Textbook of Family Medicine

The Third Edition of The Textbook of Family Medicine is by Ian R. McWhinney and Thomas Freeman. While many family medicine texts simply cover the disorders a practitioner might see in clinical practice (thus they become watered-down internal medicine texts), this one defines the principles and practices of family medicine as a separate and distinct field of practice. In the excerpt below the authors define some of the principles of family medicine.

1. Family physicians are committed to the person rather than to a particular body of knowledge, group of diseases, or special technique.  The commitment is open-ended in two senses.  First, it is not limited by the type of health problem. Family physicians are available for any health problem in a person of either sex and of any age.  Their practice is not even limited to strictly defined health problems: the patient defines the problem.  This means that a family physician can never say: “I am sorry, but your illness is not in my field.”  Any health problem in one of our patients is in our field.  We may have to refer the patient for specialized treatment, but we are still responsible for the initial assessment and for coordination and continuity of care.  Second, the commitment has no defined end point.  It is not terminated by cure of an illness, the end of a course of treatment, or the incurabilty of an illness.  In many cases the commitment is made while the person is healthy, before any problem has developed.  In other words, family medicine defines itself in terms of relationships, making it unique among major fields of clinical medicine…

2. The family physician seeks to understand the context of the illness.  “To understand a thing rightly, we need to see it both out of its environment and in it, and to have acquaintance with the whole range of its variations,” wrote the American philosopher William James (1958).  Many illnesses cannot be fully understood unless they are seen in their personal, family, and social context.  When a patient is admitted to a hospital, much of hte context of the illness is removed or obscured.  Attention seems to be focuses on the foreground rather than the background, often resulting in a limited picture of the illness.

3. The family physician sees every contact with his or her patients as an opportunity for prevention of disease or promotion of health.  Because family physicians, on the average, see each of their patients about four times a year, this is a rich source of opportunities for practicing preventive medicine.

4. The family physician views his or her practice as a “population at risk.”  Clinicians think normally in terms of single patients rather than population groups.  Family physicians have to think in terms of both.  This means that patients who have not attended for such procedures as immunization, papanicolaou smears, or blood pressure test are as much a concern as those who are attending regularly.  Electronic records make it very easy to maintain up-to-date attendance records of the whole practice population.

5. The family physician sees himself or herself as part of a communitywide network of supportive and health-care agencies.  All communities have a network of social supports, official and unofficial, formal and informal.  The word network suggests a coordinated system.  Up to recently this has often not been the case.  Too often, family physicians, hospital doctors, medical officers of health, home care nurses, social workers, and others have worked in watertight compartments without a grasp of the system as a whole.  At the time of writing, many jurisdictions are in the process of reforming general practice as a key link in the network, which will enable patients to benefit from whichever provider they require.

6. Ideally, family physicans should share the same habitat as their patients.  In recent years, this has become less common, except in rural areas.  Even here, the commuting doctor has made an appearance.  In some communities, notably the central areas of large cities, doctors have virtually disappeared.  This has all been part of the recent trend toward the seperation of life and work.  To Wendell Berry (1978) this is the cause of many modern ills: “If we do not live where we work, and when we work,” he writes, “we are wasting our lives, and our work too.”  The Love Canal disaster in Niagara Falls provides a vivid illustration of what can happen when physicians are remote from the enviroment of their patients.  This abandoned canal had been used by a local industry for the disposal of toxic waste products.  The canal was then covered over and, some years later, houses were built on the site.  During the 1960s, householders began to notice that chemical sludge was seeping into their basements and gardens.  Trees and shrubs died, and the atmosphere became polluted by malodorous fumes.  About the same time, residents in the neighborhood began to suffer from illnesses cause by the toxic chemicals.  It was not, however, until a local journalist did a health survey in the area that an official health study was done.  This showed rates of illness, miscarraige, and birth defects far in excess of the norm (Brown, 1979).  How did the cluster of illnesses in an obviously polluted encironment escape the notice of local physicans?  One can only assume that they treated patients without seeing them in their home environment.  It is difficult to believe that a neighborhood family physician, visiting patients in their homes and interested in their enviroment, would have remained unaware of the problem for so long.  To be fully effective, a family physican still eneds to be a visible presence in the neighborhood…