Wes Fabb Oration 2014 - Nurturing tomorrow's family doctors

Good afternoon dear friends. 

It is a joy and a privilege to be invited to deliver the 2014 Wes Fabb Oration.  Wes Fabb is of course a dear friend to many of us here. 

This oration honours Wes and his contribution to the development and strengthening of family medicine around the world and especially in the Asia Pacific Region. Wes served WONCA with distinction for more than a quarter of a century, first as our honorary secretary and then as our first chief executive officer until his retirement in 2001. I am humbled to follow in the footsteps of the wonderful family doctors from across the Asia Pacific Region who have delivered this oration in the past.  I also acknowledge Wes’ successors as WONCA CEO who are here today – Dr Alfred Loh and Dr Garth Manning.

As WONCA President, I start with some thank yous.  Thank you to the chair of this terrific WONCA Asia Pacific Conference, Dr Mohammad Husni Jamal, to the president of the Academy of Family Physicians of Malaysia, Datuk Dr Daniel Thuraiappah, and to all the members of the Academy who have worked so hard to ensure the success of this conference here in Kuching in Sarawak on the island of Borneo.  And my congratulations to Professor JK Lee, our WONCA Asia Pacific Regional President, to all members of the Asia Pacific Regional Council, and to all our WONCA member organisations in this region, for the great work you are doing together to ensure that all people in this region have access to a well trained family doctor supported by a great family medicine team.

The theme of this conference is Nurturing Tomorrow's Family Doctors.  It is a very fitting title for an oration honoring Wes Fabb, who devoted his career to nurturing tomorrow’s family doctors.  Husni has asked me to focus especially on how our universities are rising to the challenge of nurturing our future family doctors and to what extent medical students are being encouraged and supported to train to become family doctors. I am going to weave this theme of nurturing tomorrow’s family doctors into my presentation as I speak with you about family medicine developments across this region and also speak about Wes Fabb and his legacy to family medicine education around the world.

It is a good week to be discussing what WONCA has been doing in Nurturing Tomorrow’s Family Doctors.  WONCA has seven regions covering all the nations of the world.  Since our World Conference in Prague last year we have been working with young family doctors in each of our seven regions to support the development of young family doctor movements. Here in the Asia Pacific Region we have had the Rajakumar Movement for young and future family doctors for several years, along with similar movements in Europe and South America and South Asia.  Over the past year we have seen new movements launched by enthusiastic young family doctors in Africa and the Middle East, and this week has seen the launch of our newest movement, the Polaris Movement in North America and the Caribbean.  We now have WONCA young family doctor movements in all regions of the world.  Here is the Asia Pacific Region, I thank Naomi Harris from Australia who was the inaugural chair of the Rajakumar Movement, and congratulate the newly elected chair Shin Yoshida from Japan.

One privilege of being WONCA president is that I am invited to visit family doctors across the world to gain insights into the challenges that our colleagues face in providing the best possible care to the people of their local communities.  During this presentation I will share with you stories from some of the remarkable family doctors I have met in the Asia Pacific Region over the past year. I will also share with you images of our colleagues from this region working in their family medicine clinics.  

This is Dr James Heng-Chia Pen.  James is a rural family doctor at the Jinshan District Public Health Center on the beautiful coast in the rural north of Chinese Taipei.  Like many of you, as well as providing an excellent clinical service to the people of his community and surrounding district, James is a dedicated teacher of medical students and family medicine trainees.  He trains students from the Department of Family Medicine at the National Taiwan University Hospital, one of the major academic centres for family medicine education and research in our Asia Pacific Region.  This is what all our medical schools should be doing.  Sending their students out to learn about medicine from enthusiastic family doctors like James.

James and our other colleagues in the photos I will show you have agreed that I can share their images with you.  The patients you see in these photos are other family doctor colleagues role-playing, so that there is no breach of patient confidentiality.

When I received the invitation to deliver this oration I contacted Wes and asked if he had any stories he would like to send me that I might share with you.  Wes has recently completed his autobiography and sent me a copy.  It includes some photos of a very young Wes.  He was a serious little fellow, wasn’t he.  My favorite photo shows a young Wes at the beach, buried up his neck in sand by his family, but still smiling –  this was great preparation for those impossibly busy days as a family doctor when you feel buried up to your neck with demands but need to face them with a smile.  It was also good preparation for becoming CEO of WONCA!

As family doctors, we are all indebted to our teachers; our fellow family doctors who have taught us how to practise medicine in our communities using a combination of scientific knowledge and tender loving care.  Our mentors during our medical training and subsequent careers have influenced the sort of doctors we became. 

Like all of you, I have been fortunate to have some inspiring family doctors as my teachers and mentors during my medical career. One of my mentors was Wes Fabb.

I first met Wes in 1985.  I had recently graduated from medical school at the University of Melbourne and had been accepted into the Family Medicine Training Program of the Royal Australian College of General Practitioners.  Wes was the National Director of Education of the Family Medicine Training Program and was responsible for the training of the 2,500 trainee family doctors enrolled across Australia in the program. 

I remember the first time I heard Wes speak at a training session.  He was warm and wise and cheerful and positive.  All the qualities we think of when we hear his name.

And Wes was a great communicator.  He knew all the trainees by name and, during the coffee breaks in our training sessions, would wander around the room chatting to us all, finding out what we were doing in our training, what we were planning to do next, how we were preparing for our future careers. You felt that this important person really cared about you and your career.  Which indeed he did.

By 1988 I joined the academic staff at the Department of General Practice and Community Medicine at Monash University in Melbourne, where Wes was an honorary professor.

My research at Monash at that time involved the use of computers to support the training of medical students during their family medicine rotation.  The head of our academic department was the dynamic Professor Neil Carson.  In 1989 WONCA was holding its World Conference in Jerusalem and Neil had put in a submission to make a presentation about our computer assisted learning programs. Two weeks before the conference, Neil developed cold feet about his ability to organise the technology needed for the presentation.  Neil asked me if I could get a visa and organise flights to get myself to Jerusalem in two weeks time, and when there find and rent a computer, load our programs and help him with the presentation.  I was young and keen and didn't see this as a great barrier and two weeks later I was in Jerusalem attending my first WONCA conference.  This was before portable computers and before audiovisual departments in hotels provided computer equipment so I had to find a company in Israel willing to rent me a computer, with a separate monitor and keyboard.  The only rental company I could find was an hour’s drive from Jerusalem and they charged me $1000 USD in cash for a week’s rental, plus another $2000 in cash as a deposit.  So I withdrew the cash from the American Express office in the old city of Jerusalem and jumped in a taxi and went off to fetch the computer.  Later on I found that the taxi had taken me to the West Bank, an area that at that time was not a safe place to travel as a tourist.  But everything went smoothly and I picked up the computer and headed back to the hotel in Jerusalem for the opening ceremony of the conference. 

I remember sitting in the audience for the opening ceremony of our 1989 WONCA World Conference and seeing the row of elderly WONCA dignitaries sitting on the main stage.  And there among all these very old looking men was a very young looking Wesley Fabb, WONCA’s Honorary Secretary.

Wes was the great networker.  In Jerusalem Wes introduced me to many of the senior family medicine figures from around the world. He also encouraged Reg Perkins, who was organizing the next WONCA World Conference in Vancouver in Canada in 1992, that he should have a special focus on the use of computers in family medicine and that Reg should ask me to coordinate this.  And that’s way happened.  And so my journey with WONCA began, 25 years ago.

Wes’ wonderful wife, Marian, was also at the 1989 WONCA World Conference and encouraged me to sign up as direct member of WONCA.

Over the next few years, Wes helped me to establish links with WONCA member organisations in a number of countries.  Through Wes I received invitations to speak at WONCA conferences in places like Sri Lanka and Singapore and Hong Kong and here in Malaysia.

In 1995 Wes and then WONCA president Göran Sjönell invited me to establish and chair a new WONCA working party on the use of computers in family practice.  A few years later Wes and then WONCA president Bob Higgins invited me to join them at a World Health Organization forum on family medicine in Thailand and this started my work with the WHO.

In 2002 I was elected as president of the Royal Australian College of General Practitioners.  The Australian college was experiencing a lot of turmoil at this time and a number of senior college members provided me with advice and support, including, of course, Wes.

At the time Wes was very despondent because the Australian government had made the decision to disband the Family Medicine Program that Wes had created and built up over so many years.  The government was replacing Wes’ single national program with a network of 20 new training organisations across the country.  At the time I told Wes that I knew that he saw the Family Medicine Program as his child, but he should see the network of new training organisations as his grandchildren.  And indeed the principles of Wes’ Family Medicine Program were adopted as the core foundation of this new network of training organisations.

In 2007 I was nominated by the Royal Australian College of General Practitioners for the position of president-elect of WONCA.  At our World Council meeting in Singapore that year I came second in the elections.  I was feeling a little bit down after the election result was announced and Wes came up to me and said that this was a great result for WONCA.  I thought he was mad, but he went on to explain that this would mean that I would be involved as a leader with WONCA for an extra three years and that I should run again in 2010!  Which of course I did.  The lesson from this?  “If at first you don’t succeed, don’t be afraid to have another go.”

Wes was no stranger to the challenges of career change. In 1993 Wes and Marian had left Australia and had moved to Hong Kong where Wes had been appointed as Professor of Community and Family Medicine in the medical school at the Chinese University of Hong Kong.  Wes had become a full time academic at one of our region’s leading medical schools.

This is Wes as a medical student.  You will note that he is a lot better dressed than most medical students today.  Our medical schools shape our health systems and are also shaped by our health systems. Doctors are granted substantial privileges and resources by society. These privileges imply a corresponding responsibility to participate in improving health systems and training the next generation of doctors to meet the needs of our societies. While our medical schools have the capacity to influence health care systems, they do not always choose to do so. Some medical schools pursue research and technological developments that have limited relevance to the urgent, unmet health care needs of the communities where they are based.

Social accountability involves a commitment by medical schools to direct their education, research and service activities towards the priority health concerns of the community, region or nation that they serve. Such responsibility to society should guide every medical school and permeate their entire scope of activities. The four values used to assess progress in our health systems- relevance, quality, equity and cost-effectiveness– are equally important for our medical schools.

Over the past fifty years there has been a worldwide movement to address the social relevance of medical education and this has led to major reforms. In the 1950s medical educators and clinicians recognized problems with the disease-oriented education model that focused on the often unusual conditions of hospitalized patients and treatment of disease without an emphasis on the actual health of individuals and populations. Reformers sought ways, during the latter half of the 20th century, to adapt medical curricula to become more responsive to the health needs of people and communities, and to prepare the next generations of doctors to provide high quality, comprehensive medical care 

Teaching methods were developed to integrate basic sciences with clinical problem-solving and engage medical students with patients in the context of the patients’ families and environment. Community-oriented education, often based in family medicine settings, was designed to help students understand the complexities of interactions between the health of the individual, the population and the environment, how illness presents differently in various settings, and how to intervene in ways that are acceptable and efficient.

These reforms were the foundation of much of the pioneering work of Wes Fabb in revolutionizing the training of family doctors in Australia. In 1973 Wes had established the Family Medicine Training Program of the Royal Australian College of General Practitioners.

The year before WONCA had been established at the World Conference on General Practice held in Melbourne in 1972.  Wes was there at the birth of WONCA and was elected to head up a committee looking at family medicine education and assessment.

WONCA was started by 18 colleges and academies from around the world.  WONCA now has 118 Member Organisations representing over 500,000 family doctors in 130 countries around the world.  The 500,000 family doctors represented by WONCA, and including all those of us here, each year have over 2 billion consultations with our patients.  Two billion.  That’s the scope of our current work and our influence.

But we need to do more. We need to work to ensure that every family doctor, every GP, every primary care doctor, joins us in our commitment to deliver high quality primary care to our patients and communities. And we need to expand our commitment to the education and training of family doctors and quality care and primary care research to the 80 nations of the world where WONCA does not yet have a presence, which includes many nations in the Asia Pacific Region, especially in the Western Pacific.

In the words of our very first WONCA president, Dr Monty Kent Hughes, speaking to the first WONCA world council in 1972: “the future of our professional discipline will depend on our ability to work together in the service of humanity.”

WONCA provides the global voice of family medicine.  We are also the eyes and the ears of global health care observing and listening to our individual patients and our communities and identifying their health care needs.  And we are the head and the heart of global medicine – combining our scientific knowledge with tender loving care. 

WONCA represents you and your professional college or society at a global level.  WONCA advocates for the important work you do every day in meeting the health care needs of your patients and your communities.

Why do we do this?  Because family medicine is important. 

Because the evidence is clear that health systems based on strong primary care, which includes strong family medicine, are the most efficient, equitable and cost-effective.

Because strong family medicine is the best way to improve the health of individuals, families and communities. 

Because every family should have a family doctor who the members of each family can trust for their medical care and advice. 

Because family doctors are part of the social fabric of our societies and we work to keep the fabric of health care together.

The family doctor has an important role to play in the life of every family in every community in every nation of the world.

In the words of Professor Ian McWhinney, one of the giants of our profession who passed away two years ago, “ideally, family doctors should share the same habitat as their patients.”  This allows us to best understand the social context of our patients’ lives. 

Wes understood this social context well.  Much of Wes’ life has been based in rural communities and I think this had a strong influence on Wes’ approach to global family medicine.  Wes was born in 1930 in a tiny country town in rural Australia called Ultima.  He later spent the early years of his career working as a rural family doctor in a town called Yarra Junction.  And now he and Marian have retired to life in the rural coastal town of Inverloch.

Last month we released new WONCA Rural Medical Education Guidebook. In one wonderful chapter, Dr Susan Phillips from Canada writes about the images of rural doctors and challenges the stereotype of the rural doctor as a “rugged male”.  Susan did a search of Google images and described her findings. 

Susan states, “The typical picture of the family physician and, the rural doctor in particular is the rugged male.”  I did a Google search and, sure enough, my Google search brought up the same image.  Susan goes on, “Although hardly scientific, a Google search of why doctors choose rural practice unearthed many images of male physicians hiking across fields and forests (often wearing stethoscopes), riding horses, or roasting pigs on a spit. On those rare occasions when women are pictured, they are at work, smiling at children, and wearing those white lab coats most of us abandoned years ago. A recurrent picture is what might be labelled ‘The Big Fish’, not because the doctor gets to be ‘a big fish in a small pond’ (a role some might seek) but because the male rural doctor is often holding his catch of the day – a big fish!”

Susan says that “such images can deter young female doctors from rural family practice. If learners do not see themselves in their preceptors or work mentors, they will avoid such practice settings.  Yet while the icon of the rural physician is stereotypically male and not inviting for women, women are drawn to remote practice with the same frequency as men.” Perhaps it is the attraction of the rural setting as ‘a place to make a difference’ rather than  ‘the big fish’ that explains why women doctors might choose a career as a rural family doctors.

While our clinics may be different from country to country, what is important is the way we are the same – through our commitment to comprehensive, continuing, coordinated whole person care. Through care that is person-centred, and family and community-oriented.  Through first-contact care, acute care, chronic disease management, prevention and health promotion.  And through our understanding of the interplay between population health and the health of individuals in our communities.

This is the wonderful Professor Barbara Starfield who showed through her research comparing health systems in many different countries, that comprehensive care by generalist primary care doctors is not only more cost-effective, but also leads to better health outcomes at a population level than compartmentalized narrow specialist care.

Barbara, through her research, provided us with the evidence of the benefits of primary care in lowering the cost of care, improving access to services, and reducing the inequities in a population’s health.

I last met with Barbara a few months before she died in 2011.  Barbara was keen to talk about the biggest challenges she saw for family medicine in the future, and what WONCA, and what Michael Kidd as the incoming president, should be doing.  I wrote it all down and here is Barbara’s last message for WONCA:

“Here are the three challenges I think you should focus on:

“How do we develop primary care research to address the challenges of care for people with comorbidities?

“How do we truly adopt patient-centredness into family medicine?

“How do we use the information from primary care to improve population health?”

There is enough in that simple statement for a dozen PhDs in family medicine.  Barbara recognised the failure of guidelines to accommodate comorbidity and multimorbidity and the need to turn our evidence-base upside down. 

Barbara recognised that primary care is person-focused, rather than disease-focused and that our health systems need to be reformed to focus on person-centred care and to embrace our greatest allies in family medicine – our patients. 

And Barbara recognized the power of the information that we are starting to collect through digital means in primary care and how this can be used to improve population health?  We need to build our own evidence base from primary care.  And where do we get this evidence from?  The answer is right in front of us.  It is from our encounters with our patients.  In the words of immediate past WONCA president, Rich Roberts, “If we want evidence-based practice, we need practice-based evidence.

Research like this is critical to family medicine and is another key role for our medical schools.  We all appreciate that research is a core component of family medicine training, scholarship and clinical practice in all our nations.

This is Dr Yin Shoulong, a rural general practitioner in Tai Shitun Village in China, who hosted my visit to his clinic last month. Tai Shitun is in the Mi Yun District, two hours drive north of Beijing and a very different world from the densely populated metropolis to the south.

Dr Yin lives in a typical Chinese rural village house built around a central courtyard with his clinic occupying one side of his home.  His patients are from his farming community and many are impoverished and elderly and frail. 

Dr Yin has devoted his career to supporting the health and well being of the people of his village and the surrounding district.  Recently he has become involved in providing experience in rural medicine to young family medicine trainees on rotation from the Capital Medical University in Beijing.  He is part of the primary care revolution underway across China.

China has embarked on a massive drive to train and recruit up to 400,000 general practitioners in the next seven years in order to reform the country’s health system to meet the current and future needs of the population, especially the 800,000,000 people living in rural areas.

The reforms underway in China will have implications for the rest of the world, and especially for those countries where family medicine is not yet well established.  The Chinese Government recognizes that one of the biggest challenges is training the family doctor workforce to meet the needs of both urban and rural China. If the challenges can be met with success, then this should provide lessons that will flow to many other parts of the world facing the same challenge of providing universal health coverage. This bold initiative by China needs to be supported and I am delighted that we have such a strong contingent of doctors from China here at this WONCA conference in Kuching.

One of the leaders alongside Wes in the establishment of WONCA, and the first person ever to be awarded WONCA Fellowship, was Dr Prakash Chand Bhatla from India, who once wrote that “Education and motivation of the community has to be done on a personal basis. And who is nearer to the community than the family doctor?”

Who is nearer to the community than the family doctor? As family doctors we need to be engaged by our governments and international health organisations in the planning and delivery of national and local health programs. Family doctors are part of their local community and have the trust of their local community and can be part of ensuring the successful delivery of health care programs, especially to the most vulnerable members of our populations.

Last April I visited Indonesia and this rural family medicine clinic, called a puskesmas, or Primary Health Center, on the island of Timor, about an hour north of the city of Kupang in West Timor.  This clinic has serious challenges due to its isolation.  The electricity supply is patchy at best and blackouts are frequent.  There is no running water.  Water for the clinic is drawn from a well.  I had never drawn water from a well before and enjoyed the novelty of hauling up buckets of fresh clear water from deep below the earth’s surface.  I was informed by the locals that the novelty wears off very quickly.

Yet, despite the challenges, the energetic and dedicated family doctor and her team at this clinic deliver primary care services to the members of their local community and also run a birthing centre which has led to a substantial reduction in the rate of infant and maternal mortality in the region.

There are those who say that family medicine has no real role to play in low and middle-income countries.   Well we have blown that theory out of the water.  Last year the Director-General of the World Health Organization, Dr Margaret Chan, launched WONCA’s new guidebook on the contribution of family medicine to improving health systems.  The guidebook includes a chapter from the WHO showcasing the research into the impact family medicine is having in improving health outcomes in many middle income nations including China and Thailand.  And there is a chapter outlining the remarkable work that is underway across Africa to strengthen family medicine, especially involving WONCA member organisations within Africa supporting developments in neighbouring nations. 

What these developments demonstrate is the need to strengthen the whole health care workforce, including family doctors, community nurses, community health workers, and traditional birthing assistants, and support us working together to deliver appropriate care to all people.  People in low income countries still want and deserve access to health care, access to caring clinicians, access to life saving medications.

We also need to embrace the concept of reverse innovation.  What can health systems in high-income countries learn from the health systems in lower income countries?  It is something that each of who spends time working in another health system in another country learns very quickly. 

It is also a lesson that was emphasised by another of our past WONCA presidents and the second Wes Fabb Orator, our dear friend Rajakumar from Malaysia, who once wrote that: “Experience in different health systems will make us better doctors and better human beings.”

But serious health care delivery challenges can occur in any country.  In February this year I was invited by rural family doctor and Professor of Family Medicine, Ryuji Kassai, to visit communities in the Fukushima region of Japan affected by the 2011 tsunami and the nuclear reactor disaster.

We all remember the tragedy of the March 2011 tsunami that hit the Pacific coastline of Japan following an earthquake, killing thousands of people and destroying coastal towns and villages.  And the global fears that followed when the damaged Fukushima nuclear power plant exploded releasing radiation into the atmosphere.  The radioactive contamination resulted in over 100,000 people being evacuated from their homes and a 50 kilometre exclusion zone was established around the damaged nuclear plant and the path of the radiation fallout.  Ryuki shared his experiences at that time through a widely-read blog published on the website of the British Medical Journal.

I was keen to learn about the role local rural family doctors and their teams are continuing to play in assisting in the recovery of the surviving members of the devastated communities.  It was a sobering week.

Three years later, the evidence of the damage caused on that terrible day remains.  Many people still live in temporary housing and are prohibited from returning to their abandoned homes.  Many people, especially young families, have moved away to other parts of Japan.  Many elderly people left behind grieve for their missing families, their lost homes and their lost way of life. 200,000 affected people are being followed up regularly in special clinics set up to screen for problems related to radiation exposure.

The coastline is desolate, having been cleared of the ruins and debris that was all that remained of coastal cities and rural communities and the surrounding forests destroyed by the tsunami.  The villages have gone, the farms have gone, the forests have gone.  It is like there has never been anything there.  The exception is the exclusion zone around the nuclear reactor where the damage from the tsunami is still visible with damaged buildings, upturned cars and fallen trees.  Whole villages that survived the tsunami but were subjected to radioactive fall out are now ghost towns with deserted homes and shops with empty windows and no sign of life. The local family doctors tell me that, for many elderly survivors, the impact of lifestyle risks may be worse than the radiation risks, due to increased alcohol use, poor diet and obesity, and related mental health problems and risk of self-harm and suicide

This visit was a stark reminder of the challenges people face in rebuilding their lives and their communities following catastrophic events.  And the huge impact such events have on the physical and mental health of each affected person.  But I also had the privilege to visit the family doctors of this region and discuss the roles that family doctors and the members of our teams can play in supporting our communities during and after such devastating events.

This is young rural family doctor, Dr Hiroshi Takayanagi, who is based at the Kitakata Centre for Family Medicine in Fukushima Prefecture, which is a teaching practice linked to the Fukushima medical school. 

Hiroshi works with his elderly patients to seek to reduce the impact of the forced relocation and social isolation.  He has seen many of his patients experience worsening of dementia and development of depression and anxiety.  Others have sought to find solace in overuse of alcohol or in poor nutritional choices leading to a rise in liver disease and obesity.  Some public health experts believe the health impacts on many elderly people would have been less if they had been left to live in their own homes, regardless of the nuclear contamination.

It is in times of community peril that family doctors often rise to the challenge and do so brilliantly.

Aileen Espina from the Philippines is here today.  Last November Aileen’s community was devastated by Typhoon Yolanda that causes terrible destruction and loss of life in Tacloban City and surrounding areas in the Philippines. WONCA delegates at our 2011 Asia Pacific Conference in Cebu had visited Aileen’s medical school.  It was totally destroyed and the school is now operating out of tents. Aileen and her colleagues are rebuilding their community and their medical school in Leyte and, Aileen, I pay tribute to you.

Bruce Chater is one of the leaders of our WONCA working party on rural practice.  Bruce and his wife Anne hit the headlines in Australia in 2010 when their hometown of Theodore in rural Queensland was threatened by serious flooding. Bruce and Anne and their family made sure all the people of the town, including the elderly and the frail and their beloved pets, were all evacuated safely before the flood waters arrived.  Bruce was the last person to leave before the floodwaters engulfed their town and destroyed their clinic.  And Bruce and Anne were the first ones back, setting up a makeshift clinic where Bruce looked after his patients for many months before a new clinic was built.  Ryuki and Aileen and Bruce and Anne and all their colleagues are true heros of family medicine.  They demonstrated their care for every single member of their community.  This is universal health coverage in action.

Universal health coverage has been part of the charter of the United Nations since 1948.  Universal coverage does not mean meeting the needs of 80% of the population – it means ensuring that health care is available to everybody in the world.  With over one billion people with no access to any health care at all, we still have a long way to do.

As family doctors we need to support the focus on the social determinants of health and ensure that those groups of people in our communities most at risk of poor health, the most marginalized, the most vulnerable, are not excluded from access to health care.

WHO Director General Dr Margaret Chan has become a staunch supporter of family medicine and our potential to ensure global universal health coverage.  At a meeting in Hong Kong last December Dr Chan stood up and proclaimed “I love family medicine”, which didn’t please our colleagues in the audience from other medical specialties.

Dr Chan has recognised the value of family medicine and our contribution to primary health care and to universal health coverage. Dr Chan has also recognised that primary care is not cheap and must not be a “B-team” version of health care delivery. 

In order to provide universal coverage, our countries need to stem the costs of health care, and can do so through increasing investment in community-based health services.  And at the same time there must be a movement of funding from hospitals to the community, rather then expecting more community-based care to be delivered with no increase in resources.

This is also a lesson for our universities.  More recently, there has been a growing appreciation of the overall social impacts on health.  Many of us are linked to medical schools and universities that have a strong focus on social accountability and on preparing our medical students to work where they are most needed.  My own university, Flinders University in Australia, is no exception. 

Charles Boelen and Bob Woollard in their recent work developing global consensus on the social accountability of medical schools have reminded us that “A medical school has a mandate to be socially accountable to the funders and the population where it is located, and to the nation. Medical training can be successful if it is associated with an effective health care system  - and an effective health system is dependent on successful medical training program.”

And do not underestimate the opportunities for our medical students to make a difference to health care and to outcomes while they are students in our practices in our communities. The key is to give our learners enough space to be the amazing creative individuals they are.

This is something Wes understood well during his years as a professor in the Department of Community and Family Medicine at the Chinese University of Hong Kong.

When students interact with family doctor in the classroom and in clinical settings, and perceive family doctors as valued members of health teams, they are more likely to consider a career in family practice.  Enthusiastic family doctors who demonstrate humanistic values, and provide high quality patient care and excellent teaching, serve as positive role models that many students will wish to emulate.  Conversely, if students are not exposed to family medicine during their education, they may be unaware of the content and challenges associated with family practice and be less likely to select family medicine as a career.

Students need to see a future in family medicine as a personally satisfying and beneficial career choice.  Medical school training is critical in the effort to recruit and train sufficient numbers of primary care doctors for each health system.  Medical schools have great influence in the future career choice of students.  Medical schools can promote the perception of primary care as a respected and viable career choice, or they can devalue the specialty of family medicine and the critical function of primary care within a health system, thereby leaving their communities poorer.

WONCA recognized the importance of medical schools in family medicine training when in 2007 we adopted the WONCA Singapore Statement, which says that:

“Every medical school in the world should have an academic department of family medicine / general practice, or an equivalent academic focus. And every medical student in the world should experience family medicine / general practice as early as pos­sible and as often as possible in their training.”

The paramount responsibility of WONCA, of each of our member organisations, and of each medical school, is to our patients and our communities.  Family doctors, no matter where we work, ensure that health is affordable, safe, appropriate and equitable. 

Something Iona Heath, former president of the Royal College of General Practitioners in the United Kingdom, said a few years ago really struck a chord with me, “I believe that general practice/family medicine is a force for good throughout the world.”

I am impressed with the commitment of family doctors to human rights issues.  I am convinced that family doctors right around the world care about human rights; the basic expectations we all have about how we and our families and all people should be treated. 

As family doctors we have social responsibilities. Each of us needs to be an advocate for social justice and human rights.

We need to speak out for what is right, to say “this is not OK”, and in so doing contribute to social change.

We need to contribute towards ensuring equity of access to health care – what we call in Australia “a fair go” for everyone.

And we need to care for the health of our planet as well as the health of our patients.  After all, what is good for the climate is also good for our patient’s health – reducing obesity, increasing physical activity, healthy improvements in diet, and living in a clean environment with clean air and clean water.

Why do I say that family doctors should focus on all these things.  It is because if we, as family doctors, with our privileged position in society, and our access to pretty much the entire population in our communities, don’t stand up for these things, who will?

The question Husni asked me to address in this oration is whether our universities are nurturing our future family doctors.  The answer of course is yes and no.  Some medical schools in our region are world leaders in nurturing tomorrow’s family doctors.  Others have a lot more work to do.

I was in contact with Wes and Marian last week. They sent me this photo and this message for you all:

Greetings to our Wonca colleagues

Family matters and the recent birth of two grandchildren have prevented us from attending this Asia Pacific Conference in Kuching.

We have a special affection for Malaysia dating back to the days when for several years in the late seventies and eighties I was an external examiner in the Conjoint MAFP/FRACGP examination held in Kuala Lumpur, then when we attended the previous WONCA RuralConference in Kuching in 1999, and then when I gave the inaugural Wes Fabb Oration at the A-P regional conference in Kuala Lumpur in 2002.  In the same year I was awarded Honorary Fellowship of the Malaysian Academy of Family Physicians.

We have many dear friends and colleagues in Malaysia, throughout the Asia Pacific Region, which gave birth to the Oration, and throughout the WONCA world, in which we were involved for twenty years as CEO and Administrator.

We send you all our warmest best wishes.  We know that you will be enriched by the fellowship, academic stimulation and scenic excitement of the Kuching Conference.

Wes and Marian

I end by thanking Wes for the great contributions of his wonderful career.  Even after he retired from clinical practice, Wes never forget how hard family doctors work, that many of you work under very difficult conditions, that the resources that you need to do your job are often not available, that the hours you work and the demands on your time can be arduous, that your resilience is tested regularly.  And we often feel unappreciated. And we don't often hear the words thank you. This is why WONCA has established World Family Doctor Day, held on May 19 each year, to acknowledge the important work that we do.

It has been wonderful this week to see the World Family Doctor Day activities underway all around the world celebrating the contributions wonderful family doctors make to the lives of their individual patients and their families and to the health and wellbeing of their communities.  Dada’s niece designed a logo for World Family Doctor Day which has gone viral and has appeared in campaign material in countries like Australia, China, Kuwait, Romania, South Africa and the United States.  Taiwan has produced this wonderful poster to celebrate the day.

So today, on behalf of the 2 billion people around the world who benefited from your care and support over the past year I say thank you. Thank you for your commitment to being a great family doctor.  And thank you for the important work you do every day providing health care to the people who trust you for their medical care and advice. 

Michael Kidd
Kuching, Sarawak, Borneo
22.05.14