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Considering the Education for Physicians for Brazilian Health Clinics


Considering the Education for Physicians for Brazilian Health Clinics W. Rosser, Professor and Head Department of Family Medicine Queen s University – PowerPoint PPT presentation

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Title: Considering the Education for Physicians for Brazilian Health Clinics

Considering the Education for Physicians for
Brazilian Health Clinics
  • W. Rosser, Professor and Head
  • Department of Family Medicine
  • Queens University
  • Kingston, Canada

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

  • 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

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.

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
  • 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

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
  • I will hope that most of the audience will be
    persuaded that this is a reasonable and
    achievable objective for Brazil.

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.

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

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.

What do people expect from a primary care
  • 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.

What do people expect from a primary care
  • 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

What do people expect from a primary care
  • 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.

What do people expect from a primary care
  • 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.

  • 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.

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.

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.

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
  • Clinical skills include diagnosing and managing
    common and important medical problems. (See lists
    in handout)

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.

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

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.

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.

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.

  • 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.

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.

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

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.

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.

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.

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.

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.

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

Community Experience
  • 5.Gain the ability to critical appraise the
    medical literature and incorporate it into their
  • 6.To gain skills in dealing with psychosocial
  • 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.

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)

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.

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.

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.

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

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.

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.

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

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
  • 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.

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.

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
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 .

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.

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

  • 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.

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.

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.

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. 

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

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.

  • 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.

  • 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.

  • 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