Family Medicine Development: Strategies in the Asia Pacific Region

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Family Medicine Development Strategies in the
Asia Pacific Region

• A/Prof Goh Lee Gan

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Outline

• The three eras of family medicine development
• Collaboration needed
• Aim of training programme
• Five tasks
• Standardised training programme
• Care of mother child, working adult, the
  elderly, person with chronic medical condition

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The three eras of family medicine development

• Family Medicine went through three eras in the
  Western world
• 1970s Counterculture anti-fragmentation, pro
  patient centred care
• 1980s -- Parity we are as good as you
  specialists
• 1990s -- integrative phase everybody has a
  role to play in making a difference to the
  patients outcome
• JE Scherger

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The three eras of family medicine development (2)

• Singapore like all developing countries went
  through the eras but we learnt to transit the
  eras in a more positive way
• In our development programmes we have always
  included the specialists as partners we define
  what we want from them

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The three eras of family medicine development (3)

• WONCA in Asia-Pacific has been a positive
  developmental influence
• The key committee has been the Task Force in
  Family Medicine Education
• The confluence of like-minded personalities in
  WONCA Asia Pacific helped to move quickly through
  the counter-culture towards integrative phase of
  development
• We learned to co-exist and mutually leverage on
  the strengths of the specialists and the
  generalists

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Collaboration needed

• Experience worldwide is development of Family
  Medicine needs collaborative efforts of
  stake-holders
• Ministry of Health
• National Medical Association
• Aacademic institutions
• WONCA
• Regional Medical Associations in Asia Pacific
  region

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Aims of Family Medciine training programme

• Prepare the doctor of today and tomorrow to
  undertake the critical tasks of family medicine
• Preventive care
• Reducing burden of illness early diagnosis,
  timely treatment, continuing care, palliative
  care
• Co-ordination of care
• Gate-keeping not only resource allocation but
  also set standards

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Aims of Family Medciine training programme (2)

• Empower primary care doctors to provide
• Primary care -- right first time
• Personal care -- Ideas, Concerns and
  Expectations
• Continuing care -- beyond episodic care
• Comprehensive care -- curative, rehabilitative,
  preventive promotive
• To individuals, families as units of care and the
  community both directly and indirectly

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Five tasks in training

• Five tasks need to be completed
• Syllabus development
• Knowledge base -- reading texts
• Training system
• Training of trainers (TOT)
• Continuing professional development (CPD)

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Task 1 - Syllabus development

• Three part syllabus
• Principles of FM -- consultation, communication,
  counselling, problem solving
• Care of specific groups of people people with
  chronic medical problems, children, women, adult,
  elderly
• Practice management -- record keeping, setting
  up practice, administration, quality assurance

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Task 2 - Knowledge base development

• Early disease, undifferentiated problems
• Established disease
• End stage disease
• When to refer
• Health education and preventive focus
• Knowledge of problems relevant locally

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Task 3 - System of training

• Private Practitioner Scheme (PPS)
• 1 Trainer --gt 5 trainees
• Defined programme (1-2 years)
• Tutorials -- Weekly 1 1/2 hours (40/ yr)
• -- hot items (30 min) case presentations (30
  min) discussions focussed skills teaching
• Workshops -- Monthly 1 1/2 hours (12/yr)
• Skills training -- back to hospital to learn
  basic skills and also for updates on case
  management

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Task 3 - System of training Undergraduate
education

• Singapore As Example
• Family Medicine
• Lectures 2nd year 1X 8 hrs
• Tutorials 2nd year 3X 2 hrs
• Postings 3rd year 1 week GP posting, 1 week
  polyclinic posting
• Integration with Public Health
• Primary health care
• Biostatistics
• Health behaviour in health and illness
• Community medicine case study

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Singapore Undergraduate education

• Lectures Tutorials
• Topics
• Family Medicine as a discipline
• Family in health and illness
• Doctor-patient communication
• Disease patterns and problem solving
• Consultation and counselling
• Continuing care and comprehensive care
• Emergency care and housecalls
• Terminal care
• Case based tutorials
• Family in health and illness
• Elderly care
• Principles of family medicine

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Singapore Undergraduate education

• Postings -- Exposure to different settings
• GP clinic exposure to
• Organisation of care
• Consultation process
• Housecalls
• Case learning in depth clerk one case in
  specified format
• Reason for encounter (RFE)
• Problem list
• Consultation process satisfactory or not? Why
• Learning points

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Singapore Undergraduate education

• Postings Exposure to different settings
• Government polyclinic exposure to
• Organisation of care
• Domiciliary care follow nurse on round
• Consultation learning by doing

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Singapore Undergraduate education

• Consolidation of learning from the posting
  departmental teaching on the GP posting
• Present cases clerked as a problem solving
  session
• Sharing of experiences of cases based on reason
  for encounter
• the acute case,
• the housecall,
• the problem of living case,
• the check-up case
• The follow-up care case

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Singapore Undergraduate education

• Consolidation of learning from the posting
  departmental teaching on the Polyclinic posting
• DM/HT as examples of chronic medical problems
  Care issues, The health care team
• Child care/Family planning as examples of care
  processes

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Singapore Undergraduate education

• Ideas for future programme (2002 onwards)
• GP Posting -- Extend posting to 4 weeks morning
  clinics afternoons group activities
• Longitudinal care

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Singapore Undergraduate education

• Ideas for future programme (2002 onwards)
• GP Posting Extend posting to 4 weeks morning
  clinics afternoons group activities
• GP clinic (host) general introduction,
  different age groups
• Polyclinic 1 week -- general introduction,
  different age groups
• Paediatric specialist outpatient clinic 1 week
• Corporate GP clinic -- sessions

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Singapore Undergraduate education

• Ideas for future programme (2002 onwards)
  Longitudinal care
• First year introduction to GP practice, 1
  antenatal case ? for 5 years follow-up
• Second year Acute care in GP practice, 1 adult,
  1 elderly case ? for 2 years follow-up
• Third year Community medicine case study with
  case in hospital (medicine posting) ? for 6
  months follow-up

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Task 3 - System of training Graduate Family
Medicine Training

• Range of possibilities using Singapore as
  example
• Master of Medicine
• MOH stream since 1992
• PPS stream since 1995
• Graduate Diploma since 2000 July
• Continuing medical education and continuing
  professional development

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Master of Medicine

• MOH PPS
• 3 years 2 years
• FMTP FMTP
• 2 years hospital postings 2 years in own
  practice
• 1 year in outpatient postings
• Weekly tutorials Weekly tutorials
• Monthly workshops Monthly workshops
• Skills courses Skills courses
• Advanced FM course Advanced FM course
• MMed(FM) Examination MMed(FM) Examination

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Master of Medicine

• FMTP
• Distance learning course 8 modules _at_ 3 monthly
• Face-to-face workshops 4 sessions _at_ 3 monthly
• Syllabus
• Module 1 Principles of FM (4)
• -- Respiratory and Cardiovascular problems (3)
• -- Medical records confidentiality (1)
• Module 2 Child health (4)
• -- GI tract biliary tract (3)
• -- Notification, certification dispensing
  (1)

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Master of Medicine

• FMTP
• Syllabus
• Module 3 Continuing care (4)
• -- Oncology, blood and renal problems (3)
• -- The doctor as manager (1)
• Module 4 Elderly patient (4)
• -- Psychiatry (3)
• -- Computer use (1)
• Module 5 Community, Family Patient (4)
• --Skin disorders (3)
• --Practice issues (1)

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Master of Medicine

• FMTP
• Syllabus
• Module 6 Occupational health (4)
• -- Rheumatic, bone joint disorders (3)
• -- Setting up practice (1)
• Module 7 Gynaecological patient (4)
• -- Neurological, eye ENT problems (3)
• -- Financial management (1)
• Module 8 Obstetric patient (4)
• -- Endocrine, metabolic nutritional
  disorders (3)
• -- Quality assurance (1)

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Master of Medicine

• Examination
• Theory
• Paper 1 Essay and MEQ
• Paper 2 MCQ
• Paper 3 Slide interpretation
• Practice profile oral examination
• 6 case studies and practice log
• Oral examination (30 min)
• Practical examination
• 2 long cases medicine and paediatrics
• 4 short cases medicine, paediatrics, OG,
  surgery/orthpaedic surgery

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Graduate Diploma in Family Medicine

• FMTP 8 modules in 2 years
• Tutorials - quarterly
• Workshops
• Communication counselling
• Principles practice
• Basic clinical course (1 week)
• MCQ OSCE Examination

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System of training PPS and GDFM

• 1 Trainer --gt 5 trainees
• Two year programme (may need to modify it in
  other countries)
• Tutorials -- Weekly 1 1/2 hours (40/ yr)
• -- hot items (30 min) case presentations (30
  min) discussions
• Workshops -- Monthly 1 1/2 hours (12/yr)
• Skills training -- back to hospital

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Task 4 - Training of trainers

• Tasks of a teacher -- role model, motivator,
  disseminator, assessor, researcher
• Methods of instruction (MOI) -- Course
  organisation and design, tutorials/workshops,
  clinical teaching, case analysis, assessment
• TOT Workshop (Collaborative efforts of local and
  overseas trainers ) about 50 trainers each time.
  
• Programme development some trainers will need
  to undertake this task

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Task 5 - Continuing Professional development

• Need also to work towards a continuing
  professional development programme for ALL
  primary care doctors
• Knowledge updates
• Clinical skills capacity building
• Some research skills
• Some teaching skills for self development and
  teaching others

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Need for standardised training programme

• Important concept to consider
• The core programme must be standardised to be
  applicable across the profession -- This will
  reduce variation of care and be less confusing to
  the patient

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Care of patients through the lifecycle

• Mother and child
• Working adult
• The elderly
• Person with chronic medical condition
• They have special needs that primary care doctors
  must understand and meet. See next slide

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Mother and child

• Key points to note
• Vulnerable to poor social conditions
• Mother during pregnancy childbirth
• Child during infant toddler years
• Empowerment of the mother is the key to better
  health of the child and the nation through
  education
• Surplus income that the mother can have will be
  translated to better nutrition of the children

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More about the Mother

• Key points to note
• Pregnancy antenatal preparation-- nutrition of
  the female child, birth spacing, self-care,
  family planning
• Childbirth blood, safe delivery
• Post-natal adequate nutrition, education
• Gynaecological problems menstrual disorders and
  anemia, cancer prevention and detection

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More about the Child

• Key points to note
• The infant nutrition, immunisation, infection
  control. WHO IMCI project
• Toddler infection, injury
• Older child infection, behavioural problems,
  sexual issues
• Education of the mother is pivotal to reduce
  infant mortality

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Working adult

• Key points to note
• Need to deal with
• workstress
• occupational and work related disorders
• lifestyle and sexual issues
• chronic medical illness -- important with
  advancing age
• Requires individual and social approach

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The elderly

• Key points to note -- prevent onset of disease
  and frailty
• exercise, diet and lifestyle
• attention to acute illnesses infection --
  homeostenosis
• rehabilitation important, needs more time
• attention to the giants of geriatrics --
  instability, iatrogenic diseases, incontinence,
  intellectual failure
• Social support keeps patient in community

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Chronic medical conditions

• Key points to note
• primary prevention -- risk factors
• control, compliance and complication intervention
  
• motivation, enablement and empowerment for
  self-care
• Needs communication, counselling, care
  co-ordination skills

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Take home messages on family medicine development

• Family medicine has an important role to pay
  deliver care that is personal, primary,
  continuing and comprehensive care to the
  individual, family and community
• Family medicine development needs collaborative
  efforts professional association, university
  and government
• Take a national approach
• Train the trainers
• Encourage continuing professional development