Overcoming Specialists Apathy Toward Family Medicine Chris Jenkins

Overcoming Specialist’s Apathy Toward Family Medicine Chris Jenkins, M. D. Family Medicine global Health Workshop September 8 -10, 2010

The Problem (Consultants Need to Recognize It) • Specialists are often apathetic or resistant to the specialty of family medicine* • Need to win the active support and acceptance of specialists for FM • Goals of this talk – – Give historical context Identify reasons for specialist's apathy A few country specific examples and suggestions Formulate ideas for winning specialists cooperation and support of family medicine * ‘General practice’ is the term most commonly used outside the US

The Situation: Historical Context • Countries with specialty based medical systems – Historically • Priority was training specialists • Salaries low for all doctors but on par with salaries in other sectors • Medical profession seen as prestigious because of level of training/education • Lacked a well trained generalist. Generalists were – “Feltchers, ” bare foot doctors, etc, not seen as prestigious • Health care providers who did not specialize were poorly trained and gave low level care

The Situation: Current Circumstances • Countries with specialty based medical systems – Present • Persuaded that primary care is important – Alma-Ata Declaration of 1978 – Prevention, management of care, care of common illness, etc. • Trying to include generalists with higher levels of training into their medical systems – – Retraining programs Post-graduate residency training programs IMF and others willing to fund these efforts Transitioning to balance between primary care and specialty care • Economies changing – Government control verses private sector – Primary care seen as an economical way to provide care for many people

The Situation : Current Circumstances • Countries with specialty based medical systems – Economics • Salaries changing: – business people can make much more now – Wide gap between specialty salaries and salaries of primary care doctors » Official GP salaries often higher » Unofficial GP salaries in reality much lower • Often no jobs available for GPs – Attitudes, perceptions, values • Specialty training remains prestigious • GPs associated with low lever trained “bare foot” doctors • Other specialists do not respect GP’s training or skills

The Situation • Countries with specialty based medical systems – GP models • Poor models of general practice lead to professional dissatisfaction • Lower level of training than necessary to accomplish assigned tasks • Unattractive to medical students – Patient perceptions and attitudes • Lack accurate knowledge of specialty • Lack confidence in specialty • Under utilize services

The Situation: Specialist’s Apathy • Do not understand the role and concept of family medicine • Do not understand not convinced of the need for a well trained generalist • General practice associated with low level “feltchers” and “bare foot doctors” – Consider GPs poorly trained – “They don’t know as much as I do about my specialty. What use are they? ” • May see GPs as competition for patients

The Situation: Specialist’s Apathy • Reluctance to teach – Turf: Specialty faculty often feel GPs/FPs don’t need depth of knowledge – or shouldn’t be in their specialty teaching service at all – Specialists do not understand their role in teaching GPs • GPs trained to manage common conditions in many specialty areas and to know when to refer – Usually do not know how to teach GP residents • How to select information from their body of knowledge • How to design curriculum

The Situation: Specialist’s Apathy • Reluctance to teach, cont. – Specialists may not be reimbursed for teaching GPs but it requires more work on their part – Economics: Students represent future competition • Specialists don’t understand referral systems – Drafted from their own specialty to head GP departments and be faculty • Specialists not involved – Neglected by national planners – Not adequately involved in planning the training of the new specialty – They don’t “own” their role in the new specialty

Specialty Apathy: What to Do? • No perfect solution yet • Most countries have not dealt with the problem adequately • Some have alienated other specialists • Catch 22: – specialists must be involved because there are no fully trained family doctors to begin with – Specialists usually do not want to be involved

Some Examples: China • Huge country, huge medical system • Decided in 1999 that GP would be part of medical system • Capital Medical University – write policy and design training for GP in China • Experienced the common reactions from specialists – Went slow: did not make a large scale initial attempt

Some Examples: China • The first 8 -10 years: Retraining programs – 600 hour (later reduced to 500 hours) program – Second-tier medical school graduates put through retraining – Mixed results • The next phase – residency trained GPs • Currently about 40 pilot GP programs across the country – Three years – Includes hospital training and specialty departments – Teaching specialists from these programs brought to Beijing for training

Some Examples: China • Annual national conference for specialists teaching at pilot programs, cont. – Four day conference • Two days led by faculty of CMU: government policy, national direction of GP, finances, etcetera • Two days by foreign experts in general practice: – Philosophy of GP, role in health care system, scope of practice – Role of specialists in teaching GP residents » Why they are needed » How to decide curriculum » Common conditions » Recognition of disease requiring referral » Cooperation with GPs: referrals, more interesting cases for specialists and common ones treated by GPs

Some Examples: China • Annual national conference for specialists teaching at pilot programs, cont. – Four day conference, cont. • Faculty development: how to teach – Teaching analytical thinking skills – Current adult learning theory and teaching methodologies – Precepting – Teaching in the hospital and in the clinic – Etcetera • Whole person care • Other

Some Examples: China • Annual national conference for specialists teaching at pilot programs, cont. – Four day conference, cont. – Approximately 130/year, annually for four years • Basically the same material each year with new specialists from new and older programs • New knowledge and changed attitudes • Return to programs with new appreciation for general practice, a new understanding of their role in training GPs and the complementary nature of primary care and subspecialists and some new teaching skills • A big country – 520 specialists is a small beginning but they are in strategic centers

Some Examples: China Comments from Other Programs • Relationship building with specialists is key – Invite specialists to lecture to GP residents in GP clinics – Have occasional specialty clinic for selected patients – Attend hospital and specialists sponsored CME and make one-on-one contacts – Teach English at government hospitals – the GPs become the specialists

Some Examples: China Comments from Other Programs • Money – salary is very important – Often determining factor in medical student’s specialty choice – Higher salary for residents attracts better students which improves GP reputation • Shenzhen paid GP residents 3 x what others got • Program very competitive: 1 in 5 accepted; excellent students – “Higher salary for GP jobs would make even the specialists take notice” • US example typical – primary care seen as money saver. Save more by paying FPs less – Medical students no longer want to go into FM

Some Examples: Afghanistan • A job description: outlines responsibilities with respect to the training program • Involve them in morning report and AA • Involve them in faculty meetings and decision making • Working alongside of them in medical staff committee work, e. g. , QA, infection control, etc. Thus we all serve on the medical staff, and work together to make the hospital better • Intentionally doing faculty development • “The onus is on us to prove it works”

Some Examples: Central Asia (Local Level) • Mixed efforts, mixed results – Kyrgyzstan • System made a very good effort t o train and incorporate GPs into the system • Considered the best trained GPs in Central Asia • MOH – started GP training programs in medical schools • Trained faculty to understand teach general practice • Initially recruited good students to be trained • currently – Salary problems – Emigration – Low student interest » Less qualified students now applying and fewer of them

Some Examples: Central Asia (Local Level) • Mixed efforts, mixed results – Kazakhstan • Had support of MOH but never won the minds of leaders • Had conferences for specialists to explain specialty • Medical conferences in schools by foreigners for students to promote and explain the concept and scope of practice • Failed to – – Make adequate model Create jobs for those going into general practice Pay well enough to enable practitioners to live on salary Generate enthusiasm except in a few advocates • Limping along now • However, it has received post graduate training programs with other specialties so may succeed in the long run

Summary: Gaining Specialist Cooperation • No perfect answers - a long term project • Relationships are key • Communication and doctor education is critical – Systematic program of informing and training specialists – Philosophy, role, need, practice of new specialty – New specialty not competition but collaboration • Generate referrals • Specialists do cases they trained for • GPs help them care for patients they were not trained for • Involvement in planning from beginning • Help them understand their role in training – Help develop curriculum – High level training in primary care – Reimburse for time spent in training GPs • Encourage planners to pay GPs adequately

Questions?