A plea for an initiative to strengthen family medicine in public health care services of developing countries.

An analysis of standards for the best practice of family medicine in Northern European countries provides a framework for identifying the difficulties and deficiencies in the health services of developing countries, and offers strategies and criteria for improving primary health care practice. Besides well-documented socioeconomic and political problems, poor quality of care is an important factor in the weaknesses of health services. In particular, a patient-centered perspective in primary care practice is barely reflected in the medical curriculum of developing countries. Instead, public sector general practitioners are required to concentrate on preventive programs that tackle a few well-defined diseases and that tend to be dominated by quantitative objectives, at the expense of individually tailored prevention and treatment. Reasons for this include training oriented to hospital medicine and aspects of GPs' social status and health care organization that have undermined motivation and restricted change. A range of strategies is urgently required, including training to improve both clinical skills and aspects of the doctor-patient interaction. More effective government health policies are also needed. Co-operation agencies can contribute by granting political protection to public health centers and working to orient the care delivered at this level toward patient-centered medicine.     

Extending rural and remote medicine with a new type of health worker: physician assistants

The purpose of this paper was to demonstrate that the medical workforce shortage is an international phenomenon and to review one of the strategies developed in the USA in the late 1960s: the physician assistant model of health service provision. The authors consider whether this model could provide one strategy to help address the medical workforce shortage in Australia. A systematic review of the literature about medical workforce shortages, strategies used to address the medical workforce shortage, and the physician assistant role was undertaken. Literature used for the review covered the period 1967-2006. Physician assistants provide safe, high-quality and cost-effective primary care services under the direction of a doctor and respond to workforce shortages in rural and remote areas, family practice medicine and hospital settings. This model of health care provision has been adopted in several other developed countries, including England, Scotland, the Netherlands and Canada. The physician assistant concept might provide Australia with a novel strategy for addressing its medical workforce shortage, particularly in rural and remote settings.     

The role of the schools of public health in the development of primary health care

Starting with the assumption that the schools of public health can and should be major promoters of primary health care but that they have not fully utilized their potential, the paper reviews the different interpretations of primary health care and their implications for the recruitment policies, educational objectives, teaching methods and research orientation of the schools. Four interpretations (primary health care as a set of activities; as a level of care; as a strategy of organizing health services; and as a philosophy permeating the entire health care system) are identified. It is suggested that most industrialized countries already have a primary medical care system which has to be transformed into primary health care. A blueprint for this transformation is outlined. Many of the changes included in the blueprint are related to the concept of primary health care as a strategy. Schools of public health can play a major role in implementing the necessary strategic changes and in training their implementers. The training of actual primary care providers for leadership; increased emphasis on management in the curricula; and reorientation of research towards primary health care are underlined as particularly important elements in the new role of the schools of public health.     

Population-based health principles in medical and public health practice.

Traditionally, medical education, research, and practice have focused on the care of the individual but an increasing emphasis on the care of populations has raised awareness among academic medical centers, integrated delivery systems, and managed care organizations of the value of embracing population-based health principles. Five principles are relevant in this regard: a community perspective, a clinical epidemiology perspective, evidence-based practice, an emphasis on outcomes, and an emphasis on prevention. This article describes these interrelated concepts together with specific strategies to effect implementation. Widespread awareness and adoption of these principles will have a profound impact on medical and public health education, practice, and ultimately the public's health.     

分级诊疗制度实施中医院检验科如何提供区域检验服务的思考

随着我国分级诊疗制度的实施,三级医院检验科面临分级诊疗带来的挑战和机遇。理性评估检验科的优势、劣势、机会和威胁,积极响应国家政策的号召,适时调整学科发展的方向,集医学检验之优势资源,整合检验设备,发挥在医学服务、技术创新、质量管理和人才培养等方面的引领作用,积极探索并大力发展区域医学检验机构和尝试分级检验模式,服务基层群众,提升检验行业的公信力和竞争力;以拓展服务领域,开创良好的检验医学发展前景。     

Designing Web-based telemedicine training for military health care providers

BACKGROUND: The purpose of the study was to ascertain those learning objectives that will initiate increased use of telemedicine by military health care providers. Telemedicine is increasingly moving to the center of the health care industry's service offerings. As this migration occurs, health professionals will require training for proper and effective change management. The United States Department of Defense (DoD) is embracing the use of telemedicine and wishes to use Web-based training as a tool for effective change management to increase use. This article summarizes the findings of an educational needs assessment of military health care providers for the creation of the DoD Web-based telemedicine training curriculum. METHODS: Forty-eight health care professionals were interviewed and surveyed to capture their opinions on what learning objectives a telemedicine training curriculum should include. RESULTS: Twenty learning objectives were found to be needed in a telemedicine training program. These 20 learning objectives were grouped into four learning clusters that formed the structure for the training program. In order of importance, the learning clusters were clinical, technical, organizational, and introduction to telemedicine. FINDINGS: From these clusters, five Web-based modules were created, with two addressing clinical learning needs and one for each of the other learning objective clusters.     

Improved training in primary health care: field follow-up essential

A strategy was developed for the evaluation of a management course for medical officers assigned to rural hospitals in the Sudan. The training program on primary care and rural hospital management was designed by the Faculty of Medicine of the University of Gezira, the Center for Population and Family Health of Columbia University, and the Sudanese Ministry of Health. The 3-week training program was designed to deal with: primary care strategy and priority measures such as immunization, oral rehydration, nutrition and growth monitoring, antenatal care, the identification and referral of high-risk pregnancies, and child-spacing; the planning, implementation and evaluation functions of management, using the community as a learning laboratory; and the selected policies and rules of the Ministry of Health, with emphasis on the control of epidemics an the management of drug supplies and information reporting systems. Assessment tools were introduced during the training for use during field visits to trainees 3-5 months later. These follow-up visits involved both conversational interviews and structured data collection. During the field visits 26 rural medical officers gave information on locations of hospitals and durations of assignments; areas served; hospital and primary care unit personnel, vehicles, petrol allowances, refrigeration, maternal and child health records, immunization equipment and supplies, and drugs; road conditions and distances between regional hospitals and outlying units; key events since training; primary care and hospital problems, assessment of needs and resources, objectives and strategies for the next 12 months; 12-month implementation plans and training activities undertaken or planned; planning and perception of supervision; supervisory visits made to rural hospitals by senior officers of the Ministry of Health; use of training materials; management audit exercies; trainees' impressions of the course; and support given by projects of the Ministry of Health or nongovernmental organizations. The field assessment revealed that 60-80% of the trainees were using newly learned techniques and initiating new primary care activities and viewed the fieldvisits as supportive and important to continuation with their new undertakings.     

Youth gambling problems: a public health perspective

Problem gambling has recently emerged as a significant public health issue. While most efforts target adult pathological gamblers, there is growing concern that adolescents and young adults represent the highest risk group for gambling problems. Prevailing public health initiatives addressing youth problem gambling are only beginning to be examined. Drawing upon the Ottawa Charter for Health Promotion as a guiding framework, a prevention model and framework for action are presented to better understand and address problem gambling from a population-based perspective. This framework applies denormalization, protection, prevention, and harm-reduction principles to youth gambling problems and describes primary, secondary and tertiary prevention objectives. A foundation for the development, implementation and evaluation of comprehensive, multi-level health promotion and prevention strategies for youth problem gambling is provided.     

医防融合背景下我国基层医疗卫生机构医防工作现状及认知调查

目的 通过调查我国5省基层卫生人员医防工作的参与情况与对开展医防融合工作的认知现状, 探讨目前基层医防融合工作存在的问题,为促进基层医疗卫生机构医防融合工作提供参考依据。方法 采用多阶段分层抽样,根据地域方位差异分别抽取四川、贵州、江西、江苏和广东5个省,再依据经济状况每省选取3个区县,共15个区县的乡镇卫生院和社区卫生服务中心(站)的卫生人员(6 439名)进行问卷调查与访谈, 对调查数据进行描述并对医防融合工作参与情况与认知现状进行检验。结果 从事公共卫生工作的958名卫生人员中,仅有292人(30.5%)同时参与公共卫生服务与医疗服务,有615人(64.2%)只参与公共卫生服务; 51.7%的公共卫生工作人员以独立公共卫生服务的方式参与基本卫生服务。从事公共卫生工作的卫生人员主要以护理学和临床医学专业为主,仅15.6%的人员具有预防医学专业背景。从事临床医疗工作的1 964名人员中,1 464人(74.5%)医疗服务与公卫服务均参与,但对基本公共卫生服务的投入时间相对较少。不同岗位的卫生人员参与医防工作的情况不同(=2 208.874,P<0.001)。结论 基层临床医疗工作与公共卫生工作机制相对独立。公共卫生工作人员因缺乏疾病诊断治疗能力或无处方权而不能很好地参与到临床医疗工作中; 临床医疗工作人员因缺乏公共卫生知识和技能对公共卫生服务的参与受限。 建议整合医防融合服务机制,打造基层整合型服务; 培养基层医防复合型人才,加大全科医生培养力度。     

推进实施性研究在中国公共卫生领域的应用

随着医学实践的迅速发展,循证医学将最佳证据、临床经验和患者价值有机地结合,循证公共卫生在公共卫生领域的作用也日益突显。然而,仅有约50%的循证医学证据能够真正转化成常规的卫生保健服务,且转化过程耗时长。为了弥合从最佳证据到临床或公共卫生应用之间的鸿沟,实施性研究作为一门新兴学科应运而生。本文介绍了实施性研究的产生背景、发展、理论和方法,并讨论其在中国公共卫生领域的应用及面临的挑战。     

VIOLENCE AGAINST WOMEN: AN EDUCATION PROGRAM FOR RURAL COMMUNITY HEALTH WORKERS

ABSTRACT: This study aimed to identify the educational needs of community-based rural health professionals regarding violence against women, and was funded under the Rural Health Support, Education and Training (RHSET) program. Focus groups and teleconferences were conducted with health workers, organisations and key individuals in the Wide Bay Region, Queensland, Australia. As a result, an education package has been designed that will provide specific training in violence against women for rural and remote health professionals working in the field. Rural health community workers identified the need to enhance their intervention skills and understanding on the issue of violence against women. A distance education framework based on adult and guided learning principles has been developed to meet this need. Six areas were identified as important learning needs and included: (i) violence against women as a public health concern; (ii) The role of the community health worker; (iii) How the community health worker can empower women experiencing violence in their lives; (iv) Enhancing and developing supportive networks; (v) Building on community development action; and (vi) Where to next for community health workers.     

Rural interprofessional education: promoting teamwork in primary health care education and practice

In a climate of increasing incentives to work effectively within a primary health care team, the ability of various health care professionals to collaborate comes into focus. The principles of effective teamwork can be learned and this learning is most effectively achieved in the field under the supervision of experienced preceptors. It is also enhanced if learners have the opportunity to participate actively in the team and do so from undergraduate level. A 3 year project is underway in Victoria involving rural primary care placements for mixed groups of nursing and medical students. The students are educated in the field by medical and nursing tutors and preceptors who are currently working closely together. The learning objectives include understanding the principles of collaboration, teamwork and various roles in the health care team within a primary health care framework. The present paper describes the context for an evolving interprofessional education project in rural primary care, designed to promote collaboration. It outlines the policy underpinning the project's development. It provides a brief review of the associated evidence base, highlighting barriers to and enablers of interprofessional education. Lessons learnt during the implementation and evaluation of this project will guide efforts to extend the reach of interprofessional education across the primary health care sector.     

疾病预防控制机构公共卫生医师规范化培训的内涵建设思考

规范化培训是医师,包括公共卫生医师成长的重要阶段,当前疾病预防控制机构公共卫生医师规范化培训正在进行试点,关于公共卫生医师的规范化培训应包含什么内容,以及如何进行培训,都在摸索和积累经验的过程中。文章就“规范化”为切入点,对公共卫生医师规范化培训中涉及的师资选择、教学内容、教学过程、教学主客体、教学条件、教学管理体系等内涵设计提出建议,旨在提供思路,以规范公共卫生医师规范化培训的建设。     

Two models of primary health care training

Summary. In 1991, the Fiji School of Medicine restructured the training of its medical students, dividing the 7-year course into two phases. Students now undertake a 3-year community-oriented primary care practitioners course, after which they may elect to continue practice in a primary health care role, or to undertake further hospital-based training to complete their medical degree. The course responds to the health needs of the South Pacific, and the local patterns of morbidity and mortality, rather than measuring itself against the curricular demands of its more developed neighbours, Australia and New Zealand. At the same time, the Tropical Health Program of the University of Queensland Medical School responded to demands from the Aboriginal and Torres Strait Islander community to develop primary health care training at degree level. This was intended to complement other strategies undertaken by the Aboriginal and Torres Strait Islander Studies Unit such as the recruitment and support of indigenous students through mainstream health professional education. There was a need to address health priorities that are very different to those of the Australian population as a whole, as well as the sociopolitical and cultural context as it affects both students themselves and health issues in their communities. Both institutions have chosen problem-based teaching/learning as appropriate to their courses, and content is also similar, though with emphases that reflect the differing contexts. The two courses are examples of innovative responses by centres with university medical faculties to specific issues in health education.     

DEVELOPMENT OF ORAL HEALTH TRAINING FOR RURAL AND REMOTE ABORIGINAL HEALTH WORKERS

ABSTRACT: Research data exists that highlight the discrepancy between the medical/dental status experienced by Aboriginal people compared with that of their non-Aboriginal counterparts. This, coupled with a health system that Aboriginal people often find alienating and difficult to access, further exacerbates the many health problems they face. Poor oral health and hygiene is an issue often overlooked that can significantly impact on a person's quality of life. In areas where Aboriginal people find access to health services difficult, the implementation of culturally acceptable forms of primary health care confers significant benefits. The Aboriginal community has seen that the employment and training of Aboriginal health workers (AHW), particularly in rural and remote regions, is significantly beneficial in improving general health. In the present study, an oral health training program was developed and trialed. This training program was tailored to the needs of rural and remote AHWs. The primary objective was to institute a culturally appropriate basic preventative oral health delivery program at a community level. It is envisaged that through this dental training program, AHWs will be encouraged to implement long-term preventive measures at a local level to improve community dental health. They will also be encouraged to pursue other oral health-care delivery programs. Additionally, it is considered that this project will serve to strengthen a trust-based relationship between Aboriginal people and the health-care profession.     

John Flynn meets James Mackenzie: developing the discipline of rural and remote medicine in Australia

This commentary is a reflection on the lives of two men, whose qualities seem to reflect those needed in the establishment of the academic discipline of rural and remote medicine in Australia. The two men displayed three characteristics which those involved in change require: they were there; they equipped themselves to make a difference; they were not afraid of where change might take them. If rural and remote Australasia is to receive appropriate health care, the main medical workforce has to be made up of contextually trained rural generalists. This rural doctor will be a general practitioner with the additional competencies of paediatrician, internist, obstetrician, anaesthetist, surgeon, emergency physician and so forth, depending on the needs of both rural hospital and community. Without training for this role, our ageing rural workforce will never be renewed. Our medical schools, postgraduate councils and colleges are currently failing to provide appropriate numbers of such Australian trained graduates to fulfil the needs of rural communities. That task needs to be carried out by an academic discipline of rural and remote medicine, working through all these bodies. The current tripartite structure of medical education (4-6 years medical school, 2-3 post-graduate years, 4 years vocational training) with metropolitan domination and frequent transfer of responsibility, is directly contributing to the crisis in rural medicine, where 'rural and remote' is seen as an occasional tourist destination, rather than the centre of the process. The Rural Clinical Schools model needs to be expanded to provide a platform for appropriate education and a training pathway not only for medical students, but also for prevocational, vocational and established rural generalists. Only in this way will we be able to convert the 'Tsunami of medical graduates' expected in 2010 to an adequate supply of rural and remote generalists into the future.     

Australian issues in the provision of after-hours primary medical care services in rural communities

OBJECTIVE: In 2003 the Rural Doctors Workforce Agency in South Australia (SA) facilitated the 'SA Rural Hospital After Hours Triage Education and Training Program'. It was designed to improve communication between rural general practitioners (GPs) and nurses undertaking after-hours triage, provide training in triage for rural nurses and develop local collaborative after-hours primary medical care models that can be applied in other settings. DESIGN: The program consisted of a series of three workshops. The first workshop provided an opportunity for GPs and nurses to discuss local issues relating to after-hours primary medical care service delivery. This was followed by a one-day workshop on triage for nurses. A follow-up refresher workshop was conducted approximately six months later. SETTING: Twenty-three rural communities in SA. PARTICIPANTS: Rural GPs and nurses working in rural communities. RESULTS: This paper reports on the issues highlighted by clinicians in providing after-hours primary medical care in rural and remote communities. These included community expectations, systems of care, scope of practice, private practice/public hospital interface, and medico legal issues. CONCLUSION: The issues facing after-hours health services in rural communities are not new. There are many opportunities for improvement of systems. A formal program including workshops and training has provided a useful forum to commence service improvements.     

Introducing training in primary health care programme management into the curriculum

A short account of the objectives and strategies of Gezira Medical School in relation to community medicine and primary health care is given. The introduction of primary health care programme management into the curriculum is described. Preliminary evaluation of the first course reflected positive results for students' achievement and acceptance. The experience proved the feasibility of integrating health care programme management into the undergraduate curriculum.