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Fostering dynamic capabilities in liquid healthcare: How Family Medicine "works"
di Marika D’Oria   

Lo scopo di questo articolo è di celebrare la dignità del lavoro dei medici di famiglia, riflettendo sulla loro pratica attraverso la metafora della “Modernità liquida” di Bauman. Considerando il contesto europeo ed italiano, verranno suggerite tre possibili azioni educative per l’educazione degli adulti nella sanità, al fine di comprendere e condividere la naturale “dynamic capability” della Medicina di Famiglia nel superare la liquidità professionale.

The aim of this paper is to celebrate the dignity of the work of family physicians, reflecting about their practice through the metaphor of Bauman’s “Liquid modernity”. Considering the European and the Italian context, three possible educative actions will be suggested for adult education in healthcare, to understand and share the natural dynamic capability of Family Medicine to overcome professional liquidity.

“What has been cut apart cannot be glued back together.

Abandon all hope of totality, future as well as past,

You who enter the world of fluid modernity.”

Zygmunt Bauman, Liquid Modernity

1. Introduction

In the modern scenario of liquid healthcare, the background of adult education requires to answer to the newest formative needs, and to train healthcare professionals, as well as students, to systemic and qualified abilities for clinical practice (Sturmberg & Martin, 2013). The labor market provides innovative challenges and expectations that not always consider the individual educative necessities, focusing on market efficiency and impactive outcomes. Certainly, clinicians must develop attitudes, competencies and clinical tools to implement new treatments and perspectives in a changing world, through knowledge, theories and best practices (Mazzeo, Milillo, Cicchetti & Meloncelli, 2009). However, the educative risk is to assess professional curricula which do not consider the relationship between policy requests, social emergencies and individual needs, which also vary in relation to the topic and level of the learner (Guldal, Windak, Maagaard, Allen & Kjaer, 2012). As we will see, most issues on liquid care are common with other health occupations, so it is important to learn from who always deal with complexity every day.

2. Stability beyond liquidity: a dynamic capability

One of the most important healthcare profession, that everyone meets during a lifetime, is the figure of the family physician. All over the world, family physicians must deal with uncertainty every day: they know a wide-spectrum of pathologies, they must confront with different symptoms not always easy to recognize, they educate people to healthy lifestyles, while they must visit almost 30 patients a day, remembering all their differences and stories, managing their time and facing with patient’s significant others. Also, biographic histories are collected during a consultation, to frame the illness process into an individual and familiar context (Asen, Tomson, Young & Tomson, 2004). Then, in Public Health management, Family Medicine has a pivotal role because physicians are the “gatekeepers” of the National Health System (N.H.S.). Their work particularly:

  • Requires universal and fair access to their duty;
  • Is all-encompassing, with free healthcare intervention;
  • Feels the shadow of malpractice: between the preventive “excess” of zeal and the abuse of prescriptions;
  • Needs different specialty trainings, compared to other medical specialties.

In this paper we wish to consider how can they face uncertainty in every day practice as a dynamic capability (Helfat et al., 2007), even if they are not trained to do so during their professional programs: the concept of “dynamic capability” usually highlights organizational and managerial competences, including processes of change directed toward learning and innovation, as well as the decision frames that co-align an organization to the economic, social, cultural and political changes (Helfat et al., 2007). Even if this concept was born in business and organizational context, and is firmly linked to an economic impact, in this paper we will consider especially the acquisition of organizational and professional learning strategies, that persist during systemic changes.

3. What does liquid healthcare demand to adult education?

The career of family physicians is drenched in liquidity. First, a liquid identity is shaped along the historical background, since the Countries were committed to give the citizens an equal and well-distributed healthcare service, which almost responds to the fundamental necessities of the population, such as hygiene, food, safe water and basic sanitation (W.H.O., 1978). The figure of the family doctor was formally established within Primary Care since the 19th century, and nowadays is based on a care relationship where trust between doctor and patient is crucial to build a therapeutic alliance. This relationship requires a dialogic recognition, between the actors, that should be constant and reliable all over the time, despite of policy changes (Salling Olesen, 2007). However, in Italy, this professional figure changed its name in relation to the doctor’s graduation period: before 1978 – year of birth of the Italian NHS – physicians were called “medici della mutua”, distinguishing them from other physicians by referring to their remuneration. As years go by, they became “medici di famiglia” (family doctors) because of the changes brought by The Declaration of Alma Ata (1978), by which the World Health Organization (W.H.O.) stated new goals in healthcare, aiming to protect health and well-being in a global sense. Today, they are also called “medico di fiducia” (trusted physician) or “medico curante” (healing doctor), while it is partially correct to call them “medico di medicina generale” (general practitioner), because not every general practitioner works with families. In Great Britain, instead, they are known as family doctors, family physicians or general practitioners, while in the U.S. they are no more called general practitioners since 1970, because of variations in the educative programs.

Secondly, a liquid work surrounds their practices, touched by a constant feeling of hesitation due to the precarious conditions on the Collective National Agreements, that delay to declare new guidelines for Family Medicine about financials, organization, minimum level of assistance needs, and community services.

Third, they follow a liquid education, because the Italian specialty on Family Medicine is not pursued by the University (unlike other European countries) but from regional centers that provide them the programs. Most, these professionals are different from other specialties for the nature of medical issues that they have to handle. But liquid are also their work places, fragmented between outpatient clinics, domiciliary visits, and technological items (such as the consultation over the phone) (Wilm, 2014). Liquid are still the skills required to them, shaped on the patient’s needs and expectancies, because to choose the appropriate intervention that should be “patient-centered” surely involves a deeper comprehension and knowledge of the same, in a holistic view. Then patients’ stories, embodied emotions, illness narratives, weird episodes and worries flow all together in the description of their situation which, of course, enrich the overall meaning by giving more complexity to the clinical analysis (Zannini, 2010). And liquid is the population that access their services, which varies for purposes, socio-cultural and medical requirements, while physicians must be able to provide them with equal and adequate protected time, even in shortness of it.

To celebrate Bauman’s (2013) “liquid modernity” metaphor, we can state that Family Medicine has a natural and “dynamic capability” to deal with liquidity while economic, social, political and professional factors push it to enhance more flexible workers: a tricky point that claims a great reflection, also from medical education, because the pressure of hectic timing can be hazardous for the quality of diagnostic and therapeutic procedures.

Then, as a social commitment, medical educators should identify learners’ needs, expectations and motivation, to create meaningful experiences that will help them to be aware of their implicit knowledge gained on field, and to valorize this implicit ability to deal with liquid situations. Continuing education may sustain this awareness to insure competent and reflective doctors, responsible for the care of the patient but also for their own learning and practice. Consequently, as an ethical issue, adult education should take care of the disorienting dilemmas (Mezirow, 2000) addressed by learners, understanding how this clinical field naturally lives and co-exists with ambiguity in the modern collapse of ideologies: a core theme for healthcare providers.

4. Minding the gap between formal, informal and non-formal education

The fragmented knowledge on human diseases in different medical specialties may lead to a schizophrenic observation of the ill body, but this separation cannot concern Family Medicine that, conversely, always interacts with human complexity (Checkland, Harrison & Marshall, 2007). Managing the complexity is one of the most important issues requested by healthcare systems (Sturmberg et al., 2013) to adult education, and today it seems to concern also other medical areas: leaving from a biomedical approach, in fact, the necessity of a wider perspective on health issues includes the safeguard of well-being in a global view, and this is one of the crucial goals for the still actual international challenges (WHO, 1978). For this purpose, around the world, every kind of clinician must formally update his/her competencies, due to the renewal of sanitary emergencies and technologies: this educative matter can find its solution in the Continuing Medical Education (C.M.E.).

Basically, the education of a family physician is driven to achieve successfully specific competencies and, at the same time, it requires to train their soft skills (e.g., empathy, leadership, problem-solving, clinical decision-making, resilience) that, by definition, are difficult to teach directly, so they need to be created also in informal and non-formal situations (EPALE, 2016; Windsor, Douglas & Harvey, 2012). In 2002, the European World Organization of Family Doctors (WONCA-Europe) defined the figure of family doctors as who “guarantee the continuity of healthcare” or the gatekeepers of citizens’ assistance, because they manage both acute and chronic diseases, asymptomatic illnesses, and promote health and well-being in a physical, psychological, social and cultural dimension. The actual debate of Italian politics and policies, focuses the family physicians’ training on the following competencies (Ambrosetti, 2007):

  • Clinical, for individuals: actions of prevention, diagnosis, cure, and rehabilitation that guarantee to the patient the best health state possible;
  • Clinical, for communities: such as clinical and preventive medicine;
  • Organizational and professional: by participating to programs conducted by the NHS;
  • Certification: especially about the health conditions of patients, in the cases provided by law;
  • Communicative: developing and spreading the sanitary culture among individuals and population;
  • Educative and informative: by which an alliance with the citizens is developed, for their benefits.

Meantime, in the European background (WONCA-Europe, 2011), the Family Medicine specialty should educate clinicians to:

  • Person-centered care: to take care of the doctor-patient relationship requires an attention focused on the patients and their context, promoting their empowerment in a longitudinal continuity;
  • Community orientation: the family physician is guarantor of the community health, and promote prevention;
  • Specific problems-solving skills: such as decision-making based on the incidence and the prevalence, but also to understand illnesses and diseases in early undifferentiated stages;
  • Comprehensive approach: looking at acute and chronic problems, and promoting health and wellbeing;
  • Primary care management: especially about care coordination and advocacy, first contact, and open access at all health problems;
  • Holistic modeling: physical, psychological, social, cultural and existential.

The organization and management of this practice also complies with strategies, national plans, protocols, guidelines, clinical tasks, communication with patients, and colleagues (other family physicians, specialists, administrators, nurses and so on). However, there is no evidence that leads to understand how they learn to manage uncertainty, not expected in educational programs. Most importantly, most of them work and offer their self as a therapeutic instrument, so the vocational respect for fragility to ameliorate human conditions, even the worst, is a professional wisdom and an andragogic theme (Reid, 2016) also for medical education, that should be considered too.

5. How can future healthcare professions learn from Family Medicine?

Despite decades of gains in biomedical knowledge, improvements in prevention, treatment and diagnostics, and a daily explosion of clinical challenges, Family Medicine takes also care of time, silence, unclear situations, and long-term conditions. While most educative approaches try to find the “newest solution” to change older cultures, less andragogic studies attempt to deeply understand what remains constant, when everything becomes fluid: which is the pattern that make Family Medicine “work”?

To manage unexpected events and to educate patients and relatives on “moving to a better life” are not shortcomings, but precious values that require a strong trust in the care relationship. Medical competence also includes an awareness on the ethical density of this bond in which, thus, is possible to achieve the genuine intersubjective contact required for an effective therapeutic alliance (Charon, 2004). In fact, the long-term collaboration between patient and physician, opens the doors to a deeper interaction with illness processes, participating in a dialogue in which the patient is recognized as “competent” about his own story, who can share his point of view with the physician, that connects latencies and evidences for a clinical decision, between quantity and quality. In this way, the widespread fear of the fall of certainties leaves the place to the co-existence of opposite situations which seems to be, paradoxically, a systemic solution to reach a certain harmony (Bateson, 1991). This invisible family doctors’ capability could be carefully studied in adult education, because of their adaptation without losing an effective, sensitive, professional and scientifically grounded position. If the crisis caused by liquid times implies the possibility of innovation (Bauman, 2007; Reid & West, 2016), unfortunately, there is a lack of information in the literature about this kind of resilience in Family Medicine, probably nested to the structural liquidity that lies beneath the nature of this practice (Rowe & Hogarth, 2005): in turn, we can admit that this capability is a wisdom “gained on field”.

In 2012, the European Academy of Teachers in General Practice (EURACT, 2012; 2015) undertook a needs analysis on physicians’ education, underpinning to assess a comprehensive formative model for them, that should be collaborative and outlined the basic principles that can be used for local purposes: in a wider perspective, we can hypothesize three applications that are possible in Italy.

The first one consists in implementing  research with physicians about their own experience. Reflection in medical education settings (Zannini, 2015) introduce active learning, particularly when encourage to draw from personal experience (Annacontini & Gallelli, 2014; Jõgi, 2014). Thus, Family Medicine is not just a job, but becomes an aptitude (WONCA, 2011) whilst andragogy links and integrates learning experiences in a lifelong, lifewide and lifedeep perspective (Knowles, Holton & Swanson, 2015). By giving voice to the efforts and knowledge (Zarifis & Gravani, 2014) and supporting the autonomy of learners in Continuing Medical Education programmes, a transferable wisdom and a dynamic co-specialization can be promoted among professionals (Sytse & Schreuder, 2013). For this purpose, the formative approach of communities of practices may also be useful (Lave & Wenger, 1991; Merriam, Courtenay & Baumgartner, 2003), especially within family medicine groups, associated teams that share organizational and clinical rules, and settings.

The second strategy is consists in supporting their learning from the practice, in field: given that a paradigm shift in medical education is necessary to bridge communication for learning across nested levels of the health care system, community of practices can offer value in creating a culture of learning at the organizational level, while the Health Care System can promote new opportunities to observe family medicine and research to understand the common challenges, as a recursive and explorative way to participate in an active and community-based learning. This form of assessment will identify and promote best practices and solutions, recognizing and avoiding dysfunctional activities and making appropriate use of resources and successful interaction for adult learners.

Third, andragogy can start with learners’ proximal needs and motivations, and promote the goal of engaging patients by understanding their experiences as customers during organizational changes, (Richardson & Grose, 2009) and helping them, their families and providers (Patient-Centered Outcomes Research Institute, 2014), to have a high-quality Health Care System.

6. Conclusion

This paper wish to celebrate the dignity of Family Medicine work that “ endures” despite all the natural uncertainties brought in everyday challenges, thanks to a natural dynamic capability that should be study from andragogy, to better understand which strategies can be followed in systemic healthcare changes, in order to maintain a high-quality service for citizens and community. Coping with transformation and indistinct situations is a skill required for every medical profession, even in a world that requires evidences, clear outcomes, standards and guidelines. A possible solution consist in making adult education and healthcare professionals work together, to enlighten and be aware of how they naturally overcome complexity. This is a tacit wisdom that remains stable over the time, a “solid” heritage silently transmitted also in liquid modernity. A dynamic capability that enables physicians to thrive in contexts characterized by ambiguity, beyond the contexts themselves, through the cultures, all over the time.


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