Designing International Training Programs 2013 AAFP Family Medicine Global Health Workshop October 10-12, 2013 Baltimore, Maryland

2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Jeff Markuns has indicated he has no relevant financial relationships to disclose.

Designing International Training Programs Jeff Markuns, MD, EdM AAFP Global Health Workshop 2013

Objectives At the end of this session, participants will be able to: Outline key education and professional development issues for Family Medicine Identify helpful resources such as the Wonca Guidebook and the Wonca Standards for Postgraduate Education in Family Medicine Apply strategies from these resources to reflection on past experience and future training efforts

Wonca Guidebook 1.What is Family Medicine education and training? 2.Why is Family Medicine education and training different from other types of medical education? 3.How should Family Medicine education and training be implemented?

What is FM training?

What is Family Medicine? The specialty field of medicine focused on primary care

What is primary care? Essential health care focused on and accessible to individuals and families in the community through a regular point of entry, ideally provided at an affordable cost and with community participation Includes health promotion, disease prevention, health maintenance, education, and rehabilition Preferably provided in a ‘medical home’ by a team of providers Core clinical service delivery model for a comprehensive primary health care approach

What is primary care? Primary care is an essential component of primary health care, but it is NOT equivalent to primary health care PRIMARY HEALTH CARE Health education 1 Mother & Child care FP 2 Immuniza- tion 3 Epidemics prevention 4 Basic treatment 5 Clean water sanitation 6 Food & Nutrition 7 Essential drugs 8

What is primary care? (WHO) Provides a place where people can bring a wide range of health problems; Is a hub through which patients are guided through the health system; Facilitates ongoing relationships between patients and clinicians; Builds bridges between personal health care and patients’ families and communities; Opens opportunities for disease prevention, health promotion and early detection of disease; Utilizes teams of health professionals, including physicians, nurse practitioners, and assistants with specific and sophisticated biomedical and social skills

What is FM training? Access or first-contact care Comprehensiveness Continuity of care Coordination Prevention Family-orientation Community-orientation Patient-centeredness

Access or first-contact care Who is sick and who is not? If sick: –Determine diagnosis –Assess severity –Management plan or refer Skills in facilitating access –Cultural competency –Expanded hours –After-hours care –Coordination with team

Comprehensiveness The family doctor should be able to: care for patients of all ages, genders and cultures; diagnose and manage a wide range of illness not limited by organ system; recognize and be familiar with all local common diseases; provide emergency services and surgical interventions consistent with their training, local need and available resources; promote family planning and deliver a full range of reproductive health services; evaluate patients’ risk for future illness and provide preventative services.

Comprehensiveness Requires opportunity to care for types of undifferentiated patients typically seen at point of first contact Best to train under a supervisor with expertise in managing undifferentiated complaints (typically a family doctor) Beyond a simple skill, includes attitude: provide maximum care feasible within a patient-centered approach

Continuity of care Informational –Train in medical record management Longitudinal –Train to work in an interdisciplinary team Interpersonal –Opportunity to experience and practice health care with patients over time –Assign responsibility for first-contact care of a specific panel of patients –System may emphasize other components: i.e. tension between access and continuity

Coordination Teamwork Systems-based training System needs to support coordination. Know patients' rights and health professionals' responsibilities. Quality improvement principles and methods. How to serve as health activists for patients and for the community.

Prevention Primary, secondary, tertiary, quaternary Basics include: –understanding patterns of diseases; –assessing risk factors; –appropriate selection and use of screening tests; –understanding and applying age-specific and sex-specific prevention recommendations; –motivating patients to change their behavior.

Family orientation Family history Genograms Family dynamics and life cycle Family counseling Women’s health, including family planning and reproductive health services

Community orientation Community-oriented primary care (COPC) Grounded in person-focused clinical care Integration between individual clinical care and public health initiatives

Patient-centeredness each individual patient is an infinitely complex system that requires an expertise that goes beyond disease-based guidelines and population-based interventions health of an individual person is the result of a complicated set of interactions, impacted not only by that person’s behavior and genetics, but also by their family and community, and a group of specific co-morbidities unique to that person a person’s personal life and health goals ultimately drive their health-seeking behaviors

Patient-centeredness Doctor-patient communication skills Patient-centered clinical method: –exploring both the disease and illness experience; –understanding the whole person; –finding common ground regarding management; –incorporating prevention and health promotion; –enhancing the doctor-patient relationship; –being realistic.

Patient-centeredness Ethical foundation Social justice and equity Cultural competency Integrative approaches to care Patient empowerment

How to Implement Build FM infrastructure –Academic –Human resource –Physical and financial Develop teaching programs –Undergraduate –Post-graduate –CME

Academic Infrastructure Establish and evaluate curriculum –Agree on the nature of family medicine –Establish detailed learning objectives and expected competencies, based on community needs –Develop core curriculum goals designed to facilitate achievement of these competencies –Select best teaching methods and educational experiences to accomplish objectives –Plan longitudinal curriculum –Establish system for evaluation and feedback of learners –Establish or meet criteria for program evaluation, recognition and certification

Academic Infrastructure Establish a department or unit of Family Medicine Build relationships –Enter into partnership with hospitals and medical schools –Affiliate with regional, national and international associations, such as WONCA

Human Resource Infrastructure Recruit leaders, teachers and staff –Provide TOT in Family Medicine principles and curriculum development Recruit patients –Marketing primary care to patients Recruit trainees

Physical and Financial Infrastructure Secure funding Organize family practice teaching centers Establish hospital, specialty and community teaching sites

Develop Teaching Programs Pre-service In-service

Develop Teaching Programs Pre-service –Undergraduate curriculum integration –Family Medicine-specific experiences –Modifying factors impacting students’ choice of careers

Pre-service program checklist  Describe the health care system and the position and impact of primary care  Describe which conditions are handled by primary care and which by other levels of care  Select differences in diagnostic procedures and treatments related to incidence and prevalence in primary care, as compared to secondary and tertiary care  Discuss the doctor patient relationship unique to family practice  Explain differences between illness and disease, using the patient centered clinical approach

Pre-service program checklist  Perform and explain a patient-centred consultation  Provide care to patients over time (same patient, several visits)  Evaluate and manage patients with chronic diseases over time  Evaluate, diagnose and propose initial management for patients with common acute presentations  Deal with situations of clinical uncertainty  Discuss ethical aspects in family practice  Demonstrate respect for patients’ culture and sensitivity to their own beliefs and assumptions  Provide health promotion and disease prevention counseling

Develop Teaching Programs In-service vocational training –Traditional post-graduate specialty training –Retraining practicing physicians –CME

Traditional post-graduate World Federation for Medical Education standards in Family Medicine, developed by Wonca

Re-training

CME Assess participants' needs, outline objectives, select appropriate methods. Balance lectures with active learning methods to engage learners. Precede small group activities with adequate preparation and specific tasks. Limit small groups to no more than 12 participants to facilitate interaction and discussion. Bring cases or encourage participants to bring their own for discussion.

CME Allow participants to practice skills and receive feedback. Provide exercises to directly apply new skills to the active clinical setting. Use family physicians as teachers when appropriate. Identify challenges and discuss strategies for applying new skills. Include methods of evaluation sufficient for determining competency. Gather feedback from participants to improve future sessions

Learner and Program Evaluation Are the clinical services, or teaching programs, meeting the most important needs of the communities or learners? Are learners satisfied with their education, or do they identify additional skills necessary for high quality practice? How can the quality of services or teaching be improved? Is there new information suggesting different ways to deliver the services for lower costs? Are the benefits of the services fairly distributed? Do graduates have satisfactory options to provide services where they are needed? Are patients satisfied with the care provided by family doctors?

Your Experience What training programs have you been involved with? How do these relate? What else do you need?

WFME-Wonca Standards Provide standards for: Self assessment and program quality improvement New program development Peer review Recognition and accreditation

WFME-Wonca Standards 1. Mission and Outcomes 2. Training Process 3. Assessment of Trainees 4. Trainees 5. Staffing 6. Training Settings and Educational Resources 7. Evaluation of Training Process 8. Governance and Administration 9. Continuous Renewal

Online Resources s/WorkingParties/Education.aspxhttp:// s/WorkingParties/Education.aspx medicine-in-low-resource-countries/ medicine-in-low-resource-countries/