3. Content
What you have to know to be a family
physician
Primary Health Care
COPC
Something else...
I want to share with all of you
4. Primary Health care
(
Declaration of Alma-Alta
Sept 12, 1978
Essential health care
Appropriate technology
Affordable and sustainable
Community based
Water, housing, sanitation, nutrition,
traditional medicine
5. Primary Health Care
2A3C
(Accessibility)
(Accountability)
(Continuity)
(Comprehensiveness)
(Coordination)
6. Primary Health Care
First contact care
2A3C
(Accessibility)
(Accountability)
(Continuity)
(Comprehensiveness)
(Coordination)
7. Primary Health Care regardless of the presence or
First contact care absence of disease
2A3C
(Accessibility)
(Accountability)
(Continuity)
(Comprehensiveness)
(Coordination)
8. Primary Health Care regardless of the presence or
First contact care absence of disease
2A3C Integrationist
(coordinating role)
(Accessibility)
(Accountability)
(Continuity)
(Comprehensiveness)
(Coordination)
9. COPC is.....
A systemic approach to the practice of
medicine in the community built on
principles of epidermiology and
community organizing
11. COPC blends..
Public health vs. Personal health Care
Epidermiology and Primary care
Community empowerment
Medical services, housing, water
supplies,sanitation...
Preventive medicine
Health promotion
12. COPC Process
COPC: Health Care for the 21st Century, Rhyne et al, 1998
13. COPC Process
Geographic
Special population
Health care coverage
“community”
COPC: Health Care for the 21st Century, Rhyne et al, 1998
14. COPC Process
Quantitative
Geographic Qualitative
Special population
Health care coverage
“community”
COPC: Health Care for the 21st Century, Rhyne et al, 1998
15. COPC Process
Quantitative
Geographic Qualitative
Special population
Health care coverage
“community”
COPC: Health Care for the 21st Century, Rhyne et al, 1998
16. COPC Process
Quantitative
Geographic Qualitative
Special population
Health care coverage
“community”
COPC: Health Care for the 21st Century, Rhyne et al, 1998
17. Challenges to COPC
The cost of doing business
Reimbursement favors clinical services and
technologic procedures
Precise definition of COPC
Chasm between clinical practice and
public health
Fragmented health care system
Medical education
18. Future Roles
Eliminate
inequity
Consumer
empowerment
Family physician
19. Medicine is a social science and politics is a
medicine on a grand scale Dr. Rudolf Virchow 1821~1902
20. Context of Primary Care
USA late 1960s ~early 1970s
Vertical health approach in Malaria eradication
Technology + doctors ≠ health
Medical missionary: basic health service
Christian Medical Commission
1970, it created this term “primary health care”
Communist China
21. Context of Primary Care
USA late 1960s ~early 1970s
Vertical health approach in Malaria eradication
Technology + doctors ≠ health
Medical missionary: basic health service
Christian Medical Commission
1970, it created this term “primary health care”
Communist China Rural, not urban
preventive not curative
combined Western and traditional
medicines
22. Alma-Ata
China vs. Soviet Union
Soviet Union will offer $US 2 million
Cold war
Western technology decline
Grossroots, and socio-political alternatives
Approved by acclamation
A victim of the ideological clash
between communism and capitalism
23. Root of COPC
Sidney and Emily Kark, South Africa
Society for the Study of Medical Conditions
Among the Bantu
Pholea, Kwazulu-Natal, 1940
Institute of Family and Community Health,
University of Natal at Durban
1948, apartheid restriction
25. COPC: A Path to Community
Development
H. Jack Geiger
Late 1960s~early 1970s
Northern Bolivar County in
the Mississippi Deltas
Medical services, housing,
water supplies, sanitation
Community empowerment
program
Self-perpetuating
26. Primary care in the driver’s
seat?
Rising health expenditure
Multiple disease and different disciplines
Better health outcome
Lower costs
Greater equity in health
27. Better Health outcome
Policy relevant determinants of health- an international
perspective. Health Policy 2002; 60(3):201-218.
28. Better Health outcome
Policy relevant determinants of health- an international
perspective. Health Policy 2002; 60(3):201-218.
29. Lower cost
Poorer primary
care, spend more
Stronger the
primary care, the
lower the total
health care
expenditures
Policy relevant determinants of health- an international
perspective. Health Policy 2002; 60(3):201-218.
32. Consultorio: 600 pts or 150
families
Consultori--> Poclinico
Each poclinico ser ves 30-40
consultorio
How Cuba Achieve?
GPs spend spend half-day per week
joining their patients for specialist
visits in policlinico
2001, 35% residency
graduates specialized further
Consultorio➙Policlinico
33. Consultorio: 600 pts or 150
families
Consultori--> Poclinico
Each poclinico ser ves 30-40
consultorio
How Cuba Achieve?
GPs spend spend half-day per week
joining their patients for specialist
visits in policlinico
Complementary and
Alternative medicine
2001, 35% residency Herbal medicine, acupuncture,
graduates specialized further homeotherapy, floral/essence therapy...
Green Medicine
Consultorio➙Policlinico
Natural Medicine Clinics
34. Major effecting factor
Policy relevant determinants of health- an international
perspective. Health Policy 2002; 60(3):201-218.
37. First contact
Acute problem: burnt
hand, first symptoms of
convulsion, sprained ankle,
paralysis
Children
Woman: OCP, irregular
menstruation, lump in breast
Psycho-social problems:
relationship problems, suicidal
ideation, work-related stress
38. Comprehensiveness
Tx and F/U:
hyperthyroidism, acute CVA, UC,
MI
Technique procedure: removal
of warts, IUD, removal of rusty
spots on cornea, joint injection
Cervical screen
Health education: smoking,
diet or alcohol intake
Family planning
42. 2004: Primary care
The Future of Primary Medicine NEJM (2004) 351;7, 710~712
43. 2006: Will it Survive?
Primary Care-Will It Survive? NEJM 355;9, 861-864, 2006
44. 2006: Will it Survive?
Primary Care-Will It Survive? NEJM 355;9, 861-864, 2006
45. 2007: Saving Primary Care
Graduating Family physician decreased
by 12% since 1998
35% of physicians are aged >55y/o
March 2007
FM programs: 100 fewer positions (500 fewer
than 2000)
88% of those were filled; only 42% from US
AM J Med 2007;120:99-102
46. Exodus
Money
Pay subspecialist 5-40 times more to perform a
procedure than pays a primary care physician
to discuss whether the precedure is consistent
with the patient’s goal
Payment system do not recognize the value of
avoiding more expensive care
Telephone, e-mail, coordinate
Lifestyle: controllable life
47. Exodus
Hamster Health Care
“Across the globe doctors are miserable because they
feel like hamsters on a treadmill. They must run faster
just to stay still.” Morrison and Smith, BMJ, 2000; 321;1541-1542
Substantial work outside the office
Administrative paperwork
48. Running Hamster
Time require to deliver all highly
recommended chronic care services:
10.6 hours/day Is there time for management of patients with chronic
diseases in primary care? Ann Fam Med 3:209-214 (2005)
Time require to deliver all highly
recommended preventive services: 7.4
hours/working day Primary Care: Is There2003 Time for Prevention??
AJPH 93(4): 635-641
Enough
Raised expectation
49. Time is enough?
Duration of visit
US: 16.5 min
Australia: 15 min
New Zealand: 14.9 min
Mean time spent
per year
US: 29.7 min
Australia: 83.4 min
New Zealand: 55.5 min
Diagnostic scope of and exposure to primary care physicians
in Australia, New Zealand, and the United States: cross
sectional analysis of results from three national surveys
BMJ 2007;334;1261-1267
50. Saving Primary Care
Discarding the Artisan model
Promoting a New Vision
As quarterback,rather than decathlete
Changing Medical Groups
information system
Training Programs
Schedule patients examination
AM J Med 2007;120:99-102
51. Saving Primary Care
Improving professional lifestyles
Predictable work hours, less call, more
flexibility
Financial incentives
Reimbursement system
too heavily weighted procedure
Zero-sum game
AM J Med 2007;120:99-102