Delivery of essential surgery by family physicians.

Primary health care provides the framework for delivering the socially-informed, comprehensive and patient-centred care underlying robust health-care systems and is, therefore, central to achieving universal health coverage. Family physicians are best placed to embody primary health care's dual focus on community and population health because they are often employed in rural or district hospitals with limited human resources, particularly a lack of specialists. Here we want to illustrate how additional training for family physicians, the key clinicians in primary care, can play a critical role in reducing disparities in access to surgical, obstetric and anaesthesia care in low- and middle-income countries and in rural or remote settings. Examples are given of how training programmes can be developed in low-resource settings to equip family physicians with life-saving surgical skills and of how family physicians in high-income countries can be trained in the surgical skills essential for working overseas in low-income settings. Policy-makers should promote surgical practice among family physicians by supporting family medicine programmes that include additional surgical skills training and by expanding opportunities and incentives for family physicians to serve in rural areas. Moreover, national surgical plans should include a primary health care strategy for surgical care and, globally, family physicians should be considered in discussions of surgical care. Finally, surgeons, anaesthesiologists, obstetricians and family physicians should be encouraged to collaborate in ensuring that all patients, regardless of place of residence, receive safe and timely surgical care.

Les soins de santé primaires établissent le cadre requis pour des soins complets adaptés aux patients, gages d'un système de santé solide. Ils jouent donc un rôle central dans la mise en place d'une couverture maladie universelle. Dans ce contexte, les médecins de famille sont les mieux placés pour incarner une double perspective, la santé communautaire et la santé des populations, car ils travaillent souvent dans des hôpitaux ruraux ou de district qui disposent de ressources humaines limitées, surtout en termes de spécialistes. Le présent document montre dans quelle mesure une formation complémentaire dédiée aux médecins de famille, acteurs clés des soins de santé primaires, peut avoir un impact décisif sur la diminution des inégalités d'accès aux interventions chirurgicales, obstétriques et anesthésiques dans les pays à faible et moyen revenu, ainsi que dans les milieux ruraux ou isolés. Il existe de nombreux exemples qui illustrent la façon dont les programmes de formation peuvent être mis en œuvre dans les endroits manquant de ressources afin que les médecins de famille acquièrent des compétences chirurgicales vitales, et qui indiquent comment les médecins de famille des pays à haut revenu peuvent apprendre des techniques de chirurgie essentielles pour travailler outre-mer ou dans des régions plus défavorisées. Les législateurs devraient promouvoir la pratique chirurgicale chez les médecins de famille en soutenant les programmes qui incluent une formation complémentaire aux techniques de chirurgie, et en multipliant les opportunités et sources de motivation pour que les médecins de famille exercent dans les zones rurales. Par ailleurs, les projets nationaux devraient comporter une stratégie de soins de santé primaires pour les actes chirurgicaux et, globalement, les médecins de famille devraient être pris en compte dans les discussions consacrées aux interventions chirurgicales. Enfin, chirurgiens, anesthésistes, obstétriciens et médecins de famille devraient être encouragés à collaborer pour s'assurer que tous les patients, quel que soit leur lieu de résidence, puissent bénéficier de soins chirurgicaux au moment opportun et en toute sécurité.

La atención primaria de salud establece el marco para la prestación de una atención socialmente informada, integral y centrada en el paciente, que es la base de los sistemas sólidos de atención sanitaria y, por lo tanto, es fundamental para lograr la cobertura sanitaria universal. Los médicos de familia son los que mejor pueden asumir el doble enfoque de la atención primaria en la salud de la comunidad y de la población porque trabajan con frecuencia en hospitales rurales o de distrito que tienen recursos humanos limitados, en especial por la falta de especialistas. En este documento, se pretende ilustrar cómo la capacitación adicional de los médicos de familia, quienes son los profesionales clínicos clave en la atención primaria, puede desempeñar una función esencial en la reducción de las desigualdades que existen para acceder a los procedimientos quirúrgicos, obstétricos y de anestesia en los países de ingresos bajos y medios y en los zonas rurales o remotas. También se dan ejemplos de cómo se pueden elaborar programas de capacitación en entornos de bajos recursos para preparar a los médicos de familia con técnicas quirúrgicas que salvan vidas y de cómo se puede capacitar a los médicos de familia de los países de altos ingresos sobre las técnicas quirúrgicas esenciales para que trabajen en el extranjero en entornos de bajos ingresos. Los responsables de formular políticas deben promover la práctica quirúrgica entre los médicos de familia mediante su apoyo a los programas de medicina familiar que incluyan una capacitación adicional sobre técnicas quirúrgicas, así como la ampliación de las oportunidades y de los incentivos para que los médicos de familia presten servicios en las zonas rurales. Además, los planes quirúrgicos nacionales deben incluir una estrategia de atención primaria de salud para la intervención quirúrgica y, a nivel mundial, los médicos de familia se deben tener en cuenta en los debates sobre la intervención quirúrgica. Por último, se debe alentar a los cirujanos, anestesiólogos, obstetras y médicos de familia a que colaboren para garantizar que todos los pacientes, sea cual sea su lugar de residencia, reciban servicios quirúrgicos seguros y oportunos.

Developing family practice to respond to global health challenges: The Besrour Papers: a series on the state of family medicine in the world.

OBJECTIVE: To assess family medicine's role in developing strong, coordinated, community-based, integrated health care systems in low-resource settings globally. COMPOSITION OF THE COMMITTEE: A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with selected international colleagues with expertise in international family medicine practice, health systems and capacity building, and teaching to map family medicine globally and give a bird's eye view of family medicine internationally. METHODS: Following a background literature review, the authors collectively reflected on their substantial international experience to attempt to describe best practices for various contexts. REPORT: With the failure of vertical, disease-oriented models to provide sustained improvements in health outcomes, the need to develop integrated primary care involving the most appropriate health professionals for differing contexts is becoming apparent worldwide. Health system planning is required to develop policies on health professional training to achieve this. Advocating and offering appropriate incentives for, and coordination of, local opportunities within the health system also becomes paramount. The adaptability and generalist nature of family medicine allows it to respond to the unique needs of a given population. Family physicians with adequate financial and physical resources can function most effectively as members of interdisciplinary teams, thus providing valuable, comprehensive health services in any area of the world.

Family medicine around the world: overview by region: The Besrour Papers: a series on the state of family medicine in the world.

OBJECTIVE: To demonstrate how family medicine has been recognized and integrated into primary health care systems in contrasting contexts around the world and to provide an overview of how family physicians are trained and certified. COMPOSITION OF THE COMMITTEE: Since 2012, the College of Family Physicians of Canada has hosted the Besrour Conferences to reflect on its role in advancing the discipline of family medicine globally. The Besrour Papers Working Group, which was struck at the 2013 conference, was tasked with developing a series of papers to highlight the key issues, lessons learned, and outcomes emerging from the various activities of the Besrour collaboration. The working group comprised members of various academic departments of family medicine in Canada and abroad who attended the conferences. METHODS: An initial search was conducted in PubMed using a family medicine hedge of MeSH terms, text words, and family medicine journals, combined with text words and terms representing low- and middle-income countries and the concept of family medicine training programs. A second search was completed using only family medicine terms in the CAB Direct and World Bank databases. Subsequent PubMed searches were conducted to identify articles about specific conditions or services based on suggestions from the authors of the articles selected from the second search. Additional articles were identified through reference lists of key articles and through Google searches. We then attempted to verify and augment the information through colleagues and partners. REPORT: The scope of family medicine and the nature of family medicine training vary considerably worldwide. Challenges include limited capacity, incomplete understanding of roles, and variability of standards and recognition. Opportunities for advancement might include technology, collaboration, changes in pedagogy, flexible training methods, and system-wide support.

Current Status of Family Medicine Faculty Development in Sub-Saharan Africa.

BACKGROUND AND OBJECTIVES: Reducing the shortage of primary care physicians in sub-Saharan Africa requires expansion of training programs in family medicine. Challenges remain in preparing, recruiting, and retaining faculty qualified to teach in these pioneering programs. Little is known about the unique faculty development needs of family medicine faculty within the sub-Saharan African context. The purpose of this study was to assess the current status and future needs for developing robust family medicine faculty in sub-Saharan Africa. The results are reported in two companion articles. METHODS: A cross-sectional study design was used to conduct a qualitative needs assessment comprising 37 in-depth, semi-structured interviews of individual faculty trainers from postgraduate family medicine training programs in eight sub-Saharan African countries. Data were analyzed according to qualitative description. RESULTS: While faculty development opportunities in sub-Saharan Africa were identified, current faculty note many barriers to faculty development and limited participation in available programs. Faculty value teaching competency, but institutional structures do not provide adequate support. CONCLUSIONS: Sub-Saharan African family physicians and postgraduate trainee physicians value good teachers and recognize that clinical training alone does not provide all of the skills needed by educators. The current status of limited resources of institutions and individuals constrain faculty development efforts. Where faculty development opportunities do exist, they are too infrequent or otherwise inaccessible to provide trainers the necessary skills to help them succeed as educators.

Future of Family Medicine Faculty Development in Sub-Saharan Africa.

BACKGROUND AND OBJECTIVES: High-quality family medicine education is needed in sub-Saharan Africa to facilitate the future growth of primary care health systems. Current faculty educators recognize the value of dedicated teacher training and ongoing faculty development. However, they are constrained by inadequate faculty development program availability and institutional support. METHODS: A cross-sectional study design was used to conduct a qualitative needs assessment comprised of 37 in-depth, semi-structured interviews of individual faculty trainers from postgraduate family medicine training programs in eight sub-Saharan African countries. Data were analyzed according to qualitative description. RESULTS: Informants described desired qualities for a family medicine educator in sub-Saharan Africa: (1) pedagogical expertise in topics and perspectives unique to family medicine, (2) engagement in self-directed, lifelong learning, and (3) exemplary character and behavior that inspires others. Informant recommendations to guide the development of faculty development programs include: (1) sustainability, partnership, and responsiveness to the needs of the institution, (2) intentional faculty development must begin early and be supported with high-quality mentorship, (3) presumptions of teaching competence based on clinical training must be overcome, and (4) evaluation and feedback are critical components of faculty development. CONCLUSIONS: High-quality faculty development in family medicine is critically important to the primary care workforce in sub-Saharan Africa. Our study describes specific needs and recommendations for family medicine faculty development in sub-Saharan Africa. Next steps include piloting and evaluating innovative models of faculty development that respond to specific institutional or regional needs.

Family Medicine Global Health Fellowship Competencies: A Modified Delphi Study.

BACKGROUND AND OBJECTIVES: Many US medical schools and family medicine departments have responded to a growing interest in global health by developing global health fellowships. However, there are no guidelines or consensus statements outlining competencies for global health fellows. Our objective was to develop a mission and core competencies for Family Medicine Global Health Fellowships. METHODS: A modified Delphi technique was used to develop consensus on fellowship competencies. A panel, comprised of 13 members with dual expertise in global health and medical education, undertook an iterative consensus process, followed by peer review, from April to December 2014. RESULTS: The panel developed a mission statement and identified six domains for family medicine global health fellowships: patient care, medical knowledge, professionalism, communication and leadership, teaching, and scholarship. Each domain includes a set of core and program-specific competencies. CONCLUSION: The family medicine global health competencies are intended to serve as an educational framework for the design, implementation, and evaluation of individual family medicine global health fellowship programs.

Partnerships creating postgraduate family medicine in Kenya.

Culminating a decade-long process, the first family medicine residency program in Kenya, among the first in Africa outside Nigeria and South Africa, was launched in 2005. Three diverse stakeholders are collaborating in their individual and joint missions: Moi University Faculty of Health Sciences (MUFHS), educating medical students to serve rural Kenyans; the Institute of Family Medicine (Infa-Med), a church hospital-based non-governmental organization aiming to introduce family medicine in Kenya; and the Ministry of Health (MoH), working to create an efficient government health care workforce for 32 million Kenyans. MUFHS brings central facilities, enthusiastic academic leadership, and long-term vision. Infa-Med contributes start-up resources, expatriate family medicine faculty, and well-established hospitals for training. MoH is giving political support to the new specialty as well as scholarships to MoH medical officers entering the 3-year residency program leading to the degree of Master of Medicine in Family Health. Among the lessons learned through this process are the importance of melding the missions of all partners, of integrating clinical with community care of the underserved, and of deriving curriculum from African and international evidence on how to marshal available resources to meet Kenya's national needs. Opportunities continue for internal and international collaboration.

Open source approaches to health information systems in Kenya.

This paper focuses on the experience to date of an installation of a Free Open Source Software (FOSS) product, Care2X, at a church hospital in Kenya. The FOSS movement has been maturing rapidly. In developed countries, its benefits relative to proprietary software have been extensively discussed and ways of quantifying the total costs of the development have been developed. Nevertheless, empirical data on the impact of FOSS, particularly in the developing world, concerning its use and development is still quite limited, although the possibilities of FOSS are becoming increasingly attractive.

A patient lifting intervention for preventing the work-related injuries of nurses.

UNLABELLED: The average age of nurses is projected to be 50 years in 2010 [17]. Because nurses are older, a work injury prevention program should change how nurses lift patients. The purpose of this evidence-based practice improvement project was to examine a new lifting intervention. METHOD: An evidence-based process was used to implement an effective lifting intervention, including a back school, a lift team, and mechanical lifting equipment, on the orthopedic and neurology units in a Minnesota hospital. A two-week pilot determined if enough work would be generated to justify hiring a permanent lift team. Then the entire lifting intervention was studied on the two units. RESULTS: The injuries for the two units decreased from 21 to 9 injuries, while the salary and work replacement costs were $48,220 and $2,560 in 2001 and 2002, respectively. The lift team averaged 80 lifts per day and 95% of the nursing staff attended the back school. CONCLUSION: The lift team and new mechanical lifting equipment were successfully disseminated resulting in significant reductions in costs. Suggested improvements include additional supervision and lift team scheduling changes, regular staff meetings, and ongoing education.