This month we have a fascinating interview with Dr Ueli Grueninger, who designed the Wonca Tree. In the interview, Ueli discussed the start of the Wonca tree idea and how it has developed over time, including reflections on its relevance to us as family medicine doctors. Read Ueli’s reflections about the tree, and how it can shape all of our ideas and practices as an emblem of Wonca Europe and our shared values.
Dr Charlotte Morris, EYFDM Liaison to the Wonca Europe Executive Board compiled Ueli’s answers below. They have relevance to all of us as a community of family medicine doctors.
Q1: How did the idea for the WONCA Tree start?
Well, my short answer could be: I needed a slide to illustrate a 2004 lecture titled "Do We Still Need Family Doctors?".
But come to think of it… This idea must have started 28 yrs before that talk, right after I graduated from Medical School. That was when a family doctor opened my eyes to what it means to practice family medicine in real life. Exhausted and drained by six years of study and exams I had felt an urgent need to experience the day-to-day work of a doctor. I had the good luck to find a family doctor who had run an extended and busy family practice in the countryside all his life; he was about to retire and was looking for support.
This doctor gave me the privilege of working alongside him for several weeks and subsequently serving as his deputy for six months during consultation hours and frequent house calls.
That family doctor opened my mind and heart for family medicine: through his daily example, his careful guidance, his rich medical and social experience, his subtle humour and his loving and respectful interaction with his patients. What a gift for life!
After completing my postgraduate training in general internal medicine, I embarked on a long professional journey through several areas related to primary care (patient education, preventive medicine and public health, medical education & legislation). And finally, I ended up back in General Practice and Family Medicine, as executive director of the Swiss College of Primary Care Medicine, starting there in 2003.
And that is where I first came up with the idea for the WONCA Tree:
One of my first public assignments was to give a talk at a symposium at the University of Basel in autumn 2004. The talk’s title - chosen by the organizers - was ‘Do we still need family doctors?’ This was quite provocative and reflected the precarious situation of family doctors at the time.
And this brings me back to your question: How did the idea for the Wonca Tree start?
During my research I came across the first edition of the WONCA Europe definition of General Practice & Family Medicine, published less than two years before. I was impressed: this document was a highly important work by renowned colleagues from all over Europe, and an ideal blueprint to show Family Medicine’s importance.
But my problem was: this definitions document counted about 10’000 words on a total of 52 pages, all letters, basically no illustrations!
How on earth could I present the message of this seminal work in a concise and persuasive manner? Should I select a few sentences? Or just keywords? Make a list? Or do a mind map? Nothing really convinced me.
I am a visually oriented person: I was looking for something more appealing, persuasive, easy to grasp at a glance!
A new approach was needed — and I needed a break.
The next day, my wife and I went for a hike in the near-by foothills of the Alps…
The tree
….and that's when inspiration struck:
I saw that special tree, standing strong and tall on a hill.
This tree fascinated me:
- A tree: an organic structure, a living being, strong, in full growth!
- Such an image is an icon. It is a symbol.
And I realized, this tree was ready to become a powerful symbol for something strong the symbol for strong and growing General Practice & Family Medicine!
That was it. The WONCA TREE Idea was born!
The rest was work and patience (since I am neither an artist nor a computer whizz kid!
The original WONCA Tree graphic from early 2004 ©UG
The original tree graphic from 2004 reflects the structure and hierarchy of the WONCA definitions - at a glance - as the saying goes: A picture says more than 1000 words!:
- The six branches are the six Core Competencies (task fields of Family Medicine
-
The 11 leaves are the 11 Characteristics (abilities or skills) of Family Medicine
(= these are the abilities/skills that every family doctor should master, when working in the above mentioned 6 task fields) - The three main roots of of Family Medicine (attitude-science-context)
And so, in early 2004 the WONCA tree graphic was ready for the world!
And that was just the start!
Q2: How has the Wonca Tree EVOLVED and SPREAD over time? And WHY?
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First: How has the WONCA Tree GROWN and SPREAD over time?
Once the WONCA Tree was born and ready in 2004, it quickly began to take root and spread:
- The WONCA Tree had its world premiere in BASEL/Switzerland in August 2004, where I used it to give a strong answer to my talk’s question ‘‘Do we still need family doctors?’
- In the WONCA community the Tree graphic was adopted early on:
- the WONCA Tree had its Sneak preview in Orlando, Florida a little earlier in 2004, where a good friend of mine and council member presented it at the WONCA Council Meeting
- and it was first published in the WONCA World News in June 2004 (in an article including the WONCA Tree graphic).
- In the official publications of WONCA Europe’s Definition of General Practice / Family Medicine the WONCA Tree appeared since 2005 in all new editions
- In Europe the Tree has been adopted over the last 20+ years by most WONCA Europe member countries, from Portugal to Scandinavia and Ukraine, from Greece to Portugal (19+). (see Footnote ‚WONCA Tree in EUROPE)
- Beyond Europe, the WONCA Tree graphic has found worldwide dissemination over the last 23 years. The WONCA Tree orchard, as I sometimes jokingly call it, extends now beyond Europe across all continents (possibly except Africa).
This is quite overwhelming, and I must confess I have stopped counting citations and reading abstracts after 180+ citations …
Here are some examples: trees in different languages, cultures, countries 2004-2011-2023)
Samples from the WONCA Tree orchard 2004-2025
For me it is almost unbelievable how widely such a graphic concept is taken up across so many languages, cultures, political and health systems
What I find remarkable, too, is that the original tree graphic needed only two amendments since 2004:
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A first amendment in 2011 introduced and stressed the important role of patient empowerment. It was inserted as a reaction to the evolving expectations towards health care: doctors should explicitly take into account the needs of their patients created by social and cultural changes, and work with them in partnership.
WONCA tree 2005 vs 2011
A second amendment in 2023 clarified on what ground, on what foundation the WONCA tree is rooted. The 3 concepts of One Health, Planetary Health and Sustainability were now explicitly defined as the essential components of that foundation (hence the term ‚bedrock‘)
WONCA Tree version 2023 (with CC license as of 2025)
Both amendments are the result of deliberations within the WONCA European Council that is in charge of keeping the WONCA Definitions up-to-date.
And finally, WHY has the WONCA tree evolved and spread in the way it did?
What is the secret behind the strength, growth, and spread of the WONCA TREE?
I think there are two important aspects to consider:
- the WONCA TREE graphic was developed as a mnemonic device, as a memory-aid
—> as the saying goes: a picture is worth a thousand words (or even 10,000) - over time the WONCA Tree has become a meme!
As you might know memes can be seen as „as cultural analogues to genes in that they self-replicate, mutate, and respond to selection pressures“
So: being a meme, the WONCA Tree can and very probably will further disseminate and strengthen the WONCA DEFINITIONS and hence Family Medicine!
Q3 - WHAT is the WONCA Tree ’s relevance to clinical practice?
And HOW can it be used day-to-day by family medicine doctors to improve the healthcare they deliver?
I see three aspects in this question: Why - where - how?
….
1) WHY is the WONCA Tree relevant to clinical practice?
I did design the WONCA Tree as a memory aid:
- As an image it is easily recalled.
- It is a powerful brand symbol for Family Medicine.
- It conveys at a glance an overview of what Family Medicine is all about
Put simply: the WONCA Tree is a means of communication.
2) WHERE is the WONCA Tree useful?
The WONCA Tree graphic and metaphor …
…. is useful in clinical practice for providing a shared understanding of family medicine
- in day-to-day work in healthcare teams
- in medical education and training at all levels
- for collaborating with peers and partners in medical settings
- and – last but not least – in contact with the patients and their relatives and families
….and moreover, the WONCA Tree is useful, too, for communicating with a wider target public,
because this tree is an easy-to-remember medium and thus it provides a shared frame of reference about what Family Medicine is and what it can do.
Here I’d just like to quote what former WONCA President Igor Svab wrote as early as 2005, a year after the introduction of the WONCA Tree:
“It [the tree] has already become a very useful instrument in negotiations such as…. policymakers, politicians, decision makers, with educators”
and I will add:
- with professional organizations,
- with the media,
- and hence, with the public large
3) And finally: HOW can the WONCA tree be used by family physicians in their DAILY PRACTICE to improve the healthcare services they provide?
I have seen multiple situations where the WONCA Tree-graphic and -concept can support and improve healthcare delivery in daily practice.
In Germany and Switzerland, for example, I saw the WONCA Tree on a poster in the waiting area or in consultations rooms, on patient handouts and even on the homepage of practices.
Thus, the WONCA Tree graphic can help a practitioner….
- To inform and inspire health care teams and collaborators
- And important: to build a productive working relationship with patients…
- … because a WONCA Tree poster in the waiting area or at the reception desk is an eye catcher and works as a policy statement.
- And a WONCA-tree poster in the consultation room can guide patient and doctor as a kind of roadmap for planning a consultation in a multi-problem situation
I will stop here, and I am sure: you can certainly think of many more uses in day-to-day clinical practice.
Q4: Can you tell us about the RECENT change regarding the Wonca tree and why this is important?
The most recent change was at the end of 2025:
it concerns the rules for reprint permissions,
and and it happened on my request.
Why? - Well, it’s a fact:
- people and trees get older
- but trees live longer than people
- and and I say it with a smile: that is also true for me.
Therefore, 20+ years after I had created the WONCA tree graphic (and 10+ years into my retirement) I felt that it was time to scale back my administrative involvement regarding reprint permissions for the copyright-protected WONCA tree graphic.
For this reason, the WONCA Europe Board accepted in 2025 my proposal that the procedure for granting reprint permissions be streamlined, by switching for the vast majority of reprint requests to a Creative Commons-licensing (as used by Wikipedia).
Therefore the new rules are as follows:
-
For non-commercial use and adaptation (f.ex. translations) …
… the WONCA tree is now freely licensed under the Creative Commons licence BY-NC-SA 4.0 . This licence is free of charge, and it no longer requires written permission for use and adaptation of the tree – provided that authorship of the graphic is acknowledged (that is the acronym „BY“), use is non-commercial („NC“) and all derivative works are shared under the same licence („SA“).
b) However, for commercial use (books, paid products, commercial publications)….
…. a written permission continues to be mandatory for use of the copyright-protected WONCA tree graphic. And this permission must still be requested from the WONCA Europe Secretariat
For all non-commercial users, this simplified procedure eliminates the copyright-related paperwork.
For me, this brings mixed feelings: no more administrative work, but alas, Iess often valuable personal contacts with colleagues from the global family doctor community.
(For all details see https://www.woncaeurope.org/page/wonca-tree )
Q5: Can you talk about an inspiring family medicine specialist you feel embodies the values of the Wonca Tree?
I have been fortunate to meet many inspiring family doctors in Switzerland.
I have already mentioned one of them, Dr.S., a country doctor in a rural area, who was my first and probably most important medical teacher, right after Med School. It was he who lit my lifelong interest in family medicine. During a six-months stint in his practice I learned from Dr.S. - through his personal and professional values - what it means to practise medicine in real life – this was to shape and influence my entire professional life. Later, I found all his lessons reflected in the WONCA definitions and the WONCA tree.
Q6: Please tell us what book you are reading at the moment.
I have just finished reading the following book:
Autocracy, Inc.: The Dictators Who Want to Run the World,
by Anne Applebaum, 2024 New York (Doubleday)
Anne Applebaum, a U.S. and Polish citizen, is an award-winning historian, journalist, and author of books on the history of communism, the development of civil society, governments, regimes and autocracies in Central and Eastern Europe.
With her latest books on authoritarian tendencies in Europe and the USA, the historian Anne Applebaum investigates very topical, disturbing developments.
In her current book, which is based on extensive research, she analyzes in detail the relations and networks between autocratic states and autocratic regimes in the 21st century, as they operate from America to Europe, Africa and Asia.
Applebaum notes that
“These autocracies do not necessarily share a common ideology, but they very often collaborate to increase their economic power and control against the democratic and liberal countries. Their goals are power and not seldom personal wealth.”
WHY did you read this book? Would you recommend it?
For me this book is highly relevant: Autocratic states and regimes exert an ever-increasing influence and pressure on global politics, global economy, the global environment. And this has an impact - indirectly or directly - on individual and global health, too.
Anne Applebaum's book offers valuable insights into how autocratic regimes work. and what can be done against their machinations.
- It shows me in what key areas autocracies are highly active (such as propaganda and media control, trade in weapons and technologies, and money laundering)
- It provides many examples of how autocratic governments collaborate to increase their economic power and control against democratic and liberal countries, and – last but not least – how they infiltrate, undermine and attack liberal and democratic societies in order to gain ever more economic power and personal wealth.
Anne Applebaum concludes clearly and unequivocally:
“Democracies are no longer safe. The rule-based world order of yesteryear is challenged, threatened, attacked by autocratic states and autocratic regimes.”
She calls on democracies to fundamentally reorient their policies to combat this new type of threat from autocracies, and she identifies possible ways to do so.
1 4. Pro memoria: Two later amendments (details see Q2):
- in 2011 plus one leaf «Patient Empowerment»,
- in 2023 plus the foundation («Bedrock»), consisting of OneHealth, Planetary Health, Sustainability
2 The WONCA tree in European countries (>=19): Portugal, Ukraine, Finland to Greece (Ukraine, Portugal, Spain, Greece, France, UK, Ireland, Belgium, Germany, Austria, Switzerland, Sweden, Norway, Finland, Poland, Romania, Bulgaria, Georgia, , Ukraine, and possibly more to find…)
3 re worldwide dissemination of the WONCA Tree: ASIA: Japan, Vietnam, Hongkong , China, Indonesia; AUSTRALIA; the AMERICAS: Brazil (see BARROS et al.); EUROPE: Ukraine, Portugal, Spain, Greece, France, UK, Ireland, Belgium, Germany, Austria, Switzerland, Sweden, Norway, Finland, Poland, Romania, Bulgaria, Georgia, Ukraine, , … and more;
4 MEME: A meme is idea, behavior, or style that spreads by means of imitation from person to person within a culture and often carries symbolic meaning representing a particular phenomenon or theme.[4] A meme acts as a unit for carrying cultural ideas, symbols, or practices, that can be transmit- ted from one mind to another through writing, speech, gestures, rituals, or other imitable phenomena with a mimicked theme. Supporters of the concept regard memes as cultural analogues to genes in that they self-replicate, mutate, and respond to selective pressures.\5 In popular language, a meme may refer to an Internet meme, typically an image, that is remixed, copied, and circulated in a shared cultural experience online.
source: https://en.wikipedia.org/wiki/Meme