Considering the Education for Physicians for Brazilian Health Clinics

1
Considering the Education for Physicians for
Brazilian Health Clinics

• W. Rosser, Professor and Head
• Department of Family Medicine
• Queens University
• Kingston, Canada

2
Presentation Outline

• Introduction
• What do people want from physicians?
• What are the principles that address the needs
  and wants?
• Methods of educating primary care physicians for
  these roles.
• Strategies for Physician Education for the
  Brazilian Model of Primary Care.
• Ideas

3
Introduction

• Primary Care delivery systems can be subdivided
  into two different strategies.
• Delivery by a personal health care provider Each
  person can identify their personal physician or
  health care provider and the system works to
  maintain continuity for each person or family
  with one or two providers.
• Clinic or polyclinic system Each person attends
  any clinic where care is provided as required by
  a primary care provider without any effort to
  provide personal or continuity of care

4
Personal Health Care Provider

• Many countries from the British Commonwealth
  focus on this model including the UK, Ireland,
  Canada, Australia, New Zealand, South Africa.
  Other European countries like Holland , Belgium,
  and some Scandinavian countries (Finland ,
  Denmark, Estonia, Latvia)
• Other countries such as Germany, France, Japan
  have mixed systems that may have personal private
  care and clinic care in public systems.

5
Clinic or Polyclinic System

• Almost all countries in the former Soviet system
  use a Polyclinic as do a number of European
  countries. Often, private health care can be
  personal and public care is in the Polyclinic
  model.
• In many developing countries, primary health care
  is provided by alternate health care workers and
  not physicians. These individuals may also
  function in a clinic or personal health care
  model.

6
Personal Health Care

• Many of the issues around effective primary
  health care relate to personal health care. Since
  I only have experience with this type of system,
  I am clearly biased towards this style of
  delivery and the remainder of my talk will assume
  a personal type of primary health care delivery
  system.
• I will hope that most of the audience will be
  persuaded that this is a reasonable and
  achievable objective for Brazil.

7
What do people need from Medicine?

• In the twenty first century, people express the
  same fundamental needs for medical care as humans
  have expressed since the beginning of time.
• People need a healer who responds to all problems
  that beset them in their homes, their families
  and their communities.
• They need assistance when sick, in pain, or
  confused to organize their concerns, and to
  advocate for them whatever happens.

8
What do people need from Medicine?

• Only a personal provider can meet these needs.
• Even with the revolutionary changes in medical
  knowledge and technology over the past 40 years,
  the pattern of needs from the community has
  changed very little.
• White 40 years ago and Green in 2001 found that
  during 1 month, of 1000 adults, 750 would
  experience some illness or injury, 500 would
  manage the problem themselves, 250 would seek
  some professional advice, 9 would be admitted to
  hospital 5 would be referred to another
  physician. Less than one would go to a teaching
  hospital.

9
What do people expect from a primary care provider

• 1.Expert Clinician People want a provider that
  is knowledgably able to gather information about
  a problem and effectively develop a strategy to
  manage most conditions most of the time.
• The provider needs to be up to date and sensitive
  to the patients family, community and specific
  cultural needs.

10
What do people expect from a primary care
provider?

• 2. A skilled scholar, scientist, and appraiser of
  new medical knowledge. The provider needs skills
  in self assessment, self directed learning, and
  needs to be an information master, able to
  critically assess new information and determine
  if it will benefit any patient in the community
  setting. Since much new knowledge is developed in
  tertiary care teaching hospitals, it is often not
  transferable to the community.

11
What do people expect from a primary care
provider?

• 3.A skilled interviewer. Patients want a provider
  that understands their viewpoint and is sensitive
  to their feelings and response to their illness.
  This includes providing the patient with an
  understanding of their problem.
• 4. A Health Advocate. The provider needs
  awareness of the determinates of health and be
  proactive in forming healthy public
  policy.(example)

12
What do people expect from a primary care
provider?

• 5. Adaptable.Patients want their provider to
  adapt their thinking to different strategies in
  providing care.They want a provider with a
  passionate commitment to seek the truth, and have
  the integrity to use knowledge to the optimum
  benefit of their patient.
• 6. Collaborative The provider must work
  effectively with other health care providers on a
  team as well as with families and communities.

13
What do people expect from a primary care
provider?

• 7. A steward of precious resources. Using
  consultations wisely, tests according to their
  value to the patient and discussing the risks and
  benefits relative to cost of any therapy.
• 8. A healer. The provider must be able to use
  their personal strengths to encourage healing and
  provide moral support for the benefit of the
  patient. This requires knowledge of ones own
  strengths and weaknesses and personal biases and
  how they may affect relationships with patients.

14
Summary

• Peoples needs and wants from the medical care
  system tend to focus on the presence of a
  personal health care provider who is a skilled
  and knowledgeable clinician with a scientific
  background and an expert in dealing with health
  problems within the environment in which the
  population functions. People want this individual
  to respect them and to be sensitive to their
  personal situation.

15
Principles of Education

• A review of principles for primary care, general
  practice, and family medicine covering input from
  approximately 20 countries found convergence
  around the Four Principles of Family Medicine
  developed by the College of Family Physicians of
  Canada. References for the international
  principles are provided.

16
First Principle

• The physician- patient relationship is central to
  the role of the family physician. Trust and
  respect are essential to sustain a partnership
  sufficient to solve the problems presented by
  each patient.
• Family physicians use repeated short visits to
  build relationships with patients and to promote
  the healing power of physician patient
  interactions. Advocacy for individuals and the
  community arise from this relationship.

17
Second Principle

• Family Physicians are skilled clinicians.
• Clinical skills include expertise in dealing with
  ambiguity and uncertainty in diagnosis and
  management of chronic disorders, emotional
  problems, acute medical crisis, preventive
  strategies and complex bio-psycho-social
  problems.
• Clinical skills include diagnosing and managing
  common and important medical problems. (See lists
  in handout)

18
Family Physicians are skilled clinicians

• Diagnostic strategies include those of watchful
  waiting to diagnose undifferentiated problems.
  Skills also include provision of a number of
  services to a population (list included).
• All of these approaches involve sensitivity to
  the individual and their context.
• Each physician must be able to self assess the
  quality of their work and reflect on how they
  could improve.

19
Third Principle

• Family Physicians are a resource to a defined
  community Brazilian clinics serving a defined
  population are more organized to meet this
  principle than primary health care services in
  most other countries.
• Population/public health principle merge with
  primary health care provision including steps to
  monitor the health of the community. Data
  collection needs to be organized to measure
  health outcomes so the impact of services can be
  monitored.

20
Fourth Principle

• Family Medicine is dynamic in responding to the
  changing needs of the community Ideally, each
  Brazilian clinic would have methods of monitoring
  community needs, community outcomes and also be
  connected to neighboring clinics.
• This connection would allow for provision of
  comprehensive services. Clinics need the ability
  to measure and adapt to the changing needs of
  their community. Self assessment and self
  learning remain integral.

21
Using Four Principle to Produce Physicians,
Nurses, and Health Workers

• Style of educational programs.
• Duration 2 to 5 years of postgraduate training
  may be influenced by content of undergraduate
  medical programs and the defined role of the
  family physician.
• Location In some countries, most of the education
  is hospital based. Many programs are moving to
  have education occur in community clinics or
  organized community based teaching practices.
  Different countries require different roles, some
  including intra-partum obstetrics, minor surgery,
  anaesthesia , emergency room work, and care of
  patients in hospitals or nursing homes.

22
Educational Models

• Affiliation The structure and affiliation of
  educational programs is quite variable. In
  Canada, all programs are affiliated with a
  University requiring faculty appointments for all
  educators. In the U.S., more than half the
  programs have only a hospital affiliation and do
  not require university appointments.
• In the UK and other commonwealth countries, the
  vocational training program is run independent
  of the university by the RCGP. However, each
  University has a small Department of Family
  Medicine for teaching undergraduates and
  conducting research.

23
Accreditation

• The setting of educational objectives and
  standards for a country and then having a system
  to assess how these standards are being met on a
  regular basis is extremely important in achieving
  a uniform standard for educational programs. I
  understand that standards have been developed for
  Brazilian clinics.
• Brazil has developed a final assessment prior to
  gaining specialty status. Examinations and
  standards are usually set by the same body that
  accredits programs.

24
Eligibility for Examination

• When a program is starting, it is important to
  acknowledge experienced practitioners for their
  skills. It also accelerates developing
  considerable numbers of specialists quickly.
• A number of countries have two routes to be
  eligible to take the specialty examination. The
  residency route and the practice eligible route.

25
Practice Eligible Route

• Usually there is a minimum requirement of
  practice experience in a health clinic (usually
  3-5 years).
• The candidate is asked to demonstrate that they
  are up to date by attending approved continuing
  medical education courses. (in Canada 250 hours
  over the 5 years)
• Practice eligible candidates may undergo an audit
  of their practice or records to assess
  eligibility.

26
Residency Training Programs

• The content of residency programs varies widely
  between countries.
• In the U.S. and Canada, there is an expectation
  that graduates will provide in hospital care,
  intra partum obstetrics, and emergency room care,
  and conduct minor surgical procedures.
• In most European countries, the expectation is to
  function only in a community office practice.
• In some countries, even office procedures such as
  pap smears are not part of the role.

27
Residency Training Programs

• Once the functions of the primary care physician
  or provider in a country have been determined,
  the objectives for the educational program need
  to be developed.
• Detailed objectives and determination of
  measuring minimum skills or competence need to be
  developed from the Principles.

28
Program Styles

• As mentioned, the residency program duration
  ranges from 2-5 years. In Canada, and I
  understand Brazil, there is a two year program,
  The US and the UK have 3 year programs, Australia
  has a five year program.
• Duration of the program is influenced by the
  structure ie Canada the entire 2 years are
  integrated with family medicine in the community.
  US usually integrated with community but more
  hospital rotations. UK two years completely
  hospital based with little or no connection to
  GPs and one full year in general practice. This
  model has been criticized.

29
Community Integration

• Over two years the resident spends a minimum of 8
  months full time in Family Medicine teaching
  clinics. During this time they build up their own
  patient practice. They then spend 16 months
  working in medicine, surgery, psychiatry,
  pediatrics, obstetrics, gynecology, and
  emergency. They may also spend time in care of
  the elderly, palliative care, remote medicine and
  many other areas.
• While away from family practice, most residents
  return to their practice to see their
  patients ½ day per week. This allows continuity
  of care and integration with community practice.

30
Residency Training Programs

• In three year programs (US and UK), 1 full year
  is spent in family medicine and the other two
  years are spent in hospital often with little
  connection to Family Medicine.
• Another model is to spend three or four half days
  a week following a group of patients in the
  community practice for the entire 2 or 3 years.
  This is complicated as all other experiences in
  hospital has to be built around the resident
  leaving 3-4 half days per week.

31
Community Experience

• In community teaching clinics residents
• 1. Gain clinical experience by seeing patients
  that they follow over time
• 2. Learn the patient centered approach usually by
  being directly observed by faculty or videotaping
  sessions with patients.
• 3.Gain a theoretical and practical understanding
  of dealing with clinical uncertainty.
• 4. Gain practical experience with common and
  important clinical problems

32
Community Experience

• 5.Gain the ability to critical appraise the
  medical literature and incorporate it into their
  practice.
• 6.To gain skills in dealing with psychosocial
  issues.
• 7.To learn to monitor and describe the needs of
  the community served by the clinic.
• 8. To learn to evaluate the quality of care
  delivered in the practice.

33
Community Experience

• 9. Residents are expected to complete a small
  research project related to activities in the
  clinic. This allows them to gain an understanding
  of research methods and to answer important and
  practical research questions.
• 10. Residents are also expected to conduct an
  audit of some aspect of their clinical work (such
  as rate of pap smears in eligible women, number
  of patients with a recorded BP etc)

34
Community Experience

• 11. Residents are expected to keep a log of their
  clinical work either manually or by computer so
  that their clinical experience can be assessed
  against objectives.
• 12. Residents keep a log of minor surgical
  procedures completed with a sign off by faculty
  that the individual is competent to do the
  procedure themselves.

35
Learning the principles

• The physician- patient relationship is central to
  the role of the family physician.
• Achieved by seeing, following and establishing
  relationships with a cohort of patients in a
  community practice.
• The resident needs to have interviews monitored
  and critiqued. The resident needs to reflect on
  how they can improve. They also need a
  theoretical understanding of the objective.

36
Learning the principles

• The community clinic setting requires a clinical
  teacher who can monitor and critique the resident
  while following a group of patients over time.
  Ideally, the clinic would have an electronic data
  recording system and a video camera to record
  interviews. Part of the residents learning would
  be to function in the clinic team. The supervisor
  would need to evaluate and feed back on the
  residents progress regularly.

37
Learning the principles

• Family Physicians are skilled clinicians.
• The clinical skills are learned in the clinic
  environment working with a skilled clinician.
  This experience recorded by log should be
  supplemented with an ongoing academic half day
  program that covers the latest management of
  common and important problems in practice
  behavior science skills. Monitoring and
  assessment of the residents patient centered
  method and how the resident deals with
  uncertainty is essential

38
Learning the principles

• Family Physicians are a resource to a defined
  community The community clinic is essential in
  this learning. Learning basic epidemiologic
  skills, having a system that allows assessment of
  community needs and conducting research or audits
  on how these needs are met are in addition to an
  ongoing seminar program that is required.

39
Learning the principles

• Family Medicine is dynamic in responding to the
  changing needs of the community. The resident
  needs to participate in learning self assessment
  skills, skills in determining how to best acquire
  knowledge to keep skills up to date. A specific
  academic seminar program is needed over months or
  years to develop these skills.

40
Possible Structure

• In Brazil, the community clinics provide the
  ideal setting in which to provide the community
  experience for one resident.
• A teaching clinic would have a clinical teacher
  as the physician who would be an excellent
  clinician and have teaching skills gained through
  a faculty development program. The clinic would
  have some computer record system and videotaping
  capacity.

41
Possible Structure

• A program would require the number of teaching
  clinics needed for each resident to follow a
  group of patients over the two or three year
  period.
• All the residents would come together in a
  central location at least weekly for their
  academic program, their video tape reviews, and
  their continuing evaluation.

42
Possible Structure

• The faculty to run such a program (ideally from a
  University but could be hospital based) would
  consist of the clinical faculty located in the
  community clinics, educators located centrally
  who would supervise the clinic faculty and
  provide faculty development and the ongoing
  academic theory programs for the residents and
  researchers who would support the research
  program in the residency and conduct research in
  the network of community clinics.

43
Possible Structure
University Faculty of Medicine
Department of Family Medicine Department Head
Central Office Office of Clinical
Educators Office of Clinical Researchers
Teaching Community Health Clinics
50-100 Teaching Clinics
Each with a clinical teacher and resident
44
Education in Center

• The central office is responsible for
  coordinating all the residents experience in the
  community and in hospital. They would need to
  ensure that hospital experience was relevant to
  their objectives .

45
Education in Center

• A University Department of Family Medicine would
  be responsible for undergraduate teaching in the
  medical school. All students should gain an
  understanding of the Principles of Family
  Medicine. This would include diagnosis and
  management of common and important problems in
  the community.

46
Undergraduate Family Medicine

• Teaching clinical skills
• Teaching interviewing skills.
• Teaching problem based learning
• Providing lectures on common clinical problems

• Providing lectures on dealing with clinical
  uncertainty
• Providing lectures on dealing with bio- psycho-
  social problems.
• Providing clinical experience in community based
  teaching clinics.

47
Research

• This structure would provide a remarkable
  practice based research network. 50 clinics with
  4,000 patients in each or 200,000 patients.
• Recommendation from the World Organization of
  Family Physicians
• All member countries should develop sentinel
  practices to provide surveillance reports on
  illness and diseases that have the greatest
  impact on patients health and wellness in the
  community. These practices provide a base to
  collect essential research data.

48
PBRNS Contribution to Research Capacity Building

• collecting empirical data from FP
• relating FPs to researchers and focus research
  on important questions from practice
• disseminating research results in practice
• stimulating research interest in FPs.

49
Examples of Family Medicine Research

• Family physicians at the University of Toronto
  tested a sore throat scoring system in both a
  Toronto teaching practice and a community based
  family practice in a small town. They used an
  already developed scoring system as a predictor
  of patients with or without positive
  streptococcus cultures from the pharynx which
  could reduce antibiotic prescribing by up to 75.
  

50
Family Medicine Research

• A group of researchers at Queens University
  studied management of hypertension in a research
  network of 50 community practices. Their findings
  include the fact that home measurements of blood
  pressure provide different results than
  conventional office readings.They have also found
  that patients follow their BP lowering
  directions, and are equally satisfied when they
  have either three or six month follow up for
  elevated blood pressure. 

51
Family Medicine Research

• Michael Klein at the University of British
  Columbias Department of Family Medicine
  conducted a series of trials on the value of an
  episiotomy and found that midline episiotomies
  consistently produced more pain and more damage
  to the perineum than natural tears. Medio-lateral
  episiotomy, although less traumatic than the
  midline, produced significantly more pain and
  complications than did natural tears. These
  studies have influenced a world wide decline in
  episiotomies.  

52
Family Medicine Research

• A University of Toronto group found that treating
  women for cystitis after testing the urine for
  white cells and nitrites reduced antibiotic use
  in cystitis by 27. This paper was selected as
  the outstanding Canadian Family Medicine research
  paper in 2002.

53
Conclusions

• The Brazilian clinic model, with 25,000
  functioning clinics in the community providing
  medical care to more than 30 of the population
  is a remarkable achievement.
• To optimize the potential benefits to Brazil of
  this achievement, a workforce of physicians and
  nurses specifically trained to function
  effectively in this environment is needed. A
  stimulating and attractive career opportunity
  needs to be created to attract medical students.

54
Conclusions

• This phenomena presents a great opportunity to
  develop academic and research programs that have
  the potential to greatly improve the health of
  the entire population.
• Models from around the world need to be adapted
  to the needs of communities in Brazil.

55
Conclusions

• The potential to greatly improve the health and
  economic well being of Brazilians is present and
  the challenge to the University of Sao Paulo is
  to provide a major contribution to this
  development.