Policy bite: Applying definitions of FM - lessons from regions, rural, and residents

Photo: Amanda Howe with residents in Gramado

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As the President reports, we were both privileged recently to attend the WONCA Rural Health conference (in Brasil) and the IberoAmerica (CIMF) summit meeting (in Ecuador). The debates between us, the formulation of policy statements based on the meetings, and the experiences and concerns of younger doctors frequently centred on questions about how we define our discipline, and ensure its unique characteristics are recognised by others.

At one level, I am surprised this seems difficult – I have been arguing this cause for my whole career, and WONCA has a number of statements and policies which address this: some are translated, all are translatable, and we have been discussing definitions (see last month’s policy bite). But of course, it is different to apply something to real life – as our students find when their knowledge of respiratory conditions has to be applied to the undiagnosed breathless patient! ….

Some of the questions being asked were:

• Who is a family medicine (FM) specialist?

There were examples of people being called ‘family doctors’ within some countries who had not had speciality training, or were seen as not having had enough speciality training to merit the name. A survey presented in Quito from the Ibero-America member countries showed that almost half do not currently have an recognised accreditation of their training for FM.

• What is needed for practising FM?

There has been a long running debate about the additional skills needed to make rural and remote practice safe and effective: looking across the world, the breadth of clinical practice does vary enormously. Some FM doctors do maternity work, some cover trauma and surgical or medical emergencies, some do other extended roles (working in substance misuse or palliative care services, for example). This diversity of practice needs us to be clear about what is and is not FM within the system.

• Why is FM training important?

Some countries (not only in South America) are trying to provide medical access in all communities by:
(a) sending newly qualified young doctors to the most under-served areas,
(b) using doctors with no postgraduate qualifications for community service, or
(c) using doctors imported from other countries to increase medical capacity.

All these strategies may make sense if your main aim is ‘a doctor for every community’, but these doctors often do not do the job that an FM specialist would do. Similarly, some steps towards universal coverage are focusing on upskilling of ‘non-doctor’ health professionals. This approach again needs us to be clear about what FM would add to the health care system in a way that these other valuable colleagues cannot.

So, how can you tell if FM is being practised in a clinic, or being designed into a new service?

Here are a few criteria you can use to discuss the extent to which a particular model is (or is not) reaching a minimum standard for FM to be present. These are broadly derived from the WONCA Guidebook,(The contribution of FM to improving health systems).

• What is the training of the doctors?

Do they have an FM qualification - and if so what did it involve (length of training, source of accreditation, etc)

• What is the scope of practice of the doctors?

Do they focus on problem solving and diagnosis – or only symptom relief? Are they seeing patients on a reactive / walk – in / one off basis – or do the records show that there is some continuity? Can the doctor or patient book forward for follow up, and does the ‘system’ bring people back to a particular doctor most of the time?

• Do they see patients of all ages and conditions? Or is their case mix narrower?

If the latter, how long have they been seeing this more limited group of patients, and do they have any other clinical work where they do the ‘whole’ FM role?

• Would their routine practice be objectively seen as person – centred? Do they relate to the patients as people, or to specific technical or disease-oriented activities?

• Is their clinic offering a non-communicable disease management service, with planned followup for reviews of e.g. diabetics, hypertensives: and do they offer screening and preventive work (women’s health checks, child development, vaccines etc) as PART of the routine service?

• If they are working in hospital, or with access to hospital beds, what is the routine balance of their work?

Offering emergency care or in-patient care as well as the comprehensive ambulatory services above denotes an added role, but a doctor who is spending most of their time covering surgical emergencies may not really be working as an FM doctor any more.

• Finally, are they the first point of access to medical contact for their patients, and do the hospital specialists need a referral to see their patients?

This is the ‘signpost and gatekeep’ function, as used for example in the U.K. NHS, which makes FM cost effective in the system.

These questions can be posed for formative or political purposes, for discussion and for debate.

In Rio, I saw residents in one of the new favela (shanty town / poorest housing) public service clinics being given their own patients, for whom they would care for the duration of their training there. The clinic was offering a fully comprehensive service, and the supervising doctors there were FM qualified.  Photo shows Amanda with residents at the favela clinic.

I also heard from doctors who were running their own private clinics – with continuity of care, but with less consistent contact with patients (who can access hospital and diagnostic services direct), and who were struggling to provide a full range of services.
I met doctors who were doing a huge range of services in rural and remote settings – skills I gave up twenty years ago because I worked within three miles of a major hospital.

And elsewhere I have met non-FM qualified doctors running their own clinics with nurses and pharmacists, well loved by their patients with good continuity, but without the full ‘preventive to palliative’ offer that would define a mature FM service.

My conclusions –

1. include, support, and upskill any colleagues and services which have some of these components and are aiming at others;
2. use case studies to show hospital colleagues and politicians how FM’s offer differs from other models
3. keep your focus on creating and maintaining FM within all health systems.

I had an interesting conversation with one ministry official where there was a ‘light bulb moment’ as they heard how we run all the NCD primary and secondary prevention services from FM in the U.K. – they had not understood that this work could be done outside hospital, at community level, integrated with other clinical care, and potentially at lower cost. “So that’s why we need to have FM specialists?” Well, yes, plus a few other reasons too.

Amanda Howe
President Elect

Amanda’s quick checklist

How can you tell if FM is being practised in a clinic, or being designed into a new service? What is the training of the doctors? Is there some continuity? What is the scope of practice of the doctors? Do they see patients of all ages and conditions? Is their clinic offering a non-communicable disease management service, and screening and preventive work? Would their routine practice be objectively seen as person – centred? Is it integrated?  If they are working in hospital, or with access to hospital beds, what is the routine balance of their work? Finally, are they the first point of access to medical contact for their patients, and do the hospital specialists need a referral to see their patients?