THE FAMILY MEDICINE MOVEMENT

The term general practitioner was introduced into the English language around 150 years ago and referred to the way most physicians practiced medicine in England. They were surgeons, obstetricians, and pediatricians and they perscribed drugs. ⁴ Later, with the development of the specialties, the general practitioner almost disappeared. After World War II the term general practitioner became popular as being the cornerstone of the English National Health System. In 1957 John Hunt, one of the founders of the Royal College of General Practitioners, referred to general practice as a world movement, going beyond local health services and party politics toward grouping family physicians. This movement recognized that modern medicine, in order to reach maximal benefits, must reach patients early at the home level and provide continuous care, including prevention of any illness, mental or physical. ⁵

In many countries, particularly the United States, the term “family medicine” was introduced to signify almost the same as general practice and became very popular. The American Academy of Family Physicians is second in number only to the American College of Physicians. In Latin American the Instituto Mexicano de Seguridad Social (IMSS) assumed a pioneering role by adopting the scheme of family practitioners and introduced in Latin America the concept and the term. The Seventh Panamerican Conference of Medical Education in 1978 was devoted to the subject of family medicine. Many countries of Latin America have had national meetings devoted to family medicine. The World Organization of National Colleges Academies and Academic Associations of General Practitioners Family Physicians (WONCA) represented all the groups interested in the area.

In the context of this movement primary care is synonymous with the care given by the general practitioner or family medicine specialist. The family medicine movement has been one answer to the health system crisis of industrialized countries characterized by extreme, dehumanized, and depersonalized health care.

THE COMMUNITY MEDICINE MOVEMENT

It can be said that the Flexner Report allowed science to be introduced in medical education. However, the emphasis in the Flexnerian model was the scientific study of the individual patient in a university hospital bed. A number of years ago a growing concern about the social and psychological demands of patients began to appear. The need to study the patient within his social milieu began to influence medical education, and several community studies were undertaken by universities. The influence of John Grant and his principles for community projects were important in shaping this community medicine movement.

The leadership role of this movement has come primarily from the academic community. Several American foundations, notably Rockefeller and Kellogg, have contributed significantly to the development of this movement, which was defined by Moshe Prywes as the “the First-born” of a marriage between medical education and medical care. ³ To the organizers of this meeting COPC is an approach to health care delivery that undertakes responsibility for the health of a defined population practiced by combining epidemiologic study and social intervention with the clinical care of individual patients, so that the primary care practice itself becomes a community medicine program. ² A strikingly similar definition was given by Lathem when he said: “Community Medicine is that branch of medical science which is concerned with the health needs and conditions and with dealing with these by appropriate methods and interventions, of population groups of known size and composition.” ³ So, although having had predominantly academic origins, the community medicine movement is actively contributing to improvements in the ways health services are provided to populations of the country or region.

Several of the better known projects have been projects in which universities have become involved in primary health care delivery. Lathem and Newberry's edited volume describes some of these projects. ⁶ A more recent development has been the emerging of clinical epidemiology, which probably originated from community medicine, since it stresses the need for clinicians to use sound epidemiologic criteria in order to make community projects successful.

THE PRIMARY CARE MOVEMENT

In the developing world during the late sixties and seventies there was increasing emphasis on more equitable health care distribution. Urbanization, together with rapid demographic growth, generated enough political pressure to force governments to study and implement strategies to increase coverage of the health system. The 10-year plan for health in the Americas, signed in 1972, is a typical example of the desire to increase coverage. ⁷ In 1977 the Thirtieth World Health Assembly decided in Resolution WHA 30.43 that the main target of governments in the coming decades should be “the attainment by all citizens of the world by the year 2,000 of a level of health that will permit them to lead a socially and economically productive life.” ⁹ According to Chaves ⁸ this provided stimulus for the Primary Care Movement that took a defined form under the leadership of the World Health Organization (WHO) and UNICEF in a meeting held at Alma-Ata, U.S.S.R., in September 1978. A brief review of the recommendations of Alma-Ata is pertinent to understand the meaning of primary care in this context. According to the Alma-Ata Declaration, the following should be included in primary care:

1.

education concerning prevailing health problems and methods of preventing and controlling them;

2.

promotion of food supply and proper nutrition;

3.

an adequate supply of safe water and basic sanitation;

4.

maternal and child health care, including family planning;

5.

immunization against the major infectious diseases;

6.

prevention and control of locally endemic diseases;

7.

appropriate treatment of common diseases and injuries; and

8.

provision of essential drugs. ⁷

As defined at Alma-Ata primary care requires participation of the individual and the community and can be delivered by health workers, professionals, nonprofessionals, technicians, and even empirical personnel. Alma-Ata gave priority to the health agent or community health worker as a way to reach people in dispersed rural areas or on the periphery of the big metropolitan areas, where availability of health professionals is limited. It was stressed that the training of physicians and nurses should include the training and supervision of these health workers.

As can be seen from this brief summary, primary care, in the Alma-Ata context, is a very ambitious program that involves systems such as education, agriculture, housing, and public works. Since health is considered a basic right of individuals, the definition of primary care becomes a strategy designed to assure the fulfillment of this right. It is obvious that primary health care in this context includes many activities not included in the primary care as defined in the family medicine movement.

Primary health care as defined in Alma-Ata can be visualized in the form of a pyramid. A wide base includes the many aspects of areas such as self-care or care given by the family; a smaller intermediate section that corresponds to the care given by nonprofessionals, technicians, auxiliaries, etc.; and the top of the pyramid, which corresponds to the small part of primary care that requires professional care. On the other hand, as is frequently done, health care can be classified according to the level of complexity. A graphic representation would show a pyramid with a wide base of the many low-complexity (primary care) problems, an intermediate section corresponding to secondary care, and the top section, representing problems of higher complexity or tertiary care. From an institutional point of view, the primary level corresponds to the health care, the secondary level to the general hospital with the four basic specialties and high technology. According to this scheme, a physician working at the base should be called a primary care physician regardless of the training. It is conceivable that specialists such as pediatricians can work at the secondary level and still be called primary care physicians. This often leads to confusion.

Much of the semantic discussion can be overcome by visualizing these two pyramids (as in Figure 1). The top of the primary care pyramid imbricates into the base of the health care pyramid, indicating that the primary care problems requiring professional attention belong to the low-complexity section, and in few cases it may even belong to the secondary level. An example could be the existence of hospital privileges for a general practitioner in a general hospital.

FIGURE 1

1 Relationship of two pyramids to explain the extension of the primary health care concept.

This representation of the relationships of the two movements is taken from the excellent book by Mario Chaves, Health, A Strategy for Change. ⁸ It is obvious that the definition of primary care is closely bound to the social and economic conditions of a country and the definition is relative to the situation of health care. What constitutes primary care in a developed country may be intermediate- or even high-complexity care in a less developed one. Given the wide diffusion and acceptance received by the Alma-Ata conference, I think the term primary care as defined by WHO should be preserved. It is probably easier to abandon the classification of primary, secondary, and tertiary care and introduce the corresponding low, intermediate, and high complexity of care. In the same way the practice of a general practitioner in the English health system and the practice of a family medicine specialist in the United States should not be called primary care, but rather general practice or family medicine. By the same token, projects related to the health of given populations or community medicine projects need not have the term primary care included. It is understood that the larger part of their efforts would be devoted to primary care, but, certainly, all levels of complexity will be touched.

AN INTERNATIONAL PERSPECTIVE ON COPC

The emergence of several independent movements with different origins, in different parts of the world, and yet with strikingly similar objectives points to recognition of the worldwide need for a COPC approach. As I mentioned earlier there is a need, on the part of government agencies (health ministries) of both developed and lesser developed countries, for a means to increase coverage of health services and reduce costs. The Alma-Ata mandate is compelling for less developed countries, yet, in affluent countries like the United States, there continues to be a growing concern about rising costs of medical care.

From an educational perspective there is a need to expose health professionals to COPC. This has taken two slightly different approaches. One emphasizes clinical epidemiology. This approach has been sponsored most notably in the United States by the Andrew W. Mellon Foundation and the Milbank Memorial Fund. The aim of this movement is to introduce in medical schools, and more specifically in the clinical departments, a more quantitative approach to problems such as the prevalence and causal factors of the more important diseases in the area. There has been some success meeting this goal. McMaster University in Canada and the University of Pennsylvania in the United States have assumed a training role for clinicians of different countries.

The other educational approach to exposing health professionals to COPC has taken the form of a worldwide Network of Community Oriented Educational Institutions for Health Sciences. Under the auspices of the World Health Organization and support from the Rockefeller Foundation, several educational institutions with innovative approaches to community oriented medical education have organized a network with the primary objectives being the interchange of experience in this area and help in the diffusion of the concept. The University of Limburg, in Maastricht, the Netherlands, has been appointed by the rest to act as secretariat for the group. In the United States, Michigan State University and the University of Pennsylvania belong to the network, while the University of New Castle in Australia, University of Tromso in Norway, Universidad Autonoma Metropolitana of Xochimilco in Mexico, Universidad del Valle in Colombia, McMaster in Canada, Ben Gurion University of Israel, and others from different parts of the world make up the remainder of the group.

AN ATTEMPT TO IMPROVE THE SURGICAL CARE DELIVERY IN THE CAUCA VALLEY

The following is an example of what could be called a community medicine project involving surgery, an area not frequently included in similar projects. Although it had its origin at the Universidad del Valle in Cali, Colombia, after a succesful demonstration project, it has been officially adopted by several cities and institutions in Colombia. Since it deals with low-complexity procedures, it could also be called “surgical primary care,” but, in accordance with the previous considerations, we have not used that term.

The Department of Surgery of the Health Division of Universidad del Valle undertook a large systematic study of the surgical care system of the Cauca Valley, one of the geopolitical divisions of Colombia, with the purpose of seeking ways to increase the coverage of the system. An inventory of physical and surgical manpower resources was carried out. During 1 full year all surgical interventions were studied and later were classified into four different levels of complexity. An experimental surgical unit was organized in the university hospital, and a model of high productivity and low cost for low-complexity operations was tested. After successful results, the model was adopted by the city of Cali and several other cities of Colombia. More detailed accounting of this study can be seen elsewhere. ^{10 , 11} The most striking results were:

1.

Thirty-two percent of the existing 478 surgeons performed less than one operation per week. The mean yearly productivity was 120 operations, with striking differences with the specialties.

2.

Of the 76 operating rooms, 46 were located in Cali, the capital city of the Cauca Valley. Mean utilization of the operating rooms was 42 percent. As a consequence, it was recommended (and accepted) that no new operating rooms be constructed in the Cauca Valley.

3.

Of the 50,782 surgical interventions carried out during calendar year 1974, three-fourths were of low levels of complexity and could be performed on an ambulatory basis with immediate discharge after recovery from anesthesia. Similar results were found in the United States using the same classification of the interventions of low complexity.

4.

Twenty-eight procedures make up nearly 90 percent of the low-complexity operations, although they belong to different anatomical regions and, consequently, to different specialties.

5.

The cost of a herniorrhafy performed under the experimental model was $30. (U.S. currency) in 1976. Under the traditional system, the cost was five times higher.

6.

Patient satisfaction and acceptance were excellent under the experimental model.

Overall, this COPC demonstration project in the Cauca Valley has been very successful and has been adopted elsewhere by other institutions in Colombia.

Stephen C. Joseph

I want to pick up on two themes followed by Dr. Guerrero, which are also related to the papers of Drs. Abramson and Geiger. These themes are:

1.

The problem of semantics, nomenclature, and jargon in defining what we are about.

2.

The importance of the existing worldwide network of those involved in community oriented primary care, or whatever name may be the fashion of the time or place.

I do not mean to obscure the different emphases of the various labels. Certainly COPC, as the newest term, has differences from community health, community medicine, social medicine, primary care, comprehensive health care, and so on. But, whatever labels we place on our efforts, we are, all of us in this field, the professional offspring of John Grant ¹ and Will Pickles, ² and our midwives are named Kark ³ and Deuschle. ⁴

COPC, in all its guises, has twin driving forces or underlying objectives. These are access (sometimes called availability or entitlement; sometimes expressed in terms of equity) and relevance, using epidemiology to show the relationship between a community's highest priority health needs and the deployment of resources to serve them. These twin objectives have been present as part of COPC and related efforts both in the United States and other affluent countries (with perhaps greater emphasis on access than on relevance), and also in analogous activities in the developing countries (with perhaps the emphasis reversed).

For example, there has been a heavy emphasis in U.S. COPC, as Jack Geiger described in his paper, on “bringing the poor into the mainstream.” Most COPC activities in the developing countries have been trying to find ways to stretch very scarce resources to cope with the most high-priority problems (e.g., the development of village health workers, of essential drug formularies, etc.) and have not had much hope of achieving universal or even majority access for the mass of the population.

This was, of course, the great challenge of Alma-Ata, and the greatest excitement of having been there was to see the world health community take up the ideal of fusing the twin objectives of access and relevance as the main means of improving world health, as applicable in Boston as in Bombay or Bogota. ⁵

While my remarks today are concerned more with the organization and delivery of services, let me at least mention that these twin concepts of access (I will use the word equity from here out) and relevance need also to be embedded in COPC efforts in medical and other health professional education. ⁶

When preparing my remarks, I thought for a time of taking a small sample of this group gathered here at Airlie House, a sample at various ages and career stages, and plotting, or at least calculating, the number of significant prior professional interactions among the sample. In the end, I decided not to; however, I hope you will accept my point in anecdotal form; we are possessed of a worldwide and unusually interconnected network. This network gives us both resiliency and continuity when, in a given period in a given country, we find ourselves in hard times and in a political and economic climate hostile to our COPC aspirations. This is clearly the case at present in our own United States. Our COPC international network (though no one would recognize it by that name) is characterized by slow but evolutionary progress and has taken root and spread almost everywhere that I can think of, and certainly in every country that I have seen, in the past few decades. It is the existence of this network that leaves me less pessimistic for developments in my own country, not that I would urge complacency or less than full-scale criticism of policies that work against equity or relevance, anywhere. But I am confident that our dispersed efforts have a great survival value, that they will continue to gain in impact and momentum, and that we will, all of us, continue to borrow seeds and grains from far places with which to cultivate our own gardens.

COPC has been the most international in all of medicine; it is also important to note that it has proceeded by a process of evolution rather than by quantum revolutionary research advances. These two characteristics have meant that our field shows major local variation in adaptation and coloration and that most of the major tools have been discovered and rediscovered many times. However, in all our diverse settings, whether in affluent or poverty communities, three principles have generally been considered as defining COPC. I want to add a fourth “pillar” to our list, not because I think it has not been thought of before (on the contrary, it is almost always an integral part of any program of COPC), but the fourth element often is left out of the formal listing. The first three pillars are, of course:

1.

The care of a defined population or community, with the full and active involvement of that community.

2.

The linkage between clinical care and preventive, promotive, and public health services, utilizing a multidisciplinary health care team.

3.

Adding the tools of epidemiology and the behavioral sciences to the physician's bag.

The fourth pillar of COPC, which I will amplify later, might best be termed:

4.

Social and political activism aimed at the root causes of illness and wellness.

Many years ago, Virchow said that “Politics is medicine writ large.” We have learned from the international context, and especially from the transnational context, that the converse is also true. One need only think of recent international controversies over the promotion and marketing of infant formula, or over the export and use of banned pesticides, or over the behavior of the multinational pharmaceutical industry, to see very sharp and important examples of how larger political and economic issues affect, not just health in the abstract, but community oriented primary health care, all the way from the health environment of the denominator community, to the costs and benefits of organized services, right down to the clinical primary care of individual patients.

In the history of COPC development, one does not have to look at international issues to track the attention paid to underlying political, social, and economic issues. Back in the days of the Office of Economic Opportunity's Neighborhood Health Center Program, I remember food production cooperatives in Mississippi, lawyers in health centers working on such issues as lead paint in New York City, and a variety of other direct social and political initiatives that were at the heart of what that program was all about. This social activism in the cause of COPC is, I submit, as important as the other three central principles.

I end up, then, with four pillars in my definition of COPC. That definition can be, and has been applied in, settings as widespread as Watts, Wales, and West Africa. This array of international perspectives, at once similar and yet diverse, from which we continue to learn from each other is the proof of our relevance and also our greatest strength.

Keith Bolden

Dr. Guerrero has mentioned the virtual disappearance of the general practitioner earlier in this century. This, of course, was true in America, but in the United Kingdom there never was any question of the general practitioner disappearing. Indeed, since 1911 the health care system has been structured on this very person, and the 1948 National Health Service Act only reaffirmed this point of view. There are a great many assets for patients in having personal and continuing care from one clearly identified family doctor. This has always been possible within our system, because patients have to access all health care through their family doctor.

My colleague in Exeter, Dr. Dennis Gray, classified general practitioner care into six components. These are primary care, family care, domiciliary care, preventive care, continuous care, and holistic care. Dr. Guerrero defined primary care, and it has been covered elsewhere in these proceedings and on many other occasions. Family care is very clearly described and documented with its virtues by Huygens in his classic book from the Netherlands on family medicine. Domiciliary care and the value of seeing the patient in his own home has been clearly shown by Dennis Gray in his James McKenzie lecture to the Royal College of General Practitioners in 1977.

Preventive care and the important role that the family doctor has to play in this has been clearly identified in the recent Royal College of General Practitioners publication by a working party on this subject. A marvelous example of preventive care is given in this document. It outlines two Nigerian villages that were studied by this group. They looked at the underfive clinic that had been established in the village. This clinic combined preventive and curative services on a daily basis. It was staffed by two nurses and six midwives and dealt with 41,000 visits by under-fives each year. In the neighboring comparison village, there was a local dispensary employing one dispenser and two midwives. It dealt with 3,700 child welfare visits in a year.

The difference in under-five mortality between the two villages was striking and cannot be accounted for by any factor other than health inputs. For example, infant deaths were halved, and child mortality rates in the study village were a third of that in the other village, with a significant growth difference between the children in the two villages. Ninety-nine percent of the study children had vaccinations and only 45 percent in the other village. As can be seen from this simple example in primitive conditions, a great deal can be done with preventive care.

Computerization was mentioned in an earlier paper, and for the past 7 years I have been involved in the Exeter computer project. This project was originally conceived as a means of computerizing the whole of the health care area—both the hospital and the community aspects of it. Unfortunately, over the years, with the steady restriction of funds the original framework has had to be modified, but, nevertheless, this project is still running, and computerization of a community is possible.

Great interest has been shown in the use of computerization in primary care in Britain, and various ways of implementing this for the benefit of the community are being explored. Major epidemiologic and preventive care advantages to the community will result from computerization of clinical records, which will enable such information as the incidence of hypertension and diabetes to be recorded or the identification of at-risk groups for various preventive activities such as immunization or cervical smears.

The conclusion of this important report places the responsibility for preventive care firmly in the lap of the general practitioner as a coordinator of these activities within his practice. It was interesting to me that Dr. Guerrero was making a claim for the universities to be responsible for this particular field. However, the implications of this general practitioner responsibility are that the family doctor must have the resources to accept it, and he must have efficient record and recall systems and the full cooperation of the primary health care team.

Finally, we come to continuous and holistic care. The Leeuwenhorst Working Party in 1977 defined the general practitioner as a doctor who provides personal, primary, and continuing care. If the doctor, seen by the patient on each occasion, is different, the many advantages of continuous care are lost. The Leeuwenhorst job definition states that the doctor should have empathy with the patient and should use the therapeutic relationship that develops over a period of time for the benefit of that patient. The implication of this is that the patient needs to see the same doctor on more than one occasion, if that doctor is to become his personal doctor.

Working together with the personal care of the doctor is the practice team and the members of this team, who include the secretaries and reception staff, the nurses, and the community workers such as health visitors and midwives. These members should also offer personal and continuing care so that they all work together on a personal and continuing basis to complete the concept of COPC.

Given this emphasis, there is then the matter of training this team. Vocational training for general practice in the United Kingdom has developed rapidly in the past 10 years, culminating in the Vocational Training Act of 1981, which firmly puts the general practitioner on an equal postgraduate training footing with a specialist in a hospital. There are many schemes producing highly trained young doctors to enter general practice. These doctors, besides being trained in the well-recognized fields of clinical knowledge, also include in their training other aspects, such as behavioral patterns, practice organization, and the implementation of principles of preventive care within the population for whom they are responsible.

All patients, as I have said, have access to health care through their general practitioners, and it therefore makes it much easier to implement policies of care related to the community the practitioners serve. Alongside the training of family doctors are parallel developments for the other members of the primary health care team. The Royal College of General Practitioners and the Association of Medical Secretaries have long recognized the necessity of a training program for reception staff. Health visitors have to undergo extensive training, including a 1-year, full-time course. At present, I am in a working party with the Royal College of Nurses developing postgraduate training for practice nurses. In addition, there have been some experimental courses such as the one we are running at Exeter. This is a course that has been run on a research basis to look at the ways in which one might train members of the remedial professions on a postgraduate basis. It has proved to be a highly popular course and is giving these people postgraduate support from their peers, which they have never had before.

Now, finally, what about the patient? Patient satisfaction studies in the United Kingdom still show that most patients think highly of their family doctor. However, there are indications that all is not as satisfactory in this area as one might wish, and those complaints can be traced to situations where the practice was not organized on the basis of pesonal care. A recent trend has been the establishment of patient participation groups described in another report fom the Royal College of General Practitioners, and I am sure that this liaison between the health care professionals and the patients can only be good and will expand.

Indeed, I think the challenge of this decade is to involve the patient in his or her own health care, and this, in fact, seems to me to be the basis and cornerstone of COPC.