Developing high quality Family Medicine practice to safeguard the health of our population and towards a healthy development of our health care system

Albert Lee 李大拔, William C W Wong 黃志威, Samuel Y S Wong 黃仰山, Antonio A T Chuh 許晏冬, Augustine T Lam 林璨, Clement K K Tsang 曾廣加

HK Pract 2005;27:368-372

Summary

The recent discussion paper on the future service delivery model for our health care system has highlighted the importance of family physicians. It is important to highlight the unique skills of family physicians and explore how best to build up the basic competencies from undergraduate to postgraduate level. A system of certification for family physicians is needed but we must take into account the historical development of Family Medicine in Hong Kong. The certification system must be reasonable in assuring basic standards. It should also be possible for all practicing primary care physicians to achieve without great difficulty. One should use the concept of professional development for doctors already in practice to achieve the basic competencies in Family Medicine. The family physicians must be well positioned in the health care delivery system and the future system should enable them to be more directly involved in chronic disease management, preventive health services and health promotion activities. All these initiatives need to be put in action as soon as possible.

摘要

最近關於我們衛生服務系統未來服務模式的討論文章強調了家庭醫生的重要性。 強調家庭醫生的獨特技能以及如何將基本能力從本科水平提高到研究生水平， 是很重要的。我們要有一個家庭醫生的認證系統，但我們必須考慮到香港家庭醫學的發展歷史。 認證系統必須確保有合理的基本標準，同時又能讓所有執業的基層醫生不太困難地達到這些標準。 我們應該利用專業發展的概念，讓已經執業的醫生達到家庭醫學的基本能力。 家庭醫生必須在衛生服務提供系統中佔有合適的位置；未來的系統也應使他們能更直接地參與慢性病管理、 預防衛生服務和健康促進活動。所有這些想法都需要儘快付諸行動。兩個論壇的報告。

Introduction

In a recent article in Lancet, the researchers concluded: " ....... abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity account for most of the risk of myocardial infarction worldwide in both sexes and at all ages in all regions."¹ Cost effective behavioural and pharmacological treatments for high blood pressure, diabetes, and raised cholesterol have life saving impacts and should be implemented routinely at primary health care level. There is overwhelming evidence that prevention is possible when sustained actions are directed both at individuals and families; as well as the boarder social, economic and cultural determinants of non-communicable disease.² All these would not be achieved in any country without investment in adequate training of family physicians (FPs) who would provide holistic and comprehensive preventive and curative care in primary care setting. That is why the recent discussion paper on future service delivery model of health care system re-emphasizes the importance of primary medical care and the concept of FPs.³

The discussion has also pointed out the problems of over utilisation of accident and emergency services for non-urgent problems up to level of 70%.³ Recent local studies have also been conducted to explore the factors associated with non-urgent utilisation of emergency services and intervention to minimise the problems. The findings suggested that patients need quality primary health care in the community so they can receive good primary, comprehensive, whole person and continuing care.^4,5 The role of FPs must not only be re-emphasized but as matter of urgency, put into practice and action.

The special and unique skills of family physicians

The discussion paper defines a family doctor as follows: "A family doctor can be a general practitioner, a Family Medicine specialist, or any other specialist. The important point is for the patient to have a continuing relationship with the doctor of his/her choice, and that the doctor has the mindset and training of managing problems at the primary care level in a holistic way".³ We believe that the nomenclature of family doctors, primary care doctors, or FPs is a relatively minor issue. The more pertinent issue is that that FPs need to receive proper and supervised training before they can start their own private practice. This has been the greatest drawback of our health care system and this must be rectified with the health care reform. The specialty of Family Medicine is breadth rather than depth and it needs to act across different clinical specialties and also beyond the health sector. The special skills are comprehensiveness and holistic care, and ability to handle a wide range of high prevalence health problems irrespective of age, sex and the body systems involved. FPs also know both what the population desire and need as they have daily and close interaction with them. This is the reasoning behind the establishment of primary care trusts in the UK. The nature of the work and skills of FPs put them in best position to provide care at patients' initial point of contact and also continuing care. These unique skills are not easy to acquire. They require substantial training, mentoring, and continuing professional development. Many citizens in the community have a wide range of health problems but only a small fraction require in-depth investigations and treatments. Therefore, a good quality and effective Family Medicine service can manage the majority of health problems in the community setting, so leading directly and indirectly to saving of health care costs.

There is plenty of evidence that health care costs are saved by high quality Family Medicine.⁶ FPs are more selective in their investigations.⁷ The use of accident and emergency departments⁸ and hospital admissions⁹ is decreased. Problems are treated at an earlier stage, rendering expensive treatments for late complications less necessary.¹⁰

Undergraduate medical education in Family Medicine

As large proportion of patients and their problems are handled by doctors working in the community, a strong undergraduate medical education programme in Family Medicine is needed for all medical students irrespective which specialties they will enter in future. The general objective should be for all students to understand the concepts and practice of management of patients in a primary, unreferred setting in the community, including how this fits into the total pattern of health care, and into the possibilities of vocational training for Family Medicine in Hong Kong.^11,12 For those students who pursue their careers in secondary and tertiary care, they would work more effectively with family physicians in providing seamless health care if they have gained a better understanding of principles and practice of Family Medicine.

The specific objectives of the undergraduate Family Medicine course at the Chinese University of Hong Kong are:¹¹

1. to perceive the skills and capabilities of family physicians and the potential value of Family Medicine in health care;
2. to be aware of the highly prevalent health problems in primary care as undifferentiated problems at early stage and the ways to handle them appropriately in community setting;
3. to understand disease and its management as part of the entire setting of the patient's life, in pathological, sociological and pharmacological terms and also in relation to the patient's family, occupation and environment;
4. to be acquainted with the unique difficulties of diagnosing disease which presents in an early, undifferentiated form, and of its management outside specialized hospital units;
5. to appreciate the skills in managing multiple problems in a patient in co-ordinated manner;
6. to recognize the need for continuing care in the community of patients with chronic illness;
7. to appreciate the fact that total patient care requires teamwork with other professionals such as nurses, and other community resources;
8. to realize the importance and be familiar with methods of disease prevention and health promotion in the community;
9. to be effective self-directed learners in view of the need for life-long learning required of a professional.

For those students pursuing a career in Family Medicine, they would build on these knowledge and skills to further enhance their competency to practice as FPs. It is equally important for students working in other specialties to have acquired this knowledge and skills so they would interface more effectively with FPs. Problems will arise from interfacing between primary and secondary care if doctors in secondary care have never been exposed to the teaching of Family Medicine. Therefore, a good undergraduate Family Medicine programme is indispensable for effective health care delivery.

Professional development for family physicians

There is also debate as to who can be qualified as FPs. In many developed countries, all doctors entering Family Medicine practice need to undergo vocational training. Vocational training in Family Medicine has been in place for over two decades in Hong Kong as Hong Kong College of Family Physicians (HKCFP), which was the first academic college established in Hong Kong. The HKCFP also being the first college started the vocational training programme for FPs and qualifying examination i.e. Fellowship of the Hong Kong College of General Practitioners (FHKCGP) and subsequently the Conjoint Fellowship of the Hong Kong College of Family Physicians (FHKCFP) and the Royal Australian College of General Practitioners (FRACGP) in the 80s before the establishment of the Hong Kong Academy of Medicine. The only problem is that the vocational training is not mandatory.

One would understand that in the past there were limited training posts in Family Medicine so one could not have all primary care doctors in practice with formal vocational training in Family Medicine. However the Hospital Authority began to have training posts for FPs in the mid 90s and more community based training posts are now available since the take over of general out-patient clinics in 2003 from the Department of Health. Although the number is still behind the expected number, it has reached a reasonable critical mass for young graduates to be trained in Family Medicine before they start their own practice. It is, therefore, reasonable to consider that newly qualified doctors should complete the basic training (four years programme) of HKCFP before they can be certified as FPs and practice independently. The certification should start sooner rather than later for the new generation of doctors. Otherwise, it will forfeit the purpose of vocational training. Those young doctors being trained should have a more formal recognition than their contemporary colleagues who just walk in to practice.

The idea of certification is good and at the start it should include every doctor who wants to practice primary care to join in. Doctors with high initiative should be encouraged to take up various trainings on a voluntarily basis. Certification is highly desirable as such safeguards represent a gold standard for primary care doctors. However, there are other alternatives that can promote the practice of high quality Family Medicine for doctors currently practicing in the community. These doctors might be encouraged to undertake continuous professional development activities. In doing so, they will demonstrate that they have gained deeper understanding of the concepts of Family Medicine and know how to put in practice, as well as gain knowledge of evidence based primary care.

One should view the educational process as learning from mature students. However, it does not mean that anyone can be FPs. The discussion paper has mentioned that primary care doctors need the mindset and skills in management of health problems in community setting. This will be the basis of competency required which is expansion of knowledge and skills of undergraduate Family Medicine teaching. Primary care doctors need to deepen their knowledge in the theory and practice of Family Medicine in order to meet the challenge of developing quality Family Medicine services, and also reflect upon their clinical practice.12 Taken into account the lack of formal training in Family Medicine in the past, academic institutions have developed postgraduate programmes in Family Medicine to empower the primary care doctors to practice under the concepts of Family Medicine, e.g., the Diploma and Master programmes of the Chinese University of Hong Kong aim: ¹²

1. to enhance course participants understanding of the principles and practice of family practice;
2. to equip primary care physicians with special knowledge and skills in some specialized areas to meet their ever-expanding role of family physicians;
3. to help course participants develop a critical approach to their daily practice by closely examining their own work, by learning about the work of others, and by developing a critical approach to published work in order to improve their professional performance;
4. to provide course participants training in research methods, and appreciation of the existing body of research findings so that they can undertake their own research independently.

Although postgraduate taught programmes cannot be viewed as equivalent to formal vocational training, they would provide the educational opportunity to build up the basic competencies for FPs. These programmes can also serve as good foundation for the practicing FPs to pursue more advanced professional development leading to a higher qualification in Family Medicine such as Fellows of HKCFP and RACGP.

Certification of family physicians

A society must have a system to certify FPs to promote the concept of Family Medicine. It does not stop other specialists or non-specialists to practice in community. It is just an indication of recognition for those practicing as FPs. Doctors from other specialties can still be certified as FPs if they fulfil the basic requirement.

The process of certification needs to take into account the historical development of Family Medicine in Hong Kong. Although completion of four years basic training or having a higher qualification in Family Medicine such as FHKCFP and FRACGP or equivalent should be the best benchmark, this cannot be the only route. One would only consider that all newly qualified doctors nowadays should complete basic training in Family Medicine satisfactorily before certification as FPs.

For doctors currently practicing in the community, they should be committed to professional development to demonstrate that they have gained deeper understanding of the concepts of Family Medicine and knowing how to put in practice. They should also have knowledge of evidence based primary care. They can do this stage by stage and achieve the goals within a certain period. The postgraduate diplomas offered by various institutions are able to fulfil this goal. The whole process of certification must bear the spirit to help all the doctors practicing in the community to become certified so we can have a large pool of workforce in Family Medicine.

The way forward

Once we have established benchmarking for FPs in practice, there must be actions within the health care system to re-emphasize good primary health care. Without concrete action, all discussions on health care reform will be on paper only. Once we have a system of Family Medicine practice in place, the practicing FPs should then be better integrated into the entire health care system irrespective whether they are in private or public practice. They should also be more involved in management of chronic illnesses, preventive health services and health promotion activities. Services for some special client groups such as maternal and child health, student health can also be integrated under the hands of practicing FPs rather than compartmentalized services.^13-15 In fact, the practicing FPs should be regarded as frontline health care personnel in the entire health care system while the hospital services would streamline their services for real acute emergency cases, serious illnesses, and illnesses requiring advanced technology in terms of diagnosis and treatment.

The public sector should also re-orientate some of their nursing and allied health services towards primary health care and support the FPs to manage the patients in the community. The concept of primary care practitioners need to evolve in parallel to development of Family Medicine as complementary services. The FPs in the community would then organise themselves in fulfilling their role as gatekeeper to hospitals and providers for continuing care. In doing so we should keep ourselves well aware of the development of Family Medicine around the world, and interchange our experience with other authorities.

There are still some issues to be further discussed and resolved. One should provide incentives for doctors already practicing in community particularly those holding other specialist qualification to undergo professional development in Family Medicine. What are the incentives for young doctors to undergo training in Family Medicine and how would they face competition from specialists practicing in the community who also hold certification in Family Medicine? Should we consider making some changes in the format of higher training to allow trainees to acquire more knowledge and skills of other disciplines as special areas of interest? The discussion on the importance of primary health care started long time ago. The Primary Care Working Party report in 1991 has made good recommendations to take it forward.¹⁶ Greater involvement of doctors practicing in community and experts in Family Medicine will facilitate the process. We have waited for a decade and we cannot afford to wait for another decade.

Conclusion

Adequately trained FPs provide holistic and comprehensive preventive and curative care in primary care setting. There is ample evidence that high quality Family Medicine is cost-effective. Undergraduate medical education should equip students with concepts and practice of management of patients in a primary setting in the community. This is a good start. Mandatory training in Family Medicine for all future graduates who would like to practice as FPs is an issue which we might consider. Doctors currently practicing in primary care should be encouraged to undertake continuous professional development activities. In doing such they might upgrade their practice and improve the quality of care to patients.

Key messages

1. Adequately trained family physicians would provide holistic and comprehensive preventive and curative care in primary care setting. Health care costs are saved by high quality Family Medicine.
2. Undergraduate medical education should equip students with concepts and practice of management of patients in a primary, unreferred setting in the community.
3. We might consider the issue of providing four years of basic training to newly qualified doctors before they can be certified as family physicians and practice independently.
4. Doctors currently practicing in the community should be encouraged to be engaged in professional development to demonstrate that they have gained deeper understanding of the concepts of Family Medicine and are able to improve their standard of care in their practice.