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FAMILY MEDICINE ORIENTED PRIMARY CARE

1 Vision Of Family MedicineOriented Primary Care

2 Introducing Family MedicineTo Health Care Systems

3 A Family MedicineTraining Programme For Indonesia

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FAMILYMEDICINEORIENTEDPRIMARYCARE

CHAPTER 1 VISION OF FAMILY MEDICINEORIENTED PRIMARY CARE

Associate Professor Goh Lee GanWonca Regional President, Asia Pacific

OutlineChallenges in health care systemsMeeting peoples needsIs family medicine the solution?Making things work Towards Unity For HealthClosing the financial gap a 6-Strategy roadmapWhere do we go from here

CHALLENGES IN HEALTH CARE SYSTEMS

The universal challenges to optimal health care delivery in health care systems are theresult of the dream and reality struggle. The dream is the desire of the differentstakeholders policy makers, health professions, academic institutions, health caremanagers, and communities to meet their subsystem goals of quality and equity in eachstakeholders perspective. The reality is that such a system will not be sustainable. Theinterim results are well-known: limited health budget, rapidly rising costs as moreunprevented disease burden takes its toll, inequitable distribution of resources betweenneed and want, and inefficiencies in delivery of care as different stakeholders work

towards a subsystem optimum. The reality is the need for relevance and cost-effectiveness. The solution A balance is needed between quality and equity on the onehand and relevance and cost-effectiveness on the other hand.

Various models have been introduced to find the balance 1978 Alma Ata Declaration:Primary Health Care for All (WHO, 1978), Improving health systems: the role of familymedicine (WHO Europe, 1998), and the WHO-Wonca vision of family medicine(WHO-Wonca Working Paper, 1994). To varying extent, some balance towards equity isbeing achieved.

The lack of unity for health is now seen to be the cornerstone that the variousstakeholders in the health care delivery system need to address A new unity based on acommon vision is needed. This has led to the WHO and Wonca working jointly towardsunity for health in the WHO-Wonca TUFH (Towards Unity For Health) Project across theworld. In this project, the primary care doctor has a role of bridging the differentstakeholders to work toward a common vision for health care delivery.

MEETING PEOPLES NEEDS

What do people need from the health care delivery system has been addressed in a

WHO-Wonca Working Paper, Making Medical Practice and Education More Relevant toPeoples Needs: The Contribution of the Family Doctor, the result of the 1994 Ontario,

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Canada Conference and subsequently by WHO Europe in 1998 in its paper Frameworkfor Development of FP/GP.

Family Medicine, by the nature of its work and core values, can help health systems tomeet peoples needs which are to:

Address common health problems Improve access to care and equity Integrate prevention and care, physical and psychological, acute and chronic diseases Collaborate and co-ordinate care with the health care team more efficiently

and cost-effectively Integrate care of individuals, families and communities.

IS FAMILY MEDICINE THE SOLUTION?

Family medicine is the bridge and not the solution. The 1994 Ontario, Canada

Conference Paper alluded to earlier had this to say:

To meet peoples needs, fundamental changes must occur in the health care system, inthe medical profession and in medical schools and other educational institutions. Thefamily doctor should have a central role in the achievement of quality, cost effectivenessand equity in health care systems.

The family doctor is a good bridge between hospital care & public health; he is able tohelp save costs through being a five star doctor, a model conceptualized by Dr Charles

Boelen, a WHO staff who is now a healthcare consultant. The five star doctor is onewho is:

Care provider, Decision maker, Communicator, Community leader, and Manager of healthcare resources.

How does a family doctor (syn. primary care doctor, general practitioner) help to save

costs? Some examples illustrate the possibilities:

Treatment of acute problems timely and appropriately, getting things right the firsttime particularly in children and the aged prevents death and disability.

Encouraging appropriate lifestyle to control chronic diseases will reduce diseaseburden and truly save costs to the individual, family, community, and nation.

Diet, exercise and weight control (DEW) together they will prevent or reduce theprevalence of hypertension, heart disease, diabetes mellitus, hyperlipidemia and thedownstream consequences from strokes, heart disease and the long termcomplications of diabetes mellitus.

Smoking respiratory consequences of chronic obstructive lung disease, cancer of thelung and ischaemic heart disease are prevented or reduced.

Sexual behaviour sexually transmitted infections including AIDs are prevented.

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FAMILYMEDICINEORIENTEDPRIMARYCARE MAKING THINGS WORK TOWARDS UNITY FOR HEALTH

How does working towards unity for health work? The common vision of reduction ofdisease burden, and promotion of health will place the use of limited healthcare budgetsto achieve the greatest impact on health status. The activities among the stakeholderswill not be divergent. There will be self-care by patients motivated to keep themselves

healthy and to avoid unnecessary use of health resources; appropriate level of use ofservices and not more healthcare and in particular, hospital care; primary care doctors not

just doing gatekeeping and the denial of care but to encourage the appropriate use ofresources where appropriate. The outcome of such healthcare reforms in the minds ofthe stakeholders will be health systems that meet peoples needs.

CLOSING THE FINANCIAL GAP A 6-STRATEGY ROADMAP

Closing financial gap needs to be systems oriented. There are six strategies that need tobe considered and implemented in parallel.

Alignment of Vision Strategy 1

Work towards unity for health: work together for the benefit of all stakeholders. Need for meetings and discussions on how unity for health can be achieved. Work towards appropriate level of care self-care, primary care, and hospital care

(secondary care and tertiary care). Deal with sub-maximisation of goals due to conflict of interests of carers between

levels of care. The primary care doctor can play a 5-star doctor role here in remindingall stakeholders the ultimate goal of health care which is the reduction of disease

burden and promotion of health.

Set Quality Standards Strategy 2

Cost control without standards result in cutting of quality Pay attention to outcome standards examples are control of blood pressure, diabetes

mellitus, obesity, lipid levels, and the levels of disability and mortality in the community.

Reduce Unnecessary Expenditure Strategy 3

The easiest first to reduce expenditure will be to reduce variation of care define bestpractice based on available standards.

Work towards standardisation of services with clinical guidelines get a buy-in bystakeholders, publicise them, promote them, update them to keep them current.

Need the support of all primary care doctor, specialists and patients. Full payment or co-payment by users for non-essential expenditure is a useful cost

control measure need a political will to implement this.

Training Strategy 4

Train ALL stakeholders on their unity role in the health care system. How can they best contribute to close the financial gap must be the common vision.

Pay Everybody Equitably Strategy 5

Poor payment results in cutting corners this is the biggest reason for a failed primary

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care healthcare delivery system it becomes a system with the proverbial outcome ofpenny wise and pound foolish.

Payment may not always be in dollars and cents. Recognition and mutual support for the mission of reducing the financial gap in the

healthcare system are powerful incentives as equity in kind.

Adequate funding for the primary care and prevention have big benefits in savingsthat has never been truly comprehended or never implemented because of lack ofpolitical will. Premium or consultation fee has to be adequate only then can unseen costs be

controlled e.g. unnecessary referrals, incomplete care, reluctance to useessential drugs.

Premium or consultation fee has to be adequate only then will the optimal benefitsof the GP be realised.

Prevention must have an adequate budget for training and implementation ofpatients and doctors it is not free to the health care system. And it is a worthwhile

investment for the healthcare system in the short, medium and long run.

Financing system for the primary care doctorThe important considerations for a managed care system are: Adequate consultation fee for a visit. Number of times per year which will depend on gender and age. Medicine at cost plus 15%.

Some formulas for managed care: Acute conditions = [(Consultation + medicines + injections) X visits per year]/12 per

month e.g. in Singapore NTUC pays [$20 + $5 + 2]X6/12 = $13.50 per head/year. Chronic conditions = [(Consultation X average of 4 extra visits a year) + (medicines at

cost plus 15% X12 months)]/12 per month.e.g. in Singapore NTUC pays ([$20 X 4] + [medicines at cost plus 15% X12 months])

/12 per month.

Payment system for the primary care doctor can be a variety of methods depending onlocal factors and arrangements. Examples within the managed care system can be: Once-off payments for more severe conditions requiring second line medicine

Example, Augmentin for a more severe cellulitis.

Minor procedures Standardised fees will help to reduce variation of costs. Fee-for-service These require the support of the health care provider not to introduce

unnecessary visits or be willing not to charge for visits where the patients is followedup for safety sake (there must be social capital in the community for this to work):Acute condition = $X for consultation & medicineChronic condition = $Y for consultation & medicine

Encourage Best Practice Strategy 6

Discussions and presentations on best practice will spread the best solutions to closethe financial gap in health care.

The healthcare system may wish to consider the best stakeholders of the year awardon best practice policy maker, health professionals, academic institutions, healthmanagers & insurance providers, communities these will encourage best practice.

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FAMILYMEDICINEORIENTEDPRIMARYCARE WHERE DO WE GO FROM HERE

Get the message across that closing financial gap can only succeed if stakeholders areall working towards unity for health.

Organise discussion groups on how to close the gaps by the stakeholders. Discuss on the funding for primary care and prevention.

TAKE HOME MESSAGES Controlling health care costs is everybodys job, not just the policy makers job or the

GPs job. Work towards a 6-point strategy. Do something today about closing the financial gap of the health care system.

CHAPTER 2 INTRODUCING FAMILY MEDICINETO HEALTH CARE SYSTEMS:SINGAPORE, INDONESIA, MYANMAR

Associate Professor Goh Lee GanWonca Regional President, Asia Pacific

OutlineThe Singapore ExperienceThe Indonesian Experience

The Myanmar ExperienceCritical success factors in the introduction of family medicineSyllabus for family medicine trainingFive tasks in training

THE SINGAPORE EXPERIENCE

Critical Success Factor in Introducing Family Medicine into the Singapore

Health Care System: Link Up with Stakeholders

Ministry of Health wanted a vocational training programme; is supportive. College of Family Physicians, Singapore saw the opportunity to promote Family

Medicine through Wonca. The University had sympathetic supporters on adoption of Family Medicine

as a discipline. An external change agent was available. In Singapores case, a Family Medicine

expert was invited to meet up with the various stakeholders to discuss the place offamily medicine, training requirements and organizational matters.

The Hospital specialists were convinced of the importance of well-trained primarycare doctors who were individually willing to contribute their efforts towards trainingthe doctors.

Sequence of developments

1988: pilot Family Medicine programme hospital rotation programmes andpolyclinic posting as pilot vocational training programme.

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1991: started the definitive Masters Programme in Family Medicine hospital based(Programme A) 3-year programme.

In 1993: first examination leading to MMed (Family Medicine) was conducted with 9passes out of 17 who sat.

1995: started Private Practitioners Scheme (Programme B) doctors in primary carepractice 2-year programme entry to programme with experience of at least 4

years in active general practice. 2000: started the Diploma in Family Medicine 2 years course, leading to Grad Dip

Family Medicine entry to programme at experience of at least 1 year inclinical practice.

MMED FAMILY MEDICINE (SINGAPORE)

The Master of Medicine in Family Medicine examination was established in the NationalUniversity of Singapore following the approval by the University Senate in 1991. Initially,it was a programme for medical officers in the public sector healthcare system; this isnow known as Programme A. In 1995, it was felt to be important to have a training

programme leading to the same examination for doctors already in the private sector;this is now known as programme B.

Programme A Modular Course (made up of 3-monthly courses X 8 for the 2 years) the syllabus is

shown in Tables 1A & 1B. The Course is now run as a composite of distance learningset of notes and face-to-face sessions of case-based workshops; application of thecourse material takes place at the clinical and experiential level and tutorials areconducted to take the learning and application further.

Weekly Tutorials & Monthly Workshops focused on case based issues and learning

areas in patients seen in the direct experience of doctors in training. Skills courses BCLS. Hospital rotating postings six monthly rotations, 4 choices out of a list of disciplines

namely, internal medicine (compulsory), paediatrics, O & G, orthopaedics, geriatrics,psychiatry, A& E, dermatology, general surgery.

Examination.

Programme BThe course components are: Modular Course (made up of 3-monthly courses X 8 for the 2 years) the same course

as for Programme A is attended by the Programme B participants (and also the GradDip Family Medicine trainees).

Weekly Tutorials & Monthly Workshops 40 a year X 2 years focused on case-basedissues and learning areas in patients seen in the direct experience of doctors intraining: this is the key component of learning and teaching in this programme.

Skills courses BCLS, Clinical examinations skills course. GP Practice (4 years experience at entry plus 2 years during the programme) Examination.

MMed Examination

3 parts Theory Essay paper (3hours and 4 questions), MCQ (3hours and 120 questions) &

Slide interpretation (1 hour and 30 questions).

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FAMILYMEDICINEORIENTEDPRIMARYCARE Practice Log 1 week profile, 6 case studies (30 minutes oral examination).

Clinical 2 long cases (each 45 minutes); 4 short cases (each 15 minutes).

Grad Dip In Family Medicine

This programme grew out of the recognition that the MMed (Family Medicine) 3 years(Programme A) & 2 years (Programme B) may be too demanding for many family

doctors. Accordingly a Grad Dip Family Medicine was created and launched in 2000. Todate, the programme is in its third year and we have 70 doctors who have graduated.

Grad Dip Family Medicine components: 2 year-course Same modular course for distance learning as the MMed (Family Medicine) course (2 years) Quarterly tutorial (not weekly & monthly as for MMed (Family Medicine). Own clinical practice or hospital work or Government outpatient clinic. Simpler exam 100 MCQ & 10 KFP (3 hours), 10 OSCE based on GP clinical scenarios

(each 9 minutes).

THE INDONESIAN EXPERIENCE

The introduction of family medicine in Indonesia as family medicine oriented primary carehas three reasons to make it succeed:

There is a critical mass of primary care leaders, university teachers, and insuranceproviders, as well as Ministry of Health primary care leaders who have been exposedto the concepts and understanding of the role that family medicine can play in thehealth care delivery system.

Indonesian needs family medicine oriented primary care doctors to be effective gatekeepers in the health care delivery system.

The project between Singapore International Foundation (SIF) & IndonesianMinistry of Health allowed the transfer of skills and knowledge on the organizationand development of a family medicine programme.

What were done right

Time and efforts spent to foster a common vision of the various stakeholders in healthcare delivery on the place of family medicine primary oriented care resulted in goodacceptance of the discipline.

TOT as the transfer of knowledge created a critical mass of committed primary careleaders to spearhead the development of family medicine in the postgraduate andalso in the undergraduate level.

Attention to syllabus and content of family medicine will ensure that the familymedicine programme is built on a focused knowledge and skills base.

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The Stakeholders who are positive for its introduction are: Ministry of Health Indonesian Association of Family Physicians Indonesian Medical Association Universities Ministry of Education

Insurance providers

THE MYANMAR EXPERIENCE

Invitation of Singapore Medical Association and Myanmar Medical Association (MMA)was the entry point for in-depth introduction of family medicine learning and teachingstrategies into Myanmar.

Reason for entry of family medicine into Myanmar Health Care Delivery System GPas primary care provider is recognized to be important. Prior exposure of medicalleaders to the concepts and the role of the family doctor is again important.

Family Medicine Workshop & interaction with MOH & MMA as the means to transferof technology.

Knowledge Transfer Activities

The Myanmese medical leaders met their counterparts from Singapore and discussedthe tasks of organizing a family medicine programme, syllabus and teaching methods.Myanmar has since developed its course and implemented it.

Demonstration of a GP Clinical Teaching Session (Small Group) was done in Yangon. Clinical Short cases sessions were conducted jointly with the Myanmese hospital

specialists for the primary care doctors from Singapore and Myanmar. Visit by Family Medicine programme director designate to Singapore to study training

implementation details in greater depth.

CRITICAL SUCCESS FACTORS IN THE INTRODUCTION OF FAMILY MEDICINE

Some Observations

There are common important milestones in introducing Family Medicine into health caresystems in Singapore, Indonesia and Myanmar. These are:

Adequate presentation to stakeholders on what Family Medicine can contribute important not to over-promise.

Explanation, discussion and involvement of stakeholders in the planning and localdevelopment is an important factor.

External help in developing the curriculum, teaching methods, TOT ideas, andorganization of the training programme expedites the implementation of the trainingprogramme. In the case of Singapore, Australia and UK provided the external help.

Suitable Programme For Rapid Development

The experience from Singapore and Myanmar suggests a Diploma in Family Medicine as

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FAMILYMEDICINEORIENTEDPRIMARYCARE the best level to work towards for rapid introduction. The following are suggested

features of such a programme: Duration 2 years or 1 year. Modular course for distance learning. Workshops for face-to-face exchange of experience and skills. Assessment MCQ, KFP, OSCE are valid and reliable instruments.

SYLLABUS FOR FAMILY MEDICINE TRAINING

The following syllabus was developed for the Singapore programme based on a study ofAustralian, British and American family medicine programmes. It is generic for use in anyfamily medicine programme.

Aim of Training Programme

At the end of the programme, the participant should have achieved the following:

Primary care to have knowledge and skills to be right at the first time. Personal care to have the ability to deal with ideas, concerns and expectations (ICE)of patients, family members and significant others in the patients world.

Continuing care to have a core value to take care of the patient beyondepisodic care.

Comprehensive care to have the concept of curative, rehabilitative,preventive &promotive components of care and be able to adopt these as core values in theplanning and implementation of care. This has been developed into a model by Stott& Davis as acute care, behavioural modification, continuing care, and diseaseprevention & health promotion.

Family as unit of care to have the core value of managing the individual and thefamily unit as an integral system of relationships, care and concerns of the patient.

Emphasis on Care of Patients in the Lifecycle

The care of specific groups of patients is a key concept for the family doctor. The specificgroups of patients are: Mother and child Working adult The elderly Persons with chronic medical condition.

In recent years, mens health too has been included as a focus of learning and teachingtoo. The excess morbidity and mortality is being addressed.

Mother and ChildThe basic principles to be understood are: Vulnerability to poor social conditions

- Mother: during pregnancy & childbirth- Child: during infant & toddler years

Education of the mother is the key to better health.

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More about the MotherOther basic principles to be understood are: Pregnancy: need to educate the patient to prepare for it nutrition of the female

child, birth spacing, self-care, family planning. Childbirth: safe delivery, nutritional status of the mother is important. Post-natal: adequate nutrition, education.

Gynaecological problems: menstrual disorders and anemia, cancer preventionand detection.

More about the ChildOther basic principles to be understood are: The infant: nutrition, immunisation, infection control, WHO IMCI project. Toddler: infection, injury. Older child: infection, behavioural problems, sexual issues. Education of the mother is pivotal to reduce infant mortality.

Working AdultOther basic principles to be understood are: workstress. occupational and work related disorders. lifestyle and sexual issues. chronic medical illness important with advancing age.

These issues require an individual and social approach

The ElderlyThe family physician needs to pay attention to areas of care that will prevent or delayonset of disease and frailty: exercise, diet and lifestyle. attention to acute illnesses & infection homeostenosis. rehabilitation important, needs more time. attention to the giants of geriatrics instability, iatrogenic diseases, incontinence,

intellectual failure.

Persons with Chronic Medical Conditions

The family physician needs to work on the following to reduce the disease burden fromchronic medical conditions hypertension, diabetes mellitus, hyperlipidemia, obesity,ischaemic heart disease, stroke and bronchial asthma: primary prevention risk factors. control, compliance and complication intervention. motivation, enablement and empowerment for self-care. communication, counselling, care co-ordination skills on the family physicians part.

The model of care that has been developed to deal with such conditions is diseasemanagement.

TIME TABLING STRATEGIES FOR SELF STUDY AND FACE-TO-FACE LEARNINGThe big challenge in the implementation of any syllabus of family medicine is the large

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FAMILYMEDICINEORIENTEDPRIMARYCARE number of topics that need to be considered. The strategies found useful are:

Modularisation Group related topics together e.g., those of importance to a specialgroup; or respiratory and cardiovascular systems being considered together becausethe key organs are both in the chest cavity and have similar symptoms. The result ismodularization. The order of study of the modules is generally not crucial.

Distance learning Introduce distance learning which is to have notes and topics of

a module defined for the learner for his or her own self study. Module sizing Determine the size of a module and the time to be devoted. This

depends on the interplay of which are the critically important topics that must becovered and the time available. The grouping of topics into must know, good toknow, and nice to know is one way of helping to make decisions of what to include.

Portfolio learning Introduce the technique of portfolio learning which is for eachcourse participant to record on one page each case which offers something to learn inthe course of daily practice the following: (a) brief description of the case history,clinical findings and other tests; (b) why is this case included difficulty in diagnosis,pitfall avoided, mistake made, successful management, and other reasons; (c) learning

points. Over time, these cases become the learners portfolio for learning andteaching. These are the cases that the course participant bring to the class discussionin the tutorials.

Face-to-face learning Include face-to-face teaching sessions which can be smallgroup, or big group, and in some situations one-to-one. These can be (a) case-basedworkshops where case-based scenarios that the learners have worked on asassignments are discussed in class; (b) case based tutorials where cases from portfoliosare discussed; (c) clinical skills sessions e.g., physical examination techniques, problemsolving exercise, or learning a new technique like counseling, communication, stress

relaxation techniques. In other words, self-study is not enough. There is a need forface-to-face sessions. The number of face-to-face sessions to the number of modulesof self-study will depend on the ability of the participants to meet. The frequency maybe weekly or fortnightly for small groups of 5-6 to meet for tutorials and monthly toquarterly big group meetings for workshops.

FIVE TASKS IN TRAINING

There are five generic tasks in setting up a Family Medicine Programme. They are:

Syllabus development Knowledge base reading texts Training system Training of trainers (TOT) Standardised training programme

Task 1 - Syllabus Development

Three part syllabus see Table 1 made up topics in the columns of whole personmedicine, disease management by body systems, and practice management. Principles of FM column 1 and row 1 of Table 1 consultation, communication,

counselling, problem solving; Care of people of different age groups and areas of care patients with chronic medical problems, children, women, adult, elderly.

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Systems medicine CVS & Resp; GI; blood & renal & oncology; Psychiatry; Skin;Emergency, Bones & Joints; Nervous system, Eye, ENT; Nutrition, metabolic,endocrine problems,

Practice management managing information & medical records, confidentiality,computerization; managing people and resources; managing facilities and utilities;managing finances including managed care; managing quality.

Task 2 - Knowledge Base Development

Compile as a teaching programme, knowledge and best practice related to relevantproblems in the setting covering: Early disease, undifferentiated problems. Established disease. End stage disease. Referral. Health education and preventive focus.

Task 3 - System of Training

Some thought into the organization and administration of the training system isnecessary. Areas to be addressed are 1 Trainer to n trainees; a good number for n is 5. Two year programme is adequate; one year may be a bit rushed. Tutorials Weekly tutorial of about one to one-half hours will be adequate (40/ yr).

Each could be organized to have time for hot items could be an ECG, an aspect ofcare to share, a drug update that the participant had learnt in the past one week(30 min); case presentations (30 min X 2 cases); and discussions.

Workshops Monthly 1 1/2 hours (12/yr) these are devoted to more in-depth casediscussions where specialist resource persons may be invited.

Skills training back to hospital to learn examination of patients.

Task 4 - Training of Trainers

Attention to develop a corps of trainers is crucial. The areas to pay attention to are: Tasks of a teacher role model, motivator, disseminator, assessor, researcher. Methods of instruction (MOI) lecture, workshop, tutorial, clinical teaching,

case analysis. TOT Workshop practice skills learning and transfer of technology designing a

course; teaching skills required of a workshop, a tutorial, a presentation, and a one-to-one coaching and mentoring; paper assessment instruments i.e., MultichoiceQuestions (MCQs) and Key Feature Problems (KFPs); practical assessment instrumentsi.e.,Objective structured clinical examination (OSCE), short clinical cases, andlong cases.

Task 5 - Standardised Training Programme

Important concept to remember for sustainability in the long run. The core programme must be standardised.

Care provided by practitioners need to be consistent irrespective of provider conceptof best practice and reasonable competence.

Reduce variation of care concept of practice guidelines.

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FAMILYMEDICINEORIENTEDPRIMARYCARE References and further reading

CFPS website: http://www.cfps.org.sgFabb W, Goh LG. Family medicine development in the Asia Pacific Region. Sing Fam Physician Jul-Sep 2001:27(3):31-36.Goh LG, Lim J, Goh MC. Cultivating habits for life-long learning. Sing Fam Physician Jul-Sep 2001:27(3):50-53.

Table 1A. Family Medicine Syllabus Year 1 Singapore

Period Whole person Disease mgmt Practice mgmtmedicine - by body systems 1 study inOne module 4 units of study 3 units of study bracketsin 3 monthsOne modulehas 8 studyunits

Jul 2002 Practice skills Respiratory disorders 1C: Medical records Sep 2002 1A1 Principles & Cardiovascular & confidentialityof Family of Family MedicineMedicine 1A2 Consultation 1B1 Respiratory

skills infections

1A3 Counselling 1B2 Non-infective1A4 Communi- respiratory

cation disorders1B3 Ischaemic heart

disease

Oct 2002 Child & adolescent Gastrointestinal 2C: Notification, Dec 2002 2A1 Acute disorders certification,

paediatrics 2B1 Upper GI and dispensing2A2 Develop- disorders

mental 2B2 Lower GIpaediatrics disorders

2A3 Adolescent 2B3 Liver & Biliarymedicine disorders

2A4 Behaviouralpaediatrics

Jan 2003 Continuing care Urinary Tract, Blood 3C: Managing Mar 2003 3A1 Principles & Oncological disorders the practice

3A2 Hyper- tension 3B1 Oncologicaldisorders3A3 Diabetes 3B2 Urinary tract

mellitus disorders

3A4 Palliative 3B3 Anaemia,care bleeding,

haematologicalcancers

Apr 2003 Elderly health Psychiatric disorders 4C: Computer use; Jun 2003 4A1 Ageing, 4B1 Anxiety & Medical

fitness, & confusion Informationassessment 4B2 Community system;

4A2 Stroke & psychiatry Research

rehabilitation 4B3 Depression;

4A3 Frail elderly emergencies

4A4 Prescribing

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Table 1B. Family Medicine Syllabus Year 2 Singapore

Period Whole person Disease mgmt Practice mgmtOne module medicine by body systems 1 study inin 3 months 4 units of study 3 units of study bracketsOne modulehas 8 studyunits

Jul 2003 Community, Family Skin disorders, 5C: Standard of Sep 2003 & Patient STI & AIDS care, managed

5A1 Human 5B1 Non infective care, infamousbehaviour dermatoses conduct& beliefs 5B2 Infective

5A2 Family in dermatoseshealth & 5B3 Acne, pigment,illness nail & hair

5A3 Public health disordersdiseasecontrol &immunisation

5A4 Preventivemedicine

Oct 2002 Adult Health Rheumatic, Bone & 6C: Setting up Dec 2002 6A1 Occupational Joint Disorders practice:

health 6B1 Emergency medical &6A2 Workplace care; housecall legal

hazards & 6B2 Rheumatic, perspectivesoccupational bone & jointdiseases disorders

6A3 Fitness to 6B3 Sports &work: return accidentalto work injuries

6A4 Travel

medicine

Jan 2003 Womens Health (1) Neurological, Eye & 7C: Financial Mar 2003 7A1 Family ENT Disorders management

planning 7B1 Common accounting,& infertility Neurological medical

7A2 Common Disorders perspective gynaecol- 7B2 Eye disorders

ogical 7B3 Ear, nose, &disorders throat disorders

7A3 Gynaecol-ogicalcancers

7A4 STD, HIV& AIDS

Apr 2003 Womens Health (2) Endocrine, metabolic & 8C: Quality assurance Jun 2003 8A1 Anetnatal Nutritional Disorders

care, & 8B1 Nutritionaldrug use counsellingin 8B2 Metabolicpregnancy disorders

8A2 Medical 4B3 Endocrine

disorders in disorderspregnancy

8A4 Postnatal carepregnancy

8A3 At-risk

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FAMILYMEDICINEORIENTEDPRIMARYCARE Further reading

Kerjasama Depkes IDI Fakultas Kedokteran. Pedoman Pelatihan Dokter Keluarga, 2003

CHAPTER 3 A TRAINING PROGRAMEFOR INDONESIA

Dr Sugito Wonodirekso, Wonca Country Representative & Associate Professor Goh Lee Gan, Wonca Regional

President, Asia Pacific

This chapter is reviewed from the Buku Pedoman Pelatihan Dokter Keluarga, writtenas a consensus of prominent general practitioners and lecturers from several stateuniversities. The first edition of the Pelatihan was in 2000. A second edition was

produced in 2003. The writing and publication of the document was supported by theIndonesian Ministry of Health.

The programme will make use of different teaching methods distance learning, face-to-face seminars and workshops, and experiential learning in the practice. The topicschosen are focused on medical conditions which are common, important or have a greatimpact on health status if left uncontrolled.

The Family Medicine syllabus is structured into four modular packets A, B, C, & D.Packet A deals with the concepts of family medicine

Packet B deals with managing the practicePacket C deals with medical technical skills and care in specific situationsPacket D deals with applied medicine in the various age groups.

The Family Medicine syllabus will be updated from time to time in line with the localneeds and tailored information from various sources to keep up the latest developmentsin science and technology. The content of each package (especially package C, D) arelikely to have some alterations. Package A and B would have fewer changes, since theydeal with principles and concepts.

The topics in each of the packages will need to be modularized along some pragmaticstrategies. Some guidance has been given in the Kerjasama-IDI-Fakultas Kedok-teran handbook.

Further refinement can be along the sections and chapters in this Primer which havebeen summarized in Table 1. The final selection of topics, teaching methods will dependon the balance of the need to standardize, local need and relevance, as wellas practicality.

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Table 1. The Topics for Packet A, B, C & D Covered in this Primer

Packet A Concepts of family medicine Section 3(Each topic below can be a self-study unit)

1. The central values of family medicine2. Personal care, Continuing care and comprehensive care3. Family as a unit of care4. Emergency care, housecalls and home care

5. Palliative care

Packet B Managing the practice Section 4

(Each topic below can be a self-study unit)

1. Managing people and resources2. Managing facilities and utilities3. Managing information medical records, confidentiality, computerisation4. Managing finances including managed care5. Managing quality

Packet C Medical Technical Skills & Care in Specific Situations C(A) Practice Skills

Section 5 (Each topic can be a self-study unit)

1. The consultation process2. Communication skills3. Counselling skills4. Changing behaviour5. Disease management6. Emergency care skills

Packet C Medical Technical Skills & Care in Specific Situations C(B) Common symptoms

Section 6 (A group of 4 topic can be a self-study unit)

1. Fatigue 2. Weight loss 3. Fever 4. Dyspepsia5. Breathlessness 6. Cough 7. Sorethroat 8. Chest pain

9. Diarrhoea 10. Constipation 11. Vomiting 12. Abdominal pain13. Skin rash 14. Backache 15. Joint pain 16. Giddiness17. Headache 18. Insomnia 19. Persistently crying baby20. Red eye

Packet C Medical Technical Skills & Care in Specific Situations C(C) Specific disorders

Section 7 (Each topic can form 3-4 self-study units)

1. Cardiovascular and respiratory disorders2. Gastrointestinal disorders3. Renal, hematological and disorders4. Psychological disorders

5. Skin disorders6. Bone & Joint disorders7. Nervous system, eye, and ENT disorders8. Nutritional, Metabolic, and Endocrine disorders

Packet D Applied medicine in the various age groups

Section 8 (Each topic can form 3-4 self-study units)

1. Child and adolescent health2. Womens health3. Mens health4. Health of the working adult5. Elders health

6. Public health

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FAMILYMEDICINEORIENTEDPRIMARYCARE

CHAPTER 1 VISION OF FAMILY MEDICINEORIENTED PRIMARY CARE