By Professor Doris Young
Department of Family Medicine
NUHS
In most developed countries, the discipline of Family Medicine (FM) or General Practice (GP) is well established. Many people have a GP or their own family doctor who looks after them and their families. They live near the neighborhood and serve as their local doctor, counsellor and trusted friend. They provide health screening, diagnose their problems, manage them and co-ordinate their care. In other words these GPs act as their advocates to navigate the complex health care pathways for them. International studies show that a well-developed primary care system with GPs or family doctors and basic health care providers deliver more cost efficient care.
The case for a different model of care in Singapore
It is not uncommon for some people here to go straight to hospitals when they feel unwell. Others seek health care from their familiar neighborhood doctors, though some choose to go from one doctor to another. They may even get medicines from one and then see another for other problems. Of greater concern is the phenomenon of some people taking medicines, going for expensive tests that they don’t need, and consulting multiple sub-specialists for chronic diseases – all without any co-ordination or continuity of care. Is this type of health services sustainable in a country like Singapore, which is grappling with an increase in chronic diseases like diabetes, high blood pressure, heart diseases and cancer even as the population is also ageing and requiring more health care and services?
The role of family doctors
So what kind of health care professionals can meet the projected needs of Singapore in the next few decades? The country needs to train and produce more family doctors who can provide patient-centred, comprehensive continuity care to the community.
Most people require basic health care services, screening and assessments, reassurance and help with minor non-life threatening conditions. If they develop chronic illnesses, they require Family Primary Care professionals to treat, monitor progress to prevent complications, keep them in the community and leaving only the very complex patients to be managed by sub-specialists. People need to monitor their own conditions with the support of a well-trained and well integrated team of health care professionals. Older people need to be screened early to detect illnesses and frailty so that interventions can be initiated early to keep them healthy and living in the community with their family and friends.
I believe it is the responsibility of the entire Singaporean community, and the effort should include the medical schools, the postgraduate residency training programmes, the specialist Colleges (College of Family Medicine and the Academy of Medicine) supported by the Ministries of Education and Health. Last but not least, the community needs to embrace and value the concept of having a family doctor to care for them.
The role of the medical schools
To begin with, medical schools need to select the right mix of students from a diverse background. In addition to academic grades, we need to select people who like to work with people, who are problem solvers, good listeners and communicators, good advocates for the needy and disadvantaged, can deal with uncertainties and have a holistic view of health care delivery.
Next, the medical undergraduate curriculum should feature early and continuous exposure to Family Medicine and primary care, so that students can learn about the various types of clinical presentations and how problems are solved and managed at the community level. They should appreciate that many people do NOT need to go to a hospital to receive care and if they do, they can return to the family doctors to continue their care at home. Candidates for admission to medical school must also evince genuine interest in providing comprehensive care to the population assigned to their locality. They must be interested to work in a team to solve health problems together.
Finally, the postgraduate training of family doctors ought to be integrated with the undergraduate training programme in terms of curriculum, teachers and setting. There can exist different training providers BUT the end point of assessment should be standardised in order to ensure that we are training quality family doctors.
Bringing it all together
This vertical Integration of Family Medicine training programmes ensure education about general practice from medical students through vocational training to continuing medical education. A truly vertically integrated FM training programme has to integrate the learners, the curriculum, the teachers and the settings.
To integrate learners, we have to know who they are. The demographics of our learners –medical students and future residents – are different from the demographics of their GP teachers. Placing medical students and residents together in a shared learning environment creates opportunities for mutual learning, supported by the GP teachers. Together they undertake continuing medical education.
Another task associated with the vertical integration of GP training involves the curriculum. Residents can build on what they have learnt in medical school through to hospital work and then to general family practice.
With the new problem-team based curriculum adopted by many universities, graduates have a different learning style and the GP training programme must be modified regularly to reflect what is being taught in medical school and to deliver information in the most accessible way. Students are now taught critical appraisal skills, research methods, rational prescription of medicines and the use of evidence-based medicine. They can share some of these skills with their GP teachers.
Photo: Regional Health System Planning Office, NUHS
Integrating the teachers will also enhance GP education. At present, teachers come from different backgrounds – from the polyclinics, private practice, academia. These groups overlap in their roles and yet the employment conditions and qualifications are different. We need appraisals and quality assurance to be put in place. Integrating the teachers means bringing them together in training seminars, offering university-affiliated appointments or, better still, fractional appointments with university departments so they can build a career structure for themselves.
The teachers can also benefit from the universities’ teaching and learning quality assurance programmes as well as involvement in the development or delivery of CME/postgraduate diploma/certificate/masters courses to enhance their skills as educators. Some may choose to do a higher research degree such as a PhD. This choice will result in an increase in quality teachers and researchers in general practice. It will raise the status of Family Medicine as an academic discipline.
Finally, there needs to be an integration of settings where we teach our GP learners. Just like the hospital settings, undergraduate students and postgraduate residents learn together and interact with each other under the preceptorship of their GP teachers. They would then also have the opportunity to work together with an inter-professional team of nurses, allied health and community workers.
NUS Medicine’s approach
We will be embracing this approach and aim to encourage more medical students to undertake Family Medicine as a career. We will expand and extend students’ exposure to FM both in terms of content and length of the FM curriculum. Students will be placed in Family Medicine and primary care settings from Phase 1 through to Phase 4 and perhaps even 5 so that they can appreciate the ability and role of the FM practitioner to deliver comprehensive, continuing and home care. They will learn together with nurses and other allied health professionals to care for people in the community.
We also plan to integrate undergraduate and postgraduate Family Medicine training more closely in terms of curriculum, teachers and the settings. As the practice of Family Medicine and general practice is diverse in Singapore and ranges from one-person to group practice to polyclinics, we will ensure that teachers are trained to the same standards so that our students and residents are exposed to mentors and trainers of high quality.
Family doctors as mentors and role models
They need to be good mentors and role models for young students and residents by practicing quality care, using best evidence to treat their patients, prescribing affordable medicines and following up their patients judiciously. Another opportunity is to work with neighbouring doctors to share care and provide continuity of care so that patients don’t default to emergency rooms and hospitals because of inaccessibility. They need to be part of the primary care networks and raise the standards and status of Family Medicine so young doctors can aspire to join the profession.
To conclude, the future of Family Medicine in Singapore is bright as both the Ministries of Education and Health are working together to ensure that the training of family doctors can meet the emerging needs of the ageing population, both in terms of preventive care and treatment. It will take time, but the day is coming when family doctors will be the primary caregivers for Singaporeans.
“It will take time, but the day is coming when family doctors will be the primary caregivers for Singaporeans.”