About Family Medicine

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1. The Need of primary care physicians a. Indicator for Indonesia Sehat 2010 (Healthy Indonesia 2010) Indonesia is considered a nation having poor performances in health sector compared to other countries in South East Asia. High Infant Mortality Rate (IMR), i.e. 34/1000 live births, high Maternal Mortality Rate (MMR), i.e. 228/100.000 live birth, and low life expectancy at 69.1 years illustrate how poor health practitioners’ performances are. Moreover, it also has high prevalence rate of malnutrition and communicable diseases such as Tuberculosis that should have been eliminated with proper health care system. It is also worsened by various issues related with unequal and low quality public healthcare and uncontrolled increase of its cost causing newly poor group due to illness. Those factors make health sector in Indonesia worse. It is understandable that World Health Organization (WHO) puts Indonesia at low rank of 100 on healthcare system among its 192 country members. Primary healthcare system is very important for national healthcare system because it creates better health outcome, lower cost and higher equity in health sector. Global healthcare data shows that better primary healthcare system means better public health status and much efficient services. In 2007, Starfield reported that countries having appropriate healthcare system tend to achieve lower Low Birth Weight rate, lower Infant Mortality Rate (post neonates) and higher life expectancy. WHO’s Health Report in 2003 emphasizes that the key to increasing health status and achieving Millennium Development Goals 2015 is empowerment of primary healthcare system. This is because the system is better in providing easier access to health care facility, commitment to achieve equal rights in healthcare, public participation in constructing and implementing healthcare agenda and inter-sector approaches. Indicator for Indonesia Sehat (Healthy Indonesia) 2010 (Ministry of Health, 2003) suggests that health state be common responsibility of every individual, community member, government and private sector. Health sector’s main task is to maintain and increase each and every citizen’s wellbeing, without abandoning therapeutic effort and or patient healing. Thus, health care priority is promotional and preventive actions combined with curative and/or rehabilitative methods. Maintaining and increasing comprehensive individual, family and public health state require healthy environment. Therefore, improving healthy environment is an additional priority. Other missions to carry out are (1) activating national development by applying health perspective; (2) encouraging public independency in healthy living; (3) preserving and improving quality, equal, and affordable healthcare; and (4) maintaining and increasing individual, family and public health including their environmental condition. Based on those vision and missions, primary healthcare system is obviously a necessity. Family medicine as a form of primary health care may respond to the need of promotional, preventive, curative and rehabilitative health care. Faculty of Medicine Gadjah Mada University, as a health education institution, feels responsible for providing qualified primary care doctors. Professional primary doctor training/education design that is parallel with current development of family medicine science needs to be well-planned and supported by related interests. Significant improvement of primary healthcare system performance requires a systematic, structured and continuous reform. Better implementation of this process needs a team focusing on system development. This includes service system and program plan, financing, management, human resources development and research. The development intends to improve performance of national, provincial and district/municipal healthcare system particularly on aspects related with primary healthcare system. Specifically, science development reflects attention of Faculty of Medicine Gadjah Mada University to contribute to primary healthcare system performance in Indonesia through research, education, training, consultation and assistance. b. Alma Ata Declaration, 1978 (health for all) Alma-Ata Declaration was established in an International Primary Healthcare Conference in Alma Ata, Rusia in 1978. It emphasizes the importance of primary healthcare having the following characteristics: (1) reflecting and revolutionized from economic condition, socio-cultural and political characteristics of a nation and its environment, based on application of real outcomes from social, biomedical and healthcare researches and public health experiences; (2) showing main public health issue, providing promotional, preventive, curative and rehabilitative services in accordance with public needs; (3) at least containing: education on how to handle health issues and methods to prevent and control them; promotion of appropriate food supply and nutrition; supply of adequate clean water and basic sanitation; health care for pregnant women and children including family planning; immunization to major transmittable diseases; prevention and control to local endemic diseases; proper medication for common diseases and accidents; and essential pharmaceutical supply; (4) in addition to health sector, it involves all sectors and related aspects including community and national development, such as agro industry, farm, food, industry, education, housing, infrastructure, communication, and other sectors; and asking for coordination from all sectors; (5) requiring and improving individual and public confidence at maximum level and participation in planning, organizing, operational and control to primary healthcare using local, national and other resources appropriately, and eventually developing public capacity to participate through proper education; (6) must be implemented by an integrated, functional and mutually supporting reference system, leading to progressive improvement of comprehensive healthcare for every individual, prioritizing the most needed; (7) working as a health team to respond public health needs in local and referential level, depending on health workers, including doctors, nurses, midwifes, equipment and available community workers, and well trained traditional healer/midwifes technically and socially c. Importance of Primary Healthcare Development Doctor learns disease science. In a clinical setting, a doctor will not meet patients telling him their diseases. They will only tell complaints. For decades, general practitioners are taught by secondary care specialists. Problem is different education and service settings may cause inadequate level of primary care medical education competence. General practitioners are greater in number but their competences have not been utilized in maximum level. Education is costly yet it focuses only on curative aspect with its limitations. It’s a wasteful method. A specialist may return to campus to improve competence in previous department, whereas a GP/FM/Primary Care Doctor has no department to obtain scientific development. Secondary care specialists settle most continuing education for General Practitioner. Pharmaceutical company sponsorship is a great contribution for their activities. Meanwhile, General Practitioners are burdened with continued education fee (conferences, seminars, scientific workshops) surpassing their incomes. For example, for each patient a GP earns Rp. 5000 to 10.000 whereas a scientific seminar costs Rp 25.000 to Rp 200.000. When GP performs more health prevention and promotion, applying minimal use of medication (meaning more healthy patients), pharmaceutical company sponsorship will likely to avoid that GP. Thus, GP is enforced to perform curative effort resulting in ineffective public healthcare. Fee for GP’s curative care is definitely lower than specialist. Therefore, GP appears to be a destiny not objective. Below is a table illustrating why the U.S. patients have lowest satisfaction level due to inappropriate primary health care and its high cost Four principles of Family Medicine/Primary Care  Primary  Personal  Comprehensive  Continuous Those principles are derived into 9 Family Medicine Principles: 1. Comprehensive and holistic 2. Continuous 3. Preventive priority 4. Coordinative and collaborative 5. Integrate patient and family 6. Considering family, work environment, and home environment 7. Uphold ethics, moral and law 8. Cost effective and quality awareness 9. Auditable and accountable WONCA – WHO 2004: General practitioners/family doctors are specialist physicians trained in the principles of the discipline. They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespective of age, sex and illness. They care for individuals in the context of their family, their community, and their culture, always respecting the autonomy of their patients. They recognize and they will also have a professional responsibility to their community. In negotiating management plans with their patients they integrate physical, psychological, social, cultural and existential factors, utilizing the knowledge and trust engendered by repeated contacts. General practitioners/family physicians exercise their professional role by promoting health, preventing disease and providing cure, care, or palliation. This is done either directly or through the services of others according to health needs and the resources available within the community they serve, assisting patients where necessary in accessing these services. They must take the responsibility for developing and maintaining their skills, personal balance and values as a basis for effective and safe patient care. DOCTOR Definition – Indonesian Family Physician Association (PDKI) Jakarta: Doctor is the first health practitioner a patient meets in a primary healthcare system/facility to deal with his health problems – regardless of disease type, organ, age, and gender – as early and comprehensive as possible using holistic, continuing approach in coordination and collaboration with other healthcare professionals, applying effective and efficient principles of services prioritizing on prevention and upholding professional, legal, ethics and moral responsibility.” His service (authority) is limited to basic medical competence he obtained during basic medical education. FAMILY PHYSICIAN Definition – PDKI Jakarta: Family Physician is a health practitioner whom patient first meet (in healthcare facility) to solve health problems – regardless of diseases, organ, age, and gender – as early and comprehensive as possible using holistic, continuous approach in coordination and collaboration with other healthcare professionals, applying effective and efficient principles of services prioritizing on prevention and upholding professional, legal, ethics and moral responsibility.” His services (authority) is limited to basic medical competence he obtained during basic medical education plus primary medical competence he attained through structured CME/CPD or specialized program of family medicine.