Interview with WONCA president

WONCA President interviewed in Spain

www.semfyc.es

Internationally renowned WONCA President, Professor Richard Roberts, is probably the best person to know the status of Family Medicine worldwide. His constant travels and studies, in addition to his role as President of WONCA, afford him a unique overview of the world situation.

At the 31st Congress of the Spanish Society of family and Community Medicine (semFYC), held from 8–10 June, 2011, in Zaragoza, Professor Roberts took time to share his knowledge and experiences; to speak directly with members of Congress; and to be interviewed by Dr José Miguel Bueno of News semFYC. The status of Wonca and Family Medicine around the world; the situation of Family Medicine in a time of global economic crisis; and the possible creation in Spain of the specialty of Emergency Medicine are just some of the topics discussed in this interview.

1. What should members of semFYC know about Wonca?

It is the only organisation that brings together all the family doctors in the world. Itwill be as powerful and effective as we family physicians decide it should be.

2. The economic crisis has put health services generally and Family Medicine specifically in a key position. What model of health services best supports Family Medicine?

I think our health systems should enable family doctors to do as much as we can for as many patients as possible. The more our availability to our patients is limited (by hours, gender, age, or presenting complaint), the more their care is fragmented across an assortment of other professionals who are strangers to them, with the risk that more errors will occur and they will be harmed.

3. You know many of the health systems of countries around the world. What is your opinion on the situation in Spain?

Many of us see Spain as a country that made the difficult and important decision in the 1980s to commit to a Family Medicine model, instead of continuing with the previous model of ambulatory care provided by general physicians with no post-graduate training in primary care. Spain quickly discovered the benefits of rebuilding the system with family physicians - improved outcomes and decreased health care costs.

4. In Spain, the economic crisis is leading to cutbacks in the public health system. What do you think should be the response of family doctors?

Innovate, be creative. Create novel ways to be more accessible to your patients and community (SMS, e-mail, group visits, etc.). Go to your patients and your community to share your concerns, and ask their advice. Prove your worth by obtaining and presenting the results of your improvements in care that give better outcomes and save money. Be consistent in your messages – you will need to communicate your messages many times to the Ministry of Health, other leading Spanish stakeholders, and the public.

5. In Spain, we are having a lively debate on the creation of the new specialty of Emergency Medicine. We know that your country, the United States, was one of the first to have this medical specialty. Based on the U.S. experience, do you think Spain should create this new specialty of Emergency Medicine?

If it does, I feel sorry for Spanish citizens, because it represents a further fragmentation of the health system. In the U.S., the literature shows that a considerable portion of emergency services are still being provided by family physicians. About half of our family physicians continue to provide emergency services.My sense is that when a specialty of Emergency Medicine is created in a country and separates from Family Medicine, it is usually because one or more of the following happened.

• the accessibility of patients to their family doctors was considered inadequate.
• the academic reputation, financial position, quality improvement, and research of Emergency Medicine were
• advancing slower than desired.
• the work life of family physicians who provide emergency care and those who provide more comprehensive
• care became very different.
• communication between doctors providing emergency services and those providing more comprehensive services deteriorated or ceased to exist.

The model I like best is that of Canada, where doctors begin as family physicians and then develop an interest in emergency medicine. They are still considered family physicians. If there is a different specialty in a country, it is vital that emergency physicians and family doctors work in close collaboration for the benefit of the patient.

6. As you know, the role of Family Medicine at Spanish universities is under-developed. What are the contributions and status of Family Medicine in academia, as perceived by professionals and the public?

It is essential that Family Medicine is viewed as a respected member of the academic community. Each medical school should have a department of Family Medicine and an adequate number of family physician faculty. Those academic departments should serve as a connecting point between the research community and primary care, and should provide support for research (e.g., statistical and study design expertise) for those doing primary care research. These conditions are necessary to increase the interest of medical students in Family Medicine; to promote research that is useful for family physicians; and to demonstrate to other professionals and the public the importance and complexity of Family Medicine.

7. What impressions of Family Medicine in Spain will you take home, after attending the 31st Congress of semFYC?

Spanish family physicians and semFYC have accomplished much and should be proud of those accomplishments. You have gone from having no family doctors to having thousands in a short space of time; you have improved the health of the Spanish people and the outcomes of the Spanish health system. You have the respect and attention of the Ministry of Health and Social Policy. Most importantly, you are reaching out to young doctors and medical students to encourage, support, and help them develop their leadership skills. I think the greatest challenge you face in these trying times is to keep faith: you must maintain your confidence in your ability to live up to the challenges of these difficult times. Engage in more dialogue with the media so that they and the public better know who you are and what you value. Consider the creation of a TV series about the daily life of a family doctor, use social media to get out your messages, and so on. Finally, you must achieve your place in medical schools to enhance the status of family physicians and advance the discipline of Family Medicine.

8. Professor Barbara Starfield has recently died. What you think her greatest legacy has been?

Barbara's legacy has been to show the world the value of primary care and the dangers and cost of care that is fragmented and focused on specialists. She did this by meticulous research, by consulting with many governments, and by mentoring numerous young researchers. Her main message was that the people benefit most when their health system is centred in a relationship with one family doctor whom they trust and who does all he/she can do for them.

9. In your column in the June 2011 issue of Wonca News, you reflected on your recent attendance at the World Health Assembly, which was focused on non-communicable diseases. You were concerned that the increased visibility of primary health care achieved in recent years may be overshadowed again by an excessive focus on specific diseases and that we should support the initiative "15 by 2015." What do you hope members of Wonca and semFYC will do?

Contact your health ministries and foreign affairs departments. Ask to join your country’s delegation to discuss these issues at the UN Summit on Non-Communicable Diseases in New York City on 19–20 September. Remind them of our three key messages: (i) integrate health care and do not fragment it further; (ii) remember that the strength of each health system depends on the strength of its primary care system; (iii) support the "15 by 2015" initiative which seeks, by 2015, that those who fund health care and research should dedicate 15% of their funds for targeted diseases (vertical programs) to the support of the primary care infrastructure (horizontal programs).

10. In your lecture during the student day at the semFYC Congress, one of your final slides was "More important than knowing the disease is knowing the person with the disease". Why did you decide to end your speech with this message?

I believe that technical knowledge, such as which medication to prescribe for a specific disease, is easier to obtain than the knowledge of the patients being treated (their unique biology, preferences, values, etc.). Patients expect that we know and treat them as unique individuals, and not merely as some abstract statistical average from a population study. For example, we can prescribe the “best” medication for a condition, but unless we know the patient well there is a good chance that the medication will not be used at all (because of lack of trust in our prescription) or not used correctly (because we do not know the barriers to using the medication as prescribed). What good is our knowledge of the disease and the “best” medication if we are unable to persuade the patient of the importance of using it as prescribed?