SPrinciples of Family Medicine Common Lecture

Principles of Family/General Practice and the Role in NepalDr Katrina Butterworth

ObjectivesDefine what is General PracticeGain an understanding of the role of General Practice internationallyAppreciate the specific contribution that General Practice makes to health care in Nepal.

Question for discussionWhat are the distinctive features of Family (General) Practice?What is the role of the generalist?

Principles of Family MedicineFirst point of medical contact in health care system regardless of age, sex, diseaseIn some countries gate keeper to secondary care.Commitment to the person rather than type of diseasePatient centred

Principles of Family medicineManages both acute and chronic illness, often simultaneouslyAble to deal with undifferentiated complaints early stagesRecognizes emergencies and manages immediatelyAble to tolerate diagnostic uncertainty, remaining committed to the patient

Principles of Family MedicineConsultation process is uniqueFocused on ongoing relationship with patient and familyContinuity of care is key in some countries, GP maintains primary responsibility for patient even after tertiary referral. Co-ordinator of care.Familiar with community and family context knows whole family

Principles of Family medicineBalance care of individual patients with population healthIn some countries co-ordinate immunization and screening programmesEvery consultation opportunity for health promotion as well as curative.Manager of resources for both individual patient and the community (planning of health care)

Principles of Family medicineIdeally part of the community where their patients liveAvailable for home visitsInvolved in community networks of health care provision

Definition by Oleson et al (BMJ 2000:320, 354-7)GP is a specialist trained to be in the first line of health care provision, providing initial careTakes care of patients irrespective of disease or any social or personal characteristicsManages resources in health care system for benefit of the patientInvolved in prevention, diagnosis, cure, care and palliation integrating biomedicine, psychololgy and sociology

THE ROLE OF THE GENERALIST:Have a perspective of the whole and act as communication centre.Doesnt have to cover the whole field of medicine but should recognize red flagsKnowledgeable about common conditions (specialist doesnt always know more)Able to live with uncertainty (skill all doctors need, but many not good at)

THE ROLE OF THE GENERALIST:Attitudes and skills are more important than factual knowledge. Only men who are themselves whole can understand the needs and desires of other men. Balance and wholeness are important! Crosses clinical and social boundaries - interface between clinical practice and counseling professions. Act as an interpreter to mediate between the patients subjective experience and the scientific explanation.

Questions for Group discussionWhat are needs in Nepal?What are the difficulties/distinctives in Nepal?

THE NEEDUrban Growth (global - rural urban shift)Lack of Human Resources and Poverty especially rurallyDisparity of Access to Health careKathmandus doctor density was estimated to be 25 times more than rural Nepals 20 year difference in life expectancy between rural and urban Nepali population.Need for Family Doctors - whole family, continuity of care, appropriate referral and resource use (can address 85-90% needs)

Why Focus on Primary Care?Improves Health Indicators - Sri Lanka and Kerala have best in South Asia (BMJ 3 April, 2004)US Research found that increasing the number of General Practitioners by 1 per 10,000 (33%) decreases mortality by 70 per 100,000 (9% fewer deaths). Increasing the number of specialists by 1 per 10,000 (8%) increases mortality by 16 per 100,000 (2% more deaths).Shi et al The Journal of the American Board of Family Practice (2003)

Better OutcomesCare by a General Practitioner:Reduces disparities in health (the gap between rich and poor), Reduces the effect of income inequality Improves self-rated health

Starfield B, Shi L, Macinko J Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502

Patients with Primary Care Doc Spend Less After taking into account the patient's characteristics, health insurance status, diagnosis, health perception, and smoking status, study subjects with a primary care physician as their personal physician "had 33% lower annual adjusted healthcare expenditures and lower adjusted mortality, The average total expenditure for those seeing primary care physicians was $2,029 compared with $3,100 for those using a specialist as a personal physician.

Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experienceThe Journal of Family Practice August, 1998;47:103-104, 105-109.

WHY?Specialists tend to over investigate and over treat (Iatrogenic morbidity)Doctor may easily be working outside of his field of expertise GPs deal with a broad range of problemsSpecialists tend to be less good at communicating with their patients leading to more errors.

The role of the MDGP in NepalCaptain of the health care team especially in the primary health care centres and the district hospitalOversees mid level health care workers, who provide much of the primary care (not enough GPs to provide all the primary care)Teaches, trains and supportsAn excellent physician who can deal with the majority of cases they seeTrained in essential life saving procedures e.g. Caesarian section, appendicectomy, basic orthopaedic skills

The role of the MDGP in NepalVital part of the government strategy to achieve maternal child health MDG goalsIntegrate clinical expertise, a patient-centred, socially aware approach and a public health perspective.One or two fully trained GPs placed in the Primary Health Centre and District Hospital, are able to provide the sort of comprehensive holistic service that the people need

Difficulties for General Practice Not everyone who calls themselves a GP is trained in its specialty (especially in India)Lack of specific UG and PG Family Practice medical education.Vulnerability of living with uncertainty doctors feel need to be seen to have all knowledge Pressure of the immediate and urgent against health promotion and prevention.Balance of individuals (the patient in front of you) and the population. Specifically, the patient and the wider family needs, community needs of clean water, sanitation and better housing.

Difficulties in NepalLack of continuity of care. Patients pick and choose doctors, difficult to build up commitment/ responsibility; fragmented care and inappropriate investigation. To be where the people are lack of desired facilities for personal and family well-being and growthDifficult to see people in homes especially in rural areas.Lack of gatekeeper role which best achieves equity of care with appropriate use of resources. Can still help patients choose and get appropriate care from different parts of the system.Inadequate referral people not seen at right level of care

Some EVIDENCE2007 NSI retrospective study of Nepal government district hospitals where an MDGP doctor was present for five or more years during the period 2053 62. 19 district hospitals were identified and in 12 of these district hospitals, MoHP Annual Reports showed that the presence of an MDGP doctor was associated with more deliveries, more OPD visits and more operations

2010 review of NSIs Rural Staff Support Programme (RSSP) Presence of an MDGP doctor - patient utilization (Gulmi - OPD patients increased by almost 3 fold, the number of deliveries by over 2 fold and the number of admissions by approximately 1.4 fold) and comprehensive emergency obstetric care (CEOC) rose dramatically. Community interviews - availability of MDGP made a tremendous difference in the service provided to patients; they were appreciated.

SUMMARYGood primary care is good for everybody. Strengthening district health systems is the most appropriate way to promote primary health care. General Practitioners (GPs) are the most effective doctors for providing primary health care. There are appropriate and complementary roles for Primary Care and Specialist Physicians. Nepal, as a nation with limited resources and a large number of poor people needs far more well-trained, committed General Practitioners.