The Status of Family Medicine Training Programs in the Asia Pacific

ORIGINAL ARTICLES

The Status of Family Medicine Training Programs in the Asia Pacific Chirk Jenn Ng, MMed, PhD; Cheong Lieng Teng, MMed, FRACGP; Adina Abdullah, MMed; Chin Hoong Wong, MbBch, MRCGP; Nik Sherina Hanafi, MMed, PhD; Stephanie Su Yin Phoa, BSc; Wen Ting Tong, MMedSc

BACKGROUND AND OBJECTIVES: The family medicine training demands for health care in the com- programs in the Asia Pacific (AP) are evolving. To date, there is munity and to improve its quality, a lack of comprehensive and systematic documentation on the there is a need to train adequate status of family medicine training in the AP. This study aims to numbers of competent primary care determine the status of family medicine training at both the un- doctors.3 dergraduate and postgraduate levels in medical schools (universi- Academic family medicine de- ties or colleges) in the AP. partments along with departments METHODS: In 2014, the authors conducted a cross-sectional on- of health and professional colleg- line survey to assess the undergraduate and postgraduate fam- es have been instrumental in edu- ily medicine programs in academic family medicine departments cating, training, and assessment of from AP countries. A 37-item online survey questionnaire was sent family medicine trainee doctors from to key informants from academic institutions with established fam- undergraduate to postgraduate lev- ily medicine departments/units. Only one response from each fam- el.4,5 Development and establishment ily medicine department/unit was included in the analysis. of academic family medicine depart- ments in the Asia Pacific region is of RESULTS: The medical school and country response rates were interest as it holds the world’s most 31.31% and 64.1%, respectively. The majority of the medical populated countries. Many of these schools (94.7%, n=71/75) reported having a department/unit for countries have aging populations.6 family medicine. Family medicine is recognized as a specialist de- gree by the governments of 20/25 countries studied. Family medi- All these factors result in increasing cine is included in the undergraduate program of 92% (n=69/75) demand for trained family medicine 7 of all the participating medical schools. Only slightly more than doctors to work in primary care. half (53.3%) (n=40/75) reported conducting a postgraduate clini- Although there has been increas- cal program. Less than one third (26.7%) (n=20/75) of the medi- ing family medicine training in the cal schools conducted postgraduate research programs. Asia Pacific region, it is not equal to the development in other re- CONCLUSIONS: Undergraduate training remains the focus of gions of the world such as the Unit- most family medicine departments/units in the AP. Nevertheless, ed Kingdom (UK),8 United States,9 the number of postgraduate programs is increasing. A more rigor- and Northern and Western Europe.10 ous and long-term documentation of family medicine training in This is not surprising as the evolu- the AP is warranted. tion of academic family medicine (Fam Med 2016;48(3):194-202.) began in the 1950s in the UK and

From the Department of Primary Care he importance of primary primary health care as the key to Medicine, University of Malaya, Kuala Lumpur, health care has been recog- achieving health for all.2 World- Malaysia (Drs Ng, Abdullah, and Hanafi, Ms nized since 1978 in the Alma wide, family medicine, or general Tong and Ms Phoa); Department of Family T 1 Medicine, International Medical University, Ata Declaration. The World Health practice, is becoming an established Negeri Sembilan, Malaysia (Drs Teng and Organization (WHO) has identified discipline. To cater to the increasing Wong).

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1969 in the United States. Whereas, take up core clerkships or periods of research team, who are members most of the countries in the Asia Pa- clinical instruction. Once students from academic family medicine de- cific region began family medicine obtained their medical doctorate partments and professional family training in the 1980s with a few ex- (MD) degree, then they are eligible medicine organizations, scrutinized ceptions: Australia, Malaysia, Singa- to proceed with full clinical training and agreed on the content of the pore, and South Korea in the 1970s. in a family medicine residency pro- questionnaire. The questionnaire In Sub-Saharan Africa, family medi- gram accredited by the Accreditation was then pilot tested with three cine was recognized as a specialty in Council for Graduate Medical Ed- family medicine experts from three 2007, and the first batch of full-time ucation (ACGME). Once they com- established family medicine depart- trained family physicians entered plete the 3-year residency program, ments in the Asia Pacific region. As into the health system in 2011.11 they then must pass the certifica- there were only minimal changes Due to variation of demography, tion exam by the American Board to the questionnaire, the responses culture, geography, politics, and econ- of Family Medicine (ABFM) and only from the three experts were included omy, the family medicine training then can practice as a board-certified in the analysis. programs in the Asia Pacific vary family physician.13 in terms of training model, dura- To date, there is a lack of compre- Data Collection Process tion, and pathways.12 For instance, hensive and systematic documenta- The online questionnaire was sent New Zealand has a 3-year vocation- tion on the status of family medicine to key informants from academic al training program involving two training in the Asia Pacific region. institutions with established fami- stages of training; general (Practice Therefore, this study aims to deter- ly medicine departments or units or Education Programme [GPEP1]), mine the status of family medicine who are teaching family medicine as which is a 1-year placement in a training at both the undergraduate part of the undergraduate curricu- training practice after junior hospi- and postgraduate levels in medical lum. Two approaches were used to tal training and GPEP2, a 2-year im- schools (universities or colleges) in determine if a medical school has a mersion in general practice, based the Asia Pacific region. We believe family medicine department, unit, or on continuing professional develop- this is the first step toward identify- program: (1) online search and (2) by ment participation and workplace ing and narrowing the gaps in family report from resource persons (Table assessments. In Malaysia, after a medicine training across the region. 1). After we had compiled the list of 3-year mandatory community ser- key informants of the family medi- vice as a junior doctor followed by Methodology cine departments from each country, a self-directed training program, a Study Design we contacted them using the Sur- 2-year mentored distance-educa- This cross-sectional study was con- veyMonkey online survey program. tion will lead to diploma in family ducted between March and August We reminded the nonrespondents up medicine or a pass in the conjoint 2014 using an online survey meth- to three times, 1 to 2 weeks apart. RACGP-Malaysian exam will lead od (SurveyMonkey), which allowed To optimize the response rate, each to a fellowship in general practice. the researchers to capture respons- family medicine department or unit Hong Kong has a 6-year specialty- es from participants from countries might receive more than one invita- training program by the Hong Kong in the Asia Pacific region, based on tion. Only one response from a fam- College of Family Physicians. Sin- the United Nations composition of ily medicine department is included gapore has a joint government uni- macro-geographical regions and sub- in the analysis; duplicates are sought versity private-practice approach regions.14 and discarded. Figure 1 illustrates with a three-level training pathway. the data collection process of this The first level leads to a diploma in Research Instrument study. family medicine, the second level is This study used a survey question- a 3-year training program leading to naire consisting of 37 items. It was Data Analysis a Master’s degree, and the final lev- developed following a literature re- Descriptive analysis was performed el is 2 years of training to obtain a view and discussion among research- to summarize the results using fre- membership with the Fellowship of ers. In order to assess the training quencies, mean, medians and per- the College of Family Physicians.12 capacity of the academic department, centages. SPSS 20.0 (SPSS Inc, In the United States, family medi- the questionnaire aimed to assess Chicago, IL) software was used to cine training is a state- or univer- five domains of an academic family manage and analyze the data. sitybased program that begins in medicine department: background medical school (4 years) and contin- information about the family med- Ethical Approval ues in residency (3 years). During icine department, undergraduate This study obtained ethics approval medical school, students must pass program, postgraduate clinical and from the University of Malaya Medi- two of the United States Medical Li- research programs, national policy, cal Centre Medical Ethics Commit- censing Examinations (USMLE) and and accreditation. Experts from the tee (Reference: 201401-0683).

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Table 1: Strategies to Identify the Presence of a Family Medicine Department or Unit and Training in Medical Schools

To determine presence of family medicine in the medical school: (1) Online search • A search on all medical schools from the Asia Pacific region listed on the AVICENNA directory was conducted to determine if they had a family medicine department/unit or program. • If this information was not found, an in-site search for family medicine (or equivalent terms such as general practice and primary care) using Google (search string: “family medicine” site: [website url]) was conducted. • In cases where the university’s website was not found or if there were any issues assessing the website, a simple Google search was performed using the search words “family medicine” (or equivalent terms) and the university’s name. • When there were no results using the search strategy, we assumed the university did not have a family medicine department, unit, or training program. When there was a direct relation found between that university and the subject of family medicine, even if there was no family medicine department or unit found on the university’s website, we listed the medical school as potentially having a family medicine department, and the contact details of the dean were obtained. • For medical schools that had a department webpage for family medicine, the head of the department was invited to participate in the study. When the head of the department was not available, another member of the department was contacted. When the members of the family medicine department were not publically available, the dean of the medical department was contacted, and he/she would be asked to recommend a suitable candidate to participate in the study. • The researchers also sought information from experts (“resource person”) who were knowledgeable in the field of family medicine from each country.

Results five for academic staff (interquartile 0–52). In 2013, the median number Study Response Rate range [IQR]: 3–8, range: 0–32), one of students enrolled into the under- Of the 76 countries and 983 medical for professor (IQR: 0–1, range: 0–4), graduate programs was 205 (IQR: schools in the Asia Pacific region, 313 two for associate or assistant profes- 125–350, range: 20–1,300). Most of medical schools from 39 countries sor (IQR: 1–4, range: 0–22), one for the undergraduate family medicine had family medicine programs. How- senior lecturer/lecturer (IQR: 0–4, programs (87.5%, n=63/72, three ever, only 98 medical schools from 25 range: 0–25), and zero for research- medical schools did not respond) countries responded. Therefore, the er (IQR: 0–1; range: 0–40). The me- were accredited by a national ac- medical school response rate of the dian number of staff with a PhD was creditation body (Table 2). study was 31.31% (n=98/313) (Fig- two (IQR: 1–4, range: 0–13). The common teaching methods ure 1) while the country response used were clinical teaching (92.6%, rate was 64.1% (n=25/39). Family Medicine Recognition n=63), followed by lectures (80.9%, Out of the 98 medical schools, and Training. Family medicine n=55) and classroom teaching responses from 23 medical schools is recognized as a specialist degree (77.9%, n=53) while the most com- were removed due to non-consent, by the governments of 20 countries mon assessment methods were mul- incomplete answers, and duplicates. studied. Family medicine is includ- tiple choice questions (70.6%, n=48), Therefore, only 75 medical schools ed in the undergraduate programs followed by objective structured clin- were included in the data analysis. of 92% (n= 69/75) of all the partici- ical examination (OSCE) (63.2%, Figure 2 illustrates the responses pating medical schools. Among the n=43) and short answer questions from countries in this study. participating medical schools, 53.3% (47.1%, n=32). (n=40/75) conducted postgraduate Status of Academic Family clinical and 26.7% (n=20/75) con- Postgraduate Program (Clinical) Medicine Departments/Units ducted research programs (Table The median duration for clinical in the Asia Pacific 2). There was an increasing num- postgraduate programs in these Family Medicine Departments/ ber of family medicine departments medical schools was 3 years (IQR: Units and Academic Staff. Out of or units involving both undergradu- 2–3, range: 1–4). The number of the 75 medical schools, 94.7% (n=71) ate and postgraduate programs since trainees in the current semester was reported having a department or 1985 (Figure 3). 19.5 (IQR: 5–40.5, range: 1–450). unit for family medicine, and most The majority (90.9%, n=37/39, one were independent departments Undergraduate Program medical school did not respond) of (78%) (n=55/71). The median number The median duration for under- the medical schools reported that of full-time staff teaching in the fam- graduate family medicine postings their clinical postgraduate programs ily medicine department or unit was: was 7 weeks (IQR: 2–10, range: included hospital attachment. The

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Figure 1: Data Collection Process of the Online Survey

Selection of countries Countries Based on the United Nations composition of Countries in the region of macro geographical regions -­‐ and sub regions Asia and Oceania n=76

Selection of medical schools

Based on the AVICENNA Medical School Directory *Hong Kong, Taiwan and Macau were separated from mainland China and included because they have established FM programs

Medical schools

Medical schools selected n=983 (from 51 countries) Countries without FM department/unit/programs n= 12*

*Azerbaijan, Cambodia, North Korea, Fiji, Kuwait, Laos, Macau, Mongolia, Papua New Guinea, Turkmenistan, Uzbekistan, Vanuatu Schools with FM

departments/units/programs n=313 (from 39 countries)

Online survey data collection method, SurveyMonkey online survey program .

Invitations sent n= 376 key informants

Medical schools with FM

departments/units/programs responses n= 98 Removed -­‐ Non-­‐consent = 1

-­‐ Incomplete questionnaire = 13 -­‐ Duplicates = 9

Final responses

n=75 (from 25 countries)

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Table 2: The Status of Family Medicine Undergraduate and Postgraduate (Clinical and Research) Training and Accreditation by Countries in the Asia Pacific

Recognition FM in of FM as a FM in Post- FM in Post- Under- Post- Medical No of Specialist Under- Graduate Graduate graduate graduate Country Schools Institutions Degree in graduate (Clinical) (Research) Institution Institution (n=25) With FM Responded the Country Program Program Program Accreditation Accreditation Australia 19 9 Yes 9 1 1 9 5 Bahrain 3 2 Yes 2 1 0 2 1 China 27 1 Yes 1 1 0 1 1 Hong Kong 2 1 Yes 1 0 0 1 — India 11 2 * 1 0 0 1 1 Indonesia 18 10 * 9 2 4 9 6 Iran 14 1 No 0 0 1 — — Iraq 8 2 Yes 2 2 0 2 2 Japan 27 5 * 3 5 4 3 3 Kazakhstan 6 1 Yes 1 1 1 1 1 Lebanon 6 2 Yes 1 2 0 2 2 Malaysia 11 7 Yes 7 4 3 6 4 Nepal 5 1 Yes 1 1 — — — New Zealand 2 1 Yes 1 0 1 1 1 Oman 2 1 Yes 1 0 0 1 1 Pakistan 7 3 Yes 3 2 0 2 3 Republic of Korea 35 5 Yes 5 5 3 5 5 Saudi Arabia 11 2 Yes 2 0 0 1 2 Singapore 2 1 No 1 1 1 1 1 Sri Lanka 5 4 Yes 4 0 0 4 4 Taiwan 11 1 Yes 1 1 1 1 1 Thailand 13 2 Yes 2 1 0 2 2 Turkey 33 8 Yes 8 7 0 5 4 United Arab Emirates 1 2 Yes 2 2 0 2 2 Viet Nam 8 1 Yes 1 1 0 1 1

% 80% 92% 53.3% 26.7% 84% 70.7% (n) (313) (75) (20/25) (69/75) (40/75) (20/75) (63/75) (53)

* The recognition of family medicine as a specialist degree in the country was unable to be determined as there were discrepancies in answers among participants within the country.

median total duration for the hos- (94.9%, n=63), followed by case Postgraduate Program (Research) pital posting was 18 months (IQR: presentations (94.9%, n=37) and Of the 75 medical schools, 26.7% 13.5–30.75, range: 2–40). Of these lectures (89.7%, n=35), while the (n=20/75) have research postgrad- medical schools, 71.8% (n=28/39) re- common assessment method was uate training programs. The re- ported that their programs required multiple choice questions (74.4%, search programs offered by most a research dissertation. n=29), followed by practice-based medical schools was Master’s by re- The most common teaching meth- assessment (61.5%, n=24) and the search or coursework (non­clinical) od used in the postgraduate clini- portfolio (60.5%, n=23). (85%, n=17/20), followed by PhD pro- cal programs was clinical teaching grams (65%, n=13/20) and Medical

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Figure 2: Countries in the Asia Pacific Region Included in This Study

Doctorate (MD) programs (45%, Discussion still young and have a small number n=9/20). The State of Family Medicine of staff. However, this might limit The median duration for Master’s Training in the Asia Pacific the training capacity and the abil- programs was 2 years (IQR: 2–3, This study revealed that there has ity to establish postgraduate courses. range: 2–4), and the current num- been significant development of fam- The progress of academic fami- ber of students was five (IQR: 3–103, ily medicine training in the Asia Pa- ly medicine in the Asia Pacific re- range: 2–200). The median duration cific region in the last 2 decades. The gion varies among the countries in for MD programs was 3 years (IQR: establishment of family medicine de- the region. The majority (20/25) of 2.5–3, range: 2–3), and the current partments or units has been grow- the countries represented in this number of students was 1.6 (IQR: ing since 1995. Seventy-one out of 75 study recognize family medicine as 0.5–2.5, range: 0–3). The median du- medical schools in the region report- a specialist degree. Although the ration for PhD programs was 3 years ed having a family medicine depart- recognition of family medicine as a (IQR: 2–4.5; range: 2–6), and the cur- ment or unit. Of the four medical specialist degree in the country was rent number of students was 6.62 schools that did not have a family unable to be determined in India, In- (IQR: 1.5–9, range: 1–33). medicine department or unit, family donesia, and Japan in this study, a The formats for these programs medicine teaching in the undergrad- literature review found that family were reported to be mainly by dis- uate level was integrated into the medicine is a recognized specialist sertation and thesis in the major- undergraduate medical curriculum. degree in India but not in Indone- ity of medical schools. Collectively, This study also found that there sia15 and Japan.16 the medical schools had eight Mas- were more undergraduate than post- The recognition of the need to de- ter’s programs, two MD programs, graduate family medicine clinical velop family medicine into a special- and five PhD programs. Fifty-three programs available. Only a quarter ized discipline is influenced by the medical schools reported that their of the medical schools offered post- health care system, medical educa- postgraduate programs were accred- graduate family medicine research tion system, and needs of the coun- ited by a national accreditation body programs. This probably reflects the tries. In Japan, the development of in their country (73.6%, n=53/72). stage of the development of family academic family medicine is still at medicine in the region where most of its early phase. A universal health the family medicine departments are care insurance system in the country,

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Figure 3: The Number of Undergraduate and Postgraduate Departments, Units, or Programs Established by Year*

Undergraduate 25 Postgraduate

20

15

10 Frequency (n) Frequency 5

0

Year

* n=44

which allows Japanese patients to postgraduate research training. Central and Eastern Europe (CEE), seek treatment wherever they pre- Further, there were many medical some of the family medicine depart- fer, had led to overuse of specialized schools, which reported to include re- ments are chaired by general prac- care. Although, in recent times, a vo- search dissertation as part of their titioners.20 In Europe, the majority cational training program has been postgraduate clinical program. Al- (80.7%) of the medical schools are in- organized by the Japanese Acade- though the number is not many, this volved in family medicine teaching,10 my of Family Medicine.16 In Indo- may reflect that family medicine but this is only observed in 313/983 nesia, despite the need for primary training in the Asia Pacific region (31.8%) medical schools in this study. care doctors in the country, there is recognizes research as an important The inclusion of family medicine a lack of family medicine specialists way to advance the discipline. For as part of the undergraduate cur- to teach in the undergraduate and example, Australia’s competency in riculum was found in almost all of graduate levels.17 It has been recom- primary care research is compara- the medical schools within the par- mended by WHO that Indonesian ble to countries with well-established ticipating countries of this study ex- primary care doctors should uptake academic family medicine, such as cept for Indonesia (9/10), Iran (0/1), additional postgraduate education Canada, Germany, The Netherlands, Japan (3/5), and Lebanon (1/2). This as family doctors; however, the rep- the United Kingdom, and the Unit- is comparable to countries in CEE resentative board of the Indonesian ed States.18 whereby most of the medical schools Medical Council instead decided to in the region have a family medicine improve family medicine training at Situating Asia Pacific Academic component in their undergraduate the undergraduate level.17 Indone- Family Medicine in the World teaching except for Czech Republic sia is currently developing its family Many of the medical schools in (3/7) and Russia (13/51).20 In sub-Sa- medicine postgraduate and special- this study have a department/unit haran Africa,10 universities in eight ist training program and is working for family medicine. In contrast all countries (Sudan, Ghana, Nigeria, toward family medicine specializa- medical schools in the UK have a DR Congo, Rwanda, Uganda, Kenya, tion in the country (based on an open family medicine/general practice and Tanzania) do not have family comment by an Indonesian partici- department with at least one pro- medicine as part of their under- pant of this study). fessor of family medicine in each de- graduate medical training by 2010. This study found that medical partment.19 Our study revealed that However, in terms of the average du- schools from Australia, Indonesia, one medical school in our study did ration of family medicine posting in Iran, Japan, Kazakhstan, Malay- not have full-time academic staff the undergraduate program included sia, New Zealand, South Korea, teaching family medicine but fami- in this study (7 weeks), this finding Singapore, and Taiwan provided ly physicians who teach part time. In is comparable to medical schools in

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Northern Europe with 5–13 weeks of productivity among family medicine Schools” used in this study did not family medicine clinical rotation and faculty members.23 In CEE, the lack include all the medical schools in is longer than most medical schools of a research culture and shortage each country. Lastly, not all univer- in Eastern or Southern Europe.10 of relevant infrastructure hinder re- sities have a website accessible to This study found that the teaching search careers among general practi- the public, which limits our online methods in family medicine under- tioners rendering research activity to searches. graduate programs within the Asia be less active in the region as com- Pacific region are still using con- pared to family medicine teaching.20 Conclusions ventional teaching methods such Among the strategies that could in- This pilot study highlighted the as lectures and classroom teach- crease and improve research train- need for more rigorous and long- ing. Lectures involve a bigger group ing in AP include establishing more term tracking of family medicine of students while classroom teach- family medicine departments, in- training in the Asia Pacific region. ing limits to a smaller group; both creasing research partnerships, and Although undergraduate training are conducted in a didactic manner. giving access to resources such as remains the focus of most family In countries with more established computers and the internet.24 medicine departments/units, an in- family medicine training, such as creasing number of them are offer- the UK, family medicine training Study Limitations ing postgraduate family medicine has shifted from didactic teaching There are several limitations to this programs. A more representative to small-group and practice-based study. First, not all medical schools sample is needed to confirm and gen- teaching.8 More advanced teaching from each country responded to eralize our findings. methods, such as usage of electron- our survey. For instance, only a few ACKNOWLEDGMENTS: This study received ic materials and online methods, medical schools in China, Japan, funding from the University of Malaya are only reported by three medical and Korea that have family med- (RG519-13HTM). schools in our study. The lack of us- icine programs responded to our CORRESPONDING AUTHOR: Address corre- age of electronic multimedia to sup- study. We believe that language is spondence to Dr Ng, Department of Primary port clinical teaching may be due to the main contributor to this lack of Care Medicine, Faculty of Medicine, University students’ preference for direct obser- response, and this has been point- of Malaya, 50603 Kuala Lumpur, Malaysia. 011-603-7949 2306. Fax: 011-603-7957 7941. vation of health providers in practice ed out by Hays (2003) as one of the [email protected]. rather than relying on IT as a form challenges in developing a collabor- of learning as found in the UK.21 ative and cohesive academic family References 3 The median duration for postgrad- medicine in the Asia Pacific region. 1. International Conference on Primary Health uate clinical training conducted by We used English in the survey as it Care. Declaration of Alma Ata. 1978. medical schools in the Asia Pacific is a common language. However, we 2. World Health Organization. Primary health region is 3 years. This is similar to found that many countries in this care. Report of the International Conference on Primary Health Care. USSR, Alma Ata, 1978. the duration of the family medicine study did not use English. Second- 3. Hays R. 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Ann Fam Med 2012 Nov-Dec;10(6):503-9. This study found a small num- sor and associate professor. Different 8. Major SC, Booton P. Involvement of general ber of family medicine departments interpretations of these terms may practice (family medicine) in undergraduate offering research programs. Incom- lead to inaccurate results as well as medical education in the United Kingdom. J petence in research skills has been limit the comparisons of the findings Ambul Care Manage 2008;31(3):269-75. identified as a significant factor in in this study. Fourthly, the database influencing research activity and “WHO Avicenna Directory of Medical

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