How to work in family medicine
If you’re not a people-orientated person, you should probably stop reading now: family medicine is all about understanding the individual behind the illness, says Professor Julia Blitz
As Hippocrates (460 – 370 BC) said: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” While Hippocrates might have put this in a rather extreme form, it is true to say that family physicians place great importance on understanding the person who is ill (though definitely not at the expense of knowing about their disease).
Though not unique to family medicine, the cornerstone of this specialty is a focus on the patient, rather than a focus on a particular set of diseases, age group of patients, or procedural technique.
Francis Peabody said in 1926: “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” Later, in 1972, Ian McWhinney (seen by many as the father of family medicine as a new discipline), said that the integration of behavioural science and clinical medicine would enable the family physician to deal with both the behavioural factors that led to a patient’s healthcare decisions, and the patient’s clinical issues that needed to be managed.
Family medicine addresses the issues around the patient’s health belief system, their lifestyle choices, their supportive and destructive relationships, and the impact of their economic status on their health choices.
Some of the joys of family medicine come from the continuity of care: building a relationship of trust with the patient (and often members of their family) over extended periods of time (sometimes your whole career in practice).
The breadth of family medicine means that you are able to help patients with a multitude of problems, falling within any of the domains of paediatrics, psychiatry, gynaecology, obstetrics, medicine, orthopaedics, and infectious diseases, to name a few. You need to have a broad range of skills, but one of the most important is to know the limits of your own abilities, so that you refer the patient to specialist colleagues whenever this is appropriate.
The intellectual challenge of family medicine is dealing with the so-called undifferentiated patient
The intellectual challenge of family medicine is dealing with the so-called undifferentiated patient, particularly when patients often present to us in the early stages of the disease process. Unlike in other disciplines, the patient has not yet been through the first stage of sorting into a likely domain of pathology.
One does not know if the woman presenting today with lower abdominal pain may have an ectopic pregnancy, appendicitis, or a desperate need to fall pregnant. Does the man who presents with a headache have a brain tumour, a subarachnoid haemorrhage, a tension headache or a desire to be booked off work? Is this set of symptoms self-limiting, whose natural course will be to resolve, or are these symptoms in the early stages of evolving into something more serious?
One of the best ways to keep improving and updating your skills as a family physician is to develop relationships with the specialist colleagues you refer patients to, so that they give you feedback on what management plans they have chosen for the patient and what outcomes they have achieved.
Family physician training in South Africa aims to produce specialists who are able to not only practise competently in district hospitals, but who are also able to work with teams of healthcare professionals to improve healthcare outcomes of the communities they serve.
In order to train, you need to be accepted onto the Masters degree programme by any one of the South African medical schools and to be employed by one of the provincial Departments of Health as a registrar.
Training takes four years, three of which need to be in a registrar post. Many of these posts are no longer attached to tertiary hospitals (as with most other specialist training), but are shifting to be based in district hospitals.
If you choose to spend one of the four years not in a registrar post, you still need to be in an appropriate job where you are supervised, but you can use the year as an opportunity to decide if you like family medicine before you start your registrarship, or to pursue something outside the usual curriculum.
The final examination at the culmination of your training is the Fellowship of the College of Family Physicians examinations, which comprise clinical exams and examination of the research project that you complete during your degree programme.
Working as a family physician
Family physicians work closely with clinical nurse practitioners, particularly when working within primary care at clinics and community health centres.
In the public sector they are important members of the district-based clinical specialist team, where they work closely with obstetricians and paediatricians in an attempt to improve South Africa’s chances of decreasing neonatal, child and maternal mortality. In the private sector, a family physician can work in solo practice or in a group practice, in urban or rural areas, or for non-governmental organisations.
The actual nature of your particular practice is determined less by the scope of the discipline that you have chosen to specialise in, but more by the needs of the community that you work in. In other words, if you practise in a rural town, you may be more likely to take on some of the hospital duties including giving anaesthetics and doing gynaecological and general surgery.
The actual nature of your particular practice is determined less by the scope of the discipline that you have chosen to specialise in, but more by the needs of the community
If your practice is in an affluent area of a big city, you may be more likely to focus on ambulatory care dealing with non-communicable diseases and psychological problems. It is really important for you to know the network of other resources that your patients can access, whether these are patient support groups, allied healthcare professionals, counsellors, hospices, for example.
The spectrum of practice which you can choose from is almost limitless and it is easy to find a niche that suits your personality and your interests.
Working hours can be long, as it is often family physicians who provide both office hours and after-hours services. However, in the private sector more and more use is being made of after-hours emergency units, so that these duties can be shared. In the public sector, the bulk of the afterhours work is often done by the interns, medical officers and registrars, giving some relief to the family physician.
In the public sector family physician specialists are paid at the same level as other specialists. In the private sector, family physicians are not yet recognised as being able to charge specialist rates. Your income can be derived from any combination of consulting, procedures, assisting with surgery, dispensing medication, sessions at the local government clinic or hospital, or clinical trials for pharmaceutical companies.