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Introduction to Family Medicine Foundations of Learning The Foundations of A Curriculum For Postgraduate Education in Family Medicine"What is family medicine? There are two popular misconceptions about the nature of family medicine. First is the "Amalgam Myth," which states that family medicine is simply a melding together of the major clinical disciplines along with some behavioral science. The educational challenge, in this way of thinking, is to combine the right specialties in the correct proportions. We hear arguments from various special interest groups that there should be more time for training in their specialty areas. If family medicine programs acquiesced to all of these suggestions, the programs would be five or six years long! The major error in this way of thinking is that family medicine is seen as nothing more than the sum of its parts; there is nothing special about it. It consists of the "easy parts" of each of the specialties it comprises. The second is the "Specialty Myth." In our attempt to achieve credibility with our academic colleagues, and status in the eyes of the public, we lay claim to the family as our area of expertise and become just another specialty. But, as Howard Stein argues so cogently, this approach betrays our philosophical and historical roots. "Our legitimacy lies not in the ownership of disease entities or social units, but in the world-view of interrelatedness which we reintroduce into medicine. If we are able to resolve our identity conflict without choosing either of these two extreme solutions ...family medicine can fulfill its promise of becoming ...a discipline that transcends specialties as it integrates them into a new whole".1 Family medicine shares with general internal medicine, and other primary care disciplines, a recognition of the need for what McWhinney calls a "transformed clinical method" 2 one that places, at its center, the importance of understanding patients' experiences of their illnesses. Such understanding requires physicians to make contact with patients in a deeply personal way, and this is one of the reasons that continuity of care is so important. Developing such a relationship usually requires repeated interactions over time. It can make considerable demands on the physician's personal strength and character and is not for the faint-hearted or immature. One example, which illustrates the distinctiveness of family medicine, is the care of dying patients. Deliberately involving oneself in the last stages of another person's life, investing time and energy to become attached to someone who will soon die, is a daring and courageous act. Physicians, deprived of their "bag of tricks," have no cure to offer. Their knowledge of drugs and available support services may ease their patients' suffering, but, more than anything else, it is their attentive concern and love that are helpful to the patient. Two Views Of MedicineAn ancient Greek carving of Asklepios, the Greek god of medicine, with his two daughters, Hygiea and Panacea, provides a clue to the distinctiveness of family medicine. Hygiea became the goddess of prevention; Panacea, the goddess of treatment. This statue reminds us that, for at least 2,000 years of medical history, there have been two quite distinct points of view about human sickness. One of these views is reductionistic and focuses on finding the disease, the "thing" that is wrong, and fixing it; the other examines the whole person in his or her environment and seeks to encourage ways of living more wisely and to promote healing. The first approach, the search for a panacea, is dramatic and exciting and appeals to our deeply unconscious longings for immortality. For example, if we conquer the rejection problem in organ transplantation or develop better mechanical hearts, then there seems to be no limit to how long we might live. This approach emphasizes the physician's curative role: diseases are real entities to be discovered by physicians and then eradicated by specific remedies. The second approach, which emphasizes living sensibly and accepting the inevitability of death, has much less appeal in an age of technology and "miracle" cures. This approach stresses the physician's role in patient education and nurturance and places greater demands on physicians' personal qualities. Disease is not seen as an entity with a life of its own but as inseparable from the sick person in the context of his or her family and environment. Classifying the disease is not as important as making a healing connection with the patient and assisting the vis medicatrix naturae: the healing power of nature. The traditional physician argues that three things are important in medicine: diagnosis, diagnosis, and diagnosis. But often such precision is impossible or too costly, not only in economic terms but also in terms of suffering or risk associated with investigation. We must remember that diagnosis is a means to an end, not the end in itself. The goal of medicine was expressed best in an ancient aphorism: "To cure sometimes, to relieve often, to comfort always." 3 The coexistence for millennia of two such divergent approaches to medicine suggests that the mysteries of disease are too great to be encompassed by either approach alone. Each has its own distinctive focus, methods, and mission, and each demands a different approach. In the past 50 years, the overemphasis on the reductionist approach has made it difficult for physicians to understand, or even imagine, other ways to comprehend the problems their patients bring to them; it is also a major cause of the current confusion in family medicine education. The reductionist approach has led to a simplistic understanding of the biomedical model, in which medical practice is equated with applied science, and an outdated seventeenth-century notion of science underlies the conventional biomedical model. 4 I have rarely met a physician who does not care deeply about his or her patients, but I have seen many doctors behave AS IF they did not care. The problem was not their intentions but their conceptual framework: their misunderstanding of their task led them astray. Translating These Frameworks Into PracticeThe central issue is how these conceptual frameworks are translated into practice. The task of isolating a biomedical cause of a patient's suffering is worlds apart from the task of understanding patient's experience of being ill. The first demands the ability to sift through the patient's personal story of illness, discard all that makes the patient's narrative unique, find what is universal, and discover the disease. The second requires physicians to "steep" themselves in the experiences of their patients in a very personal way, to understand their patients' feelings and individual frames of reference. The first task requires physicians to ask questions such as: Where does it hurt, when did it start, what makes it better or worse? The second task requires physicians to seek to understand, by asking: How is the illness disrupting your life, why do you think the illness is happening, why now, how do feel about the experience, how are you coming to terms with it? These questions are especially relevant to patients with a terminal illness or a chronic disabling condition. The first set of questions are neutral and detached, while the second set are more personal and involved, more like the questions one asks while seeing to understand a poem. In The Death of Ivan Ilych, Tolstoy. contrasts the two ways of looking at illness "To Ivan Ilych only one questions was important: Was his case serious or not? But the doctor ignored that inappropriate question. From his point of view it was not the one under consideration, the real questions was to decide between a floating kidney, chronic catarrh, or appendicitis... All the way home (Ilych) was going over what the doctor had said, trying to translate those complication, obscure, scientific phrases into plain language and find in them an answer to the question: 'Is my condition bad? Is it very bad? Or is there nothing wrong?' 5 These two modes of comprehending our patients' problems are vastly different and perhaps require us to use opposite cerebral hemispheres. It is not easy to integrate these two modes of understanding, and perhaps this is why we still have different models of medicine: there is still no satisfactory synthesis of the two. Physicians need years of experience to integrate these two approaches into their clinical method. First-year medical students seem quite skilled at comprehending a patient's point of view. But after one or two years, they become so preoccupied with disease and with missing something serious that their interviews become very doctor-centered. Often, only near the end of residency training do they begin to strike a balance. CurriculumAny curriculum exemplifies the dominant values and world view of the educational system. Just as medicine reflects a dialectical struggle between two contrasting points of view, the domain of medical education demonstrates a parallel conflict. With a reductionist approach to curriculum, learning is defined as the acquisition of information presented by experts. Most curriculum questions are reduced to technical concerns: What core knowledge should be emphasized; how long should each rotation be; which teaching techniques are most likely to achieve the desired outcomes; how can students be evaluated to assure program planners that the educational "product" has achieved the objectives? With a holistic approach, on the other hand, learning is a matter of sharing and discovering personal meaning; knowledge is something a person constructs or negotiates with others. The curriculum is planned collaboratively by both teachers and students to create learning environments that challenge them to reflect deeply and critically on their own experiences and the unique meanings their actions have for themselves and others. The emphasis is on the curriculum each experiences rather than the curriculum on paper. It seems ironic that the dominant paradigm of curriculum in academic family medicine, since its inception in the 1950s, is a technological one. Assumptions are held that education is technical and teachers are technicians: the goal is to transmit a body of knowledge. A good program has a list of objectives and an evaluation system linked to these objectives. Objectives should be written as clear descriptions of behaviors that learners can demonstrate by the end of the program. It is hard to disagree with these sentiments: both teachers and learners need to know where they are headed. But this exclusive focus on terminal behavioral objectives may divert our attention from two other aspects of curriculum which deserve equal attention: · The learning environment · The relationship between teachers and learners Why does the learning environment matter? Why could our residents not learn their craft equally well in hospital as in a family practice office? The educational concept of "transfer of training" is important if we are to answer this question. The more the learning setting approximates the practice setting, the more likely the student is to remember what was learned. There are several reasons why this is true: First, the spectrum of disease reflects the setting. Kerr White's 6 classic study in the 1960s showed that in a typical American community of 1,000 people, in an average month 750 fell ill or had an injury. Of these, 250 saw a doctor, then were referred to a specialist, and only one ended up in a teaching hospital. It is obvious from White's findings that conditions common in the community setting will be rare in the hospital and vice versa. Our residents repeatedly comment that they have rarely seen common rashes, sprains, and emotional problems before coming to the family practice office. Because prevalence has a profound effect on the predictive value of tests, the approach to investigation must be different in the office and in the hospital. In the hospital, it may be very appropriate to order a battery of tests for conditions because these conditions are more likely in this select sample of the population. It is also more economical to do tests all at once in the hospital if this will hasten earlier discharge. Such a testing strategy is inappropriate in the ambulatory setting: the payoff is less and time can be used to clarify the problem. Second, the responsibilities are different in the hospital and in the family practice office. On specialty services, residents assume responsibility for managing a narrow range of problems in their patients. Third, the role of patients varies with the context. In hospital, patients are often seriously ill and are in no position to have much voice in what happens to them - they are generally passive and dependent. Ambulatory patients are much more autonomous and want, and often demand, to play a key role in decisions about investigation and management. Fourth, the value systems reflect the environment. McWhinney has pointed out the importance of the learning environment. "Learning to be a family physician requires a change of perspective that can only take place where the new perspective is dominant. If students are to have certain values and certain ways of thinking and feeling, they must be educated in a setting in which these qualities are all pervasive. And their teachers must be people who exemplify these qualities. 7 Family medicine represents an approach to patients, which is open-ended and not delimited by discipline: the commitment is to the patient, not to a body of knowledge. Anything the patient wants to talk about is relevant. Caring and compassion are valued more highly than the ability to recite the latest facts. One issue facing family medicine programs is whether family medicine block time should consist of a long block time in one setting or of shorter times in a variety of settings. Longer time in one setting has the advantage of allowing continuity of patient care and a continuing relationship with one teacher. The importance of relationships and personal development is thereby emphasized. The teacher becomes a mentor who can provide support and both challenge and assist the resident to assimilate the professional identity of a family physician. But this approach demands highly skilled teachers who are prepared to become involved with residents in a meaningful way, and who can deal with the occasional, but inevitable, interpersonal problems such intimate relationships create. Providing residents with a variety of practice settings shows them different systems and capitalizes on each teacher's strengths. But relationships are less intense and less demanding. Another disadvantage is the cost and emotional stress of frequent moves. Why does it matter who the teacher is? It would not matter if residents were learning only information and skills. But our residents are also developing their personal identities as family doctors. More than anything else, medical education is the education of character - the development of mature compassion, the willingness to form close bonds with people who are disabled or dying, and the ability to lend strength and courage to others who are suffering. To do this, residents need a mentor - a family doctor teacher whom they can respect as a role model. It is crucial for residents to develop a strong, confident identity as family physicians. Much of what they are learning about the craft of family medicine cannot be put into words, and they learn much by unconscious mimicry. Attitudes and values are more caught than taught by interacting with a respected role model. As Marinker states: "It was not the curriculum which made us Doctors, it was our teachers".8 Such a relationship takes time to develop. Both teacher and learner need courage to expose themselves to the risks inherent in close relationships. These risks highlight the need for programs of continuing faculty development and support for all teachers. One of the teacher's central tasks is to convey a sense of excitement and respect for the discipline of family medicine. Our graduates should be proud to be family doctors; they should be sufficiently well educated that they can hold their heads high and not be intimidated. They carry the torch, first lit by Hippocrates, for a paradigm of practice that has been almost lost amidst the glamour of technology and the wish for magical panaceas. Family medicine can help to restore balance between the two paradigms that form the foundation of medicine. CONCLUSIONS1. Family medicine represents an approach to patients, which incorporates the biomedical model but goes beyond it. Its practitioners seek to understand, not only the patient's disease, but also the patient's personal experience of illness. The doctor's task is to treat and cure disease, whenever possible, but always to provide comfort and support to the patient and his or her family to make a healing connection with patients that alleviates the anguish and loneliness that often accompany disease. This approach springs from the nature of family practice itself: the family physician is a generalist and has a broad interest in anything the patient wants to talk about; family medicine is a community-based discipline; the family physician is a resource to a practice population; the family physician's responsibilities arise from the special qualities of the doctor-patient relationship. 9 2. Much of the confusion and many of the arguments about educating family doctors stem from a lack of agreement about the fundamental task of medicine and the role of doctors. This disagreement can be understood as a dialectical conflict between two paradigms of medicine, which have existed for at least the last 2,000 years. 3. An appropriate curriculum for family practice training must reflect the special nature of the discipline. As much as possible, training should occur in settings that reflect the values and ideals of family practice. Special attention must be given to residents' personal and professional development and to the central importance of the teacher-learner relationship - W. Wayne Weston. REFERENCES:1. Stein HF. Family medicine as a meta-specialty - and the dangers of overdefinition. Fam Med 1981 May-Jun; 13(3):3-7. 2. McWhinney IR. The Need for a Transformed Clinical Method. In: Stewart M. Roter D, eds. Communicating with medical patients. Newbury Park CA: Sage Publications, 1989:25-40. 3. This saying has been attributed to William Osler. 4. Engel GL. How much longer must medicine's science be bound by a seventeenth century world view? In: White KL. The task of medicine. Menlo Park CA: They Henry Park CA: The Henry J. Kaiser Family Foundation, 1988:113-36. 5. Tolstoy L. The death of Ivan Ilych. In: Perrine L. Ed. Story and structure, 5th ed. New York: Harcourt Brace Jovanovich, 1978:520-44. 6. White KL, Williams, TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-92. 7. McWhinney IR. Family Medicine in perspective. N Engl J Med 1975;293:176-81. 8. Marinker M. Medical education and human values. J R Coll Gen Pract 1974;24:445-62. 9. Challis EB, Grant IN, McNab JW, et al. Report of Task Force on Curriculum, Section of Teachers of Family Medicine. Willowdale, ON: College of Family Physicians of Canada, 1989.
"A man's experience is his reality. A duck's legs though short, cannot be lengthened without discomfort to the duck, a crane's legs, though long, cannot be shortened without discomfort to the crane." - Chuange Tsu Source: Prof. W. Wayne Weston Introduction to Family Medicine - Foundations of Learning |
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