The 7 Habits of Great Family Doctors.

The values and principles of family medicine constitute the foundation of our discipline. Societal trends are always reflected in health systems, and first of all in primary care. Change is a continous process. To maintain and develop the foundation of family medicine, it is necessary to reflect continously on the values and principles of our profession. That enables us to adapt to change without losing sight of our values and working method.

This survey gives an idea of how family doctors globally work to maintain and develop their professional identity. The form of «advices» and description of «habits», make the outcome of the survey accessible and useful for primary care professionals at all steps in their  professional career.

The format lives up to an old wise saying: «Man needs more to be reminded, than instructed».

Thank you to Florian for his «Golden Nuggets» and for carrying out this survey.

My commentary consists of two parts: the specific habits and themes that were identified and the potential scientific impact of the survey. I aimed to write my commentary in the style of a review for a research paper.

The 7 habits described seem reasonable. The advice with the most responses (127) was to invite the patient to share their history without interruption. Mere listening is not enough. Active listening requires sitting in an open position, making eye contact, and resisting distractions like screens. I agree that relationships can be a superpower for family doctors by helping build trust and improve patient and professional satisfaction. Yet, most patients are seen only a few times by any one doctor. We need more skill in optimizing therapeutic relationships at every visit with every patient. Several of the habits focus on ways to arrive at a correct diagnosis. Yet, only about 1 in 4 consultations involve a new problem. The bigger challenge today is to develop skills in helping people make necessary lifestyle changes and manage chronic conditions. Continuous learning is a key habit for any professional. I was surprised that none of the respondents apparently advised learning critical appraisal skills (e.g., POEMs vs DOES) or anticipated the changing learning environment with the advent of artificial intelligence (AI).

The 4 themes are difficult to challenge, although I would suggest an opening phrase other than,
“What’s your biggest concern today?” This suggests that every visit involves a concern or problem. So many visits today may have been requested by the doctor for preventive services or administrative purposes that the patient may not feel that they have a concern or problem. Better is something more general such as “What would you like to discuss today?” or “How may I help today?”

The article appropriately notes the challenges of putting these bits of advice into practice. I believe that the strategies and tools of Human Factors Science will become more widely known and used, as they appear to offer the best approach to meaningful and sustained change. The quality movement has also provided examples of approaches to quality improvement that have been helpful in primary care, such as quality circles, practice tutors, audit, case reviews by the care team, and so on.

Like most research studies, it raises more questions than it answers. What advice would patients or physician staff give to their family doctors? What attributes or behaviors do health system leaders seek in family doctors? Finally, even the most frequent advice given (“listen to the patient”) was cited by only 1 out of 4 respondents (127 out of 468). How did the other 3 out of 4 respondents feel about that piece of advice, or any other advice for that matter? These additional questions can be answered through an expanded study design that combines qualitative and quantitative data using mixed methods (focus groups, individual interviews, semi-structured surveys for patients, physicians, staff and leaders, etc.).

It makes an interesting read to see how an international group of family physicians view their discipline – and experience the competences required to perform their professionalism.

Reassuring is that family physicians from different countries, working under different health systems and facing different socio-economic and cultural conditions share such a broad common ground. It emphasizes that family medicine, primary care, is an international discipline, bound by common core values in caring for patients and communities.

That, in my view, is a positive side that can not treasured enough: too often academics, policymakers and educators assume that family physicians, primary care, present just a local addition to an otherwise ‘universal’ healthcare. The opposite is true: we share values and competencies over national borders, irrespective of the rules and regulations of the health systems imposed upon us. This is the unfathomed power of family medicine, a power to rely on in international collaboration to improve the health of populations.

But the paper deserves some critical reflection as well. First, it is in the presentation of number of respondents who supported key components of our discipline. The danger is that this may lead to a quantitative valuing, in which the items drawing the largest support are seen as the most important. As I see it, all are important, and their importance is in applying them in coherence, connected to the needs of patients and populations. This need of applying interconnected measures underscores the complexity of family medicine, in caring for all patients, with unselected health problems. Again something that can not be stressed this strong enough or we would give way to the view that primary care is just a ‘simple’ field of practice.

And related to this: we tend to describe our work in broad terms using big words – like empathy or intuition – without problematize what is behind it. Empathy is an important value in connecting to patients and communities. But under what conditions will it be beneficial? Intuition is important but how does it work? Unless we are able to dig into their true meaning big words may remain empty boxes – to the detriment of the most important discipline in the health system.