The Need to Train Physicians for Rural Primary Health Care in Latin America: Some Family Medicine Experiences*

ABSTRACT: Training strategies to prepare physicians for rural primary care generally have not been a feature of medical education in Latin America. The emergence of family medicine as a specialty discipline has resulted in a number of primary care educational initiatives which are designed to give students or residents the knowledge and skills necessary to practice in rural settings. Specific programs in Mexico, Colombia, Chile, and Argentina are identified and discussed. These programs were selected because they raise a number of educational and manpower planning issues which teachers of family medicine and rural primary care need to address if the long-term viability of these programs is to be achieved. These issues include: the role of the community as an educational laboratory, the supervision of community-based learning experiences, the development of strong clinical and community health promotion skills, the reinforcement of positive primary care learning throughout training, and the development of rural health role models. Manpower planning issues to be addressed include: developing a more precise identity for the primary care physician, a re-examination of the pasantia or year of required community service, developing closer ties between the medical schools and the Ministries of Health and other institutional employers of physicians, and encouraging successful programs to share their experiences with others.     

Health beliefs and behaviors of physician assistants in Texas: implications for practice and education

Concern has been expressed over how the volume and effectiveness of physicians' practices relative to prevention can be increased. While a review of the health care services provided by physician assistants in medical practices indicated an emphasis on health education and patient counseling, there has existed an absence of data regarding their beliefs and practices in the area of health promotion. Based upon an analysis of self-reported data from 256 respondents (89%) of a random sample (n = 289) of the 870 physician assistants in Texas, it appears that physician assistants perceive themselves as having a role in health promotion, are generally satisfied with their preventive health care role, view health promotion activities as being more important in the future, and disagree with the idea that health promotion would not be well received by patients. They routinely gather information on health behaviors and discuss or recommend ways to reduce at-risk behavior. Furthermore, while expressing certainty about their knowledge and skills to educate and influence individuals to change certain risk behaviors, physician assistants indicate less certainty about patient follow-through when it relates to such activities as smoking, drinking, and the use of illicit drugs. Considering the perceived challenge and the view that health promotion will become an even larger component of the physician assistant's future role, these findings suggest a need for additional skills training to better assist patients to modify their more complex health risk behaviors.     

A physician role typology: colleague and client dependence in an HMO

This paper reports on physicians' role definitions in one prepaid group practice, a health maintenance organization (HMO). Colleague and client dependence are reviewed and analyzed as separable dimensions of physician role definitions. Data are derived from documents, interviews, and staff questionnaires collected in 1979-1980. The evidence reported suggests widespread colleague dependence in the HMO. Physicians consulted with one another about patient care and engaged in informal referral and review, developing practice standards; and some of these physicians relied on colleagues for handling their patient visits when needed. In relation to their patients, some physicians viewed themselves as bureaucratic officials relatively dependent on client approval in carrying out their health care activities, while others saw themselves as trusted medical experts in a setting free of nonmedical constraints in patient care. The relationship of organizational structure to these different role definitions is discussed. Classifying these HMO physicians according to a fourfold typology of professional dependence shows that most are Organizational Physicians (Type I), who are both colleague and client dependent. Collegial Physicians (Type II) are colleague dependent and, at the same time, do not perceive clients as demanding. Implications for quality of care and physician satisfaction and turnover are considered.     

Teaching performance improvement: an opportunity for continuing medical education

Practicing physicians generally are not engaged in either the methods of performance improvement for health care or the measurement and reporting of clinical outcomes. The principal reasons are lack of compensation for such work, the perception that the work of performance improvement adds no value and is a waste of time, the lack of knowledge and skill in the use of basic tools for outcomes measurement and performance improvement, the failure of medical educators to teach these skills, and the inability of mentors to model their use in practice. In this article, an overview of the history of quality improvement or performance improvement in general and the adoption of two methods of improvement (Plan-Do-Study-Act and SIX SIGMA) by health care is given. Six simple tools that are easy to understand and use and could be used in every continuing medical education (CME) program are then explained and illustrated. Postgraduate medical educators and CME program directors must step up to the challenge of teaching these skills. By learning to include them in planning, evaluation, policy making, and needs assessments of CME programs, the skills of every physician could be improved. Additional goals of every CME program could be accountability for outcomes, reduction of errors, alignment of incentives, and advocacy for the very best in evidence-based health care. To develop activities that affect physician practice and population health, CME professionals must partner with performance improvement experts for needs assessment and evaluation of outcomes data. An understanding of performance improvement principles helps those in performance improvement and those in CME to determine which educational activities might be expected to influence physician competency and performance.     

Family medicine as an academic discipline: progress, challenges, and opportunities

Family practice as a specialty, now just over 20 years of age, arose in response to increasing public pressure and societal needs, not primarily from a breakthrough in new clinical knowledge or technology advances. Its academic discipline of family medicine is necessarily derived more from its clinical principles and functions in practice than from a unique body of knowledge and skills. Nevertheless, the mixture of knowledge, skills, and attitudes are collectively unique as applied by the family physician, and are teachable, learnable, and subject to critical inquiry and research. This paper presents an overview of the progress, present challenges, and future opportunities of family medicine as an academic discipline. A comparative analysis of the literature in the three primary care specialties reveals more commonalities than differences. Family practice has much to contribute to needed reforms in medical education and the health care system. The field is ideally positioned to be an active part of future resolutions to today's problems in both arenas.     

Patient pain in primary care: factors that influence physician diagnosis

BACKGROUND: The accurate recognition of patient pain is a crucial, but sometimes difficult, task in medical care. This study explored factors related to the physician's diagnosis of pain in primary care patients. METHODS: New adult patients were prospectively randomized to care by primary care providers at a university medical center clinic. Study participants were interviewed prior to the initial visit, and their level of self-reported pain was measured with the Visual Analog Pain Scale and the Medical Outcomes Study Short Form-36. The medical encounter was videotaped in its entirety and later analyzed using the Davis Observation Code to characterize physician practice style. Patient satisfaction was measured immediately after the visit. A review of the medical record was used to assess physician recognition of patient pain. RESULTS: For all patients (N = 509), as the amount of pain increased, the percentage of patients having pain diagnosed by the physician also increased. Female patients reported a greater amount of pain than male patients. When women were in severe pain, they were more likely than men to have their pain accurately recognized by their physician. The correct diagnosis of pain was not significantly related to patient satisfaction. Physician practice styles emphasizing technically oriented activities and health behavior discussions were strongly predictive of the physician diagnosing patient pain. CONCLUSIONS: The diagnosis of pain is influenced by the severity of patient pain, patient gender, and physician practice style. If the routine use of pain assessment tools is found to be effective in improving physician recognition and treatment of patients' pain, then application of these tools in patient care settings should be encouraged.     

Community-oriented primary care: historical perspective

BACKGROUND: Community-oriented primary care (COPC) is a systematic approach to health care based upon principles derived from epidemiology, primary care, preventive medicine, and health promotion. We describe the development of COPC from an historical perspective. A critical assessment of current trends and implication for physician education and practice of COPC will be discussed in a companion article in the next issue of The Journal. METHODS: MEDLINE was searched using the key phrase "community-oriented primary care" Other sources of information included books and other documents. RESULTS AND CONCLUSIONS: In the 1950s, Sydney Kark showed dramatic positive changes in the health status of the population of Pholela, South Africa, using this approach. Similar approaches showed positive change in the health status of poor and underserved populations in the United States. The results were so impressive that the Institute of Medicine recommended widespread application of COPC in the United States. Successful COPC practices, however, have historically required considerable external funding from private and government sources. Thus, controversy about the feasibility of implementation of COPC in mainstream primary care practices developed. Schools of medicine and the discipline of family medicine have struggled to implement effective training in COPC within traditional medical school and residency structures. Yet, the societal need for recognition of and intervention in community health problems and coordination of community health resources continues.     

Presidential address: Preventive medical practice

Review of national programs in the past decade suggests that there is a developing consensus regarding the need for preventive services, but the proportion of them that physicians provide is decreasing. As teachers of preventive medicine, we should have a particular concern with the physician's performance in providing preventive services. Specialization, practice organizations, and comprehensiveness of payment for medical care appear to be related to the volume of preventive services provided. Organized primary care practice sites, where other health professionals are available, seem especially well-suited to providing preventive services. A review of several effective preventive activities involving physicians (child and adult immunizations, early detection and treatment of PKU infants, and stroke prevention) indicates that current prevention practice is less than desirable. Better performance can be attained through successful national and community programs of consumer and physician education. Implications of these observations for medical undergraduate and graduate education in prevention are discussed.     

Health promotion in different medical settings: women's health, community health and private practice

This paper describes the health promotion role of doctors in two medical practice settings: women's and community health centres, and fee-for-service practice. It proposes the establishment of divisions of primary health care in Australia which would be multi-disciplinary and focus on community-wide health issues. The paper is based on data from an interview survey of medical practitioners who had worked in metropolitan Adelaide women's and community health centres and from a questionnaire survey of GPs in private practice. The types of health promotion activity by the doctors in the different settings are discussed. It is concluded that private practice GPs are involved primarily in providing health education advice to individual patients. Doctors within women's and community health centres are more likely to report involvement in group health promotion activity and broader community development initiatives. The study concludes that health promotion which focuses on the health of the local community is best conducted within multi-disciplinary health centres. GPs in private practice are limited by the structure of their setting (particularly the fee-for-service basis and reliance on a single discipline) to health promotion which focuses on the needs of individual patients.     

Compliance with five health promotion recommendations in a university-based family practice

Although numerous recommendations are available to guide the primary care physician's provision of preventive health services, a minority of Americans receive recommended care. This study assessed the extent to which patients in a large, university-based family medicine program were receiving five well-accepted health promotion services. These services included fecal occult blood testing, Papanicolaou smears, mammography, serum cholesterol measurements, and tetanus immunization. Demographic factors associated with receipt of these services were assessed. A minority of active patients received the five health promotion services in the recommended interval: fecal occult blood testing 13%, Papanicolaou smear 41%, mammography 16%, cholesterol measurements 20%, and tetanus immunization 19%. The patient's physician practice group, type of medical insurance, physician visit frequency, and increasing age were associated with compliance with the five studied health promotion services.     

Prevention and health promotion in clinical practice: the views of general practitioners in Europe

BACKGROUND: Disease prevention and health promotion are important tasks in the daily practice of all general practitioners (GPs). The objective of this study was to explore the knowledge and attitudes of European GPs in implementing evidence-based health promotion and disease prevention recommendations in primary care, to describe GPs' perceived barriers to implementing these recommendations and to assess how GPs' own health behaviors affect their work with their patients. METHODS: A postal multinational survey was carried out from June to December 2000 in a random sample of GPs listed from national colleges of each country. RESULTS: Eleven European countries participated in the study, giving a total of 2082 GPs. Although GPs believe they should advise preventive and health promotion activities, in practice, they are less likely to do so. About 56.02% of the GPs answered that carrying-out prevention and health promotion activities are difficult. The two most important barriers reported were heavy workload/lack of time and no reimbursement. Associations between personal health behaviour and attitudes to health promotion or activities in prevention were found. GPs who smoked felt less effective in helping patients to reduce tobacco consumption than non-smoking GPs (39.34% versus 48.18%, P < 0.01). GPs who exercised felt that they were more effective in helping patients to practice regular physical exercise than sedentary GPs (59.14% versus 49.70%, P < 0.01). CONCLUSIONS: Significant gaps between GP's knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention in primary care.     

Physicians, guidelines, and cognitive tasks

Using a case study analysis of the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Treatment of Asthma, this article compares the workflows and knowledge requirements of primary care practice to the structure and content of a well-respected set of clinical guidelines. The authors show that there are discrepancies between physician workflow and the structure of the EPR-3, as well as between physicians' knowledge requirements and the content of the EPR-3. The analysis suggests that closing the gap between medical knowledge and practice will require alternative ways to represent guidelines' knowledge and recommendations.     

Community-oriented primary care: critical assessment and implications for resident education

BACKGROUND: Community-oriented primary care (COPC) is a systematic approach to health care based on principles derived from epidemiology, primary care, preventive medicine, and health promotion that has been shown to have positive health benefits for communities in the United States and worldwide. METHODS: MEDLINE was searched using the key phrase "community-oriented primary care." Other sources of information were books and other documents. RESULTS AND CONCLUSIONS: Because of lack of predictable reimbursement for COPC services and difficulties encountered incorporating COPC in medical and residency curricula, widespread application of COPC has not occurred. Recent trends in public health initiatives, managed health care, and information technology provide an environment ripe for application of COPC in medical practice. Also, recent recommendations made by the Strategic Planning Working Group of the Academic Family Medicine Organizations and the Association of Family Practice Residency Directors regarding specific community competencies for residency training have direct bearing on COPC and family medicine educators. These trends and recommendations, properly configured, will produce a medical training and practice environment conducive to COPC.     

Primary Care Professionals’ Feedback on Smiles for Life Curriculum

To assess the value of Smiles for Life: A National Oral Health Curriculum (SFL) in influencing oral health practices of primary care professionals (PCPs). The National Maternal and Child Oral Health Resource Center’s Partnership for Integrating Oral Health Care into Primary Care (PIOHCPC) project is working with five project teams in Georgia, Illinois, Maryland, Michigan, and Rhode Island that are integrating interprofessional oral health core clinical competencies into primary care practice. The competencies were developed to facilitate change in the clinical practice of PCPs working with vulnerable or underserved populations that lack or have limited access to oral health care. An initial PIOHCPC project requirement was for PCPs (physicians, nurse practitioners, nurse midwives, nurses) to complete at least two SFL courses based on their project population of focus (eg, pregnant women, children, adolescents). The curriculum consists of the following courses: Course 1: Relationship of Oral and Systemic Health; Course 2: Child Oral Health; Course 3: Adult Oral Health; Course 4: Acute Dental Problems; Course 5: Oral Health for Women: Pregnancy and Across the Lifespan; Course 6: Caries Risk Assessment, Fluoride Varnish, and Counseling; Course 7: The Oral Exam; and Course 8: Geriatric Oral Health. Three months after completion of the SFL courses, a 10-question feedback form was sent to PCPs. PCPs working in primary care settings (community health centers, local health department, medical center women’s health clinic) serving pregnant women, children, and adolescents who completed at least two SFL courses as part of the PIOHCPC project. Thirteen PCPs (three physicians, three nurse practitioners, three nurse midwives, four nurses) completed the feedback form. One hundred percent of respondents strongly agreed/agreed that SFL courses (1) reinforced the importance of oral health to a patient’s overall health and well-being, (2) increased their awareness of and familiarity with oral health issues in their patients, and (3) increased their confidence in integrating oral health care into primary care. Seventy-seven percent of respondents strongly agreed/agreed that SFL courses helped reduce barriers to incorporating oral health care into primary care. Sixty-two percent of respondents strongly agreed/agreed that integrating oral health care into primary care improved their patients’ oral health outcomes. The majority (ranging from 85 to 100 percent) of PCPs strongly agreed/agreed that SFL courses helped them integrate the interprofessional oral health core clinical competencies into primary care. Three months after completing SFL courses, PCPs indicated that the curriculum had a positive influence on oral health practices in the primary care setting. These findings are consistent with a 2017 study that examined SFL influence on clinical practice and found that the curriculum positively influenced oral health practices in the primary care setting. Additional feedback could be gathered 1 year post-training to assess retention of PCPs’ practices related to integrating oral health care into primary care. Oral health training is essential for enhancing PCPs’ knowledge and practices related to integrating oral health care into primary care. To respond to the need to integrate oral health care into primary care, SFL should be considered as a training for PCPs. Health Resources and Services Administration.     

SOCIAL DETERMINANTS AND SOCIAL NEEDS

Over the last thirty years, consistent and compelling evidence has documented strong associations between socio-economic risk factors and health outcomes. This has led to a growing number of payment and practice innovations across the health care sector related to identifying and addressing patient social risks alongside more traditional biomedical care. In 2018, the National Academies of Sciences, Engineering, and Medicine (NASEM) convened a one-year national expert committee charged with examining the potential for integrating social care and health care services to achieve better health outcomes and to help overcome major challenges facing the U.S. health care system. Over the course of 2018-2019, the NASEM Consensus Study Committee conducted multiple literature reviews and held several open meetings to gather evidence related to the charge. Though much of the innovation in this field relates to primary care, evidence was also reviewed from other health disciplines. The final committee report highlights five health care sector approaches to providing social care and to strengthening the social resources landscape, including increasing awareness about patients’ social risks; making adjustments to clinical care based on social needs; providing assistance to more consistently and effectively link patients with community-based social resources; better aligning health care resources with community social care activities; and ensuring the health care system is involved in advocacy activities to strengthen social resources. The report also explores the workforce demands of social and medical care integration; health information and technology needs of social and medical care integration; payment models that can support integration; and other major barriers to integration. The NASEM report articulates concrete approaches for the health care sector to address social needs as one part of comprehensive strategies to improve patient and population health and health equity. Key policy recommendations based on the report findings include designing a health care system to accommodate the five approaches; recruiting and training a workforce able to provide social care; developing financing mechanisms that support integrated care activities; improving an interoperable digital infrastructure across health and social care sectors; and funding, conducting, and translating research on effectiveness and implementation of integrated care activities. 40 funders convened to support the NASEM consensus study.     

The patient's view of the acceptability of the primary care in Poland

OBJECTIVE: The aim of the study was to determine how the time factor affected the patients' perception of the acceptability of the primary health care system and to assess their satisfaction with family physician care. DESIGN: A series of cross-sectional studies was conducted in 1998, 2002 and 2006, using face-to-face interviews with structured questionnaires. SETTING: The study was performed in Gizycko, Poland, where family physician services were introduced in 1995. STUDY PARTICIPANTS: Three surveys were conducted, each involving 1000 subjects. Every time, random sample was taken, after selecting a subgroup of patients using medical service within the previous week. MAIN MEASURES: Acceptability of the primary health care system (accessibility, the patient-practitioner relationship, the amenities of care, patient's preferences), perception of the changes in primary care and overall satisfaction with family physician care. RESULTS: Between 1998 and 2002, an improvement was noted, lasting till 2006, in such accessibility components as the possibility of making an appointment by phone or at a definite hour. Some aspects of the patient-doctor relationship indicate that family physician care is directed at illness rather than health-oriented. The level of patient satisfaction was high. CONCLUSIONS: Generally, patients are satisfied with primary care reform and implementation of the family physician system. However, it is easier to improve accessibility of services than physician's personal qualities and the patient-practitioner relationship. Expressive functions of a physician (listening and reassuring) and activities regarding health promotion require special attention in the process of education of family physicians.     

Outing lesbian health in medical education

Lesbian health is emerging as a distinct discipline in practice and research. Evidence is increasingly available that lesbians are a unique and underserved population in the health care system. They display reduced health seeking behaviors and have specific risk factors which potentially affect their health and well being. They also have specific health issues in fields as diverse as fertility, sexual health and mental health, which require specific knowledge from health care practitioners. Above all, lesbian health care consumers repeatedly decry the lack of sensitivity and knowledge that they experience in their interactions with providers, and call for improved training. However, medical education generally ignores lesbian health at all levels. In this paper, the inclusion of lesbian health in medical education programs is reviewed, and recent political initiatives involving gay and lesbian health in Australia are discussed. The paper concludes with suggestions to integrate lesbian health in medical training.     

THE HEALTH EFFECTS OF THE INTERNATIONAL TRANSFER OF MEDICAL TECHNOLOGY

The rapid international transfer of medical technologies to the developing countries is in progress, promoting a “high technology” model of medicine mat is reflected in the structure of hospitals and university faculties, and medical education and practice. The resulting growth of specialties and sub-specialties in hospitals may inhibit the development of appropriate, village-based primary care services. Postgraduate medical education programs donated by the United States, Australia or Europe may disregard the vital issues of provision of universal primary care and local control of health services, and train doctors to devote resources to high technology urban models of care. Medical graduates emigrate to industrial countries because they find no “market” for their services in villages, where needs are the greatest. Bilateral foreign aid programs, WHO sponsored projects, multinational corporate transactions and medical missions and education have been important sources of technology transfer. While a national pharmacopoeia requires only 200 drugs, with 17 basic drugs in village clinics, most patients are denied suitable drug therapy because of inadequate primary care and the inappropriate transfer and promotion of over 4000 drugs that are expensive, incompletely tested in local conditions, or toxic. The deficiency in basic health services means only about 4 million of the 80 million children born each year in Africa, most of Latin America and South East Asia are effectively immunised with available vaccines. There are some apparently successful examples of appropriate health systems, based on the principles of universal access to primary care by health workers, and a national referral system to secondary and tertiary care. Effective monitoring of technology transfer and the development of appropriate health services involves important roles for the WHO and greater international co-operation among community health workers.     

Update: Primary care is not the same as primary health care, or is it?

As primary health care (PHC) evolves from its original conceptual level enunciated in 1978 at Alma-Ata to its present formal body of knowledge and practice, 2 definitional problems arise: whether PHC is a transient jargon or label attached to nothing or whether the older, more restricted term primary care (PC) is the same as PHC. The 1st problem has been rendered irrelevant, but the 2nd remains unsolved. Some controversy exists in both literature and practice. Some health care professionals, especially general practitioners, use the terms interchangeably. This may be because of historic traditions based on the biomedical model of education and practice. The term primary care is credited to the Lord Dawson report of 1920, concerned with the reorganization of medical services in England which resulted in the setting up of health centers. Since 1960 under the National Health Service, general practitioners provided curative and preventive services on a 1st-contact medical basis and by 1962 the term was used to denote general practice. This tradition could have then spread to other western countries, including the US and to developing countries. To humanize this biomedical model, Engel proposed the biopsychosocial model which takes into account the biomedical aspects of disease, the patients' social context, their perception of illness and the interaction of the physician and the health care system. This increased health awareness contributed to the evolution of PHC, which evolved from small-scale experiments. A graphic representation of the relationship between primary (medical) care and primary health care illustrates the various consumer levels and the health care system. The multi-disciplinary concept of primary health care is not interchangeable with primary care.