Health clinics in Malaysia provide both curative and preventive roles to patient and surrounding community. Being a specialist posted in health clinic, FMS must equip themselves with various skill and knowledge in order
i. To function as clinical leader,
ii. To provide specialize care that is accessible to patient and community,
iii. To act as effective gatekeeper,
iv. To function as the resource specialist in coverage area,
v. To provide holistic care,
vi. To develop good liaison with specialist in secondary care,
vii. To improvise health care in the community,
viii. To act as patient’s advocate,
ix. To guide Medical Officer and supporting staffs on clinical areas
x. To conduct research in order to improve patient care
1. Function as a clinical leader
A clinical leader is a person who leads the clinical decision and clinical works in his/her coverage area. In order to carry this role, a FMS must:
· Be knowledgeable in all aspect of clinical conditions that commonly encountered at primary care level. This role can be achieved by self-audit, getting updates, attending Continuous Medical Education (CME) sessions including via on line, adopting lifelong learning concept and discussion with other specialist counterparts.
· Be skilful in clinical areas. This role can be achieved by upgrading knowledge and conducting clinical procedures that can be carried out in primary care level. In order to do this, FMSs may need to refresh /sharpen clinical skill by attending refresher courses, doing attachments and the most important thing is keep on conducting the procedures to avoid losing their clinical skills. Keep on learning and invent on new thing in order to enrich your clinical capability.
· Be a clinical champion in your coverage area. In order to acquire this, an FMS, apart from being knowledgeable and skilful, he/she must function and appear as a respected clinician who can treat various conditions that can be managed as outpatient by specialist in secondary care (unless certain procedures that are not feasible at primary care level). This standard must be set by every FMS in order to appear at par with specialist in secondary care and to differentiate them from medical officers working in primary care. FMS must be able to make decision on critical clinical matters. By portraying this important role, other primary care providers may feel handicap to function without existence of FMS guidance.
2. Capability to provide specialize care that is accessible to patient and community.
One of the reasons for putting a specialist in health clinic is to ensure that specialised care is accessible to patient and community. This is in conjunction with the aim of providing care near to home. In order to do this, a FMS must be able to ensure specialize care can be received by as many as possible in the community. This role can be conducted by managing patients that are referred to them and conducting clinical round to guide medical officers on proper patient care. Apart from taking care of patients in the clinic, it is also important to ensure similar patient care can be provided to other nearby clinics without FMS by consultation visit and phone consultation.
3. Function as effective gatekeeper
Traditionally the primary care doctor serves as a gatekeeper, regulating whether or when specialty consultation and treatment are needed. If a referral is made, it is to specialist who has a contract with, or is a member of that particular organization. Pre negotiated discounts and fewer overall referrals lead to savings. After the treatments are finished, there is continuity of care as the patient continues to be followed by his or her primary care doctor (Lloyd M, Managed Care Magazine April 1996).
However, the problem with the gatekeeper model is that it is designed to limit, rather than to truly integrate, patient care. The lack of integration results in delayed or inappropriate referrals. It causes inappropriate tests or procedures to be done prior to, or instead of, referrals. This in turn, leads to progression of disease, and worse and more expansive outcomes.
In Malaysia, the gatekeeper role is not the same as practised in other countries. FMS is expected to provide integrated patient care and only refer when there is a clear indication. Patients are expected to be managed at primary care level unless it is beyond the FMS’s capability. It is crucial for FMS to ensure medical officers refer patient to secondary care appropriately by providing consultation between FMS and medical officers and clear referral guidelines, continuous guidance and clinical audit. Effective gatekeeper role and co-ordinator of care will ensure that patients get better care. The provider morale will also improve and in the long run there will be cost savings.
4. Function as the resource specialist in coverage area
FMS is expected to be contactable for clinical consultation either via direct consultation, telephone, SMS or email. FMS must acquire the skill of giving relevant advice and education using different strategies including safe practice approach and. identifying danger signs
FMS is also expected to conduct or organize regular CME sessions especially with medical officers not just in a particular clinic but also in a wider coverage area within the district. FMS must be able to identify current clinical problem in his/her particular coverage area and this include handling a disease outbreak where the Public Health Physician may be taking charge of preventive / control measures for community in general and FMS need to identify disease, give proper treatment and provide safe and preventive advice. So, FMS must place himself/herself in the frontline in terms of clinical care as well as to be the resource in preparing documents such as guidelines and standard operating procedures. By heading the clinical session with other medical officers through CME sessions, FMS will be the key clinical person in certain coverage area. It is important that an FMS must be clinically competent and knowledgeable in all clinical areas at the primary care level.
5. To provide holistic care
A FMS is expected to provide care “from womb to tomb” and should be able to provide at least initial management for complaints related to various systems. Many clinical problems should be able to be settled at the primary care level. The care is not just directly to the patient but also indirectly to his or her family members, relatives and community who may have influence on patient’s illness. These tasks if conducted well will portray the beauty and uniqueness of Family Medicine Specialty and clearly reflect the capability and complexity of tasks conducted by FMSs.
In order to be able to carry these challenging tasks, a FMS must be brave to manage certain conditions at the primary care level and explore new things within the scope of patient care. Seeking updates, going for attachments and liaising with specialists in secondary care are among the strategies that can be taken. Apart from giving benefit to patients, it will uplift the values of primary care services in this country. FMSs must not be rigid in their scope of work. Enriching the primary care services that is needed by surrounding community must always be looked positively and regarded as an honour rather than regarded as unnecessarily increasing the existing workload. Willingness of FMS to function according to patients’ and communities’ needs will reflect being responsible and sensitive to existing needs.
In view of the wide scope of work, one strategy that a FMS can adopt is by delegating and empowering medical officers to carry out certain tasks. Medical officers should be regarded as valuable partners in patient care. FMS can identify potential medical officers especially the senior ones and train them to carry out certain specific tasks. For instance, appoint one medical officer each to be responsible for Non Communicable Diseases, Communicable Diseases, Mental Health, Maternal & Child Health, School Health, Adolescent Health, Elderly Services, Children with Special Needs and Home Care Nursing. In a bigger clinic setting with many medical officers, more than one medical officer can be appointed to take care of certain programs. For instance, under Non Communicable Diseases, one medical officer can be appointed for diabetes, hypertension & cardiovascular activities and another medical officer to take care of Quit Smoking Services. For Communicable Diseases, one medical officer can be appointed to be responsible for Tuberculosis, HIV/STI & harm reduction against HIV/AIDS and emerging diseases. However in a smaller clinic setting, the task can also be shared with assistant medical officers and staff nurses. Usually the Medical Officer in-charged (MOIC) will run all administrative activities such as general administrative measures of the clinic, MS ISO and Panel Penasihat Kesihatan etc.
Empowering, delegating and giving some freedom to make decisions will make the medical officers feel trusted, important and shared authority in patient care. Making the medical officers feel responsible and to be answerable to certain condition also can improve their self-esteem and attract more medical officers to stay longer and be productive at primary care setting. Hopefully, in the long run, they will be interested to take up Family Medicine programme. FMS must not be irresponsible and let things to be fully taken care by medical officers! FMS still holds the responsibility of clinical care and should be answerable to any problems or shortfalls in his/her coverage areas.
6. To develop good liaison with specialists in secondary care
Good liaison with specialists in secondary care is very important. Apart from getting clinical updates, good liaison will give better perception towards FMS’s credibility. Liaison could be in the form of seeking opinion regarding patient care, conducting shared care and following up patient’s progress after referral to secondary care. Communicating with specialists in secondary care will not just give one way benefit but should be regarded as an opportunity for specialist in secondary care to be updated on the various progress and new things in patient care that occur in health clinics and primary care services. It will give a clear picture of various tasks and roles conducted by FMS.
FMSs need to develop rapport with specialists in secondary care by introducing themselves at any opportunity such as while attending CME sessions conducted in hospitals or by Malaysian Medical Association, attending meetings for specialists organized by the state health departments and during telephone consultations.
In order to obtain good perception from other specialists or working colleagues, FMS may need to develop certain soft skills. Actions that can be taken include:
· Speaking confidently and fluently
· When giving an opinion, always consider the two parties’ interests and phrase your sentence so that you can speak concisely, appear experienced and matured in giving opinion
· Always try to speak up when you are in a meeting (officially or unofficially) with other specialists so that your presence is felt and appreciated.
· Always feel and act as a clinical representative from primary care who can rationalize the services, defend or rectify any shortfalls and weaknesses with an open mind without appearing too defensive.
· Polish your English so that you are able to talk fluently.
7. To improvise health care in the community
The scope of work for FMS is not just limited to clinic setting but also to the wellness of community under health clinic’s coverage area. It is essential for FMS to understand the health status of his/her surrounding community, disease burden and potential disease threats. Among examples: to know the number of people living with diabetes, hypertension, asthma, mental illness, HIV, tuberculosis etc in the community. FMS can also contribute to plan community interventions such as cardiovascular screening, diabetes intervention, early identification of danger signs among sick children and antenatal mother, mental wellbeing and harm reduction measures against HIV/AIDS etc.
FMS can collaborate with local Public Health Specialists or medical officers. There might be some overlapping task between FMS and Public Health Specialists. It should be perceived as shared responsibility to the community and both parties could work together to achieve one common goal. FMS must be sensitive with disease trend in the community by looking at the notification on disease surveillance. The paramedical staffs usually plot the trend while FMS is responsible to monitor.
8. To act as patient’s advocate
FMS is expected to be an advocator for their patients’ health and wellbeing. This will strengthen FMSs’ credibility through patients’ perspective. It gives authority in terms of clinical aspect and a clear reflection of a clinician role in the community. FMS can create linkages between various patients’ need and local existing resources that can provide help especially in psychosocial aspects. In term of improving clinical aspects, FMS may justify for new drugs, clinical instrument or better clinic infrastructure in order to improve care to patients; through certain platforms such as attending meetings within department / state level or through related local Non-Government Organization. Some examples are Breast Feeding Support Group, National Association of Diabetes (NADI), harm reduction/ HIV related support group, support group for patients with mental illness and support group for children with special needs etc.
To guide medical officers and supporting staffs on clinical areas
FMS is responsible to make sure that medical officers and other supporting staffs see and treat patients properly. FMS must not just sit in their own consultation room and only limit patients seen by them. It is the responsibility for FMS to develop rapport with medical officers and other supporting staffs so that good clinical networking can be established.
A new medical officer who is posted to health clinic under FMS coverage should do clinical attachment with FMS and other senior medical officers for at least two weeks in order to understand their functions at primary care setting and services that are provided. Medical officers should take turns to do the clinical presentation during CME session while FMS supervise and provide clinical input. This will make medical officers update their clinical knowledge. The CME can be in the form of discussing about clinical matters, clinical practice guidelines or even journal clubs. FMS can create an email mailing list with the medical officers and supporting staffs in order to improve communication and distribute information. When conducting clinical audit, it should be to guide them rather than to find faults. FMS must portray good leadership and example. Through this strategy, FMS can be seen as a mentor / clinical sifu and working environment can be more pleasant.
9. To conduct research in order to improve patient care
Doing research is an evidence-based practice to explore or find answers for certain clinical doubt. It also shows FMS is concerned about the clinical outcomes of patients under their care. This reflects high standard and quality patient care. Involvement in research also makes work life more interesting as one explores new processes, interventions and outcomes.
Even though research can be an important element, as clinician, the time allocated for this function should be around 5-10% of FMS main duties. It will be good if FMS can allocate 1 to 2 afternoon sessions in a month for research in related activities. Doing research in a team is a smart way of doing many things with time and human resource constraints. The information obtained via research must be shared with others by making presentation in conferences or publishing in medical journal. This will also give good image to FMS and its fraternity.
In conclusion, FMSs play very important curative and preventive role in the Malaysian primary care setting. It is the responsibility of FMSs to carry themselves well, to portray excellent image and function to ensure good reflection to the fraternity. Good emotional quotients, soft skill, responsible, responsive and clinically competent are among important values that FMS must have.