A recent commentary in the Journal of the American Medical Association (JAMA vol 302, p994, http://jama.ama-assn.org/cgi/content/extract/302/9/994) proposes "systems medicine" as a new paradigm for moving medicine "from reductionism to holism." However, commentary itself takes an unfortunately narrow view and primarily biologic view, focusing mainly on the integration of genomics with disease prevention.

It seems to me a true systems approach must address issues at multiple levels that affect patients individually or as communities: biology, personality, communication, culture, lifestyle, socio-economics, and environment. For example, while diabetes risk may be partially related to genetic vulnerability, an individual's risk of diabetes is also significantly mediated by lifestyle factors and socioeconomic factors, while cultural and communication factors may play a major role in his or her understanding of the disease.

This broader view of systems medicine is nothing new to those in primary care. Focusing on first-contact care, long-term person-focused care, comprehensiveness, and care coordination we are already well-positioned to practice "systems medicine". Family physicians, in particular, are trained to address the multiple systems levels that bear on patients' lives and well-being.

Shifting to a truly systems based approach really would represent major advance forward for medicine. But in order to make the first step towards this advance, we must ensure adequate funding, institutional and academic support, and clinical structures to support a strong primary care enterprise.

Coincidences are the food of blogs.

Last weekend our media was full of the return to the ring of NZ's favourite heavy weight boxer David Tua, complete with the pre fight hype, posturing and verbal abuse so typical of the sport. This was while I was researching the guidelines for traumatic brain injury diagnosis and management for a medicolegal case. How could I be comfortable watching the glorification of a brawling boxer who would deliberately, in a few hours time traumatise the brain of an opponent for significant personal gain, while before me lay the clinical records of an accidental head injury patient, to be analysed for the possible outcome of shaming and blaming a doctor who I am sure at no point had intent to maim or wound.

My discomfort was aggravated when the fight finished in the 2nd round with the loser clearly suffering significant brain trauma. A GCS of 14, judging from the short clip of the defender's corner after the bout ended. I bet someone did a CT of his head, probably funded by the public accident insurance. I wonder if anything was found?

Drawing parallel between two vastly different circumstances might seem unfair and some friends have railed against me for complaining about the oxymoron of labeling boxing as a sport and then supporting its banning. They point out that air sports, including some I have personally engaged in, have a far higher death rate. But a glider pilot does not fulfill a personal need by causing grievous body harm to a fellow human. Another pointed out that this was only the top echelon of the sport, for amateurs had head protection which presumably allow them to punch the opponent even harder in the head. Good for releasing all that aggression. Somewhat reassuring, until I saw another TV clip of bar patrons fighting over the outcome of the Tua fight! Presumably they were professionals.

Straining my single brain cell, I wondered why the UK had banned fox hunting but professional boxing continues...do humans care more for foxes than fellow humans? Do we need a new species. Homo Sulgerius.

Now this could get silly and the anti-boxing thing has a certain element of being the domain of greenie, libertarian, tree huggers, but didn't the World Medical Association and the British Medical Association call for the sport to be banned, and the national medical associations of Australia, Bangladesh, Canada, Denmark, Finland, Ghana, Ireland, New Zealand, Nigeria, Norway and South Africa have all lent support to this.

Why do nations permit and glorify such deliberate injury (with long term sequelae) to a fellow human for personal gain, both financial and emotional but forbid so things like smoking in public places because there is a small risk of unintentionally causing harm to other humans. Is it just that boxers have effectively given consent to being harmed when they take up the sport? Is that informed consent? Is it before or after the brain injury sets in?

As the debate in the USA over national healthcare “reform” has progressed in recent months, I’ve been saddened to see the focus shift more and more to the political. Most news coverage these days tells us who is for or against this or that financing mechanism, or which components are in or out because they might affect a bill’s popularity with legislators and constituents. There are even reports of distortions and misrepresentations by one side or the other, just to score points with the voting public.

Where is medicine in the midst of this? And where in the world is the patient?

On some days I resign myself to the thought that any effort to get something done involves politics. Even the simplest change in office processes or hospital policies, sooner or later runs into at least basic political considerations of who will get offended, who will support it, and how do we get it funded. To an extent, politics IS indeed just a part of any group process of getting things done.

Still, if we in the USA are truly hoping to “re-form” (re-do, re-build, or even re-imagine) health care, I am left wondering where the voice of doctors, on behalf of patients, is in all of this. Are we just content to play party politics along with everyone else? Are we mainly looking out for our own interests, and rooting for the politicos we most believe in? Or can we find a common vision to advance and proclaim “THIS is what we believe health care must be”?

Most political parties have certain things they stand for, whether or not a specific statement of purpose is articulated and written. Most religious or faith-based organizations have some common statement of belief or creed. Such an implicit or explicit definition of identity gives focus and direction.

Do we in medicine have a common belief or purpose around which we can rally, and from which we can derive a vision for the future of health care? What is our mission statement? What is our vision? What is our identity?

Many medical schools still recite the Hippocratic oath at commencement, but in practice the statement used is often adapted, modernized, or adjusted to fit the times. For the most part, we’ve abandoned the supposed original oath for something more comfortably conforming to 21st century medicine. What is left hardly serves as a unifying statement of purpose for the profession.

There are, however, other statements and documents born out of modern medicine that can give us some direction…

• The Declaration of Geneva states that for a physician, “the health of my patient will be my first consideration” (www.cirp.org/library/ethics/geneva)

• The Universal Declaration on Bioethics and Human Rights advocates “access to quality health care and essential medicines, especially for the health of women and children” (www2.unescobkk.org/eubios/udbhr.pdf )

• For those of us in the USA, American Medical Association’s “Principles of Medical Ethics” calls physicians to not simply provide “competent medical care,” but to also “support access to medical care for all people” and work for “the betterment of public health” while regarding “responsibility to the patient as paramount.” (http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.shtml)

Some may see engaging in further discussion of these statements and their application, as so much hot air or impractical ivory tower thinking. Some would rather focus on the practicalities of patient care, and bypass critical reflection on the ideas these statements advocate. Some may say, “I know that’s what we’re supposed to do, we just need to figure out how to do it.”

The problem is, NOT everyone knows or even agrees that “this” is what we are supposed to do. Those outside medicine have their own political, economic, and social views of what they want health care to be.

It is incumbent on us as physicians to think critically about who we are, what we do, and why we do it. We then need to articulate this to the greater body politic, and advocate for OUR vision of what health care for our patients means. To reach that point, perhaps we need to focus again on some of the foundational ethical statements that have been developed for modern medicine, so that we can develop a common vision of what medicine should be, and how we can best care for those entrusted to us.

We, as doctors, need to let those around us know where we stand.