Family Medicines: a Strategic Weakness Essay

Recently the trends of urbanization and fast population plus expose s everal problems to wellness sell organisation in Vietnam like dearth of wellness sustenance manpower, low step of cargon, unwarranted distri moreoverion of wellness bursting charge manpower in antithetical geographic aras, peculiarly the serious shortage of docs in Mekong Delta and North-west highland atomic number 18as as specialists function to locate their employments in urban health check exam centers where they could have access to go technology, entertainive go and consultations from dissimilar specialists while plain areas are underserved and unhurried apprehension becomes highly technocratic, fragmented and episodic.Further to a greater extent than, the shortage of mendeleviums in major(ip) cities results in a seriously permanent overload at primaeval take and several(prenominal) medium hospitals like Oncology, Pediatrics, Obstetrics and Gynecology .. etc.. In susta in commensurate issues, deficit of Family medication a basic launching of modern health parcel out in the field, is identified as 1 of main ca routines of such problems in Vietnam health solicitude constitution.The purpose of this Essay is to allow a theoretical reciprocation and analysis about the Family medication weakness in Health get by dodging and Family physician insufficiency in Vietnam to bring out understand about their impacts to the health fretting clay at present and roughly proposed answers and recommendations to modify these deficits. 2. Family medication and its roles in manhood(prenominal) health attending system. In modern-day practice of medicine, Family medicine remains the foundation st matchless of health anguish service in the fellowship.As the just about kindle and challenging of aesculapian disciplines it is based on six fundamental principles * essential coil do * family manage * domiciliary rush * continuing maintenance every last(predicate) above principles are all designed to achieve * preventive like * ain care (Pereira Gray, 1980). In the contemporary climate where medical exam work are fragmented and on that point are competing interests at that place is a greater need than ever for familiarists.In those principles, elementary care is the backbone of the health care system and encompasses the following functions * It is first contact care, serving as a point of entry for the forbearing into the health care system * It includes perseveration by virtue of caring for patients in sickness and health over some period * It is door-to-door care, distinguishing from all the traditional major disciplines for its functional content. It serves a coordinative function for all the healthcare involve of the patient * It assumes continuing responsibility for individual patient follow-up and community health problems * It is a high personalized type of care (Rakel 2011) In the 2008 report, the earth ly concern Health Organization (WHO) reaffirmed the sizeableness of primary health care with its report radical health care straight off more(prenominal) than ever and its emphasizes that primary care is the best way of coping with the illnesses of the 21st century, and that better use of existing preventive measures could reduce the globose burden of ailment by as much as 70%.The commentary emphasizes that primary care brings promotion and prevention, cure and care together in a safe, effective and socially productive way at the interface amongst the population and the health system. The key challenge is to put pot first since good care is about stack (WHO, 2008). sooner than afloat(p) from one short-term priority to another, countries should make prevention equally essential as cure and focus on the rise in degenerative complaints that require long-term care and strong community support.Furthermore, at the 62nd terra firma Health Assembly in 2009, WHO strongly reaff irmed the values and principles of primary health care as the basis for strengthening health care system world replete(p). The essence of Family medicine is continuity of care and the evidence for its contribution to prize of care and better outcomes as follows * Lower all arrange morbidness * Better access to care * Less re-hospitalization * Fewer consultations with specialists * Less use of emergency service Better detective of adverse effects of medical persuasiveness interventions. Role definition of Family physician varies considerably two among family physicians and among pile with whom they interact. about individuals, peculiarly other medical specialists, see family medicine as exactly another name of general practice. For others, family medicine is synonymous with primary care. A large proportion of family physicians further elaborate their role to include idiom on personalized and humanized care.A smaller group adds a troika component to their role caring for fa milies. The largest proportion who subscribes to this last notion appoint to family physicians treating all members of a family (Cogswell, Sussman, 1982). In view of Family medicine, Family physicians are generalists who primarily draw their scientific medicine and technical expertise from five older specialties inner medicines, pediatrics, surgery, obstetrics-gynecology and psychiatry-neurology.Compared to these specialties, family medicine is still a young report marked twain by rapid expansion and by adjustment, variety, ambiguity and conflict in the images and definition of the role of family physician. As the largest caring scope in healthcare services, the quality and quantity strengths of Family physician force play key roles to remedy the health quality of depicted object population. Globally the scope of Family medicine is prolonged with the recent view of global health care which is a field at the intersection of several disciplines epidemiology, economics, demogra phy and sociology.The term global health, as opposed to international health, implies consideration of the health inevitably of the people of the livelong planet above the concerns of particular nations. That means global health has wide scope and r for each one to equity that the term of international health. The global health innovation in Family medicine raises the changes in primary care record as follows * All population has to deal with the same risk of health due to the phenomena of traveling and immigration. Increase the gap between the poor & international ampere the rich globally. * The process of the urbanization/globalization. * Increase of the population in the world. * minify of the resources for health care. * Global warming phenomena. * Vaccination Era. * Evidence Based medicament in daily practice. * Increase the bad behavior such as fast food, tobacco, stress, use alcohol * simple health care change to Primary care model(Pham Le An, 2009). Such comprehensive changes kindle the scale of Family medicine in healthcare.In order to promote the global health support as well as strengthen the co-operation of national members, the humanity Organization of National colleges and Academies (WONCA), arena Organization of Family physicians in WHO, was formally established and based in Singapore after the Fifth World Conference on General Practice in Melbourne in 1972. 3. Family medicine situation in Vietnam Although Family medicine basis had been established in the world for over 40 long period, Family physicians, the most recently recognized specialists in Vietnam, are in the enigmatic situation of developing the occupational role which they concurrently occupy.Family medicine had been only if approved for establishment by Vietnam Ministry of Health since 2000. Until 2003, Family medicine strong point was established at 3 aesculapian Universities of Hanoi, HCMC City and Siamese Nguyen province to train Family physicians and its specialist s. However, its development was spontaneous with 7 Family medicine clinics (in both public and mysterious sectors) nationwide and not strategically organized at all take aims so far.There are only 59 post-graduated specialists and near 1,1 General practitioners who partly handle the roles of family physicians per 10,000 people averagely. The imbalance between Family medicine and other specialists can be seen by the ratio of 7,2 Medical loads per 10,000 people in boilers suit (Vietnam General Statistics Office GSO 2011) and the healthcare system only satisfies about 60- 70% of the demands and are train than neighbor countries like Thailand, Singapore, Malaysia, Philippines.. tc. In 2011 report, Vietnam Ministry of Health forecasted the demand of 34,000 General practitioners more to obtain 10 Medical rejuvenates/10,000 people in 2020 and this is a significant challenge to all 19 Medical fosterageal Universities/Colleges to educate Medical doctors and post-graduate takes in medicine which capacities render 4,800 graduated Medical doctors every year to add around 3,500 physicians more a year.Not only the quantity of family physicians is seriously insufficient, but to a fault their quality to fulfill the roles of a family physician does not meet the needs of the patients and social development. The General practitioner fosterage programs dont lie student to the WHOs critical requirements of good doctors in Family medicine, even though the criteria are more and more demanding by time, for example, the newer criteria of John Murtagh in 2001 What makes a good General Practitioner? * Develop rapport and good conversation skills * Ask the right questions * Be astute and observant * Develop optimal ethical and professional standards * Have a fail-safe diagnostic schema * Develop supportive networks * Know essential therapeutics * Develop basic adjective skills * Be well prepared for emergencies * Know yourself and your limitations including own genera l practitioners. The importance of certain specific competences and soft-skills in family physician force are emphasized in many studies.An interesting survey on patient care by representative health consumers conducted at St Vincents hospital Melbourne revealed that the most alpha attributes of good doctors were (in some order of importance) caring, responsibility, empathy, interest, concern, competence, experience, confidence, sensitivity, perceptiveness, diligence, avail business leader and manual skills. Additionally, there are neither comprehensive mansion programs for Family physicians at Medical Universities/ Colleges in Vietnam nor supporting policy to them and general practitioners practicing at outback(a) or rural areas so far.With effort to resolve the overload situation of profound hospitals in major cities, spew 1816 of Vietnam Ministry of Health deployed in 2008 with the purpose of Fielding revolve professionals from upper level hospitals to deject levels to remediate the quality of medical care achieved some initial results such as transportring some technologies and conducting on-site training to improve skills and qualifications for lower level health care professionals initially up the quality of medical care at lower levels, especially in the mountainous, remote areas with staff shortageetc, but its couldnt obtain one of basic goals to reduce overcrowding for upper level hospitals, especially central level hospitals because it made the shortage of central level and specialty hospital more serious by the rotation. 4. Impacts of Family Medicine weakness in Healthcare system & Family physician insufficiency in Vietnam.Due to low dependableness and poorly structured family physician network, patients tend to bypass to specialists/ central level hospitals (Vietnam Ministry of Health 2011 Report), opposite with the trend in the world in which healthcare activities for chronic affections such as diabetes, hypertension, asthmaare m oved from in-patient to out-patient services with comprehensive treatment protocol at each level (Dang new wave Phuoc, 2012) The irregular bypass causes the overload at Central level and specialty hospitals and the overloading condition becomes more serious, i. e, bed using capacity at Central hospitals increase from 116% (2009) to 120% (2010) and 118% (2011).Its extremely high in some specialty hospitals such as K (Cancer) Hospital 249%, Bach Mai Hospital 168% Cho Ray hospital 154% Central Obstetric and Gynaecological hospital 124% .. etc. High capacity occurs in some specialties such as Oncology, Cardio-vascular, orthopedics (at 100% of hospitals), Obstetrics and Gynaecology, Paediatrics (at 70% of hospitals) while 36,8% of General hospitals are overloaded. The similar situation also happens in Consulting Departments with 80 exams/day/doctor while 60% 80% of patients at Central level hospitals could be examined at local level and 40% of surgery cases at Central level hospital co uld be performed at local levels (Ministry of Health send off to decrease workload of Central level hospitals 2012- 2020)With the cost in health care, the deficit of Family medicine in Vietnam is one of reason making the medical expenses of patient higher. Total Expenditure on health as % of gross domestic product (5. 1) is fairly high while General Government expenditure on health as % of total expenditure on health (28. 5) is so low to neighbor countries (Susan, 2005). The most cost-effective healthcare systems depend on a strong primary care base. This has been confirmed by a variety of studies comparing the care given by physicians in different specialties because primary care provided by physicians specifically trained to care for the problems presenting to personal physicians, who know their patients over time, is of higher quality than care provided by other physicians.When hospitalized patients with pneumonia are cared for by family physicians or full-time specialist hospi talists, the quality of care is comparable, but the hospitalist incur higher hospital charges, longer lengths of stay, and use more resources (Smith et al. , 2002). Similarly, the greater quantity of primary care physicians practicing in a nation, the lower is the cost of health care. The cost of healthcare is inversely proportional to the percentages of generalists practicing in that nation. According to OECD Health (Organization for Economic Cooperation and Development OECD Health Data, June 2005), United soil has twice the percentage of family physicians but half the cost to U. S.. Administrative budget items accounts for a major part of the high overhead cost (31%) of U. S. health care (Woolhandler et al. 2003).Countries with strong primary care have lower overall health care costs, improved health care outcomes, and healthier populations (Starfield, 2001 Phillips and Starfield, 2004). The shortage of Family physicians and Family medicine deficits also cause other problems in health care as follows * Incomplete or unsuccessful Primary health care performance. * The gap between urban care and rural care in the health care network. * The competition among specialties lack of cooperation in chronic disease care, increase the cost of management. * Barrier in teaching ambulatory care and doing out-patients research in academies (Pham Le An, 2009). In society, Family medicine meets some resistances of patients such as family hysicians are unfairly treated as general consultants, home caring doctors and even in medical community, they are considered as incompetent doctor, poor specialist, unfair competitive doctor.. etc. Many other specialists and hospitals managements list Family physicians as one of financial losing causes to their hospitals. Such unfair treatments make many Family physicians feel uncomfortable with the specialty and their roles of Family physician. The reliability of patients and society to them is fairly low and this specialty does not d ecoy the general practitioners to count. 5. Some proposed solutions & recommendations to improve Family medicine.In order to improve the Family medicine in Vietnam, it requires a comprehensive strategy with strong supports of government, educational institutes and society. Within the limit of this essay, I would like to propose some solutions and recommendations as follows a. Increasing the quantity of Family physicians with excessly trained General practitioners and using the retired medical doctors The greater the military issue of primary care physicians in a country, the lower is the deathrate rate and the lower cost (Rakel, 2011). In the United States, a 20% increase in the number of primary care physicians is associated with a 5% decrease in mortality (40 fewer demolition per 100,000 population), but the benefit is even greater if the primary care physician is a family physician.Adding one more family physician per 10,000 people is associated with 70 fewer death per 100, 000 population, which is a 9 reduction in mortality (Rakel 2011). A study of the major determinants of health outcomes in all 50 U. S. states found that when the number of specialty physicians increases, outcomes are worse, whereas mortality rates are lower where there are more primary care physicians (Starfield et al. , 2005). Starfield (2000) states, the higher the primary care physician-to-population ratio, the better most health outcomes are (p. 485). Researches in England reveal that with each Family doctor more in 10,000 people (about 20%), adjusted mortality will reduced about 5% in chronic diseases (Gulliford 2002).The increase of Family physicians obviously reduces the workload at Central level and specialty hospitals (49. 3% of out-patient and 59% of in-patient totally) because with many researches in the world, over 90% of patients are taken care with better service by Family physicians in developed medical or developed countries (Didier, 2011). They can help patients an d their relatives in 80% health problems acute or chronic diseases without complications or no need to transfer to Specialty hospitals (Dang avant-garde Phuoc, 2012). To compensate the continuing decline of the number of students entryway primary care as a common trend in the world (Bodenheimer et al. 2009) and insufficiency of graduated general practitioners, a policy to support general practitioners and retired medical doctors to practice as Family physicians such as additional training about Family medicine, financial supports, incentiveshould be prepared and experienceed. Rather than other countries where Family physicians usually work at home or their private clinics, Vietnam has a wide network of local level medical centers at wards/hamlets and popularly private clinics/medical units. This advantage allows Family physicians to practice and deploy the primary care programs easily and popularly. b. Family physician conformation training programs Quality of care and the inade quacy of medical training are two major concerns of Family physicians. Eventually, medical schools and residency programs graduated more specialists and fewer physicians trained for primary care.To improve their quality of care in accordance with global health principles, proposed solution is to build emerging curricula of family practice residency programs to envisioning family physicians as flat specialists who can deal with the large majority of patients needs on a continuing basis (Rakel, 2011) and envisioning this role as integrating humanized care with a high level of competence in scientific medicine. In contrast to the training of the general practitioner, the additional training that family physicians receive is think to make them more proficient generalists in scientific medicine through and through formal training in appropriate interpersonal skills and in the behavioural and social sciences.Implementation of this role, however, requires reorganization within the medica l system (Folsom, 1966) for continuing, comprehensive care by primary physician is difficult if not infeasible within the normative organizational structures of highly specialized medical centers. As Family physicians play the important role in primary care, the Global health awareness program should be combined into General practitioner and Family physicians training curriculum for being sure about the quality of primary care as follows (i) Clerkship adding knowledge of burden global disease in the world such as tuberculosis, malaria, Preventive care vaccination modify skills such as clinical making decision, dialogue. ii) Orientation Adding knowledge of new emerging infectious disease like SARS, non communicable diseases, traumatism care, human immunodeficiency virus/AIDS (iii) Residents adding knowledge of prenatal care, neonatal care, chronic care, mental health care, adolescent care Emergency care in disaster improving skills such as doing research and practice Emergency c are in disaster, Behavioral care after disaster, Kangoroos program, Obs-Gyn care program build up the kin center care with WIN- WIN theory for both developed and developing countries to increase of cooperation and Team work. In addition, the cooperation among experts in different medical fields should be strengthened for teaching, managing, doing research to promote the concept relationship center care through many activities * Establish cross Medical Education, Patients clubs. * Build the bridge or amalgamate the teaching contents in Family medicine with the other specialties like Pediatrics, conventional Medicine ( Oriental nutrition, Shiatsu), Cancerology (Palliative care), Multidiscipline (Disaster care, EBM, chronic care). Communication through Internet/ motion-picture show conference and Electronic medical The WHO 2008 report emphasizes the appropriate use of nurture and communication technologies to improve access, quality and efficiency in primary care. The generator has made a small contribution to basic patient education (also known as doctor education) by the production of common patient handouts which are available for print out from General practitioners computers or for one page photocopying from the book Patient Education (Murtagh J 2008). Besides the residency training programs, on-going training courses to improve the competences and skills of Family physicians should be set for attributes considered most important for patient satisfaction ( billet Keister et al. , 2004a).Overall, people want their primary care doctor to meet five basic criteria to be their insurance plan, to be in a location that is convenient, to be able to schedule an duty assignment within a reasonable period of time, to have good communication skills, and to have a reasonable amount of experience in practice. They especially want a physician who listens to them, who takes the time to explain things to them, and who is able to effectively integrate their care (Stoc k Keister et al. , 2004b, p. 2312). c. Others solutions and recommendations (i) Building an incentive final cause and financial supporting policy to Family physicians, especially whom working in remote and rural areas The effectiveness of this model had been proved in many countries, particularly in Thailand and Malaysia where healthcare conditions are fairly similar to Vietnam.Contrarily, the recent P4P (Pay for Performance) policy of Thailands of Ministry of Health to replace the incentive scheme to Family physicians creates several problems to healthcare force and patients and is considered as a main cause leading the Family physicians despicable to major cities. With relation between income and satisfaction, in an analysis of 33 specialties in U. S. , Leigh and associates (2002) found that physicians in high-income procedural specialties, such as Obs Gyn, ENT, ophthalmology and orthopedics, were the most dissatisfy. Physicians in these specialties and those in internal medic ine were more likely than family physicians to be dissatisfied with their life historys.Among the specialty areas most satisfying was geriatrics. Because the population older than 65 years old in U. S. has doubled since 1960 and will double again by 2030, it is important to have sufficient primary care physician to care for them. The need for and the rewards of this type of practice must be communicated to students before they locate how to spend the rest of their professional lives. Patient satisfaction correlates strongly with physician satisfaction, and physicians satisfied with their lifes are more likely to provide better health care than dissatisfied ones. Physician satisfaction is associated with quality of care, particularly as measured by patient satisfaction.The strongest factors associated with physician satisfaction are not personal income, but rather the ability to provide high-quality care to patients. Physicians are most satisfied with their practice when they can have an ongoing relationship with their patients, the freedom to make clinical decisions without financial conflicts of interest adequate time with patient and sufficient communication with specialist (DeVoe et al. , 2002). Landon& colleagues (2003) found that rather than declining income, the strongest predictor of decreasing satisfaction in practice is the loss of clinical autonomy. This includes the inability to obtain services for their patients, control their time with patients, and the freedom to provide high-quality care. ii) Compulsorily assigning General practitioners/ Family physicians to practice at local level hospitals, the servicing term at local level hospitals must be reasonable and acceptable. (iii) up facilitates of local level hospitals/clinics, enforcing the lower level hospitals to experience modern technologies and quality control. This allows Family physicians to better serve patients as some achievements of Project 1816 of Vietnam Ministry of Health. (iv) Involving patients for private and family health care and prevention, structured information supporting treatment. (v) Improving the reputation of Family medicine and physicians in society through public media take like television, newspaper.. etc, medical education programs and medical community.Even after the specialty is formally acknowledged by institutionalized medicine, family physicians have experienced a variety of negative responses from medical colleagues in other specialties. Carmichael (1978) perceived 3 stages in the reactions of those in medicine to Family medicine first, the field was ignored second, it was actively opposed and then, family medicine is entering a third stage of doable co-optation by medicine. 6. Conclusion The weakness of Family medicine and insufficiency of family physicians cause many strategic consequences to the healthcare system in Vietnam. Their correction requires a long-term strategy to increase the quantity of Family physicians, quality of care, revise the residency training programs, improve its reputation in the society .. etc.In conclusion it seems appropriate to paraphrase Dr Robert Rakel in his keynote presentation to the fourteenth WONCA World Conference to reaffirm the Family medicine era in the contemporary medicine Regardless of how computer literate we are or how high our technology or whether the setting is urban or rural, good medical care in the future will continue to depend on patient care provided by a concerned and compassionate family physician. The physician will be governed by ethics, not economics, by a confederacy with the patient, not politics and by compassion and communication, and not by capitation. high-priced medical care in the future will depend, as it does now and always has, on the quality of our interaction with the patient Dr Robert Rakel 14th WONCA World Conference) REFERENCES 1. 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