Report from Dr Eunice Carrapiço - WONCA Europe Montegut Scholar 2016

This was my first attendance of a WONCA conference. The experience was a highly fruitful and impressive one. My first positive and striking emotion was the sense of belonging to an enormous family of world family doctors, where visions, hopes, will, creativity and efforts can converge to improve health, human solidarity and well-being all over Earth.

The agenda for the conference was, in my perspective, very well structured, offering a great quantity, diversity and coherent distribution of themes, approaches and sessions during five working days. This model allowed each participant to build his own personal conference program.

Personally, and reviewing my notes, I would like to underline some aspects and ideas that I most appreciated and took home.

I very much valued the impressive range of themes, perspectives and practical issues, going from policies, organizational issues, spiritual concerns and approaches in clinical practice, to clinical topics and precise practical procedures potentially offered in order to increase the utility of the action of the family doctor and his/her team in the caring of their patients. One example of this last point was that of periarticular infiltrations and myofascial syndrome treatment. Another crucial aspect was quaternary prevention and the concept of “not to do” recommendations to avoid damaging patients and increase their safety within health care services and systems.

I had the opportunity to participate in some workshops. In one of them I was able to validate and reinforce one technique that I had already initiated in my Family Health Unit (USF) of S. João do Estoril, in Portugal: corticosteroids injections for periarticular rheumatic diseases. In this workshop I was challenged to improve my skills and to lengthen the weekly period for these procedures from 1 hour to 3 hours, extending this offer to three family health units, covering 45,000 people. At the same time, this organizational change will also allow the training of more FM trainees and young family doctors from other units on the acquisition of these skills, enlarging their scope of care for their patients.

Another key point I took home was the reinforcement of the importance of including, in FM residency programs and in the continuous medical education and development of all family doctors, the awareness of the need and the habit of reflexive thinking and self-understanding of one’s own emotions, weaknesses, strengths and resources in association to the process of building effective doctor-patient relationships and higher levels of quality of care. This is done best in small groups and using narrative methods. The concept of “Balint 2.0” groups, using social networks, is a nice illustration of how this reality can be pursued nowadays.

Moving to another angle of human reality, I must highlight the opportunity to enlarge my perspectives and learn some practical ways of including the spiritual human dimension in clinical practice. I was able to identify and establish connections with a network dedicated to this theme. At the same time, in my local practice, my colleagues and I have decided to explicitly include this topic in our clinical practice. In order for that to happen, this year we will initiate weekly discussions and sharing of experiences involving two family doctor trainers and eight family medicine residents from our unit.

Other fruitful learning experiences were those of discovering the remarkable efforts in order to surpass the huge amount of problems and contrasts in large areas of the world such as India, Bangladesh and Africa, among others. The perception of these realities reinforced my personal decision to take place in a mission in Guinea-Bissau in the next month of march. Also in the same line of action, I have initiated contact with the Medical Faculty of Manaus (Amazonia – Brazil) in order to support the development of family medicine as an academic discipline and clinical practice in this medical school – for this, I will be making use of my own personal experience as a professor in the New University of Lisbon Medical School and as a FM residency trainer, as well as taking advantage of our common language and historical connections.

Associated to my participation in the conference, I was able to visit three family health clinics (“clínicas da família”) in Rio de Janeiro. This innovative experience has been in development in Rio since 2009. So far, more than 160 family health clinics have been implemented, achieving a coverage of primary health care (PHC) of around 65% of the people, and offering high quality PHC to persons and families living in deprived areas of Rio, as well as other urban areas. This development has done a considerable contribution to reduce the impact of social inequities in people’s health and to increase human dignity in this city with more than 6 million people. This appearance of family clinics in Rio de Janeiro has some similarities with the development, since 2006, of family health units (USF) in Portugal, where nowadays around 460 USF exist all over the country, covering about 56% of the people.

The similar characteristics of these “parallel” experiences are:

  • the organization of PHC and FM is based in medium-sized multiprofessional teams in a designed geographical area;
  • there is special attention to the principles of care and the quality of the equipment, showing that PHC is good care for all (instead of “poor care for poor people”)
  • these units belong to an universal public-funded and public-provided service;
  • the medium size (15 to 30 professionals) multiprofessional teams allow the possibility of mutual support, substitutions when needed, and the sharing of experiences and competences in a notable and rich mix of skills;
  • adaptable organizational autonomy, in order to better respond to the specific health care needs of persons and people in a given community;
  • a community-oriented concern – this aspect is much more developed in Rio than in Portugal, and in Rio it is supported by the role of community health agents (“ACS – Agentes Comunitários de Saúde”) who are simultaneously members of the community and of the professional family health team;
  • varied forms of paying the professionals and teams, depending on their quality of performance and added value to the health of people;
  • family clinics in Rio and family health units (USF) in Portugal have a wide set of common characteristics among themselves, with some similarities to the “trade mark” and “franchising” concepts, but in the public sector domain – this promotes harmonization of the range of services, of the levels of quality and of the procedures themselves, promoting equity of care among persons, families and communities.

Taking into account my current new responsibilities as part of a regional coordination team for the development of family medicine and PHC in Lisbon and Tagus Valley (3,6 millions of citizens), there will definitely be many opportunities to apply plenty of the learnings I got from this 21st WONCA Conference, as well as to influence PHC local teams, namely by reinforcing the trend of their multiprofessional nature in order to enlarge the scope and nature of their health care processes.

Finally, I would like to highlight the message passed by Amanda Howe to consider the family doctor as a social change actor and author, which stresses the power of her/his example and concludes with “we all can be leaders”.

Eunice Carrapiço

Family Doctor (Portugal)

WONCA Europe Montegut Scholar 2016