This week and next, I have a change of pace from “work as usual.” I have the privilege to be teaching in a Family Medicine program in Rwanda, and though I’ve traveled and worked in Africa before, I’m reminded once again of the things that are strangely familiar in the midst of remarkable differences…

•     Mobile phones are ubiquitous, though diagnostics such as ECGs or Blood Gas analysis are hard or impossible to come by. It is just plain odd, to me, to be in an African hospital ward, many beds to a room, yet with nearly every patient having a mobile phone tucked carefully in by the pillow or stored nearby with belongings.

•     Despite the tendency to think of “all those odd tropical diseases” that they get “over there” (at least that’s what folks at home seem to think), the most common diagnoses this week are the same as bread-and-butter diagnoses at home – pneumonia, pelvic prolapse, hypertension, heard disease and the like.

•     On the non-medical front, while folks at home were concerned about what we’d have that was safe to eat, in actuality here we’ve had outstanding meals each night at local restaurants – definitely good enough to write home about – and I have!

•     I’ve gotten back into the routine of my usual morning run (which is much nicer here at about 65 F than the 30F temperatures back home!), and while I’m used to being accompanied at times in the morning, it’s not usually by workers pushing their ware-laden bikes UP the local hill!

•     Most of all, I’m struck (as each time I come to Africa) how with much less than we have in the “developed” USA, it is possible to practice good medicine and provide great care despite much less technology and much simpler surroundings. Sure, there are times that having more labs, and more testing options would be nice, but when you have much less, you make it work – and the results may well be just as good!

Far from home, things can seem very different, but underneath, there is often much that is the same – and most of all what is the same, is the importance of providing the best care possible, one life at a time.

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.

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.