Postgraduate training in family medicine endeavors to supply doctors capable of providing comprehensive care for the majority of medical needs in a population. Nations are better served by an abundance of generalists than by an abundance of specialists.[i] Primary and secondary care delivered by generalist doctors is a cost effective way to provide health care.[ii] Generalists tend to use less health resources than specialists for comparable clinical conditions.[iii] Furthermore, a generalist can efficiently provide comprehensive care in underserved areas. It follows that developing nations should establish programs to train greater numbers of generalist doctors.
In Africa, demand for adequately trained general practitioners to provide primary and secondary health care far exceeds the output. Competent physicians to provide inpatient and outpatient care of common conditions can best be produced by family medicine training programs. Such training should not only include management of common infectious diseases and chronic medical conditions, but should also include training in common surgical procedures like cesarean section and herniorrhaphy. Family practitioners are expected to be broadly competent, since they often practice in general hospitals where specialists are not available. Furthermore, family practitioners are uniquely suited to provide continuity and family-centered care in the African society, where the family, more so than the individual, assumes primary importance. Yet, postgraduate training in family medicine is still considered a novelty in Africa, particularly in university teaching hospitals. Most current family medicine training programs exist in mission and general hospitals. Since the inception of General Medical Practice as a specialty in Nigeria in 1980, only 67 doctors have passed the examination for fellowship by the National Postgraduate Medical College as of the end of 1996. For a nation of over 120 million people, the output of specialty trained general practitioners is clearly inadequate.
Postgraduate training in the university teaching hospital can provide in-depth exposure and training in pediatrics, internal medicine, surgery, obstetrics and gynecology, as well as subspecialties. Rotation of family medicine residents through each department has been the traditional approach to accomplish the objective of broad, in-depth training. However, this disjointed, compartmentalized approach does not reflect the essence of family medicine: treatment of illnesses encompassing the broad range of medical specialties on a daily basis.
Tom developed a family medicine training program to provide continuous, comprehensive training at the Jos University Teaching Hospital in Nigeria in August 1992 with four residents. The teaching hospital serves not only as a tertiary care center, but it also provides primary care to the surrounding area; thus, family medicine training is suitable for this center. The Family Medicine Department provides all general outpatient care, comprising about 45,000 outpatients annually.
To provide residents opportunity to maintain and continually practice inpatient care skills an inpatient family medicine service was established. This service gives family medicine residents freedom to admit and care for patients in the teaching hospital. The family medicine service has five designated beds on each of the wards of medicine, pediatrics, surgery, obstetrics and gynecology, under the supervision of family medicine consultants. When a family medicine resident encounters a patient requiring admission in the outpatient or casualty department, he or she can admit the patient to the inpatient family medicine service. The resident provides inpatient care as well as follow-up after discharge with oversight by a family medicine consultant. Annual admissions to the family medicine service range from 200 to 250.
In addition, family medicine runs an antenatal clinic once weekly with 700 to 800 antenatal visits annually. When any of these women present in labor or with antenatal complications, the family medicine resident is notified to evaluate and provide treatment. This resident attends to the labor and delivery, and performs cesarean section if indicated, under the supervision of a family medicine consultant. If complications develop beyond the scope of family medicine, obstetrical consultation is obtained. The family medicine service performs about 1-2 deliveries each week and has a cesarean section rate of 15-20 percent.
The family medicine service has had a weekly day to perform surgery in the operating theatre. Common elective surgeries include hernia repairs, hydrocelectomies, anal fistulectomies, and excisional biopsies. From 30 to 50 major operations have been performed annually, and about the same number of minor procedures have been performed. Surgical consultation is immediately available when required. Though residents rotate through other specialty departments in the traditional manner as well, they return to the family medicine service between rotations to maintain skills previously acquired.
Senior residents of the Family Medicine Department are posted in 3 month blocks to act as medical superintendent of a rural comprehensive health center affiliated with the teaching hospital. The posting gives residents opportunity to independently manage a small hospital. An operating room allows residents to perfect surgical skills and provide comprehensive care.
Several advantages of family medicine training in the teaching hospital, particularly with an inpatient service, have been observed. The family medicine service enables residents to continue their responsibility for patient care, even after hospital admission. Commitment to continuity of care proves mutually beneficial for the resident as well as for the patient. The resident benefits from a longitudinal view of the patient's illness when he is the same doctor to admit the patient, to provide hospital care, and to follow-up the patient after hospital discharge. Patients benefit from improved care and efficiency when treated by a doctor already familiar with their medical histories and those of their families. By providing a setting for continuity of patient care, the family medicine service accurately reflects the reality of practice, where the general practitioner serves a specific patient population and cares for their medical problems, whether as outpatients or inpatients.
The family medicine service simulates the environment of a small hospital practice; yet it has the additional advantage of allowing residents to obtain immediate specialist consultation and input when needed and to benefit from contemporary management approaches and facilities. Additionally, family medicine training within the teaching hospital provides an opportunity to expose medical students to family medicine as a specialty to consider for further postgraduate training. There is ample evidence to suggest that the medical education one receives affects one’s choice of a specialty.[iv],[v] Graduates often choose fields other than family medicine because of a lack of emphasis, instruction, and leadership in this discipline.[vi]
Several problems remain to be overcome to establish family medicine training within teaching hospitals of Nigeria and West Africa. The majority of medical doctors within the region provide comprehensive care, even though few have pursued training beyond a single year of internship. This situation influences the perception of the specialty of family medicine by the public and the profession. Consequently, many in the medical field, especially in teaching hospitals, have unfounded notions of the purpose of postgraduate family medicine training. Common misconceptions are that general practitioners solely provide outpatient care or are simply triage officers,[vii] or conversely, that general practitioners threaten the role of the specialist because of their broad training. Unfortunately, in the environment of a tertiary care center, family medicine tends to be defined by the absence of specialization rather than by its positive features of breadth, comprehensiveness, and integration.[viii] Comprehensiveness requires the primary care provider to offer a range of services broad enough to meet all common needs in the population.[ix] Some argue that there is no role for family medicine training in a teaching hospital. There is a need to reevaluate the traditional emphasis of the teaching hospital on tertiary care by specialists, given the greater demand for providers of primary and secondary care,[x] particularly in developing countries.
Leaders of universities and teaching hospitals must make efforts to establish departments of family medicine among the academic disciplines within African medical schools. The whole of West Africa has only one university department of family medicine. As in many Western nations, family medicine throughout Africa has struggled to define its role in the university hospital. Adequate training in family medicine can be achieved in academic centers when opportunities for inpatient care and procedural skills are included.
[i] Colwill JM. Where have all the primary care applicants gone? N Engl J Med 1992;326:387-392.
[ii] Groves T, Roberts J. Primary care in the United States. BMJ 1996;313:955-6.
[iii] Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA 1992;267:1624-30.
[iv] Schmittling G, Graham R, Hejduk G. Entry of US medical school graduates into family practice residencies: 1990-1991 and ten-year summary. Fam Med 1991;23:297-305.
[v] Colwill JM. Expansion of training in family medicine — how much is enough? J Am Board Fam Pract 1995;8:499-501.
[vi] Campos-Outcalt D, Senf JH. Characteristics of medical schools related to the choice of family medicine as a specialty. Acad Med 1989;64:610-15.
[vii] Petersdorf RG. Primary care applicants - they get no respect. N Engl J Med 1992;326:408-9.
[viii] Colwill JM. Reflections on generalism in medicine. Fam Med 1988;20:405-6,462.
[ix] Starfield B. Is primary care essential? Lancet 1994; 344:1129-33.
[x] Billi JE, Wise CG, Bills EA, Mitchell RL. Potential effects of managed care on specialty practice at a university medical center. N Engl J Med 1995;333:979-83.