Family medicine is the first gateway to primary health care in health systems. This feature makes the definition of family medicine complex due to its inclusive, holistic and continuous approach. The definition of family medicine should include the professional individual aspect of the family physician as well as its duties, authorities and responsibilities.1 Since the development of family medicine, definitions of the discipline have been frequently modified and updated, continuing to the present day. Family medicine represents the most basic aspect of the health-care system, which makes developing such definitions quite complex, and definitions must be revised and updated as conditions change. The first definition of family medicine, presented in 1974, was followed by a definition by Olesen et al. in 2000, and later by the European Society of General Practice/Family Medicine (WONCA Europe) in 2002. The WONCA Europe definition was then updated in 2011. Although this last definition explains family medicine in the most detailed way, today it needs updating especially in defining the individual characteristics of family medicine and its relations with the environment. There is a need to define the highly intensive role of family physicians while considering, the physicians’ spiritual and personal agenda as human beings. The Göktaş definition of family medicine/general practice, which was suggested at the WONCA Europe 2018 conference in Krakow, Poland, represents a suitable means of completing the 2011 WONCA Europe definition in this regard.
La medicina familiar es la primera puerta de entrada a la atención primaria de salud en los sistemas de salud. Esta característica hace que la definición de medicina familiar sea compleja debido a su enfoque inclusivo, holístico y continuo. La definición de medicina familiar debe incluir el aspecto profesional individual del médico de familia, así como sus deberes, autoridades y responsabilidades.1 Desde el desarrollo de la medicina familiar, las definiciones de la disciplina se han modificado y actualizado con frecuencia, hasta el día de hoy. La medicina familiar representa el aspecto más básico del sistema de atención de la salud, lo que hace que el desarrollo de tales definiciones sea bastante complejo, y las definiciones deben revisarse y actualizarse a medida que cambian las condiciones. La primera definición de medicina familiar, presentada en 1974, fue seguida por una definición de Olesen et al. en 2000, y posteriormente, por la European Society of General Practice/Family Medicine (WONCA Europa) en 2002. La definición de WONCA Europa se actualizó en 2011. Aunque esta última definición explica la medicina familiar de la manera más detallada, hoy necesita actualizarse especialmente en la definición de las características individuales de la medicina familiar y sus relaciones con el entorno. Existe la necesidad de definir el papel altamente intensivo de los médicos de familia, considerando la agenda espiritual y personal de los médicos como seres humanos. La definición de Göktaş de medicina familiar/práctica general, que se sugirió en la conferencia WONCA Europa 2018 en Cracovia, Polonia, representa un medio adecuado para completar la definición de WONCA Europa 2011 en este sentido.
Family medicine is the first gateway to primary health care in health systems. This feature makes the definition of family medicine complex due to its inclusive, holistic and continuous approach. The definition of family medicine should include the professional individual aspect of the family physician as well as its duties, authorities and responsibilities.1
Although family medicine and general practice medicine are labelled ‘primary health care’, as clinical medical disciplines they are the mainstay of health systems at every level, affecting all parameters of health since the last century, if not since the dawn of human history. Family medicine is the primary enduring aspect in the field of health, representing the first and last point of responsibility in every aspect of human care.
Family medicine, which is at the centre of primary health care services and should be the first gateway to health systems, determines the overall quality of care provided. Consequently, the definition of family medicine and its practitioners, family physicians, can affect the development of health care overall. However, such definitions, of which many have been produced throughout history, are applied differently across countries, which leads to deviations from the main values of the discipline and, commonly, the placing of excessive workloads on family physicians. Thus, this process has resulted in family physicians’ mental state being somewhat disregarded.
The mental aspect of family physicians’ roles was discussed at the 2018 WONCA European Conference held in Krakow, Poland, under the title ‘The Standards of the Definition of Family Medicine/General Practice and its Legislation in the European Union Criteria’. At this conference, consideration of the psychological burden experienced by family physicians was added to the existing definition that was produced by WONCA Europe in 2011. Although this last definition explains family medicine in the most detailed way, today it needs updating especially in defining the individual characteristics of family medicine (pyhsician) and its (his / her) relations with the environment. This new definition adds the spiritual strength of family physicians to the scientific aspect of their daily practice.
Historical development and characteristics of family medicineIn 1910, Abraham Flexner emphasised the need to standardise American medical education,2 and in 1927 Francis Peabody highlighted the necessity of family medicine.3 In 1966, the Millis Report was published, representing an important milestone for the family medicine discipline; essentially, the Millis Report advocated the provision of specific residency training in medical faculties for family physicians, which would provide comprehensive, continuous, and appropriate education for such health-care professionals.4 Also in 1966, Dr. William R. Willard, in his report, which has played an important role in the formation of the current family medicine specialisation, drew attention to the importance of health interaction between individuals and communities and providing primary medical health care.5
In 1997, Ian R. McWhinney made recommendations to change the name of general medicine to family practice or family medicine, and to name general practitioners as family physicians, with the increasing importance of general medical practice. With the provision of comprehensive health care to families and individuals, the term family medicine became increasingly widespread and became the name of today's medical discipline.6
Robert B. Taylor stated that family physicians provide an important environment of trust in their relations with the individual and the family. He emphasised that this environment of trust ensures that the health care to be given to the individual and the family is a versatile, inclusive and continuous service, and this is the main feature of family medicine.7
Allan G. Goroll and Albert G. Mulley presented a complete definition summarising the entire responsibility of family physicians across perspectives such as clinical tasks and organisational setting. They stated that this role is referred to as primary care because it differs from that of other specialists in hospitals.8
It is important to note that the priorities and national aspects of countries’ health systems determine the quality of the health care provided; further, technological developments and applications also affect the life expectancy of individuals in health systems.9 In this regard, Barbara Starfield emphasised that primary health care has an important place in its ultimate goal, based on the fact that primary health care services are at the core of health systems. Starfield stated that there are two main objectives for any health-care system. The first aim is to bring the individual and society to the healthiest state, and the second is to minimise disparities across populations so that no particular group of people receives better or worse care than others.10
Definitions of family medicineThe first definition of a family physician was presented in 1974 at the European Conference on General Practice. Equating family physicians to ‘general practitioners’, this definition emphasised the characteristics such professionals should possess, including the knowledge, skills, and attitudes.11
In 1991, The World Organization of Family Doctors (WONCA) defined the role of family physicians as performing individual-focussed tasks, promoting the patient-physician relationship, being an advocate for the patient, performing resource management for patients, and coordinating with other services to increase the patient's access to necessary resources.12
Frede Olesen and colleagues, in a 2000 paper, argued that the WONCA definition should be updated, suggesting that, rather than focussing on the boundaries between general practice and other medical disciplines, the core aspects of the family physician discipline must be clarified. Olesen et al. also felt that the new definition should provide a framework for research, teaching, and development.13
Chris van Weel, at a family medicine conference in 2001, mentioned the need for academic development in family medicine. He also talked about the benefit of acting together in education, training and research in primary health care. He suggested reconsidering all definitions of the discipline and developing a clearer definition of the role and characteristics of family medicine/general practice.14
As a result of the characteristics, content, and widening scope of the practise of family medicine, existing definitions quickly became obsolete. In 2002, WONCA created a new definition of family medicine.15 This 2002 definition was revised later in 2005 and finally in 2011 by adding general characteristics and core competencies of family medicine.16
In 2016, WONCA prepared a document that sets the standards for family physicians to ensure the worldwide similarity of their work and to continuously improve their profession on a scientific basis. In this document, similar to the worldwide Medical Education Standards, the global standards that family physicians should have while practicing their profession and 9 features that will ensure their professional development are summarised Among these 9 features, there are principles such as that family physicians are physicians for the individual, what their duties and responsibilities are, they should be audited and documented, the content of their education, educational resources, the continuity and evaluation of their education, the provision of professional organisations and their constant updating and renewal.17
The distinctive feature of the family physician, distinguishing it from other specialisations, is that it is human-oriented. This causes the work of the family physician to represent a passionate practise with spiritual power. “Family medicine is medicine centered on the patient, on the person, not on the illness. The patient seeks the family doctor not only because he or she suffers from this or that illness – which could be treated very well by the corresponding specialist – but because the family doctor is his doctor. It is not the doctor who takes care of your heart, or of your liver, or of your depression, or your arthrosis. The doctor takes care of him, the person. A professional reference, a true vade-mecum that is consulted as a bedside book. ‘Bedside doctor’ is the former name of the family doctor, and the basis of his relationship with his patients is, precisely, the relationship itself and not the patients’ suffering from this or that disease. Thus, the patient can and should seek the family doctor for any health reason, and the doctor will do well to ask himself, when he is ready to see a patient: ‘What will enter through that door?’ In fact, a person can pursue any career, and that makes family medicine a passionate practice. Even surrounded by this spirit of adventure and simplicity with classic flavor, family medicine is today much more than a style or a charisma restricted to some medical professionals. It is a recognized specialty, an academic discipline with its own unique knowledge, values, and methodology that underlie its system and allow it to be transmitted as science.”18
In 2015, Michael Kidd made it clear the importance of being different. Kidd drew attention to the fact that family physicians should defend human rights due to their social responsibilities, and develop the society by openly telling what is right and wrong. He stated that family physicians, who have easy access to the whole population, are the closest professional group to the society and individuals with their privileged position and the importance they attach to ethical values, and they should be proud of these characteristics. Kidd stated that it is important for family physicians to be different and this is due to their guidance.19
Ethical dilemmas are one of the most important issues faced by family physicians while performing their duties. The family physician must be careful in this regard. A working group formed by WONCA Europe recommends investigating the causes of ethical dilemmas in family medicine practice, resolving, preventing and raising awareness of these dilemmas by working together and developing principles.20
ResultThe Göktaş definition, Krakow, 2018Existing definitions have defined family medicine and the responsibilities of family physicians in detail. However, while these definitions emphasise the importance of family medicine, they are insufficient for the definition of family medicine in today's conditions and need to be updated. A comprehensive definition could further underline the strategic role of these health-care professionals. Considering the multidisciplinary characteristics of primary health care services, and the need for family physicians to possess good characteristics and high levels of responsibility, it is necessary to also define family physicians as having rights and freedoms. Family physicians should be rescued from the pressures placed on them by their respective parties, so that they can perform their role without unnecessary burden. Family physicians must be appreciated for performing such a complex task. As family medicine standards are difficult to establish within health systems, family physicians may feel stuck with their multitude of tasks and responsibilities. Physicians are not machines; so, how can they protect themselves from the burden caused by these responsibilities? Family physicians should be protected in such a way that the level of control and risk of punishment at every stage of their occupation is minimised. Family physicians should be free to work as they wish, provided they continue to perform a positive role.
In 2018, Olgun Göktaş, at the WONCA Europe 2018 congress in Krakow, Poland, added family physicians’ spiritual strength to the 2011 definition produced by WONCA Europe. Göktaş’ definition of family medicine is designed to ensure all partners and society recognise the importance of the family physician in health systems. The inclusion of family physicians’ spiritual power in the definition of family medicine will positively affect perceptions of family physicians and enable them to work comfortably. When family physicians are protected and valued, the discipline of family medicine can develop further. Needless to say, these definitions should be translated into standards that suited to each country's unique context.
The Göktaş 2018 definition is presented below (Göktaş’ additions are presented in bold text): “General practitioners/family doctors are specialist physicians trained in the principles of the discipline. They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespective of age, sex and illness. They care for individuals in the context of their family, their community, and their culture, always respecting the autonomy of their patients. They recognise they will also have a professional responsibility to their community. In negotiating management plans with their patients they integrate physical, psychological, social, cultural and existential factors, utilising the knowledge and trust engendered by repeated contacts. General practitioners/family physicians exercise their professional role by promoting health, preventing disease and providing cure, care, or palliation and promoting patient empowerment and self-management. This is done either directly or through the services of others according to health needs and the resources available within the community they serve, assisting patients where necessary in accessing these services. They must take the responsibility for developing and maintaining their skills, personal balance, and values as a basis for effective and safe patient care. Like other medical professionals, they must take responsibility for continuously monitoring, maintaining and if necessary improving clinical aspects, services and organisation, patient safety and patient satisfaction of the care they provide.”16Family physicians specialise in clinical medicine and provide primary care services in all kinds of health systems. The family physician has the ability and authority to make and apply a wide range of health decisions within his/her discipline, and can perform this duty anytime and anywhere, and is autonomous in regard to supervision. Family physicians are the physicians of all people and all health-care professionals, who they collaborate with when referring patients.
There is a global need for the updating of family medicine, the development of clear standards, and the application of these standards. This newest and latest definition of family medicine can represent a guide for such an endeavour.
The Göktaş definition of family medicine/general practice protects the family physician and increases his/her spiritual power and personal agenda. With this power secured, the family physician can work with increased self-confidence. In particular, this definition encourages all partners associated with family physicians and family medicine to respect family physicians. This will lead to the pursuit of standardisation in family medicine around the world. By applying universal standards, family physicians will be able to focus on their patients, and will be able to provide more motivated service in their role, a role that represents the most important aspect of the most critical element of health systems.
Author's contributionOG, conceived, designed and did writing and editing of manuscript, did review and final approval of manuscript.
Ethical considerationsThis manuscript has not been submitted to, nor is under review at, another journal or other publishing venue. The article complies with the Helsinki Declaration.
FundingThis manuscript received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interestThe author declare that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
I would like to thank Editage (www.editage.com) for English language editing.
