Received date: October 24, 2016, Accepted date: November 09, 2016, Published date: November 16, 2016
Citation: Turabian JL (2016) Commentary on the Book “The Family Doctors: Images and Metaphors of the Family Doctor to Learn Family Medicine”. J Gen Pract (Los Angel) 4:273. doi: 10.4172/2329-9126.1000273
Copyright: © 2016 Turabian JL. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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The conceptual elements and skills that promote the mastery of family medicine, such as contextual knowledge, continuity of care, the clinical interview, comprehensiveness, coordination, and so on, are often difficult to explain and to understand. Medicine is often learned through a mechanistic metaphor of biology and a military metaphor of war. However, these fundamental concepts of family medicine have nothing to do with the metaphor of the machine or the metaphor of war. In this book, “THE FAMILY DOCTORS: Images and Metaphors of the Family Doctor to Learn Family Medicine”, these concepts are explained through metaphors that are more explanatory, nicer, sweeter, and more playful. Thus, among other metaphors, the family doctor is presented as the genie in Aladdin’s lamp, as a drinker of Chinese tea, a classic painter, an explorer on a desert island, as a bass, a plug, a photographer, an historian, a person eating spaghetti or cherries, a cat, a civil engineer, a catalyst, a meteorologist, a detective, a fisherman rather than a hunter, a sculptor, a sea turtle, a golfer, a filter coffee, a diver, a poet, a billiards player, a mother who picks up her baby, and a nuts and bolts mechanism. Thinking based on metaphors and comparisons is a way of making a concept so suggestive, interesting and surprising, that it reaches people more easily. The value of family medicine lies in its distinctiveness from academic medicine. Thus, the family doctor should be encouraged to use a non-conventional form when thinking about the problems that are presented in the consultation, for example, thinking on the basis of metaphors.
The family doctor is the general practitioner who assumes professional responsibility for attention to the whole patient, not selecting according to undifferentiated problems, and who has committed himself to the person independent of age, sex, disease, organs or corporal systems. The clinical specialty of family medicine focuses on the patient. It is based on evidence, centered on the family, and orientated to the problem. Family physicians acquire and maintain a wide range of skills that depend on the needs of the patients and the communities they serve. The scope of their practice is not defined by diagnoses or procedures, but by human needs. Family physicians do not treat diseases; they take care of people. The nodal points in the life cycle of the family, such as birth, severe illness, and end of life, deserve special attention. Family physicians are experts in the management of common problems, recognizing the important diseases, discovering hidden conditions, and managing acute and chronic diseases [1-3].
Family physicians emphasize health promotion and disease prevention. Their knowledge, skills, and attitudes are directed to the practice community, and are based on current scientific knowledge and focused on the continuous improvement in quality. Family practice requires special skills to be able to identify concerns, negotiate plans and help to solve problems. The recognition, integration and prioritization of multiple concerns and the synthesis of solutions are critical clinical competencies.
The wide variety of human needs requires the guidance of clinical processes, shared responsibility, and the management of uncertainty. A focus on the person requires observation skills, communication skills, and understanding. Family medicine is, first and foremost, a specialty of primary care and primary health care is expanding and becoming much more complex in this new era of information systems .
However, family physicians are not a conglomerate of miniature versions of pediatricians, internists and psychiatrists, but are specialists in their own right, with their own borders and specialist content [5,6].
The academic discipline of family medicine is unique and coherent. It has a core of knowledge, skills and attitudes that are common to all clinical specialties, and to other specialties in community medicine, the behavioral sciences and the social sciences. However, family medicine uses them in a unique way, applying them to their own contexts and thus constituting a recognizable unitary and specific, differentiated set of skills. Thus, although the work of the family doctor is enormous - encompassing the areas of pediatrics, internal medicine, and psychiatry, and most of the remaining medical specialties-its methods and working tools are different or overlap with those used by specialists in related fields.
The conceptual elements of family medicine and the skills that promote its mastery are “material” (methods/processes), used as bricks to construct the building of family medicine (context, continuity, interview, comprehensiveness, coordination, etc.).
These conceptual materials have real value: the building may be destroyed but the materials used retain their value, and these are the foundations of family medicine, although they are also applied in other specialist fields in accordance with their own methods . Therefore, it is logical that the concepts and theories that belonging to family medicine are often difficult to explain and to understand [8,9].
But, these concepts can be explained through metaphors . Metaphors enable us to understand something that is unknown in terms of its familiarity. For this reason, they are used frequently in all sciences that adopt common words to name complex realities.
The metaphors are analogue devices, used to illuminate reality. Metaphors can simplify expert knowledge, not by ignoring or reducing the inherent complexity, but by providing a point of entry for its comprehension. They are a means of generating ideas, promoting creativity, and constructing concepts and theories. Thinking based on metaphors and comparisons is a way of transforming a concept into something that is so suggestive, interesting, and surprising, that it reaches people more easily [11-15].
We should choose, for educational purposes, certain words and images that have a metaphorical dimension in the field of family medicine. They have been chosen for their capacity to compare the tasks of the family doctor and to allow us to gain a better understanding of his or her work [16-19].
Medicine is often learned as a mechanistic metaphor (based on the machine) of biology. It is also accompanied by a military metaphor of war. The disease is a war: inflammation is the battle against germs and the battle is lost if the germs win the infection. It is immunity that expires in battle. The disease is described in terms of a battle engaged in the nineteenth century. The bacteria invade and leukocytes strike. These are images of romantic battles, British troops attacking the army of the Caliph, killing three of the British and thousands of dervishes while the British commander observes the great victory through field glasses.
The drugs are understood through the metaphor of “magic bullets”. Medical education can be understood through a military metaphor: hierarchies, ranges, structures (department head, tutors); uniforms (robes, pyjamas); and training to be in the firing line (always working between life and death, the call at three in the morning like a walk through a minefield). The professor who teaches the medical students has been in war and has learnt from the experience.
In family medicine, however, these mechanistic or military metaphors are neither useful nor desirable. They are metaphors that do not correspond to the fundamental conceptual basis of family medicine. Living organisms have properties that are not machines: they grow, regenerate, heal, learn, and organize themselves. An organism is particularly complex and uncertain.
The fundamental concepts of family medicine are better explained through other metaphors, ones that are more explanatory, nicer, sweeter, and more playful . Thus, among other metaphors, the family doctor can be presented as the family doctor as a jazz musician (Figure 1, Table 1) [20-22]. The family doctor as a tourist that opens a folded map. (Figure 2, Table 2) [23,24], the genie in Aladdin’s lamp, as a drinker of Chinese tea, a classic painter, an explorer on a desert island, as a bass, a plug, a photographer, an historian, a person eating spaghetti or cherries, a cat, a civil engineer, a catalyst, a meteorologist, a detective, a fisherman rather than a hunter, a sculptor, a sea turtle, a golfer, a filter coffee, a diver, a poet, a billiards player, Sancho Panza, a mother who picks up her baby, and a nuts and bolts mechanism .
|The improvisation of a jazz musician in one piece, within an overall musical structure, gives the sense of collective creation and interdependent responsibility.|
|The trumpeter in a jazz band is one of the musicians and he is not external to them. He does not perform from the front, but as one member of the set. He provides a great freedom of musical expression to the components of the band and facilitates their individual and collective splendour. He determines the parts of the repertoire and beats time. He is creative, funny. His facilitative leadership channels energies, and he is one more member of the team.|
|The music that the “family doctor plays in each office is a music that sounds like jazz: it has great variability, contexts, patterns, models, actors and relationships with potential interactions”. Everyone is different, and therefore his families, his environments, his expectations, his problems, his desires, are also different.|
|The interview between the doctor and the patient goes beyond the structured protocols, and, in a search for our own style, we must “pass through them” to understand the patient and ourselves. The good jazz musician has his own speech since, through his technical skills he has learned to know and to play his best “notes”. Above all, he is a good musician because he listens to other musicians and has learned to improvise his “musical” answers, focusing on understanding and feeling each musical phrase without a predefined guide.|
Table 1: The family doctor as a jazz musician.
The diagnosis in family medicine involves deploying a map that allows a panoramic vision. A diagnosis in the model of family medicine can be seen as a map. The map uses certain standard schemes as the contours, the symbols of roads, rivers, and bridges. These symbols are similar on all maps but each map is built to a scale. The map is useful but it is necessary to know its scale. Similarly, for the family doctor, a diagnosis of a fractured femur is certainly a fractured femur, but its significance in scale depends on the landscape or context. In the model that focuses only on the disease, the broken femur is a broken femur and nothing else.
In family medicine there is a tendency to think in terms of individual patients in their particular environments rather than abstractions and generalizations. Family physicians have difficulty separating the illness from the person who has it. The ideal is to integrate the particular and the general, to see the universal in the particular (the map and the territory).
To make an accurate diagnosis the family doctor must “deploy” a multisystem model, or an “open map” that integrates the various levels of the patient's condition to allow for the proper selection of the road down which the treatment should go. However this integration is difficult. The analysis, coordination, integration and implementation of this knowledge within a bio-psychosocial intervention are difficult. But this is what characterizes the family doctor, and you have to learn to do it.
Table 2: The family doctor as a tourist that opens a folded map.
Thinking based on metaphors and comparisons is a way of making a concept so suggestive, interesting and surprising, that it reaches people more easily.
The value of family medicine lies in its difference from academic medicine [20,25]. It is a unique discipline that defines itself in terms of relations, especially the relations between the doctor and the patient, and family physicians tend to think in terms of individual patients rather than in abstractions and generalizations. Family medicine is based more on the metaphor of an organism that it is on a metaphor of a mechanistic biology and it is unique as an area of medicine that transcends the duality of body and mind.
Therefore, the family doctor should be encouraged to think about the problems that are presented in the consultation in a nonconventional form, for example, on the basis of metaphors.
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