Family Medicines: a Strategic Weakness

Recently the trends of urbanization and fast population increase expose several problems to healthcare system in Vietnam like shortage of healthcare manpower, low quality of care, unreasonable distribution of healthcare manpower in different geographic areas, particularly the serious shortage of physicians in Mekong Delta and North-west highland areas as specialists tend to locate their practices in urban medical centers where they could have access to advanced technology, supportive services and consultations from other specialists while rural areas are underserved and patient care becomes highly technocratic, fragmented and episodic.

Furthermore, the shortage of physicians in major cities results in a seriously permanent overload at Central level and some specialty hospitals like Oncology, Pediatrics, Obstetrics and Gynecology .. etc.. In sustainable issues, deficit of Family medicine – a basic foundation of modern healthcare in the world, is identified as one of main causes of such problems in Vietnam healthcare system.

The purpose of this Essay is to provide a theoretical discussion and analysis about the Family medicine weakness in Healthcare system and Family physician insufficiency in Vietnam to better understand about their impacts to the healthcare system at present and some proposed solutions and recommendations to improve these deficits. 2. Family Medicine and its roles in global healthcare system. In contemporary medicine, Family medicine remains the foundation stone of healthcare service in the community.

As the most interesting and challenging of medical disciplines it is based on six fundamental principles: * primary care * family care * domiciliary care * continuing care All above principles are all designed to achieve: * preventive care * personal care (Pereira Gray, 1980). In the contemporary climate where medical services are fragmented and there are competing interests there is a greater need than ever for generalists.

In those principles, primary care is the backbone of the health care system and encompasses the following functions: * It is first – contact care, serving as a point of entry for the patient into the healthcare system * It includes continuity by virtue of caring for patients in sickness and health over some period * It is comprehensive care, drawing from all the traditional major disciplines for its functional content. It serves a coordinative function for all the healthcare needs of the patient * It assumes continuing responsibility for individual patient follow-up and community health problems * It is a high personalized type of care (Rakel 2011) In the 2008 report, the World Health Organization (WHO) reaffirmed the importance of primary health care with its report “Primary health care now more than ever” and its emphasizes that primary care is the best way of coping with the illnesses of the 21st century, and that better use of existing preventive measures could reduce the global burden of disease by as much as 70%.

The commentary emphasizes that ‘primary care brings promotion and prevention, cure and care together in a safe, effective and socially productive way at the interface between the population and the health system’. The key challenge is to “put people first since good care is about people” (WHO, 2008). Rather than drifting from one short-term priority to another, countries should make prevention equally important as cure and focus on the rise in chronic diseases that require long-term care and strong community support.

Furthermore, at the 62nd World Health Assembly in 2009, WHO strongly reaffirmed the values and principles of primary health care as the basis for strengthening health care system worldwide. The essence of Family medicine is continuity of care and the evidence for its contribution to quality of care and better outcomes as follows: * Lower all cause morbidity * Better access to care * Less re-hospitalization * Fewer consultations with specialists * Less use of emergency service Better detective of adverse effects of medication interventions. Role definition of Family physician varies considerably both among family physicians and among people with whom they interact. Some individuals, particularly other medical specialists, see family medicine as merely another name of general practice. For others, family medicine is synonymous with primary care. A large proportion of family physicians further elaborate their role to include emphasis on personalized and humanized care.

A smaller group adds a third component to their role: caring for families. The largest proportion who subscribes to this last notion refer to family physicians’ treating all members of a family (Cogswell, Sussman, 1982). In view of Family medicine, Family physicians are generalists who primarily draw their scientific medicine and technical expertise from five older specialties – internal medicines, pediatrics, surgery, obstetrics-gynecology and psychiatry-neurology.

Compared to these specialties, family medicine is still a young field marked both by rapid expansion and by change, variety, ambiguity and conflict in the images and definition of the role of family physician. As the largest caring scope in healthcare services, the quality and quantity strengths of Family physician force play key roles to improve the health quality of national population. Globally the scope of Family medicine is extended with the recent view of global health care which is a field at the intersection of several disciplines: epidemiology, economics, demography and sociology.

The term global health, as opposed to international health, implies consideration of the health needs of the people of the whole planet above the concerns of particular nations. That means global health has wide scope and reach to equity that the term of international health. The “global health” concept in Family medicine raises the changes in primary care nature as follows: * All population has to deal with the same risk of health due to the phenomena of traveling and immigration. Increase the gap between the poor & the rich globally. * The process of the urbanization/globalization. * Increase of the population in the world. * Decrease of the resources for health care. * Global warming phenomena. * Vaccination Era. * Evidence Based Medicine in daily practice. * Increase the bad behavior such as fast food, tobacco, stress, use alcohol… * Primary health care change to Primary care concept (Pham Le An, 2009). Such comprehensive changes upgrade the scale of Family medicine in healthcare.

In order to promote the global health support as well as strengthen the co-operation of national members, the World Organization of National colleges and Academies (WONCA), World Organization of Family physicians in WHO, was officially established and based in Singapore after the Fifth World Conference on General Practice in Melbourne in 1972. 3. Family medicine situation in Vietnam Although Family medicine basis had been established in the world for over 40 years, Family physicians, the most recently recognized specialists in Vietnam, are in the enigmatic situation of developing the occupational role which they simultaneously occupy.

Family medicine had been only approved for establishment by Vietnam Ministry of Health since 2000. Until 2003, Family medicine specialty was established at 3 Medical Universities of Hanoi, HCMC City and Thai Nguyen province to train Family physicians and its specialists. However, its development was spontaneous with 7 Family medicine clinics (in both public and private sectors) nationwide and not strategically organized at all levels so far.

There are only 59 post-graduated specialists and around 1,1 General practitioners who partly handle the roles of family physicians per 10,000 people averagely. The imbalance between Family medicine and other specialists can be seen by the ratio of 7,2 Medical doctors per 10,000 people in overall (Vietnam General Statistics Office – GSO – 2011) and the healthcare system only satisfies about 60- 70% of the demands and are lower than neighbor countries like Thailand, Singapore, Malaysia, Philippines.. tc. In 2011 report, Vietnam Ministry of Health forecasted the demand of 34,000 General practitioners more to obtain 10 Medical doctors/10,000 people in 2020 and this is a significant challenge to all 19 Medical educational Universities/Colleges to educate Medical doctors and post-graduate levels in medicine which capacities supply 4,800 graduated Medical doctors every year to add around 3,500 physicians more a year.

Not only the quantity of family physicians is seriously insufficient, but also their quality to fulfill the roles of a family physician does not meet the needs of the patients and social development. The General practitioner training programs don’t orient student to the WHO’s critical requirements of “good doctors” in Family medicine, even though the criteria are more and more demanding by time, for example, the newer criteria of John Murtagh in 2001 “What makes a good General Practitioner? : * Develop rapport and good communication skills * Ask the right questions * Be astute and observant * Develop optimal ethical and professional standards * Have a fail-safe diagnostic strategy * Develop supportive networks * Know essential therapeutics * Develop basic procedural skills * Be well prepared for emergencies * Know yourself and your limitations including own general practitioners. The importance of certain specific competences and soft-skills in family physician force are emphasized in many studies.

An interesting survey on patient care by representative health consumers conducted at St Vincent’s Hospital Melbourne revealed that the most important attributes of good doctors were (in some order of importance) caring, responsibility, empathy, interest, concern, competence, knowledge, confidence, sensitivity, perceptiveness, diligence, availability and manual skills. Additionally, there are neither comprehensive residency programs for Family physicians at Medical Universities/ Colleges in Vietnam nor supporting policy to them and general practitioners practicing at remote or rural areas so far.

With effort to resolve the overload situation of Central hospitals in major cities, Project 1816 of Vietnam Ministry of Health deployed in 2008 with the purpose of “Fielding rotated professionals from upper level hospitals to lower levels to improve the quality of medical care” achieved some initial results such as transferring some technologies and conducting on-site training to improve skills and qualifications for lower level health care professionals; initially improving the quality of medical care at lower levels, especially in the mountainous, remote areas with staff shortage…etc, but its couldn’t obtain one of basic goals to reduce overcrowding for upper level hospitals, especially central level hospitals because it made the shortage of central level and specialty hospital more serious by the rotation. 4. Impacts of Family Medicine weakness in Healthcare system & Family physician insufficiency in Vietnam.

Due to low reliability and poorly structured family physician network, patients tend to bypass to specialists/ central level hospitals (Vietnam Ministry of Health – 2011 Report), opposite with the trend in the world in which healthcare activities for chronic diseases such as diabetes, hypertension, asthma…are moved from in-patient to out-patient services with comprehensive treatment protocol at each level (Dang Van Phuoc, 2012) The irregular bypass causes the overload at Central level and specialty hospitals and the overloading condition becomes more serious, i. e, bed using capacity at Central hospitals increase from 116% (2009) to 120% (2010) and 118% (2011).

It’s extremely high in some specialty hospitals such as K (Cancer) Hospital: 249%, Bach Mai Hospital: 168%; Cho Ray hospital: 154%; Central Obstetric and Gynaecological hospital: 124% .. etc. High capacity occurs in some specialties such as Oncology, Cardio-vascular, Orthopaedics (at 100% of hospitals), Obstetrics and Gynaecology, Paediatrics (at 70% of hospitals) while 36,8% of General hospitals are overloaded. The similar situation also happens in Consulting Departments with 80 exams/day/doctor while 60% – 80% of patients at Central level hospitals could be examined at local level and 40% of surgery cases at Central level hospital could be performed at local levels (Ministry of Health – Plan to decrease workload of Central level hospitals 2012- 2020)

With the cost in health care, the deficit of Family medicine in Vietnam is one of reason making the medical expenses of patient higher. Total Expenditure on health as % of GDP (5. 1) is fairly high while General Government expenditure on health as % of total expenditure on health (28. 5) is so low to neighbor countries (Susan, 2005). The most cost-effective healthcare systems depend on a strong primary care base. This has been confirmed by a variety of studies comparing the care given by physicians in different specialties because primary care provided by physicians specifically trained to care for the problems presenting to personal physicians, who know their patients over time, is of higher quality than care provided by other physicians.

When hospitalized patients with pneumonia are cared for by family physicians or full-time specialist hospitalists, the quality of care is comparable, but the hospitalist incur higher hospital charges, longer lengths of stay, and use more resources (Smith et al. , 2002). Similarly, the greater quantity of primary care physicians practicing in a nation, the lower is the cost of health care. The cost of healthcare is inversely proportional to the percentages of generalists practicing in that nation. According to OECD Health (Organization for Economic Cooperation and Development – OECD Health Data, June 2005), United Kingdom has twice the percentage of family physicians but half the cost to U. S.. Administrative overhead accounts for a major part of the high overhead cost (31%) of U. S. health care (Woolhandler et al. 2003).

Countries with strong primary care have lower overall health care costs, improved health care outcomes, and healthier populations (Starfield, 2001; Phillips and Starfield, 2004). The shortage of Family physicians and Family medicine deficits also cause other problems in health care as follows: * Incomplete or unsuccessful Primary health care performance. * The gap between urban care and rural care in the health care network. * The competition among specialties: lack of cooperation in chronic disease care, increase the cost of management. * Barrier in teaching ambulatory care and doing out-patient’s research in academies (Pham Le An, 2009). In society, Family medicine meets some resistances of patients such as family hysicians are unfairly treated as “general consultants”, “home caring doctors” and even in medical community, they are considered as “incompetent doctor”, “poor specialist”, “unfair competitive doctor”.. etc. Many other specialists and hospitals’ managements list Family physicians as one of financial losing causes to their hospitals. Such unfair treatments make many Family physicians feel uncomfortable with the specialty and their roles of Family physician. The reliability of patients and society to them is fairly low and this specialty does not attract the general practitioners to study. 5. Some proposed solutions & recommendations to improve Family medicine.

In order to improve the Family medicine in Vietnam, it requires a comprehensive strategy with strong supports of government, educational institutes and society. Within the limit of this essay, I would like to propose some solutions and recommendations as follows: a. Increasing the quantity of Family physicians with additionally trained General practitioners and using the retired medical doctors: The greater the number of primary care physicians in a country, the lower is the mortality rate and the lower cost (Rakel, 2011). In the United States, a 20% increase in the number of primary care physicians is associated with a 5% decrease in mortality (40 fewer death per 100,000 population), but the benefit is even greater if the primary care physician is a family physician.

Adding one more family physician per 10,000 people is associated with 70 fewer death per 100,000 population, which is a 9 reduction in mortality (Rakel 2011). A study of the major determinants of health outcomes in all 50 U. S. states found that when the number of specialty physicians increases, outcomes are worse, whereas mortality rates are lower where there are more primary care physicians (Starfield et al. , 2005). Starfield (2000) states, “the higher the primary care physician-to-population ratio, the better most health outcomes are” (p. 485). Researches in England reveal that with each Family doctor more in 10,000 people (about 20%), adjusted mortality will reduced about 5% in chronic diseases (Gulliford 2002).

The increase of Family physicians obviously reduces the workload at Central level and specialty hospitals (49. 3% of out-patient and 59% of in-patient totally) because with many researches in the world, over 90% of patients are taken care with better service by Family physicians in developed medical or developed countries (Didier, 2011). They can help patients and their relatives in 80% health problems: acute or chronic diseases without complications or no need to transfer to Specialty hospitals (Dang Van Phuoc, 2012). To compensate the continuing decline of the number of students entering primary care as a common trend in the world (Bodenheimer et al. 2009) and insufficiency of graduated general practitioners, a policy to support general practitioners and retired medical doctors to practice as Family physicians such as additional training about Family medicine, financial supports, incentive…should be prepared and implemented. Rather than other countries where Family physicians usually work at home or their private clinics, Vietnam has a wide network of local level medical centers at wards/hamlets and popularly private clinics/medical units. This advantage allows Family physicians to practice and deploy the primary care programs easily and popularly. b. Family physician residency training programs: Quality of care and the inadequacy of medical training are two major concerns of Family physicians. Eventually, medical schools and residency programs graduated more specialists and fewer physicians trained for primary care.

To improve their quality of care in accordance with global health principles, proposed solution is to build emerging curricula of family practice residency programs to envisioning family physicians as “horizontal specialists” who can deal with the large majority of patients’ needs on a continuing basis (Rakel, 2011) and envisioning this role as integrating humanized care with a high level of competence in scientific medicine. In contrast to the training of the general practitioner, the additional training that family physicians receive is intended to make them more proficient generalists in scientific medicine through formal training in appropriate interpersonal skills and in the behavioral and social sciences.

Implementation of this role, however, requires reorganization within the medical system (Folsom, 1966) for continuing, comprehensive care by primary physician is difficult if not impossible within the normative organizational structures of highly specialized medical centers. As Family physicians play the important role in primary care, the Global health awareness program should be combined into General practitioner and Family physician’s training curriculum for being sure about the quality of “primary care” as follows: (i) Clerkship: adding knowledge of burden global disease in the world such as: tuberculosis, malaria, Preventive care: vaccination; improving skills such as clinical making decision, communication. ii) Orientation: Adding knowledge of new  emerging infectious disease like SARS, non communicable diseases, traumatism care, HIV/AIDS; (iii) Residents: adding knowledge of prenatal care,  neonatal care,  chronic care, mental health care, adolescent care;  Emergency care in disaster; improving skills such as: doing research and practice Emergency care in disaster, Behavioral care after disaster, Kangoroo’s program, Obs-Gyn care program; building up the relationship center care with WIN- WIN theory for both developed and developing countries to increase of cooperation and Team work. In addition, the cooperation among experts in different medical fields should be strengthened for teaching, managing, doing research to promote the concept “relationship center care” through many activities: * Establish Continue Medical Education, Patient’s clubs. * Build the bridge or integrate the teaching contents  in Family medicine  with the other specialties like Pediatrics, Traditional Medicine ( Oriental nutrition, Shiatsu), Cancerology (Palliative care), Multidiscipline (Disaster care, EBM, chronic care). Communication through Internet/ Video conference and Electronic medical: The WHO 2008 report emphasizes the appropriate ‘use of information and communication technologies to improve access, quality and efficiency in primary care. The writer has made a small contribution to basic patient education (also known as doctor education) by the production of common patient handouts which are available for print out from General practitioners’ computers or for one page photocopying from the book ‘Patient Education’ (Murtagh J; 2008). Besides the residency training programs, on-going training courses to improve the competences and skills of Family physicians should be set for attributes considered most important for patient satisfaction (Stock Keister et al. , 2004a).

Overall, people want their primary care doctor to meet five basic criteria: “to be their insurance plan, to be in a location that is convenient, to be able to schedule an appointment within a reasonable period of time, to have good communication skills, and to have a reasonable amount of experience in practice”. They especially want “a physician who listens to them, who takes the time to explain things to them, and who is able to effectively integrate their care” (Stock Keister et al. , 2004b, p. 2312). c. Others solutions and recommendations (i) Building an incentive scheme and financial supporting policy to Family physicians, especially whom working in remote and rural areas: The effectiveness of this model had been proved in many countries, particularly in Thailand and Malaysia where healthcare conditions are fairly similar to Vietnam.

Contrarily, the recent P4P (Pay for Performance) policy of Thailand’s of Ministry of Health to replace the incentive scheme to Family physicians creates several problems to healthcare force and patients and is considered as a main cause leading the Family physicians moving to major cities. With relation between income and satisfaction, in an analysis of 33 specialties in U. S. , Leigh and associates (2002) found that physicians in high-income “procedural” specialties, such as Obs – Gyn, ENT, ophthalmology and orthopedics, were the most dissatisfied. Physicians in these specialties and those in internal medicine were more likely than family physicians to be dissatisfied with their careers.

Among the specialty areas most satisfying was geriatrics. Because the population older than 65 years old in U. S. has doubled since 1960 and will double again by 2030, it is important to have sufficient primary care physician to care for them. The need for and the rewards of this type of practice must be communicated to students before they decide how to spend the rest of their professional lives. Patient satisfaction correlates strongly with physician satisfaction, and physicians satisfied with their careers are more likely to provide better health care than dissatisfied ones. Physician satisfaction is associated with quality of care, particularly as measured by patient satisfaction.

The strongest factors associated with physician satisfaction are not personal income, but rather the ability to provide high-quality care to patients. Physicians are most satisfied with their practice when they can have an ongoing relationship with their patients, the freedom to make clinical decisions without financial conflicts of interest adequate time with patient and sufficient communication with specialist (DeVoe et al. , 2002). Landon& colleagues (2003) found that rather than declining income, the strongest predictor of decreasing satisfaction in practice is the loss of clinical autonomy. This includes the inability to obtain services for their patients, control their time with patients, and the freedom to provide high-quality care. ii) Compulsorily assigning General practitioners/ Family physicians to practice at local level hospitals, the servicing term at local level hospitals must be reasonable and acceptable. (iii) Improving facilitates of local level hospitals/clinics, enforcing the lower level hospitals to implement modern technologies and quality control. This allows Family physicians to better serve patients as some achievements of Project 1816 of Vietnam Ministry of Health. (iv) Involving patients for private and family health care and prevention, structured information supporting treatment. (v) Improving the reputation of Family medicine and physicians in society through public media channels like television, newspaper.. etc, medical education programs and medical community.

Even after the specialty is formally acknowledged by institutionalized medicine, family physicians have experienced a variety of negative responses from medical colleagues in other specialties. Carmichael (1978) perceived 3 stages in the reactions of those in medicine to Family medicine: first, the field was ignored; second, it was actively opposed; and then, family medicine is entering a third stage of possible co-optation by medicine. 6. Conclusion The weakness of Family medicine and insufficiency of family physicians cause many strategic consequences to the healthcare system in Vietnam. Their correction requires a long-term strategy to increase the quantity of Family physicians, quality of care, revise the residency training programs, improve its reputation in the society .. etc.

In conclusion it seems appropriate to paraphrase Dr Robert Rakel in his keynote presentation to the 14th WONCA World Conference to reaffirm the Family medicine era in the contemporary medicine: “Regardless of how computer literate we are or how high our technology or whether the setting is urban or rural, good medical care in the future will continue to depend on patient care provided by a concerned and compassionate family physician. The physician will be governed by ethics, not economics, by a partnership with the patient, not politics; and by compassion and communication, and not by capitation. Good medical care in the future will depend, as it does now and always has, on the quality of our interaction with the patient” Dr Robert Rakel – 14th WONCA World Conference) REFERENCES 1. Alain J. Montegut, The Power of Primary Care for the Future of health care: Is Family Medicine the Answer? 1st International PHC Conference Doha, Qatar 1 – 4 November 2008 2. Bodenheimer et al. , 2009. Bodenheimer T. , Grumbach K. , Berenson R. A. : A lifeline for primary care. N Engl J Med  2009; 360:2693-2696. 3. Cogswell BE, Sussman MB, Family Medicine: A new Approach to Healthcare (Marriage & Family review, ISSN 0149-4929; v. 4, no. 1/2), The Haworth Press Inc. 1982. 4. Dang Van Phuoc : Plan to decrease workload of Central level hospitals 2012- 2020 – Vietnam Ministry of Health, 2012. 5. Didier L. Roles of Family medicine, Texbook of Family medicine for the co-operation between Liege University – Brussel and Vietnam, Medicine Publisher, 2009. 6. DeVoe et al. , 2002. DeVoe J. , Fryer G. E. , Hargraves L. , et al: Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care?. J Fam Pract  2002; 51:223-228. 7. Gulliford, J Public Health Med 2002; 24:252-4, and personal communication 9/04. 8. Landon et al. , 2003. Landon B. E. , Reschovsky J. , Blumenthal D. : Changes in career satisfaction among primary care and specialist physicians, 1997–2001. JAMA  2003; 289:442-449. 9. Leigh et al. , 2002.

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