1. Quandaries and Questions When Starting a Family Medicine Residency Program in an International Setting Peter Burgos MD FAAFP

2. 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. Peter Burgos MD has indicated that he has no relevant financial relationships to disclose.

3. Key Factors Necessary for Successful Family Practice Program Development Good doctors Good business plan Good medical school/ educational system connections Good government relationships Good patient population access Boelen C, Haq C, Hunt V, Rivo M, Shahady E. Improving Health Systems: The contribution of Family Medicine. A Guidebook. A Collaborative Project of the World Organization of Family Doctors (Wonca) and The World Health Organization (WHO). WONCA 2002. 3

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5. Key Questions to Address Today What is the best model to use in developing a Family Practice training program? How do you integrate Family Medicine training with other goals you might have? 5

6. Key Questions How can a beginning Family Practice program make the jump to sustainability? (If a program begins with International sponsorship, when is the best time for the foreign support team to exit and let the local team carry the work forward?) 6

7. Best Model Models include: Independent program development Assisting national programs as a faculty member of an indigenous program. Assisting programs as a guest lecturer on a "short term" basis while maintaining credible academic credentials/ role in home country. 7

8. What are some other possible models? 8

9. “Short Term” Advantages: –High respect given to the visiting lecturer “with slides” –Credentials and skills are maintained in home country, and cutting edge knowledge and techniques can be communicated to local doctors –If repeated trips, relationships can develop which can form the basis for effects on local practice and life changes. 9

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13. “Short Term” Disadvantages –Misunderstanding the listener’s objectives/ goals –Misunderstanding the listener’s background knowledge or context –Not really effectively changing the practice 13

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16. What are other advantages and disadvantages of serving using the “short-term” model? 16

17. Assisting National Programs as On Staff Faculty Advantages –It is their program. As a guest, in facilitating local program, no need to worry about: Government support Credentialing of the Family Practice graduates Good jobs for trainees after graduation Business model –Opportunity to form ongoing relationships that can effect change potentially greater than for “short term” worker 17

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19. Assisting National Programs as On Staff Faculty Disadvantages –No control over the curriculum –May be difficult to achieve some goals Orphanage work Countryside poor HIV work 19

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21. What are other advantages and disadvantages of serving using the assisting national program model? 21

22. Independent Program Development Advantages –Impress people at a distance. Impact life and effect change up close. –A smaller contingent of highly trained, truly changed in outlook Family Practice doctors can be trained, and these can function “as yeast that leavens bread” –Easier to implement personal goals (HIV work, orphanage work, disaster relief, international service to the poor) 22

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32. Independent Program Development Disadvantages –Outside the credentialing system –Outside of the recognized career path system, so future employment becomes a concern. –Outside of the recognized business system, so have to create or find business niche and patient populations that need service. –Funding the program is your responsibility 32

33. Control Over the Curriculum 33

34. Opportunity for Formation of Deeply Impactful Relationships That Can Effect Change 34

35. Ability to Incorporate Other Goals and Objectives 35

36. Ability to Really Know What is Going On and to Target Teaching to the Local Situation 36

37. Opportunity to Deeply Affect a Strategic Core 37

38. Government Support 38

39. Secure Jobs Available for Graduates 39

40. Freedom From Need for Funding Development 40

41. Ease in Credentialing 41

42. Ability to Maintain Personal Medical Skills/ Credentials 42

43. Key Questions to Address Today (Review) What is the best model to use in developing a Family Practice training program? How do you integrate Family Medicine training with other goals you might have? 43

44. Key Questions to Address Today (Review) How can a beginning Family Practice program make the jump to sustainability? (If a program begins with International sponsorship, when is the best time for the foreign support team to exit and let the local team carry the work forward?) 44

45. Review of Key Factors Needed for Formal Family Practice Residency Training Good doctors Good business plan Good medical school/ educational system connections Good government relationships Good patient population access 45

46. Sustainability Key Difficulties Surface When One or Another of These Key Factors is Absent or Weak 46

47. Medical School Affiliation Problem Need for Credentials for our Graduates 47

48. Creative Solution #1 Our residents are going through a Government recognized Master’s level training program in order to gain academic credentials that are recognized within the Chinese system. This Master’s level training is done after their initial Family Practice training with our program, and concurrent with their serving as Junior Faculty on staff. 48

49. Creative Solution #2 We continue to develop relationships with local medical schools in our city who assure us that they will help us to get the needed credentials for our residents. –We give lectures to their residents –We help them with articles in journals for Family Medicine and an Evidenced Based book on Family Medicine 49

50. Creative Solution #3 (Rejected) We could merge our program with a local program. This solution was rejected because in the merger, we would lose control over the curriculum (specifically, our residents would no longer be able to participate in the orphanage work, nursing home and countryside clinic charitable service, etc.) 50

51. Good Business Model Problem #1 Although we have a good business model for our international clinic, in order to have a sustainable model, we need to have a good business model for our Chinese doctors who currently see mostly charitable patients (non- paying orphans, HIV patients, Nursing Home patients) 51

52. Good Business Model Problem #2 Because we are outside the Chinese recognized insurance system, patients with insurance do not want to see us because they would be required to pay out of pocket. 52

53. Good Business Model Problem #3 The Chinese insurance system reimbursements, while perhaps adequate for a Family Practice doctor seeing many patients every hour, does not reimburse doctors adequately who practice using our current Family Practice training model (Careful history and physical, de-emphasis on, from our perspective, unnecessary ordered lab and imaging) 53

54. Creative Solution #1 Open a “VIP” styled clinic which can charge a higher price commensurate with clinical skills being provided where our Chinese doctors can see Chinese for-pay patients in addition to the charitable patients that they currently see. 54

55. Creative Solution #2 Creatively cooperate with those in the business community that have special expertise in setting up clinics, marketing to the population we want to target, or who want to financially invest. 55

56. Good Doctors Problem Our recruiting in recent years has been less successful than in the initial years of our organization. This is possibly because: 1)Limited budget availability is reflected in low resident salaries. 2)Credentialing uncertainties and uncertain future job opportunity 3)Brighter opportunity elsewhere as China’s medical and economic infrastructure develop. 56

57. Creative Solution Good business model may lead to increasing revenues, thus affording opportunity for salary increase. Continue to seek resolution for credentialing difficulties. VIP clinic hire for graduates who have performed well may be a competitive bright opportunity for our Chinese graduating Family Practice residents. 57

58. Toward Sustainability Problems hindering sustainability often relate to absence or weakness of one of the key factors necessary for development of a Family Practice program: Good doctors Good business plan Good medical school/ educational system connections Good government relationships Good patient population access 58

59. Key Sub points Toward Sustainability Creativity is key Careful analysis of the local situation (listening to local team), how it is changing, and how it is predicted to change helps guides decision which lead to ongoing relevance Mistakes are possible/ risk is not absent 59

60. Key Questions Addressed Today What is the best model to use in developing a Family Practice training program? How do you integrate Family Medicine training with other goals you might have? 60

61. Key Questions Addressed Today How can a beginning Family Practice program make the jump to sustainability? (If a program begins with International sponsorship, when is the best time for the foreign support team to exit and let the local team carry the work forward?) 61

62. Thank you! 62

63. References Boelen C, Haq C, Hunt V, Rivo M, Shahady E. Improving Health Systems: The contribution of Family Medicine. A Guidebook. A Collaborative Project of the World Organization of Family Doctors (Wonca) and The World Health Organization (WHO). WONCA 2002 63

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