappiness since infancy. 

Around 2 or 3 years old, a child may become opponent to affirm himself (Marcelli, 

2009). 

Dealing with a difficult child 

First, we have to pay attention to the normal development and particularly to the 

period of the opposition phase (between 18 months and 2 years and a half). It is a 

period of self-affirmation but it is also a phase where the parents need to establish 

clear rules and boundaries. They must set limits for the child within a climate of love 

and respect. If this period has been difficult, the child may become an “enfant-roi” 

“child king” (French concept in sociology, Houssonloge, 2008). 

Secondly, we need to evaluate the acute or chronic aspect of the difficulties. Usually, 

acute conduct disorders might be related to life events such as divorce or separation, 

disease of a parent or a grandparent, death or placement outside the family, boarding 

school,... 

Chronic aspects of behavioural difficulties might be linked to the child’s history. He 

might be unwanted, unloved or involved in couple problems. His parents could be 

mentally ill or violent. He could be neglected or abused. 

He may be suffering from hyperkinesis (ADHD) or other psychopathological symptoms 

such as depression. 

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We need to pay attention to 4 aspects: 

1. The child history: the conception (desire or not), the pregnancy (with eventual pre-term birth or hypoxaemia), 

childbirth and psycho-developmental aspects such as food, sleep, exercise, speech, school, toilet-trained… 

2. The family history: history of the parents, history of the couple, brothers and sisters 

3. Recent life events 

4. Psychosocial aspects 

We introduced workshops for family doctors, with the aim of increasing their understanding of “difficult children”. 

Group sessions of 30 to 35 Belgian family doctors were organized. As in any workshop, the participants had to find 

their own answers. They were noted on a flip-chart, synthesized and, if needed, enriched with backup literature by the 

expert. 

During these workshops, they had to first focus on normal child development and particular difficulties at different 

ages. Next, they had to propose, through case reports and videotapes, practitioner-specific solutions to help the child 

and his family. 

Child difficulties often arise in families with relationship problems. Throughout 2 video sessions, FDs were trained to 

recognize normal child development and to assess acute or chronic difficulties. 

The first videotaped situation concerns Mehdi, a young Moroccan boy. He is 2 1/2 years old. We see him at home 

during a meal with his brothers and sisters. He is the youngest of 5 children. He pushes his plate away. He can speak 

but is difficult to understand. He stamps his feet, ask for an orange and has a fit of temper. His sister tries to show him 

a book: he doesn't want this book; he wants another, precisely the one he may not have. 

His mother says that it was not the same with the others; she doesn't understand, she brought him up the same way... 

The second situation concerns Jérôme, 11 years old. He attends the consultation with his father. His mother is at the 

hospital for an operation. He remains silent. The practitioner tries to talk to him: nothing. We learn that the father had 

a hectic adolescence which he acknowledges in front of his son but he wishes a different one for him. We feel his pride 

when he recounts his adventures. Since their marriage, the parents have moved many times throughout the country 

and have practised several professions. The father no longer sees a first son he has from a previous marriage. We don't 

understand why. When he was very young, Jerome went to live with his grandmother for long periods during which his 

parents came to visit once a week. 

The father doesn't understand: "Jerome has everything to be happy: a bicycle, a TV set in his bedroom... In spite of all 

that, he has fits of temper and sometimes pees on the carpet." At school he gets bad grades and the parents were told 

to consult a physician. “Nothing works any more. I hit him, I encourage him, it is just the same" says the father. 

The boy has no activities, no hobbies with his father: he goes alone to holiday camps. 

Participants have then to work in small groups. They share their experiences. 

The questions are: “What difficulties does the child present?” – “How do you explain this behaviour?” – “What 

conclusions can you draw from this?” - “What would you suggest to the mother or to the father?” - “What would you 

say to him or her?” 

In conclusion, FD’s are in the front line and in the best position to detect such issues regarding the ‘difficult child’. 

Providing them with the tools and skills to assist them in dealing with such situations can improve primary and 

secondary prevention of child and adolescent psychopathology. 


 

The FD is the closest professional in detecting primary signs of dysfunction in child development. 

259


 

 

 

He knows many details of family history and he has the confidence of the parents. 

He needs to acquire abilities to recognize and manage parents‘ difficulties with their children. 

He has a major role in primary and secondary prevention of child psychopathology. 


http://www.woncaeurope.org/content/14-helping-family-physicians-managing-families-difficult-child 

References 

Marcelli D. Enfance et psychopathologie, Masson, 2009. 

Houssonloge D. L’enfant-roi, fait isolé ou produit de notre société ? Analyse UFAPEC 2008. 

© Charley Kondraski 

260


Raluca Zoițanu, MD 

ralucazo@gmail.com 

85 – Family Systems Medicine: A New View of Training General 

Practitioners into Family Doctors 

Raluca Zoițanu, MD 

Romanian National Society of 

Family Medicine (SNMF) - Young 

GP Group Coordinator 

Vasco da Gama Movement - 

Image Liaison 

Bucharest, Romania 

Co-author 


Introduction 

Human beings are social beings. They are bred and grow up in families, and nowadays 

even extended families. 

We all know the words “he looks like his dad, she resembles her mother” and other 

little ‘pearls of wisdom’ that reflect the trans-, inter- and intragenerational influence. 

So, it comes as no surprise that there is a huge influence on people with a disease or 

illness from their surrounding family members. When you have a patient in front of 

you, you actually have a whole family sitting there, and even threads to grandparents' 

sayings, doings and beliefs. You are confronted with a network that speaks from one 

mouth – even in the case of an influenza presentation. 

Family systems medicine refers to the intersection between relationship dynamics 

and medical care. 

Why a training in Family Systems Theory? 

In order to provide the best care to patients, family physicians have to know the social 

and cultural context of their patients. Family Systems Medicine allows practitioners to 

think of the relationships of their patients, starting from families, to the community 

and other organisations or networks. Family Medicine focuses on the individual, in his 

context. At the basis of a Family Systems Medicine training is the understanding that 

there is more than biology alone. 

It is argued here that to become a Family Doctor, a general practitioner should be 

trained in Family Systems Theory. 

What constitutes good training? 

A good model is in the Iceberg Model of Futuristic Thinking offered by Sohail 

Inayatullah. 

He argues that we are confronted with litanies, offer advice and prescriptions, often 

to find out that it didn't work. “I want to lose weight, I want to quit smoking, I want 

my relationship to work, I want to sleep” are some of the litanies in a doctors' daily 

life. 

Doctors should then look for the social causes, the world view of the patient and 

finally the metaphors that are embedded in his family. Inayatullah called it The Causal 

Layered Analysis. 

So a good training is one where doctors learn to work with metaphors, give meaning 

to world views and social causes and act upon it. 

Asking the “apocalyptic question” (what is the worst thing that can happen?), empowering (what would you do if I 

261


gave you a magic wand, what would you wish for?), understanding the role of “the position in the family of origin” 

(first born, only child, sibling of a sick or handicapped brother/sister, etc), knowing not only the “genetic tree” but also 

the “relationship tree” with the subjective force of ties (single bond, double bond, triple bond, broken bond, distant 

bond, inexistent bond), knowing the important dead family members, seeing the elephant(s) in the room, being aware 

of and even knowing the secrets of the family (abuse, abortion(s), alcohol, drugs, jail time, etc) ... these are important 

topics in a training programme. 

What is the result of good training? 

It will come as no surprise that doctors trained this way often find that essential hypertension (or primary 

hypertension or idiopathic hypertension) is the form of hypertension that by definition, has no identifiable cause – 

unless you look at all the influencing strings of family, community, world view and metaphors. 

Then treating hypertension (or other psychosomatic diseases) becomes a chess play in 3 dimensions – not only 

antihypertensive drugs, but a biopsychosocial approach is needed. 

A Family Systems training also gives you the wisdom that family systems are homoeostatic systems – they contain the 

problem, also the solution, and strive for an equilibrium – panta rhei. 

Intervision as a follow up of training 

Continuous Professional Development (CPD) is essential for every family doctor. 

Often, you get stuck in a “patient puzzle” - you see the pieces, but no way to get to an (elegant) solution. Then 

intervision or “inter-peer learning” is a good way to keep learning in the minefield that Family Systems Theory has 

opened. 

Two know more than one, a group knows more than two … if it is a safe environment. 

That group becomes a family by itself – as with any group of people that share a common interest. 

A (2-year) training in Family Systems Theory is like learning to swim. You get your 50-metre diploma but under no 

circumstances can you swim an Olympic distance in an Olympic time – yet this is what you need to be able to do when 

you're a professional Family Doctor. Training is more than just reading a book, attending a few classes – it needs retraining, 

day by day, year by year. Sometimes a coach is needed and sometimes switching of coach and learning other 

methods is needed. 

Conclusion 

The litany of this essay is simple – learn, learn the family words and language, for goodness sake! 

The social causes as to why this is not yet a reality in Family Medicine is layered in the World Views and Metaphors of 

our teachers. 

“Medicine is a hugely biological matter, psychosocial topics are just a tiny bit of the reality and besides, they are the 

topics of some soft scientists, not aware of the importance of our profession”. 

There is an elephant in the room. 


 

 

 

 

In order to become a complete Family Doctor, you should be trained in Family Systems Theory. 

Taking biopsychosocial factors into account (as evidence-based as possible) leads to better therapy. 

Inter-peer learning is a strong teaching method. 

There is an elephant in the room. 


http://www.woncaeurope.org/content/54-family-systems-medicine-new-view-training-general-practitioners 

References 

Amy Begel, http://familysystemsmedicine.com/index.html (retrieved December 2014) 

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Taanila A, Larivaara P, Korpio A, Kalliokoski R., Evaluation of a family-oriented continuing medical education course for 

general practitioners. Med Educ. 2002 Mar;36(3):248-57. 

Larivaara P, Taanila A. Towards interprofessional family-oriented teamwork in primary services: the evaluation of an 

education programme. J Interprof Care. 2004 May;18(2):153-63. 

Launer J, Lindsey C., Training for systemic general practice: a new approach from the Tavistock Clinic. Br J Gen Pract. 1997 

Jul;47(420):453-6. 

Pekka Larivaara, Erkki Väisänen, and Jorma Kiuttu, Family systems medicine: A new field of medicine 

1994, Vol. 48, No. 5 , Pages 329-332 

John Launer, Conversations inviting change http://www.johnlauner.com/81.html (retrieved December 2014) 

R. de Bernart, L. Polenzani, A. Bussotti, S. Giovannoni, E. Messina, Training General Practitioners In Systemic Relational 

Theory And Practice http://woncaeurope.org/content/ew19-training-general-practitioners-systemic-relational-theoryand-practice-workshop 

(retrieved December 2014) 

Sohail Inayatullah, Causal Layered Analysis at TEDxNoosa (retrieved December 2014) 

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Isabel Santos, MD, Med, PhD 

misabelpsantos@gmail.com 

86 – Assessment of the Professional Attitudes of General 

Practitioners 

Isabel Santos, MD, Med, PhD 

Associated Professor at NOVA 

Medical School, Lisbon, Portugal 

Vocational Training Coordinator 

of Family Medicine at the Lisbon 

and Tagus Valley Region 

Purpose 

For many years, professional attitudes have been a matter of concern (1). In recent 

years, the public perception of inappropriate attitudes and behaviours of some 

members of the profession highlighted the necessity either of a better assessment or 

a more detailed definition of professionalism. In this scenario different codes and 

declarations have emerged and with this, the rise of an increasing scrutiny inside and 

outside the medical profession. In this context, the issue of assessment of 

professional attitudes has been raised at WONCA meetings, at larger or minor 

conferences, world and regional level. Nevertheless, the approach to this issue is 

erratic and not systematic. 

Definition of Professionalism 

There is no universally agreed conceptual definition of medical professionalism. The 

shifting nature of the organizational and social milieu in which medicine takes place is 

perhaps the reason why there is no universal agreement (2). Nevertheless, as 

Hammer (3) stated about professionalism “You know it when you see it. You certainly 

know it when you see its antithesis. And you know it when you are expecting to see it, 

but do not”. Today’s definition of medical professionalism is evolving – from 

autonomy to accountability, from expert opinion to evidence-based medicine, from 

self-interest to teamwork and shared responsibility. 

Attitudes, professionalism and assessment may be approached separately or in an 

integrated way that makes it even more complex. The assessment of professionalism 

must begin with a shared definition of the knowledge, skills, and attitudes to be 

assessed. To date, there is no WONCA shared definition of medical professionalism 

but revisiting several declarations, statements and papers we may list the following 

set of behaviours (4): 

 

 

 

 

 

 

 

 

Subordination of own interests to the interests of others; 

Adherence to high ethical and moral standards: 

Response to societal needs, and behaviours; 

Evidence of honesty and integrity, caring and compassion, altruism and empathy, 

respect for self, patients, peers, nurses, and other health care professionals; 

Accountability for themselves and colleagues; 

Recognition when there is a conflict of interest to themselves, their patients, 

their practice 

Demonstration of a continuing commitment to excellence; 

Ability to deal effectively with high levels of complexity and uncertainty; 

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Critical reflection upon actions and decisions; 

Incorporates the concept of one’s moral development and one’s responsibility to the profession; 

Demonstrate sensitivity to multiple cultures; 

Maintain competence in the body of knowledge. 

The Learning Environment 

Attitudes are formed through various types of social learning. With the exception of childhood upbringing and 

personal cultural context, there is some evidence that the learning environment through adulthood, particularly at 

medical undergraduate and postgraduate study level, influences professional attitudes(5). 

Therefore, we have to acknowledge the professional values of health organizations. Nowadays there is a conflict in 

learning practice environments between what is asked of the GP/FD regarding managed care policies (what we have 

TO DO) and the ethical guidelines issued (what we have TO BE). If we want to progress with the measurement of 

professionalism in medical practice we have to clarify the differences among these values in order to solve this 

dissociation. A dialogue needs to be established. It has to be clear that family doctors are called to advocate health 

care values rather than government or corporate values. 

There must be an emphasis on the importance of professional behaviour in the institutions and everyone should be 

accountable, using the same measures. 

As stated previously, learning of professional attitudes starts to develop early on, even prior to Medical School (public 

news about doctors, in particular about family doctors) but it is throughout medical school, during residency and later 

on in practice that professional values have to be viewed , tested, and assessed. For every level of this continuum it is 

critical to align the values of the profession with societal needs; to align teachers’ undergraduate medical values with 

the values learned during residency or within the professional world of practice. Positive feedback is important but we 

should not escape negative feedback from peers either. The family practice community needs to be a structured 

learning environment where professionalism is acknowledged and rewarded and unprofessional behaviour results in 

negative consequences. Until now, some of these issues have not yet been addressed at WONCA meetings. 

Assessment tools 

An evaluation of professionalism must focus on the reasons for a behaviour, rather than just the behaviour itself. 

Professional behaviour assessment tools must take into consideration the contexts in which unprofessional behaviours 

occur, the conflicts that lead to lapses in behaviour, and the reasons the choices were made. Assessment cannot rely 

on a single tool or approach. Tools that exist include (6,7): 

a) evaluations by faculty tutors or supervisors – rating forms are the most commonly used instrument and typically 

have one global “professionalism” item; 

b) Scales to rate professionalism by nurses and patients but this has shown to be very time consuming and requires 

multiple responses per resident and student, which may make it impractical; 

c) Peer evaluation – however, students, residents and professionals are very reluctant to provide negative feedback 

about fellows; 

d) Self-evaluation – but most self-assessment focuses on assessment of knowledge and skills, rather than professional 

behaviours; 

e) Standardized patients; 

f) Simulations. 


The culture of professional attitudes is as important as the expressed curriculum learning. If we want to progress 

in the development of assessment of professional attitudes we need: 

A consensus of what we are evaluating, 

To decide on the possibility of utilising the same tools with each admission process to assess professionalism 

during or at the end of each learning or practice process; 

To clarify the level of professionalism in each development stage; 

A mixed method to measure the professionalism culture should be defined and validated; 

To encourage reflective practice and self-reflection. 

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http://www.woncaeurope.org/content/64-assessment-professional-attitude-general-practitioners-gps 

References 

1. Rosen R, Dewar S. On being a doctor. Redefining medical professionalism for better patient care. King’s Fund Publications, 

2004 

2. Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Defining professionalism in medical education: A 

systematic review. Medical Teacher 2014 36:1, 47-61 

3. Hammer DP. Professional attitudes and behaviors: The “A’s” and “B’s” of professionalism. American Journal of 

Pharmaceutical Education, 2004;64: 455:464. 

4. Levenson R, Dewar S, Sheperd S. Understanding Doctors. Harnessing professionalism. King’s Fund, 2008 

5. Hendelman W, Byszewski. Formation of medical student professional identity: categorizing lapses of professionalism, and 

the learning environment. BMC Medical Education 2014, 14:13 doi:10.1186/1472-6920-14-139 

6. Wilkinson TJ, Wade WB, Knock LD. A Blueprint to Assess Professionalism: Results of a Systematic Review. Acad Med. 2009; 

84:551–558 

7. Hawkins RE, Katsufrakis PJ, Holtman MC, Clauser BE. Assessment of medical professionalism: Who, what, when, 

where, how, and … why? Medical Teacher, 2009 ( 31);. 4:348-361. (doi: 10.1080/01421590902887404) 

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Giuseppe Maso, MD 

giuseppe.maso@gmail.com 

87 – Family Medicine and Sustainability 

Giuseppe Maso, MD 

Head, Course of Family 

Medicine, Udine University, 

Italian Journal of Primary Care 

(IJPC) Editor in Chief. 

Sustainability and sustainable development is the process which fulfils the necessities 

of the present generation without depriving the future ones of the same chance to 

satisfy their needs. Even if Family Medicine wasn’t involved in the movement since its 

rise, it appears evident that it is inevitably involved in the new aspect of 

contemporary culture. Sustainability is an important key lecture for Economy and 

Architecture, however, to date Family Medicine has been an inactive participant in 

this field, only recently becoming conscious of its role. 

The resources which this generation is carrying into the future are not only material 

but, in particular, cultural, ethical and professional: 

 

 

 

Cultural, because our way of life attempts to impose efficiency in many different 

tasks and functions within a complex society and as a result creates many 

restrictions (specializations? Sub-specializations?). In this way we are losing the 

global perspective by focusing on the particular. In family medicine the essential 

problem is never particular and the whole is always essential. Family doctors have 

taken charge of the necessary process of simplification, with the main purpose of 

bringing back a global vision to the particular as well as the fragmented 

knowledge of specialized branches of medicine. This hidden, restless, personal 

engagement has witnessed the existence of an epistemological process which, 

though undervalued, is of extreme importance in health care and support. This 

remarkable process of synthesis and integration, silently carried out by family 

doctors, may become one of the greatest achievements of modern medicine as a 

whole. 

Ethical, because the greatest interest of Family Medicine is man within his own 

environment, primarily his family. Family Medicine is a guarantee of equity and is 

the principal author of the reduction of disparities in assistance, especially in 

areas where inequalities are greater. Human beings, whose nature has remained 

unchanged over the ages, still express needs and pains associated with their 

biological, psychological, social, emotional and rational sides; any distress always 

stems from any one of these aspects, although to different and variable extents. 

A suffering person usually looks for another human being who is willing and able 

to understand his/her uneasiness (disease) as a whole, someone who is able to 

find out its origins and offer a possible solution to satisfy these needs. This 

request for help is nearly always addressed to a doctor: a family doctor who is 

also advocate, intermediary and adviser. 

Professional, because Family Medicine derives its roots from scientific knowledge, 

technological application, laws and rules, traditions, deontology, ethics and 

agreement between men. Scientific and biological knowledge and application of 

new technologies constantly change the parameters of Family Medicine, which 

also develop in response to social pressures, although sometimes with resistance 

from family physicians themselves. A change in any part of this complex system of 

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relationships clearly affects the Discipline, which is under the influence of a multitude of conditioning influences, 

almost without realizing it, on a daily basis. 

Within any single relationship between Family medicine and its satellite worlds, other sub-systems may come to light 

which, as a whole, contribute to the building of a universe of related cosmic worlds within an ever-moving and everchanging 

galaxy. The Discipline must preserve its identity within this context whilst conserving its’ main focus of the 

holistic approach to human beings. To preserve Family Medicine means to preserve respect, consideration, nobility 

and the freedom of every man. In this context, the areas in which the pathway to sustainable development guides 

Family Medicine are: 

Figure: Cosmology of Family Medicine 

Bioethics, evidence-based medicine, patient education, primary prevention, primary health care organization, robotics, 

recording of patient data, the teaching of family medicine, and Family Medicine itself. 

The actions we need to take are: 

 

 

 

 

 

 

 

 

 

Strive for the highest quality of family doctors and provide continuing education to ensure the retention and 

learning of real clinical skills. 

Improve the study of humanities in the curriculum of future doctors. 

Improve research in Family Medicine. 

Always apply the criteria of quality, equity, cost-effectiveness and subsidiarity. 

Ensure free choice of management information systems. 

Decrease most of the bureaucratic burdens. 

Give citizens the opportunity to choose their preferred doctor regardless of geographical location and the 

number of patients per doctor. 

Allow doctors and nurses organizational freedom. 

Knowledge, research and discussion regarding sustainability and sustainable development in Family Medicine 

are still at “the gates of dawn”. 


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Survival of family medicine is essential for survival of equitable and effective health systems. 

Independence and autonomy of family physicians must be defended: only a free man can take care of another 

free man. Only high quality family doctors can ensure the survival of the discipline. 

Family medicine is the medicine of the person and guarantees the freedom of treatment for each individual. 


http://www.woncaeurope.org/content/72-family-medicine-and-sustainability 

References 

Bisconcin M., Maso G., Mathers N.: The European Textbook of Family Medicine: Passoni Editore, Milano; 2006. 

Maxmen J.S.: The Post-Physician Era: Medicine in the Twenty- First Century. John Wiley & Sons, New York, 1976. 

Maso G., Marchetto S.: La Ricerca in Medicina di Famiglia: Passoni Editore, Milano; 1995. 

Maso G., Bisconcin M.: Robotics in Family Medicine: a proposal for a chart. Wonca- Dublin, Ireland, June 14-18, 1998. 

Maso G., Mathers N.,: How can we analyse the role of family medicine using the principles of evidence-based medicine? 

EJGP 2004; 10:134-5. 

Morin E. Les sept savoirs necessaries à l’éducation du future. Unesco, Paris, 1999. 

European Commission: Green Paper on mobile Health (“mHealth”). Brussel, 10.4.2014. 

269


Ilkka Kunnamo 

ilkka.kunnamo@duodecim.fi 

88 – How to Build an Ideal Healthcare Information System? 

Ilkka Kunnamo, MD, PhD, 

Adjunct Professor of General 

Practice, University of Helsinki 

An ideal healthcare information system (HIS) improves the quality of care and patient 

safety, and makes work easier and faster. Whilst achieving both of these goals, it also 

increases the cost-effectiveness of healthcare. The HIS should support the key tasks of 

the FD, particularly the provision of patient-centred and coordinated care, easy access 

and continuity. 

Best available knowledge at fingertips 

The first task of a HIS is to provide access to all medical knowledge and display it to 

both clinicians and patients in a format that is user-friendly. The knowledge must be 

searchable with any terms that the users come across in their daily practice and 

communication. The knowledge should be updated continuously and assessed for the 

quality of evidence with guideline recommendations transparently derived on the 

basis of the evidence. The recommendations should be graded for strength. 

Personalized medicine and decision support 

The total number of different data items (the sum of all diagnoses, tests, drugs, 

procedures…) is already about 100 000. This number will increase exponentially when 

whole-genome sequencing and analysis of gene expressions and proteins become 

routine. Computer systems are needed to integrate this data alongside available 

medical knowledge. Clinical decision support integrated with EHRs can already 

improve care and patient safety. It allows personalized medicine – the tailoring and 

application of guideline recommendations individually for each patient. 

HIS supporting the specific tasks of the FD 

The HIS facilitates communication between patients and their FD, as well as within 

the network of professionals that create virtual teams to provide patient-centred 

care. Patient empowerment is promoted through the sharing of medical knowledge, 

by supporting home measurements, and motivating and guiding self-care. Safe 

communication via personal health records, e-mail and video messages enables 

contact sometimes outside office hours, and simultaneously reduces long hours spent 

in the office and provides more flexible schedules for the FD. Continuity of care is 

improved. 

The HIS supports the role of the family doctor as the coordinator of care. The FD has 

access to data recorded by other health professionals. Much of the data will be 

recorded by patients, either by themselves via intuitive user interfaces of personal 

health records (PHRs), or automatic monitoring devices. All professionals must have 

access to this data through consent of the patient. Correspondingly, data recorded by 

professionals into electronic health records (EHRs) must be available for patients via 

their PHRs or via a national EHR archive. Measures of functional ability and quality of life are used in the assessment of 

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patients and care planning. 

The HIS protects the FD from information overflow and excessive workload by filtering important information, 

displaying summary data on one screen and prioritizing tasks. It gives primary responsibility to the patient as long as 

they are able to interpret the information. The HIS continuously monitors the data of all patients and simultaneously 

displays gaps in care to the FD. The HIS supports patient-centred care when a treatment plan is established by the 

patient, the FD, and multi-professional team. Care protocol templates are available for creating evidence-based plans, 

which are tailored to meet the goals and preferences of the patient. The HIS monitors that the goals set by the patient 

and FD together are met, and sends reminders to both the patient and the professional when necessary. Health 

inequalities will be reduced by targeting resources for people who have the most to gain from healthcare 

interventions. 

A comprehensive decision support system is particularly helpful in the care of typical primary care patients with 

multimorbidity when discordant recommendations from single-disease guidelines need to be streamlined. The 

comprehensive medication review is a tool that analyses data from the EHR against decision support regulations and 

drug databases, checking evidence-based indications, laboratory monitoring alerts, warnings on reduced dosage in 

renal insufficiency, drug interactions and contraindications, potentially inappropriate drugs in the elderly, cumulative 

adverse effect risks of polypharmacy, maximum dosing and cross-allergies. The tool facilitates safe reduction in 

polypharmacy. 

Practice and research united 

An ideal healthcare information system (HIS) learns from every patient, every intervention and its outcome. Every data 

item in the electronic health record contributes to the body of medical knowledge as it is anonymously stored in a 

research database that contains the follow-up data of all patients. Associations can be detected, and hypotheses 

tested using such nationwide and international databases. Targeted, multi-centre randomized trials will be easy to 

perform by using software that automatically collects baseline and follow-up data from the EHR, and helps to record 

study-specific data on web-based electronic case record forms. The HIS also maintains a portfolio of the FDs 

experience in caring for different types of patients, and performing various interventions, and helps in identifying 

needs for continuous medical education. 

Basic principles of HIS 

To achieve these goals, certain basic principles need to be followed. The database where patient data are stored and 

the software applications displaying and processing the data must be separated and connected via open interfaces. 

This will allow the development of user-friendly software, including mobile apps, which are connected to the data. 

Competition in software development will improve usability. All data regarding each patient from both primary and 

secondary care must be accessible by means of the patient’s permission (“one patient – one record”). Data 

confidentiality and safe communication between healthcare providers and their patients must be ensured. The coding 

of data must be nationally and internationally agreed to make automatic processing of the data possible, and allow 

high-quality software to be distributed across borders and languages. The key structured data set consists of a problem 

list, current medication list, results of measurements and laboratory tests, performed procedures, and functional 

assessment. 

Responsibility of the whole population (for the FD, a list of patients and practice population) is enabled via patient data 

that can be aggregated, monitored, sorted and searched. Patient-centredness should be the guiding principle in 

software design, with virtual team building around patients, and patients themselves (not only professionals) as key 

users of medical software. 


 

 

 

 

Empowerment of patients is a strategic goal in building health information systems. 

Patient-centredness requires that one patient has one record – across primary and secondary health care. 

Coding of patient data allows processing by computer and enables clinical decision support, personalized 

medicine, and automation of many tasks. 

The primary care team can take care of the whole population via the information system and ensure that care 

can be offered equally to everyone who would benefit from health care interventions. 

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Cross-sectional data from electronic health records of populations is used to create new knowledge. 


http://www.woncaeurope.org/content/140-how-build-ideal-healthcare-information-system 

References 

Grossman C, Gooldby A, Olsen LA, McGinnis M. Engineering a learning health care system. A look at the future: workshop 

summary. Institute of Medicine and National Academy of Engineering. The National Academies Press, Washington 2011. 

http://www.nap.edu/catalog.php?record_id=12213 

Hoffman TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision-making. 

JAMA 2014;312:1295-1296. 

Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a 

systematic review of trials to identify features critical to success. BMJ 2005;330:765 

Koopman RJ, Kochendorfer KM, Moore JL et al. A diabetes dashboard and physician efficiency and accuracy in accessing 

data needed for high-quality diabetes care. Ann Fam Med 2011;9:398-405. 

Wang CJ, Huang AT. Integrating technology into health care. JAMA 2012;307:569-570. 

272


Merete Jorgensen, MD 

mejor@sund.ku.dk 

89 – Making Sense of Chronic Disease 

Merete Jorgensen, MD 

University of Copenhagen, Dept. 

of General Practice, Denmark 

Co-author 

Kirsti Malterud MD, PhD 

Research Unit for General 

Practice, Uni Research Health 


The number of people with chronic disease is increasing due to longer lifespan under 

better conditions and improved capacity for prevention and treatment of many lifethreatening 

diseases. A chronic disease always induces changes in a person’s life and 

might result in negative effects on quality of life and well-being. From a socioeconomic 

point of view and from the doctor’s perspective, there is a lot of knowledge 

about chronic diseases. But how do patients perceive life with a chronic disease? 

Patients do not always perceive themselves as ill when diagnosed (1). Patients have 

various ways of coping with a chronic disease. Can we as family doctors (FDs) 

contribute to a more successful coping process? 

We performed a qualitative study based on analysis of audiotaped consultations 

initiated by two key questions. The patients had a variety of chronic diseases. Twenty 

women and seven men seeing their FD (the first author, their FD) in family practice 

were included. The key questions dealt with the feeling of mastering life with a 

chronic disease (2). 

To have a feeling of control was important for our patients (3). Developing a personal 

explanatory illness model appeared necessary to gain control. Our patients created 

inner images of their illnesses by combining the perception of symptoms with the 

information provided by their doctor. 

If the explanation from the doctor did not coincide with the perceived symptoms, it 

caused a lot of anxiety and distress. Emotions played an important part in the coping 

process (4). 

Visualizing the disease could be helpful in improving understanding. A patient with 

chronic lower back pain was for example, shown a plastic spine and then said that she 

understood the anatomy and cause of the pain. Another patient saw the inside of her 

knee during arthroscopy and then fully understood her symptoms. 

The future and issues related to treatment were of the utmost importance to our 

participants. We usually emphasize that the prognosis is important. Giving the 

condition a name was equally important, because how can the doctors treat a disease 

that they cannot even name? Naming the disease was also important for the 

participants when talking to friends and family about the disease. 

For two of our patients the disease was an advantage in their new life. A younger 

father with a heart problem could be at home and take care of his son when he 

returned from school. An elderly woman with post-polio syndrome was glad that she 

could stay at home and read a lot of books, her favourite occupation. Her sons tried 

to persuade her to go for a daily walk. 

The participants explained why it is important that the doctor listens to the patient. A 

young man with epilepsy wanted to tell the doctor his experiences about the 

associations between stress and attacks, but the doctor was more interested in the 

concentration of anti-epileptic drugs in the blood tests. The young man was 

273


disappointed, and the doctor might thereby have missed some important information. 

Cultural differences in illness perception were also observed. A young Turkish woman with pain in her joints and 

muscles did not understand that the word “rheumatism” as the term used by Turkish doctors did not have the same 

meaning in our country (5). 

The key question design, triggering off the responses we have systematized in our project, is implemented in the 

context of clinical practice. It can be used as a clinical strategy for prompting a new dialogue, or - as in this study – as a 

research tool providing access to knowledge from patients on specific issues. The theoretical and methodological 

foundation of this design has previously been presented and discussed (6). 

The key question procedure does give access to the full truth, but provides a partial and temporary insight into a 

specific domain – in this case about what could make a difference for patients with chronic diseases. We wanted to 

describe how patients experienced life with a chronic disease. Compared to a traditional interview study, the key 

question design holds a special potential for clinical validity, since the study context is similar to the situation where 

the findings are to be applied. 

What this study adds to previous knowledge 

As FDs we can explore patients’ resources by focusing on what the disease means to the patient. According to 

Antonovsky, people hold different levels of General Resistance Resources (7). As doctors we can explore these. Our 

findings demonstrate how making sense of a chronic disease is a complex process, not just a matter of talent. 

Kleinman and Aujoulat emphasized the therapeutic effect of illness narratives (8). To appreciate the patient’s 

experience and be able to help, the doctor must witness a life story to validate its interpretation and to affirm its value 

for the patient. 


 

 

Behind every patient with a chronic disease we find an unique person. 

To clarify the patients' explanatory illness model is important. 


http://www.woncaeurope.org/content/bf103-making-sense-chronic-illness 

References 

1. Albrecht G L, Devlieger P J. The disability paradox. Soc Sci Med 1999;48:979-987. 

2. Malterud K. Key questions – a strategy for modifying clinical communications. Transforming tacit skills into clinical 

method. Scand J Prim Health Care 1994; 12:121-127. 

3. Cameron LD, Moss-Morris. Illness-related cognition and behavior. In: Kaptein A, Weinman J. Health Psychology. 1. edition. 

The British Psychological Society and Blackwell Publishing Ltd; 2004: 84-110 (chapter four). 

4. Foxwell R, Morley C, Frizelle D. Illness perceptions, mood and quality of life: A systematic review of coronary heart disease 

patients. Journal of Psychosomatic Research 2013; 75: 211-222. 

5. Bates S M, Rankin-Hill L. Control, Culture and Chronic Pain. Soc Sci Med 1994;39:643-644. 

6. Malterud K, Hollnagel H. Encouraging the strengths of women patients - A case study from general practice on 

empowering dialogues. Scand J Publ Health 1999;27:254-9. 

7. Antonovsky A. Unravelling the Mystery of Health. San Francisco: Jossey Bass Publisher, 1987. 

8. Kleinman A. Patients and healers in the context of culture. An exploration of the borderland between anthropology, 

medicine, and psychiatry. Berkeley CA: University of California Press, 1980:71-83. 

274


Karen M Flegg, MBBS(Hons) FRACGP 

karen.flegg@bigpond.com 

90 – A Practical Approach To Teaching Medical Students About 

Community Services 

Karen M Flegg MBBS (Hons) 

FRACGP FACRRM MIPH 

Member at large of WONCA 

World Executive 

WONCA editor since 2010. 

Co-author 

Charles Bou Sleiman, MD, DIS 

Public Health (Lille, France), 

FRACGP, Senior Lecturer at ANU 

This article is based on a presentation delivered by Dr Karen Flegg, Senior Lecturer 

from the Australian National University (ANU), at the WONCA Europe conference held 

in Basel, Switzerland, in 2009. The aims of the presentation were to describe an 

experiential method of medical students learning about community services; to 

outline the objectives of the programme; and to present an evaluation of students’ 

views. 

Background 

The Australian National University (ANU) is located in Canberra, the capital city of 

Australia, with a population of approximately 360,000 people. In 2004, a new medical 

school was established at the ANU, delivering a four-year postgraduate medical 

degree. In the third year of their programme, students had a five month semester of 

integrated family practice and community paediatrics. Students spent four days per 

week in clinical attachments, mostly in private family practice clinics and community 

and hospital-based paediatrics. A minimum of six weeks of the five months of family 

practice was spent in rural towns. 

Programme Objectives 

The broad aim of the community placements programme was to teach medical 

students about the community services to which family doctors might refer their 

patients, or which the patients might be attending without the family doctor’s 

referral. Specific objectives are outlined in Table 1. 

Practical Application 

The programme involved the students spending 13 half days in various community 

services and organisations. Five of the placements were scheduled by faculty staff and 

were mandatory, namely the Aged Care Assessment Team, a sexual health clinic, the 

after-hours medical service, a maternal and child health clinic, and a ‘special 

education’ school. The students also had to organise a visit to a rural community 

pharmacy. 

For the other seven required placements, called ‘selectives’, the students chose and 

organised according to their own interests. The ‘selectives’ were required to include 

at least one geriatric or respite service, one primary care medical service, one 

paediatric service, two allied or community health services, one community 

organisation (NGO), and one other. Examples of ‘selectives’ are given in Table 2. 

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TABLE 1 – Specific objectives and rating on how effective placements were in meeting the objective 

Specific Objective 

Effectiveness rating 

4 or 5 out of 5 

n = % 

To experience the range of health services available in the community. 71 of 84 84.5 

To understand the role of community services in primary health care and 

paediatric care. 

To be able to select appropriate services for patients and work within a 

multidisciplinary team that optimises care. 

To understand how to organise good quality referrals to community 

services by knowing what information the service needs. 

To be able to explain the service to patients and or their families and 

develop a care plan incorporating other service providers. 

66 of 84 78.6 

67 of 84 79.7 

56 of 84 66.7 

70 of 83 83.3 

TABLE 2: Example ‘selective’ placements 

Primary care medical service 

Paediatric services 

Geriatric and respite services 

Allied and community health 

services 

NGOs 

Other 

Youth health drop-in FD clinic refugee health service 

aboriginal health service 

"mother craft" nursing residential service for mothers and babies 

‘SIDs and kids’ education evenings 

Falls prevention clinic, aged care residence, dementia unit 

Community nurse 

Allied health practitioners e.g. dieticians, podiatrists, chiropractors, naturopath, 

optometrist, dentists, 

guide dogs for the Blind 

National brain injury foundation 

Pegasus (horse) riding for the disabled 

funeral homes (undertakers) 

Alcoholics Anonymous meetings 

Students were to aim for a variety of services, including in rural and urban areas, and then to spend about three hours 

at each service. They were asked to investigate how the service worked, who were the people providing the service, 

who the service was provided to, how the service was accessed by patients, and who funded the service. They were 

required to present a reflective writing task of 500 words on how the placements they had attended met the 

objectives of the programme. 

Evaluation of the Programme 

Three cohorts of students over a period of 18 months completed an evaluation on how effectively placements met the 

objectives. Table 1 shows the results. 

Comments collected showed the usual variation of enthusiasm from medical students. Positive student comments 

included: "Important to learn what community offers”, “Initially I thought it would be a waste of time but found it 

informative and moving”; “Was a great experience"; “Very effective for learning - wish I could do more”. Negative 

comments included: “I was wasting time. I could have been learning real medical stuff”; “Difficult to organize”. 

One of the most challenging experiences repeatedly reported by students was attending Alcoholics Anonymous 

276


meetings. 

Discussion 

It is generally acknowledged that giving medical students a broader insight into health services can have lasting effects 

and encourages a more holistic viewpoint (1). 

Community service experiences are associated with improved academic performance, critical thinking, leadership, and 

conflict resolution, enhanced knowledge and acceptance of different ethnicities and cultures, greater understanding of 

the nation’s social problems and increased commitment to future community service (2). Many medical schools in 

Australia over the past two decades, have included such a broader approach (3) and while a minority of students may 

see this programme as ‘soft’, the majority come to value some of the insights achieved. As a result of feedback from 

students and staff about the difficultly in arranging placements, changes have been made since 2009. 

There are now only four compulsory placements (Aged Care Assessment Team, Sexual Health Clinic, Special Education 

school, Rural Pharmacy). It is suggested that students undertake at least six optional placements however there is 

neither a limit, nor a requirement to do any such ‘selectives’. As a result of this change in policy there was considerable 

variability in the uptake of students completing ‘selective’ placements (see Table 3). 

TABLE 3: Students Uptake of optional ‘Selective’ Community placements in 2013 – semesters 1 and 2 compared 

Number of ‘selective’ program Placements per student Semester 1 cohort Semester 2 cohort 

1 or less 6 23 

2 6 7 

3 5 4 

4 3 3 

5 or more 10 1 

Total 30 students 

Total 38 students 

The students are encouraged to choose their ‘selective’ placements in discussion with their clinical supervisor, and to 

use the community services available to patients of their placement family practice as a source of selection. It is now 

preferred for students to follow patients they have met in their family practice or paediatrics placement, into the 

community service they use. 

The reflective writing task on community placement has been removed from the portfolio items, but the student can 

discuss their placement with their academic or clinical supervisor. 

Conclusion 

The recent change in programme has meant less work for the administrative staff in organising placements and 

generally the students are happy with the ability to schedule their own ‘selective’ community placements and 

especially with the flexibility in the choice. 

As always, some students will do the absolute minimum required when there is any choice in the broadness of the 

education. It has also been noted that since ‘selective’ community placements became optional, the number 

undertaken decreases in semester two when the summative exams are approaching. 

Faculty remain convinced that undertaking such placements provides a sound and valuable education and experience 

but has to be balanced against the manpower involved in organising these. Ideally broad-based education must be 

balanced against practicalities. 

277



 

Most students valued the chance to experience a variety of community health services and organisations. 

Students value the opportunity to follow the patient’s journey from family practice to allied health. 

 

 

 

Reducing administrative load enhanced student responsibility and opened the door for self-motivation. 

Some students will always do the minimum possible at the expense of their own broad education. 

Comprehensive placement programmes present logistic difficulties for students and staff. 


http://www.woncaeurope.org/content/op-019-practical-approach-teaching-medical-students-about-community-services 

References 

1. Bleakley A. Broadening conceptions of learning in medical education: the message from teamworking. Med Educ 

2006;40:150–157. 

2. Astin AW, Sax LJ. How undergraduates are affected by service participation. J College Student Dev 1998; 39:251–263. 

3. Moore M, Bolte K, Bennett P. Innovative training for rural medical students. The Clinical Teacher 2012; 9: 238–242 

278


Berk Geroğlu, MD 

berkgeroglu@hotmail.com 

91 – New Technologies to Support Family Doctors 

Berk Geroğlu, MD (1) 

VdGM Secretary 

Co-authors 

Candan Kendir Çopurlar, MD (2), 

Fikret Merter Alanyalı, MD (1), 

Tuğba Onat, MD (2), 

Hüseyin Can, MD, Assist. Prof.(3) 

Carl Steylaerts, MD (4) 

1 Family Medicine Clinic, İzmir 

Tepecik Training and Research 

Hospital, İzmir, Turkey 

2 Department of Family 

Medicine, Faculty of Medicine, 

Dokuz Eylul University, İzmir, 

Turkey 

3 Department of Family 

Medicine, Faculty of Medicine, 

Katip Çelebi University, İzmir, 

Turkey 

4 GP, Belgium 

Introduction 

"One day in the future, you will be able to call anyone everywhere in just a few 

seconds by using a mobile device. Furthermore, this device also will be your computer 

... and there’s more: As a family doctor you will even be able to check your patient's 

blood pressure levels with the same device!?!". 

Those days are not so far removed from today. Micro-CT-scanners, handheld 

ultrasonography, wearable microchips that monitor your vital parameters 

continuously, DNA sequencers in your toothbrush, hyperspectral imagers to detect 

melanomas in an early stage, the MRI scan (at 15dB) in your kitchen while you bake 

an egg, the gold nano-bullets in your bloodstream covered with antibodies to look for 

certain proteins, the thought control through a (Google) helmet for thought sharing, 

chips implanted in your eye to monitor your blood glucose and other haematologic 

parameters, you name it, it is or will be available over the coming years. 

Personalised Medicine, Precision Medicine 

We did a Pubmed search in November 2014 with “technology + primary care” as 

keywords and we accessed 8186 articles. All articles were written between 1969- 

2014. When we looked at the results in more detail, we observed that 3450 of them 

were written in the last 5 years; over forty percent of all the articles. This 

demonstrated to us the increasing importance of technology usage in primary care. 

There is a trend that people become more individualised in a global world, people 

want personal care, a personal doctor, and no mistakes. So they will welcome 

technology in the doctor-patient relationship. 

Body Sensors, Microchips, Nanorobots in Blood, Wearable e-skins 

Consider a tiny, wearable sensor that collects data and reports on the status of your 

body. It will measure vital signs continuously and alert the physician if there is 

something wrong. 

With the help of a wireless transmitter, a microchip will circulate in your bloodstream 

and if it detects any local infection, it will detect the infection and treatment can be 

initiated. What if a nanorobot in your bloodstream could detect a problem before the 

disease manifests itself in your body? 

Nanobots, called respirocytes, can keep tissue vital up to four hours even when it is 

de-oxygenated as in a heart attack or stroke. They can also repair the damaged area 

and keep away platelets from the damaged area. 

Also, with the help of wearable e-skins, when medical assistance is needed, an alert 

from patients' e-skin will be transmitted to the medical centre and patients’ data will 

be shared without any effort. No need to call an ambulance, no need to worry about location! 

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Multi-functional Radiology 


It is obvious that radiology plays an important role in the diagnosis of diseases today. Consider doing an MRI scan at 

home in the future... Furthermore, there may not be a need to run diagnostic tests like MRI scan, CT scan, Doppler 

USG, etc. One multi functional machine will detect any kind of medical problem, symptom and biomarker. The machine 

will also be able to detect cancer from its outset. 

Telemedicine, Holographic Data Input, 3D Printed Bio-materials and Drugs 

In the future, the patients will monitor their vital signs and without the need to attend their health centre, they can 

inform their physicians. 

On the physician side, patients' data will be accessible through means of holographic visuals. Screens and keyboards 

will be projected through all surfaces in clinics and patient data will be stored only in the cloud drives. 

3D printers will be available for everyday use and when the physician offers a medication, the drugs and any patented 

molecule will be available to be printed at the patient's bedside. When the patient is injured, it will be possible to print 

a new tissue or simple organ by using 3D printers. Furthermore, with these printers, it will also be able to print 

humanoid robots. They can serve a sick child, educate an autistic child and can also serve as personal assistant to the 

elderly. 

Augmented Reality 

It is known that keeping patient’s records in mind is a challenge for a physician! Augmented reality means living a life 

which is augmented by computer-generated input like audio, video, graphic or data such as FDS. A digital contact lens 

or Google Glass will be the best assistant to a physician. It will supply information regarding a patients’ health status or 

will help to consult with colleagues from other professions. 

Procreation and Contraception 

Today, implantable systems can release hormones for up to 16 years as a method of birth control. In addition, another 

method is by using stents in the ovarian tubes that can be opened and closed simply through creating a magnetic field 

over the abdomen. You want a baby? Open! No baby? Close! 

There will be a day when women get sick and tired of giving birth and request cloning; an extra-uterine device that will 

function as a womb and designed for home usage. Expecting parents can watch their baby grow. Live. On their 

bookshelf. 

Conclusion 

Once upon a time, having medical records and diagnostic images on the physician's computer were a great 

technological advance. Today, we are talking about nanotechnology, microchips under the skin and magical glasses. It 

is already known that with the Human Genome Project, it is possible to have personalized drugs according to genomic 

background. In 20 to 30 years, by altering the genomes of a person, it will be possible to be ageless and disease-free. 

Family doctors will then also be personal doctors, but with the help of all the technology, there will be more time for a 

congruent doctor-patient relationship. 


 

 

 

Today, at the beginning of the 21st century, lots of promising new technologies are emerging. 

Some of the future technologies include: body sensors, microchips, nanorobots in blood, wearable e-skins, 

multi-functional radiology, telemedicine, holographic data input, 3D printed bio-materials and drugs.In the 

future, we expect to print a new tissue or simple organ by using 3D printers and become ageless and diseasefree. 

Family doctors will stay forever. 


http://www.woncaeurope.org/content/125-new-technologies-support-general-practitioners 

280

References 


http://www.forbes.com/sites/robertszczerba/2014/11/23/tech-trends-shaping-the-future-of-medicine-part-1/ 

http://www.wfs.org/futurist/2014-issues-futurist/may-june-2014-vol-48-no-3/rx-disruption-technology-trends-medicineand 

Michio Kaku, Physics of the Future: How Science Will Shape Human Destiny and Our Daily Lives by the Year 2100, 2012. 

Rick Docksai, “Futurists Explore the Next Horizon,” Nov-Dec 2013, p. 51. 

http://www.healthcare.philips.com/main/about/future-of-healthcare/index-video.wpd Access Date: 25.10.2014. 

http://www.washingtonpost.com/blogs/innovations/wp/2014/07/17/this-amazing-remote-controlled-contraceptivemicrochip-you-implant-under-your-skin-is-the-future-of-medicine/ 

Access Date: 08.11.2014. 

Cohen J, Int J Technol Assess Health Care. 1989;5(1):103-9. 

Reproduced with 

permission 

Bertalan Mesko, MD, PhD 

The Futurist May-June 

2014, 32-3 

www.wfs.org 

281


Maria D Perez-Carceles 

mdperez@um.es 

92 – Patients' Rights and the Views of Family Doctors 

Maria D Perez-Carceles 

Professor in Legal Medicine 

Department of Legal Medicine, 

School of Medicine, University of 

Murcia, Spain. 

Co-authors 

M.D. Medina (2), J.E. Pereniguez 

(2), E. Osuna (1), A. Luna (1) 

1 Department of Legal Medicine, 

Regional Campus of 

International Excellence 

“Campus Mare Nostrum”, School 

of Medicine, University of 

Murcia, Spain. 

Department, Murcia Health 

Service, Murcia, Spain 

In democratic countries, the rights of patients have in general evolved in parallel with 

the recognition of the role of citizens in society, and have been favoured not only by 

the influence of health institutions and organizations, but also by the impetus of civil 

society and by scientific developments (1). However, in recent decades, the growing 

complexity of health systems, the development of science and health-related 

technology, the growing bureaucracy, team work and broader general access have led 

to medical practice becoming more risky, impersonal and dehumanized. All this 

means that patients’ rights need restructuring and reviving as a key feature of the 

doctor-patient relationship. In addition, there is a growing need to establish new ways 

of ensuring patients’ rights to protection in the face of new developments in 

information technology, genetics and the globalization of clinical research (2). 

Under no circumstances can we claim excellence in assistance by simply applying 

maximum scientific rigour if, at the same time, we do not accept the norms, 

particularly those related with the protection of patients’ rights. Nevertheless, despite 

its importance, there are few studies which consider professionals´ attitude in 

general, and those of family doctors in particular, towards patients’ rights. 

In 2007 we carried out a descriptive, cross-sectional study based on a postal 

questionnaire answered by 227 family physicians randomly selected from 72 Health 

Centres in the province of Murcia (south-eastern Spain)(3). The questionnaire 

included social and professional variables, and an evaluation of job satisfaction and of 

importance to patients’ rights (both based on a Likert scale of 1-5; 5 being the highest 

level of satisfaction/importance). 

The most valued right in the overall view of the doctors questioned was the right to 

suitable health care within a humane framework (4.86; 95%CI, 4.81-4.91), while the 

least valued right was the access to medical records (3.91; 95% CI, 3.76-4.05). These 

results contrast with those obtained 15 years ago, when the most valued rights were 

complete technical assistance and the freedom to decide on treatment, while the 

least valued was assistance in a humane framework. It seems that, over this period of 

time, professionals have chosen to prioritize the human quality of the doctor-patient 

relation over scientific-technical quality. Indeed this right has evolved from being the 

least appreciated to becoming the most valued one. 

In contrast with the generally held opinion concerning the dehumanization of modern 

medicine, these results underline a growing tendency to recognize the real 

importance of personal values and of recovering the human aspect of health 

assistance. 

The least valued right is patients´ access to their medical records, which seems to 

point to a certain lack of awareness on the part of professionals’ concerning current 

Spanish law (Law 41/2002), which, as in most countries, establishes the patients´ right 

to access medical records and to obtain a copy of the same. As has been documented 

in other countries, it seems necessary for healthcare providers to be better informed of the patients’ rights to access 

282


information (4). 

We found statistically significant differences in the assessment of patients’ rights, which depended on various social 

and professional factors; for example, a direct association between doctors´ satisfaction and their views on patients’ 

rights; and a significant correlation between the overall evaluation of rights and total satisfaction (P=.039). Older 

doctors attribute more importance to certain rights. Probably their longer work experience has shown that the greater 

the patient’s involvement in deciding their treatment and the greater the understanding of the risks and benefits of 

the same, the more profitable the doctor-patient interaction is and the greater the likelihood of compliance with the 

treatment, resulting in an improved quality of any assistance (5). 

Doctors working in an urban environment have a higher overall view of patients’ rights, while those working in a rural 

environment tend to attribute more importance to the right to privacy. Family doctors are frequently the doctor not 

only of the patient in question, but also of their relatives, which on occasions can become a source of conflict, 

especially regarding the rights related to confidentiality. It seems that this a harder task to comply with in a rural 

environment. 

On the other hand, the right to information, to choose doctors and the access to medical records are more valued in 

the urban environment, where the concept of autonomy is more widely accepted. Work overload is associated with 

some rights being less valued, and doctors with fewer patients on their lists give them more importance. 

It is evident that quality health assistance requires the respect of people’s autonomy, which implies having the time to 

listen, inform, obtain consent and record the symptoms in health history, which is difficult with the growing pressures 

of health services. 

Physicians working in a centre accredited for teaching value patients´ rights more, especially those involving a better 

knowledge of law (choosing doctors, treatment acceptance, access to medical records, etc.). 

The mean job satisfaction of family doctors was 2.79 (95% CI, 2.71-2.87). The importance of analysing professionals’ 

degree of satisfaction lies in the fact that, among other factors, the quality of health services is directly related with the 

degree of satisfaction of those working in it. The overall degree of satisfaction of the family doctors in the present 

study was lower, consistent with other authors’ findings. There is a direct and significant association between 

professional satisfaction and the value given to patients´ rights: family doctors who are more satisfied give more 

importance to patients´ rights (6). 

While recent years have seen advances in doctors’ recognition of patients’ rights, there is insufficient evidence 

concerning the effectiveness of such advances, and further investigation is necessary in this respect. The first goal in 

ensuring that health policy revolves around the patient is to guarantee respect for patients´ rights (7, 8). This involves a 

sense of obligation and cooperation on the part of all health professionals. It is necessary to increase awareness of the 

importance of patients’ rights and the responsibility that all carers share in respecting the same. 


 

 

 

 

 

Overall, family doctors attach a lot of importance to patients’ rights. 

Physicians should be better informed of some patients’ rights, e.g., patients´ rights to access medical records. 

Supplementary training to observe some patients' rights is necessary. 

Social and professional characteristics seem to have some influence on their attitudes of family doctors to 

patients’ rights. 

The doctors with greatest professional satisfaction tend to attach greater importance to patients’ rights. 


http://www.woncaeurope.org/content/bp6-patients%E2%80%99-rights-and-views-family-doctors 

References 

1. Mira JJ, Lorenzo S, Guilabert M, Pérez-Jover V. Do Spaniards know their rights as patients? Int J Qual Health Care 

2012;24(4):365-70. 

2. Hyder AA, Wali SA, Khan AN et al. Ethical review of health research: a perspective from developing country researchers. J 

Med Ethics 2004;30:68-72. 

3. Pérez-Cárceles MD, Pereñíguez Barranco JE, Pérez Flores D, Osuna Carrillo de Albornoz E, Luna Maldonado A. Attitudes of 

283


family doctors to patients' rights. Aten Primaria 2007;39(1):23-8. Spanish. 

4. Parsapoor A, Mohammad K, Malek Afzali H, Ala'eddini F, Larijani B. Observance of Patient's Rights: A Survey on the Views 

of Patients, Nurses, and Physicians. J Med Ethics Hist Med. 2012 2;5:5. 

5. Di Matteo MR, Sherbourne CD, Hays RD, Ordway L, Kravitz RL, McGlynn EA, et al. Physicians’ characteristics influence 

patients’ adherence to medical treatment: results from the medical outcomes study. Health Psychol. 1993;12:93-102. 

6. DeVoe J, Fryer Jr GE, Hargraves JL, Phillips RL, Green LA. Does career dissatisfaction affect the ability of family physicians to 

deliver high-quality patient care? J Fam Pract 2002;51(3):223-8. 

7. Beach MC, Duggan PS, Cassel CK, Geller G. What does ‘respect’ mean? Exploring the moral obligation of health 

professionals to respect patients. J Gen Inter Med 2007;22:692-5. 

8. Dickert NW, Kass NE. Understanding respect: learning from patients. J Med Ethics 2009;35:419-23. 

284


Marc Jamoulle, MD 

marc.jamoulle@doct.ulg.ac.be 

93 – About Quaternary Prevention: First, Do No Harm. 

Marc Jamoulle, MD 

Family doctor, Department of 

General Practice, University of 

Liege, Belgium 

Wonca International 

Classification Committee & 

Wonca Informatics Working 

Party Member 

Towards patient-doctor relationship-based care 

Clinical prevention, under the influence of public health, has been organised in a 

chronological manner since the middle of the 20th century. A paradigm shift from a 

chronological to a constructivist relationship-based preventive pattern of care (1) 

offers new insight into the practice of doctors, and brings to light the concept of 

quaternary prevention, a critical look at medical activities with an emphasis on the 

need not to harm. Quaternary prevention addresses the fundamental question of 

what constitutes too much or too little medicine. It is the fourth form of disease 

prevention, but also the fourth frame of action for family doctors. 

Figure 1. Four fields of the patient-doctor encounter based on relationships. The 

doctor looks for diseases. The patient could feel ill. Timeline is obliquely oriented 

from left to right, from alpha to omega, from birth to death. Anyone will become 

sick and die, doctors as well as patients (Jamoulle 1986). 

The shift from time-based prevention towards a relationship-based organisation 

offers new perspectives into a physician’s work. He or she observes him- or herself, 

and questions the ethical limits of their activities. In this sense, quaternary prevention 

is aimed more at the doctor than the patient. Moreover, the four definitions of 

prevention published in the WONCA Dictionary of Family Medicine (2) offer a 

structured way to discuss the activities of family doctors, including ethical 

considerations on the patient-doctor encounter. Quaternary prevention, also known 

as P4, is a new term for an old concept: first, do not harm. This concept enforces 

disciplines and attitudes such as evidence-based medicine, quality assurance, 

defensive medicine, avoiding abusive nosographic diagnoses and ethical issues 

including those linked to a heartsink patient. 

285

Quaternary concept expanding worldwide 


Disseminated by the colleagues of the WONCA International Classification Committee (WICC), the P4 concept is now 

widely recognized in Europe, Canada, South America and Asia. Astonishingly, quaternary prevention has lain dormant 

for two decades. With the expansion of Internet and social networks and facing the worldwide over-diagnosis 

movement, family doctors are now recently jostled with the idea. Endorsed by the Society of Brazilian Family and 

Community doctors (SBMFC), Quaternary prevention has been proposed as a core concept of the Brazilian health 

system (3) and has induced an international move in the whole of South America. Following the Quaternary Prevention 

Workshop during the WONCA Europe Basel Conference in 2010, the Swiss journal Primary Care published a paper on 

P4 in 6 languages (4). During the WONCA World Conference in Prague in 2013, a P4 seminar was organized with 

speakers from New Zealand, China, Iran, the UK and Belgium (5) and a poster was translated in French, Spanish, 

Portuguese, Vietnamese, Thai and Chinese (6) followed by a publication in the Hong Kong journal of family doctors. 

And during the recent P4 seminar in Lisbon WONCA conference in 2014, the tiny room was crowded with enthusiastic 

young doctors while the WONCA past president Richard Roberts was presenting the idea as seminal for the future of 

WONCA. 

Figure 2. The patient-doctor relationship is at the origin of the four types of activities. The arrow shows that the P4 

attitude is impacting all the activity (Jamoulle & Roland 1995)(Wonca dictionary 2003). 

The enthusiasm generated around this topic shows that the P4 concept is used as a framework for a multifaceted 

repositioning of current questions and limitations of medical practice: disease invention, Attention Deficit 

Hyperactivity Disorder market extension, transformation of symptoms into disease, osteoporosis marketing, breast 

cancer epidemiology and screening, incidentaloma issues, flu & HPV immunisations, drug marketing in mental health, 

hypertension or dyslipidaemia, as well as empathy and communication or the value of the symptoms including when 

medically unexplained. 

And this list is not exhaustive. Quaternary prevention involves the need for close monitoring by the doctor himself, a 

sort of permanent quality control on behalf of the consciousness of the harm they could, even unintentionally, do to 

their patients. Quaternary prevention is about understanding that medicine is based on a relationship, and that this 

relation must remain truly therapeutic by respecting the autonomy of patients and doctors. P4 attitude acts as a 

response to the family doctor facing over-medicalisation, as a resistance, a rallying cry against the lack of humanity of 

whole sectors of medicine and their institutional corruption(7). 

A growing P4 network 

The P4 network has now members in Brazil, Argentina, Uruguay, Bolivia, Ecuador, Peru, Canada, Iran, China, India, 

Thailand, Vietnam, Belgium, France, Germany, Italy, Spain and England expressing through websites, Facebook and 

Twitter. After the 2013 Curitiba Meeting in Brazil, members of the Brazilian P4 group have written the Curitiba 

Manifesto on quaternary prevention (8). For information about quaternary prevention-related events, links, 

bibliography and slides, have a look at the WONCA International Classification Committee website under the 

286

Quaternary Prevention rubric (www.ph3c.org/P4 ). 



 

 

 

 

 

Prevention is not always better than cure. 

Prevention is a co-construction between patient and doctor. 

Ecology of health care requires a mastery of do's and don'ts. 

Medicine can be dangerous for your health. 

First do no harm. 


http://www.woncaeurope.org/content/ws-057-about-quaternary-prevention 

References 

1. Jamoulle M. Information et informatisation en médecine générale [Computer and computerisation in general practice]. In: 

Les informa-g-iciens. Presses Un. Namur, Belgium: Presses Universitaires de Namur; 1986:193–209. 

2. Bentzen N. Wonca Dictionary of General/Family Practice. Maanedsskr. Copenhagen; 2003. 

3. Norman AH, Tesser CD. Prevenção quaternária na atenção primária à saúde: uma necessidade do Sistema Único de Saúde 

[Quaternary prevention in primary care: a necessity for the Brazilian Unified National Health System]. Cad Saúde Pública / 

Ministério Da Saúde, Fundação Oswaldo Cruz, Esc Nac Saúde Pública. 2009;25(9):2012–2020. Available at: 


4. Kuehlein T, Sghedoni D, Visentin G, et al. Quaternary prevention: a task of the general practitioner. Prim Care 2010. 

18:350–4. http://www.primary-care.ch/docs/primarycare/archiv/fr/2010/2010-18/2010-18-368_ELPS_engl.pdf 

5. Jamoulle M, Tsoi G, Heath I, Mangin D, Pezeshki M, Pizzanelli Báez M. Quaternary prevention, addressing the limits of 

medical practice. Wonca world conference Prague 2013 Retrieved from 

http://www.ph3c.org/PH3C/docs/27/000322/0000469.pdf 

6. Jamoulle M, & Roland M. Quaternary prevention. From Wonca world Hong Kong 1995 to Wonca world Prague 2013. In 

Wonca world conference Prague 2013 (Poster). Retrieved from http://www.ph3c.org/PH3C/docs/27/000284/0000435.pdf 

(available also in Chinese, Thai, Vietnamese, French, Spanish & Portuguese on www.ph3c.org/P4 ) 

7. Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. Int J Health Policy Management. 

2015 Feb ;4(2):61–4. http://www.ncbi.nlm.nih.gov/pubmed/25674569" 

8. Silva André Luiz da, Mangin Derelie, Pizzanelli Miguel, et al. Manifesto de Curitiba: pela Prevenção Quaternária e por uma 

Medicina sem conflitos de interesse. Rev Bras Med Família e Comunidade. 2014;9(33):371–374. 

doi:10.5712/rbmfc9(33)1006. 

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Nazan Karaoglu, MD 

drnkaraoglu@gmail.com 

94 – War – Terrorism – Ethical Challenges and Family Physician 

Education 

Nazan Karaoglu, MD, Associate 

Professor, Head of Medical 

Education and Informatics 

Department, Necmettin Erbakan 

University Meram Medical 

School, Konya, Turkey 

Co-author 

Francesco Carelli, MD 

In spite of the fact that we are living in a modern, civilized world, every living 

creature- human beings, animals and plants-get a slice of natural or man-made 

disasters. Of course it is not possible to predict and shape the future but it seems that 

in most of the events as the main player in these disasters, man has had a chance to 

prevent them. The history of our world holds the clues as to what could have been 

prevented and what could not. Please take a history book from your country and have 

a look. Human beings like to break The Golden Rule stating that one should treat 

others as one would like others to treat oneself, defying all religions which decree "Do 

to no one what you yourself dislike” Koran (1). 

Let’s go to our specific profession “medicine” and more specifically “family medicine”. 

Throughout the history of man, physicians have featured in these disasters, 

sometimes as medicine man, shaman or as doctor. This means that the conflicts 

encountered by physicians throughout humanity are not new. Since ancient times, 

depending on universal humanistic rules and the history of medicine - written or 

verbal - physicians have had ethical rules underpinning their lives in addition to their 

practice. Unfortunately, the wealth of experience does not mean great expertise and 

still “our daily routines confront us with situations that neither we nor Hippocrates 

could have anticipated” (2). The basis for medical ethics education was established. In 

general, the aims of this education are; awareness of values and ethical conflicts, 

knowledge of basic ethical principles, professional obligations and law and practical 

skills in clinical reasoning and decision making through the use of ethical principles 

(3,4). Although physicians know what to do in most situations, in most of the cases 

the dilemmas they face are complex and they are required to face them alone and 

manage according to their own standards within ethical boundaries (2). Specifically, 

ethical challenges are more frequent in family practice and more complex and this 

complexity stems from the nature of the work within primary care (3). 

The Characteristics of Family Medicine Which May Create Ethical 

Dilemmas Are: 

1. The emphasis on the patient as a psychosocial being, presenting in the context of 

culture, family, and community. 

2. The existence of social and cultural diversity in the patient population. 

3. The involvement in decision-making processes of multiple stakeholders, more 

than one of whom may be the physician’s patient. 

4. The interaction of the physician with vulnerable patient populations such as 

minors and the mentally disabled. 

5. The physician’s responsibility to manage the full spectrum of health conditions. 

6. The responsibility to provide personal care to a patient over a prolonged period 

of time. 

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7. The inclusion of patients of all ages in the patient population. 

8. The pressure of conflicting duties on the family physician due to health care system organization and change 

(3) 

“Doctors are often among the first to witness evidence of torture, massacres or of other forms of cruel and degrading 

treatment” (5). Physicians accompany military forces during war to serve the army and they participate in military 

clashes which are contrary to our medical codes (2). 

Unfortunately, there are findings that some physicians participated in human rights abuses including falsification of 

medical-legal reports of alleged torture, physical mutilation as a form of punishment and falsification of death 

certificates among those surveyed (6). Physicians are not only torn between humanity, personal feelings, national 

policies, and medical ethics during times of war and terrorism, but also in daily practice, even in safe places with no 

apparent acts of violence they encounter challenges (2,7). 

It is claimed that modern life in times of peace as well as war and global terrorism, raises issues physicians have not 

encountered before (2). Uniquely, family physicians are often in the front line of organizational and social change and 

must be able to adapt to the increasing complexity of medical care options, expectations of patients and society, 

increasing cultural diversity of patients, and the health system organization (3). 

Despite the strong evidence-based need for ethics education, recognized globally by professional organizations in 

family medicine, there were indications that ethics teaching was not being provided in residency programs (8). 

It is well recognized that ethics teaching must: 

be integrated throughout medical training, building on the ethics education received in medical school and 

continuing into residency, 

aim to “custom-fit” the learner’s needs at different stages of medical training, as new roles and 

responsibilities provide new ethical challenges, and 

address the particular ethical issues that occur in the resident’s chosen specialty (8). 

In conclusion; although we are living in a time of progress and civilization, numerous natural and man-made disasters 

are taking place all over the world. Vague opinions are put forth by the medical societies and ethical boards, but there 

is no clear statement concerning these issues (2). 


 

 

 

 

Before being a doctor, a physician is a human being, who should never forget The Golden Rule. 

“Medicine” as a profession rooted in ancient times, carries huge experience regarding humanity, but still 

faces challenges that are not predictable in every patient-physician encounter. 

Some physicians such as those working for the army are in conflict with the ethical codes of medicine but 

family physicians who are primarily confronting organizational and social changes face greater challenges. 

Family medicine carries a specific complexity regarding ethical issues because of the particular nature of 

primary care. Regardless of times of peace or war, modern life raises specific ethical issues that result in a 

need for a planned professional ethics education in family medicine. 


http://www.woncaeurope.org/content/p-215-war-terrorism-ethical-challenges-and-family-physician-education 

References 

1. http://en.wikipedia.org/wiki/Golden_Rule (accessed in 30 October 2014) 

2. Kivity S, Malke Borow M, Shoenfeld Y. Hippocrates Oath is challenged. Isr Med Assoc J. 2009; 11(10): 581-4. 

3. Manson H. The need for medical ethics education in family medicine training. Fam Med 2008; 40(9): 658-64. 

4. Ogle K, Sullivan W, Yeo M. Teaching ethics in family medicine. Introducing a faculty handbook. Canadian Family Physician 

2013; 59: 1126-7. 

5. Tobin J. The challenges and ethical dilemmas of a military medical officer serving with a peacekeeping operation in regard 

to the medical care of the local population. J Med Ethics 2005; 31: 571–4. 

6. Reis C, Ahmed AT, Amowitz LL, Kushner AL, Elahi M, Iacopino V. Physician participation in human rights abuses in Southern 

Iraq. JAMA 2004; 291:1480-6. 

7. Rosner F. Ethical dilemmas for physicians in time of war. Isr Med Assoc J 2010; 12(3): 133-5 

8. Manson H, Satin D, Nelson V, Vadiveloo T. Ethics Education in Family Medicine Training in the United States: a National 

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Survey. Fam Med 2013; 46(1): 28-35. 

Anette Hauskov Graungaard, MD, GP, PhD 

mxb897@sund.ku.dk 

95 – Parents of a Newborn Child With Severe Disabilities: 

Coping, Resources and Needs. A Qualitative Study. 

Anette Hauskov Graungaard, 

MD, GP, PhD, 

Senior researcher at the 

Research Unit for General 

Practice, Copenhagen, Denmark 

and General Practitioner at The 

Clinic of General Practice, 

University of Copenhagen. 

Parents normally expect their newborn child to be healthy but a few percent of 

newborn infants will turn out to have some kind of disability or inherited disease even 

in countries with neonatal screening. Parents, who realise that their newborn child is 

disabled, experience severe physical and emotional stress. They have to adjust their 

present life, dreams and goals to a different and unforeseen reality. Some parents 

adapt well to this situation whereas others report long term distress and difficulties 

(1). These outcomes do not always correspond with the severity of the condition. A 

former paper from this study reported that the diagnostic process had a significant 

impact on parental reactions and adjustment to the diagnosis, especially in cases 

where it was not possible to state a certain diagnosis (2). We have also reported 

about the severe daily strain from taking care of the child, very little sleep at night, 

fear of losing the child concurrent with very stressful interactions with the social 

service system in particular (3). In this third part we moved on to examine how 

parents deal with their on-going challenges and how to support them (4). 

The aim of this study was to explore how parents coped with the birth of a severely 

disabled child, how they maintained their energy levels and personal resources to 

continue coping and areas where they struggled. The role and support of the social 

service system and the health care system were examined in detail. 

We used a qualitative design to explore parents’ experiences during a two year period 

following the diagnosis of a child’s disability. Children with expected severe multi 

disability were included (see table 1). 

Parents were identified at the paediatric ward at The Danish State Hospital in 

Copenhagen and interviews were conducted in the home of the family by the first 

author. Interviews were repeated two years after the first interview. Mothers and 

fathers were interviewed independently. Parents were allowed to tell their story and 

experiences freely and we specifically explored sources of daily stress, how the 

parents evaluated their situation, sources of resources and the interaction with the 

health care system and the social service system. 

Findings were analysed with a Grounded Theory approach and interpreted in a 

theoretical framework of Lazarus and Folkman’s theories on coping (5) and 

Fredrickson’s Broaden-and-build theory of positive emotions (6), as well as theories of 

positive illusions and benefit finding during severe adversity. 

We found that parents continually created and sustained their personal resources 

through positive cognitive reappraisals of their circumstances, the consequences of 

those circumstances and their coping possibilities. A model was developed in order to 

illustrate the intimate relationships between coping and resources (fig.1). 

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Table 1: Characteristics of the interview families 

Sex of child Age at interview Siblings Diagnosis 

Male 2 months First child Unknown 


Male 8 months First child Infantile spasms 


Female 1 month First child Lissencephali 


Male 27 months Sister 5 years old Wolf-Hirschhorn syndrome, diagnosed 

18 months old 

Female 1 month Sister 30 months old Down’s syndrome 

Figure 1 

Several coping strategies were identified that supported parents’ maintenance of resources including; emotional 

bonding, identifying supportive social relations, creating mental respite, meaning-making, benefit finding, evaluating 

existential beliefs, taking action, normalization. 

Parents were taking action in order to relieve the disabilities by, for example, joining elaborate exercise programmes 

other than those recommended by the paediatricians. By taking responsibility, parents were stimulating their own 

resources, as cited by this mother: 

I feel, after joining the training programme, those families (in the programme), it’s another … it’s a more optimistic 

view, that is easier for me to handle… because it is necessary, otherwise you don’t survive this... and it’s like we can do 

something, it is possible to make a difference. 

The resource-creating process from this activity is illustrated in figure 2 below. Blue arrows indicate expected effect of 

exercise on the child; the green arrows illustrated the resource-creating effect on the parents. 

We also found both personal and circumstantial causes of resource deterioration, often caused by the parents’ 

interaction with the health care system and social service system. 

When parents had to apply, document, argue and participate in numerous meetings etc. in order to receive necessary 

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help from the social service system this seriously deteriorated parental resources as stated by this mother: 

It feels like a fight. And it often feels demeaning. If I apply for something, I only do it if I really think it’s something that I 

need. I would never apply for something that could be just nice to have; it would be nice to have a television for him, 

but such things I would never apply for… and you have to push for answers, and take care not to seem irritating, 

because they (the social workers) have so much power. 

Figure 2 

The effect on parental resources is again illustrated with green arrows, and the blue arrows illustrate the lacking effect 

regarding the strategy of obtaining help from the system. When experiencing bureaucracy, huge time expenses and 

uncertainty about their future due to the structure of the social service system, parents’ resources deteriorated. 

Figure 3 

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The strongest source for resource-creation was parents’ appraisal of emotional bonds. Emotions for the child; love, 

responsibility and pride were essential. The communicative response from the child was vital in creating meaning, 

bonding and hope. These positive emotions infused parents with energy and purpose in their continuing care-giving. 

Furthermore, a strengthened marital relationship and the experiences of family and friends contributed to forming a 

close family network. 

Meanings and consequences of this study 

The theory of resource-creation is proposed as an addition to the current understanding of coping and the role of 

positive emotions. Coping and resources were found to be closely interrelated thus parental coping can be 

strengthened by identifying and support the parents’ resources. 

Parents with a disabled child are at risk of chronic sorrow and depression, as found in recent studies (1;7), so 

intervention is clearly needed. Other studies of coping in this parent population have found poor parental coping was 

related to feelings of threat to the family, poor health in the family and lower family satisfaction (1). 

As coping can be improved through intervention (8), it is possible for health professionals to support parents’ resourcecreation 

in a number of ways, even in very severe cases of disability as other factors in and around the child and the 

family often play a significant role in parental well-being. 


 

 

 

 

 

Parents of a disabled child experience severe stress in all domains of life. 

They may be at risk of developing their own mental and physical health problems, but many parents seem to 

cope quite well. 

Parental resources are closely connected with their ability to maintain caring for the child and cope with daily 

life. 

Coping and resources may be supported or counteracted by the health care and social service system. 

Emotional bonding to the disabled child is a main source of resource to parents. 


http://www.woncaeurope.org/content/bpop15-parents-newborn-child-severe-disabilities-coping-resources-and-needs-qualitative 

‘The final, definitive version of this paper has been published in Health (London) March 2011 vol. 15 no. 2 115-136 by SAGE Publications Ltd, All 

rights reserved. © [The Author(s)]’ 

http://hea.sagepub.com/content/15/2/115 

http://hea.sagepub.com/content/15/2/115.full.pdf+html 

References 

1. Resch JA, Elliott TR, Benz MR. Depression among parents of children with disabilities. Fam Syst Health 2012; 30(4):291- 

301. 

2. Graungaard AH, Skov L. Why do we need a diagnosis? A qualitative study of parents' experiences, coping and needs, 

when the newborn child is severely disabled. Child Care Health Dev 2007; 33(3):296-307. 

3. Graungaard AH, Skov L, Andersen JS. Becoming a client of the Danish social service system increases stress in parents of 

disabled infants. Dan Med Bull 2011; 58(6):A4270. 

4. Graungaard AH, Andersen JS, Skov L. When resources get sparse: a longitudinal, qualitative study of emotions, coping and 

resource-creation when parenting a young child with severe disabilities. Health (London) 2011; 15(2):115-36. 

5. Lazarus RS, Folkman S. Stress, appraisal and coping. 1. 1984. New York, Springer Publishing Company. Ref Type: Serial 

(Book, Monograph) 

6. Fredrickson BL. The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. 

Am Psychol 2001; 56(3):218-26. 

7. Whittingham K, Wee D, Sanders MR, Boyd R. Sorrow, coping and resiliency: parents of children with cerebral palsy share 

their experiences. Disabil Rehabil 2013;35(17):1447-52. 

8. Folkman S, Moskowitz JT. Coping: pitfalls and promise. Annu Rev Psychol 2004; 55:745-74. 

293


Igor Švab, MD, PhD 

igor.svab@mf.uni-lj.si 

96 – Family Doctors' Career Towards Academic Level: Why and How 

Igor Švab, MD, PhD, FRCGP 

(Hon.) 

Head of dept of Family Medicine 

and Vice-dean, Medical faculty 

Ljubljana, Slovenia 

Former president of Wonca 

Europe 

Co-authors 

Francesco Carelli, Christos Lionis, 

Paul Wallace, Chris van Weel 

Introduction 

Over the last 40 years, there has been an accumulation of evidence on the 

importance of family medicine. There is more than enough evidence that the strength 

of a country’s primary care system is associated with improved population health 

outcomes, that health systems with a strong primary care orientation tend to be more 

equitable and accessible and that primary care delivered by family physicians reduces 

costs and increases patient satisfaction with no adverse effects on patient outcomes. 

But although the key contribution of primary care in producing good public health 

outcomes is now obvious, there has been less success in achieving the recognition of 

primary care as an academic discipline. Academic recognition is one of the key 

elements of equal status with other, well established disciplines, which also enables 

specific approaches to teaching and research. Because of this, family medicine 

societies throughout Europe have invested substantial resources in achieving this 

goal. 

Within this arena, family medicine had to find its unique position (1), and at the same 

time lead the way for a better alliance between academia and the field of patient 

care. This required a simultaneous paradigm shift in the worlds of health policy and 

research and development, which may explain the time and effort required. 

One of the key steps in this process was the writing of the European definition of 

family medicine (2). The development of theoretical models was a great intellectual 

challenge and helped in creating teaching and research agendas and curricula for 

family medicine worldwide (3-4). The work of experts in the theory of family practice 

successfully demonstrated how family medicine differs conceptually from other 

medical and health care disciplines and provided a much needed conceptual 

framework for teaching and research agendas. 

Challenges and Problems 

consumers and providers where academics are often excluded. 

There is often a feeling that nothing much has changed for family practitioners 

outside the ivory tower of academia, and it is probably safe to conclude that in most 

countries family medicine has still not received the recognition that it deserves. 

One of the big challenges in recognition of family medicine is the primary care 

paradox (6) which looks at the belief that although family physicians provide poorer 

quality care of specific diseases than specialists, primary care is nonetheless 

associated with better health, greater equity, lower costs, and better quality of care. 

Unravelling the paradox depends on understanding the added value of primary care. 

It needs to be recognised that there are limitations as to what family medicine 

academics can achieve. The opinion of the clinician and academic bodies is no longer 

regarded as sacrosanct and a new dialogue is emerging between health care 

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On the other hand, the benefit of this partnership is seen in the fact that countries which have achieved high standards 

in academic family medicine are characterized by equally high standards and esteem for family medicine. In these 

countries, professional organizations have understood that the benefit of academic bodies is often hard to measure 

directly, but is viewed with respect by policy-makers and the public. 

Secondly, by joining the academic arena, family medicine is subject to the same criticisms as all the other academic 

disciplines about the detachment of academic medicine from reality and following agendas of its own that have 

nothing to do with the real problems. If family medicine academics do not maintain close links with their practising 

colleagues, this may become a real threat. 

Key Success Factor 

In the countries where family medicine has flourished academically, academic family medicine has managed to 

maintain and further develop good collaboration between practice and theory. Teaching practices and research 

networks are the natural environments for research and education in family medicine as much as laboratories and 

hospital departments are the environment for basic and clinical sciences and departments of family medicine are often 

a model for how collaboration between theory and practice can be achieved (5). 

In order to maintain this link, a close cooperation between professional and academic organizations is necessary. This 

is not always easy, but is vital, and in particular in primary care and family medicine. This goes back to its central role in 

any healthcare system: to be effective, interventions should address the prevailing important health problems in the 

population under care. In other words, implementing and modifying innovations to meet local needs is an integral part 

of primary care development. This requires family practice with an academic connection in every community (7). This 

is the key factor of academic success in family medicine, where the discipline can fulfil its potential in contributing to 

the academic arena. 

Conclusion 

Regardless of obvious problems that still exist, the achievements in the academic development of family medicine in 

Europe have been remarkable. Family medicine has been successful in creating its theoretical background and in 

promoting itself as an academic discipline (8). Throughout Europe, many academic departments of family medicine 

have been established and it is now customary for every student at medical school to be taught about family medicine 

as part of the core curriculum. Specific training for family medicine is recognised as a standard for modern patient care 

and accepted as a rule in the EU, and is an aspiration for most of the countries that want to join it. 

Family medicine is well placed to take over the responsibilities of a well established discipline. Theory has been useful 

in explaining why family medicine is unique, but new steps now need to be taken in order to prove its value to the 

public. They can be made only through partnership between the professional organizations and academic bodies. In 

order to maintain this link, a close cooperation between professional and academic organizations is necessary. 


 

 

 

Family medicine has achieved its goal of academic recognition in Europe. 

In order to do that, it has had to adapt. 

The need to maintain its specificities is now as important as it was decades ago. 


http://www.woncaeurope.org/content/es4-general-practitioners-career-towards-academic-level-why-and-how 

References 

1. Švab I., Bulc M., Academic medicine: What does an outsider have to offer? Croatian Medical Journal, 2004. 45(3): p. 254- 

255. 

2. Allen, J., et al., The European definition of general practice/family medicine. 2002: Wonca Europe. 

3. Heyrman, J.et EURACT Council, The Educational agenda of general practice/family medicine. 2004, Leuven: EURACT. 1-37. 

4. Hummers-Pradier E., et al. Research agenda for general practice/family medicine and primary care in Europe: EGPRN 

2009. 

5. Stange, K.C., Ferrer R.L. The Paradox of Primary Care. Ann Fam Med, 2009. 7(4): p. 293-299.6. 

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6. Thomas P., et al., Networks for research in primary health care. British Medical Journal, 2001. 322(7286): p. 588-590. 

7. Van Weel C., Sparks B., Caring for people's health around the world: a family physician in every community. Family 

Medicine, 2007. 37: p. 616-7. 

8. Brekke M, Carelli F, Zarbailov N, Javashvili G, Wilm S, Timonen M, Tandeter H. Undergraduate medical education in general 

practice/family medicine throughout Europe - a descriptive study. BMC Med Educ. 2013 Dec 1;13:157. 

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Robert Glendenning 

r.glendenning@sheffield.ac.uk 

97 - A European Observatory for Primary Care Development 

Robert Glendenning, Research 

and Development Manager 

(retired), Academic Unit of 

Primary Medical Care, The 

University of Sheffield 

An observatory is a location used for observing terrestrial or celestial events. Also, it 

could be seen as a place where professionals, academics and citizens meet to 

consider new information about primary care/family medicine and share data that 

could lead to the development of policy and practice in this field. Public access to 

health information/data is greater than ever and in other fields there are examples of 

the involvement of citizens in helping to catalogue data (see The Galaxy Zoo)(1). In 

the health context, the Coulter Study in 2005 clearly demonstrated a desire from 

citizens to be involved in the development of primary care (2). 

In this current ‘age of data’, GPs/Family Physicians have access to a large amount of 

information. However, this data is not analysed nor measured in a routine way. 

Typically, when used, it is for limited purposes and small projects. 

At the same time, companies such as Google are exploring ways of gathering lifestyle 

data automatically and systematically from individuals for public and commercial use. 

Therefore it seems pertinent and timely for healthcare professionals, academics and 

citizens to give consideration to the establishment of processes and structures that 

would place these stakeholders in the forefront of this data revolution about lifestyle 

and primary care and the development of both policy and practice that could flow 

from such collaboration. 

The concept of a European Observatory for Primary Care Development was 

developed some years ago(3). What should it look like? A good example was found in 

Ireland; the Heartwatch Programme (4). 

You need one (or several) goals, you name the parameters needed to screen and 

collect information and perhaps additional parameters typically known to family 

physicians, e.g. the Family Apgar. 

You then have to ensure privacy, involve the public in the collection and ‘datamining’ 

of the information, and report back to the individual patient as well as the general 

public. 

A European Observatory might sit atop of a collection of National Observatories 

accessing data from local observatories, cities, counties, depending on geographical 

and demographical parameters. A purposive sample could be determined as a 

starting point and data collected. A local observatory can report back to the individual 

patient and other stakeholders using all media resources. A National Observatory can 

search for trends. When new policies are implemented, one can measure the impact 

or its absence. 

Some trends only show up after 20 years, e.g. the effect of the onset of legalised 

abortion and the decline of crime and crime-related diseases (5) needed some time 

and shrewd researchers could see a difference between causality and a plausible 

relationship. 

So, what benefits would a European (and why not later, a Global) Observatory provide? 

Perhaps as a starting point one might investigate ‘what already exists’. One example is to be found at: 

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http://www.who.int/influenza/surveillance_monitoring/updates/latest_update_GIP_surveillance/en/ . 

But what should a European Observatory for Primary Care Development monitor and display? 

Some possibilities might include medical education, e.g. medical schools offering a well-designed and internationally 

approved programme for a higher degree in Family Medicine; data on obesity, child mortality, teenage pregnancies 

and other parameters that reflect the impact of family medicine on a community. 

Other starting points might include; the correlations that Barbara Starfield published (6) demonstrating one way 

forward to better quality and better health. 

In terms of existing organisations, cognisance needs to be given to what role they might play and how the varying 

interests and foci of these organisations could facilitate the development of a European Observatory. Such 

organisations might include: European Observatory of Medical Demography UEMO, EQuiP, EFPC. 

Next, the question of who, where and how the Observatory should be hosted? It is argued here that any host 

organisation would need sufficient drive and endeavour and a commitment to working with the politics and 

practicalities of the existing field. Also it would need the vision and resources to take the work forward. From the 

limited work done in 2005-6 my view was that a FD College with a desire to take a European perspective would be 

well-placed to lead the establishment of an Observatory with a possible link into WONCA Europe and WHO Europe. 

Perhaps at this time a better approach would be to consider how a consortium of Colleges might be able to develop 

sufficient mutual support and pooled resources to develop a vision of an Observatory and consider what first steps 

might be necessary to make the vision reality. Another consideration might be how other potentially interested parties 

(e.g. research bodies, local government, charities, etc.) might wish to contribute at an early stage. It is argued here that 

early stage involvement of ‘other parties’ in health and care development greatly assists sustainability. An example of 

this is the involvement of a city authority in the Heartwatch Programme in the UK. Here, local government worked 

together with primary care and the NHS to link-up sport and leisure services to the Heartwatch Programme. 

Finally, one way forward would be for an interested party (a College?) to identify resources to initiate a scoping 

exercise that identifies interested organisations and the resource that they would be prepared to offer the 

development of a consortium. Also, it could help to establish common areas of health concern where systematic and 

coordinated data could be collected. This could be done from 2 perspectives: focus on where existing work has already 

been done at a national level; or, areas where little work has been done but there is an international recognition of the 

importance of particular health concerns. A good example of this second (and preferred) option is that of dementia. In 

a report in 2011(7), it was recommended that it is necessary to ‘build more cooperative networks across Europe’ in 

order to create ‘greater coherence and synergy in research and understanding and opportunities for developing new 

comparative methodologies...and the harmonisation of data’. 

It is hoped that this essay will provide the incentive for the latent idea of a Primary Care Observatory to be reestablished 

on the European primary care agenda and challenge a critical mass of organisations to fund some further 

work to scope and develop plans for coordinated activity. 

Take home messages: 

 

 

 

An Observatory would facilitate the coordination of data and shared learning; 

Its development needs a critical mass and a ‘lead partner’ to ‘kick-start’ the work. 

A scoping exercise would provide the development agenda. 


http://www.woncaeurope.org/content/cf102-european-observatory-primary-care-development-interim-findings-feasibility-study 

References 

1. http://www.galaxyzoo.org/ 

2. BMJ 2005; 331: 1199 ‘What do patients and the public want from primary care?’ 

3. CF10.2 A European Observatory For Primary Care Development: Interim Findings Of A Feasibility Study, Wonca Europe, 

2006 

4. https://www.irishheart.ie/media/pub/heartwise/2006/heartwatchnationalprog.pdf 

5. Leigh A, Wolfers J. Abortion and Crime, AQ: Journal of Contemporary analysis 72, 4 (2000) in: Levitt S, Dubner S. 

Freakonomics, 2005 

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6. Starfield B. Family Medicine Should Shape Reform, Not Vice Versa. Family Practice Management. 28/05/2009 

7. The European Dementia Research Agenda; www.ilcuk.org.uk, 2011 

299


Knut-Arne Wensaas, MD, PhD 

knut-arne.wensaas@uni.no 

98 – New Era for Clinical Research in Primary Care 

Knut-Arne Wensaas, MD, PhD 

Senior Researcher, Research Unit 

for General Practice, Uni 

Research Health, Bergen, 

Norway 

Specialist in Family Medicine, 

Kalfaret Health Centre, Bergen, 

Norway 

Primary care is the cornerstone of the health services in many countries. 

Nevertheless, most of the knowledge that we base our practice on is derived from a 

secondary or tertiary care setting. The need for more research performed in primary 

care is urgent. It is essential to establish an infrastructure for independent research 

that is relevant to general practitioners (GPs), their patients and to the community. 

Such an infrastructure was set up years ago in the form of primary care research 

networks in the UK, Netherlands and the US (1-3), and there are new initiatives 

elsewhere, for instance in Ireland (4) and Norway (5). 

Clinical trials in primary care have almost been synonymous with pharmaceutical 

trials. These trials have to go through an extensive process to ensure patient safety 

and scientific quality, and the pharmaceutical companies provide an infrastructure 

that secures that the involved practices will deliver what is demanded and adhere to 

protocol. The requirements that have to be met call for resources that most academic 

institutions cannot even dream of, and participation in such trials gives GPs the 

possibility to take part in research of high quality. 

Participation in pharmaceutical trials offers many advantages, but there are also 

uncertainties and pitfalls, for both physicians and patients. One task of the GP in 

clinical practice is to balance pros and cons in a long line of different encounters every 

day, and sometimes to assist her patients in living with the necessary compromises 

and consequences. How to relate to the pharmaceutical industry is yet another area 

where these skills are needed as there are common, but also potentially conflicting, 

interests. 

The industry itself is eager to point out the benefits for the physicians: Professional 

development and recognition, taking part in the evolution of medicine, and the 

opportunity for additional income (6). There should be no misunderstanding about 

the fact that there is a lot of money involved in recruiting patients for pharmaceutical 

trials. How much the GP should receive for his/her effort is always debatable, but the 

compensation should at least reflect the actual work involved. On the other hand the 

amount should not seduce GPs into taking part in bad science. 

There are studies that will gain new knowledge or improve treatment options, but 

there is also a risk that some are just as much aimed at prolonging patent rights or 

strengthen market position. A thorough evaluation of proposed projects may be 

difficult, beyond the capacity of the average GP, and there should be a process for 

systematic assessment of protocols for studies aimed at primary care. 

Participation in trials is often considered beneficial by patients that are included. 

Several studies have shown that other benefits than physical improvement is of 

importance to the patients. The combined perceived advantage of additional 

monitoring, the opportunity for assessment by a specialist and an altruistic 

motivation to help others is a consistent finding across several studies. 

The assertion that patients will receive better follow up by participating in trials, with improved clinical outcomes from 

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study participation itself as an effect, is uncertain. The conclusion of summarized research on comparing the outcome 

of patients within or outside clinical trials is that there is no clear evidence of such an effect (7). There is a risk that the 

inclusion and exclusion criteria might bias the study population towards someone with a better prognosis, and other 

forms of bias can also influence the results. This has been most extensively studied in cancer research, but there is no 

reason that it should be different in primary care studies. A possible effect of this kind of bias is that the 

generalizability of the studies may be questionable, and assessing this is important to GPs who see a cross section of 

the general population. 

The challenges introduced by current changes in demography cannot be met with yesterday’s solutions. Technological 

development paves the way for innovations in primary care, and we already see the possibilities for data gathering and 

disease monitoring by the use of patients’ home devices. This opens exciting possibilities for improved care and 

improved research, and family doctors should be at the forefront of this development and help secure that new ideas 

are introduced and properly tested. 

We know that a large proportion of patients are willing to participate in clinical trials (8). We also know that GPs will 

benefit from taking part in studies, and participation in research should be considered an integrated part of primary 

care, not different from secondary care. This is not the case today. Therefore attitudes must change and sufficient 

resources, both time and money, must be allocated. This cannot just be the responsibility of the pharmaceutical 

industry and there must be an alternative based on existing health services and the academic institutions. Lessons 

from the UK and the Netherlands have taught us that establishing comprehensive public research networks is an 

efficient and cost-effective strategy to support high quality research in primary care. 

Primary care research networks tie a number of general practices together under the common umbrella of a 

coordinating organisation based inside or outside the academic institutions. The infrastructure should be robust and 

sustainable, and the network must be able to deliver services essential to both researchers and participating GPs: 

1. Recruit a sufficient number of GPs and practices capable of delivering patients to clinical trials. 

2. Provide tools for extracting data from electronic patient records. 

3. Assess practices and certify those ready for research. 

4. Evaluate feasibility of proposed projects. 

5. Estimate fair compensation for participating doctors, based on actual cost and time required. 

6. Support inclusion of patients into clinical trials, and secure data from these patients. 

7. Promote implementation of research based knowledge into clinical practice and health policy. 

A primary care research network is the laboratory where we all need to bridge the current gap between clinical work 

and academic general practice in many countries. It will be the place where we can study research questions important 

to GPs, our patients and the community. 


 

 

 

 

Changes in demography call for innovations in both research and care. 

Practice based research in primary care is urgently needed. 

A permanent infrastructure is essential to secure that feasible projects are completed as planned. 

Primary care research networks are a well documented foundation for high quality research. 


http://www.woncaeurope.org/content/3870-clinical-trial-primary-care-physicians-it-beneficial 

References: 

1. Sullivan F, Butler C, Cupples M, Kinmonth AL. Primary care research networks in the United Kingdom. Bmj. 2007;334:1093- 

4. 

2. van Weel C, de Grauw W. Family practices registration networks contributed to primary care research. J Clin Epidemiol. 

2006;59:779-83. 

3. Peterson KA, Lipman PD, Lange CJ, Cohen RA, Durako S. Supporting better science in primary care: a description of 

practice-based research networks (PBRNs) in 2011. Journal of the American Board of Family Medicine: JABFM. 

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2012;25:565-71. 

4. Irish Primary Care Research Networks [cited 2014 Nov 30]. Available from: www.ipcrn.ie 

5. Rortveit G. Research networks in primary care: An answer to the call for better clinical research. Scand J Prim Health Care. 

2014;32:107-9. 

6. Pharmaceutical Product Development: Advantages of Being a Clinical Trial Investigator. [cited 2014 Nov 30]. Available 

from: www.ppdi.com/Participate-In-Clinical-Trials/Become-an-Investigator/Advantages.aspx 

7. Peppercorn JM, Weeks JC, Cook EF, Joffe S. Comparison of outcomes in cancer patients treated within and outside clinical 

trials: conceptual framework and structured review. Lancet. 2004;363:263-70. 

8. Comis RL, Miller JD, Aldige CR, Krebs L, Stoval E. Public attitudes toward participation in cancer clinical trials. Journal of 

clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:830-5. 

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Radkin Honzák, MD 

vselek@lf1.cuni.cz 

99 – Family Therapy Skills for Medical Practitioners 

Radkin Honzák, MD 

Institute of General Practice, 

First Faculty of Medicine, Charles 

University in Prague 

Co-author 

Bohumil Seifert, MD, PhD 

Introduction 

Despite societal changes, the family remains the most basic unit in society. The 

general practitioner is, more than other health care providers, involved and 

associated with the family and develops a perceptive awareness of a family´s nature 

and style of living. One challenge in general practice is the need to pay attention to 

the stresses, social changes, and expectations of family members over time, as well as 

the effect that these and other family interactions have on the health of the individual 

patient (1). The concern is not only with psychological and psychosomatic disorders, 

but it is also emerging with chronic disease management in particular, which is 

becoming the major topic for general practice in our time. One example is the 

importance of the family's perception of disease and the treatment of diabetes (2). 

A family-oriented approach is one of the basic attributes of general practice (3, 4). 

Family-oriented primary care involves thinking about the patient's problem in the 

context of the whole person and the person's significant others. These other persons, 

such as family members, can eventually be invited to help or be involved in the 

assessment or treatment processes. Although this can be considered a simplified 

model of family therapy in general practice, family therapy is in fact a much more 

complicated method, requiring specific competence, technique and allocated time, all 

of these conditions being barely achievable in daily routine practice. 

Family therapy is one of the psychotherapeutic techniques used primarily in the 

treatment of psychosomatic disorders. It is proposed that – whenever possible – the 

whole family, not just the individual labelled as the bearer of the symptoms, enters 

into the treatment. A symptom is considered a stabilizing element in a dysfunctional 

family. The aim of treatment is to improve communication in the family and improve 

its functioning in order to stabilize the illness into healthier patterns without 

symptoms. 

Family therapy uses a range of counselling and other techniques including: Structural 

therapy, Strategic therapy, Systemic/Milan therapy, Narrative therapy, 

Transgenerational therapy. Therapy usually takes place in multiple sessions spaced 

out over several months. Family therapy can be used in a variety of clinical settings, 

including general practice. There are few reports in the literature about the use of 

family therapy in general practice (5,6). 

However, under current health care systems, it is not the task of a family doctor to 

engage in family therapy – unless they hold a particular interest and special training. 

Rather, it is the task of a family doctor to look for signals that make a contextual 

approach necessary, and then act upon it appropriately. 

In order to find signals one has to undergo training in: 

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non-verbal signals, especially the micro signals of contempt (7) 

 

 

 

designing a family tree 

designing a diagram of bonding and loyalty 

signals of abuse or other malfunctioning. 

Moreover, communication, transaction and interaction analysis are essential skills. “Active listening” narrows the 

boundaries of interpretation and understanding, clarifying the picture; 

“What do you mean by …?” 

This helps us to get away from overmedicalisation, away from only using the medical microscope and learning to use 

the telescope that is required in such a setting. The concept “medically unexplained symptoms” is inappropriate here, 

since the symptoms can very well be explained but the doctor needs to be able to use the right “scope”. 

A doctor that stays in touch with himself and as humble as possible will go a long way. 

Conclusion 

Primary care or family doctors can learn additional skills to engage in untangling the puzzle a family presents. It is not a 

recipe that you learn from a cook-book, rather you learn it by observation, training, re-training and intervision. 


 

 

 

 

Pay attention to family interactions and consider them with regard to your patient. 

Explore the perception of chronic disease and its management in your patient's family. 

Family-oriented approach in general practice is not family therapy. 

GPs with special interest can become family therapy specialists after completing training and adjustment of 

practice organizations. 


http://www.woncaeurope.org/content/14-w-family-therapy-skills-medical-practitioners 

References: 

1. Rakel R, Rakel D. Textbook of Family Medicine, Elsevier, 2011; chapter 1. The Family Physician, page 5-9 

2. Altamash S. Family Therapy. Indian J Endocrinol Metab. 2013; 17(Suppl 1):S292-4. doi: 10.4103/2230-8210.119619 

3. McDaniel S, Campbell T, Hepworth J, Lorenz A. Family-Oriented Primary Care, Springer Science-Business Media, Inc, 2005 

ISBN: 978-0-387-98614-2 (Print) 978-0-387-26310-6 (Online) 

4. The European definition of general practice, revision 2011, WONCA Europe, www.woncaeurope.org 

5. Graham H, Senior R, Lazarus M, Mayer R, Asen, K. Family therapy in general practice: views of referrers and clients, BJGP, 

1992; 25-28 

6. Senior R. Family therapy in general practice: „We have a clinic here on Friday afternoon“, Journal of Family therapy, 1994; 

16: 313-327 

7. John Gottman in: Malcolm Gladwell, Blink (2005). Little, Brown and Company 

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Richard G Roberts, MD, JD 

Richard.Roberts@fammed.wisc.edu 

100 – What We Do 

Richard G Roberts, MD, JD 

FAAFP, FCLM, FPAFP (Hon), 

FRACGP (Hon), FRCGP (Hon) 


University of Wisconsin School of 

Medicine & Public Health, 

Madison, Wisconsin, USA 

Immediate Past President, World 

Organization of Family Doctors 

(WONCA) 

Past President, American 

Academy of Family Physicians 

Family doctors and primary health care professionals are currently in vogue. 

International agencies, health ministries, and health systems proclaim the value of 

health services based on primary care. Thus, it is understandable that family doctors 

assume that their place in health care is secure. While that assumption is 

understandable, it is risky. 

The Declaration of Alma-Ata (1) concluded in 1978 that primary care produced better 

outcomes, improved equity, and cost less than specialist-based systems. The 2008 

World Health Report (2) confirmed that primary care remains essential in the 21 st 

century. In the thirty years between those two documents, a number of studies 

demonstrated the key attributes that make primary care valuable (3). 

This chapter will review the attributes and contrast them against the changing reality 

of Family Medicine, and the potential for family doctors to lose their hard earned 

status. I will focus on what I believe are the six most important attributes. To make 

them easier to remember, I will use alliteration and name the attributes with a word 

beginning with “C.” At the end of the brief discussion for each attribute, a critical 

question is posed that can be used to assess the performance of a family doctor, 

primary care practice, or health system on that attribute. 

What is there to “C” in family doctors and primary care? 

Convenience – Historically, primary care has been where people first enter the health 

care system. Yet, there is a growing array of other settings where people now enter: 

emergency departments, urgent care, out of hours or home care services, hospitals, 

specialist practices. People also engage the system through telephone advice lines, 

websites or other electronic portals, and so on. Consequently, the number of first 

contact visits in primary care has diminished. Even within primary care, the number of 

first contacts with the family doctor has decreased relative to other members of the 

primary care staff. Health systems are under pressure to make it easier and more 

convenient to enter the system. Family doctors with reduced hours and limited 

availability are less easy and convenient for patients. 

Critical question: How easy it is for patients to contact their family doctors? 

Coordination – A vital role of primary care is to assure coordination of the many 

services a patient may require. In many systems, professionals other than family 

doctors provide these functions. Known as care managers or coordinators or 

navigators, the training of these professionals ranges from nursing to social work to 

on-the-job. There is also a wide variation in their ability to integrate and make 

coherent the often disparate care plans generated by various consultants or other 

specialists. 

Critical question: How involved are the family doctors in coordinating and 

integrating their patients’ care? 

Context – A crucial element of knowing the patient is an awareness of her or his context. Understanding patients’ 

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families, communities, work, religion, and other social determinants of health provides important insights into their 

health. Family doctors appear today to be less likely to live in their patients’ community or remain in a single locale. 

Critical question: How well do the family doctors know their patients’ context? 

Comprehensive – Better outcomes and lower costs result when family doctors provide most of the care needed by 

their patients (4). Fragmenting care across more professionals, even within the primary health care team, diminishes 

the skills of the family doctors (5). Decisions to delegate tasks or to limit clinical activities to narrow areas of interest 

shrink the scope of services provided by the family doctors. 

Critical question: How comprehensive are the services that the family doctors provide? 

Competence – Patients deserve and expect competence. Particular individuals, both within or outside the primary care 

team, may perform certain services more skilfully than the family doctor. Yet, the small marginal gain in a specific 

technical skill may be offset by too limited a perspective of or trust by the patient, with better overall outcomes when 

that specific service is provided by the family doctor. Moreover, family doctors with inadequate training, time, or 

motivation often fall victim to a self-fulfilling prophecy: “The less I do, the less I feel confident and skilled to do.” 

Critical question: How skilled are the family doctors to provide the services needed by their patients? 

Continuity – One of the most important attributes of primary care is the continuity of the interpersonal relationship 

between the family doctor and the patient (6). Continuity permits greater knowledge of the patient by the physician 

and promotes greater trust in the physician by the patient (7). It is possible to extend, but not delegate, the continuity 

relationship to other members of the care team. In other words, the family doctor must have sufficient direct 

involvement with the patient for a trusted relationship to develop. Building on that relationship, other members of the 

care team can then be trusted to provide various services for, and develop their own relationships with, the patient. 

Critical question: How strong is the relationship between patients and their family doctors? 

Practices and family doctors that answer “VERY” to all six critical questions provide better primary care. Health care 

systems that have strong primary health care do better. Thus, the best health care systems are those that respond 

positively to a single essential question: 

How well do the family doctors know, foster trust in, and provide services for their patients? 

Conclusion 

In essence, good family doctoring comes down to leveraging trusted relationships and providing comprehensive 

services, thereby achieving better outcomes (8). The risk today is that in our pursuit to measure well against diseaseoriented 

metrics and to manage growing patient needs and demands, we will give in to the temptation to limit our 

availability to our patients and fragment their care across more disease-focused professionals. Our challenge is to 

develop new strategies and technologies to better know and better serve our patients. Family doctors are not valued 

because of what we think we do or say we do or used to do. We are valued because of what we do. 


 

 

 

 

Health care systems do better when they are built on strong primary care. 

Strong primary care depends on six key attributes: convenience, coordination, context, competence, 

comprehensiveness, and continuity. 

Recent trends suggest that family doctors, and their practices, may not be performing on the six attributes as 

well as before or as desired. 

Family doctors must develop improved strategies to better know, foster trust in, and provide more services to 

their patients, or their relevance will decline. 

References 

1. Primary health care: report of the International Conference 1. on Primary Health Care, Alma-Ata, USSR, 6–12 September, 

1978, jointly sponsored by the World Health Organization and the United Nations Children’s Fund. Geneva, World Health 

Organization, 1978 (Health for All Series No. 1). 

2. The world health report 2008: primary health care now more than ever. Geneva, World Health Organization, 2008. 

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3. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly 

2005;83(3):457-502. 

4. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality 

experience. J Fam Pract 1998;47: 105–109. 

5. Campbell SM, McDonald R, Lester H. The experience of pay for performance in English family practice: a qualitative study. 

Ann Fam Med 2008;6:228-34. 

6. Starfield B, Horder J. Interpersonal continuity: old and new perspectives. Br J Gen Pract. 2007; 57(540):527-9. 

7. Roberts RG. The art of family doctoring: a global view. Eur J Gen Pract. 2013 Mar;19(1):59-61. 

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Michael Kidd 

michael.kidd@flinders.edu.au 

Job Metsemakers 

job.metsemakers@maastrichtuniversity.nl 

Epilogue 

So this is the end of this book, but it is also the beginning. 

We hope that by reading this book you have discovered, or rediscovered, the richness of our professional discipline of 

family medicine, the breadth and variety of the issues which we address in our daily work as family doctors, the ability 

of family medicine to adapt with the challenges posed by the different health systems in each of our countries, and the 

great joy that comes from the privilege of being a family doctor. 

The take home messages in each chapter underscore the core concepts of family medicine, that apply wherever in the 

world we work, and provide valuable advice from our global panel of experts that each of us can adapt to our everyday 

work. 

We hope that, like us, you have been inspired by the contributions from our colleagues from around the world. 

We thank all the contributing authors, and we thank the editorial team led by Mehmet Ungan and Carl Steylaerts, for 

this remarkable publication. 

As we said, this is the end but also the beginning, and we look forward to this being just the first in a series of books 

providing important lessons from family medicine. 

And we leave you with three final Take Home Messages: 

 

 

 

The contributions to this book have demonstrated how much each of us can learn from our family medicine 

colleagues; 

The contributions to this book have reinforced the special distinctiveness of our professional discipline of 

family medicine and the qualities that we need to nurture and cherish; 

We hope you will take the lessons you have gained from reading this book, and apply them to your own 

clinical practice, and that you will continue to provide excellent care to the people in your community who 

trust you as their family doctor to provide them with medical care and advice. 

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Acknowledgements 

Writing this acknowledgement is like describing your first honeymoon night. Almost everybody knows how it goes, so 

it is futile to try it. Those who don't have had the experience, well, let's not spoil it for them. 

We owe a lot to a lot of people, all over the world. 

Those who want to compile and edit a book like this, will enter into the same unknown territory as we did. And will 

refer to friends and colleagues and secretaries all over the globe. We thank all of them. 

The list would be endless, suffice it to be acknowledged that we didn't do this alone. 

Just two persons cannot be dismissed. 

Leo Bormans, the compiler and editor of the World Books on Happiness, Love and Hope, gave us a tremendous 

example on how to do this. And Janko Kersnik acted as a hidden power behind the scene. Thank you both. 

The WONCA Europe Executive Board, presided by Job Metsemakers, decided that this book would be an excellent gift 

to all the general practitioners and family doctors all over the world. Free of charge. Let's thank them. 

As mentioned in the Prologue, some of the authors weren't the original submitters of the abstracts that were chosen 

by the independent jury. They acted as stand-in or, if you like, body double. They did great. 

Thanks! 

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20 Years of WONCA Europe – Some History 

In 1959, the Societas Internationalis Medicinae Generalis was founded in Vienna as the first European GP organisation. 

In 1972, WONCA was founded as the first global GP/FM society. In 1992, WONCA organised a first WONCA Europe 

congress in Barcelona, Spain. 

In 1994, the “Group of 8” - being 4 members of WONCA and 4 members of SIMG decided in Estoril, Portugal to merge 

the 2 organisations into the European Society of General Practice / Family Medicine, and it was inaugurated in 1995 in 

Strasbourg, France, in the European Parliament. 

Since then, 6 Presidents have led the organisation. 

Frede Olesen (1995-98) Chris van Weel (1998-2001) Philip Evans (2001-04) 

Igor Svab (2004-10) Tony Mathie (2010-13) Job Metsemakers (2013-16) 

In 2001, some of the former Executive members gathered in Vienna. They called it Veteran's Day and a few pictures are 

on the website at http://www.woncaeurope.org/content/veterans-day-2000-part-1, 

http://www.woncaeurope.org/content/veterans-day-2000-part-2, http://www.woncaeurope.org/content/veteransday-2000-part-3. 

Nostalgia rules! 

WONCA Europe's history is however by far and foremost … in the abstracts of the thousands of contributors that 

research, teach, develop and apply quality measures, contemplate about prevention and/or rural medicine … and 

think about the past, the present and the future. Not to mention the Special Interest Groups, working on the 

boundaries of our and other's specialty. 

Wherever we go, someone took that path long before we did. The future reflects history. 

Words awaken the spirit, examples inspire that same spirit. And that's what it is all about. WONCA spirit. 

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What is a World Book? 

It is a series of 100 titles selected from 20 years of World and European WONCA Congresses, by concept small essays 

on the topic inviting to read more. It is in no way meant to be exhaustive text book material, but short and crisp texts 

to highlight why the title was selected in the first place. 

Why a World Book? 

When you have an Anniversary, WONCA Europe's 20 th to be precise, it is time to reflect, to look out for more, and for 

exchanging gifts. Selecting the best 100 titles, asking the original or guest authors to make a crisp contribution is a way 

of honouring our past, but also a few good moves into the future. The future of the World, of Family Medicine, of 

WONCA. Hence the title ;)) 

Since the selection was biased by a European look, we decided to name it European Edition. 

How did we do it? 

Collecting the abstracts, making them digitally available, correcting for language, selecting a long list, asking a 

competent jury (Executive Members of the Board of WONCA Europe and WONCA World) to come to a short list of 100. 

What is to be expected from a World Book? 

Inspiration. Also a sense that when you present at WONCA, your work is not lost and there is a chance that – who 

knows when! - there will be more to follow. When? As soon as someone comes with the idea … 

Volunteering 

One can ask oneself: what's all this volunteering good for? (Perhaps you didn't know: all the authors did this for free, 

including the editors). 

Let's use the Ant's Theme: an ant doesn't ask whether it is useful to live, she just carries out a task, like the rest of the 

tribe. And by doing so, the tribe survives and thrives. 

Enjoy ! 

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