Research in general practice

The current healthcare system of Turkey has failed to meet the health needs of the people. Neither the people who use the healthcare services nor the providers are satisfied with current healthcare delivery. Transition from this system of hospital-based health services towards a general practice-based health care system is the core content of the reform process in Turkey. However, although a period of ten years has elapsed, this process has made little progress and the draft laws from 1994 have not yet been enacted. Retraining general practitioners in primary healthcare (PHC) towards general practice/family medicine (GP/FM) and vocational training in GP/FM are challenging issues for the reform process and for academic general practice departments. Following the decision of the Higher Educational Council (HEC) in 1993, departments of general practice have been established in 21 of the 45 medical schools. Despite many substantial problems, there are promising developments in GP/FM in Turkey.     

Family practice: professional identity in transition. A case study of family medicine in Canada

With increasingly fewer family physicians in many countries and students less interested in primary care careers, generalists are becoming an endangered species. This situation is a major health care resource management challenge. In a rapidly changing health care environment, family medicine is struggling for a clear identity-a matter which is crucial to health system restructuring because it affects the roles and functioning of other professions in the system. The objective of our study was to explore representations of roles and responsibilities of family physicians held by future family and specialist physicians and their clinical teachers in four Canadian medical school faculties of medicine, using both focus groups and individual interviews. In addition to family medicine, we targeted residency programs in general psychiatry, radiology and internal medicine-three areas that interface significantly between primary care and specialized medicine. In each faculty, respondents included the vice-dean of postgraduate studies; the director of each relevant program; educators in the program; residents in each specialty in their last year of training. Findings are centred around three major themes: (1) the definition of family medicine; (2) family medicine as an endangered species, and (3) the generation gap between young family physicians and their educators. The sustained physician-patient relationship is considered a core characteristic of family medicine that is much valued by patients and physicians-both generalists and specialists-as something to be preserved in any model of collaboration to be developed. Overall, two divergent directions emerge: preserving all the professions' traditional functions while adapting to changing contexts, or concentrating on areas of expertise and moving towards creating "specialist" general practitioners, in response to a rapidly expanding scope of practice, and to the high value attributed to specialization by society and the professional system.     

Training and application of community-oriented primary care (COPC) through family medicine in Catalonia, Spain

The community-oriented primary care (COPC) approach, implemented in various countries by family physicians, general practitioners, and other primary care workers, integrates clinical medicine with aspects of public health. A process of 20 years of training health professionals (40-hour workshop) by the professional association of family physicians (Catalan Society of Family and Community Medicine), training family medicine residents and giving support to health teams in Catalonia, Spain, generated a present group of 30 primary care teams involved in community health projects. This paper describes and analyzes factors related to changes in the health system, the role of family medicine in Spain, and to features of the COPC approach and its training methods as elements that narrow the gap between training and practice.     

Family medicine: a medical care alternative for Latin America

This paper presents the experience of a residency in family medicine organized 7 years ago by the medical school of the Universidad Autónoma de Nuevo León, Mexico. The residency aims to prepare physicians to provide primary health care. In efforts to teach graduate students the social as well as the biological causes of diseases most commonly reported at the primary care level, graduate students take courses in clinical disciplines, social and behavioral sciences and public health. In its training methodology the program combines teaching, service and research. By now, the department of family medicine has graduated five classes of specialists, all of whom are working in the field of family medicine at the primary level. This fact is particularly worth noticing in a country where there are thousands of unemployed/underemployed physicians. It is suggested that family physicians are satisfying an unmet medical demand of many thousands of Mexicans, and that the care provided by them is less expensive and of better quality than the same care provided by other specialists.     

The National Area Health Education Center Program and Primary Care Residency Training

The Area Health Education Center (AHEC) program was established in 1972 to improve the supply, distribution, retention and quality of primary care and other health practitioners in medically underserved areas. Through academic/community partnerships, regional AHECs offer a broad array of educational programs for students, residents and practicing health professionals. With primary care medical education a core part of AHEC programs, AHECs have been involved in decentralized residency training from the outset, with particular attention to family medicine. This paper provides an overview of the national AHEC program, its core components and its support for primary care residency training. Although AHECs have achieved considerable success in training primary care physicians for their respective states, continued refinements of programs are needed to address the needs of the most rural and underserved communities.     

Emotional distress,occupational stress and burnout among Family Doctors in Europe: Monitoring and testing of interventions is required

In recent years, the medical literature from a wide range of medical specialities has exploded with publications on the theme of emotional distress, stress and burnout in the practice of medicine. Improving the work-life of health care providers is necessary to optimise health system performance. COVID-19 has caused considerable additional pressure on health services across Europe and there have been calls for interventions to address the psychological and occupational stress caused by the pandemic. Although there is an ongoing need to monitor these factors among family physicians, and other staff working in primary care across Europe, we must also identify supports and promote them. Further research is needed to explore causative factors and provide convincing evidence in relation to effective interventions.     

Primary health care for whom? Village perspectives from Nepal

Over the last decade, many developing nations have embraced Primary Health Care (PHC) within their national health plans. PHC, in contrast to earlier approaches to national health development, emphasizes community participation and basic health care for the poorer segments of society. The research reported here finds that in the enthusiasm for the PHC concept in Nepal, important sociocultural processes have been overlooked. This paper describes the relationship between certain sociocultural factors and PHC activities in rural Central Nepal. It reveals a contradiction between the stated PHC intentions to address local interests and promote community participation on the one hand, and the actual approach taken on the other hand. Specifically it argues that PHC is encountering problems in Nepal for three reasons: (1) PHC fails to appreciate villagers' values and their own perceived needs. In particular, PHC is organized primarily to provide health education, whereas villagers value modern curative services and feel little need for new health knowledge. (2) PHC views rural Nepali culture only pejoratively as a barrier to health education. Alternatively, local cultural beliefs and practices should be viewed as resources to facilitate dissemination and acceptance of modern health knowledge. (3) In attempting to incorporate Nepal's traditional medical practitioners into the program, PHC has mistakenly assumed that rural clients passively believe in and obey traditional practitioners. In fact, clients play active roles and are themselves in control of the therapeutic process. Thus, instead of attempting to recruit traditional practitioners to do its work, PHC should recognize the precedent for community participation in Nepal's traditional medical system and develop the respect for villagers' own ideas and values that traditional practitioners already possess.     

Training doctors for family practice in primary health care work in Sri Lanka

Over one-third of the doctors in Sri Lanka are involved in the delivery of PHC. They form one of seven categories of PHC workers—others being the ayurveda physician, the assistant medical practitioner, nurse, midwife, traditional healer and unqualified practitioner. PHC workers function either in the government or private sector. Their functions in the PHC system are not defined and are dependent on state health policies and people's expectations of health care.The secondary and tertiary levels of the health system are managed by the government through a network of hospitals. These hospitals provide Western type health care facilities free to the people. Government PHC workers have access to referral facilities and back up services provided through this hospital system.Doctors functioning within the PHC system had neither undergraduate nor postgraduate training in PHC. Private general practitioners were the first to realise the need for training doctors in PHC. They sought and got government and university approval for postgraduate training in family practice.The family practice training programme is conducted by the Postgraduate Institute of Medicine of the University of Colombo. The course consists of educational and clinical components which could be completed in a minimum of 1 year or maximum of 4 years.Nine private general practitioners and 19 government medical officers registered for the course. Fifteen completed the course in 1 year.Family practice trained doctors will function in a PHC system in which the services provided are not coordinated. Changes in the PHC system are being considered. Government is proposing to establish health centres manned by doctors with sub-centres manned by lesser trained health workers.The medical profession has suggested a unified PHC system and a national health insurance scheme.The exact role of the family practice trained doctor in the country's PHC system cannot be defined. Family practice training should influence and be influenced by changes in the PHC system in Sri Lanka.     

Reducing unmet needs: a prevocational medical training program in public health medicine and primary health care in remote Australia

OBJECTIVES: To describe the development and implementation of a prevocational medical training program in public health medicine and primary health care in remote Australia and to evaluate the program's adherence to adult learning principles. METHODS: Reports, funding applications and other relevant material relating to the program were reviewed to document learning objectives, and teaching and program implementation strategies. RESULTS: The 24-week program employs two prevocational medical practitioners each year and comprises four weeks at Fremantle Hospital's sexual health clinic followed by 20 weeks in the Kimberley. Curriculum objectives include clinical and public health aspects of sexually transmitted infection management, immunisation, clinical audit and quality improvement, primary health care in remote Aboriginal communities, oral and written presentation skills and working as part of an interdisciplinary team. Teaching strategies used were in accordance with adult learning principles. CONCLUSIONS: Prevocational medical training in public health medicine and primary health care in remote Australia is achievable and reduces current gaps in prevocational medical education.     

Predicting career decisions in primary care medicine: a theoretical analysis

Entering the 1960s, more than half of the medical doctors in the United States were family physicians, pediatricians, or general internists. Today, about one-third of all U.S. physicians are primary care practitioners. Although opinions vary on the optimal ratio of primary care to specialty physicians, in the mid-1990s, the consensus among leaders in medicine was that more primary care physicians would be needed to ensure access to quality care. The target output of graduates was set for a minimum of 50% primary care physicians, and medical school admission committees responded. The present study examines research related to career decision making in primary care medicine. We address career decision making in primary care with the expectation that selection of a medical residency is based on multiple factors, and multivariate statistical techniques comprise the most appropriate statistical procedure for developing predictive models of medical student residency choice. Additional multivariate studies for simultaneous analysis of multiple dependent and multiple independent variables are needed to determine whether health policy planners and medical schools should continue to address the distribution of primary care physicians through medical school admissions. Further to enabling prediction, researchers must renew efforts to base investigations on theoretical models, summarizing and organizing previous research, and providing one another with means to focus future studies while building on previous work.     

Evaluation of primary health care reform in Estonia

Estonia began to reform its health care system by reorganizing primary health care (PHC). Ten years ago, the health care system was inefficient, supply was biased towards institutional care, and PHC was almost non-existent in the western understanding: it was provided by different specialists in policlinics, and the financial basis of the system was in crisis. The reform had the following aims: to develop PHC by introducing family medicine, to guarantee the whole population access to family doctors' services, and to secure stable funding for these services. In 1998, a new phase in the reform was introduced through the creation of a new funding system for primary care services. The aim of this paper is to present a practically applicable set of indicators to evaluate PHC reform in terms of health economics criteria and then to apply these indicators in evaluation of the Estonian PHC reform.     

Family medicine and psychosocial knowledge: how many hats can the family doctor wear?

The paper examines the impact of teaching family physicians psychosocial skills and knowledge during their residency training in family medicine. The idea put forth by the family practice profession that family physicians are trained to treat their patients' biological, as well as psychosocial problems, is important to the social work profession since social workers have had primary responsibility in treating patients' psychosocial problems in the health care arena in the United States from 1904 until now. In order to learn about the effect of adding psychosocial knowledge to the family practitioner's training curricula, the author conducted an exploratory and comparative study to see if family practitioners had any more psychosocial knowledge than other primary care physicians. No significant differences were found. Implications of the study for family medicine and social work, primary health care, and social/health policy are discussed.     

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.     

Development of family medicine in Ukraine

Abstract

This article includes a personal history of a family physician working in Ukraine. In June 2012, Pavlo Kolesnyk, Ukrainian Assistant Professor and a Family Doctor was awarded the second Montegute Scholar grant and had the chance to attend the Wonca Europe Conference 2012 in Vienna. In many developed countries, family medicine is already well established. In Ukraine, which has the legacy of a socialist health care system the implementation of the discipline started only at the end of the last century. The changes in the health care system were of greater importance in primary care and family medicine. It gave greater decentralization of the health care system and supported investment in primary care. This article describes the development of family medicine in undergraduate and postgraduate education. Whilst family medicine is officially a priority of health care policy, there is still a long process ahead. Family medicine needs financial support from the government and doctor's wages have to be increased, to prevent this branch of medicine being unpopular among graduating medical students.     

National health system steps in Turkey: concerns of family physician residents in Turkey regarding the proposed national family physician system

Many countries are currently struggling with the public desire for improved health care and provision of basic services on the one hand, and the rising costs of health care on the other. Turkey is acutely experiencing this problem because of its relatively advanced level of economic development and its relatively low level of health status compared to Organization for Economic Cooperation and Development and European Union countries. Since 1990, there has been vigorous debate in the Turkish society regarding the best way to improve public health through improved primary health care. The current government is pursuing a proposal that has been mentioned before, but in a more serious effort than has been previously made. This is an approach to primary care based on systems such as those in the United Kingdom and in Germany, and the basic components are family physicians who have a particular list of patients whom they provide care for. Financing of the system is to be provided with a new general health insurance scheme. In this study, 38 family practice residents at the 3 major training hospitals for this specialty completed an investigator-designed questionnaire for the purpose of characterizing their concerns regarding this proposed system of primary health care delivery. The participants' responses indicated that the new system, which is known as the Family Physician System, will contribute importantly toward raising the overall level of health in Turkey. Specific expected benefits include closer patient-physician relationships, increased job satisfaction on the part of family physicians, and an overall increase in income for the physicians working in the system.     

Extent of utilisation of maternal care services of P.H.C. by the families of a rural area

The utilization of the maternal health care services offered by an upgraded primary health care (PHC) facility in a rural area of West Bengal, India was assessed. Information on the use of the maternal services by pregnant women over a 5-year period was collected from a house-to-house sample of 100 families living less than 1 hour away from the health facility and having at least 1 child born into the family in the previous 5-year period. Women in 58% of the families used the prenatal services of the facility, 6% received prenatal care from private practitioners, and 36% received no prenatal care. Reasons given for not using the facility were 1) using the clinic was too time consuming, 2) the staff was unfriendly, 3) a lack of interest in the services provided. There was no significant differences between prenatal service utililizers and nonuser in regard to caste differences. Utilizers were somewhat more likely to live in households with a literate household head than nonusers. The number of visits made by the utilizers ranged from 1-5, but many respondents had difficulty recalling the exact number. Utilizers were no more likely than nonusers to use the delivery services of the PHC. Among the 58 women who used either the prenatal services of the PHC or of private practitioners, 34 had their deliveries at the PHC, 23 at home and 1 in the hospital. Among the 42 women who received no prenatal care, 15 gave birth at the PHC center, 20 at home, and 4 at nursing homes. Home deliveries were conducted either by untrained midwives or by family members. 3 cases of neonatal tetanus and 1 case of maternal tetanus were reported in the community during the 5 year period. All of these births occurred at home. Only 6% of the 100 mothers used the postnatal services of the PHC center. The findings indicate that the provision of upgraded services by itself is insufficient to overcome the lack of health care motivation on the part of the target population.     

Monitoring quality in Israeli primary care: The primary care physicians' perspective

ABSTRACT: BACKGROUND: Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally. Goals To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care. METHOD: The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians - 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans. Main findings The vast majority of respondents (87%) felt that the monitoring of quality was important and two-thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71%) supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners). At the same time, support for the program was widespread even among physicians who are young, board-certified in family medicine, and salaried. Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems. CONCLUSIONS: The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified.     

Assessment of the association between the qualification of physicians and nurses in primary healthcare and the quality of care

This study sought to establish the association between the attributes of primary healthcare (PHC) and the professional qualification of physicians and nurses. For data collection, the child version of the Primary Care Assessment Tool (Child PCA-Tool) was applied to the caregivers of children resident and registered in the areas covered by the family health teams. The attributes of PHC were evaluated using the scores of the caregivers in the test. After bivariate analysis, seeking an association between the degree of orientation to the PHC and the socioeconomic and demographic characteristics, as well as the professional characteristics of the health units, a multivariate model was established using Poisson regression. The teams in which there were professionals with residence in family health or family and community medicine achieved higher scores than those in which the professionals did not have this qualification. The authors concluded that specialization in residence in family and community medicine for physicians, and residence in family health for nurses, have higher potential for the transformation of the care model, based on the attributes of the PHC.     

Family medicine in Iran: the birth of a new specialty

Since the revolution of 1978-1979, the government of Iran has worked toward development of a primary health care system to improve basic health for its citizens. Although infant mortality and other parameters have improved, increasing urbanization and poor lifestyle choices continue to present major challenges to improving overall health statistics in the country. Generalist physicians, with no training beyond medical school graduation, have not inspired confidence from patients or specialist colleagues. Therefore, many patients prefer to receive care for common health complaints from specialist physicians. Health care for many individuals tends to be episodic, driven by patient concerns for acute illness rather than by patient-centered, longitudinal care. The government of Iran has decided to develop family medicine as a specialty within the country to help respond to these problems. Based on an initial consultation with some leaders in the Ministry of Health and Medical Education, as well as students, nursing staff, subspecialists, administrators, and medical educators, a number of suggested steps were recommended to support the development of family medicine in Iran. These involved, among others, further development of the specialty and parity with other specialties, development of faculty and curricula, and a plan for financing rural health care.     

A comparison of occupational stressors in selected allied health disciplines

Work-related stressors have been linked to a number of diseases, both physical and psychological. Previous studies have revealed that the stressful occupational components are particularly apparent in health care occupations. Occupational sources of stress in three allied health disciplines--nuclear medicine technology, radiologic technology, and medical technology--were studied over the last three years via responses from approximately 500 practitioners. The top five stressors in each discipline were as follows: nuclear medicine technology--equipment malfunctions, add-on examinations, uncooperative physicians, lack of staff, and uncooperative patients; radiography--disrespectful physicians, inadequate pay, unnecessary examinations, lack of staff, and lack of respect; and medical technology--equipment breakdown, poor management practices, difficult coworkers, lack of time, and exposure to human immunodeficiency virus. It is crucial for administrators and fellow health care professionals to be aware of and address those areas of job-related stress that may impact the quality of patient care and the well-being of the allied health professional.