SPECIALTY TRAINING AND CAREER STRUCTURE FOR FAMILY MEDICINE IN BRUNEI DARUSSALAM

OUTLINE Brunei Darussalam Background Primary Health Care System & background Outpatient Services Basic Specialty Training (Family Medicine) Career Progression Advanced Specialist Training (Family Medicine) Challenges

BRUNEI DARUSSALAM Population 390,000 Young population – 39.2% below 19 years Malay 66.6% 4 districts – Brunei Muara District (69.3% of population) Life expectancy 77.8 yrs female & 75.2 yrs male Infant mortality rate 7.6 per 1000 live births Information from ‘Health Information Booklet 2007’

PRIMARY CARE SERVICES NOW BEFORE Decentralisation IN LINE WITH MINISTRY OF HEALTH NATIONAL HEALTH CARE PLAN (2000-2010) TO PROMOTE PRIMARY HEALTH CARE PRIMARY CARE SERVICES Decentralisation NOW BEFORE RIPAS Hospital Brunei/Muara – 7 H/Cs (June 2000- March 2001) Belait - 3 H/Cs (Oct 2002) Tutong - 4 H/Cs Postgraduate Training

PRIMARY HEALTH CARE SYSTEM Health centres (14) and clinics (13) providing outpatient services and maternal and child health services Travelling health clinics (13) Flying medical services (4) School health services

Mukim Berakas Gadong Sengkurong Serasa Mentiri Kota Batu Lumapas Kilanas Pengkalan Batu Sengkurong H/C is the oldest health centre – opened in Oct 1992 PAPHRSB Sg Asam H/C – started 1996 Each health centre has smaller catchment area and closer to the community

OTHER PHC PROVIDER 1 private hospital – Jerudong Park MC Ministry of Defence – 5 medical centres Brunei Shell Petroleum – Panaga Health Centre Private GP clinics – 21

OUTPATIENT SERVICES First point of contact for patients Gate-keeper to secondary care (referral rate 1-5% & admission rate <1%) Comprehensive & holistic care Minor illnesses & chronic cases Provide comprehensive services Holistic care – continuity of care to the patient, getting to know patient and family Health screening eg pap smear, checking for risk factors of IHD etc.

SERVICES IN HEALTH CENTRES MEDICAL RECORD TRIAGE LABORATORY RESULTS OPD DOCTOR CONSULTATION

SERVICES IN HEALTH CENTRES TREATMENT ROOM PHLEBOTOMY DISPENSARY RADIOLOGY

SERVICES IN HEALTH CENTRES MCH DENTAL DIETICIAN COMMUNITY PSYCHIATRY

OTHER SERVICES Extended hours services (out of hours) DOTS for tuberculosis treatment Smoking cessation clinic Well women clinic Weight management clinic Ophthalmology clinic

FAMILY MEDICINE TRAINING Vocational training rotations Masters in Primary Health Care (Feb 2004) – previously Postgraduate Diploma in Primary Health Care (Feb 2000) MRCGP [International] (Nov 2005)

VOCATIONAL ROTATIONS Rotations organised by Division of Outpatient Services 2 years hospital rotations and 1 year GP placement Previous clinical experience can be accredited prior to joining the program

VOCATIONAL ROTATIONS Components of hospital training 6 months - internal medicine, paediatrics and obstetrics & gynaecology (3 months of community MCH for male doctors) 3 months – psychiatry and accident and emergency 3 months - surgery / dermatology / ENT (optional clinical placement)

PRIMARY CARE TRAINING Postgraduate Diploma in Primary Health Care - February 2000 3 years part time academic modular programme & vocational training 2 cohorts – 23 doctors graduated Awarded by St George’s Hospital Medical School, London, United Kingdom 23 doctors have graduated including local, expatriate and doctors from Royal Brunei Armed Forces

PRIMARY CARE TRAINING Nov 2003 – RCGP examiners attended the 2nd cohort PGDipPHC exams PGDipPHC accredited as MRCGP[INT] 1st cohort awarded MRCGP[INT] by Accreditation by Prior Experiential Learning (APEL)

MASTERS IN PRIMARY HEALTH CARE Masters in Primary Health Care – Feb 2004 15 modules in 3 years Awarded by Universiti Brunei Darussalam Gradual handover to local tutors from St George’s Hospital Medical School, London 4 cohorts of doctors undergoing training – maximum of 8 per cohort We trained 2 of our 1st cohort local doctors to do Masters in Medical Education in Cardiff and currently we have completely take over the Masters in Primary Health Care programme from SGHMS.

MASTERS IN PRIMARY HEALTH CARE DATE YEAR 1 YEAR 2 YEAR 3 FEB Critical Appraisal Skills & Reflective Learning Mental Health Child Health APRIL Hypertension / Ischaemic Heart Disease Minor Illness Respiratory Medicine JULY Teaching & Learning Communication, Counseling & Consultation Skills Registrar Led Hot Topics SEPT Diabetes Infectious Disease Care of the Elderly / Palliative Care NOV Research Skills & Methods Women’s Health Family Practice as a Profession

MASTERS IN PRIMARY HEALTH CARE YR 1 YR 2 YR 3 MSc 9 X 3000 WORDS ESSAYS TAUGHT MSc (6 drs) 3 X 3000 WORDS ESSAY 1 x 20000 WORDS THESIS RESEARCH – BASED MSc (2 drs)

MRCGP [INTERNATIONAL] Brunei Darussalam accredited as centre for MRCGP [International] examinations 2nd site to Oman - November 2005 Exam based qualification – open to local and overseas doctors 2 components a) OSCE (12 stations) b) MCP (Multiple Choice Paper) So far we have candidates from saudi arabia, pakistan, australia and malaysia.

WHAT NEXT AFTER BST? After completion of their GP training – some general practitioners have been given expanded roles such as in MCH services, school health services, HPEU, district health officer, KBS, KBM, TB, academic/medical education, e-health and administration

Senior Medical Officer CAREER PROGRESSION Salary Scale Position Qualifications M16 - M16A Medical Officer MBBS MBChB M17 – M17A Senior Medical Officer MSc PHC MRCGP[INT] M18 – M21 Specialist AST Family Medicine

ADVANCED SPECIALIST TRAINING New concept and development for family medicine specialty Progression and expanded role of general practitioners GP with special interest/subspecialty Improve quality of care given to patients To provide equivalent quality specialist care in primary care setting

ADVANCED SPECIALIST TRAINING Increase accessibility of specialist care to the community Recognition of general practitioners as a specialist care provider Wider scope of recognition as an area of specialty In line with proposed new scheme of service

ADVANCED SPECIALIST TRAINING Increase workload of general practitioners for chronic care management Reduce referral to hospital Reduce workload and waiting time of hospital specialists Able to prescribe certain restricted specialist drugs

ADVANCED SPECIALIST TRAINING Medical education Public health Ethics and medical law Healthcare quality Health promotion and education E-health / Health informatics Research Health management & planning Identified priority areas Clinical areas Non clinical areas

ADVANCED SPECIALIST TRAINING Diabetes Minor surgery Endocrinology Dermatology Gastroenterology Rehabilitation Elderly health Palliative medicine Sports medicine Adolescent health Cardiology Men’s health Women’s health Child health Mental health Infectious disease e.g. tuberculosis Respiratory disease STI Rheumatology

ADVANCED SPECIALIST TRAINING 3 years (2 years + 1 year elective) Collaboration with RCGP for clinical placements and fellowship portfolio assessments – MOU signed May 2009 Postgraduate Dip/MSc (GP with special interest) + Clinical placement +/- FRCGP Starting September 2009

CURRENT SITUATION New recruitment for GPs– emphasis on training and postgraduate qualifications All local Bruneian doctors wishing to pursue career in GP have to go through mandatory vocational training rotations and MSc PHC

CURRENT SITUATION MRCGP [International] is a required qualification to enter Advanced Specialist Training program (in collaboration with RCGP) 38% (30 out of 78) have vocational training / postgraduate qualifications in family medicine

CHALLENGES Continuing battle for family medicine to be recognized as a specialty Increasing demand and expectation from patients and colleagues Recruitment and retaining problems for trained family medicine doctors

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