FAMILY MEDICINE ORIENTED PRIMARY CARE

1 Vision Of Family Medicine Oriented Primary Care 2 Introducing Family Medicine To Health Care Systems 3 A Family Medicine Training Programme For Indonesia

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CHAPTER 1

VISION OF FAMILY MEDICINE ORIENTED PRIMARY CARE

Associate Professor Goh Lee Gan Wonca Regional President, Asia Pacific
Outline Challenges in health care systems Meeting peoples needs Is family medicine the solution? Making things work Towards Unity For Health Closing the financial gap a 6-Strategy roadmap Where do we go from here

CHALLENGES IN HEALTH CARE SYSTEMS

The universal challenges to optimal health care delivery in health care systems are the result of the dream and reality struggle. The dream is the desire of the different stakeholders policy makers, health professions, academic institutions, health care managers, and communities to meet their subsystem goals of quality and equity in each stakeholders perspective. The reality is that such a system will not be sustainable. The interim results are well-known: limited health budget, rapidly rising costs as more unprevented disease burden takes its toll, inequitable distribution of resources between need and want, and inefficiencies in delivery of care as different stakeholders work towards a subsystem optimum. The reality is the need for relevance and costeffectiveness. The solution A balance is needed between quality and equity on the one hand 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 family medicine (WHO Europe, 1998), and the WHO-Wonca vision of family medicine (WHO-Wonca Working Paper, 1994). To varying extent, some balance towards equity is being achieved. The lack of unity for health is now seen to be the cornerstone that the various stakeholders in the health care delivery system need to address A new unity based on a common vision is needed. This has led to the WHO and Wonca working jointly towards unity for health in the WHO-Wonca TUFH (Towards Unity For Health) Project across the world. In this project, the primary care doctor has a role of bridging the different stakeholders 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 to Peoples 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 Framework for Development of FP/GP. Family Medicine, by the nature of its work and core values, can help health systems to meet 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, in the medical profession and in medical schools and other educational institutions. The family doctor should have a central role in the achievement of quality, cost effectiveness and equity in health care systems. The family doctor is a good bridge between hospital care & public health; he is able to help 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 one who 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 first time particularly in children and the aged prevents death and disability. Encouraging appropriate lifestyle to control chronic diseases will reduce disease burden and truly save costs to the individual, family, community, and nation. Diet, exercise and weight control (DEW) together they will prevent or reduce the prevalence of hypertension, heart disease, diabetes mellitus, hyperlipidemia and the downstream consequences from strokes, heart disease and the long term complications of diabetes mellitus. Smoking respiratory consequences of chronic obstructive lung disease, cancer of the lung and ischaemic heart disease are prevented or reduced. Sexual behaviour sexually transmitted infections including AIDs are prevented.
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MAKING THINGS WORK TOWARDS UNITY FOR HEALTH

How does working towards unity for health work? The common vision of reduction of disease burden, and promotion of health will place the use of limited healthcare budgets to achieve the greatest impact on health status. The activities among the stakeholders will 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 of services 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 of resources where appropriate. The outcome of such healthcare reforms in the minds of the 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 to be 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 reminding all 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 best practice based on available standards. Work towards standardisation of services with clinical guidelines get a buy-in by stakeholders, 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 of penny 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 savings that has never been truly comprehended or never implemented because of lack of political will. Premium or consultation fee has to be adequate only then can unseen costs be controlled e.g. unnecessary referrals, incomplete care, reluctance to use essential drugs. Premium or consultation fee has to be adequate only then will the optimal benefits of the GP be realised. Prevention must have an adequate budget for training and implementation of patients 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 doctor The 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 on local 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 followed up for safety sake (there must be social capital in the community for this to work): Acute condition = $X for consultation & medicine Chronic condition = $Y for consultation & medicine Encourage Best Practice Strategy 6 Discussions and presentations on best practice will spread the best solutions to close the financial gap in health care. The healthcare system may wish to consider the best stakeholders of the year award on best practice policy maker, health professionals, academic institutions, health managers & insurance providers, communities these will encourage best practice.
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WHERE DO WE GO FROM HERE

Get the message across that closing financial gap can only succeed if stakeholders are all 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 MEDICINE TO HEALTH CARE SYSTEMS: SINGAPORE, INDONESIA, MYANMAR

Associate Professor Goh Lee Gan Wonca Regional President, Asia Pacific
Outline The Singapore Experience The Indonesian Experience The Myanmar Experience Critical success factors in the introduction of family medicine Syllabus for family medicine training Five 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 of family medicine, training requirements and organizational matters. The Hospital specialists were convinced of the importance of well-trained primary care doctors who were individually willing to contribute their efforts towards training the doctors. Sequence of developments 1988: pilot Family Medicine programme hospital rotation programmes and polyclinic 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 9 passes out of 17 who sat. 1995: started Private Practitioners Scheme (Programme B) doctors in primary care practice 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 in clinical practice. MMED FAMILY MEDICINE (SINGAPORE) The Master of Medicine in Family Medicine examination was established in the National University 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 is now 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 learning set of notes and face-to-face sessions of case-based workshops; application of the course material takes place at the clinical and experiential level and tutorials are conducted 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 B
The 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 Grad Dip Family Medicine trainees). Weekly Tutorials & Monthly Workshops 40 a year X 2 years focused on case-based issues and learning areas in patients seen in the direct experience of doctors in training: 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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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. To date, 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 care has three reasons to make it succeed: There is a critical mass of primary care leaders, university teachers, and insurance providers, as well as Ministry of Health primary care leaders who have been exposed to the concepts and understanding of the role that family medicine can play in the health care delivery system. Indonesian needs family medicine oriented primary care doctors to be effective gate keepers in the health care delivery system. The project between Singapore International Foundation (SIF) & Indonesian Ministry of Health allowed the transfer of skills and knowledge on the organization and development of a family medicine programme. What were done right Time and efforts spent to foster a common vision of the various stakeholders in health care delivery on the place of family medicine primary oriented care resulted in good acceptance of the discipline. TOT as the transfer of knowledge created a critical mass of committed primary care leaders to spearhead the development of family medicine in the postgraduate and also in the undergraduate level. Attention to syllabus and content of family medicine will ensure that the family medicine 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 teaching strategies into Myanmar. Reason for entry of family medicine into Myanmar Health Care Delivery System GP as primary care provider is recognized to be important. Prior exposure of medical leaders to the concepts and the role of the family doctor is again important. Family Medicine Workshop & interaction with MOH & MMA as the means to transfer of technology. Knowledge Transfer Activities The Myanmese medical leaders met their counterparts from Singapore and discussed the 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 care systems 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 local development is an important factor. External help in developing the curriculum, teaching methods, TOT ideas, and organization of the training programme expedites the implementation of the training programme. 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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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 of Australian, British and American family medicine programmes. It is generic for use in any family 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 beyond episodic 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 the planning and implementation of care. This has been developed into a model by Stott & Davis as acute care, behavioural modification, continuing care, and disease prevention & health promotion. Family as unit of care to have the core value of managing the individual and the family 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 specific groups 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 teaching too. The excess morbidity and mortality is being addressed. Mother and Child The 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 Mother Other 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 prevention and detection. More about the Child Other 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 Adult Other 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 Elderly The family physician needs to pay attention to areas of care that will prevent or delay onset 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 from chronic 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 disease management.

TIME TABLING STRATEGIES FOR SELF STUDY AND FACE-TO-FACE LEARNING

The big challenge in the implementation of any syllabus of family medicine is the large
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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 special group; or respiratory and cardiovascular systems being considered together because the key organs are both in the chest cavity and have similar symptoms. The result is modularization. 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 be covered and the time available. The grouping of topics into must know, good to know, 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 each course participant to record on one page each case which offers something to learn in the 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 and teaching. These are the cases that the course participant bring to the class discussion in the tutorials. Face-to-face learning Include face-to-face teaching sessions which can be small group, or big group, and in some situations one-to-one. These can be (a) case-based workshops where case-based scenarios that the learners have worked on as assignments are discussed in class; (b) case based tutorials where cases from portfolios are discussed; (c) clinical skills sessions e.g., physical examination techniques, problem solving exercise, or learning a new technique like counseling, communication, stress relaxation techniques. In other words, self-study is not enough. There is a need for face-to-face sessions. The number of face-to-face sessions to the number of modules of self-study will depend on the ability of the participants to meet. The frequency may be weekly or fortnightly for small groups of 5-6 to meet for tutorials and monthly to quarterly 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 person medicine, 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 relevant problems 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 is necessary. 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 of care 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 case discussions 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-toone coaching and mentoring; paper assessment instruments i.e., Multichoice Questions (MCQs) and Key Feature Problems (KFPs); practical assessment instruments i.e.,Objective structured clinical examination (OSCE), short clinical cases, and long 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 concept of best practice and reasonable competence. Reduce variation of care concept of practice guidelines.
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References and further reading CFPS website: http://www.cfps.org.sg Fabb 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 One module in 3 months One module has 8 study units Jul 2002 Sep 2002 of Family Medicine Whole person medicine 4 units of study Disease mgmt by body systems 3 units of study Practice mgmt 1 study in brackets

Practice skills 1A1 Principles of Family Medicine 1A2 Consultation skills 1A3 Counselling 1A4 Communication

Respiratory disorders & Cardiovascular 1B1 Respiratory infections 1B2 Non-infective respiratory disorders 1B3 Ischaemic heart disease Gastrointestinal disorders 2B1 Upper GI disorders 2B2 Lower GI disorders 2B3 Liver & Biliary disorders

1C: Medical records & confidentiality

Oct 2002 Dec 2002

Child & adolescent 2A1 Acute paediatrics 2A2 Developmental paediatrics 2A3 Adolescent medicine 2A4 Behavioural paediatrics Continuing care 3A1 Principles 3A2 Hyper- tension 3A3 Diabetes mellitus 3A4 Palliative care

2C: Notification, certification, and dispensing

Jan 2003 Mar 2003

Urinary Tract, Blood & Oncological disorders 3B1 Oncological disorders 3B2 Urinary tract disorders 3B3 Anaemia, bleeding, haematological cancers Psychiatric disorders 4B1 Anxiety & confusion 4B2 Community psychiatry 4B3 Depression; emergencies

3C: Managing the practice

Apr 2003 Jun 2003

Elderly health 4A1 Ageing, fitness, & assessment 4A2 Stroke & rehabilitation 4A3 Frail elderly 4A4 Prescribing

4C: Computer use; Medical Information system; Research

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Table 1B. Family Medicine Syllabus Year 2 Singapore

Period One module in 3 months One module has 8 study units Jul 2003 Sep 2003 Whole person medicine 4 units of study Disease mgmt by body systems 3 units of study Practice mgmt 1 study in brackets

Community, Family & Patient 5A1 Human behaviour & beliefs 5A2 Family in health & illness 5A3 Public health disease control & immunisation 5A4 Preventive medicine Adult Health 6A1 Occupational health 6A2 Workplace hazards & occupational diseases 6A3 Fitness to work: return to work 6A4 Travel medicine Womens Health (1) 7A1 Family planning & infertility 7A2 Common gynaecological disorders 7A3 Gynaecological cancers 7A4 STD, HIV & AIDS Womens Health (2) 8A1 Anetnatal care, & drug use in pregnancy 8A2 Medical disorders in pregnancy 8A4 Postnatal care pregnancy 8A3 At-risk

Skin disorders, STI & AIDS 5B1 Non infective dermatoses 5B2 Infective dermatoses 5B3 Acne, pigment, nail & hair disorders

5C: Standard of care, managed care, infamous conduct

Oct 2002 Dec 2002

Rheumatic, Bone & Joint Disorders 6B1 Emergency care; housecall 6B2 Rheumatic, bone & joint disorders 6B3 Sports & accidental injuries

6C: Setting up practice: medical & legal perspectives

Jan 2003 Mar 2003

Neurological, Eye & ENT Disorders 7B1 Common Neurological Disorders 7B2 Eye disorders 7B3 Ear, nose, & throat disorders

7C: Financial management accounting, medical perspective

Apr 2003 Jun 2003

Endocrine, metabolic & Nutritional Disorders 8B1 Nutritional counselling 8B2 Metabolic disorders 4B3 Endocrine disorders

8C: Quality assurance

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

CHAPTER 3

A TRAINING PROGRAME FOR 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, written as a consensus of prominent general practitioners and lecturers from several state universities. 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 the Indonesian Ministry of Health. The programme will make use of different teaching methods distance learning, faceto-face seminars and workshops, and experiential learning in the practice. The topics chosen are focused on medical conditions which are common, important or have a great impact 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 practice Packet C deals with medical technical skills and care in specific situations Packet 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 local needs and tailored information from various sources to keep up the latest developments in science and technology. The content of each package (especially package C, D) are likely to have some alterations. Package A and B would have fewer changes, since they deal with principles and concepts. The topics in each of the packages will need to be modularized along some pragmatic strategies. 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 have been summarized in Table 1. The final selection of topics, teaching methods will depend on the balance of the need to standardize, local need and relevance, as well as 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. 2. 3. 4. 5. The central values of family medicine Personal care, Continuing care and comprehensive care Family as a unit of care Emergency care, housecalls and home care Palliative care

Packet B Managing the practice Section 4 (Each topic below can be a self-study unit) 1. 2. 3. 4. 5. Managing Managing Managing Managing Managing people and resources facilities and utilities information medical records, confidentiality, computerisation finances including managed care 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. 2. 3. 4. 5. 6. The consultation process Communication skills Counselling skills Changing behaviour Disease management 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. 5. 9. 13. 17. 20. Fatigue Breathlessness Diarrhoea Skin rash Headache Red eye 2. 6. 10. 14. 18. Weight loss Cough Constipation Backache Insomnia 3. 7. 11. 15. 19. Fever Sorethroat Vomiting Joint pain Persistently crying baby 4. 8. 12. 16. Dyspepsia Chest pain Abdominal pain Giddiness

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. 2. 3. 4. 5. 6. 7. 8. Cardiovascular and respiratory disorders Gastrointestinal disorders Renal, hematological and disorders Psychological disorders Skin disorders Bone & Joint disorders Nervous system, eye, and ENT disorders 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. 2. 3. 4. 5. 6. Child and adolescent health Womens health Mens health Health of the working adult Elders health Public health

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VISION OF FAMILY MEDICINE ORIENTED PRIMARY CARE

CHAPTER 1

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