William E Cayley Jr (1)
Lesley Pocock (2)
Victor Inem (3)

(1) William E Cayley Jr MD MDiv (1)
Associate Professor
University of Wisconsin Department of Family Medicine
UW Health Augusta Family Medicine Clinic
207 West Lincoln
Augusta, WI 54722
USA
T: 715.286.2270
F: 715.286.5716
Email: bcayley@yahoo.com
(2)LesleyPocock
Publisher and Managing Director
medi+WORLD International
11 Colston Avenue
Sherbrooke 3789
Australia
Phone: +613 9005 9847; Fax: +613 9012 5857;
Email: lesleypocock@mediworld.com.au
(3) Professor Victor Inem
Professor of Family Medicine
Delta State University
Nigeria
Email: inemv@yahoo.com

Mohsen Rezaeian (4)
Special Contributing author:
Associate Professor Mohsen Rezaeian
Rafsanjan Medical School
Rafsanjan, Iran
Email: moeygmr2@yahoo.co.uk

National Contributing Authors
Australia - Lesley Pocock, Dr Mike Ellis Medical Renaissance Group
Bosnia-Herzegovina - Dr Azijada Beganlic; Bosnia and Herzegovina, Family medicine doctor, PhD, the Leader of Educational family medicine center
China - Clinical Professor Cindy Lam, Hong Kong SAR, -
India - Professor Sunil Abraham Department of Family Medicine and Consultant, Low Cost Effective Care Unit, Christian Medical College, Vellore
Indonesia - Dr Sugito Wonodirekso, President PDKI
Iran - Associate Professor Mohsen Rezaeian, Dean Rafsanjan Medical School, Iran
Iraq - Professor Thamer Al Hilfy, Baghdad Medical College, Baghdad; Professor Abbas Ali Mansour, Assistant Professor of Medicine, Department of Medicine, Basrah College of Medicine, Consultant Physician -Al-Faiha Hospital, Hattin post office .P.O Box: 142
Lebanon - Dr Abdulrazak Abyad, Abyad Medical Center, Tripoli, Lebanon
Nepal - Dr Pratap Narayan Prasad (Department Of General Practice and Emergency Medicine), Institute of Medicine, Kathmandu; Dr. Bijendra Kumar Rai, Faculty of Dept of GP and ER Medicine, Dr Mark Zimmerman, Dr Bruce Hayes (NSI)
Pakistan - Professor Waris Qidwai Professor and Chair, Department of Family Medicine, Aga Khan University, Karachi
Turkey - Prof. Hakan Yaman, Chairman, Akdeniz University, Faculty of Medicine, Dept. of Family Medicine, Antalya, Turkey, Former Founding Member, Board of Turkish Family Physicians
United Kingdom - Dr Bader Mustafa, Professor Salman Rawaf PhD FRCP FFPHM, Director of Public Health/ Director of WHO Collaborating Centre, Wandsworth tPCT, London
USA - William E Cayley Jr MD MDiv, Associate Professor, University of Wisconsin Department of Family Medicine, UW Health Augusta Family Medicine Clinic, 207 West Lincoln, Augusta, WI 54722 USA
West Africa - Dr Victor Inem Professor of Family Medicine, Delta State University, Nigeria

Research Committee for Compilation of Competencies Questionnaire List
Prof Victor Inem (Nigeria, West Africa) Prof Cindy Lam, (Hong Kong/China), Dr Bader Mustafa (UK), Dr Mike Ellis, Lesley Pocock (Australia) Dr Tawfik Khoja (Director General Executive Board Council of Health Ministers for Cooperation Council States, Saudi Arabia) Dr Hakan Yaman (Turkey) Dr Fusun Yaris (Turkey), Professor Waris Qidwai, (Pakistan) William Cayley Jr MD, (US) Dr Mike Ellis, Professor Abbas Ali Mansour (Iraq), Dr Bruce Hayes, Dr Bijendra Rai, Dr Pratap Narayan Prasad (Nepal), Professor Salman Rawaf PhD FRCP FFPHM, Director of Public Health/ Director of WHO Collaborating Centre, Wandsworth tPCT, London (UK)

Family medicine is at a critical point.

It is well accepted globally that primary care is the optimum approach to healthcare for all. (1) Advances have been seen in most countries and more recently, socio-economics have played a large part in providing more pragmatic and affordable approaches to healthcare for all.

However as some nations are beginning to adopt accreditation, and postgraduate education, healthcare is becoming increasingly unaffordable everywhere. There is a global shortage of family doctors, even in wealthy countries, which are attracting large numbers of doctors from developing nations, and most families of the world go without adequate healthcare.

The medical education system is not producing enough family doctors. This is directly attributable to financial matters as universities necessarily charge high fees, thus restricting universal access to medical education and most countries restrict the number of GPs/FPs/family doctors in the educational system, to contain their own health care costs, especially where governments subsidise healthcare. It is also directly attributable to philosophical and ethical issues as everything is achievable if the will is there.

Secondary to the lack of access to quality affordable medical education and lack of access to healthcare because of population poverty, is the type of medical education offered and its ability to meet the needs of local, national and global patients (i.e. all the people of the world). Are we teaching proper practice that includes socio-economic considerations when 'best practice' is unachievable for the local conditions in a broad set of examples (within a community context and national context) and because of financial constraints on both doctors and patients?

Recent work has shown that mainstream medical curricula does not necessarily cover all national medical education needs. Those conditions that affect developing nations only, do not feature highly in mainstream medical education and the CME trials in Nepal in 2009, for example, required the development of new education to cover a substantial number of unnamed fevers and to provide better focus on all endemic conditions within the economic constraints and structures of the country (10).

Few would dispute that the global family doctor of today needs to know everything as proper family practice also addresses the psychological and social health of a community.

Increased travel, migration, tourism, migratory workforces and climate change also means any medical condition can present to any family doctor anywhere in the world. Additionally most doctors working in developing nations are doing everything purely because they are the only medical resource available to the population. Family doctors in developed nations like the United Kingdom and Australia require the GP/FP to know everything so that they can address as many health needs as possible at the primary care level and appropriately refer their patients to specialists as and if required.

Most importantly why are we not as a global community addressing parity and equity of healthcare to all by increased sharing and less national duplication of medical education resources? After all, humanity does not differ from one location to another.

This is harmonious with the following definition of a family doctor (Wonca European Region Definition 2002) (1):

A new pragmatic approach is required where we look at equity, structures, curricula and financing of the same.

Global Competencies in Family Medicine, is the result of an international collaboration of the International Fellowship of Primary Care Research Networks (IFPCRN). The Research and Author team was drawn from around 30 countries and 15 countries contributed national data. These countries however represented close to two thirds of our global population and included Low, Middle and High Income countries (based on World Bank PPP 2005).

Research is an efficient means of defining and approaching problems and this research project was conducted to obtain a 'snapshot' of family medicine in a wide range of countries and circumstances. The validity of the tool (Questionnaire) was readily verified by the fact that few additional competencies were added to the original list.

Many of these additions were in essence 'applied medicine', that is, new approaches to old disciplines and often with financial and practical constraints in mind.

A representative list of family medicine competencies was compiled by an IFPCRN group, representing 12 countries (see Research Committee).

A core list of 44 items, from an expanded list of 55 items (with sub-headings) was compiled, with provision for adding additional items not appearing in the list of 55.

This list was distributed electronically on the IFPCRN list server to national family medicine representatives in the form of a tick box questionnaire with room for additional competencies and narrative comments and resopnses gathered over a 6 month period from May 2009.

Returned data was collated onto one spreadsheet for comparative purposes .

(Click for data sheet compiled from completed questionnaires)

15 national representatives completed the survey on behalf of their nation (or region in the case of West Africa). The populations of these countries however made up well over half the global population (see Figure 1) and came close to covering two thirds of the global population.


Figure 1: Participating countries (in green) by Global Population (Reproduced with permission: © Copyright SASI Group (University of Sheffield) and Mark Newman (University of Michigan). http://www.worldmapper.org/copyright.html

Figure 1 depicts responding countries in green, by population density. The map portrays countries by comparative population density to show more clearly the global population coverage of the survey.

Participating countries also covered a good range of geographical/climatological, and socio-economic situations (coming from low middle and high economic countries) as well as high and low population density countries (as indicated in Figure 1 -where low population density Australia, for example, hardly appears on the map).

Participating countries/regions were Australia, Bosnia-Herzegovina, China, Ghana, India, Indonesia, Iran, Iraq, Lebanon, Nepal, Pakistan, Turkey, United Kingdom, USA, and West Africa.

Results were collated by participating nation and by Family Medicine Competency.

Only 1 country (Australia) covered all 44 listed competencies and the lowest coverage of competencies was in Indonesia, with 17 competencies covered. See data sheet

Each competency ticked (1 - 44) was then added and results are displayed in Diagrams 1 and 2.

Diagram 1: Coverage of competencies (alphabetically) in surveyed countries. (See Legend below for Competency names).

Diagram 2: The same data shown from most covered competency to least covered. See Legend below to match Competency with its equivalent number.

A further 16 competencies were added to the original list by the participants, as additional competencies required in their country. While this additional list was not returned to the original questionnaire fillers, several respondents added the same items. These extra competencies were: general surgery, office procedures, radiotherapy, dentistry, urbanization, economic factors, renal disease, sports medicine, sexual health (including sexual dysfunction), Nutrition (malnutrition and over-nutrition/obesity), epidemiology, microbiology, pathology, forensic medicine, spirituality and medicine, care of the disabled.

General Surgery was included as a required competency by the three poorest responding countries - Ghana, West Africa and Nepal, where family doctors are required to 'do everything'.

Office procedures (minor/office surgery) was done by Australian and United Kingdom GPs only, where there is a push for GPs to do more surgery in the office, as a health system cost saving exercise.

Distributed questionnaires also asked the respondent to provide a national overview of family medicine in their country, in narrative format. These follow in alphabetical order.

Australia
Family medicine/Primary Care is the basis (70%) of the healthcare system in Australia with all patients attending the GP, apart from Accident and Emergency hospital presentations. The GP refers the patients to specialists as/if required.

The Australian GP therefore has to 'know everything' but much of that knowledge is not put into practice - rather it is required to know who and when to refer. You could argue Australian family doctors (GPs) are 'over-qualified'.

There is increased government pressure for GPs to take on as much as possible, e.g. office procedures, and due to a shortage of rural GPs, there are increasing numbers of practice nurses to take on some of the less critical work from GPs.

Most importantly primary care is run (viably) as 'small businesses' with solo or group practices, increasingly in a multi practice environment, e.g. in conjunction with a pharmacy, radiology services, physiotherapist etc

The biggest concern in Australia is shortages of doctors in rural areas (areas where GPs have to take on a wider role) and the lack of GPs (or anyone) doing obstetrics. This is due to patient expectations (a perfect baby), possible litigation and 24-hour demands on the already overworked GP. Midwives are not used in Australia.

The GP is required to maintain Vocational Registration (VR) and must obtain triennial QA&CPD points to maintain that status.

Australia has both private and public health cover with the private system offering 'choice' and the public system providing 'free care' for the poorer members of society. Training is done in the public system and the public system possibly provides better healthcare than the private system accordingly.

Bosnia-Herzegovina
In Bosnia-Herzegovina there are specific demographic conditions and specific morbidity and mortality (exacerbated by many displaced persons because of the recent war, PTSD, CVD and malignancy (breast cancer, lung cancer and colon cancer).

China/Hong Kong
Formal structured FM training started in 1982 in Hong Kong but was only available to a few people until 1999. FM training posts have increased ranging from 20 to 90 entries a year since 1999. All the training posts are tied to service without dedicated funding, so trainees have a very heavy workload and trainers or training units are providing training without any remuneration.

The requirements and standards are determined and assured by the Hong Kong College of Family Physicians but the training posts are provided by the hospitals and clinics through their employment of the trainees to provide service.

Current training consists of four years of basic training that qualifies the doctor to become a fellow of the Hong Kong College of Family Physicians; and two further years of higher training that qualifies the doctor to become a specialist in Family Medicine.

Ghana
Family Medicine is the name of the new global concept of postgraduate training in General Medical Practice. It is a special medical discipline and the practice of it is Family Practice. Physicians trained in this discipline become Family Physicians.

It is a discipline, which has integrated the essentials of several medical specialties into a new whole for the purpose of caring for the medical needs of several people at a given time. Its approach to patient care is holistic, seeing the individual in his own totality and in the context of his family and community.

The Family Physician is a frontline Doctor, the first contact of health care, irrespective of age, sex, disease, state of health or illness. He/she sees the individual, makes a quick provisional diagnosis, offers initial treatment, investigates and maintains comprehensive and continuous management. He/she also renders preventive, supportive and rehabilitative care, which help a patient to maintain or return to as high a level of physical and mental health and well being as he can attain. At the appropriate time he/she refers to the consultant specialist at the tertiary Hospital.

A Family Physician is, therefore, trained to be highly knowledgeable in General Medical Practice with the appropriate attitude, skills and competence to enable him render quality care to his patient and keep a good doctor-patient relationship. He/she sees most of the diseases of most of the people most of the time.

The relevant contribution of the Family Physician in National Health Systems has been recognized by WHO, World Organisation of Family Doctors (WONCA), University Medical Schools, Colleges of General Practitioners and Health Centres worldwide and information regarding this has been disseminated to Ministries of Health.

This discipline is fast becoming popular internationally and we have to ensure that Ghana is not left behind. The success of the Ghana Health Service and the National Health Insurance Scheme will depend largely on the training of sufficient numbers of Family Physicians to man our district hospitals and polyclinics.

India
The challenges that the specialty faces in India are:

1. The lack of excellent training in family medicine
The medical council of India has not yet begun a University based family medicine program yet. The National Board of Examinations under the Ministry of Health and Family Welfare has accredited some hospitals to have the family medicine training. However, the lack of understanding among the specialists about the discipline and the shortage of trained family physicians has resulted in poor quality of training in most of these hospitals. There are many private institutions, which offer training for different levels of competency- from 6 months to 2 years of distance education, to the three year full time residential program of the National Board. The National Board conducts examinations for all the specialties and is limited by the fact that almost all of its members are specialists.

2. Family medicine/ general practice is seen as less lucrative and glamorous compared to the other specialties. Both the medical profession and the public seem to want the care from the specialists, which makes family medicine a less desired choice for the medical students. GP clinics manned by a single physician who only prescribes medicines will not have a reasonable income. The long working hours without break will also result in an image of a physician who is always struggling. Group practices can provide some solutions for these.

3. The lack of academic faculty in family medicine
India does not have a national college for any of its specialties, including family medicine. There is no national academic body that works on the curriculum and professional development. There are only two medical schools in the country with a department of family medicine and faculty who are dedicated to the specialty.

4. The lack of good research in primary care. This is a great need that has to be met to address the health needs of the country and to improve the status of the specialty in the academic world. Excellent primary care research will serve as a lever that will elevate the specialty so that it receives the acknowledgement and acceptance that it deserves.

5. The National Rural Health Mission (NRHM) of the Indian government which has invested a lot in improving the quality of health in rural India, has identified family medicine as the key to address the disparities in health in the country. It is currently involved in developing a curriculum for a skill based 2 year family medicine postgraduate diploma course. The course will be via distance education for a year and residential for another year.

6. The distance education department of Christian Medical College, Vellore has a 2 year postgraduate diploma in family medicine. The trainees are given modules that cover the various topics. Three contact programs are held in different parts of the country. During these contact programs, the trainees get to interact with the faculty of Christian Medical College, Vellore, through a live telemedicine link. This program attracts about 150 candidates each year. The government has begun to send their primary health centre physicians for this program from last year. (11)

Iran
Iran has a well-developed primary health care network, which offers care right down to the village level for all people in the country, as well as a well-functioning referral system.

Iranian doctors train for seven years and approximately 4000 doctors graduate every year. All graduates are required to do two years' community service, largely in rural health centres.

The health care system is specialist orientated. As a result, Iranian general practitioners are somewhat limited in their range of skills, but their basic training is sound and they have good experience from rural public health care.

It should be noted that in Iran there is no Family Medicine specialty yet, although the government considers developing such a specialty. However, general practitioners (GPs) can work as family physicians, especially within rural areas.

The country has 85,000 physicians (mainly general practitioners) with about 39,000 specialists.

The entire health system is managed by a combined ministry of health and medical education organisations. As a result of this, the university in each province is responsible for looking after public health care in the province, both in terms of providing human resource training and in terms of managing the public health system.

The structure in the provinces is around a primary health care network, which is different depending on rural and urban settings.

In rural areas primary care is provided by a health house, for approximately every 1500 people. The health house is staffed by a particular category of health worker called a behvarz, - a multi potential community health worker trained at a district level. The health houses refer to rural health centres. There are approximately 16 000 health houses around the country covering more than 90% of the rural population. Each rural health centre has one or more general practitioners working there, several health technicians (mid level workers responsible for a range of different activities including occupational health and environmental health, communicable diseases, etc), midwives, and administrative personnel.

In 1994 the provincial health organizations and the universities of medical sciences were integrated, and universities of medical sciences and health services were established. Since then, the chancellors of these universities have been responsible for education and research, and for the health care of their entire province. As a result of the integration, research has become more public health oriented and medical education more community oriented. The integration has also led to an improvement in the health situation of the country; particularly in the villages, remote areas and less developed provinces.

The general practitioners in the health centres are also responsible for visiting the referring health houses, to supervise the behvarz working in these, and to see any patients that they are having difficulty with. Many rural health centres also have delivery facilities attached to them. The corresponding structures in urban areas are health posts which are similar to health houses but cater for much larger numbers i.e. about 12 000 people per health post. General practitioners are mainly used in the emergency section and in the out-patients department. (15, 16, 17, 18)

Iraq
Family medicine as a separate specialty started in 1995 in the form of an Iraqi board and then Arabic board, which was established in 2007-2008 in Iraq with the establishment of a board of family medicine in the medical colleges. There are no FM departments in undergraduate medical colleges, only postgraduate colleges. Family medicine topics are given under the umbrella of PHC teaching as part of community medicine curriculum.

There are now more than sixty graduated family physicians in Iraq, but still they are not doing their jobs properly. The family doctors appeared after 1999 (the 1st group of graduates) - and most of them are now working in PHCCs and only a few have administrative responsibilities and some of them are in the MOHE of hospitals, or are logistic workers in the directorate of health in Iraqi governates, which is far away from their specialty to some extent.

Primary care is done primarily by general practitioners (GPs). The GPs in Iraq mostly do not have qualifications higher than primary medical school. All health care workforces in Iraq are citizens of Iraq. A lot of PHCC doctors are truly committed to their work and among the 2053 or more PHCCs in Iraq from different levels or classes, more than 50% of those centers do not have doctors to run the clinic and rely on health staff to do that.

Some of the GPs working in primary health care are those who are not motivated, and are interested but not given the chance to upgrade their knowledge.

Still primary health care centres are doing their jobs of maternal care, vaccination, and other primary care duties. All PHCCs are doing that job but innovation is absent and concern with records is more likely a routine.

The presumed referral system to hospital from primary care centres began in November 2008, but still (I see each Sunday in the hospital) more than 200 patients without referral from primary care and most of them are simple cases that can be managed by the primary care physician. This will cause exhaustion of effort of consultant physicians in the major hospitals in Iraq.

The doctors in primary health care send patients to the major hospital outpatients clinics without examining them.

Evidence-based medicine concept is not practiced in our health institutions including teaching hospitals. Still antibiotics are prescribed for all patients with flu like illnesses, cough syrup for all those with coughs and most patients force their doctor to give them injections.

Family doctors still do not practice electronic registration of patients.

There is a great overlap between the work of primary care centre and major hospitals daily overlap between private work and the governmental health system in the area. Most of the doctors have private clinics at afternoon and morning governmental health Institutes.

Despite it being 6 years after the 2003 war and with 10 times increases in salary of health providers in Iraq, there is still no great change in provision of health services. There is discrepancy between health planning and the application in practice.

There are now 10 family medicine centers all over Iraq and the plan is to have125, that is 1 family medicine center per district in iraq within the year 2014 ,and this target is far from being achieved .

Challenges and Future Trends in Iraq
Family medicine in Iraq needs re-evaluation and a lot of work needs to be done toward more improvement of the health system, otherwise this malpractice will continue for a long period.

Nigeria
Nigeria with a population of 140 million is one of the most important countries in Africa, and it has one of the most sordid political and economic histories of the continent. The country is rich in petroleum reserves and has only recently become a democracy again, having been ruled by military dictators for 34 years.

The story of Nigeria is the same for many developing economies. Nigeria has enormous potential for the production of national wealth. It is endowed with a large population and has excellent human resources, a reasonably sufficient higher educational system, excellence in professional training and discipline, a high number of sophisticated and well-trained professionals, and at long last some political stability. Yet, as one can see Macroeconomic and social indicators reveal it to be a poor, developing country, with a long distance to go to improve the daily lives of its citizens. The Year 2007 Human Development Report ranked Nigeria at 158 out of 177 countries and among the 20 poorest in countries in the world.

Nigeria is in a state of health transition meaning a shift in the demographic and epidemiological makeup of the country, and associated social conditions, attitudes, from an environment dominated by high fertility, high mortality, infectious disease and malnutrition to a low mortality, low fertility environment with a disease profile increasingly weighted towards non-communicable conditions of adult and elderly.

It is estimated that about 65% of Nigerians earn below USD$1 a day, the majority of whom are women. Infections and parasitic diseases are the predominant causes of mortality and morbidity. In addition the spread of HIV (Human Immunodeficiency Virus) infection poses a serious challenge to sustainable developments although some population groups within Nigeria particularly among the elite, have entered or passed the heath transition

A lot of Nigeria's failures are its own, but some are due to world economic conditions as well.

The health sector problem in Nigeria can be traced in larger part to the continued hierarchical organization of health care. The Health Care System in Nigeria was designed as a pyramid. The Primary Health Care level forms the base while the apex is the tertiary health care providing sophisticated specialist care and technology. The secondary level, in between, comprises the various district and state general hospitals, private general hospitals and faith-based general hospitals. The secondary care provided is comprehensive, curative and preventive with appropriate investigative and treatment facilities.

This is where the training and practice of Family Physicians at post graduate level takes place sometimes without the support of the university academic system, (n short, there is a disconnect between academic input and service delivery and training at this level of care).

Health care facilities reflect the country's administrative hierarchy, which operates from the top to bottom. In theory at the PHC level, village health posts, local dispensaries, health centers, are intended to provide the preventive and primary care needed by the people living in rural and peri urban areas. This is where the bulk of Nigeria's population lives, (a burgeoning 65%); with health personnel who bring health care as near to the people at their places of abode as possible with appropriate but minimal technology. It is where demand is greatest, and it is where preventive and primary care would have the greatest positive impact on national health. But at these lower levels of the health care hierarchy, bureaucratic authority is weakest and spending is lowest. Neither private providers nor private voluntary organizations have filled the resulting gap in the provision of health care. Although private voluntary organization, such as faith based hospitals and clinics, often are effective providers in local areas, they account for only 5 to 10 percent of all expenditures in the country.

The poor quality of primary health care in many areas is often the result of shortages of qualified staff, lack of essential supplies, unreliable health data, and insufficient numbers of facilities. In some cases though, administrative weaknesses become apparent because facilities are underused and overstaffed. Some rural primary health centers for example, were found to employ twenty health workers who treated only three or four patients a day. Lack of standards for facilities and procedures complicates matters.

Given the inadequacy of many of these Primary Health care centers, they often are bypassed by patients who decide to seek better care at full-fledged hospital (Bocar 1989). As a result, overqualified staff and expensive facilities are used in ways their planners did not contemplate.

Nepal
A Master course for GPs has been running for 25 years under a structural based curriculum.

There are 3 GP training programmes in Nepal under 3 different universities. These are Institute of Medicine IOM) in Kathmandu, BPKIHS in Dharan and NAMS in Kathmandu. The courses are similar with some curricular variations. Each has its own exam but the seniors from each institute tend to conduct exams so there is some consistency in this.

BPKIHS, Dharan is running a 3 years Medical Doctorate in General Practice and Emergency course. It is well-structured course where this course covered the following subjects:
(1st year): Emergency and Family Medicine, Gynecology and Obstetrics, Surgery and Orthopaedics, Radiology.
(2nd year): Anaethesia; Medicine; Paediatric; Community and Public Health; Psychiatric; Dermatology; Zonal Hospital; Laboratory.
(3rd year): ENT, Eye, Forensic Medicine, Dental, District Hospital.

The course equally gives importance to public health in diseases prevention, health promotion health awareness etc.

In Nepal, undergraduate and postgraduate medical education has developed rapidly. Against this backdrop of mushrooming medical institutions, there is much room for improved CME: (1) that the number of effective materials would increase, and (2) that the medical profession would more fully embrace the need for evidence-based content delivered by evidence-based modalities. The time is ripe for Nepal's medical profession to turn its attention and resources towards this essential area.

Pakistan
The front line position that we have in the health care system as family doctors will determine basic and minimum competencies and skills requirements. It is only when services at secondary and tertiary levels are lacking that we take up those responsibilities, which we are normally not required to perform.

Turkey
The following comments relate to the postgraduate curriculum in Family Practice at Akdeniz University. This curriculum overlaps to 90% with the core curriculum of the Turkish Board of Family Physicians. The following areas are 'elective': Dermatology, ENT, Radiology and imaging, endocrinology, gastroenterology, genito-urinary health; haematology, infectious diseases.

The following areas are covered in CPD: men's health; integrative medicine; musculo-skeletal health; neurology, ophthalmology; pain management; palliative care,

Additionally:
- Residents are requested to perform an assignment with at least 25 elderly patients in community. Courses on Elderly friendly PHC provided.
- Residents are requested to perform an assignment (at least 2500 words on an ethical issue in family practice)
- Family Planning & Birth Control (Certificate of the Turkish Ministry of Health provided)
- Sports Medicine (Courses provided)
- Adolescent Health (Courses provided)
- Substance abuse (Courses provided)
- Courses on homeopathy offered
- Courses on systemic family medicine offered
- Genito-urinary health offered during 8 months Gyn & Ob rotation.

USA
Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment.

A national research study was conducted by independent research firms.
The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine's basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement.
Ultimately, system wide changes will be needed to ensure high-quality health care for all Americans.

The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

Main features of the new (2010) US Health Reform Bill that will affect family medicine/primary care in the US include:

1) There will be a slight increase in the reimbursement by Medicare and Medicaid to physicians who predominantly provide primary care

2) There is going to be an effort to review services that may be "mis-valued" - i.e., perhaps re-valuing the reimbursement for some services, that primary care doctors may have been underpaid for

3) There is provision for reimbursement for pilot projects for establishing "patient centred medical homes."

Some highlights of the Bill, which will have a direct effect on family medicine in the USA are:

- Bars insurance companies from denying coverage to children with pre-existing condition
Prohibits insurance companies from denying coverage to an individual with a pre-existing condition. Also limits premium variation to 3:1 based on certain conditions such as age, geography, family size, and tobacco use
Extends the age in which a child can remain on their parents' plan to age 26
- All new insurance plans must cover preventative services. Preventative services are; evidence based services with an "A" or "B" rating from the US Preventative Services Task Force; immunizations recommended by the Advisory Committee on Immunization Practices of the CDC; and preventative care recommended by HRSA guidelines for women and children
- Provides tax credits for low income individuals to purchase insurance through state exchanges. (Reconciliation bill defines people eligible to receive tax credits)
- A 5 year pilot program would be implemented by the Secretary for patients with one or more of 10 conditions during an episode of care. Allows for expansion of the pilot if it is found to improve quality and reduce costs.
"- Establishes a non-profit corporation known as the Patient Centered Outcomes Research Institute ran by a governing board composed of the director of AHRQ and NIH along appointed stakeholders.
The Institute would identify research priorities, establish research project agenda, and study how health problems can be studied, monitored, treated and managed. The Institute will be funded through a Patient Centered Outcomes Research Institute Trust Fund with funds available without appropriation.

Limitations of this research
While data collected was representative of the global situation, not all countries were represented, due to not responding to the questionnaire.

There is differing terminology for clinical topics/disciplines, and differing requirements of family doctors within these clinical areas, across nations. Where possible, responses were streamlined (allocated an equivalent name) at time of collation.

In the UK and Australia a general practitioner is a highly qualified generalist doctor specialising in general practice/family medicine and is synonymous with a family physician. In other countries a GP is a lesser qualification who in some cases has done no postgraduate education.

For the sake of this article we used the term 'family medicine' as an academic discipline. to be inclusive of all doctors looking after patients at the primary care level. Some of these doctors also act as specialists, particularly in developing and poor nations.

Other limitations were terminology regarding naming of clinical topics/disciplines. These were streamlined after data capture into equivalently named clinical topics, however some variations may still exist.

The list of competencies in the questionnaire were the subject of original research however provision was made for adding additional national competencies taught. These additional topics were not re-broadcast to the original questionnaire fillers, so are appended as an additional 'list' only.

We do not necessarily have full data on those items not on the original questionnaire if participants forgot to add them to the list of 'others' (examples include dentistry and general surgery).

Due to a difference in terminology and groupings of clinical disciplines we can rely on the 'positive data', but the negative data (no boxes ticked) may just as much reflect missing data, as a negative response.

Generally core competencies in undergraduate or postgraduate primary care training are covered in most countries but it is the application of those skills and the number of FP/GP training years that differ.

Even in wealthy countries there are shortages of doctors and the majority of the people of the world go without optimum healthcare. Therefore governments and educational institutions are not addressing the world population's needs. These needs will become increasingly more expensive to meet and therefore quality healthcare will become even less available.

Global warming and climate change will add to the burden, as diseases are already moving into new latitudes.

Continuing war and terrorism, refugees and displaced persons will also contribute to the health problems of humanity.

Additionally "global medical education curriculum' is not meeting all the needs of national healthcare. There is a dearth of quality education on conditions only affecting poor and developing nations.

Socio-economics (poverty) of both nations and people often mean (accepted) 'best practice' is totally unachievable due to costs to both doctors and patients. While some medical education from various sources does cover this duality, medical curriculum must start addressing these needs, as unaffordability of healthcare will increasingly afflict developed as well as developing nations.

Strategic/remedial CME is one way for developing nations to bridge the gap (14). While CME is an obvious way to pick up the latest knowledge, to use it to overcome curriculum and undergraduate deficiencies is a good idea and one that can be implemented retrospectively. Many of these issues of missing curriculum could be lumped under ethics, and 'health poverty' affects the entire global population, e.g. in terms of disease outbreaks, unimmunised populations etc.

You could arguably group many issues under 'cost-effective medicine', that are currently under Integrative or Holistic medicine.

A new pragmatic approach is required where we look at these issues globally, particularly the affordability of medical education and healthcare delivery and at educational structures, curricula and financing of the same to allow all countries to deliver equity of quality healthcare to their people.