MEDICAL UNIVERSITY PLEVEN, BULGARIA FACULTY OF “PUBLIC HEALTH”

1. 10 YEARS GENERAL MEDICINE MEDICAL UNIVERSITY PLEVEN, BULGARIA FACULTY OF “PUBLIC HEALTH”

2. Realizing Primary Health Care The symbol of General Practitioners /Family Doctors in Bulgaria Rev. “General medicine” , Sofia,1999, tom I, Nr 1, page 2. Themission... QUALITY OF LIFE and GENERAL/FAMILY MEDICINE M. Goranov, MD, PhD, Chairman of BATGP “AN IDEA WHOSE TIME HAS COME!“

3. Back to the future! GP’s FOR QUALITY OF LIFE ! “The profound changes now occurring in medicine can only be fully understood if they are viewed from the perspective of history. There is nothing new about change: medicine has been changing constantly since its beginnings. …Only the pace is different.” (Ian McWhinney, “A Textbook of Family Medicine”, New York-Oxford, 1997). European Health Care Reform

4. mission… /lat.“missio”= action, burden, load/ • WARRANTY. WARRANT OF ATTORNEY FOR SOMEONE TO REALIZE SOMETHING. • CONSECUTION OF INSTRUCTIONS FOR LOYAL, DEVOTED AND TRUSTWORTHY OR PRESCRIPTIONS FOR CONVERSION OF SINNERS. • LEGATION. • MISSIONARY’S RULES. (”Petit Larousse”, Paris, 1966)

5. THE MISSION… of medicineGeneral/Family medicine today THE MISSION OF HUMAN MEDICINE TODAY: • TO IMPROVE THE QUALITY OF ACTIVE LONGEVITY; • TO BUILD UP and firmly consolidate strengthening HEALTHY LIFE STYLE, to preserve and to reestablish it; • TO INVESTIGATE AND MASTER ILLNESS and DISEASE; • TO PROTECT,TOCARE and TO CURE PEOPLE. THE MISSION OF GENERAL/FAMILY MEDICINE TODAY: • BASED ON “HOLISTIC” APPROACH /bio-psycho-social/… and • working in a team with other medical and non-medical services, • to competently offer MULTIDISCIPLINARY HEALTH CARE to • persons, families and communities, • SOLVINGNOT ONLY MEDICAL but HEALTH PROBLEMS too !

6. THE MISSION…GENERAL or FAMILY MEDICINE… That was what madefamily practice unique among others clinical disciplines, this is an idea of “THE FAMILY AS ONE PATIENT” Epistemological, family medicine is the name of body of special knowledgeandparticular approaches that includes the family, but much else besides… Since the moment in which other clinical disciplines, captivated by laboratories, high technologies and analytical methods, deserted permanent, closely integratedand daily exhaustive health problems of the individual, of the family and of the community, ONLY FAMILY MEDICINE IS THE ACADEMIC DISCIPLINE, which is in its rights to closelyaccompany and particularly attend upon them. ...And to resolve them in its properHOLISTIC APPROACH.

7. THE MISSION…PHC – General/Family medicine… • APPROPRIATEDTOOUT-HOSPITALHEALTH NEEDS,INCREASING LIFE EXPECTANCYAND QUALITY OF LIFE, GENERAL MEDICINE OF TODAY REPREZENTS A SEPARATECLINICAL DISCIPLINE, EQUAL TO OTHER HOSPITAL DISCIPLINES. • AS A NEW SCIENCE, THIS DISCIPLINE EXPLORES A NON-TRADITIONAL SPECIFIC SETTINGS OF : - NEWKNOWLEDGE, - NEWSKILLS and -NEWATTITUDES. • FAMILY MEDICINEISA BRANCH,AHIGHER EVOLUTIVE LEVEL, BASED ON THE BEST OF GENERAL MEDICINE. DO WE REIGN OVER THIS OLD NEW SCIENCE ?

8. THE MISSION…General/Family medicine - Specifics… AS A MULTIDISCIPLINARY AND POLIVALENT CLINICALSPECIALITY OF PRIMARY HEALTH CARE, I. E.A SPECIALITYOF OUT-HOSPITAL HEALTH CARE, ANDSOLVINGSOME SOMATIC AND PSYCHOLOGICALMEDICAL PROBLEMS, GENERAL/FAMILY MEDICINE SHARES ITS TERITORY WITH OTHER CLINICAL DISCIPLINES, WITH OTHER HOSPITALSPECIALITIES. BUT ! IN PHC,GENERAL/FAMILY MEDICINE USES HOSPITALAND YET CUMULATIVEKNOWLEDGE AND SKILLS IN APPROPRIATE, UNIQUE AND UNREPEATABLE MANNER, REFINING… ENRICHING… HUMANIZING THEMWITH NEW APPROACHES.

9. THE MISSION…GM/FM –Holistic approach… WHYappropriate? WHYunique? WHY unrepeatable? WHY ?... WHY ?... WHY ?...

10. THE MISSION…GM/FM - Primary Health Care… …BECAUSE there ARE DIFFERENT : • Patient’s health needs and expectations in out-hospital medicine; • Political, economical and social order for Primary Health Care; • Manners of doctor-patient communication - hospital and out-hospital; • Delimitation of some terms as: “disease”, “illness”, “anticipatory care”; • Contrivances for definition of: “health status” or“un-organized illness”; • Meanings of, and approaches to: “symptom”, “health problem”, “diagnosis”; • Patient’s unrestricted choice - of doctor, treatment, behavior or dependence; • Patient’s autonomyas personality - as a social and not onlybiological entity; • Practical use of relationships - problems and pitfalls; bereavement counseling. HEALTH PROMOTION AND DISEASE PREVENTION,REGARDED AS PART OF A CONTINUUM, HAVE THE COLLECTIVE AIMS OF WHICH ARE:1. TO IMPROVE QUALITY OF LIFE. 2. TO REDUCE BURDEN OFPREMATURE DISABILITY. 3. TO INCREASELIFE EXPECTANCY.

11. THE MISSION…GENERAL/FAMILY DOCTOR-DEFINITION : The general practitioner or family physician is a licensed specialist who is primarily responsible for providingpersonal, continuing and comprehensive carefor everyone seeking health care:for the individual in thecontextof family and for the family in thecontext of the community - irrespective of race, religion, cultureor social class; irrespective of age, sex and/or diagnosis. He is a synthesis of these functions,which is uniquely…He is clinically competent to provide the greater part of care after taking into account cultural, socioeconomic and psychological background…He deserves his patienthome, in office, sometimes in hospital… ether directly, either through the services of others… His first aim is to make early diagnosis. He includes and integratesin his workphysical /biological/, psychological /mental/and social factorsin his consideration about health and illness. He makes the initial decision about every health problem /differentiated or not/. The General Practice is a continuing fluent manifestation of classical practice in medicine, deeply rooted in the history of humanity and actually irrevocably linked with the family. /Definition of American Academy of Family Doctors/

12. THE MISSION…GP/FD and Health care - ALGORITHM: KEY POZITIONS: Gate-kipper - to specialist and/or hospital; Bridge-builder - with other medical services; Team-worker and major coordinator in PHC. КEY FUNCTIONS: First clinical decision making /problem solving/; Engaged with patient’s problems to the end; Realizing health promotion, prevention, education. КEY SKILLS AND ATTITUDES: Personality-oriented /bio-psycho-social approach/; Family-focused /solving all problems in context/; Community-relevant /beyond individual problems/. КEY ABILITIES: Care-manager /for allocation of scarce resources/; Fund-holder /……………………………../; Advocacy role/working with other authorities/. What is needed in PHC isknowledgeof initial and characteristic symptomsofsuffering or/and illness, so thatGP’sare able to estimate thehealth status, the gravity of situation or disease,the alarm signalsof the latent distress,even in caseswhere no diagnosis can be made…

13. THE MISSION...GM/FM – New knowledge and skills for… WHY ? WHICH? IN ORDERTO REALLYIMPRUVE QUALITY OF LIFE, GP/FDsNEED WIDE GENERAL CULTURE AND ALSO SPECIFIC UNDERSTANDING IN: • Cultural anthropology/ethnos,traditions, religions,education…/; • Sociology/occupation, home, environment, customs, hobbies…/; • Psychology /insight, empathy, spiritual influence, emanation…/; • Behavioral sciences/motivations, reactions, causality of illnesses…/; • Family dynamics /aspect, function, phase, cycle, assessment of family…/; • Interpersonal skills/compassion, charisma, communication…/; • Еthics, aesthetics...value system…etc. Patients and doctorsareactors in a play written by history, directed by culture, produced by politics. /Per Fugelli, 1995/

14. МИСИЯТА...GM/FM – The “winds of change”… “The man who translates the hieroglyphics of the science into the plain language of healing, certainly is the most useful.”Sir William Osler

15. Educating the general medical practitioner of the 21st century: • Education for Competence; • Education for Confidence; • Education for Co-operation. (The European Society of General Practice/Family Medicine – RCGP) …because: “WE CAN SEE ONLY WHAT WE KNOW AND FOR WHAT WE HAVE BEEN TRAINED AND EQUIPED”

16. THE MISSION...GPs/FDs – for QoL… “There is no man in the world who knows all about medicine. We have to learn to discover that our patients, their illnesses and its meaningsare much more than biological, pathological and pharmaceutical facts. We have to learn how to understand the patient as a part and in unity of his/her family against his social background… To analyze the ways in whichthesetwo factorsinfluence his/her Quality of Life. Only then we will be able to use in full value our medical knowledge and skills…” Carl Whitehouse, 1998 Emeritus Professor, Doctor Honoris Causa of MU-Pleven.

17. THE MISSION...GM/FM – The confidentiality… The confidence of the physician “If you do not believe in Yourself, how can you expect other people to do so? “If you have not an abiding faith in the profession, you cannot be happy in it. “Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become an expert.“ Sir William Osler “It is much more importantto knowwhat sort of patient has a disease than what sort of diseasea patient has.” Sir William Osler

18. THE MISSION...GM/FM – Autonomy and/or paternalism… for QoL IN PHC, SUCCESSFUL MANAGEMENT OF HEALTH PROBLEMS REQUIRES a negotiated plan, achieving a doctor-patient consensus in which the patient has ownership and understanding. Negotiation usually involves pragmatic compromise OVER A THEORETICALACADEMIC, CLINICAL IDEALS AND DOGMAS IN FAVOUR OF WHAT IS POSSIBLE, REAL, FEASIBLE AND USEFUL in the patient’s social, family and personal context /emotional – psychological – intellectual - volitional/. • AMONG GENERIC ISSUES OFETHICAL DILEMMAS • POSED BYAN AGING SOCIETY AND FACED BY PROFESSIONALS,ARE: • RESPECT/autonomy, self-determination, informed consent,paternalism?/; • BENEFICENCE/assessing risk and benefits/; • AND JUSTICE/just ways to distribute burdens and benefits/, • TAKING INTO CONSIDERATION: • THE USE OF CHRONOLOGICAL AGE AS A CRITERION IN THE ALLOCATION OF SCARCE RESOURCES; • THE ROLES OF FAMILIES, PATIENTS, AND MEDICAL PERSONENELS IN DECISIONS TO LIFE-TREATEMENT; • LIMITS ON PATIENT/CLIENT AUTONOMY IN DECISION MAKING; • RELATIONSHIPS AMONG HEALTH-CARE PERSONNEL AND SOCIAL SERVICE PROVIDERS; • THE USE OF OLDER SUBJECTS IN BIOMEDICAL, BEHAVIOURAL, AND SOCIAL RESEARCH./University of Vermont/

19. THE MISSION...GM/FM - Negotiating with the patient… NEGOTIATION IN GENERAL PRACTICE IS A COMPROMISE BUT THE OTHER NAME OF THIS COMPROMISE IS“FINDING” : • FINDING THE DECISION APPROPRIATED TO THE PATIENT – IN HIS/HER SOCIAL, FAMILY AND PERSONAL CONTEXT; • FINDING THE SPECIFIC AND SHARED STRATEGY OF ACTION, AND NOT NECESSARILY HOSPITAL, BIO-MEDICAL STEREOTYPS; • FINDING THE “PROBLEM - ORIENTED” CONSULTATION, AND NOT ONLY PRACTICING “DIAGNOSTIC-ORIENTED” MEDICINE ! • FINDING THE “PATIENT - CENTERED” MEDICINE AND NOT ONLY “DOCTOR - CENTERED“ … ! AND AT LAST ... • FINDING…THE MEDICINE OF TRUE THINGS

20. THE MISSION…GM/FM... “medicine of true things”… The Doctor (1891) By Sir Luke Fildes 1843-1927 The GP/FD must be an advocate of the human right to beimperfect

21. THE MISSION...GM/FM – Cultural and spiritual aspects… Practicing doctorsmust be ableto think about and freely to discuss not only clinical… but also cultural aspects…as well as those questions which are related to religion and religious,ethical and moral implications in health care(e.g.food of Muslims or Jews, blood transfusion and Jehovah’ followers, etc.) because: SUFFERING KNOWS NO FRONTIER… PEOPLE SUFFER INDIVISIBLE WITH THEIR WHOLE SELVES: PHYSICAL, MENTAL and SPIRITUAL. ONE OF THE MOST COMMON ERRORS WE MAKE AS PHYSICIANS IS TO TREAT PAIN BUT IGNORE OTHER DIMENSIONS OF SUFFERING: PHYSICAL ILLNESS IS ASSOCIATED WITH SPIRITUALSUFFERING;SPIRITUAL SUFFERING MAY BE MANIFESTED AS PHYSICAL OR MENTAL ILLNESS… General medicine is a меdicine of the whole person. This means that as physicians, we mustattend not only on their physical complaints or on their somatic problems, but sensitively include an awareness of their cultural and spiritual convictionsand – without imposing them on people whether pious or not – to affirm sensible religious values. PRIME(Partnership in International Medical Education)is an organization, where in conformity with the Burrswood culture of healing, physicians and of Jesus ministry focused on spiritual awareness in secular professional environments, exploring the interface between mind and spirit in patient-centered holistic approach, realizing the real whole-personmedicine.www.prime-international.org.uk The greatest sin to our human brothers is not hating them but being indifferent to them. This is the real substance of inhumanity. /Bernard Shaw/

22. THE MISSION...GM/FM – Evidence based medicine in PHC… “Unitas, Libertas, Caritas” (Uytenbogaert, anti-dogmatic theologian, ХVІІ-th century) According to Gallileo the aim of science is not opening a door to infinite wisdom but putting limits on infinite error. Unitas...where certainty is attained by numerical data; Libertas...where doubt prevails and figures cannot decide; Caritas...means respect and appreciation in patient care… … and because: “The overestimation of what medical science is capable of, has created a dangerous myth which, as our experience reveals, isunder ataboo”. (R. A. deMelker, University of Utrecht, 1998) “Some of what doctors do - collectively and individually - has no rational basis”.(An introduction to medical audit in GP, University of Liverpool, 1996) “The revolution in medical science is still not realized but obligatory crisis preceding it, is fully established.”(Dr G. Achterberg, ”Schweizerische Arztezeitung”, 1998) “The application of scientifically based guidelines is no medicine of the cookery book kind, with ready-made answers for practice, but requiresintegration of scientific knowledge with clinical experience”/R. A. Melker/

23. THE MISSION...GP/FD - The art of talking with the people… Pasteur Vesalius Mendel “Our modern doctrine is a contrivance of the word-catchers; the art of talking ratherthan the art of healing!” (Thomas Sydenham, THE WORKS, vol. I)

24. МИСИЯТА...GENERAL PRACTICE - Position in medicine… The SPECIAL AND UNIQUE POSITIONOF GENERAL PRACTICE “BETWEEN THE IVORY TOWER OF GREAT MEDICINE AND DAILY LIFE NEEDS AND DIFFICULTIES OF GRASS-ROOTS” is: • WITH A RELATIVELY INTELLIGIBLE PHILOSOPHY; • WITH A NEW STRATEGY OF CONSULTATION; • WITH A NEW SCIENTIFIC MODEL OF THE DOCTOR’S ROLE; • WITH A NEW PARADIGM OF HEALTH CARE; • WITH A MISSION REALLY HUMANE AND INTELLIGENT, WHICH HAS NEVER TOUCHED TRADITIONAL MEDICAL EDUCATION YET; • WITH A GREAT “DECLARATION OF INDEPENDENCE”, CLAIMING FOR GPs: POLITICO - ECONOMICAL INDEPENDENCE : that means a liberal profession, a conditio sine qua non for personal doctoring; MEDICO - SCIENTIFIC INDEPENDENCE ; that means a cool distance to the biomedical establishment, necessary to refine The Real Thing, which is not Coca-Cola, buta GENERAL PRACTICE AS A SPECIALTY WITH ITS OWN SPECIFIC WEIGHT, ITS OWN CORE CONTENT, ITS OWN PECULIAR SKILLS, ITS OWN PROUD IDENTITY. R.A.deMelker “Who are we, where are we from and where are we going ?"

25. IF… YOU WANT TO BE A G P (After Rudyard Kipling) HELPING EACH PATIENTREACH THE HIGHEST QUALITY OF LIFEAND HEALTH ! • IF A FELLOW - COUNTRYMAN • WOULD CURE AND CARE FOR MEN, YET • NEVER FORGET: "THE SICK ONE IS A PERSONALITY“; • IF THE FIRST APPEAL FOR HELP SCATTERED AS A PUZZLE • IN CONFIDENCE, TRUST AND HOPE - • WITH DEVOTION IS ADDRESSED TO ONE'S OWN DOCTOR; • IF THIS DOCTOR IS ABLE TO UNDERSTAND • THE PAIN OF BODY AND SOUL, • AND FIRST WILL GRASP THE PROBLEM, HERE AND NOW; • IF HE SHOULD DECIDE WHY AND HOW, SOMETIMES • THE SUFFERER WITH ANOTHER KIN-SOUL TO SHELTER - • YET NEVER LEAVING HIM WHILE HE IS ALIVE… • IF BY THE SAME ZEAL, WITH THE SAME SKILLS, • AT THE SAME WARM BREATH - • MOTHER, FATHER AND THE WHOLE TRIBE WILL COMFORT; • IF- BY CHANGINGTHEIR TINYWORLD- • GENTLY WILL PUT GUILT AND FEAR ASIDE ; • IF HE ALWAYS KEEPS CALM AND CONCERNED , • AND TURNS UP - THROUGH STORM OR IN THE HEAT, • AWAKE OR ASLEEP - AT HOME… IN THE OFFICE… • IF THIS DOCTOR CAN APPEAR • TO BE NOT ONLY ALMIGHTY BUT • A BOSOM FRIEND TODAY, A PROPHET TOMORROW; • IF HE SHOULD SPARE YOUR WOE • AND SAVE YOUR COUNTRY'S RICHES • WITHOUT NEGLECTING HIS MATRIX , • HIS OWN SPIRITUAL ESSENCE, • THEN THIS DOCTOR, MY SON, • IS MY CHERISHED, MY BULGARIAN GP . By MITKO GORANOV, BULGARIA Published in”THE KIPLING JOURNAL”, June 2004, p. 50, LONDON, UK

26. 10 YEARS GENERAL MEDICINE MEDICAL UNIVERSITY PLEVEN, BULGARIA FACULTY OF “PUBLIC HEALTH”