Correspondence to:
Dr. Waris Qidwai
Professor and Chairman, Department of Family Medicine
The Aga Khan University
Stadium Road, P.O. Box: 3500, Karachi 74800, Pakistan
Fax: (9221) 493-4294, 493-2095
Telephone: (9221) 4864842/ 4930051Ext. 4842
E-Mail: waris.qidwai@aku.edu

ABSTRACT Background: A need exists to improve the status of family doctors globally. Strategies to ensure the proper place for family doctors in health care delivery systems and health care development requires discussion, identification and implementation. Methods: This paper is a collaborative effort at international level, based on work by an interested group of family doctors, who have examined the strategies required to ensure family doctors get their due position in the health care delivery system. This effort involved write-up based on extensive literature search by all the participating authors. The lead author collected all the observations and compiled a draft manuscript. The draft was reviewed by all authors prior to final submission of the manuscript for publication. Results: Proposed strategies are discussed under following headings: i) Family medicine as the foundation for health care systems; ii) Promoting broad based scope for family practice; iii) Promoting Family medicine research and scholarship. Further discussions relate to strengthening of undergraduate and post graduate education in Family Practice and promotion of quality in family medicine with particular reference to policy and services provision. Conclusions: A multiprong approach involving efforts in promotion of family medicine in areas of education, research, and service with particular emphasis on ensuring quality of highest level, is proposed as a strategy to improve the status of family doctors. Key-words: Family doctors; improve status; family medicine; primary care. Note: The authors acknowledge with thanks, the efforts of Lesley Pocock in reviewing the manuscript.

Family physicians practice medicine in a variety of roles, including competent and compassionate caregiver, patient advocate, teacher, and professional generalist¹. The "family physician" is a generalist physician who "takes professional responsibility for the comprehensive care of unselected patients with undifferentiated problems." 1 Key values guiding family practice include continuing, comprehensive, compassionate, and personal care provided within the context of family and community². Primary care consists of primary medical care and primary health care, and is the essential foundation for any sustainable healthcare system, and family physicians play a central role in its provision^2,3.

Health care systems consisting of health service provision, harnessing human and physical resources, collecting data to inform planning, policy development through the financing of their resources and services have essentially lacked the evidence that family medicine is the cornerstone specialty for improving this system.

From developing world perspective, with Nigeria and Turkey⁴. as an example, primary health care has collapsed, secondary health care has little focused direction, and tertiary care is struggling to keep up with the pace of technological advancement in the absence of basic infrastructure that exists in the developed world. Given the inadequacy of primary health care services, they often are bypassed by patients who decide to seek better care at fully-fledged hospitals. As a result, overqualified staff and expensive facilities are used in ways their planners did not contemplate.

Most Secondary care hospitals commonly provide primary and preventive health care services, becoming in effect direct competitors of lesser facilities. In addition to longer travel time to, and longer waiting time at these hospitals, patients are deprived of the personal attention and the more frequent follow-up visits that could be provided by a local facility.

Current health care systems often fail to recognize the value of family physician care and fail to support a health care model based on primary care. The resulting inadequacies in recognition of family medicine by the general public and by medical institutions, accompanied by lack of adequate reimbursement for family physicians, have demonstrated the need to debate, identify and implement strategies to improve the status of family physicians in global health care systems.

Objectives:

1. To look at strategies that can ensure a proper place for family doctors in health systems and health care development.
2. To share knowledge and experiences on how to promote quality and excellence in family medicine issues in policy and services provision.
   

This paper is a collaborative effort at international level, based on an
effort by an interested group of family doctors, who looked at the strategies required to
ensure family doctors get their proper position in the health care delivery system. This effort
involved write-up based on extensive literature search by all the participating authors.
The lead author collected all the observations and put together a draft manuscript for publication
consideration. The draft was reviewed by all authors prior to submission of final paper
for publication.

Proposed Strategies

A strategy based on an approach that focuses at different levels is suggested.

Family medicine as the foundation for health care systems

We should foster development of systems that integrate family medicine into a foundational role in health care systems around the world. Appropriate primary care is associated with improvements in all-cause mortality, heart disease mortality, stroke mortality, infant mortality, low birth weight, and life expectancy. Furthermore, patients reporting better primary care experiences are likely to report better health³. Specific characteristics of primary care associated with improved health include: first-contact care, longitudinal care, comprehensive care, co-ordination of care, family-centered care, and a community orientation⁵.

The practice of medicine is to impart safe, effective, efficient, timely, patient-centered, and reasonable care. This can be achieved by strengthening primary care. In most countries, majority receive formal medical care in primary care, and it is in the setting most episodes of illness are treated. Clinical decisions made on first encounter influence correct use of health care resources. Effort to improve the knowledge base in primary care will lead to better medical care.

Family medicine and primary care are not identical concepts. Family physicians in different countries work with other primary care professionals in a variety of arrangements. Family medicine has to be the backbone and the foundation of new health care system. A health care system that will put the human value ahead of health economics and cost effectiveness. Family physicians work in the communities for the common good. As the trainers of the next generation of family physicians, we need to start put together the groundwork of a better health care system.

Implementing the characteristics of primary care will vary around the world, depending on factors such as health-care financing, the relationship between publicly supported and privately funded health care, and the medical infrastructure. In Uganda, traditional healers, nurses, and non-residency trained physicians all provide "primary care" due to the low doctor-patient ratio, with more trained family physicians functioning as medical superintendents or clinical supervisors. In Turkey, inline with the need of the hour, "socialized" primary health care is converted to family practice-based health system⁶. Family medicine has the potential to offer a higher level of primary, generalist care in collaboration with front-line professionals, but further challenges remain⁷. We need development of state-funded primary care, with emphasis on health promotion at the local level in coordination with public health and primary care services and accessibility of care for the disadvantaged⁸.

Family medicine has the opportunity to engage with partners and policy makers to guide development of chronic care systems, at the same time emphasizing the centrality of the patient's journey for individual patients, and working to collaborate with the multiple health-care systems a chronically ill patient may interact with¹⁹. The family physicians need to take the lead in collaborating with other medical and non-medical partners in the development of community health partnerships¹⁰.

The world population is getting older and the burden will be higher in developing countries for example in India, China. Lack of infrastructure for care of chronic conditions and the care of elderly will be a serious challenge. Initiatives of WHO and WONCA (SIG Elderly Care) can address this issue.

The methods for developing family-medicine based systems will vary from place to place. Nevertheless, opportunities exist for advocating policy change and engaging in local initiatives. It will lead to further integration of family medicine into the local health care system as the foundational source of primary health care. Such integration should help improve the status of family medicine both through measurable improvements in health-care outcomes and cost efficiency, and through demonstration that family medicine can and does provide the longitudinal, patient-centered, comprehensive care that patients seek when they ask "who is my doctor?

Promoting broad based scope of practice

Family medicine has conventionally included a very broad-based training. Although individual family physicians often tend to narrow the scope of their practice over the years, they begin equipped for a wide range of practice possibilities. These "pluripotent stem cell¹¹. of the medical profession may later be found staffing emergency rooms, serving as hospitalists, and practicing occupational medicine, as well as in the outpatient clinic. Family medicine is becoming a basis for global health activities, where a broad scope of clinical skills and knowledge are imperative. We need a clear definition of our specialty. Are we to be "full-spectrum" physicians, or are we to be chronic disease specialists? Or perhaps family medicine is destined to be a discipline divided into two subspecialties: Comprehensivists and Outpatientists (acute; Hospitalists)?¹². Comprehensiveness has been distorted for family physicians with increases in specialization. Canadian family physicians, for example, are becoming less likely to deliver babies, give anesthetics, provide care in emergency departments and nursing homes, or make house calls¹³. Other changes have expanded the role of the family physician, such as the recent recognition of the importance of primary care in provision of mental health in Bosnia¹⁴.

The environment in which family medicine is practiced can have a great effect on specifics of clinical and organizational practice. Many local drivers for these differences involve not only economics and social geography but also the wider political context. Differences in health care funding can result in an additional variation. As an example, American family physicians are much less likely than their Canadian counterparts to provide psychotherapy or formal counseling for their patients. The difference is in part due to training, but American physicians are also heavily influenced by major restrictions to reimbursement for this service by their insurance companies. Family physicians who find themselves in situations in which financial structures provide a disincentive to practicing preventive medicine may find it difficult to fulfill this core role.

The methods of family medicine are also changing in response to the ongoing explosion in medical knowledge. Fortunately, this unprecedented growth has been accompanied by huge improvements in access to that knowledge through technologies, such as the Internet, and through the availability of careful systematic reviews, such as those provided by the Cochrane Collaboration. As a result, it has actually become easier for a properly trained family physician to access the latest evidence and to apply it to patient care.

The wide variation in the scope of family physician practice leads to confusion over the nature of family medicine on the part of the public, physicians in other specialties, and policy makers. Additionally, physicians of other specialties may feel that a narrower scope of practice or lack of procedural care by family physicians implies a lower level of training, skill, or expertise.

One USA family medicine residency surveyed graduates from 1998 to 2004 regarding their current scope of practice. By 2004 there was a significant decline in the percent of graduates practicing hospital care (71 to 56%), obstetrics (40 to 23%), or emergency care (25 to 13%)¹⁵. In contrast, family physicians practicing in rural areas tend to maintain a broader scope of practice, and provide a more diverse range of procedural care as well¹⁶. An additional challenge to the scope of family medicine practice in some countries is a policy-driven demand for an increasing population health role for the family physician. While health promotion may seem an intuitive extension of continuity care, there is also concern that this merging of disciplines obscures the primary focus in family medicine on person-centered care and inappropriately introduces policy imperatives into the clinical relationship¹⁷.

Research has called into question the assumptions behind some motivations for family physicians to reduce their scope of practice. One study has questioned the assumption that maternity care causes an undue drain on personal time, and suggests that failure to provide maternity care may in fact adversely affect practice revenue and viability¹⁸. Another study found that hospitalist care actually does not provide any cost savings compared to family physician care for managing patients with common inpatient diagnoses¹⁹. In many rural areas the family physician commonly provides care for diagnoses that may be managed by specialists in urban centers. Thus, training family physicians for a broad scope of practice is essential to support the needs of rural or underserved areas²⁰.
One response to the tensions in family medicine over scope-of-practice issues was the Future of Family Medicine (FFM) project in the USA. A central FFM recommendation was the development of a "New Model" of practice emphasizing a "Basket of Services" to be offered by family physicians including: health care for children and adults, health promotion and disease prevention, acute and chronic care, maternity care, and hospital care². While the FFM recommendations provide more of a conceptual model than an agenda for change or specialty re-organization, this project is one example of a country-level effort by family physicians to define their specialty and specify a vision for a comprehensive scope of practice.

In order to help increase the stature of family physicians, it will be important to work to define the place of family medicine as a primary care field within health care systems, and to develop a consensus on the appropriate scope of practice that is both general enough to apply to family medicine world-wide, yet also sensitive to local contexts, systems and needs. An international FFM type project, conducted by an organization such as WONCA, could help establish an international consensus as to the core scope of practice essential to family medicine.

Family medicine research and scholarship

Family medicine's fundamental base of knowledge and skills draws on a long tradition of general practice "wisdom and pragmatic knowledge." Stange, Miller and McWhinney have conceptually described the "knowledge base of family practice" as an integration of inner and outer realities with both individual and collective knowledge²¹. Family medicine is not just about managing straightforward manifestations of common diseases. Rather, family medicine depends on understanding both health and disease, an understanding of how to manage uncertainty and an ability to deal with individuals both on their own and as parts of larger family or social systems. Furthermore, in rural areas and in developing nations, family physicians may need to be competent at providing first-line emergency care and surgical services²².

Family medicine research goes beyond the basic and clinical science aspects of disease to include research into health services and health systems, and also research into medical education and professional development. In order for an effective family medicine research enterprise to be established in a given country, an academic home for family medicine is necessary, as is collaboration with other disciplines and explicit efforts to link or translate the results of research directly to clinical practice²³.

Strategies to help establish family medicine research include both "top-down" efforts to establish family medicine training programs and academic departments, and "bottom-up" efforts to include front-line family physicians in research endeavors^5,23. Practice-Based Research Networks (PBRNs) provide a way to meaningfully connect front-line family physicians with primary care researchers. PBRNs allow research into the care of unselected primary care patients typical of family medicine²⁴. PBRNs also create an avenue for including community members into family medicine research, thus fostering engagement of the surrounding social systems in further understanding the nature of family medicine²⁵, and they can allow for networking amongst family physicians to identify questions of relevance to front-line care that are in need of exploring.

The variety within the discipline offers both an opportunity and a challenge for family medicine research. Family medicine research facilitates the correct operation of health care systems and secures access to health care on the basis of individuals' needs in a framework of equity of access for all persons.

A need exists to promote awareness among health care funders, planners, and publishers, of the current input of family medicine research and of its potential to ameliorate health. In order publicize family medicine research in the medical research community; family medicine research must be more widely disseminated.

Wonca, as an international body of family medicine can play a major role in promoting and highlighting the scholarly activities of family doctors. Research achievements in family medicine should be displayed to policy makers, health (insurance) authorities, and academic leaders in a systematic way. Practice systems should be developed to provide surveillance reports on illness and diseases that have the greatest impact on the population's health and wellness in the community. A clearinghouse should be organized to provide a central repository of knowledge about family medicine research expertise, training, and mentoring. National research institutes and university departments of family medicine with a research mission should be developed. Practice-based research networks should be developed around the world. Family medicine research journals, conferences, and Web sites should be strengthened to disseminate research findings internationally, and their use coordinated. Improved representation of family medicine research journals in databases, such as Index Medicus, should be pursued. Funding of international collaborative research in family medicine should be facilitated. International ethical guidelines, with an international ethical review process, should be developed in particular for participatory (action) research, where researchers work in partnership with communities. When implementing these recommendations, the specific needs and implications for developing countries should be addressed. Despite the lack of a research tradition in family practice, there has been a growing consensus among family medicine educators that research training is an important component of residency training curriculum. There are several elements that help implementing a successful research program including support of the program director, dedicated time for research, faculty involvement, access to research professionals, and opportunities for presenting papers at scientific meetings.

Family medicine scholarship can improve the stature of family physicians in three ways:

1. Enhance the generalist knowledge base of family medicine,
   
2. Develop appropriate generalist research methods and practices, such as PBRNs, and
   
3. Define and advance family medicine scholarship in order to promote the institutional academic standing of family medicine departments and individual family physician scholars.

Undergraduate Medical Education

In its 1993 document 'Tomorrow's Doctors', the UK General Medical Council emphasized an important educational paradigm shift asking medical schools to ensure students acquire knowledge and solid understanding of:

1. Health and its promotion,
   
2. Disease and its prevention, and
   
3. Management, in the context of the whole individual and his or her place in the family and society²⁶.

It underpinned the need to learn in biomedical, psychological and social contexts, based on firm epidemiological foundations in all medical schools.

Today, key questions remain. How many hours of family medicine (general practice) should be included in the curriculum? And in what content? Who will be responsible for the teaching? And finally, what are the settings for delivering the principal teachings of general practice (family medicine)?

Health centre and family medicine surgeries provide excellent opportunities for medical students to learn and develop skills in clinical problem solving, simply because of the frequency with which patients present with undifferentiated problems across the entire spectrum of disease²⁷. As a consequence, students learn to make cautious diagnostic assumptions and have to approach presenting problems with an open mind. This provides students with repeated opportunities to integrate and apply knowledge and skills learned from basic, behavioural and clinical sciences in a discriminating way^27,28. Medical students can also gain unique insights into the true prevalence and nature of disease through the exposure to the clinical epidemiology of the community²⁹. Family medicine / general practice is also the context in which anticipatory and continuing care, and the social and psychological aspects of illness and disease, can be best observed and understood²⁷.

Generally speaking, hospitals provide medical students with the best learning opportunities to recognise and manage serious conditions. However, this provides them with a misleading picture of society's medical and health problems since they are mainly exposed to a highly selected population. In the hospital context students are often exposed to a restricted bio-medical model which principally views the body as a machine, disease as a consequence of breakdown of the machine and the doctor's task as repairer of the machine^27,30. Furthermore, with more sub-specialisation and increased throughput in hospital care, its suitability for teaching medical students about the society's health problems and the whole spectrum of illnesses is questionable. There is plenty of convincing research evidence that the basic clinical skills can be taught as effectively or even better, in family practice than in a hospital setting^31,32.

The key question which must be addressed for any health system which would like to introduce family medicine education and training (both under and post graduate): Do we have the infrastructure in primary care services in the health system to introduce the curriculum for example?

Postgraduate Training in Family Medicine

Supervised by the Postgraduate Medical Education and Training Board (PMETB) the UK curriculum for post graduate general practice (family medicine) training is based on 3 years of vocational training. In line will all medical, surgical and public health specialties, the training contributes to achieving the highest standards and quality of learning. The curriculum is designed to address the wide-ranging knowledge, competences, clinical and professional attitudes considered appropriate for a doctor intending to undertake practice in modern health systems³³. The GMC publication Good Medical Practice and the UK Royal College of General Practitioners document Good medical practice for General Practitioners provided a framework against which doctors can judge their own performance and by which they can also be judged^34,35.

However, entering the vocational training scheme (VTS) for general practice in the UK is part and parcel of wider programme of undergraduate medical education, foundation school and postgraduate higher medical training, under Modernizing Medical Career (MMC)³⁰. In this programme, all junior doctors who are starting their first year after medical school (previously known as the pre-registration house officer year) will have to demonstrate explicitly that they are competent in a number of areas including communication and consultation skills, patient safety and team working, as well as the more traditional clinical skills. The two-year Foundation Programme will give trainees exposure to a range of career placements across a broad spectrum of specialties. All trainees will also have access to an educational supervisor, as well as a clinical supervisor for each placement. The programme has as its focus patient safety; progression through the programme is based on the achievement of competence, rather than time served. At the heart of this new training programme is quality of medical care. By making the continuous development of skills and knowledge central to training and by making explicit the standards of competence those doctors reach before they progress, the Foundation Programme will improve patient safety as well as medical careers³⁶.

Figure 1 sketches the new training programme for all specialties (medical, surgical, public health, general practice) in the UK under the new MMC programme.

Reinventing Graduate Education and Preparing a New Generation of Leaders

Graduate students are emerging scholars and professionals whose curiosity, open minds, and fresh perspectives will launch new ways of thinking and problem solving. If we adopt a spirit of experimentation, collaboration, and an unwavering commitment to push the frontiers of knowledge, the practice of family medicine will prosper worldwide.

As the issues facing the delivery of health care services become more complicated, their solutions must also be multifaceted. Leaders in family medicine must be able to approach problems from multiple dimensions and leverage the expertise of people in different fields to forge effective and sustainable answers. Problem solving and innovation are necessarily becoming more multidisciplinary in today's complex world.

Family Medicine program need to incorporate a clear leadership curriculum into graduate education programs to help students develop the practical skills they will need to contribute to and transform their fields, their organizations, and the world.

Promotion of quality in family medicine

Issues in policy and services provision

Many health care challenges in the 21st century will place a great demand on primary care, which can serve its purpose only if it is of high quality and evidence based. Family medicine research can contribute to many areas of primary care, ranging from early diagnosis to equitable health care^37,38.

New Rules for the 21st Century Health Care System could be summarized as the following³⁷:

• Care is based on continuous healing relationships.
  
• Care is customized according to patient needs and values.
  
• The patient is the source of control.
  
• Knowledge is shared and information flows freely.
  
• Decision making is evidence-based.
  
• Safety is a system property.
  
• Transparency is necessary.
  
• Needs are anticipated.
  
• Waste is continuously decreased.
  
• Cooperation among clinicians is a priority.

Family physicians and their health professional colleagues must assume responsibility for the constant assessment and improvement of their care. Working together on behalf of patients requires teamwork that occurs within a complex set of relationships and services. It requires skillful management with appropriate authority and collaboration as well as a mindset of vigilance and continuous process improvement³⁹.

Emphasis on quality and safety Systems is considered as one of the important characteristics of the new model of family medicine, and is fully described as: "Systems are in place for the ongoing assessment of performance and outcomes and for implementation of appropriate changes to enhance quality and safety³⁸.

Quality Improvement (QI) is a practical approach to systems or process change. A growing body of literature shows how QI principles can help create much-needed improvements in a variety of health care situations.

The goal of "rapid cycle quality improvement" is to allow teams to
1) identify what they want to accomplish
2) develop a measure for evaluating change, and
3) determine a change or an action that a QI team believes will result in an improvement⁴⁰.

Quality Improvement in Family Practice

A new recipe is presented, splitting quality improvement into 4 levels. The Q1 level corresponds to the everyday processes that guide our daily work flow. Q2 corresponds to commonly thought of outcome measures. Q3 relates to the executive functions that permit seasoned clinicians to draw generalizations about care for individual patients by synthesizing large amounts of data. Finally Q4 reflects more population-based quality improvement activities.

Each of these levels requires a different approach for improvement activities. Each must be seen in the context of an expanded "quality compass" and in the paradigm of the QI cycle. Finally, a practical application of how this could be instituted at a Family Practice residency is given⁴¹.

So, Practices will document quality and safety through ongoing analyses of practice patient care data. 36 Patient feedbacks will be solicited to ensure that the practice is meeting patients' expectations, satisfying their needs for access to the practice, and responding to the needs of increasingly diverse populations. Each practice will develop and use a structured, recurring administrative mechanism to examine the measurements of the practice and the patients under its care. Practice staff, along with representative patients, will be included in these quality improvement processes. A high priority will be on taking steps to ensure patients' safety within the practice, including the use of electronic data and decision support systems⁴².

GP and FM practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines. But, on the other side, no intervention to improve data quality has been put to rigorous enough tests. We still lack empirical knowledge as to how improvement can be brought about⁴³.

A roadmap for quality improvement in physician offices (Practice Management)

Population-based medicine targets interventions at discrete subpopulations of patients within the medical practice and anticipates needed services according to evidence-based guidelines using quality measures to track results and make adjustments.

Physicians integrate care management into their routine clinical care by using these guidelines and quality measures to assess patients' needs, create care plans and coordinate and monitor services for their patients.

In order to meet the need for better chronic care management successfully, a medical practice will need to progress through nine discrete steps⁴⁴.
I. Define the subpopulation of patients in need of care management.
2. Choose a physician performance measurement set of quality measures.
3. Use a clinical information system to track quality measures.
4. Establish patient goals for quality improvement.
5. Analyze the current workflow processes to identify areas for improvement.
6. Implement a change in the workflow process.
7. Measure and analyze results³⁸.
8. Repetitively implement workflow changes and measure results until goals are reached.
9. Sustain the improvements.

Promotion of Quality

As the number of physicians who enter residency training in family practice gradually increases, so does the need to evaluate the effect of their training and postgraduate education on the quality of care in their practices. Quality of care provided by family physicians can be measured using administrative data.

A group from the European Working Party on Quality in Family Practice (EQuiP), working with over 20 European colleges of primary care, has assessed what, in their view, is needed to improve the quality of care at the interface between general practice and specialists. Experiences and ideas from a wide range of people were gathered through focused group discussions. From these it was clear that, for real improvement at the interface of care, changes are needed in the system of care and in the ways that doctors view their roles and their performance. All providers of care need to be able to see the care system from the patients' perspective if they are to help their patients make sense of and benefit from an increasingly complex system. Cooperation between general practitioners and specialists might be improved. This includes strategic perspectives and both targets for improvement and methods for teaching, training and development that are all independent of country and health care system. The 10 targets for development identified by the group are: leadership, initial shared care approaches, task division, mutual guidelines, patient perspective, informatics, education, team building, quality monitoring systems, and cost effectiveness. Working towards these targets could provide an effective approach to improving the cooperation between the interfaces of care. Getting effective leadership is a necessary first step as implementation of such a strategy will involve significant change. Responsibility lies primarily with the medical profession.

A multiprong approch involving efforts in promotion of family medicine in areas of education,
research, and service with particular emphasis on delivery of high quality in all areas is proposed as
a strategy to improve the status of family doctors.

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