Transcript Brazil Considering the Educations of physicians for

Considering the Education for
Physicians for Brazilian Health
Clinics
W. Rosser, Professor and Head
Department of Family Medicine
Queen’s University
Kingston, Canada
Presentation Outline
Introduction
 What do people want from physicians?
 What are the principles that address the needs and
wants?
 Methods of educating primary care physicians for these
roles.
Strategies for Physician Education for the Brazilian
Model of Primary Care.
 Ideas

Introduction
Primary Care delivery systems can be subdivided into
two different strategies.
 Delivery by a personal health care provider: Each
person can identify their personal physician or health
care provider and the system works to maintain
continuity for each person or family with one or two
providers.
 Clinic or polyclinic system: Each person attends any
clinic where care is provided as required by a primary
care provider without any effort to provide personal or
continuity of care

Personal Health Care Provider
Many countries from the British Commonwealth focus
on this model including the UK, Ireland, Canada,
Australia, New Zealand, South Africa. Other European
countries like Holland , Belgium, and some
Scandinavian countries (Finland , Denmark, Estonia,
Latvia)
 Other countries such as Germany, France, Japan have
mixed systems that may have personal private care and
clinic care in public systems.

Clinic or Polyclinic System
Almost all countries in the former Soviet system use a
Polyclinic as do a number of European countries. Often,
private health care can be personal and public care is in
the Polyclinic model.
 In many developing countries, primary health care is
provided by alternate health care workers and not
physicians. These individuals may also function in a
clinic or personal health care model.

Personal Health Care
Many of the issues around effective primary health care
relate to personal health care. Since I only have
experience with this type of system, I am clearly biased
towards this style of delivery and the remainder of my
talk will assume a personal type of primary health care
delivery system.
 I will hope that most of the audience will be persuaded
that this is a reasonable and achievable objective for
Brazil.

What do people need from
Medicine?
In the twenty first century, people express the same
fundamental needs for medical care as humans have
expressed since the beginning of time.
 People need a healer who responds to all problems that
beset them in their homes, their families and their
communities.
 They need assistance when sick, in pain, or confused to
organize their concerns, and to advocate for them
whatever happens.

What do people need from
Medicine?
Only a personal provider can meet these needs.
 Even with the revolutionary changes in medical knowledge
and technology over the past 40 years, the pattern of
needs from the community has changed very little.
 White 40 years ago and Green in 2001 found that during 1
month, of 1000 adults, 750 would experience some illness
or injury, 500 would manage the problem themselves, 250
would seek some professional advice, 9 would be admitted
to hospital 5 would be referred to another physician. Less
than one would go to a teaching hospital.

What do people expect from a
primary care provider
 1.Expert Clinician: People want a provider that
is knowledgably able to gather information about
a problem and effectively develop a strategy to
manage most conditions most of the time.
 The provider needs to be up to date and
sensitive to the patient’s family, community and
specific cultural needs.
What do people expect from a
primary care provider?
 2. A skilled scholar, scientist, and appraiser
of new medical knowledge. The provider
needs skills in self assessment, self directed
learning, and needs to be an information master,
able to critically assess new information and
determine if it will benefit any patient in the
community setting. Since much new knowledge
is developed in tertiary care teaching hospitals, it
is often not transferable to the community.
What do people expect from a
primary care provider?
3.A skilled interviewer. Patients want a provider that
understands their viewpoint and is sensitive to their
feelings and response to their illness. This includes
providing the patient with an understanding of their
problem.
 4. A Health Advocate. The provider needs awareness
of the determinates of health and be proactive in
forming healthy public policy.(example)

What do people expect from a
primary care provider?
5. Adaptable.Patients want their provider to adapt their
thinking to different strategies in providing care.They
want a provider with a passionate commitment to seek
the truth, and have the integrity to use knowledge to the
optimum benefit of their patient.
 6. Collaborative: The provider must work effectively
with other health care providers on a team as well as
with families and communities.

What do people expect from a
primary care provider?
7. A steward of precious resources. Using
consultations wisely, tests according to their value to the
patient and discussing the risks and benefits relative to
cost of any therapy.
 8. A healer. The provider must be able to use their
personal strengths to encourage healing and provide
moral support for the benefit of the patient. This
requires knowledge of one’s own strengths and
weaknesses and personal biases and how they may
affect relationships with patients.

Summary
People’s needs and wants from the medical care
system tend to focus on the presence of a
personal health care provider who is a skilled
and knowledgeable clinician with a scientific
background and an expert in dealing with health
problems within the environment in which the
population functions. People want this individual
to respect them and to be sensitive to their
personal situation.
Principles of Education
A review of principles for primary care, general
practice, and family medicine covering input from
approximately 20 countries found convergence
around the Four Principles of Family Medicine
developed by the College of Family Physicians
of Canada. References for the international
principles are provided.
First Principle
The physician- patient relationship is central to the
role of the family physician. Trust and respect are
essential to sustain a partnership sufficient to solve the
problems presented by each patient.
 Family physicians use repeated short visits to build
relationships with patients and to promote the healing
power of physician patient interactions. Advocacy for
individuals and the community arise from this
relationship.

Second Principle
Family Physicians are skilled clinicians.
 Clinical skills include expertise in dealing with ambiguity
and uncertainty in diagnosis and management of
chronic disorders, emotional problems, acute medical
crisis, preventive strategies and complex bio-psychosocial problems.
 Clinical skills include diagnosing and managing
common and important medical problems. (See lists in
handout)

Family Physicians are skilled
clinicians
Diagnostic strategies include those of “watchful waiting”
to diagnose undifferentiated problems. Skills also
include provision of a number of services to a
population (list included).
 All of these approaches involve sensitivity to the
individual and their context.
 Each physician must be able to self assess the quality
of their work and reflect on how they could improve.

Third Principle
Family Physicians are a resource to a defined
community; Brazilian clinics serving a defined
population are more organized to meet this principle
than primary health care services in most other
countries.
 Population/public health principle merge with primary
health care provision including steps to monitor the
health of the community. Data collection needs to be
organized to measure health outcomes so the impact of
services can be monitored.

Fourth Principle
Family Medicine is dynamic in responding to the
changing needs of the community: Ideally, each
Brazilian clinic would have methods of monitoring
community needs, community outcomes and also be
connected to neighboring clinics.
 This connection would allow for provision of
comprehensive services. Clinics need the ability to
measure and adapt to the changing needs of their
community. Self assessment and self learning remain
integral.

Using Four Principle to Produce
Physicians, Nurses, and Health Workers
Style of educational programs.
Duration 2 to 5 years of postgraduate training may be influenced
by content of undergraduate medical programs and the
defined role of the family physician.
Location In some countries, most of the education is hospital
based. Many programs are moving to have education occur in
community clinics or organized community based teaching
practices. Different countries require different roles, some
including intra-partum obstetrics, minor surgery, anaesthesia ,
emergency room work, and care of patients in hospitals or
nursing homes.
Educational Models
Affiliation: The structure and affiliation of educational
programs is quite variable. In Canada, all programs are
affiliated with a University requiring faculty appointments
for all educators. In the U.S., more than half the programs
have only a hospital affiliation and do not require
university appointments.
 In the UK and other commonwealth countries, the
“vocational training program” is run independent of the
university by the RCGP. However, each University has a
small Department of Family Medicine for teaching
undergraduates and conducting research.

Accreditation
The setting of educational objectives and standards for
a country and then having a system to assess how
these standards are being met on a regular basis is
extremely important in achieving a uniform standard for
educational programs. I understand that standards have
been developed for Brazilian clinics.
 Brazil has developed a final assessment prior to gaining
specialty status. Examinations and standards are
usually set by the same body that accredits programs.

Eligibility for Examination
 When a program is starting, it is important to
acknowledge experienced practitioners for their
skills. It also accelerates developing
considerable numbers of specialists quickly.
 A number of countries have two routes to be
eligible to take the “specialty examination”. The
residency route and the practice eligible route.
Practice Eligible Route
Usually there is a minimum requirement of practice
experience in a health clinic (usually 3-5 years).
 The candidate is asked to demonstrate that they are “up
to date” by attending approved continuing medical
education courses. (in Canada 250 hours over the 5
years)
 Practice eligible candidates may undergo an audit of
their practice or records to assess eligibility.

Residency Training Programs
The content of residency programs varies widely
between countries.
 In the U.S. and Canada, there is an expectation that
graduates will provide in hospital care, intra partum
obstetrics, and emergency room care, and conduct
minor surgical procedures.
 In most European countries, the expectation is to
function only in a community office practice.
 In some countries, even office procedures such as pap
smears are not part of the role.

Residency Training Programs
 Once the functions of the primary care physician
or provider in a country have been determined,
the objectives for the educational program need
to be developed.
 Detailed objectives and determination of
measuring minimum skills or competence need
to be developed from the Principles.
Program Styles
As mentioned, the residency program duration ranges
from 2-5 years. In Canada, and I understand Brazil,
there is a two year program, The US and the UK have 3
year programs, Australia has a five year program.
 Duration of the program is influenced by the structure
ie; Canada: the entire 2 years are integrated with family
medicine in the community. US: usually integrated with
community but more hospital rotations. UK: two years
completely hospital based with little or no connection to
GPs and one full year in general practice. This model
has been criticized.

Community Integration
Over two years the resident spends a minimum of 8
months full time in Family Medicine teaching clinics.
During this time they build up their own patient practice.
They then spend 16 months working in medicine,
surgery, psychiatry, pediatrics, obstetrics, gynecology,
and emergency. They may also spend time in care of
the elderly, palliative care, remote medicine and many
other areas.
 While away from family practice, most residents return
to ‘their’ practice to see “their patients” ½ day per week.
This allows continuity of care and integration with
community practice.

Residency Training Programs
In three year programs (US and UK), 1 full year is spent
in family medicine and the other two years are spent in
hospital often with little connection to Family Medicine.
 Another model is to spend three or four half days a
week following a group of patients in the community
practice for the entire 2 or 3 years. This is complicated
as all other experiences in hospital has to be built
around the resident leaving 3-4 half days per week.

Community Experience
In community teaching clinics residents:
 1. Gain clinical experience by seeing patients that they follow
over time
 2. Learn the patient centered approach usually by being
directly observed by faculty or videotaping sessions with
patients.
 3.Gain a theoretical and practical understanding of dealing
with clinical uncertainty.
 4. Gain practical experience with common and important
clinical problems
Community Experience
 5.Gain the ability to critical appraise the medical
literature and incorporate it into their practice.
 6.To gain skills in dealing with psychosocial
issues.
 7.To learn to monitor and describe the needs of
the community served by the clinic.
 8. To learn to evaluate the quality of care
delivered in the practice.
Community Experience
9. Residents are expected to complete a small research
project related to activities in the clinic. This allows them
to gain an understanding of research methods and to
answer important and practical research questions.
 10. Residents are also expected to conduct an audit of
some aspect of their clinical work (such as rate of pap
smears in eligible women, number of patients with a
recorded BP etc)

Community Experience
 11. Residents are expected to keep a log of their
clinical work either manually or by computer so
that their clinical experience can be assessed
against objectives.
 12. Residents keep a log of minor surgical
procedures completed with a sign off by faculty
that the individual is competent to do the
procedure themselves.
Learning the principles
The physician- patient relationship is central to the
role of the family physician.
 Achieved by seeing, following and establishing
relationships with a cohort of patients in a community
practice.
 The resident needs to have interviews monitored and
critiqued. The resident needs to reflect on how they can
improve. They also need a theoretical understanding of
the objective.

Learning the principles
 The community clinic setting requires a clinical
teacher who can monitor and critique the
resident while following a group of patients over
time. Ideally, the clinic would have an electronic
data recording system and a video camera to
record interviews. Part of the resident’s learning
would be to function in the clinic team. The
supervisor would need to evaluate and feed
back on the residents progress regularly.
Learning the principles
Family Physicians are skilled clinicians.
The clinical skills are learned in the clinic environment
working with a skilled clinician. This experience
recorded by log should be supplemented with an
ongoing academic half day program that covers the
latest management of common and important problems
in practice behavior science skills. Monitoring and
assessment of the resident’s patient centered method
and how the resident deals with uncertainty is essential
Learning the principles
 Family Physicians are a resource to a defined
community; The community clinic is essential in
this learning. Learning basic epidemiologic skills,
having a system that allows assessment of
community needs and conducting research or
audits on how these needs are met are in
addition to an ongoing seminar program that is
required.
Learning the principles
 Family Medicine is dynamic in responding to
the changing needs of the community. The
resident needs to participate in learning self
assessment skills, skills in determining how to
best acquire knowledge to keep skills up to date.
A specific academic seminar program is needed
over months or years to develop these skills.
Possible Structure
In Brazil, the community clinics provide the ideal setting
in which to provide the community experience for one
resident.
 A teaching clinic would have a clinical teacher as the
physician who would be an excellent clinician and have
teaching skills gained through a faculty development
program. The clinic would have some computer record
system and videotaping capacity.

Possible Structure
 A program would require the number of teaching
clinics needed for each resident to follow a group
of patients over the two or three year period.
 All the residents would come together in a
central location at least weekly for their
academic program, their video tape reviews, and
their continuing evaluation.
Possible Structure

The faculty to run such a program (ideally from a
University but could be hospital based) would consist of
the clinical faculty located in the community clinics,
educators located centrally who would supervise the
clinic faculty and provide faculty development and the
ongoing academic theory programs for the residents
and researchers who would support the research
program in the residency and conduct research in the
network of community clinics.
Possible Structure
University Faculty of Medicine
Department of Family Medicine
Department Head – Central Office
Office of Clinical Educators
Office of Clinical Researchers
Teaching Community Health
Clinics
50-100 Teaching Clinics
Each with a clinical teacher
and resident
Education in Center
 The central office is responsible for coordinating
all the residents’ experience in the community
and in hospital. They would need to ensure that
hospital experience was relevant to their
objectives .
Education in Center
 A University Department of Family Medicine
would be responsible for undergraduate teaching
in the medical school. All students should gain
an understanding of the Principles of Family
Medicine. This would include diagnosis and
management of common and important
problems in the community.
Undergraduate Family Medicine
Teaching clinical skills
 Teaching interviewing
skills.
 Teaching problem based
learning
 Providing lectures on
common clinical
problems

Providing lectures on
dealing with clinical
uncertainty
 Providing lectures on
dealing with bio- psychosocial problems.
 Providing clinical
experience in community
based teaching clinics.

Research

This structure would provide a remarkable
practice based research network. 50 clinics with
4,000 patients in each or 200,000 patients.
 Recommendation from the World Organization of
Family Physicians
 All member countries should develop sentinel
practices to provide surveillance reports on
illness and diseases that have the greatest
impact on patients’ health and wellness in the
community. These practices provide a base to
collect essential research data.
PBRN’S Contribution to
Research Capacity Building
 collecting empirical data from FP
 relating FP’s to researchers and focus research
on important questions from practice
 disseminating research results in practice
 stimulating research interest in FP’s.
Examples of Family Medicine
Research

Family physicians at the University of Toronto
tested a sore throat scoring system in both a
Toronto teaching practice and a community
based family practice in a small town. They
used an already developed scoring system as
a predictor of patients with or without positive
streptococcus cultures from the pharynx
which could reduce antibiotic prescribing by
up to 75%.
Family Medicine Research

A group of researchers at Queen’s University
studied management of hypertension in a
research network of 50 community practices.
Their findings include the fact that home
measurements of blood pressure provide
different results than conventional office
readings.They have also found that patients
follow their BP lowering directions, and are
equally satisfied when they have either three
or six month follow up for elevated blood
pressure.
Family Medicine Research

Michael Klein at the University of British
Columbia’s Department of Family Medicine
conducted a series of trials on the value of an
episiotomy and found that midline episiotomies
consistently produced more pain and more
damage to the perineum than natural tears.
Medio-lateral episiotomy, although less traumatic
than the midline, produced significantly more pain
and complications than did natural tears. These
studies have influenced a world wide decline in
episiotomies.
Family Medicine Research
 A University
of Toronto group found that
treating women for cystitis after testing
the urine for white cells and nitrites
reduced antibiotic use in cystitis by
27%. This paper was selected as the
outstanding Canadian Family Medicine
research paper in 2002.
Conclusions
The Brazilian clinic model, with 25,000 functioning
clinics in the community providing medical care to more
than 30% of the population is a remarkable
achievement.
 To optimize the potential benefits to Brazil of this
achievement, a workforce of physicians and nurses
specifically trained to function effectively in this
environment is needed. A stimulating and attractive
career opportunity needs to be created to attract
medical students.

Conclusions
 This phenomena presents a great opportunity to
develop academic and research programs that
have the potential to greatly improve the health
of the entire population.
 Models from around the world need to be
adapted to the needs of communities in Brazil.
Conclusions
 The potential to greatly improve the health and
economic well being of Brazilians is present and
the challenge to the University of Sao Paulo is to
provide a major contribution to this development.