The African Family Physician Regina Wang MD Akbar

The African Family Physician Regina Wang, MD Akbar Rahman, MD, MPH

Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Regina Wang MD and Akbar Rahman MD have indicated they have no relevant financial relationships to disclose. 2

Learning Objectives 1) Re-visit American & European definitions of family medicine, and WHO’s ‘Five Star Doctor’ criteria 2) Identify core components of Family Medicine in Africa 2) Examine ways in which American Family Medicine can both be a resource for, and learn from African Family Medicine 3

Background • Urban-trained US family physicians • Work experience at multiple international sites • 1 yr working in public hospital in Durban, South Africa – NGO: African Health Placements – Employed by SA govt • Physician couple

What is Family Medicine? • AAMC ‘Family medicine is concerned with the total health care of the individual and the family, and is trained to diagnose and treat a wide variety of ailments in patients of all ages. Family medicine physicians receive a broad range of training that includes internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and geriatrics. . . Copyright © 1995 -2014 Association of American Medical Colleges. The AAMC grants permission to reproduce and distribute documents and related images available the AAMC Web site, provided that: use of documents and related images available from this site is for educational and non-commercial purposes only , this includes professional conferences

What is Family Medicine? • AAMC (contd) ‘Family physicians possess unique attitudes, skills, and knowledge that qualify them to provide continuing and comprehensive medical care, health maintenance, and preventive services. . . Special emphasis is placed on prevention and the primary care of entire families, utilizing consultations and community resources when appropriate. Family physicians employ a diverse range of cognitive and procedural skills and coordinate care with other specialists when necessary. ’ Copyright © 1995 -2014 Association of American Medical Colleges. The AAMC grants permission to reproduce and distribute documents and related images available the AAMC Web site, provided that: use of documents and related images available from this site is for educational and non-commercial purposes only , this includes professional conferences

What is Family Medicine? • AAFP: ‘The specialty of family medicine was created in 1969 to fulfill the generalist function in medicine, which suffered with the growth of subspecialization after World War II… family physicians are the only specialists qualified to treat most ailments and provide comprehensive health care for people of all ages — from newborns to seniors… Family physicians deliver a range of acute, chronic, and preventive medical care services while providing patients with a patient-centered medical home… Copyright © 2014 American Academy of Family Physicians.

What is Family Medicine? • AAFP (contd): ‘In addition to diagnosing and treating illness, they also provide preventive care, including routine checkups, health-risk assessments, immunization and screening tests, and personalized counseling on maintaining a healthy lifestyle. Family physicians also manage chronic illness, often coordinating care provided by other subspecialists. From heart disease, stroke and hypertension, to diabetes, cancer, and asthma, family physicians provide ongoing, personal care for the nation’s most serious health problems. ’ Copyright © 2014 American Academy of Family Physicians.

What is Family Medicine? • WONCA Europe 2011 ‘General practitioners/family doctors are specialist physicians. . . They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespective of age, sex and illness. They care for individuals in the context of their family, their community, and their culture. . . They recognise they will also have a professional responsibility to their community.

What is Family Medicine? • WONCA Europe 2011 (contd) ‘In negotiating management plans with their patients they integrate physical, psychological, social, cultural and existential factors, utilising the knowledge and trust engendered by repeated contacts. General practitioners/family physicians exercise their professional role by promoting health, preventing disease and providing cure, care, or palliation and promoting patient empowerment and selfmanagement…

WHO: The ‘Five Star Doctor’ • Care-provider – take into account the total (physical, mental and social) needs of the patient; – ensure that a ‘full range of treatment - curative, preventive or rehabilitative - will be dispensed…’ • Decision-maker – Decisions justified in terms of efficacy and cost. – Fair allocation of limited healthcare resource to all individuals in the community • Communicator – ‘The doctors of tomorrow must be excellent communicators in order to persuade individuals, families and the communities in their charge to adopt healthy lifestyles and become partners in the health effort. ’

WHO: The ‘Five Star Doctor’ • Community leader – Aware of needs and problems of the whole community - in a suburb or a district – Understands the determinants of health in the physical, social environments – Takes a ‘positive interest in community health activities which will benefit large numbers of people’ • Manager – Able to ‘initiate exchanges of information in order to make better decisions’ – Works ‘within a multidisciplinary team in close association with other partners for health and social development’ ‘Although the five attributes described above may equally apply to any health professional, family doctors come close to fulfilling the concept of the “five-star doctor”…’

What is Family Medicine in Africa? • FM vs GP – still indistinct – In SA, FM new discipline as of 2007 • Majority of care provided by GPs, ‘medical officers’ – No post-graduate medical education • Only 6 Sub-Saharan African countries have post-graduate FM training programs • Kenya, Ghana, Nigeria, South Africa, Tanzania, Uganda • Still an active subject of academic debate & consideration – WONCA Africa Regional Conferences (2009, 2012, 2015) – South Africa: Fa. MEC (Family Medicine Education Consortium) – Aspiration vs reality

How is the African context different? • Overall many similarities – – Holistic, person-centered care Chronic disease management ‘Primary care’ (*) ‘Full spectrum’ (*) • Differences are profound – – Numbers Resources Environment Scope, training

Numbers • Higher physician to patient ratios – US: ~ 1: 1000 to 1: 2000 – African public sector: ~ 1: 10, 000 • Longitudinal, individualized patient care ≠ possibility

Resources • Healthcare as percent of GDP – US: 17% *** – SSA: *** • Workforce – Ancillary staff: ‘professional nurses, ’ techs, etc – Generalist physicians – Specialists • Materials – Limited supply: medications (formulary restrictions), imaging equipment – Quality ***

Environment • Co-morbidities – infectious disease: HIV/AIDS, TB – poverty-related: trauma, malnutrition • Traditional health beliefs • Organization of healthcare – ‘district hospital’: pt’s second point of contact (usually) • Responsible for mgmt of patients who would often be in higher level of care in US/Europe

Scope of practice, Training • As in US & Europe, varies widely based on location & context – Unique to Africa: primarily hospital-based specialty • Formal FM training (SA) – 4 years – requires proficiency in: • Surgical obstetrics • Anesthesia • Emergency medicine (MIs, DKA), trauma care (intubation, ventilation, central lines, chest drains, etc) • African FP: responsible for clinical activities of the GPs, MOs in his/her district hospital

So who’s ‘helping’ who? . . . • Personal observation: Being an urban-trained American FP in sub. Saharan Africa is a humbling experience.

What the US FP can learn • Autonomy – Majority of new FPs joining integrated systems, multispecialty groups – US w/perennial shortages in rural areas • Resource mgmt – Different in degree, similar in principle • Emergent mgmt, procedural skills – Limited number of US programs

What US FM can offer • Technical – Chronic disease management • WHO: ‘tidal wave of non-communicable disease (NCD)’ – PCMH (*) • Not so relevant at current stage of development – EBM (*) • Caveat: validated in Western settings • Evidence base still being accumulated for many problems in SSA – Pediatric HIV/AIDS – AIDS + TB, other OIs

What US FM can offer • Growth model experience w/similar challenges – Justification • Lack of awareness/appreciation of Family Medicine as a specialty by policymakers – Education – Role clarity • Clinician? Adminstrator? Community leader? – Recruitment (*) – Retention (*)

References • • • https: //www. aamc. org/cim/specialty/list/us/336840/family_medicine. html Accessed 8/30/14. http: //www. aafp. org/about/the-aafp/family-medicine-specialty. html Accessed 8/30/14. http: //www. unige. ch/medecine/umpr/Enseignement/stage 3 ememaster/Definition_won ca_tree. pdf Accessed 8/30/14. http: //www. who. int/hrh/en/HRDJ_1_1_02. pdf Accessed 8/30/14. Reid S. Editorial: The African Family Physician. SA Fam Pract 2007: 49(9) Mash B, Downing R, Moosa S, De Maeseneer J. Exploring the key principles of family medicine in sub-Saharan Africa: International Delphi consensus process. S Afr Fam Pract 2008; 50(3): 60– 65 Mash RB, Reid S. Statement of consensus on family medicine in Africa. Afr J Prim Health Care Fam Med 2010; 2(1): 4 Reid S, Mash RB, Downing R, Moosa S. Perspectives on key principles of generalist medical practice in public service in sub-saharan africa: a qualitative study. BMC Family Practice 2011 12: 67. Moosa S, Downing R, Mash RB, Reid S, Pentz S, Essuman A. Understanding of family medicine in Africa: a qualitative study of leaders’ views. Br J Gen Pract 2013 Mar; 63(608): e 209 -16. DOI: 10. 3399/bjgp 13 X 664261 Chapter 7: “The African family physician”: development of family medicine in Africa in the twenty-first century. The Contribution Of Family Medicine To Improving Health Systems: A guidebook from the World Organization of Family Doctors, Second Edition. June 2013, editor: Michael Kidd

Acknowledgements • University of Kwa. Zulu-Natal Dept of Family Medicine – Mergan Naidoo, Andrew Ross, Ruben Naidoo, Ramona Govender