Dear Luis,
It is my pleasure and honor to participate in this Forum. It is exciting to see young family doctors taking the initiative for their education and developing innovative approaches to learning. My answers follow your questions below.
Rich

1- In this group there are Family Medicine Residents that have started their training recently. Could you please briefly present yourself? Could you talk more about you and your Work?

I am married and have 4 children, aged 17-27. My wife Laura is an exercise physiologist, triathlete, and fitness consultant. I am Professor at the University of Wisconsin in the USA. In that role, I teach family medicine residents and medical students. My scholarship focuses on quality improvement (e.g., guidelines) and primary care redesign. I serve as the director of our clinic in a rural community of 2000, 30 km south of Madison, where the university is located. Our clinic is one of 14 residency training sites in our statewide department, which in turn is part of the 1000 doctor university group practice. Our practice site has 6 faculty family physicians and 6 resident physicians (2 in each of the 3 years).

When I am not traveling, I spend a substantial portion of my time taking care of patients (about 3 days, or 6 sessions, per week). Having been at the same site for 23 years, I have accumulated a large practice. In addition to my ambulatory practice, I continue to deliver babies, attend patients in the hospital and intensive care unit, do home visits, and see patients in nursing homes. My practice also includes vasectomy, some endoscopy, and minor surgical procedures.

In addition to my clinical-teaching-administrative duties as an academic family doctor, I have also been very busy as a “medical politician” having served as President of the AAFP, among other things.

2 – In fact you are the President-Elect of WONCA. Could you please explain, from your point of view, what is WONCA?

Wonca stands for the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians. Its other name, which is easier to remember, is the World Organization of Family Doctors. Wonca was founded in 1971 and has grown to 119 organizations in 99 countries, which represent nearly 300,000 family doctors and about 80% of the world’s population (India does not yet have a member organization). In a sense, Wonca is “an association of associations,” with national colleges, including Portugal, comprising
the membership of Wonca.

Wonca has as its mission:

• To improve the quality of life of the peoples of the world.

• Fostering & maintaining high standards of care in general
practice/family medicine.

• Promoting personal, comprehensive and continuing care for the
individual in the context of the family and community.

• Encouraging and supporting the development of academic
organizations of GPs/FPs

Wonca has grown in influence and has the status of an organization with a collaborating relationship (OCR) with WHO (OMS). Over the past year, for example, Wonca has played a key role in developing several important WHO monographs (Primary Care: Now More than Ever; as well as Integrating Mental Health into Primary Care) and working with WHO global initiatives such as GOLD and GARD, which focus on respiratory disease. Wonca has
also been successful advocating before the World Health Assembly, which adopted a resolution in May of this year that for the first time said that health systems should be based on primary care and that countries should have enough family doctors.

In my view, Wonca’s main purpose, and what makes Wonca fun, is that it connects the family doctors of the world. Thare able to work together to improve vocational training, promote research, address environmental concerns, and on and on. For a more complete list of Wonca activities, Working Parties and Special Interest Groups (SIG), I would refer you to our website, www.globalfamilydoctor.com.

Wonca raises funds through membership dues paid by national colleges and by charging levies for global and regional Wonca conferences, such as the Wonca Europe meeting that occurs each year. With about USD 500 000
in annual revenue, Wonca runs on a very lean budget for a global organization. Consequently, much of the activity by family doctors through Wonca occurs electronically and on a voluntary basis.

Wonca is governed by a World Council that meets once every 3 years, in conjunction with the World Conference. The next meeting is scheduled for 16-23 May 2010 in Cancun, Mexico. I will be installed as President at that time and will serve for 3 years. I would encourage young family doctors, residents, and medical students to attend the Cancun
conference. It will be a wonderful opportunity to meet other family doctors from around the world, participate in high quality education programs, and have fun. If lack of funds to attend the Cancun meeting is a problem, you may want to approach the Portuguese college and/or the Mexican Host Organizing Committee to ask about possible bursary support.


3 –Why did you choose the title: "Primary Care in 2015"?

Because it is my sense that many medical students, residents, and young family doctors around the world look to their future with uncertainty and concern. It is difficult to predict how primary care is going to change, but I am very confident that the need, payment, and prestige of family doctors are going to rise in every country over the next 5 years.
 

4- What do you know about the Portuguese Primary Care System and our new
reforms?

I have visited Portugal 4 times over the past 15 years and have been impressed with the progress that has been made in primary care. Whenever I attend the annual meeting of a national college, I ask the college leaders to organize visits with trainees, to meet with politicians and reporters, and to spend some time in a family doctor’s
practice. I was able to do all of those things during my last visit in March 2008 to attend the Portuguese college’s annual meeting in Villamoura. Thus, while I have some knowledge of Portugal’s health system, I am most sensitive to the fact that there is much more that I need to learn.

Every health system in the world is struggling with aging populations, rising public expectations, proliferation of technology, and rising cost of care. One strategy is to pay primary care doctors based on their performance – the most prominent example of this is the Quality Outcomes Framework (QOF) in the UK. My understanding is that similar changes are contemplated for Portugal. My experience with such “pay for performance” systems is that they can raise family doctor incomes as they better organize their practices and target key diseases or sub-populations in their practice, but they can also fragment care (the doctor hands off more duties to special nurses, etc.) and erode what I view to be the most important value and tool of family doctors: the trusted relationship we have with our patients.

5- And about the primary care system in the United States? What you think about its past, present and future?

This question is impossible to answer in the brief confines of this Forum. The United States has a population of 300 million and spends USD 2.5 Trillion annually on health care. While primary care doctors comprise only about 1 out of 4 U.S. doctors, we provide about 53% of all the 1.1 billion doctor visits that occur each year.

In my view, one of the mistakes we Americans made was thinking that health care was more about tests and treatments than care and context. Consequently, even though we spend much more per capita on health services than any other country (16% of the GDP versus Switzerland, which is number 2 at 11%), the health outcomes of the U.S. rated only 37th in the 2000 World Health Report. In other words, we have spent much on specialists, hospital care, and technology, at the expense of primary care and preventive services.

As a nation, we have begun to wake up to this error. Indeed, President Obama’s health reform proposals consist of four principal goals: universal coverage so that everyone has health insurance, getting everyone a primary care doctor (“patient-centered medical home”), conducting comparative effectiveness research, and having every hospital and doctor using electronic health records that can be shared across the system.

I would point out however, that the challenges of health care reform are considerable in the U.S. While we a single country politically, we have many, many subcultures and micro-economies across the country. For example, if Portugal were a state in the U.S., it would only be the 8th most populous state. I am hopeful that we can accomplish the four goals during the current Congress.

6 - In your first answer, you describe an interesting reality, about delivering babies, attending to patients in the hospital, some interventions like endoscopy, vasectomy…

6.1- Could you please describe with more detail an ordinary week of your work, number of patients, activities, health promotion….?

I am happy to describe my schedule to you, but please remember that the work routine of every family doctor is a bit different, based on his or her community needs, interests, and personal circumstances. To get a general sense of the activities and practice realities of U.S. family doctors, I would refer you to the AAFP's website and its annual survey of U.S. family physicians. While not all of America's 100,000 family doctors belong to the AAFP, a majority do and the survey represents a good snapshot of American Family Medicine each year. The link is http://www.aafp.org/online/en/home/aboutus/specialty/facts.html.

Since you seem quite interested in the specific details of my life, I should expand on my previous discussion of my setting and situation. I am Professor in a very large Department of Family Medicine (500 staff, 150 faculty, 150 residents and fellows, spread across 5 residency programs and 250,000 square kilometers of Wisconsin) in a large medical school (1200 faculty, 800 students - 200 x 4 years each), which is in the large public University of Wisconsin (20 schools, such as law or medicine, with 30,000 staff and 70,000 students).

For the past 23 years, my practice has been in a small village (Belleville, population 1900, medical service area of about 10,000 people), which is located about 30 km southwest of Madison (metro population about 500,000), where the 3 hospitals are located at which I attend patients. I have attached some PowerPoint slides that orient you to the Belleville clinic. My home is in a community (Verona, population 10,000) about halfway between Belleville and Madison. The Madison residency program has four residency clinic/training sites, with a total of about 30 family physician faculty and 42 residents (14 per year x 3 years), including 6 at Belleville (2 per year). We are the only medical facility in Belleville.

My academic, political, and professional (e.g., Wonca) duties have me traveling about 150-180 days per year, which includes about 40 weekends (80 days), per year of travel. Most of my scholarship activities (writing, preparing presentations, doing research) come after hours or while on airplanes. On an annual basis, I am budgeted to be in clinic just over half the time (that is why during some weeks I am out of the country all week and during the other weeks I am in clinic every day).

My usual day begins about 5 am, when I get up to check email and my in-basket for our electronic health record, which is linked to the records (including consultations, lab results, x-rays) of the other 1000 University doctors and the 3 hospitals in our area. I average just over 100 emails and 100 in-basket messages each day; I also average about 100 phone calls daily. On a good day, I will try to get in a 6 km walk before leaving for work.

I leave about 6:30-7 am and drive about 30 minutes from my home to Madison to visit any of my patients in hospital or to attend a meeting, of which I have many in my role as director of the Belleville clinic. I then drive another 30 minutes from Madison to Belleville to start seeing patients, or supervising residents, by 9 am. During the weeks when I'm not traveling, I see patients about 7 sessions per week and supervise residents as they see their patients about 3 sessions per week. I usually see between 10-15 patients per 3.5 hour session. I usually work straight through the day, with no lunch time, and finish seeing patients around 5 pm. It typically takes me until about 7 pm to finish my electronic record notes and phone calls back to patients, and I am usually homore meetings or to see patients in hospital. I spend the rest of the evening visiting with family, writing papers, etc. I usually go to bed about 11 pm.

In the U.S., patients visit their family doctor about 3-4 times a year. So one difference between our system and yours, having spent time in Portuguese health centers, is that U.S. family doctors are expected to address a number of health problems during the 15-20 minute (chronic problems like diabetes and heart disease, as well as any new problems the patient brings in), while in Portugal the visits seem to be shorter (10 minutes) and focused on only 1 or 2 problems. The average full-time U.S. family doctor takes care of between 1500-2500 patients with about 5000 patient visits per year.

Our four Madison residency clinics combined average a total of about 90,000 ambulatory or clinic visits per year, which represents a practice population of about 30,000 people. In our small Belleville clinic, which does about 12,000 visits per year, we have 6 residents. Over the course of their 3 years, the residents average about 5 sessions per week in clinic, but in the first year it is about 1-2, in the second about 3-4, and in the third about 7-8. One of the other 5 faculty physicians has a clinic schedule similar to mine; the other 4 faculty see patients an average of 2-3 sessions per week and supervise residents about 0-1 session per week. We have 3 nurses, 2 medical assistants, 2 x-ray technicians, 2 lab personnel, and 6 administrative people at the clinic. Virtually every one of these support staff is part-time (2-4 days per week).

In my practice, I try to do as much for the patient as possible. I average about 1 vasectomy per month, about 1 endoscopy (flexible sigmoidoscopy) every 2 weeks, and minor surgery (e.g., skin lesion excision) about once daily. I manage about 1 fracture per week. More severe fractures (e.g., open or comminuted fractures, fractures of major joints like hips) are referred to orthopedics. I do endometrial biopsies and dilation and curretage. I have about a dozen nursing home patients and visit them about once a month, usually before or after clinic hours. I average about 1 home visit every 2-4 weeks, depending on patient needs, also before or after clinic hours. We do a number of point-of-care lab tests (INR, blood count, hemoglobin A1c, urinalysis, etc), x-rays (extremity, chest, abdomen), and other tests (spirometry, ECG, fetal monitoring, etc).

I am on call after hours and on weekends about once every 10 days. About two thirds of those call days, I am on hospital call, during which I am likely to be up most all night with 3-8 hospital admissions to one of the Madison hospitals. The other one third of call days I am on obstetrics call, when I am not supposed to be in clinic and am on duty for 24 hours to supervise any of our 42 residents who are delivering one of their patients - the Madison program averages about 1 delivery per day. When I am available, whether I am on call or not, I will try to attend the delivery of any of our Belleville patients that are followed by me and one of our Belleville residents.

We use a modified hospitalist approach to care for our residency patients in hospital. That means that two times during the year, I serve two weeks as the inpatient/hospital attending (hospitalist) and will be responsible for all of the patients admitted from our residency clinics to that hospital during those 2 weeks. The average daily census is between 10-20 patients, including some in the intensive care unit.

While on the hospital service, I have occasional opportunities to do other procedures (paracentesis, thoracentesis, arthrocentesis). During those 2 weeks, I am in clinic few or no days, depending on how busy the hospital may be. Thus, my visits to the hospitals during the 48 weeks a year when I am not the hospitalist are more for social purposes and to assist in the continuity of my own patients - I am not expected to manage the minut the hospitalist. In the U.S., patients average only 3-3.5 days in hospital, so you are constantly admitting and discharging patients all day long when you are on the hospital service.  

When I travel, my meetings, presentations, dinner functions, and so on usually go from 7 am to 10-11 pm. I stay very involved in patient care, even when I am traveling. My patients have my email address and mobile number. I start and end each day when I am traveling by checking my email and the electronic health record for new results, etc. I also try to call each day any of my patients who are in the hospital, no matter where I am. Recently, I have started to use a webcam with Skype or MSN so that my hospitalized patients can see me and I can see them when I am traveling. 

Now you know more about my life than my wife does! It is busy, enjoyable, and rewarding.

6.2 - Could you please describe the working life of a resident during residency; for example the tasks that the resident must complete during each year of the residency, the number of hours of work, the number of patients, the supervision by a senior family physician "supervisor", the educational activities, the assessment…? can you describe the reality of "your" trainees.

In the U.S., a family medicine resident will have first completed 4 years of university (typically with a major in biochemistry or another biological science), followed by 4 years of medical school. While in medical school, the last 2 years are spent on clinical and hospital services and students are expected to participate in after hours coverage about once every 5-10 evenings. During their first year, family medicine residents spend about 80-90 per cent of their time in hospital, with 1-2 month rotations in adult and pediatric medicine, intensive care unit, obstetrics, emergency medicine, surgery, and so on. They average 1-2 sessions per week in the clinic seeing their patients, while being supervised by the faculty physician. As they move into the second and third years, they spend less time in the hospital (about 50-60% in the second year and 20-30% in the third year) and more time in the clinic (about 30-40% in the second year and 70-80% in the third year). They also spend time on other specialty ambulatory experiences (dermatology, urology, and so on).

During the second and third years, they shift from being responsible for the minute-by-minute care provided by the first year residents to supervising the first year residents and "managing the hospital service." By the end of their training, the residents in our program will have delivered about 150-200 babies (about 90% while on their obstetrics rotations, about 10% will be their own clinic patients).

During their hospital rotations, they usually get experience assisting at surgery; performing thoracentesis, paracentesis, and endotracheal intubation;, managing cardiac arrest; and so on. Residents on a hospital service are "on call" (in hospital overnight) about once every 4-5 days. Residents on an ambulatory specialty rotation take phone calls after hours. Under U.S. work hour rules for trainees, residents are not permitted to work more than 30 consecutive hours, nor more than 80 hours per week. Our residents have 3-4 weeks of vacation per year.

While in the clinic, the average first year resident sees about 3-4 patients per 3.5 hour session, second year about 5-7, and third year about 8-12. In our program and clinic, the resident is viewed as a junior partner in the practice - mostly seeing their patients and sometimes seeing the patient of one of the other residents or faculty that patient's doctor is not in clinic that day. They are expected to "staff" (discuss) every patient with the faculty physician who is serving as the supervising doctor for that session. We encourage the residents to see themselves as the patient's primary doctor, and they do a very good job of that.

Residents have 1-2 half days per week of formal educational activities (lectorganized around a structured curriculum that is appropriate for their stage of training. For example, first year residents will have more teaching sessions on hospital problems since they spend most of their time in the hospital. More of the teaching sessions in the second and third years focus on ambulatory problems. They are also expected to attend several one-hour grand rounds or conferences each week.

Residents do much less moonlighting than in the past, partly because their pay is now much better (about USD 50,000 per year with excellent benefits). It is common for our residents, or their partner, to have babies while in their residency years - each year there are about 3-4 babies born to our residents. About 55-60% of our residents are female, which is similar to national trends.

I hope this gives you a more complete picture of the life of at least one U.S. family doctor and the reality of the residents in our program.

 Topo
 

Dear Professor Roberts,

it is an honour and privilege to have you on board. Many thanks for agreeing to take part in our Virtual Conference, we're all delighted. To start off, I have the following questions for you...

Dear Tiago,

My answers follow your questions below. Warm regards,

Rich

1. In your view, what will be the main innovations in the field of family medicine over the next 10 years?

I believe the innovations will reflect the changing demands and demographics of primary care. The changing demands include more chronic disease care, better risk factor management, and more complex care. The changing demographics include aging patient populations and family doctors who want more protected time for family and personal needs. Thus, I believe the main innovations will be:

1. Improved continuity, communication, coordination, and convenience of care through the use of electronic means (web-based health records, mobile telephony, e-consultations, web-based patient information, etc.). This will allow family doctors to stay better engaged with their patients’ care across the care spectrum (home, hospital, nursing home).

2. Improved management of lifestyle risk factors (exercise, diet, safety, etc.) through the use of formalized strategies that involve more and better-trained primary care team members (e.g., nutritionists, exercise physiologists, health psychologists) and community outreach approaches (e.g., community oriented primary care).

3. Improved diagnostics and therapeutics at the primary care level through the use of simpler and less costly point-of-care testing technologies and through a wider array of medications and therapies (ultrasound, etc.) in the primary care clinic.

4. Improved capacity of primary health care teams through the training and use of a wider range of professionals in the primary care clinic and through payment mechanisms such as pay for performance.

2. Family Medicine residency programs last between 2 (e.g. Canada) and 5 years (e.g. Germany). In your opinion, what should be the ideal duration and why?

The ideal length of training depends on the amount of preparation in medical school, the nature of the training while in residency, and the scope of practice of the family doctor in practice. Also important however, are the learning styles and innate abilities of the individual learner. As an example, I’ve had some trainees that demonstrated excellent skills after only 10 endoscopies and other trainees that were not competent after 100 endoscopies. Similarly, if the resident spends much of his or her training time in an observational role, rather than being responsible for the care of the patient, then that trainee will need more time to be able to assume responsibility for patient care. As another example, North American medical students typically go to university for 4 years, then enter medical school for another 4 years.

My sense is that North American medical students get more clinical experience in their final 2 years of medical students than do many medical students in Europe. Differences in the role(s) played by family doctors also matter greatly. Many North American family doctors deliver babies and are quite active in the hospital, while European family doctors tend to limit their practices to the ambulatory setting, so the nature and length of their training will likely differ.

Finally, and most importantly, we never learn medicine, we re-learn it.  The doubling time of medical knowledge is 5 years. It is vital that family doctors develop lifelong learning strategies; residency is the only the beginning of a continual learning process.

3. You must travel extensively because of your work with WONCA. What are the main problems with family medicine postgraduate and residency training in the countries you've visited so far, and what could be the possible solutions? Do the praises and complaints of US Family Medicine residents bear similarities with those from residents other countries you've visited?  

There are both similarities and differences in the concerns I hear from family medicine residents in the 20-30 countries I visit each year. Most residents are frustrated with the lack of control over their lives, working conditions, and long hours during their training. Residents around the world also seem to have concerns about the future of primary care, their role as family doctors, and the future of their health care systems. Residents also complain about the quality and availability of teaching during their training, although I cannot say that this is more in any one country. Resident incomes vary greatly, ranging between USD 12 000 per year (Brazil) and USD 50 000 per year (USA).

4. The US is going through a convoluted and controversial overhaul of its health care system. Will primary care in the US come out better in the end? 

Yes to your question. I believe that any meaningful health system reform in the U.S. will depend on improving the resources for and status of primary care. Permit me however, to first elaborate on your characterization of U.S. health reform efforts. I have spent 35 years since my earliest days as a lawyer before entering medicine, to improve the U.S. health system. I find that many outside the U.S. have a very limited and incomplete understanding of the U.S. health care system. For instance, the U.S. has more people with health insurance (280 million, or 85% of the population) than any other country. Other than Japan, none of the dozen countries with populations over 100 million people have achieved universal coverage. The U.S. health care system represents $2.5 trillion in annual spending, which is more than the total economies of all but four countries. To think that achieving universal coverage in the U.S. will be simple or straightforward is naïve.

At the same time, I would not describe the current legislative deliberations as convoluted. For those familiar with the American system of government, the process is moving forward in a fairly conventional manner.

5. We know the United States is the undisputed world super-power, but we normally we don't hear of the United States leading the way in family medicine. We tend to think more of Canada, UK, Netherlands, Australia, Nordic countries, Spain, to name just a few. Why is that? Is US primary care and family medicine overlooked or there are actual reasons for us to think like that? Will US family medicine lead the world in 2015?

With about 100,000 family doctors, the U.S. has more family doctors than all the countries COMBINED that you mentioned. Those U.S. family doctors provide about 300 million visits to about 180 million Americans each year. Yet, the countries you mentioned depend more on family - Mostrar texto das mensagens anteriores - doctors than does the U.S. Overall, about 1 in 4 U.S. doctors are primary care doctors, compared to 1 in 2 in the other countries. Also, the organization of primary care is more complex in the U.S. with 12% of U.S. doctors being family doctors, 10% general internists, and 3% general pediatricians. Overall, about 53% of doctor visits in the U.S. are to primary care physicians, compared to 92% of all health care encounters in the UK.

All of the countries you mentioned have publicly funded health systems that explicitly are built on primary care. On the other hand, in the U.S. we have a pluralistically funded system that is focused more on specialty care. Research by Bob Blendon at Harvard has shown that people in all these health systems are equally happy (and unhappy) with their systems, but for different reasons. U.S. patients do not like the cost of their specialist-focused system, British patients do not like their queues for specialist care in their GP-focused system. So, perhaps the countries you mention appear to be leaders in primary care because they receive proportionately more resources, and recognition, than their counterparts in the U.S. In other words, if much of the attention in the U.S. is focused on specialty care, then Udoctors and their contributions are more likely to be overlooked in U.S. journals and media coverage.

Yet, I should note that many of the family medicine “innovations” that are touted as “new ideas” in other parts of the world have been in common practice in the U.S. for years. For example, the U.S. has had a very well organized medical student and family medicine resident organizational structure for more than 30 years, with an annual conference that draws 3000 students and residents. By contrast, the Vasco da Gama movement in Europe is 4 years old; the Rajakumar movement in Asia-Pacific is 2 years old, and neither young family doctor group devotes much attention to medical students. The U.S. was one of a half doxen founding members of both Wonca and CIFM. Even the move toward the use of “family doctor” and away from “general practitioner” reflects an American influence. 

Additional examples of American family medicine include utilization management strategies, chronic care models, primary care practice redesign, open or advanced access scheduling, pay for performance, patient safety in primary care, practice-based research networks – all of these and more have been commonplace in the U.S. for years.  

To its credit, the RCGP in the UK casts a long shadow over the British diaspora and fosters cooperation and collaboration between Canada, Australia, and Europe. U.S. family medicine., because of its much larger size, has been less inclined to seek international collaboration; it often views itself as more self-sufficient. One of my consistent messages is that we can learn from each other all around the world. 

6. What could Portuguese family medicine residents learn from US family medicine residents?

How to provide care in the hospital and offer a broader range of services, how to navigate patients through more complex pluralistic health care systems, and how to provide customer-centered care.

7. Who would you name as the leading figures in US Family Medicine at the moment in terms of ability to innovate and produce groundbreaking work?

I could give you a list of several THOUSAND U.S. family doctors who are innovators and influence leaders. Check out the participating family doctors in the TransforMED project (www.transformed.com), the P4 project to redesign family medicine residency training (www.transformed.com/p4.cfm), the Institute for Healthcare Improvement (www.ihi.org), and so on. If you have a specific interest in a particular type of innovation, then let me know and I can try to hook you up with the right person.

8. The Portuguese Government has created a number of partnerships with leading US Universities like Harvard and MIT to help boost the scientific capacity and improve the quality of scientific human resources in Portugal. For example, http://www.hmsportugal.org (this is in English) . This sort of project seems to leave primary care aside, and instead is more focused on basic and translational science. Do you think it would be possible to create a similar sort scheme for family medicine?

It is not only possible, it is necessary to do so, or else the Portuguese health care system will drift down the same path of specialist and hospital-focused care that will cause Portugal to spend more and have worse health outcomes. Unfortunately, because they generate so much publicity for their research, many of the elite, private, Ivy League schools like Harvard and MIT are where other countries turn for advice on health system design, when in fact those institutions, which are not primary care friendly, have too often contributed to the current dysfunction of the U.S. health care system.

9. What do you think about moonlighting during residency training?

Apart from the additional financial compensation, do you think it is beneficial to family residents in terms of gaining more experience and exposure to different health problems and possibly learning new skills? My answer to this is that it will depend on the physicians, their training program, and their health care system. In the U.S., residents now have their duty hours limited to no more than 80 hours per week and no more than 30 consecutive hours. I think the duty hour restrictions have helped reduce the abuse of residents, especially for some of the surgical disciplines. At that same time however, if the resident leaves the hospital after 30 hours as required, then runs across the street to moonlight for 12 hours, it defeats the purpose of the duty hour restriction.

The advantages of moonlighting are that it provides additional experience for the resident, can instill confidence in the resident who develops a greater sense of independent decision making, can provide additional physician services to the population served by the moonlighting resident, and can provide needed financial assistance to the resident. The disadvantages are that it can undermine efforts to improve patient safety by limiting resident work hours, can drive the resident to adopt an attitude of nothing but work - to the detriment of family time and personal pursuits, and can add more stress to an already stressful time in a young doctor's life.

Some health care systems depend on moonlighting residents to make their after hours coverage work. It is ironic that many health care systems speak against moonlighting for residents yet force practicing family doctors to moonlight by paying them too little in their public day job so that they must moonlight at night in their private practice or the emergency department.

In the end, I think it is good for residency training programs to have policies that require the resident to obtain permission to moonlight and that monitor their moonlighting schedules to guard against some of the dangers I described above.

10. I totally agree with you that observational learning can be a slow process when compared to direct patient care. However, where do you draw the line between learning without supervision and possibly making mistakes and learning to be a responsible and competent physician?

I always draw the line at the patient - what is best for the patient should always come first. The pencil I use however, to draw the line is science, not speculation. Taken to one extreme, where trainees do everything with little or no supervision, one can imagine serious harm to patients. Taken to the other extreme, where trainees spend most of their time watching someone else providing the service, then the trainee has to learn to perfect the service after graduation and while out in practice, where there is little or no supervision. Yet, because we have little science to guide who and how much should be observed before being judged competent, we resort to much speculation on this issue.

People often speculate as to what the effects are of having learners perform a task versus the teacher. This is most dramatic when considering surgical procedures. Experience certainly can make a difference. Yet, at the same time, an academic surgeon may have spent the last 20 years teaching a procedure and actually has performed the procedure only a few times. As I mentioned in a previous ansservices require more experience than others) and the person performing the service (some of us learn things more quickly than others). My surgical friends tell me that younger doctors, with their video game experience, often manage the surgical robot better than the experienced surgeon.  

In medicine, we have a long way to go to better understand how to assess competency and to determine the number and types of services an individual must observe or assist before being ready to fly solo. As we learn more about human performance science, and as we develop more robust simulator models, I believe these answers will come more easily.

11. One problem with residency training in Portugal is that during hospital rotations, consultants are not very motivated to teach you certain skills, because they don’t see it as relevant to your training.

For example, in my local hospital, obstetricians are not keen in teaching family medicine residents how to deliver babies. Is this a problem of mentality? I like to think that rather than being “judged” by the specialty I am in, I would prefer to be judged by my portfolio of skills and competences. What do you think about this?

I believe that the needs of the people and the community should determine the services that a family doctor provides, not the preconceived notions of a particular specialist or specialty. I know some family doctors who have learned to do hip fracture surgery because the nearest orthopedic surgeon is 1000 km away. Regarding obstetrics, one of the lines I like to use in the U.S. is that obstetricians too often see themselves as the sole proprietors of 150 million American uteri - it is the woman who owns her uterus, not the doctor. One thing the specialists do not seem to understand is that health outcomes depend on more than just a particular procedure. In obstetrics, birth outcomes are often determined more by the 9 months of prenatal care than the 18-24 hours of labor and delivery. The relationship that the clinician has developed over the 9 months of pregnancy can be very important during the hours of labor.  

I believe that the obstetricians have painted themselves into a corner. They proclaim that every woman needs an obstetrician to manage her labor and delivery, yet they often hire midwives to do the delivery or use a rotational approach to determine who is actually in attendance at the delivery (fostering what I call stranger danger - your care is more dangerous when provided by a stranger you do not necessarily know or trust); they seem to prefer the scheduled convenience of cesarean over vaginal birth; and, because obstetricians locate only in more urban settings, they force women from rural areas to travel longer distances for care, with the attendant risk of injury or death in a traffic accident.

What do the data show? There have been a series of studies in Washington state in the U.S. that looked at the outcomes resulting from efforts to push perinatal services to large regional centers with specialists and away from family doctors in smaller communities. As fewer family doctors became involved in labor and delivery, fewer also were involved in prenatal care. Overall, birth outcomes worsened. See the following articles:

Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG. Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use. Am J Public Health. 1997 Jan;87(1):85-90.

Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA. Access to obstetric care in rural areas: effect on birth outcomes. Am J Public Health. 1990 Jul;80(7):814-8. 

Rosenblatt RA, Mayfield JA, Hart LG, Baldwin LM. Outcomes of regionalized perinatal care in Washington State. West J Med. 1988 Jul;149(1):98-102.

A similar phenomenon has been shown for infant mortality rates in Indonesia during the economic crisis of the mid-1990s when the balance of health care spending shifted away from primary care to specialty care.

Infant mortality rates went uSimms C, Rowson M. Lancet. 2003 Apr 19;361(9366):1382-5.

Reassessment of health effects of the Indonesian economic crisis: donors versus the data. The best ways to combat specialty biases about who should do what are to:

1. Use data - data from clinical trials as well as from your own practice. If you don't keep track of your own performance in practice, how can you defend it to others?

2. Develop collaborative relationships with other specialists so that they learn to trust you.

3. Use the political process - develop nurturing and trusting relationships with the women you serve, recruit politicians to the cause of family doctors providing maternity care services, and tell your story again and again (to the media, community groups, and so on).

4. Advance the science. For example, a group of family doctors here at the University of Wisconsin developed ALSO (Advanced Life Support in Obstetrics), a program to standardize and teach the skills of managing obstetrical emergencies. ALSO has been taught in 40+ countries and has been the subject of a number of studies. See the following articles:

Deutchman M, Dresang L, Winslow D.Advanced life support in obstetrics (ALSO) international development. Fam Med. 2007 Oct;39(9):618-22.

Dauphin-McKenzie N, Celestin MJ, Brown D, González-Quintero VH. The advanced life support in obstetrics course as an orientation tool for obstetrics and gynecology residents. Am J Obstet Gynecol. 2007 May;196(5):e27-8.

Ireland J, Bryers H, van Teijlingen E, Hundley V, Farmer J, Harris F, Tucker J, Kiger A, Caldow J. Competencies and skills for remote and rural maternity care: a review of the literature. J Adv Nurs. 2007 Apr;58(2):105-15. Review.

Etches D, Klein M, Handfield-Jones R Advanced Life Support in Obstetrics. Practical approaches to obstetric  emergencies. Can Fam Physician. 1998 Nov;44:2480-1.

Taylor HA, Kiser WR. Reported comfort with obstetrical emergencies before and after participation in the advanced life support in obstetrics course. Fam Med. 1998 Feb;30(2):103-7. 

Beasley JW, Damos JR, Roberts RG, Nesbitt TS. The advanced life support in obstetrics course. A national program to enhance obstetric emergency skills and to support maternity care practice. Arch Fam Med. 1994 Dec;3(12):1037-41.

Beasley JW, Byrd JE, Damos JR, Roberts RG, Koller WS.Advanced life support in obstetrics course. Am Fam Physician. 1993 Feb 15;47(3):579-80.

12. How do you see the future of mobility of family physicians across the world evolving in the future? Is it desirable (e.g : brain drain from developing nations)? In the European Union, where there is free mobility of people, there is a lot of ongoing discussion because of the different standards of training of medical students and residents across Europe. On the other hand, and unlike other professions, the recognition of medical qualifications between countries outside of Europe (e.g from Europe to the US or vice versa) is subject to a thorough, long and expensive process (e.g USMLE’s). How will the pattern of medical mobility in the US across the different states change over the next 10 years and why?

I think it is very desirable for people to be free to train and work wherever they want - it is a fundamental freedom. Yet, the brain drain from developing to developed countries and from rural to urban communities in any one country is a real problem. Ultimately, it will take family medicine proving its case to persuade policy makers, payers of health care, and the public to believe - and insist - that every family everywhere should have a family doctor.

We can do this by building on the already substantial work of people like Barbara Starfield. The 2008 WHO report (Primary Care: Now More than Ever) is a first step toward that global recognition. while I doubt that you or I will live long enough to see it, I believe that there will come a day when there will be enough family doctors for the people of the world anaround the globe to train and practice. 

To reassure the public that all those migrating family doctors are well qualified, there will have to be common standards so that a family doctor trained in North America is viewed as qualified and competent to practice in Africa, Asia, Europe, or Latin America, or vice versa. Within the U.S., the USMLE and national board certification process have accomplished that. It is fairly easy for a doctor trained in California (where I trained) to locate to Wisconsin (where I now practice). RCGP membership has provided some of that in a number of countries in Asia-Pacific. The American Board of Family Medicine is increasingly being asked to provide its board certification examination to countries in the Middle East and Asia-Pacific. World Wonca has already begun discussions about how it might bring together the national colleges and boards from around the world to develop similar standards, but those conversations will be complex and require significant time.

13 -  Please correct me if I am wrong, but I have the idea that familydoctors in the US, just like any other doctor in the US, must undertake periodic revalidation to remain board certified. How does this revalidation process work? Was it difficult to introduce revalidation in the US? Revalidation in Europe is still a controversial issue, and is lagging way behind the US. Why do you think there is so much more opposition and obstacles to revalidation in Europe? Would a European GP revalidation system help make standards of family medicine more homogenous across Europe? What do you think of the revalidation project of GP's in the UK, which is due to start soon?

14 -  You mentioned that hospital specialists do not seem happy about having family doctors performing a number of technical procedures. But unlike Portugal, this means that residents and family doctors have access to learning and training opportunities and resources. For instance, who do residents learn this procedures like endoscopies? From hospital doctors or from family doctors?

15 - I am aware that the pharmaceutical industry has a big role in sponsoring the continuous medical education of family doctors in the US. At the same time, the US must be the nation in the world with the most stringent ethical codes in terms of relationship of medical students and doctors with Pharma (for example, I am aware some medical schools do not even allow med students to interact with drug reps). Are family doctors in the US well aware of independent resources and learning sources about, for example, rational drug use? Do you foresee a future without Pharma sponsoring medical congresses and medical education? How do you think the influence of hospital specialists in the training of family doctors will evolve in the next 10 years? Will family medicine become more self-sufficient, or will residency and post-residency know-how will end up more in the hands of family medicine or hospital medicine?

Many thanks, and I send you my warmest season's wishes for you and your family.  

Tiago

Dear Tiago,

You have asked some important questions (13,14,15). I have paraphrased your questions and answered them below. Merry Christmas and Happy New Year.

Rich

1. What about revalidation of U.S. family doctors?

In the U.S., you are eligible to receive a license to practice medicine from your state after completing your MD, passing USMLE part 3 (some states also require an additional written or oral test for that state), and completing at least 1 year of postgraduate training (some states require 2 years). Once you have a license to practice, then you can obtain a DEA registration, which allows you to write prescriptions for controlled substances. After completing your residency training, you are eligible to sit for a Board examination (for family physicians, it is the American Board of Family Medicine or ABFM). If you successfully complete the Board exam, you are said to be Board certified. While not required for practice, Board certification is required by most hospitals and most health plans - so practically speaking, it is now required to be Board certified if you want to earn a living as a physican.

By the way, one key difference between many other countries and the U.S.is that in most countries, the specialty college (e.g., RCGP in the UK) is the certification, education, and advocacy group for that country's family doctors. In the U.S., the American Academy of Family Physicians (AAFP) is the education and advocacy organization, but the ABFM, which is completely separate from the AAFP, is responsible for Board certification. This pattern was established many years ago (the American Academy of Pediatrics was established in the 1930s) and I suspect was done to reassure the public that the group that certified the continuing quality of doctors (e.g., ABFM) was separate from the group that advocated on behalf of those doctors (AAFP). The U.S. does not have doctors' unions.

Family practice became the 20th U.S. Board specialty in 1969. Family practice required that everyone who wanted to become Board certified had to take the exam (i.e., practicing GPs in 1969 who wanted to become board-certified family doctors had to sit for the exam and were not automatically awarded Board certification). Also, family practice was the FIRST (and for many years the only) U.S. specialty to require every family doctor to take a Board re-certification exam. So, since the creation of the specialty in 1969, family doctors have had to take a re-certification exam every 7 years in order to continue to be Board certified. The process has recently become even more complex with the addition of specific knowledge modules that must be completed (they are called SAMs), as well as practice audits. This means that the re-certification process now involves different activities every year and not just a board exam once every 7 years.

2. How do family doctors get the training to do various procedures (endoscopy, etc)?

Sometimes, we are trained by the hospital-based specialists, who recognize that family doctors often practice in areas where there are no other specialists and access to those procedures is limited. Very different than Europe, the U.S. has some states where patients may have to travel 200 km to see a family doctor and 1000 km to see a particular specialist. It is also the case the family doctors teach other family doctors. For example, I teach our residents flexible sigmoidoscopy and vasectomy. This issue of learning new procedures, especially after completion of our formal training, is not unique to Family Medicine. Consider the case of surgeons that have been in practice more than 20 years did not receive laparoscopy training in their residency, but had to learn it through workshops and other continuing education programs. In the future, I believe that we will learn many procedures, and refresh our skills in those procedures, through simulator training.

3. What about the relationship between Pharma and physican education in the U.S.

There are two main continuing medical education (CME) accreditation organizations in the U.S.: the Accreditation Council for Continuing Medical Education (ACCME) and the AAFP. In 2008, ACCME-accredited CME generated $2.3 billion in income, $1.3 billion of which came from industry (educational grants, advertising in journals, exhibitis). Both organizations have strict rules about how industry funds CME activities. For example, such funding must only be in the form of unrestricted grants, the company may not suggest topics or speakers, physicians may not receive payments (free trips, gifts, etc) from industry, and so on. 

We have not allowed pharmaceutical representatives to visit our practice or leave free samples for many years. There are federal and state laws proposed that would require pharmaceutical companies to detail every amount they paid to physicians for any activity. For example, a huge source of medical school research funding (about half of all funding) comes from pharmaceutical companies. 

I think that the role of the pharmaceutical industry in funding CME will continue to shrink in the U.S. One concern I have is that any external source of funding (e.g., government, hospital, or health plan support for a conference) has potential strings attached to it that the audience must always be aware of and that may introduce bias into the program or speakers.

One thing we try to be very clear about is having speakers disclose fully any relationships they may have with industry. By way of full disclosure, I serve as a consultant to QuantiaMD (a communications company) and United Health Care (the largest commercial health insurance company in the U.S.), and on a global advisory board of Astellas (a Japanese pharmaceutical company).

4. How will the training of family doctors evolve over the next 10 years?

In the U.S., there has been a significant shift from other specialists providing the majority of teaching to family medicine residents toward family doctors providing that training. I have mixed feelings about that. One of the strengths of our early training programs in the U.S. was that we had the chance to learn from all the other specialties, as well as to have them become more familiar with family medicine residents. I fear that if the only training that family medicine residents receive is from family physicians, that they will have missed out on important perspectives. At the same time, it is critical that any specialists involved in the training of family medicine residents be high quality, enthusiastic teachers who are truly willing to teach the resident all of what s/he needs to learn...

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Perguntas de Juan Gérvas

Dear Prof. Richard Roberts:

It is a pleasure to read your frank and honest answers to my Portuguese colleagues. Thanks for devoting part of your time to this Conference. Some questions: 

Dear Juan,

Thank you for your questions. My responses to your questions follow  below. I hope you and your family have a wonderful holiday season,

Rich

1 - You mention home visits as an activity in Family Medicine, in your own practice. Could you comment a little bit more on the frequency and the content of home visits in your daily practice and in the USA?

I average about 1 home visit about every 2 weeks, which is about the average for U.S. family doctors (http://www.aafp.org/online/en/home/aboutus/specialty/facts/5.html). In the U.S., home visits have decreased over time as family doctors have been pressured to do more office visits, as distances between doctor and patient have increased, and as we have come to use more technology (which is hard to transport to the home). Thus, most of us now do home visits on those with mobility problems or those with terminal conditions. In many ways, I think this is a sad thing, because there are so many positive aspects to home visits: you see patients on their turf where they are the host and you are the guest (which restores much of the power imbalance in medical settings), it gives you wonderful insights into the living conditions of the person, and it is one of the more enjoyable parts of my practice. 

2 - I am not sure about focusing on "family medicine" or "general practice". I am well aware of the problems in the USA in the 60' when general practitioners there could not be "specialists" as being "general" is the oppositte of being "specialist". There are surely reasons for and against  both "family medicine" and "general practice". What is your opinion?

I suspect that the answer to this will vary by country. In the U.S., it was very important in the 1960s to identify the value of "new and improved primary care" by describing it as a new specialty, Family Medicine. It also made it easier to reassure the public that the qualified specialists in Family Medicine had the extra training and current competency to be regarded as specialists. Finally, it was important for payment, because specialists were paid more than GPs at that time. Today, there are almost no GPs in the U.S., because health plans will not pay you and hospitals do not want you on their staff unless you are a board certified specialists. In other countries, these issues, and their traditions, may be different.

3 - In some European countries there is a "patient list" and a capitation payment system, like in Ontario now (Canada, in The Netherlands, Denmark and the UK. This implies some restriction to patients' freedom but improves the "population base" of the general practitioner. Do you think the USA will follow this example in some way, or stay in the HMO style? 

The "HMO style" from the late 1970s-mid 1990s in the U.S. was to have patient lists and to be paid on a capitated basis. The idea of formal lists has considerable appeal because it makes it clear to the patient and doctor that they have an explicit relationship and shared accountability. The disadvantage is that some American patients love the mobility, and the ability, to be able to jump from one doctor to the next. Capitated payments also have their advantages and disadvantages. The advantages are that they provide the doctor/practice with funds in advance and make it possible to invest in practice infrastructure, such as information technology, additional staff to help with chronic disease management and prevention, and so on. The disadvantage is that if the capitated payments are too low or if the doctors take on too much risk (some health plans had the family doctors pay back money at the end of the year because their patients had too many hospital admissions, surgeries, or other expensive treatments!), the practice will not survive.

I believe that the best approach combines a reasonable capitation payment (to support practice infrastructure and promote preventive and chronic care services); fee-for-service (to provide incentives to family doctors to work harder and better for their patients); and periodic/quarterly bonus payments for achieving quality goals (to reward family doctors who help their patients achieve better outcomes). My understanding is that Norway uses a similar approach and a number of other countries are beginning to move in this direction (Canada, U.K., US).

Thanks a lot for your answers, Rich.

-the family is ok but unfortunately we cannot join the whole troupe (4 sons and 4 daugthers in law plus 8 granchildren) for the season, as some live far away (La Pampa, Argentina)

-hope you can join all your family and in any case enjoy the holiday season.

-regarding my questions and your answers:

-home visits are decreasing everywhere, which means we are not covering the whole spectrum of our discipline; it will be interesting to know about the reasons why; in my own practice the average is one per day

-I fully understand the American position regarding family medicine in the 60s; the problem is the strong world influence of this American option

-yes, in most countries the payment system is changing to a mixture; even in Spain, which has a salaried system, there is a mixture, including some per capita payment, some salary, and some bonus for objectives; this is also the case (without salary) in the Netherlands, the UK and so on.

Recibe un abrazo de

Juan Gérvas

Dear Richard:

It is a pleasure to read the questions and your answers. You give always excellent information.

A few quotations, if I do not disturb you, nor our Portuguese colleagues.

1/ We know the Inverse Care Law, by Julian Tudor Hart: "people who need more care received less, and this in hardest when the health system is more oriented to the market". That means that the effect of the Inverse Care Law wil be more common in countries like the USA and Switzerland, which are more oriented to the market health systems. President Obama’s reform will partly help reversing the impact of the Inverse Care Law.

2/ In the developed world there are public health systems as in Germany and France, and the Netherlands and Denmark, and Canada and Japan where there are no waiting lists; waiting lists are not always associated to whole population coverage. In fact, a good example for the USA could be Germany because freedom of choosing generalists and specialists and direct access to both (which from the European point of view is not the best example, taking into account the cost of the system and the outcomes).

3/ New technology and new development in Medicine should transfer capacity (interventions) from hospital to ambulatory care, from hospital specialists to general practitioners, from ward to office from office to patients' home. But this is not always the case. We lack appropriate knowledge about how to accelerate the impact of new technology and new development.

That's all.

Recibe un saludo cordial de

Juan Gérvas   

Dear Juan,

I am quite familiar with the work of Professor Hart and the health care systems you listed. What makes this complicated is that each country is different, and that none of them fits any ideological ideal. For example, Professor Hart was a staunch socialist who believed that government should own the means of production - i.e., government should own the health system. Yet, even his greatly admired National Health Service does not directly employ its doctors. Rather, they contract with the NHS. Also interesting is that private health insurance and using private funds to jump wait list queues are on the rise in Britain. Thus, we need to distinguish systems where government "owns" the health system (hospitals and clinics are publicly owned; doctors and nurses are employed by government) from systems where government may own some parts of the health system, but not others (in most systems, doctors are self-employed and contract with government) to systems that mandate universal insurance coverage using public health insurance (Canada, Japan) to systems that mandate universal insurance coverage but do it through private insurance (Netherlands, Switzerland), and so on. 

Even the U.S., is not a pure market system. For example, it might surprise Europeans to know that there are more Americans covered by publicly funded health programs (about 75 million persons are covered by the Dept of Defense, Medicare, Medicaid, veterans system) than there are people in any European country except Germany (82 million population). This is a most interesting topic, partly because each of us would like to believe that our system is best (at least until we speak privately with each other, as I learned in Barcelona last month). I have visited the health care systems in over 100 countries and have learned something new from each one. I have yet to visit the perfect health care system.

The point I was trying to make is that most health care systems are a reflection of the unique history, economy, politics, and current realities of that country.

Tu amigo,

Rich

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Perguntas de Manuel Rodrigues Pereira

Dear Professor Richard Roberts,

It's a pleasure to have you in this Conference Cycle. Two questions:

Dear Manuel,

Thank you for your questions, which I answer below following each of the questions. I hope you and your family have a wonderful holiday season.

Rich

1. In your point of view, currently what are the main topics of investigation about family dynamics and disease process?

This is a most interesting and, in my view, a most timely question. Ironically, even though our discipline has the word "Family" in it, we have not done much original research in family dynamics or systems since the landmark work of Jacques van Eijk and others (see references below). I don't know if this is because we feel that all our questions have been answered (which I doubt) or perhaps because our health care systems, and our societies, drive us toward a more individualistic view of health and health care.  

As our mobility and distance from family increase, and as our family size shrinks, perhaps we view family as less important or relevant than before. I hope and think not. I believe that we are about to expand greatly our ideas about health, so that we look beyond the individual to the family and community and world. I am starting to see this in the work on resilience (why do some people manage to get through difficult physical and mental health problems better than others?) and the work on complexity (so many factors affect individual patients that it is as challenging to predict how an individual will do as how the weather will behave). I believe this is an area in desperate need of fresh thinking and new research. Perhaps you could be one of the people that will lead us to that new knowledge.

van Eijk J. Serious Illness and Family Dynamics. 1. Changes in Consulting Patterns of the Unafflicted Family Members. Family Practice 1985;2:61-6.

van Eijk J. Serious illness and family dynamics. 2. Changes in consulting patterns of the afflicted family members. Fam Practice 1985;2:70-5.

Bursten B. Family dynamics and illness behavior. GP 1964;29:142-5.

2. In the USA, what about the investigation in this area?

As I wrote above, there is not much new that I am aware of in the U.S. There were several important books written on this subject in the 1980s, such as Family Medicine and Family Therapy by Mac Baird and Bill Daugherty. They also started the Collaborative Family Health Care Coalition, which became the Collaborative Family Healthcare Association. In addition, they helped to found the journal Family Systems Medicine. Another important book from that time was The 15-Minute Hour by Marian Stuart and Joe Lieberman. 

For many years, there was a wonderful conference entitled The Family in Family Medicine, that was sponsored by the Society of Teachers of Family Medicine (STFM, www.stfm.org) and held on Amelia Island, Florida. Unfortunately, I do not think that this meeting exists any longer.

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Respostas de Richard Roberts

In many of the poorest countries, the main health system problem is lack of access to anything. In some of the wealthiest countries, such as the United States and Japan, there may be very good access to highly specialized and technological services, but inadequate access to primary and preventive services. The way that health care is paid for has a very large influence on exactly which services are most valued and provided. Social determinants also play a key role in health status and outcomes: our dietary habits, exercise patterns, stress levels - all these and more affect our health.

Every system for funding and providing health care has its strengths and weaknesses. If you have a dissecting aortic aneurysm, you need immediate stabilization and surgery. If you are in a system that limits the number of thoracic surgeons and operating facilities, then you may die as a result of delayed or unavailable surgery. On the other hand, if you need better and more primary care to help prevent or manage certain conditions such as hypertension (which may lead to dissecting aortic aneurysm), and your system does not produce enough primary care clinicians or provide enough primary care resources, then you may develop those chronic conditions and suffer their consequences, including death from dissecting aortic aneurysm.

Studies done by Blendon and others (see references below) show that no country has the perfect system - in fact, people seem to be about equally unhappy with their systems, but for different reasons. For example, the British hate wait lists for operations; American do not like the expense and complexity of their health care system.

At one extreme, we could argue that health care is a right and should be free to every one. Yet, other essentials of life (food, clothing, housing) are not free. More importantly and precisely, we know that health care is never free - doctors, nurses, hospital workers, administrators, and others expect to be paid for their time and talents. Even when the care seems free - the patients are not charged at the time of service - it is still supported by taxes, which means that some may be unhappy with paying taxes to government, especially if the services are of low quality or if the government is seen as wasting the money.

At the other extreme, we could argue that health care should be a purely market service, subject to the forces of a market economy. For example, many would argue that the right to entertainment and other pleasure pursuits is a basic human right. Yet, most countries do not provide or subsidize such pursuits, but rather allow the market economy to sort out what things should be available (cinema, futbol, etc.) and what things should cost. However, we also know that health care - even in an economy as market-oriented as the U.S. - is never a purely market service. In fact, health care in the U.S. is heavily regulated and influenced by government - in many ways, more so than in Europe. Also, a purely market-driven system would allow some to go without needed services because they did not have the means to pay. This would not, and should not, be acceptable in any civilized society with the resources to do better.

Permit me now to shift from the theoretical to the practical and from a discussion at a global level to a focus on my own experience as a U.S. family doctor. As with many things in life, we can argue at either of the philosophical extremes, but they do not reflect our reality, which is somewhere in the middle. It is tempting, and overly simplistic, to poke fun at the many problems with the U.S. health care system. The movies Patch Adams and Michael Moore's Sicko are entertaining examples of this. Yet, they illuminate only the most extreme and dysfunctional parts of our health care system and do not inform the viewer that most Americans are quite satisfied with their health care (about 85%) and that many are very anxious about President Obama's proposed changes to the system. We Americans have an antipathy toward government solutions - we believe that government is not always the most efficient or effective way to solve most problems. Yet, we recognize increasingly that a purely market system for health care is a fiction. Without government involvement, we are unlikely to achieve the universal coverage and equity that are people deserve and need. So, the challenge is finding the right balance.

One misperception by many outside the U.S. is that Americans are denied health care services because of lack of insurance coverage. In my experience, that is very unusual. The situation is more complicated than that. For example, if a person presents to an emergency department in the U.S., the hospital is required by law to make sure that person receives appropriate diagnosis and treatment. The problem in our system is that lack of coverage for some people means that on occasion they do not get the right service at the right time (e.g., medication to lower blood pressure) and so end up getting care for a more expensive problems (e.g., care of their heart attack or stroke). At the same time however, more governmentally run health systems have their own access problems. I am reminded of Tony Blair, who had to wait several days to have his tachycardia definitively treated. In the U.S., even a poor person with no funds would have likely had his tachycardia treated more quickly.

As a primary care physician, I end up having to spend a lot more time and energy advocating for my patients without insurance than I would like. Sometimes, I have to ask the drug companies to get free medications, sometimes I have to ask surgeons or hospitals to discount or waive their fees so my patient gets treated, and so on. While these times are more often than I would like, they are less than they could be. I have seen similar issues in other countries however, with family doctors having to argue with their clinic or regional administrator about getting their patient a needed drug that is not on the approved formulary, or having to wait a long time to get a needed diagnostic study (CT, MRI, etc.).

So, to come to the end of this long discourse, let me sum up by listing the following.

1. No system is perfect. Every system has its strengths and weaknesses.

2. Each country must decide for itself which systems for funding and providing care work best and are most congruent with their culture.

3. Countries will need to change their systems based on the changing needs and expectations of their populations and changing economic realities. (Netherlands recently changed from a government-managed health plan to multiple private health insurance plans).

4. As family doctors, two of our primary responsibilities are to learn the nuances of our system and to help our patients navigate it by being their effective advocates.

References

Blendon RJ, Schoen C, DesRoches C, Osborn R, Zapert K. Common concerns amid diverse systems: health care experiences in five countries. Health Aff (Millwood). 2003 May-Jun;22(3):106-21.

Schoen C, Blendon RJ, DesRoches CM, Osborn R. Comparison of health care system views and experiences in five nations, 2001: findings from The Commonwealth Fund 2001 International Health Policy Survey. Issue Brief (Commonw Fund). 2002 May;(542):1-6.

Blendon RJ, Leitman R, Morrison I, Donelan K. Satisfaction with health systems in ten nations. Health Aff (Millwood). 1990 Summer;9(2):185-92.

Respostas de Richard Roberts

First - decide whether you want a national health system or a national insurance system or some other system. It is not as obvious an answer as you might think, given that health care is only one part of civil society. As you advocate for resources spent on health, it may come at the expense of education or retirement pensions or roads or whatever. It means you will want to answer fundamental questions about the roles, responsibilities, and control exerted by government, by the market, and by individuals within that society.

Second - advocate, advocate, advocate. Once you have decided on your strategy, work with other family doctors (e.g., through the Portuguese college) and potential allies to have your strategy adopted by government and by society. The media can be a very important resource in this regard. Finally, advocate for your patients as an individual family doctor, to help them get what they need no matter what system you are in.

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Perguntas de Liliana Laranjo

Dear Professor Richard Roberts:

I think it's really a privilege that, amongst your numerous daily activities, you find time to answer our questions with such concern. Thank you very much for that. I have the following questions for you:

1. I am surprised by your description of the family medicine residency in the U.S., which I think gives the resident a very broad experience in numerous fields, including many at the hospital / secondary care level. I would like to ask if there is some kind of assessment for the type of procedures one can manage after the residency (like the ones you mentioned: vasectomy, minor surgery, endoscopy and so on…). Also, what do you think should be the frequency to practice them, for maintaining that ability, and the maximum number of procedures to include in our list of services, in order to keep in touch with the main aspects of primary care? What do you think of the UK's way of assessment in this field and the creation of the term "GPs with special interests"? Finally, what is the position of hospital specialists concerning that gain of abilities by family physicians in some of the procedures they usually do?

2. I am currently a first year resident in family medicine and a first year PhD student in metabolic and eating disorders, which I can only manage since we work a medium of 40 hours per week during the residency. Is it common in the U.S. to do both things at the same time or is it really impossible because of the workload? Are there many GPs with a PhD or devoted to investigation?

3. Do you know a particular group or center in the U.S. currently doing investigation in the obesity area, specially in health literacy, health promotion and community-based interventions?

Thank you very much in advance. I wish you and your family a wonderful holiday season.

Liliana Laranjo

Dear Liliana,

Thank you for your questions. My answers follow each of your questions below. I have taken the liberty of breaking up the questions into several sub-questions.

Good luck with your ambitious and important career path. I wish you and your family Feliz Natal e Bom Ano Novo.

Rich

1. (a) Is there some kind of assessment for the type of procedures one can manage after the residency (like the ones you mentioned: vasectomy, minor surgery, endoscopy and so on…)?

Yes. We use a competency-based evaluation system, which means that faculty supervisors must observe and document that the resident has successfully mastered the procedural skill.

(b) What do you think should be the frequency to practice them, for maintaining that ability, and the maximum number of procedures to include in our list of services, in order to keep in touch with the main aspects of primary care?

This is a much more difficult question to answer, because we have little science to guide us. In fact, this has been a special research interest of mine. How do we know when someone is skilled to perform a particular task? There is very little evidence on that. For some things, such as performing a competent history and physical examination, we can use a check list to make sure that each of the important tasks for done. For other things, such as showing appropriate empathy and connecting with patients, we must make a more subjective judgment. We know that certain procedures, such as open heart surgery, have better outcomes when they are done in high volume centers (more than 300 per year). We know that for other procedures, the number of cases per year does not seem to matter much. We also have some evidence that doing too many of certain things (e.g., delivering more than 200 babies per year) also makes for worse outcomes, perhaps because we are too busy to give each woman the attention she needs. I have supervised some residents who were ready to do endoscopy on their own after doing 10, and others who just could not do it well after 50. Competence, especially with hand skills, seems to have a great deal of individual variability to it.  

(c) What do you think of the UK's way of assessment in this field and the creation of the term "GPs with special interests"? If this works for British GPs and their patients, then I am all for it.  My worry would be whether they do enough of a procedure to get and stay skilled (in Japan, most endoscopies are done by paramedical personnel, not physicians). Perhaps more importantly, will the time that the British GPs spend on their special interest cause them to be less skilled generalists who (eventually) lack the comprehensive perspective and broad scope of practice needed by their patients and community?  

(d) Finally, what is the position of hospital specialists concerning that gain of abilities by family physicians in some of the procedures they usually do? They don't like it. I view that as their problem. When a physician defines himself or herself by a procedure, then they are destined for extinction. How many iron lung specialists did we need after polio vaccine? Zero. Specialists always point to the fact that they do more of certain procedures than family doctors, but they are not able to prove better quality outcomes. In my view, much of their upset has more to do with preserving their economics and status than quality of care. For example, the American Society of Gastrointestinal Endoscopy says that a physician should have done 200 colonoscopies to be qualified (the average gastroenterology fellow does 200 in training); the American College of Surgeons says that 50 is enough (the average surgeon does 50 in training). As I said before, there is little science to guide this and this is more about economics and prestige. The advantage in family doctors doing more procedures are these:  

1. More and more of the technologies are getting easier to use (compare endometrial biopsy in the curretage days

2. Having family doctors able to do the procedures means that the doctor who knows them best and who is most  accessible to them will be doing the procedure, making it more likely that the procedure will actually get done, that the right person will be selected for the procedure, that close follow up will occur after the procedure, and that the best outcomes will result.

3. Family doctors are more likely to do the procedures only when they're needed, not because the procedure is a major source of income for them.

2. I am currently a first year resident in family medicine and a first year PhD student in metabolic and eating disorders, which I can only manage since we work a medium of 40 hours per week during the residency. Is it common in the U.S. to do both things at the same time or is it really impossible because of the workload? Are there many GPs with a PhD or devoted to investigation? 

It is very unusual for Family Medicine residents in the U.S. to study for a PhD at the same time. There are several important reasons why. First, in the U.S., the MD is considered a terminal (doctorate) level degree, following four years of undergraduate and then four years of medical school study. Second, residents in virtually any U.S. residency training program regardless of specialty are usually too busy to have much time for anything else. I would estimate that about 5% of residents have completed a PhD or other doctorate (JD - law, etc) before they start residency. Another few per cent will finish one after residency. We do need to continue to encourage more young U.S. family doctors to do research, whether or not they have a PhD.  

3. Do you know a particular group or center in the U.S. currently doing investigation in the obesity area, specially in health literacy, health promotion and community-based interventions? There are many centers across the U.S. doing excellent work on obesity research, health literacy, health promotion, and community-based interventions. Perhaps it is because there are so many of us fat Americans who can be research subjects! One of the family physicians in my own department (Dr Alexandra Adams: alex.adams@fammed.wisc.edu) also has a PhD in nutrition and is doing some very exciting obesity research with the Native American community. She would be a very good resource in this regard. You may want to correspond with her - feel free to use my name.

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Perguntas de Mónica Granja

Dear Prof. Richard Roberts:

Like Lilina wrote before me, it is very generous of you to share your time with us and I must start for saying thank you very much. I have been reading you with much interest and your statements had already given me a lot to think about.

Your description of a typical day of yours (which somewhat reminded me of Juan Gérvas) left me with the feeling that my life is a slow motion picture (while most of the days I feel it is really very busy). Also, I was astonished when you mentioned US residents work 80 hours a week and, yet, they still get pregnant during residency, since portuguese standard work week (also for family physicians and residents) is 40 hours long and we already feel we have tto little time to our family.

The portuguese primary care system being a public one (where public funding supports all levels of care), where every family physician cares for a list of 1500 to 2000 patients (leaving some hundred thousands of patients without a family physician - some say one million, but the real figure it is not clear), I believe we, family physicians, should concentrate on doing the tasks no other physician is able to do for us, leaving procedures like endoscopy, surgery, delievering babies and so on to physicians who have no other competencies, specially in family practices near urban centers with hospitals full of secondary care specialists.

Even though some of us (portuguese) stand for a style of family medicine closer to yours (US and your in particular), that is still the exception, with most of us (among which I am included) working much less hours a week and refraining from assuming tasks aside from our nuclear and classical tasks.

I wonder if our health system was insurance-based and, thus, we, doctors, were rushed to be more competitive, we would tend to work more hours a day and to be interested in going further and further into other specialties territory. May be you, having your transnational and transcultural and trasnpolitical view, could have some answer or some explanation for these differences.

Mónica Granja

Dear Monica,

Thank you for your question and your eloquent description of the dilemma faced by all family doctors. How do we balance the competing goals of continuity (Can or should I do EVERYTHING for EVERY patient?), competence (Can I be good at EVERYTHING?), and personal/family time (How do I protect sufficient time for my family and myself?).

First, I would not recommend myself as a role model. I work too hard. None of my 4 children has any interest in medicine having watched my work habits. The reasons why I work as much and hard as I do are that I love my work and I have a passion and vision to change the health system so that those that come after me can achieve these competing goals, while not sacrificing self or family.

Second, I think you always have to address Maslow's hierarchy of needs.  You need to do your best to meet the needs of yourself and family first, otherwise you won't have much left to give to patients.

Third, I actually believe there will come a day when the technology will be so robust (all the world's knowledge in your hand-held device; all the diagnostics and therapeutics in a Star Trek tri-coder) that all patients will ever need is a compassionate and well trained family doctor - although by then we might be calling that person something else (perhaps "Bones" or "Beverly Crusher" or something). 

Fourth, when it comes to deciding what procedures or services to provide, as I wrote earlier, it should be based on what your patients and community need, what you are competent to do, and what you like to do. I will use cesarean birth as an example. Before joining the university, I first practiced in a very remote community for 4 years, where there were no surgeons for 100 km. Thus, I had to perform, and I had been trained to perform, cesarean birth. In fact, I enjoyed doing the procedure, just as I enjoy most everything I have done (that's one of the problems with us family doctors - we like most everything). When I joined the university, the hospitals I was going to use had lots of surgeons and there was no need for me to continue performing cesarean sections. Also, the distance from the hospital to my new rural practice meant that it was going to be more disruptive of my clinic practice to run back and forth when a cesarean was needed. While I missed a little bit no longer doing cesareans, it was easy to get excited about some of the other things that I was able to do (like community oriented primary care projects).

Fifth, given that there are many more patients in the U.S. who need primary care doctors, it has never felt to me like I've had to compete with specialists for patients. I have more than enough patients and more than enough things I get to do. Rather, I enjoy providing a wide range of services. Doing a wide variety of procedures and continually learning new techniques keep my practice fresh, interesting, and fun.  However, I must do my essential job well and first. In other words. I must develop healing and trusted relationships with patients, serve as the first point of contact with the health care system, help to coordinate their care, manage most of their chronic conditions, and so on. If I don't find those essential tasks enjoyable, then I should probably not be a family doctor. At the same time, if doing more procedures and being able to provide more services make my job more fun and enjoyable, then I will also likely be more enthusiastic about providing the essential services.

Sixth, let me expand on and clarify my comments about resident work hours. While the maximum is 80 hours, my estimate is that most residents actually work about 50-60 hours per week. There are some weeks, such as Community Medicine, when they will work only 40 or so hours, and other weeks, such as the Intensive Care Unit, where it may be 60+ hours. It is interesting to note that those female residents who most commonly have babies during their training are usually those with a husband who is able to spend mresidents whose wives give birth during their training years are usually married to women who are home most of the time. I have not seen as many babies during training years for residents who are married to another physician.

Seventh, one thing I've learned from my conversations with thousands of family doctors around the world. There are lots of ways to do things. One advantage of the chaos in the U.S. health care system is that one can find just about every practice situation you could imagine - salaried, fee for service, entrepreneurial, part-time, full-time, too much time, hired worker, self employed. Some of the happiest family doctors I have met (both men and women) are in single handed (solo) family practices where they have provided a wide range of services and made themselves continuously available to their patients, while enjoying being their own boss and having happy home lives. Somehow they've managed to develop a practice that fits them just right, where their patients trust them, appreciate their care, realize they have personal and family lives, and rarely bother them after hours.  

I am always impressed with the commitment and caring shown by each successive generation of family doctors. My dream is that we can build a better health system that allows us to do all we can and would like to do for our patients, while also allowing us to live satisfying and healthy personal and family lives.

Keep the faith.

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Perguntas de Luís Sousa

Dear Prof. Richard Roberts

First of all, I would like to thank you for the time that you spend with us in this conference. It surely won't be easy for you to answer all your questions with your busy life, so I want you to know that we appreciate this gesture.

I would only like to make a small question:

According to your position and your vast experience in contacting with the reality of family medicine in several countries, I would like to spend part of my formation in a foreign country so that I can contact with a different reality, so I would like to ask you, which country (especially european) would you advise a family medicine trainee to choose to spend a training period and why?

I would like to thank you, and wish you and your family a Merry Xhristmas!

Best regards,

Luís Sousa

Dear Luis,

Thank you for your question. I am not sure that I'm the best person to advise you on a particular European country in which to do some training. Permit me instead however, to offer several suggestions based on my having hosted trainees from Africa, Asia, Europe, and South America.

1. Pick a country where you are reasonably fluent in the local language. Language and culture are so much of what we do that is important to be able to communicate with patients you might see in consultation.

2. Consider a practice where the family doctor(s) have a very different scope of practice. For example, if your practice in Portugal is likely to be ambulatory only, then you might want to spend time with a family doctor that sees patients in hospital, delivers babies, etc. The reason I recommend this is that it may be one of the few times you will get to see a family doctor doing such things and because your being involved in a wider range of activities may cause you to think differently about your own practice later.

3. Similarly, you might want to consider practices that are organized and funded very differently than yours is likely to be. For example, if you are likely later to work in Portugal in a large clinic with many doctors who are employed by the government, then you might want to spend time in a practice where the doctors owns and runs the practice.

Putting these ideas together (and remembering suggestion 1 about language fluency), I would recommend: France, Switzerland, or the Netherlands.

Best of luck. Please let me know what you decide.  

Have a wonderful holiday season,

Rich

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Perguntas de Maria Angélica Nunes

Dear Professor Richard Roberts:

It has been a privilege to me to participate in this conference.

Like other colleagues have written before, thank you very much for your time to answer our questions with such concern.

I carefully read your answer to the questions of Liliana Laranjo and I would like to ask you if is there any procedure for which you consider all Family Doctors should be skilled?

Merry Christmas and a Happy New Year for you, your family and friends too.

Mª Angélica Nunes

(1st year resident of Family Medicine - USF Valongo)

Dear Angelica,

Thank you for your question. It is the most profound, and the most easy to answer, of all the questions I have received. If the greatest value that family doctors bring to health care is our relationship with our patients, then it seems to me that the one skill every one of should have is the ability to develop and sustain healing trusted relationships with our patients.

I recognize that this skill may not seem like a "procedure," but I believe that specific procedures come and go (How many myelograms are done now that we have MRI and CT? How many tymapanocenteses or mastoidectomies are done now that immunizations and antibiotics have reduced the incidence of complicated otitis media or mastoiditis?) Even skills that we view as more complex, such as endoscopy, are often replaced by other technologies or delegated to other personnel (e.g., in Japan, most screening endoscopy is done by paramedical people, not by physicians).  

Thus, I would argue that family physicians should be defined, and judged, by the quality of the relationships with their patients, and not by any one procedure. The specific procedures will be determined by the needs of your patients and community, and by your interest and ability. For example, if you practice in an area with a high prevalence of lung cancer, tuberculosis, and empyema, and there is no pulmonary doctor nearby, then you will need to be skilled at pleurocentesis. If you did not have that skill upon completion of your residency, you can learn it while in practice, either "on-the-job" or by taking some additional training.

The key concept is that while others may specialize in a disease or organ system, family doctors specialize in their patients and will provide, or learn, the procedures that they need for their patients.

I wish you and your family a joyous holiday season.

Rich

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Final speech Richard Roberts:

To my dear colleagues and new good friends,

It has been a pleasure and an honor to participate in this virtual conference - thank you for the chance to learn from you. You kept me busy. If my count is correct, there were 9 individuals from 3 countries who submitted 41 questions that prompted me to write 16,082 words in response (including this response).

So many words! La Rochefoucauld wrote, "Brevity is the soul of wit." I am sorry that I was not more brief or witty, but I will keep working to do better. I also apologize that I was not sufficiently fluent in Portuguese or Spanish to respond in those beautiful languages. I will keep working on that as well.

I hope my answers were of some value to you. I know that your questions were very valuable to me. Your questions reminded me that we have many things in common. Your questions also highlighted that we practice in different circumstances and cultures that challenge us. Through sharing those different perspectives, we can learn much about each other and even more about our own situation and system if we only listen and keep our minds open to all possibilities.

Your questions focused on how health care was organized and funded in our countries and the nations of the world (family doctors see the big picture!), as well as the very specific details of professional and personal life (family doctors are very practical people who do what needs to get done!).

My holiday gift to you is to share what I have learned in almost 30 years as a family doctor when it comes to taking care of patients: focus on, listen to, trust, and advocate for the patient. 

1. Focus your attention and healing energy on the person before you. While that person may be patient number 30 of your day, you are most likely the only doctor for that patient today.

2. Listen intently to the patient and you will know what to do to help.  

3. Trust the patient. Healthy adult relationships are bidirectional - it means trusting each other. If you take care of your patients, they will take care of you.

4. Advocate for the patient. As family doctors, we do much more than tend to patients' ailments. We bring people together in our communities, we give voice to their concerns, we help create positive change for the people we serve.  

Technologies, procedures, and even specific services will come and go for family doctors. The one constant is the eternal hope and trust that people place in us when they seek our help. These are our most precious gifts, and our most powerful tools to do good. I know that each of you make, and will make, a positive difference in the lives of so many. I am proud of what you do, who you are, and what you stand for. It gives me great comfort to know that the sacred tradition of the personal doctor is being carried forward by the next generation of family doctors. Please call on me anytime I can be of help to you in your journey.

Feliz Natal e um Boa Ano Novo! Feliz Navidad y Prospero Ano Nuevo!

T(e)u amigo,