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GENERAL PRACTICE AND THE FUTURE
The College of Family Physicians celebrates its twenty-fifth anniversary this year In the early seventies, the major functions of the College were to conduct a good continuing medical education (CME) programme and run its diplomats examination (MCGP). In the eighties, the College played an important role in synergising the efforts of the Ministry of Health and the National University of Singapore to improve undergraduate and postgraduate training in Family Medicine. In the nineties, the College was given the responsibility to monitor the points system of the CME programme and to assist the School of Postgraduate Medicine in conducting the Examination leading to the Master of Medicine (Family Medicine) or MMed(FM) for short. This postgraduate degree was first conducted in 1993. Today there are forty-four graduates with this degree.
In what ways will general practice (also called family practice or primary care) be different in the years to come? An environmental scan shows that there will be increasing numbers of elderly people and because they may have multiple problems, they will demand new knowledge and skills in looking after them. The decline of acute infective causes of disease because they are understood and controlled will leave behind the noninfective chronic disease like diabetes and hypertension. Time and again, the infections still rear their ugly heads and trap the unwary - tuberculosis, opportunistic infections in the immuno-compromised and the age-old malaria are some examples. In our modern age of rapid travel and violence, there is a need to be ATLS trained.
More doctors are discovering the need to practice as a group for economic and social reasons. With the emergence of managed care, it is likely that primary care doctors will be dealing with more moderately severe diseases themselves rather than referring them away. There will be a need for primary care doctors to define the ground with their specialist colleagues: shared care arrangements for better care of the moderately severe medical problems and the chronic medical problems. The primary care doctor should know enough of the cutting edge of specialisation so that he can advise his patients competently and discuss adequately with his specialist colleagues about options of management for a given medical problem. He must be able to diagnose rare diseases amongst the common ones. How else is he going to play an effective frontline role?
It is likely the free market sentiment will stay with us. From track record we know that the free market will favour subspecialisation. Is there an answer for those who believe in broad based primary care? One answer may lie in using the power of the market by creating and promoting a better product. The public will support payment reform favouring generalists where the primary care that is delivered is what they want and need. Family doctors need to strive to do well what they are now doing. They must demonstrate that they provide better personal medical care than subspecialists for common medical problems, especially those of moderate severity. This means that they must perform at least as well on technical measures of quality, while adding other benefits that specialists cannot equal, such as greater accessibility, integration of psychological and biological approaches, simultaneous treatment of multiple problems, better merging of medical, social, community and workplace factors into personal medical care and more effective preventive medicine that truly enhances health and function.
The primary care doctor should also consider new supplementary functions that build upon traditional generalist activities. For example, they might provide highly technical home care services to meet the special needs of the growing population of housebound elderly and chronically ill for whom expensive hospital services are not appropriate.
A paper by Shultz in the Annals of Internal Medicine reflected on the relation of Internal Medicine and Family Medicine. Although his comments relate to the American scene, the ideas are applicable worldwide. He observed that political and financial changes in the American scene (which may apply to Singapore as well) have created an environment among the primary care specialists, namely Internal Medicine and Family Medicine. Although their relationship was once that of referring physician and consultant, the family physician and general internist are becoming peers, and they increasingly have similar needs and interests.
Shultz concluded that collaborative ambulatory practices can be developed that allow general internists and family physicians to work together as partners. Joint conferences could be sponsored by the two specialities. These collaborative efforts will improve understanding between the two disciplines. They will also foster the developmental growth of family medicine as a discipline. Such growth is necessary if family medicine and internal medicine are to truly collaborate in an interdependent rather than a dependent manner
Primary health care as practised by general practitioners, family physicians
and primary care
doctors in the Ministry of Health has reached an important juncture
at the close of the twentieth century. There is a need to revitalise
it in the ligh of changing trends of practice and changing disease profile.
Our biggest savings for the patient comes not from providing cheap care
but from greater use of primary care where it is the appropriate level
of care as well as through shared care with our specialist colleagues.
Reference
Shultz JW Reflections on internal medicine and famil
medicine. Ann Intern Med, 1996 Mar 15, 124:6, 600-3.