Family medicine should shape reform, not vice versa.

T he burgeoning of interest in primary care in the United States provides the family medicine community with an opportunity that should not be missed, but one that we are close to wasting. Family medicine is person-focused, not disease-focused; i.e., the rationale for the discipline is based on the health of people and populations, not the one-by-one counting of diseases, their diagnosis and their management. This puts the specialty in conflict with most of academic medicine, its affiliated teaching hospitals and specialty societies, which consider “health” to be the absence of diseases and “ill health” to be the sum of individual diseases. Diseases are professional constructs without inherent meaning. They can be and are artificially created to suit special interests. Diseases do not exist in isolation from other diseases and are, therefore, not independent types of illness but, rather, varied manifestations of ill health. What were once considered “diseases” are merely syndromes: common manifestations of diverse processes set in motion by interacting influences on health. The challenges in medical care today are vastly different and much more complex than they were a half century ago. The great successes of technological medicine in the last half of the 20th century resulted in saving lives and increasing life expectancy. People who otherwise would have died are now vulnerable to a host of other conditions that threaten their well-being. In consequence, most people, particularly as they age, now have multimorbidity: the simultaneous presence of more than one type of illness. Classifications of cause of death and disease have not kept pace with the multifactorial nature of illness causation and the phenomenon of multimorbidity. Categorizations based largely on organ systems make little sense pathophysiologically; they serve primarily to justify the division of medical practitioners into “specialties.” A more theory-driven classification would be more consistent with the etiology and manifestation of various health states, which would aid in the devising of interventions that take variability into account. In clinical practice, making a diagnosis does not necessarily assure appropriate or useful treatment, even though the purpose of making a diagnosis is thought to be to drive more appropriate interventions. Family physicians have differed from other types of physicians in applying different treatments for the same diagnosis. Moreover, different physicians behave very differently when faced with a patient with the same presenting symptoms, presumably due to differences in training and the context in which they work. Neither diagnoses nor their management can be reduced to universal “truths” that will predict health outcomes of people or populations. The World Health Report 2008, Primary Health Care – Now More Than Ever, indicates that this requires a renewed universal emphasis on primary health care – i.e., personfocused care over time, not disease-focused care.