Family Medicine as Culture Change
I had the privilege of being part of the International Conference of Family Medicine in Palestine as a Keynote speaker. In true Palestinian style it was a huge success, but the process was a nail-biting, seat grabbing ride. In other words a lesson of nudging and letting go, identifying what you could control and what I could not, understanding my role to support and trust. What a ride!!!
The conference was announced on Facebook, so I didn't know the word had gone out. I helped with the scientific committee, guiding the criteria for abstract choice and the decision of presentation, workshop vs. poster. Since I was uncertain about hotel arrangements at the conference I booked a stay at the Walled Off. As an aside, if you ever go to Bethlehem (West Bank/Palestine that is--there are a number of Bethlehems in the US. Think Bethlehem Steel) be sure and check out UK graffiti artist Banksy's effort to support the Palestinian cause and explain that perspective. Also take the tour of the nearby refugee camp with the Key made from melted keys of residences left in 1948. The experience pokes humor at the very complicated and very difficult conflict.
I was tasked with presenting a conference keynote and considered with great care what I could say that would honor all that I had experienced and seen for 2 months as well as build on the wisdom of primary care and family medicine giants from the UK and Europe. I wanted to acknowledge the hard work happening in Palestine which is decades behind seventy years of Family Medicine in the UK and fifty years in the US, and the hard work to come. So since you probably weren't there, here is a quick tour.
"This is my 4th or 5th time in Palestine depending on how you count. I am reminded that this is a hard place to live. It has been called an open prison, apartheid. People living in places like this have many challenges and run the risk of becoming victims. They risk making choices that close doors and opportunities further, above and beyond what the occupation does. Living here requires flexibility and an abundance of patience. Despite these challenges Family Medicine was born. It is now 11 years old.
"As we have heard, FM has been a struggle in other countries as well. The founders needed to start a revolution and have a vision. It was not popular in the UK or the US. It is culture change. Changing culture is difficult. It is a different way of thinking about health, not just the biomedical. It represents a different way of working with patients and with health care teams.
"We can’t know it all and what we know changes, so keeping up to date with the scientific evidence is imperative. We focus on the patient and what the patient needs. Doctors cannot do it alone, so nurses and receptionists must work with them as well as pharmacists, therapists, etc.The culture change leads to better quality, better use of health care dollars, happier patients, happier doctors and healthier communities.
"While I have been here. I am reminded that Palestine has rich traditions. October is the olive harvest. People know how to work, how to reap the benefits. People celebrated their hard work with the new olive oil which is slightly bitter. And of course there is always coffee.
"This is Dr. Y at the training center with Trainer Dr. X and a village elder. Dr. Y’s research project was on smoking prevalence in Palestine. Rates of smoking are high and rates are even higher among doctors. Few have been trained how to help patients stop smoking, but some do anyway and believe it is important. This was not what she expected to find. I watched her work hard to understand the results, talk with other faculty, talk to me, and try to make sense of her data. She hopes to attend a workshop on how to help patients quit smoking and she plans to come back and train physicians in Palestine how to help patients quit. [If she can secure a visa--no guarantees here.]
"This is another training center where the residents and staff are preparing for a Breast Cancer awareness event. Dr. # was one of the physicians who had the courage to say, I don’t know how to do something. 'Help me do a quick neuro assessment of a patient.' We talked about this at Sunday lecture, practiced on each other. Dr. # practiced on me in the training clinic when we were waiting for patients and then I watched her do an exam on a patient with a headache. The next Sunday she taught the class how to do a quick neuro exam on children, and the next Monday I watched her entertain a child by doing an exam when another doctor was interviewing the child's mother. In family medicine we ask for help. I know that has not been okay here--Palestinian doctors need to know it all and aren't supposed to ask for help, but we help each other in family medicine. In FM you cannot know it all. We must work together. This is culture change.
"We learned about the case-based discussion approach that helps us to think about other aspects of patient cases that are important in FM. Not only the proper diagnoses and management, but also how the system works or doesn’t in order to get the results you order or make sure the patient gets the test done. What the important preventive issues are for a patient? What the ethical and legal aspects of a case might involve? In Family Medicine we think about the whole person and his/her community. This is culture change.
The format for Case Based Discussions used in the UK. Take a case and focus on different aspects above and beyond the medical management, and what if the gender was different, the age, etc.
"Conferences are an opportunity to learn and refresh yourself. In the US we talk about drinking at the well—this is Jacob’s well in Nablus.
ASIDE: [Reportedly, this is where Jesus asked a Samaritan woman for a drink and offered her “living water.” It lies in the crypt of a modern Greek Orthodox church. Since it is hard to move a well, it is one of the most authentic spots in the Hold Land.]
"In order to change and grow, I encourage you to identify one or two ideas or concepts that you want to take away from the conference, that you want to integrate into how you care for patients. This is how to become a better doctor, a better person. Write that idea down or type it in your phone.
"And then nurture that idea. This is a Bedouin shepherd who is carrying a newly born baby goat in his donkey’s saddle bag. If they don’t the baby is stampeded by the large herd. Nurture your new idea like the shepherd does this baby goat. Figure out how to make it part of you practice. How to change the way you think about an issue or topic. And finally, Shukran, thank you for the opportunity to work alongside faculty and residents in the Family Medicine program. Thanks for the opportunity to speak at this conference, for MAP and the Foundation of FM in Palestine and their commitment to helping family medicine doctors change medical culture in Palestine."
And thank you dear readers . . . Wishing you light in this season of darkness.