Preparing for Primary/General Care Physicians: Issues and Strategies from some Southeast Asian Countries

Preparing for Primary/General Care Physicians: Issues and Strategies from selected Southeast Asian CountriesDr ParyonoSEAMEO VOCTECH Regional Centre

1Photos2

Outline of presentationGeneral definitionThe importance of Primary/General CareEducation and training preparation for Primary/General Care in other countries, i.e. Southeast AsiaIssues and problems Core competenciesPossible forms of continuing education and evaluationRecommendationsWays forward

3General definition (World Health Organization, 1974)Primary Care: This is front line medical care, as a rule, not limited to patients in specific age groups; it is the field of medicine where the patient usually makes his first contact with the doctor and has direct access to him or her. The role is to provide comprehensive, continuing and primary medical care.(World Health Organization, 1974)44Starfield. 1998)Primary care comprises four main features (Starfield, 1998)A first contact for any new health issue or need

Long-term, person-focused care

Comprehensive care for most health needs

Coordination of care when it must be received elsewhere (i.e. with a specialist) as well as family orientation and community orientation.

5Primary care workforcegeneral practitionersgeneral internal medicine practitionersfamily physicians

(PA)physician assistants (PAs)(NP)nurse practitioners (NPs)Nursescare coordinators6The importance of Primary Care (Shi 1992, 1994) The higher ratios of primary care physicians to population had better health outcomes (Shi 1992, 1994)

(Vogel and Ackerman,1998) The supply of primary care physicians was associated with an increase in life span. (Vogel and Ackerman,1998)

(Shi at al., 2004)A greater supply of primary care physicians was associated with lower infant mortality (Shi at al., 2004)

7The importance of Primary Care (ctd.)(Gulliford 2002)In England, the standardized mortality ratio for all-cause mortality at 15 to 64 years of age is lower in areas with a greater supply of general practitioners. (Gulliford 2002)

,(Gulliford 2002)Each additional general practitioner per 10,000 population (a 15 to 20 percent increase) is associated with about a 6 percent decrease in mortality (Gulliford 2002)

8(Franks and Fiscella 1998; Baicker and Chandras (2004). Cited from Starfield, Shi, and Macinko (2005).Areas with higher ratios of primary care physicians to population had much lower total health care costs than did other areas (Franks and Fiscella 1998; Baicker and Chandras (2004). Cited from Starfield, Shi, and Macinko (2005).

(Hawkins, D., M. Proser, and R. Schwartz. Fall 2007 as cited in Kaisar Family Foundation (2013).A higher ratio of specialists to population has been correlated with higher mortality rates while a higher ratio of primary care physicians to population is better for health. (Hawkins, D., M. Proser, and R. Schwartz. Fall 2007 as cited in Kaisar Family Foundation (2013).

9The importance of Primary Care (ctd.)GPEducation and Training Preparation for General Practitioners (GPs) /Primary/ Family Care Physicians CountryEducation and TrainingBruneiMDCMEUndergraduate(3 years in Brunei) + 2-3 years in partner universities in UK or Australia or Canada to receive MD or equivalent, Internship (2 years), postgraduate education in Primary Care and Continuing Medical Education (CME) (2-3 years).10CountryEducation and TrainingIndonesia4-6 years + 2-4 years internship => take competency examination to become GP, + 3-7 years to become a specialist, +2-4 years to become subspecialist/super specialist11Education and Training Preparation (contd.)Education and Training Preparation (contd.)http://www.nuhs.edu.sg/corporate/work-with-us/job-opportunities/national-university-hospital/medical/medical-career-paths.html#link_not_foundMalaysia5-6 years Medical school (2 years basic medical sciences + 3 years clinical skills development) + 3 years horsemanship program at public hospitals (GPs )12Education and Training Preparation (contd.)http://www.nuhs.edu.sg/corporate/work-with-us/job-opportunities/national-university-hospital/medical/medical-career-paths.html#link_not_foundSingaporeAttainment of undergraduate degree or higher + 4-7 years of Medical School + House Officer + Medical Officer +Registrar (Advance Specialist Trainee)+ Associate Consultant + Consultant + Senior Consultant13Problems and Issues in Education and Training and EmploymentBrunei:

About of Medical doctors are expatriates

(Ministry of Health Brunei)General Practitioners/ Primary Care Physicians work at private and government health clinics. The fee for using government clinics is almost free for all Brunei citizens, those working for Government, and those below 18 years of age (Ministry of Health Brunei).

Clear career paths for GPs and other Specialists (based on the new salary scheme of 2012)

14Brunei (contd.)GP/PCP offered as Postgraduate programmes is relatively new; thus the qualified GPS are still limited.UBDIn 2000, the Ministry of Health, in collaboration with the Institute of Medicine, University of Brunei Darussalam (UBD) and St. Georges Hospital Medical School, started a part-time postgraduate diploma course in Primary Health Care.

(Ministry of Health Brunei, 2009)To support capacity-building initiatives, the Primary Health Care Orientation and Training Centre was established in 1986, primarily to provide training courses on the primary health care concept for health personnel (Ministry of Health Brunei, 2009)

Source: http://www.wpro.who.int/countries/brn/3BRUpro2011_finaldraft.pdf

15Indonesia Ratio between general doctor per number of patients: 33 to 100 k (ideal 40/100 k).

MD4-6 years (Sarjana Kedokteran/MD) + 2-4 years (practical experience), then takes the competency examination to become General Practitioners.

They can continue to be specialists (4-7 years) and then super specialist (2-4 years). 16K - thousand16Indonesia (Cont.)Some Specialists work as GPs and vice versa (Doctors forum).

The competition among doctors to attract patients to their private practices is severe.17MalaysiaMMCPrimary care or General Practice is defined as any doctor who is registered with the Malaysian Medical Council (MMC) and works in a primary care clinic.

,(Ministry of Health Malaysia, 2011)The overall density of primary care clinics was 2.09 per 10000 population and the number of private clinics outnumbered the public by 6.3 to 1. (Ministry of Health Malaysia, 2011)18Malaysia (Cont.),.89The overall primary care doctor to population ratio was 2.89 per 10000 population in 2009.

.Family Medicine SpecialistOverall, 2.4% of primary care doctors were Family Medicine Specialists (FMS) and the majority of these specialists were in the public sector.

19GPs in Malaysia (contd.)In the private sector, it is provided by general practitioners (GPs), specialists in private hospitals, specialists with open access clinics and other health care providers such as dentists, pharmacists, alternative medicine therapists, Chinese and Malay traditional and spiritual healers.

(Kho, S.B., 2006)A Malaysian GP who has completed the 3-year compulsory service in the public health sector can set up a private practice without the requirement of vocational training or postgraduate examination. (Kho, S.B., 2006)

The Malaysian system allows doctors without a specialist qualification to practice as general practitioners.

2020Main services provided (public + private)78.39%chronic disease management (78.39%)

51.81%provision of home visits (51.81%)

66%occupational health services (66%)

94.54%63.28%maternal services (94.54% public, 63.28% private)

21SingaporeThe private general practitioners form an important component of the primary care system as they manage two thirds or more of the total outpatient consultations.

There are the specialists in government and restructured hospitals, National University Hospital and private specialists with consulting suites at medical centres of the various private hospitals. (Lim, L.H.)Community can go directly to see any specialist in private practice. However, the specialists in government and restructured hospitals and the National University Hospitals see patients by referral system. (Lim, L.H.)22Singapore (contd.)Family / primary care medicine is not a specialty in the specialist register

is making progress towards recognizing Family Medicine as a specialty23Common Issues related to lacking of primary doctorslimited access to care,

increasing fragmentation of care,

depersonalization of care,

deemphasis of comprehensive care-all pointing to competition between primary care doctors and specialists.

Geographic maldistribution of doctors have resulted from overproduction of specialists. 2424Regional InitiativesASEAN Created ASEAN Regional Primary Care Association

ASEANASEANASEAN, the Association of Southeast Asian Nation has 10 member countries: 10 ASEAN Member Countries, representing Brunei Darussalam, the Kingdom of Cambodia, the Republic of Indonesia, the Lao Peoples Democratic Republic, the Federation of Malaysia, the Union of Myanmar, the Republic of the Philippines, the Republic of Singapore, the Kingdom of Thailand, the Socialist Republic of Viet Nam25 ASEANKuala Lumpur Declaration: PRIMARY HEALTH CARE, THE DRIVING FORCE FOR A HEALTHY ASEAN 2020.RECOGNISING that Primary Health Care is the key to effective, efficient and equitable health service system which results in accessible, low cost and better health outcomes of health care.26 ASEANKuala Lumpur Declaration: PRIMARY HEALTH CARE, THE DRIVING FORCE FOR A HEALTHY ASEAN 2020. (cont.)ASEAN(ARPaC)ASEAN Regional Primary Care (ARPaC) Conference in 2013 (Philippines) declared among others:

..to establish postgraduate educational programs for primary care doctors and to advocate the inclusion of general practice / family medicine in undergraduate medical programs.

To work towards common standards for quality healthcare, education, training, accreditation and certification to set competencies for general practitioners / family physicians.27Japan (Outsiders view) The private practitioner in Japan is not a general practitioner. A large number of these private practitioners in Japan have spent 5 years or more in a university after graduation in order to get the higher degree of doctor of medical science, i.e. they are specialists. (Lim. L.H.)

Thus, in Japan, the doctors in private practice, the private practitioners who have postgraduate specialty training are expected to assume the role of family primary care physicians and some of them really regard themselves as such. (Lim. L.H.) 2828Japan (Insiders view)(Murai, Kitamura, Fetters, 2005)The majority of Japanese physicians receive specialty training in university hospitals or large hospitals for five to ten years, then about one third of them become private practitioners in a clinic (Murai, Kitamura, Fetters, 2005)

[]Japanese physicians are not restricted by regulations based on their training or board certification and can label themselves by the kind of practice they wish to have2929Japan (Insiders view)By default, these sub-specialty-trained doctors become Japan's self-taught primary care doctors, but they are neither systematically trained for this field nor do they have much opportunity to gain knowledge and skills necessary for primary care through continuing medical education.

Of the 80 medical schools in Japan, 30 have established sougoushinryoubu, and 96 training hospitals have established, or are preparing, a new training program3030Japan (Insiders view)About ten of the medical school sougoushinryoubu decided to use family medicine as a model for their development. An even smaller number appear to be pursuing a general internal medicine model, and the remainder has not made a commitment to a discipline. These often function as basic triage departments to funnel patients to hospital-based sub-specialists who do not want to manage undifferentiated problems.3131JapanJapanese outpatient doctors have virtually no training in primary care

Department of Community and Family Medicine developed a two-year, re-training program for individuals with at least five years clinical experience who are ready to leave hospital-based specialty care and enter the primary care world.

After high school + 6 years Med School (liberal arts, sciences basic medical science, basic clinical medical science, and clinical medicine)+ take a single national medical licensure examination+ residency training+ postgraduate training (4-6 years/rotation-based)32Core CompetenciesEuropean experiences:Primary care management Person-centred care Specific problem solving skills Comprehensive approach Community orientation Holistic modeling

Source: The Regional Organization of the World organization of Family Doctors (WONCA)WONCA Europe ( The European Society of General Practice / Family Medicine

33Additional featuresContextual: Understanding the context of doctors themselves and the environment in which they work, including their working conditions, community, culture, financial and regulatory frameworks.

Attitudinal: based on the doctors professional capabilities, values and ethics

Scientific: adopting a critical and research based approach to practice and maintaining this through continuing learning and quality improvement

34

35Possible forms of Continuing Medical Education or retraining to become a primary care physiciansReceive reorientation

Taking few courses at approved universities

On the job training

CMEContinuing education (Continuing Medical Education/CME)

36Possible forms of Continuing Medical Education or retraining to become a primary care physicians (Cont.)Recertification

Post graduate programme

Lifelong continuing professional development (Australia), it can be online and free of charge

Apprenticeship models

37Approaches to trainingtraditional : training staff designs the objectives, contents, teaching techniques, assignments, lesson plans, motivation, tests, and evaluation

experiential: the learner becomes active and influences the training process. It provides real or simulated situations and trainers roles are more as facilitators, catalysts, or resource persons

(Rama, Etling, & Bowen, 1993)performance-based: mostly task or skill centred (Rama, Etling, & Bowen, 1993)38Types of trainingPre-service: a process through which individuals are made ready to enter a certain kind of professional job.Through formal classesNeed to complete a definite curriculum and courses successfully to receive a formal degree or diploma to be entitled for a professional job In-service

In-service: a process of staff development for the purpose of improving the performance of an incumbent.a problem-centred, learner-oriented, and time-bound series of activities39Types of in-service training that can be considered:induction or orientation training: given immediately after employment

foundation training: to strengthen the foundation of their service career

on-the-job training: ad hoc or regularly scheduled training for the staff and can be done while conducting day-to-day normal activities.40Divide into 2 slides40Types of in-service training that can be considered: (Cont.)refresher or maintenance training: to update and maintain the specialized subject-matter knowledge of the incumbents

career development training: to upgrade the knowledge, skills, and ability of employees to help them assume greater responsibility in higher positions.41Divide into 2 slides41 Possible ways of evaluating the training programmes (Kirkpatrick model)Level 1, Reaction: measures how the trainees liked the programme in terms of content, methods, duration, trainers, facilities, and managementLevel 2, Learning: measures the trainees' skills and knowledge which they were able to absorb at the time of trainingLevel 3, Behaviour: is concerned with the extent to which the trainees were able to apply their knowledge to real field situations.Level 4, Results: are concerned with the tangible impact of the training programme on individuals, their job environment, or the organization as a whole.

42Divide into 2 slides42Evaluating training courses

RecommendationsThe areas of practice must be clearly defined to avoid unhealthy competition.

Continue effort to make primary care medicine as a specialty, so that other specialists not to encroach into another area of specialty for which they had not undergone further training in.

It is important for primary care doctors to improve their skills and abilities to establish both patient and specialist respect. They need to undergo training in Family Medicine.44Recommendations (contd.)Creating clear career path is needed so that Primary Care Physicians will be highly respected.

(Kidd and Watts, 2006)In order to specialize in the generalist tradition, it needs strong standards of education and training and strong government and community support. (Kidd and Watts, 2006)

ASEAN Join effort with ASEAN Regional Primary Care Association

45Further studyMake a study that show GP is needed; Not just showing numbers or stories but both convincing numbers and compelling stories using Mixed research methods:

E.g.: current statistics of GPs, number of patients served, trends

Experimental study comparing the quality of health services in the community that has higher proportion of GPs with those with lower proportion.46Further study(Cont.)E.g.: Conduct a Patient Satisfaction Survey to measure the Customers Satisfaction Index to those served by GPS and non-GP

Interview the informants or video tape the processes during data collection to make greater psychological impact to the stakeholders or the viewers of the research findings. This make them really feel and experience the situation rather than just remember and understand the fact and figures.

Find ways of sharing this findings to the stakeholders, especially to policymakers or politicians.

47Direct Quotes(Kidd and Watts, 2006) As family doctors we are specialists in primary medical care. We specialize in the generalist tradition of medical practice. We specialize in preventive care and health promotionAnd each of us is a specialist in the unique health care needs and concerns of our own unique patient population. This is all part of our generalist tradition. (Kidd and Watts, 2006)

48Related ReferencesMinistry of Health Malaysia. (2011). National Healthcare Establishments & Workforce Statistics (Primary Care) 2008-2009. Clinical Research Centre of Malaysia. Lim, L.H. (No dates). Primary and Specialist Care: Competition or Co-operation ? From: http://www.cfps.org.sg/sfp/21/213/articles/e213139.htmlStarfield, B., Shi, L., & Macinko, J. (02005). Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly,83 (3), 2005 (pp. 457502)Kidd, M.R. & Watts,I. (2006). Primary care is the answer: The role of general practice in Australia. Asia Pacific Journal of Family Medicine, 5 (2)Murai, M., Kitamura, K., & Fetters, M.D. (2005). Lessons learned in developing family medicine residency training programs in Japan. BMC Medical Education, 5 (33).

49Thank you50