The Future Built on Primary Care

Last night we arrived home from Nairobi after attending the 2016 Primafamed meeting on Family Medicine’s contribution to Sustainable Development Goal 3, also known as the main health goal (one of 17 SDGs). This brought together Family Medicine leaders and advocates from around the continent to share ideas on the current state of and future plans for the growth of Family Medicine throughout sub-Saharan Africa (SSA). Boaz, one of our residents, and I enjoyed meeting a lot of the academic “celebrities” of Family Medicine this weekend. When you are widely published in a field, your nametag will get frequent glances!

Reflective of the broader reach of the Sustainable Development Goals to include climate change, human rights, and equity, this weekend we discussed the importance of expanding primary health care (PHC) across SSA and improving its quality while honing the message of the function of Family Medicine as the “expert generalist.” The emergence of the SDGs from the Millennium Development Goals (MDGs) has required a maturation process or perhaps an improvement in the measurement of success, especially when it comes to healthcare delivery. The SDGs call for lofty goals such as ending the HIV/AIDS epidemic while imploring countries to achieve Universal Health Coverage. While many argue the merits and scope of the SDGs, along with the importance of other relevant factors necessary for success, SDG #3 will benefit greatly from this renewed focus on primary care.

Family physicians appear appropriately trained and positioned to lead the teams to deliver the first point of healthcare, especially in low-resource settings. We know from American research that sufficient access to primary care leads to improved health outcomes, reduced health disparities,and lower costs.

So, if we have this body of evidence formulating over the past two decades, why then were only 14.5% of the available residency (postgraduate) positions in the most recent match of US physicians in primary care, with just 11.7% of the total in Family Medicine? And why do many SSA countries have such difficulty finding interested applicants for postgraduate training in Family Medicine?

We discussed many factors this weekend that I tagged as “push” and “pull” factors, fashioned after the described influences on brain drain. The “push” or input factors occur during medical school. Is the curriculum in Family Medicine strong and longitudinal, are there preceptors to serve as strong role models and supportive Deans, and does the student get a good sense of what primary care truly looks like in the community? The “pull” factors occur after post-graduate training, which is largely dependent upon an encouraging Ministry of Health creating a favorable regulatory environment and tempting practice atmosphere. Is there a career path for that fully-trained Family physician and how attractive is that path?

Ultimately, recruitment depends on the appeal of the specialty.

The distinctive feature of primary care is the focus on the whole patient. This requires an understanding of their whole situation, including elements like their community, nutrition, access to weapons, and family dynamic. This appreciation comes from continuity, truly knowing a patient, and results in higher satisfaction for patients in addition to the prevention of disease. I have seen it in Austin in the diabetic truck driver who lost 40 pounds in six months, stopped smoking, and then no longer required medications to lower his blood sugar. And I have seen it in Chogoria where thorough education surrounding a new hypertension diagnosis and proper blood pressure management and monitoring will likely stave off a stroke, and resultant disability, for many years.

A society requires productive citizens to develop. To be productive, citizens must have health. To live in a state of health, people must have access to safe water, nutrition, and sanitation along with basic primary healthcare.

The individual and structural problems may differ throughout the world, but the solution, with many practical local adaptations, remains the same. A system built on a strong foundation of primary care reaches vulnerable populations, effectively manages the bulk of their disease burden, and has the potential to efficiently blaze the trail to success with all SDGs, not just #3, by 2030. While it is impossible to accurately quantify the societal return on investment, the time to redirect efforts to implement strong primary care systems is now.

Arguably my favorite part of conferences is the networking. But the aim is not merely social. Informal interactions amongst colleagues is important to build in supervisory support in the clinic, create networks for research, and to learn what others are doing to energize your current efforts at your home institution or to inspire improvement. Most importantly perhaps, in a young and growing field, it is nice to simply connect with others in the region just like you. Young professionals can hear from wiser ones through war stories shared over dinner and seasoned veterans can impart their knowledge on the next generation of leaders in their craft.

Before returning back to Chogoria, we stopped to get some food for take away on the road. The residents’ appreciation of their free lunch took me back to the many free dinners and lunches I have been thankful to share with mentors in Texas. “It’s just what your consultants are supposed to do for you. It’s part of it!” I explained. Teaching and mentoring is fun, but it’s the shared meals that solidify the special bonds among physicians at all stages.


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