College Of Family Physicians Convocation 2005

01 Oct 2005

By Prof K Satku, Director of Medical Services

Venue: MOH Auditorium, College Of Medicine Building

Associate Professor Cheong Pak Yean,

President, College of Family Physicians;

Professor Stuart Murray,

The 2005 Sreenivasan Orator;

Distinguished guests, colleagues, ladies and gentlemen,

It gives me great pleasure to join you this afternoon to witness the convocation of doctors who have successfully completed the Graduate Diploma in Family Medicine, and to welcome them into our midst as family physicians.

With the proposed Family Physician Register in the horizon, those of you who have just completed the course must feel an added sense of purpose and pride. With these additional skills you will be ready to meet the challenges and responsibilities of being a family physician in the coming new era of family medicine.

Today, while Singaporeans enjoy a relatively long life-expectancy of 79 years, about 9 of those years are spent in disability, dependent on care givers for activities of daily living. Chronic diseases account for approximately two-thirds of this burden.

As our population ages, we expect to see more of the elderly having not just one or two, but several chronic diseases at the same time. They might be managed concurrently by a few specialists in the hospitals. The key to reducing the number of years spent in disability is prevention, early detection and treatment, as well as sustained lifestyle changes.

Family physicians should not only manage their patients holistically but should also efficiently coordinate the care given to their patients by various specialists. This should be the outcome in every responsible health care system.

MOH will put in place the necessary infrastructure to facilitate this change. This will ensure that our patients can live healthier lives with fewer disabilities, at a lower health care cost and with care delivered largely at the primary level.

Let me give you the example of the Singapore National Asthma Programme which was extended to the polyclinics in 2004 to test out these strategies. Preliminary results from one of the polyclinics have shown a 30% decline in the number of acute asthmatic attacks amongst patients in the programme. The number of acute referrals to hospitals has also decreased from 3 cases per month to almost zero.

In 2004, MOH also initiated disease management programmes for diabetes and hypertension run by family physicians in the polyclinics.

The programme ensures that adequate consultation time is provided for family physicians to appreciate the backgrounds of their patients, to counsel and educate them according to their needs, and to facilitate the human touch that is critical in building the successful doctor-patient relationship - a relationship so essential for influencing health behaviour.

Although patients have to pay a little more for the longer consultations, the feedback I have received is that they are happy with the improved standards of care. To address the increasing demands for such clinics, 3 more FP clinics will be set up by November this year.

On another front, MOH has proposed a regulatory framework for opticians and optometrists to ensure that training infrastructure is put in place to enable optometrists to upgrade and provide better refraction services to our patients within the community.

Likewise, the proposed Family Physician Register is yet another such initiative designed to ensure that structured and directed training programmes are available to enable our doctors provide the right level of care in the community.

A strong base of family physicians is expected to improve the coordination and continuity of care of patients with chronic diseases and ultimately improve clinical outcomes.

For example a family physician's patients who are obese or who have a strong family history of certain cancers can be proactively screened or encouraged to modify their lifestyles before the disease sets in.

Patients are also more likely to be compliant to treatment if a family physician knows his medical conditions well.

While many GPs, through their years of practice, have gathered experience to care for this type of patients, a system needs to be put in place to ensure that newer generations of family physicians will acquire the necessary skills much earlier in their professional career.

Having said that, the Family Physician Register is but one of the many measures that MOH and the profession as a whole have to take to bring about the transformation of primary care.

For example, there is tremendous potential for the use of information technology or IT in enhancing primary care delivery. New medical evidence is making chronic disease management protocols more complex and it will be increasingly difficult for any doctor to keep up with the latest treatment protocols.

Judicious use of IT in primary care can empower the family physician with appropriate decision support tools to ensure that chronic disease management is up-to-date. This will free up precious consultation time for health education, care coordination and to better understand the patient's social and occupational issues. I was told that there are already pockets of such IT developments amongst private practitioners but much more can be done to encourage widespread adoption of such IT systems.

To further realize the potential of IT in primary care, the exchange of medical information between hospitals and family physicians should ideally become seamless. With the introduction of the electronic medical records exchange system in April 2004, medical records can now be shared between public hospitals and polyclinics.

A huge potential remains, for more and better linkages between the medical record systems of the private and public sectors. For example, timely exchange of medical information between public hospitals and family physicians will facilitate the follow-up of patients who have completed treatment at the hospitals.

Similarly, IT systems should help to optimize the use of specialist resources by allowing family physicians to obtain specialist input on complicated cases before upstream referral. The receiving specialist should be able to review medical records online and advise the family physician to complete any required investigations or treatment before he decides to refer the patient.

The IT developments that I have highlighted can be costly and solo-practice clinics may find difficulty in embarking on them. MOH will continue to work with all stakeholders to promote these linkages, and to exploit IT fully in order to achieve the most efficient delivery of holistic primary care.

However, the seamless availability of medical information to specialists through IT systems must not result in the movement of patients to hospitals without the involvement of a family physician to coordinate care.

This is an aberration seen today, even without the seamless IT system. There are a number of patients who prefer to seek specialist treatment without first consulting their family physicians.

A paper in the British Medical Journal suggested that patients who went directly to specialists were less likely to be ill, increasing the chances that diagnostic and therapeutic procedures were applied inappropriately.

The study concluded that despite consumerist trends in most developed nations, patients would continue to need family physicians to guide them through an increasingly complex healthcare system.

As such, MOH will continue to explore ways to support the role of family physicians so that they may help to safeguard patient interests and ensure that specialist resources are utilized in the most efficient way.

We will also explore ways to help strengthen and sustain long-term family physician-patient relationships. For example, ageing patients with increasing medical needs may find that as a result of reduced income and increased complexity of disease, they can no longer afford to continue seeing the family physician they have been seeing for years.

We want to explore ways to help these patients remain under the care of the same family physician who they have been with for the past many years.

The task will not be easy but it is our belief that long term family physician-patient relationships are essential if we want to secure better health outcomes for all Singaporeans.

So far, I have spoken about family physicians in relation to their hospital colleagues and with their patients. Family physicians must also actively explore ways to integrate their practice horizontally with the practices of other family physicians.

While it may be necessary for certain family physicians to develop additional expertise in geriatrics or psychiatry to enhance the care they provide, family physicians must resist the temptation to sub-specialize and must continually upgrade their skills and knowledge in the broadest sense in order to retain their generalist role.

Due to the increasing complexity of primary care, maintaining the breadth and depth of family medicine practice will become increasingly difficult. No man is an island. Multi-practitioner interactive functional groups in the primary care sector will enable family-physician-groups to discuss complicated cases together, to share and learn from each other, and to coordinate and manage more complex medical conditions within the community. We are currently exploring incentivising such groups by accrediting them as CME providers for family medicine.

To facilitate and support the greater involvement of family physicians in the management of his patients in the community, he must also have access to laboratory and radiological investigations with rapid turnaround times so that critical medical decisions can be made better and faster at the primary care level.

Horizontal integration with other family physicians may result in economies of scale that can justify the establishment of laboratory and radiological facilities in every township, while immediate access to specialists in diagnostic radiology and pathology for reporting purposes may become a non-issue with the help of Telemedicine services.

MOH will explore ways to support such infrastructural developments within the community. The College must in turn ensure that family physicians are appropriately trained to take advantage of these support services to bring about a more efficient delivery of primary care within the community.

As an added benefit, horizontal integration will also permit more time for family physicians to take part in continuing medical education and generally encourage a more flexible work-life balance. All these features will ultimately bring about better health outcomes for Singaporeans.

Despite our many efforts a new era of primary care will not emerge if we do not concurrently step up our efforts in primary care research. Monitoring of clinical outcomes in the primary care sector is necessary if family physicians are to continually develop better and more cost effective models of care for chronic diseases within the community.

Research will also help policy makers ensure that our strategies are correctly positioned to effect the transformation of primary care. The polyclinics in our two public health care clusters are well positioned to take the lead in this but GP groups and perhaps even solo practitioners should not feel left out.

The College must find ways to encourage family physicians to embrace primary care research so that the profession as a whole will be able to develop this culture of inquiry, innovation and excellence. These are qualities that family medicine will need to foster in order to secure its position alongside established specialities like internal medicine, paediatrics and surgery.

When the Family Physician Register is established in 2007, a Family Physicians Accreditation Board will be appointed to manage the register and also to ensure that training programmes remain relevant to the emerging and changing roles of family physicians.

The Ministry of Health will continue to provide the necessary legislative support and infrastructure for the profession to meet the challenges of primary care. However it is the College which has the greater duty.

Perhaps it is time to stop burdening doctors with examinations. Perhaps it is time to repackage the GDFM and other qualifying examinations without a focus on examinations but as a programme of skills acquisition, continuing learning and continual assessment. A programme that will facilitate life long learning and incidentally entry to the FP register.

You must ensure that the training stays relevant to the needs of family physicians.

The College must be an inspiration so that experienced practitioners will step forward to lead the profession into the new era of primary care.

I have tremendous faith that the College will rise to this challenge. However translating training programmes into clinical practice that can secure better clinical outcomes requires more than just thoughtful planning.

Many years of hard work and dogged perseverance by members of the College will be required. This will be an arduous task that only the most dedicated amongst you will be able to perform. Many will be looking to you and you must not fail.

To mark the start of this long but necessary journey, MOH will officially release the public consultation paper on the proposed Family Physician Register today. A copy of the consultation paper is on the way to every registered medical practitioner.

You will find that the criteria for registration are both achievable and inclusive. Existing general practitioners who do not wish to register may continue their practice and will not be negatively affected.

However, I believe that the majority of these primary care doctors will gladly join us in this quest.

The Family Physician Register is but the beginning of our efforts to reshape primary care. I urge all of you to consider the proposal for the register and suggest where it may be improved.

In closing, I would like to extend my warmest congratulations to the 5 doctors who are conferred fellowships of the College of Family Physicians and the 42 GDFM recipients. The future of family medicine is as much in your hands as it is in mine and the College's. We are proud to have you with us on this journey.

Thank you