The Besrour Conferences

In 2010, Dr Sadok Besrour, a family physician affiliated with the University of Montreal in Quebec, challenged the College of Family Physicians of Canada (CFPC) to reflect on its role in advancing the discipline of family medicine globally. Providing vision and support, Dr Besrour invited the CFPC to determine if the College had such a role and, if so, what that role could be.

At the time of this invitation, many Canadian academic departments of family medicine (referred to here as departments) were engaged in international partnerships to support the development of family medicine in various countries with a growing number of family physicians dedicated to family medicine’s contribution to global health. The CFPC, through its Global Health Committee, responded by proposing a series of 3 annual consultation meetings involving Canadian and international stakeholders to determine more precisely what was needed from the CFPC in the global context.

This resulted in the establishment of the Besrour Conference and subsequently led to the creation of the CFPC Besrour Centre, a hub of collaboration to advance family medicine globally. This paper describes the planning and outcomes of the first 3 Besrour Conferences held in November 2012, 2013, and 2014, respectively. It provides the background and the foundation for a series of articles describing the process and the outcomes of the conferences, the first of which appears in this issue (page 596).¹

Rationale

For 60 years, the CFPC has provided a robust foundation for family medicine training and practice in Canada. The high regard given to Canadian family medicine confirms the success of the CFPC. The CFPC’s role as a national and international leader in family medicine, its commitment to social accountability, and the quality of its members and their eagerness to learn through collaboration all contributed to the CFPC’s openness to exploring how it could contribute to family medicine globally.

The CFPC’s decision to proceed was also rooted in the recognition of the value of family medicine as a global medical intervention. In 2008, the World Health Organization endorsed primary care as a means of improving global health. The report states that primary care is able to “respond better—and faster—to the challenges of a changing world.”² Michael Kidd, in 2013, pointed out that, although family doctors might occupy different roles in different medical systems, family medicine is essential to the development, functioning, and improvement of health care systems globally.³ Barbara Starfield and colleagues’ extensive research in the systemic and biomedical outcomes of family medicine focused on outcomes like hospitalization and immunization rates, and provided evidence that supports the discipline as a means of improving global health.^4,5 More research in this domain is needed as more countries recognize the benefits of family medicine and devise implementations of the specialty in diverse medical, cultural, and physical environments.

Methods

The Besrour consultation process was carried out over 3 consecutive yearly conferences held in tandem with the CFPC Family Medicine Forum to allow international delegates to attend Family Medicine Forum, to witness the depth of the Canadian expertise in this discipline, and to have an opportunity for networking.

Participants

The first 3 Besrour Conferences were by invitation and included a carefully curated list of participants. To ground the consultation process in existing Canadian expertise and experience, each of the 17 departments was invited to select 1 Canadian and 1 international delegate. Over the 3 years, all 17 departments participated in the conferences. Some departments sent additional delegates. Canadian participants reflected the breadth and depth of Canadian family medicine, with physicians from rural and urban settings; clinicians, educators, and researchers; and pioneers and recent graduates. Most Canadian participants were (and are) engaged in international partnerships to advance family medicine in a specific country.

Other selected experts included Canadian and international deans of medicine. These comprised 3 Canadian deans of medicine who were trained as family physicians, as well as deans of medicine from Tunisia (Sfax and Tunis), Indonesia (Aceh), Haiti (Quisqueya University), and Ethiopia (Addis Ababa). The president of the Canadian Council of Deans of Medicine and the president of the Conférence Internationale des Doyens et des Facultés de Médecine d’Expression Française (CIDMEF) were also present. In addition to the support of its leadership, the CIDMEF also brought attention to the notion of the social accountability of medical school, which is a pillar of the CIDMEF’s agenda and an issue of great relevance to family medicine training. Michael Kidd, President of WONCA and a strong advocate for family medicine, also took part in 2014. Representatives of the leadership of the American Association of Family Practitioners and the Caribbean College of Family Physicians also attended.

Thirty-five international delegates participated in the conferences over 3 years, of whom 7 attended more than once. Most international delegates were leaders in family medicine education and many were working to establish family medicine as a new discipline in their countries.

Representatives from the World Bank and Health Canada were also notable participants in the 2014 conference. In addition to making formal presentations, representatives from both organizations attended the 2-day conference, sharing candidly in discussions and debates, and providing insight into the perspectives of their respective institutions.

Box 1 summarizes the countries represented at the first 3 Besrour Conferences.

Box 1. Countries participating in the Besrour Conferences, 2012–2014.

The following countries were represented at the conferences:

• Australia

• Brazil

• Canada

• Cayman Islands

• Chile

• China

• Ethiopia

• Guyana

• Haiti

• Indonesia

• Jamaica

• Kenya

• Laos

• Mali

• Nepal

• Palestine

• Tanzania

• Tunisia

• Uganda

• United States

• Uruguay

Themes

Each of the 3 Besrour Conferences was guided by a theme meant to bring into increasing focus the desired outcomes of the consultation process. The themes also paved the way for a collective reflection to confirm the perceived need for a permanent organization, the Besrour Centre, to support the vision and related activities developed through the consultation process.

The first conference focused on developing a vision, a mission, and strategic priorities for the emerging collaborative process. The second conference focused on the first strategic priority: to establish family medicine as a viable and effective element of health systems. This second conference also sought to determine whether Besrour participants could effectively translate their dynamic discussions into concrete collaborative work to advance their mutual agenda. This was confirmed in the creation of the Besrour working groups in November 2013. The first 2 Besrour Conferences tested, refined, and engaged the commitment of those directly involved in family medicine development. The third conference, while continuing the work already started, also aimed to more deeply engage leaders and decision makers, such as deans of medical schools and the World Bank, in the vision of the Besrour process. Table 1 summarizes the themes of the 3 first Besrour Conferences.

Table 1.

Themes of the Besrour Conferences

YEAR	THEME
2012	Building capacity in family medicine in low- and middle-income countries
2013	Strengthening the foundations
2014	Innovating for action: tools and strategies to advance global family medicine

Results

Besrour Conference 2012: strategic priorities

In 2012, the Besrour Conference produced a vision, a mission, and 5 strategic priorities on which to focus the collaborative work done through the proposed Besrour Centre. Box 2 summarizes these strategic priorities.

Box 2. Besrour strategic priorities.

The following 5 strategic priorities were developed at the first Besrour Conference in 2012:

• Establish family medicine as an effective, viable, and pivotal element of health systems

• Strengthen continuing education and knowledge support for family physicians toward a comprehensive, effective, and community-responsive scope of practice

• Collaborate with the global community to support family medicine accreditation and certification

• Enable effective family medicine faculty development

• Build knowledge for family medicine through scholarship and evaluate the effects of family medicine on health outcomes

Besrour Conference 2013: working groups

In 2013, the Besrour Conference produced 4 working groups (Table 2). Three working groups were tasked with producing tools or developing strategies to achieve the first strategic priority. A fourth working group developed a workshop to prepare non–family medicine faculty to train family medicine learners where there were no or insufficient family physicians to assume teaching roles.

Table 2.

Besrour working groups

YEAR	WORKING GROUP	ACCOUNTABILITY
2013	Narratives in family medicine training	Compile key information about the establishment of family medicine training programs based on the experience of Besrour partner countries
2013	Advocacy for family medicine, community engagement, and the ethics of international partnerships	Develop an advocacy framework for the development of family medicine, aimed at various key audiences such as policy makers, deans of medical schools, non–family medicine specialist colleagues, and the general population Develop a tool kit to enable community engagement toward the establishment of family medicine in various settings Develop tools to facilitate the development of international educational partnerships based on ethical principles
2013	Paper series	Develop a series of papers highlighting the key issues, lessons learned, and outcomes emerging from the various activities of the Besrour collaboration
2013	Faculty development for non–family physician faculty	Develop a workshop to enhance the ability of non–family physician faculty to train family medicine residents in emerging family medicine settings
2014	Continuing medical education	Develop tools and strategies to enhance the competencies of generalist clinicians not trained as family physicians

Two additional important outcomes in 2013 included confirmation of the key role of academic departments in the development of the discipline globally and the importance of understanding, measuring, and promoting medical generalism, even outside of our immediate discipline.

Besrour Conference 2014: progress and future directions

The 2014 conference resulted in 4 main outcomes. First, the work produced by the 2013 working groups was presented. Outputs of the 4 working groups included a collection of narratives about the emergence of family medicine training in various countries, a plan for a series of papers and an early draft of a first article presenting various aspects of the reflection and activities of the Besrour collaboration, a draft advocacy framework for global family medicine, and a faculty development workshop.

Second was the confirmation and refinement of the working groups. Community engagement was included as a focus of activity for the Advocacy Working Group. A new group was formed to address the continued medical education of generalist physicians, including those who have not been trained as family physicians but who constitute a large contingent within the primary care sectors of many countries.

Third, this conference called for the development of research teams to further demonstrate the effects of family medicine in the Global South in an academically rigorous manner.

Fourth was the clear endorsement and commitment of the Besrour participants, of the CFPC, and of Dr Besrour toward the establishment of the Besrour Centre. The Besrour Centre, currently being organized into a legal, fully functioning entity, will be a hub of collaboration to support the working and research groups, to potentially create new ones, to apply existing expertise through consultation, and to disseminate the outputs of the collaborative work through scholarly publications, the Besrour website, and the media.

Discussion

Several notable conclusions are worth highlighting. The consistent engagement of the Besrour participants over 3 years confirmed the need for international collaboration to advance family medicine globally. It further indicates openness to having the CFPC assume a leadership role to that end. The work accomplished since 2012 points to a considerable degree of alignment and commitment between the funder, the Canadian departments of family medicine, the participants (Canadian and international), and the CFPC. Ongoing efforts will be needed to outline pathways of collaboration that continue to meet the needs and aspirations of various stakeholders while we progress.

The Besrour process highlighted the wealth of experience and expertise among Canadian family physicians. Also noted was the strong hope by Canadian family physicians to see their knowledge and experience transformed and woven into a mature discipline responsive to the various settings in which it is practised. Among international partners, the Besrour process revealed a deep knowledge of what is needed in their communities, extensive clinical experience, a commitment to medical education, a great deal of courage, and a remarkable determination to grow the discipline of family medicine for the benefit of their communities.

The Besrour Conferences also faced challenges. While the ability to work in both French and English was recognized as an explicit asset of CFPC activities including the Besrour Conferences, ensuring the full participation of francophone delegates was difficult. The use of simultaneous translation during the conference and the determination of bilingual participants to act as translators did not address the language barriers that limited participation in small group discussions. Continued efforts will need to be made to ensure that all can effectively interact with the depth to which the Besrour collaboration requires.

For the working groups, attempts to come together across time zones using telecommunication technology also presented challenges. All communication platforms used presented challenges, and efforts will need to be made to find more effective and reliable ways to communicate in order to continue the work of the Besrour Centre, a challenge shared by many working in global health.

Beyond the barriers of language and technology, subtle cultural differences also affected how individuals engaged in the process. Care will need to be taken to accommodate cultural differences in order to enable the full engagement of all partners in the planning, oversight, participation, and dissemination of Besrour activities.

One of the rich outcomes of the conference process was the ability of participants to share, reflect on, challenge, and celebrate ideas about the strengthening of family medicine. This iterative and interactive process, while less amenable to measurement, is nonetheless central to the success of the Besrour process. The safe and open environment created through trusting relationships will need to be nurtured and protected as the Besrour Centre and the conferences grow.

Our eagerness for clear, prompt, and measurable outcomes will need to be balanced with an equal commitment to a process that is inclusive, iterative, and respectful of relationships, and that takes time.

As we look to the future, we note that the collaborative efforts central to the Besrour Centre will need to persist and deepen. Efforts will be needed to reach out to key stakeholders to motivate and engage their full and respectful participation, and to create the conditions that invite rather than curtail their involvement. Thought will also need to be given to ways in which new Besrour collaborators can be included.

Conclusion

Canadians have much to learn from the Besrour partners, and it will be up to Canadian collaborators to translate those lessons into improvements for our own patients and communities. The first 3 Besrour Conferences provided a dynamic and effective process to establish the foundation of the Besrour Centre. As we move beyond this inaugural phase, we find strength in our consensus, we find purpose in the need for robust family medicine globally, and we find inspiration in the vision of health for all.