The Role of Family Practice in Different Health Care Systems

Discussion

Considerable progress has been made in the methods for the analysis of the content of family practice.^42-48 Episodes of care are a critical unit of analysis, and it is timely to recognize the importance and feasibility of using episodes of care prospectively in electronic patient records.¹²

A major limitation of international comparative studies on the content of family practice is that no nationally representative data on reasons for encounter, diagnoses and episode of care over time are available. The Dutch, Japanese, and Polish data used in this study reflect the contribution of highly motivated, research-oriented family physicians who were not representative for their respective national family practice conditions; rather, they documented in much clinical detail what the content of family practice could be in these countries under optimal conditions. The US NAMCS data were representative for the national health care system, but they lacked data on episodes of care over time. The increasing use of electronic patient records in US practice networks is a very encouraging development, but has not resulted yet in a database that fulfills the criteria for this comparative study.

It is clear that under very different conditions, substantial proportions of all symptom/complaint reasons for encounter, incidence rates, and encounters per diagnosis are covered with the respective top thirty distributions for the four countries studied. Reasons for encounter as a representation of the patient’s demand for care and the diagnoses as the physician’s interpretation of the need for care follow a common pattern. Given the limitations of the study, they allow us to globally characterize the family physician’s contribution to national health care systems in different countries. The striking resemblance in the distribution of common symptoms and complaints supports the concept of the reason for encounter as a core element of the consultation with a family physician. Similarities between the four databases are much better reflected in the manner that patients formulate and express their demand for care than in the diagnoses assigned by family physicians.

Family practice appears to become what the profession, the patients, and the national conditions permit; it is akin to an antibody reacting to the specific antigens of a nation.^44-51 Given the substantial variations across countries, several of the “resulting antibodies” appear to be remarkably similar, which suggests a coherence derived from the way people become sick and seek care. The substantial differences in incidence and utilization in episodes of care for common diseases usually allowed an interpretation along these lines. In the discussions with the national project leaders, their interpretations and explanations had high face validity, allowing a better understanding of the data as characteristic for the position of family practice in the four countries. For example, the high utilization for hypertension in Japan can be explained by legal limitations to the amount of medication per prescription, while the high utilization for upper respiratory tract infection and prevention in Poland also reflects formal requirements. Also, the important role of psychological problems in Dutch, and to a lesser extent in US family practice, reflects its importance in training programs, in contrast with the near absence of such problems in Japan and Poland.

Gynecology and obstetrics are in the core business of family practice in the Netherlands, but in the US, gynecologists provide a substantial contribution in addition to the role of family physicians. Japanese family physicians play practically no role in this area, while in Poland the role of family physicians is limited to gynecology with only a small contribution to contraception and pregnancy. Although respiratory problems are important for family physicians wherever they work, the high incidence and utilization in Poland can also be explained by the need for sickness certification from the first day of illness.

The Japanese system requires multiple encounters per episode during a short period of time. For example, patients with sinusitis, bronchitis, gastritis, or a self-limiting musculoskeletal problem, are often seen 3 or more times per week. In the Netherlands, the health care system requires a large number of repeat prescriptions or refills by the family physician. A trained medical secretary practically always deals with this, and these encounters are considered as “indirect encounters.” The utilization per episode of care in Poland and the Netherlands is rather similar.

The uneven distribution in the relative contribution of family practice to the care for common conditions indicated that US patients also see other providers for common problems. The NAMCS data cannot tell us whether a limited group of the population brings most of their health problems to a family physician, or whether most people visit a series of physicians (Ob/Gyn, Eye, ENT, Psychiatry) depending on who they consider most fit for each problem.^51,52