Considering the Education for Physicians for Brazilian Health Clinics

1. Considering the Education for Physicians for Brazilian Health Clinics W. Rosser, Professor and Head Department of Family Medicine Queen’s University Kingston, Canada

2. Presentation Outline Introduction What do people want from physicians? What are the principles that address the needs and wants? Methods of educating primary care physicians for these roles. Strategies for Physician Education for the Brazilian Model of Primary Care. Ideas

3. Introduction Primary Care delivery systems can be subdivided into two different strategies. Delivery by a personal health care provider: Each person can identify their personal physician or health care provider and the system works to maintain continuity for each person or family with one or two providers. Clinic or polyclinic system: Each person attends any clinic where care is provided as required by a primary care provider without any effort to provide personal or continuity of care

4. Personal Health Care Provider Many countries from the British Commonwealth focus on this model including the UK, Ireland, Canada, Australia, New Zealand, South Africa. Other European countries like Holland , Belgium, and some Scandinavian countries (Finland , Denmark, Estonia, Latvia) Other countries such as Germany, France, Japan have mixed systems that may have personal private care and clinic care in public systems.

5. Clinic or Polyclinic System Almost all countries in the former Soviet system use a Polyclinic as do a number of European countries. Often, private health care can be personal and public care is in the Polyclinic model. In many developing countries, primary health care is provided by alternate health care workers and not physicians. These individuals may also function in a clinic or personal health care model.

6. Personal Health Care Many of the issues around effective primary health care relate to personal health care. Since I only have experience with this type of system, I am clearly biased towards this style of delivery and the remainder of my talk will assume a personal type of primary health care delivery system. I will hope that most of the audience will be persuaded that this is a reasonable and achievable objective for Brazil.

7. What do people need from Medicine? In the twenty first century, people express the same fundamental needs for medical care as humans have expressed since the beginning of time. People need a healer who responds to all problems that beset them in their homes, their families and their communities. They need assistance when sick, in pain, or confused to organize their concerns, and to advocate for them whatever happens.

8. What do people need from Medicine? Only a personal provider can meet these needs. Even with the revolutionary changes in medical knowledge and technology over the past 40 years, the pattern of needs from the community has changed very little. White 40 years ago and Green in 2001 found that during 1 month, of 1000 adults, 750 would experience some illness or injury, 500 would manage the problem themselves, 250 would seek some professional advice, 9 would be admitted to hospital 5 would be referred to another physician. Less than one would go to a teaching hospital.

9. What do people expect from a primary care provider 1.Expert Clinician: People want a provider that is knowledgably able to gather information about a problem and effectively develop a strategy to manage most conditions most of the time. The provider needs to be up to date and sensitive to the patient’s family, community and specific cultural needs.

10. What do people expect from a primary care provider? 2. A skilled scholar, scientist, and appraiser of new medical knowledge. The provider needs skills in self assessment, self directed learning, and needs to be an information master, able to critically assess new information and determine if it will benefit any patient in the community setting. Since much new knowledge is developed in tertiary care teaching hospitals, it is often not transferable to the community.

11. What do people expect from a primary care provider? 3.A skilled interviewer. Patients want a provider that understands their viewpoint and is sensitive to their feelings and response to their illness. This includes providing the patient with an understanding of their problem. 4. A Health Advocate. The provider needs awareness of the determinates of health and be proactive in forming healthy public policy.(example)

12. What do people expect from a primary care provider? 5. Adaptable.Patients want their provider to adapt their thinking to different strategies in providing care.They want a provider with a passionate commitment to seek the truth, and have the integrity to use knowledge to the optimum benefit of their patient. 6. Collaborative: The provider must work effectively with other health care providers on a team as well as with families and communities.

13. What do people expect from a primary care provider? 7. A steward of precious resources. Using consultations wisely, tests according to their value to the patient and discussing the risks and benefits relative to cost of any therapy. 8. A healer. The provider must be able to use their personal strengths to encourage healing and provide moral support for the benefit of the patient. This requires knowledge of one’s own strengths and weaknesses and personal biases and how they may affect relationships with patients.

14. Summary People’s needs and wants from the medical care system tend to focus on the presence of a personal health care provider who is a skilled and knowledgeable clinician with a scientific background and an expert in dealing with health problems within the environment in which the population functions. People want this individual to respect them and to be sensitive to their personal situation.

15. Principles of Education A review of principles for primary care, general practice, and family medicine covering input from approximately 20 countries found convergence around the Four Principles of Family Medicine developed by the College of Family Physicians of Canada. References for the international principles are provided.

16. First Principle The physician- patient relationship is central to the role of the family physician. Trust and respect are essential to sustain a partnership sufficient to solve the problems presented by each patient. Family physicians use repeated short visits to build relationships with patients and to promote the healing power of physician patient interactions. Advocacy for individuals and the community arise from this relationship.

17. Second Principle Family Physicians are skilled clinicians. Clinical skills include expertise in dealing with ambiguity and uncertainty in diagnosis and management of chronic disorders, emotional problems, acute medical crisis, preventive strategies and complex bio-psycho-social problems. Clinical skills include diagnosing and managing common and important medical problems. (See lists in handout)

18. Family Physicians are skilled clinicians Diagnostic strategies include those of “watchful waiting” to diagnose undifferentiated problems. Skills also include provision of a number of services to a population (list included). All of these approaches involve sensitivity to the individual and their context. Each physician must be able to self assess the quality of their work and reflect on how they could improve.

19. Third Principle Family Physicians are a resource to a defined community; Brazilian clinics serving a defined population are more organized to meet this principle than primary health care services in most other countries. Population/public health principle merge with primary health care provision including steps to monitor the health of the community. Data collection needs to be organized to measure health outcomes so the impact of services can be monitored.

20. Fourth Principle Family Medicine is dynamic in responding to the changing needs of the community: Ideally, each Brazilian clinic would have methods of monitoring community needs, community outcomes and also be connected to neighboring clinics. This connection would allow for provision of comprehensive services. Clinics need the ability to measure and adapt to the changing needs of their community. Self assessment and self learning remain integral.

21. Using Four Principle to Produce Physicians, Nurses, and Health Workers Style of educational programs. Duration 2 to 5 years of postgraduate training may be influenced by content of undergraduate medical programs and the defined role of the family physician. Location In some countries, most of the education is hospital based. Many programs are moving to have education occur in community clinics or organized community based teaching practices. Different countries require different roles, some including intra-partum obstetrics, minor surgery, anaesthesia , emergency room work, and care of patients in hospitals or nursing homes.

22. Educational Models Affiliation: The structure and affiliation of educational programs is quite variable. In Canada, all programs are affiliated with a University requiring faculty appointments for all educators. In the U.S., more than half the programs have only a hospital affiliation and do not require university appointments. In the UK and other commonwealth countries, the “vocational training program” is run independent of the university by the RCGP. However, each University has a small Department of Family Medicine for teaching undergraduates and conducting research.

23. Accreditation The setting of educational objectives and standards for a country and then having a system to assess how these standards are being met on a regular basis is extremely important in achieving a uniform standard for educational programs. I understand that standards have been developed for Brazilian clinics. Brazil has developed a final assessment prior to gaining specialty status. Examinations and standards are usually set by the same body that accredits programs.

24. Eligibility for Examination When a program is starting, it is important to acknowledge experienced practitioners for their skills. It also accelerates developing considerable numbers of specialists quickly. A number of countries have two routes to be eligible to take the “specialty examination”. The residency route and the practice eligible route.

25. Practice Eligible Route Usually there is a minimum requirement of practice experience in a health clinic (usually 3-5 years). The candidate is asked to demonstrate that they are “up to date” by attending approved continuing medical education courses. (in Canada 250 hours over the 5 years) Practice eligible candidates may undergo an audit of their practice or records to assess eligibility.

26. Residency Training Programs The content of residency programs varies widely between countries. In the U.S. and Canada, there is an expectation that graduates will provide in hospital care, intra partum obstetrics, and emergency room care, and conduct minor surgical procedures. In most European countries, the expectation is to function only in a community office practice. In some countries, even office procedures such as pap smears are not part of the role.

27. Residency Training Programs Once the functions of the primary care physician or provider in a country have been determined, the objectives for the educational program need to be developed. Detailed objectives and determination of measuring minimum skills or competence need to be developed from the Principles.

28. Program Styles As mentioned, the residency program duration ranges from 2-5 years. In Canada, and I understand Brazil, there is a two year program, The US and the UK have 3 year programs, Australia has a five year program. Duration of the program is influenced by the structure ie; Canada: the entire 2 years are integrated with family medicine in the community. US: usually integrated with community but more hospital rotations. UK: two years completely hospital based with little or no connection to GPs and one full year in general practice. This model has been criticized.

29. Community Integration Over two years the resident spends a minimum of 8 months full time in Family Medicine teaching clinics. During this time they build up their own patient practice. They then spend 16 months working in medicine, surgery, psychiatry, pediatrics, obstetrics, gynecology, and emergency. They may also spend time in care of the elderly, palliative care, remote medicine and many other areas. While away from family practice, most residents return to ‘their’ practice to see “their patients” ½ day per week. This allows continuity of care and integration with community practice.

30. Residency Training Programs In three year programs (US and UK), 1 full year is spent in family medicine and the other two years are spent in hospital often with little connection to Family Medicine. Another model is to spend three or four half days a week following a group of patients in the community practice for the entire 2 or 3 years. This is complicated as all other experiences in hospital has to be built around the resident leaving 3-4 half days per week.

31. Community Experience In community teaching clinics residents: 1. Gain clinical experience by seeing patients that they follow over time 2. Learn the patient centered approach usually by being directly observed by faculty or videotaping sessions with patients. 3.Gain a theoretical and practical understanding of dealing with clinical uncertainty. 4. Gain practical experience with common and important clinical problems

32. Community Experience 5.Gain the ability to critical appraise the medical literature and incorporate it into their practice. 6.To gain skills in dealing with psychosocial issues. 7.To learn to monitor and describe the needs of the community served by the clinic. 8. To learn to evaluate the quality of care delivered in the practice.

33. Community Experience 9. Residents are expected to complete a small research project related to activities in the clinic. This allows them to gain an understanding of research methods and to answer important and practical research questions. 10. Residents are also expected to conduct an audit of some aspect of their clinical work (such as rate of pap smears in eligible women, number of patients with a recorded BP etc)

34. Community Experience 11. Residents are expected to keep a log of their clinical work either manually or by computer so that their clinical experience can be assessed against objectives. 12. Residents keep a log of minor surgical procedures completed with a sign off by faculty that the individual is competent to do the procedure themselves.

35. Learning the principles The physician- patient relationship is central to the role of the family physician. Achieved by seeing, following and establishing relationships with a cohort of patients in a community practice. The resident needs to have interviews monitored and critiqued. The resident needs to reflect on how they can improve. They also need a theoretical understanding of the objective.

36. Learning the principles The community clinic setting requires a clinical teacher who can monitor and critique the resident while following a group of patients over time. Ideally, the clinic would have an electronic data recording system and a video camera to record interviews. Part of the resident’s learning would be to function in the clinic team. The supervisor would need to evaluate and feed back on the residents progress regularly.

37. Learning the principles Family Physicians are skilled clinicians. The clinical skills are learned in the clinic environment working with a skilled clinician. This experience recorded by log should be supplemented with an ongoing academic half day program that covers the latest management of common and important problems in practice behavior science skills. Monitoring and assessment of the resident’s patient centered method and how the resident deals with uncertainty is essential

38. Learning the principles Family Physicians are a resource to a defined community; The community clinic is essential in this learning. Learning basic epidemiologic skills, having a system that allows assessment of community needs and conducting research or audits on how these needs are met are in addition to an ongoing seminar program that is required.

39. Learning the principles Family Medicine is dynamic in responding to the changing needs of the community. The resident needs to participate in learning self assessment skills, skills in determining how to best acquire knowledge to keep skills up to date. A specific academic seminar program is needed over months or years to develop these skills.

40. Possible Structure In Brazil, the community clinics provide the ideal setting in which to provide the community experience for one resident. A teaching clinic would have a clinical teacher as the physician who would be an excellent clinician and have teaching skills gained through a faculty development program. The clinic would have some computer record system and videotaping capacity.

41. Possible Structure A program would require the number of teaching clinics needed for each resident to follow a group of patients over the two or three year period. All the residents would come together in a central location at least weekly for their academic program, their video tape reviews, and their continuing evaluation.

42. Possible Structure The faculty to run such a program (ideally from a University but could be hospital based) would consist of the clinical faculty located in the community clinics, educators located centrally who would supervise the clinic faculty and provide faculty development and the ongoing academic theory programs for the residents and researchers who would support the research program in the residency and conduct research in the network of community clinics.

43. Possible Structure

44. Education in Center The central office is responsible for coordinating all the residents’ experience in the community and in hospital. They would need to ensure that hospital experience was relevant to their objectives .

45. Education in Center A University Department of Family Medicine would be responsible for undergraduate teaching in the medical school. All students should gain an understanding of the Principles of Family Medicine. This would include diagnosis and management of common and important problems in the community.

46. Undergraduate Family Medicine Teaching clinical skills Teaching interviewing skills. Teaching problem based learning Providing lectures on common clinical problems Providing lectures on dealing with clinical uncertainty Providing lectures on dealing with bio- psycho- social problems. Providing clinical experience in community based teaching clinics.

47. Research This structure would provide a remarkable practice based research network. 50 clinics with 4,000 patients in each or 200,000 patients. Recommendation from the World Organization of Family Physicians All member countries should develop sentinel practices to provide surveillance reports on illness and diseases that have the greatest impact on patients’ health and wellness in the community. These practices provide a base to collect essential research data.

48. PBRN’S Contribution to Research Capacity Building collecting empirical data from FP relating FP’s to researchers and focus research on important questions from practice disseminating research results in practice stimulating research interest in FP’s.

49. Examples of Family Medicine Research Family physicians at the University of Toronto tested a sore throat scoring system in both a Toronto teaching practice and a community based family practice in a small town. They used an already developed scoring system as a predictor of patients with or without positive streptococcus cultures from the pharynx which could reduce antibiotic prescribing by up to 75%.

50. Family Medicine Research A group of researchers at Queen’s University studied management of hypertension in a research network of 50 community practices. Their findings include the fact that home measurements of blood pressure provide different results than conventional office readings.They have also found that patients follow their BP lowering directions, and are equally satisfied when they have either three or six month follow up for elevated blood pressure. 

51. Family Medicine Research Michael Klein at the University of British Columbia’s Department of Family Medicine conducted a series of trials on the value of an episiotomy and found that midline episiotomies consistently produced more pain and more damage to the perineum than natural tears. Medio-lateral episiotomy, although less traumatic than the midline, produced significantly more pain and complications than did natural tears. These studies have influenced a world wide decline in episiotomies.  

52. Family Medicine Research A University of Toronto group found that treating women for cystitis after testing the urine for white cells and nitrites reduced antibiotic use in cystitis by 27%. This paper was selected as the outstanding Canadian Family Medicine research paper in 2002.

53. Conclusions The Brazilian clinic model, with 25,000 functioning clinics in the community providing medical care to more than 30% of the population is a remarkable achievement. To optimize the potential benefits to Brazil of this achievement, a workforce of physicians and nurses specifically trained to function effectively in this environment is needed. A stimulating and attractive career opportunity needs to be created to attract medical students.

54. Conclusions This phenomena presents a great opportunity to develop academic and research programs that have the potential to greatly improve the health of the entire population. Models from around the world need to be adapted to the needs of communities in Brazil.

55. Conclusions The potential to greatly improve the health and economic well being of Brazilians is present and the challenge to the University of Sao Paulo is to provide a major contribution to this development.