Key words: challenges, life-learning environment, business environment, patient care environment, the heart of general practice

While the health of communities worldwide will always require a substantial injection of government or public money it is imperative that primary care seeks to be self sustainable in the interests of viable national healthcare systems.

Keeping healthcare at a healthy 70-30 mix of primary care and specialist care is the first step to a sustainable national approach. Patients in the United States for example, where health care costs are greatly increased per head of population, are twice as likely as patients in Britain to see a specialist during any 12 months. This large difference is partly because patients refer themselves more often in the United States, even when they must pay for the full costs of care. In the United Kingdom, access to specialists has generally not been possible without a general practitioner's authorisation. (1)

It would seem to the writer that a free market system, where the family doctor practice is run as a small business would be the optimum way to go - given that the 'average family doctor' is usually in an isolated practice in a community setting and reasonably independent. This way the patient becomes the 'customer' and the more practiced, highly skilled and knowledgeable the doctor is, the better the patient care given and the more patients will return and recommend the services of the practice to others.

This also gives the family doctor both the incentive and the requirement to keep his/her skills and knowledge up to date and it is thus a self perpetuating system and one that at least goes a good way toward sustainability. The system should be outcome based for maximum benefit. That is, where required, practice should change where continuing education, or policy indicates.

Regionally, nationally and locally, costs will still be incurred outside of this system, (study, research, technology, therapeutics, development) but again great savings would be made if these costs were shared around the world and the knowledge shared in return.

In the case of developing nations sometimes the very basics need to be shared. We have been involved in several recent initiatives to do just this. A project with the International Atomic Energy Agency of the United Nations, designed to overcome a world shortage of oncologists and involving years of research into both technical and content issues, has recently been validated as global curriculum and will be used to train 900 oncologists every five years - with an emphasis on upskilling doctors in developing nations.

Our own World CME project has been extended free of charge to World Bank designated low income nations and is being used as a national accreditation and QA&CPD program where none previously existed While a small degree of customization has been required the online self administering system 'bridges the gap' as far as access to high quality resources is concerned.

The life-learning environment therefore requires access to formal targeted, and self-elected education and those programs that contribute to outcome-based learning are optimum. Education at decision-making time has been argued as the best method (2), but these programs leave little room for error, whereas considered 'behaviour change' as a 'reflection activity ' after an educational program is of a permanent nature. 'Referral to information' to make a diagnosis has to be a lesser approach than 'learning the requirements' and making 'positive changes' The former does not imply new knowledge - it implies 'lack of knowledge'.

CME-CPD should also increasingly be international medical education with increased tourism, migration and transitory workforces, medical education should no longer stop at national borders.

The business environment for the family doctor in his/her own practice requires basic administration, financial management and people handling skills, though in an optimum environment additional health professionals or support staff can be brought into the business to share the burden of care, and into specialised and appropriate positions. This should also increase the financial return of the practice.

The patient care environment is the most challenging and the most important. These days the family doctor is responsible for the patient's health, within the context of the family and the community. Preventive medicine, counseling and breaking bad news, public health, and public information are increasingly the domain of the family physician.

The family doctor best way to provide the breadth of universal care and family doctors often give their services free to support the poorer members of their communities or arrange community support services for them.

Family doctors usually have their own families and familial and societal obligations and it is always a struggle to balance the needs of all, with the primary care doctor often the one who is overstretched in trying to meet all obligations.

Governments and public bodies should support these valuable community resource people in terms of financial and respite support, public recognition, and legislation to lessen the burden where possible.

What is best practice on a regional and global basis? Best practice encompasses more than optimum patient care - it needs to be defined within many contexts. Contexts include content issues - level of language (ESL) ethnic or geographical contexts, availability of services (customization and localization) and respect for all cultures, religions and sexes. It also extends to delivery methods of care.

Best practices is an interesting area. While we address the situation of the rural and remote practitioner in our own programs, by spelling out best practice for those with access to high end facilities but providing where possible, alternatives for the rural and remote practitioner. This may often entail going back to the original 'arts of general practice' - physical examination and careful history taking.

Best practice on an international level however takes on a very different dimension. Factors such as extreme poverty and deprivation, poor geographical access, lack of public health and sanitation services, war, pestilence, drought, natural disasters and hazards of occupations, all contribute to complex 'cause and effect' scenarios so that the economic status of a country has a direct relationship on the health of its people via negative factors relating to lack of public health services.

While we can attempt to meet these challenges and provide pragmatic local alternatives, the dream of being able to provide universal internationalised medical education and information will require a more peaceful, equitable and compassionate world society to overcome the grosser inequities.

We all have a vested interest in the health of all people even at the most selfish level. Polluted air, the greenhouse effect, drought, lack of water, and disease outbreaks, be they human or domestic animal, affect us all, as SARS and Avian flu outbreaks have shown us.

This century provides a new set of problems, and problems of a more residual nature. Social unrest, climate change, less availability of clean water, polluted air in the main population centres, and increased levels of stress and depression are becoming mainstream health issues even in high income nations. Perhaps if we can look at them as challenges, and itemise and quantify the problems and set up programs to overcome them, then the problems are already half solved.

Positive advancement of societies can be assisted through asking our family doctors , to take a leading role in the health and welfare and living conditions of the society they live and practice in, and through this practice, teach tolerance and respect of all people. Nearly every community has a family doctor, albeit one who is often under educated and under resourced.

General practice is therefore a very big picture profession, as it deals with humanity everyday. A family doctor in Ottawa probably has more in common with a family doctor in Lagos than members of his/her own community as both deal with the vagaries of humanity every day.

Family doctors may feel they are isolated and ineffective, but they deal with the big pictures in the global health arena every day - be they observation, immunisation, care of the psychological and health of the community or the practical aspects of health, such as the call for access to clean water and air.

General practice/primary care/family medicine is probably the most demanding of all medical professions due to breadth of knowledge required, through being the first contact point with patients and their ailments, through breaking bad news to the terminally ill and the chronically ill, and have to feel helpless when patients cannot afford remedies; and when they see the depressed, the downtrodden and the abused to whom no practical help can be given. Family doctors must be mentors, teachers, friends, and confidantes.

But also what an opportunity they have to heal, to advise, to achieve, to befriend, to build up lasting relationships with generations of people, to deliver babies and watch them grow into fine citizens, and what an opportunity to make a meaningful difference at the grass roots level of society.

Therefore urge our governments and NGOs and those to support these gems within our midst and encourage them to continue to shoulder the burden of care.

The 'heart of general practice' is therefore equally if not more vital to the ongoing health of our communities and we need to give these gems within our midst, as much support as possible, on all levels.