Building family medicine postgraduate training in Jamaica ...

Education for Primary Care (2015) 26: 18–23

© 2015 Radcliffe Publishing Limited

Building family medicine postgraduate training in Jamaica: overcoming challenges in a resource-limited setting A Standard-Goldson DM (Family Medicine) MPH Family Medicine Programme Coordinator

P Williams-Green BSc DM (Family Medicine) Masters of Arts (Distance Education) Lecturer in Family Medicine

K Smith BSc (Hons) Postgrad Diploma (Family Medicine) Lecturer in Community Health

W Segree MBBS MPH Retired Lecturer in Family Medicine

K James MBBS MPH Lecturer in Public Health

D Eldemire-Shearer CD BA MBBS DPH PhD Professor of Public Health and Ageing Department of Community Health and Psychiatry, University of the West Indies, Jamaica

PRIMARY CARE EDUCATION: WHAT WORKS WELL IN JAMAICA ⦁⦁ Need for GP training has been recognised since 1970s. ⦁⦁ Strong hospital component of GP training. CHALLENGES WE HAVE FACED ⦁⦁ Short-term and philanthropic funding runs out. ⦁⦁ University funding for GP training sometimes precarious. WAYS IN WHICH WE HAVE ADDRESSED OUR CHALLENGES ⦁⦁ Attempting to learn from previous experience of programmes that have collapsed. ⦁⦁ Maintaining focus on the particular learning needs of GPs. ⦁⦁ Building an accreditable programme which meets the demonstrated learning needs. GENERALISABLE LEARNING FROM OUR EXPERIENCE ⦁⦁ Be clear about what it is that GPs need to learn. ⦁⦁ Conduct meaningful learning needs assessment in your own context. ⦁⦁ Capitalise on the enthusiasm and experience of a few champions. ⦁⦁ Work hard at establishing collaboration between academia and health service.

Keywords: distance education, family medicine training, Jamaica, resource-limited setting

SUMMARY This paper recounts the development of family medicine postgraduate training in Jamaica, the challenges faced and lessons learned. A self-

administered questionnaire was completed by past trainees exploring the perceived usefulness, strengths and weaknesses of the programme. The results of this study helped guide the strengthening of family medicine training in a resource-limited setting.

Building family medicine postgraduate training in Jamaica 19

INTRODUCTION The development of family medicine globally Historically physicians were generalists but over the centuries the concept of specialists dealing with defined conditions evolved. As early as 1923 Francis Peabody noted that specialisation had led to a fragmented healthcare delivery system.1 In 1966, in the USA, the Mills Commission Report and the Willard Committee Report both gave official recognition to the concept of a new specialty in primary care.1 Over the past four decades the specialty of family medicine has emerged worldwide. The World Organisation of National Colleges, Academies and Academic Associations of General Practitioners and Family Physicians (WONCA) was formed in 1972. There are now 126 member organisations in 102 countries.2 McGahn et al3 report that family physicians provide more than 90% of healthcare for patients throughout their lives. They further report that several decades of accumulated evidence shows that a healthcare system that focuses on primary care is more effective, more efficient and more equitable. There are more than 460 Family Medicine Residency Programmes in the USA. Hall et al noted that there is no national database that answers the question ‘where are our graduates and what exactly are they doing?’. Nor has there been any assessment of whether the programmes prepared them for the world at large.4 This paper examines the development of family medicine postgraduate training in Jamaica.

BACKGROUND The Jamaican perspective Jamaica is the largest English-speaking island in the Northern Caribbean with a population of 2.7 million and is in the middle of the demographic transition. There are over 300 government-funded primary care health centres across the island as well as private general practitioners. Government centres are classified from Types I to V. Types I and II offer basic maternal and child health (MCH) services under the direction of a public health nurse. The approximately 50 Type III and above centres have a resident doctor and offer both MCH and ‘curative’ services including chronic disease management for which there are national guidelines. The doctors in these health centres are often recent graduates with little experience and no postgraduate training who, especially in rural areas, may have little recourse to consultation with senior colleagues. Since the establishment of the University of the West Indies (UWI) in 1948 the majority of doctors gain undergraduate training from this institution.

Doctors are allowed to enter general practice following undergraduate training and a one-year internship. The need for training of general practitioners (GPs) was recognised in the 1970s and began as a series of postgraduate continuing medical education (CME) sessions in the then Department of Social and Preventive Medicine, UWI (Jamaica).4 Family medicine training with a three-year Masters and four-year Doctor of Medicine (DM) programme started with the aid of a Kellogg Foundation Grant in 1980. These programmes were offered as fulltime and part-time options with the full-time option functioning as a full residency programme. The curriculum was designed based on existing North American and United Kingdom models taking into account the needs of the Caribbean populations. This programme had a strong hospital-based clinical component with residents rotating through specialised disciplines at the University Hospital of the West Indies (UHWI), attending to both hospitalised and ambulatory patients. Areas relevant to family medicine were taught at regular lectures and seminars. The aim was to provide a programme that would enable the physician to practice beyond the boundaries of disease and regard the patients in the context of their life, environment and circumstances.5 Intended learning outcomes were that these family physicians would be able to plan, organise, implement and manage primary health care services, promote good health, prevent disease in the context of limited resources and a changing environment. They would also be able to conduct research and contribute to the storehouse of knowledge and experience.6 The programme suspended intake of students in 1991 when the Kellogg Grant ended as there were no established posts for either lecturers or residents. General practitioners, although still very interested in postgraduate training, could not afford to leave their practices for 3 to 4 years and pay to pursue the course. Doctors entering primary care practice continued to gain experience, knowledge and skills in an ad hoc manner. Graduates and former family medicine faculty established both the Association of General Practitioners of Jamaica and the Caribbean College of Family Physicians (CCFP), which offer regular CME conferences. These family physicians lobbied assiduously to introduce legislature for relicensure based on compulsory CME. At a workshop in 1997 stakeholders from the University of the West Indies, the Pan American Health Organisation, several Ministries of Health in the Caribbean, the CCFP and other general practitioner organisations and the Caribbean Public Health Organisation met to discuss the redevelopment of postgraduate training in family medicine. Distance education was proposed as an approach to deliver training.6 The theoretical part of the Family Medicine Programme was to be delivered by this medium thus allowing residents to continue to earn while studying. Hospital rotations as the

20 A Standard-Goldson, P Williams-Green, K Smith et al

main means of gaining clinical proficiency were to be deemphasised, with greater emphasis being placed on ambulatory care, self-directed learning using modular assignments, problem-based learning and clinical audit.7 The UWI has the responsibility for medical undergraduate and postgraduate training but does this in close collaboration with the Ministry of Health who continue to employ persons during postgraduate training. The three-year Masters of Family Medicine was restarted in 2001 after four years of preparatory work including the development of distance education modules, a collaboration between family medicine faculty and distance education specialists. Module manuals were designed so that postgraduate students would work through them independently with email/telephone access to a course tutor for guidance. Clinical sessions were arranged with private GPs and specialists. The relatively high cost of the programme compared to other post-graduate training programmes, the loss of income or time lost to employers when students took time from their work, inadequate learner support because of lack of adequate feedback between tutors and students and concerns about the level of clinical exposure all resulted in the suspension of the programme in 2006. The restart of the programme in 2010 sought to draw on the strengths of the previous programmes and avoid pitfalls that prevented sustainability. This will be explored in the discussion section. The aim of the study was to examine the perception that past trainees had of the UWI (Jamaica) Family Medicine Programme. These perceptions would help to identify strengths and weaknesses of past programmes thus providing guidance going forward.

MATERIALS AND METHODS Family medicine faculty members undertook a cross-sectional survey to examine the previous programmes. The study population consisted of graduate students of the MSc and DM Programmes of the UWI (Jamaica) during the years 1980–1995 and 2001–2006. From the records of the Department of Community Health and Psychiatry, UWI, Jamaica, a list of past trainees was obtained. Persons with current contact information were contacted by email and asked to complete a 14-item self-administered questionnaire containing both open- and closedended items. The questionnaire captured background socio-demographic information, opinions and perceptions regarding strengths, weaknesses and utility of the programme. The answers to openended questions were grouped according to themes and several direct quotes were also utilised. It was also possible to hold in-depth interviews with respondents where they elaborated on the strengths and weaknesses of past programmes. The experiences of the authors were also explored.

FINDINGS A review of departmental records showed 43 candidates in the past programmes (Table 1). Table 1 Candidates pursuing the Family Medicine Postgraduate Programme at University of the West Indies, Jamaica Years

Total number MSc of candidates graduates

DM graduates

1980–1995

16

16

11

2001–2006

27

19

1

43*

35

12

Total *Two deceased

From 41 eligible persons for this study, contact information was obtained for 22. In spite of two emails and in some cases phone calls, only eight persons responded to the questionnaire. Notwithstanding this low response rate some useful information was gleaned from the open-ended questions and augmented by in-depth interviews. This information is captured in Table 2.

DISCUSSION All past trainees reported that the programme led to an upgrade of their knowledge and skills. Recent trainees spoke to an increased awareness of patientcentred care and evidence-based medicine as well as life-long learning. Evidence-based medicine has been defined as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research’. 7 These skills have been shown to be important in family medicine training and practice. Respondents expressed concern about the level of training of primary care doctors in the Caribbean. International literature speaks to the importance of family medicine training. Margaret Chan, DirectorGeneral of the World Health Organisation (WHO) speaking at the opening ceremony of the 20th WONCA world conference in Prague stated that A health system where primary care is the backbone and family doctors are the bedrock delivers the best health outcomes, at the lowest cost, and with the greatest user satisfaction.8 At a WHO workshop convened in Jakarta, Indonesia in 2011 the topic ‘Strengthening the Role of Family/ Community Physicians in Primary Health Care’ was examined. In the Executive Summary of the WHO report (2011) it was stated that:


Table 2 Perceptions of past trainees of the Family Medicine Postgraduate Programme at University of the West Indies, Jamaica Area of interest

Group 1: 1980–1995 n=4

Group 2: 2001–2006 n=4

Personal usefulness of programme

⦁⦁ Upgrade of knowledge and skills ⦁⦁ Opportunity to teach undergraduate students ⦁⦁ Interaction with postgraduate residents in other specialities

⦁⦁ Increased awareness of patient-centred care and evidencebased medicine ⦁⦁ Introduced to practice-based research ⦁⦁ Promoted life-long learning

Relevance of programme to healthcare in the Caribbean

⦁⦁ ‘Lot of primary care around the Caribbean is poor, unsupervised; programme offers opportunity to improve family medicine/primary care in the Caribbean’ ⦁⦁ Can help to decrease government health costs ⦁⦁ Can help provide high-quality primary health care services to the people of the Caribbean

⦁⦁ Patients looked at more holistically ⦁⦁ Programme broadened competencies in areas not well covered in undergraduate training ⦁⦁ ‘A healthy Caribbean population is dependent on effective and efficient primary health care services’

Strengths of the programme

⦁⦁ Small groups with individual attention ⦁⦁ Good support by faculty ⦁⦁ Good library facilities

⦁⦁ ⦁⦁ ⦁⦁ ⦁⦁ ⦁⦁ ⦁⦁

Weaknesses of programme

⦁⦁ No previous graduates around to offer assistance ⦁⦁ Lack of communication with programmes on other campuses ⦁⦁ Difficulty in getting sponsorship ⦁⦁ Lack of recognition of importance of family medicine ⦁⦁ Lack of appropriate jobs for graduates from the programme

⦁⦁ Delivery of modules did not enhance regular and meaningful exchange between tutors and students ⦁⦁ Treated like undergraduates during clinical rotations at University Hospital ⦁⦁ Teaching in hospital not targeted for family medicine resident ⦁⦁ Need for more primary care-based rotations ⦁⦁ Not enough practice in techniques – need for procedural workshops ⦁⦁ Not enough exposure to alternative medicine ⦁⦁ Not enough exposure to treatment of HIV/AIDS ⦁⦁ Laboratory disciplines not covered ⦁⦁ Lack of a career path for graduates

The epidemiologic and demographic transition, as well as the consequences of globalization, urbanization and climate change on health, require an effective health system based on primary care. This system should focus more on health promotion, disease prevention, and continuity of care, to which family physicians/general practitioners can significantly contribute. As ‘gatekeepers’ at primary care facilities, they can improve the cost-effectiveness of health-care delivery and appropriate triaging for referral care.9 There are continuing efforts by the Ministry of Health to strengthen primary care in Jamaica making the training of family physicians relevant. The strengths of both programmes were assessed in the formulation of the renewed programme. In the absence of funded residency posts it remained necessary to offer a programme where the trainee could continue to work and earn while

In-depth and extensive academic material ‘Able to call on tutors anytime’ Distance component allowed flexibility of working at own pace Involvement with family medicine preceptor Portfolio development skills Clinical audit skills

acquiring postgraduate training. Residents are required to be employed in either a government health centre or private primary care centre for the duration of the programme. It is important to have dialogue with their supervisors from the outset to get support that will allow day-releases for programme commitments. Based on the expressed weakness of the previous ‘distance-based’ programme there was a conscious effort to increase the interaction between faculty members and trainees as well as among trainees and to strengthen clinical aspects. In the previous ‘distance-based’ programme, module manuals were provided to the trainees which they were required to work through at their own pace over a specified timeframe. There was an assigned course tutor with whom the trainee could communicate for guidance. The comment was made that ‘delivery of the modules did not enhance regular and meaningful exchange between tutors and students’. In addressing this, use is now

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made of web-conferencing technology so that each module is delivered over a six- or ten-week period with once-weekly web-conferences where the course tutor presents material and involves the trainees in discussions. This modality allows for building of relationships not only between faculty and trainees but among trainees who are geographically separated. Evaluations done by residents since the restart in 2010 indicate that the web-conference lectures and discussion time add depth to the knowledge gleaned from reading the module manuals. Also, because the web-conferencing platform allows for recording of sessions they find this useful for revision. Note was taken of the comments that during hospital exposures family medicine trainees were ‘treated like undergraduates’ and teaching was not ‘targeted for Family Medicine Residents’. Prior to the restart of the programme, members of the family medicine faculty met with the hospital consultants to sensitise them to the purpose of the programme and the role of the specialist rotations. Their input was sought in developing appropriate objectives for each rotation. Over the past four years residents have increasingly reported being recognised on ward rounds and in specialist clinics as family medicine residents and having questions and discussions particularly relevant to family medicine directed at them by the specialist consultants. This early involvement of the hospital specialists has improved the interaction not only with residents but also with family medicine faculty where there is now a greater sense of parity. The family medicine preceptorship which existed in the ‘distance-based’ programme was retained and strengthened. Each family medicine trainee is assigned a family medicine preceptor/clinical facilitator who is responsible for guiding the trainee in acquisition and honing of knowledge and skills relevant to family medicine. These facilitators include GPs in private practice and they attend training workshops at least once a year. Clinical facilitators meet with their assigned resident twice a month in a clinical setting where clinical acumen can be assessed, cases discussed and guidance given. The family medicine clinical component was also strengthened with on-line clinical presentations looking at the management of patients in the family medicine setting. These presentations are prepared by a resident, family medicine or specialist consultant. Also there are three one-week face-toface block sessions each year. This speaks to the expressed need for procedural workshops. These workshops utilise the skills of family medicine and specialist colleagues. Topics such as minor surgical procedures and family medicine case discussions are done at these workshops. The schedule for these workshops has to be fixed from the start of the year so that the residents who are employed at different centres across the island can arrange for the time off and travel to the family medicine centre. The programme is based at the Department of Community Health and Psychiatry (formerly Social

and Preventive Medicine) of the UWI (Jamaica Campus) and therefore the programme coordinator and course tutors are university lecturers. The specialist rotations are done at the University Hospital of the West Indies and other hospitals accredited by UWI for postgraduate medical training so consultant specialists oversee this training. Family medicine preceptors are postgraduate trained family physicians or senior general practitioners who maintain CME accreditation with the CCFP. The lack of a clear career path for graduates expressed by both previous groups of graduates remains an area of concern. However, there is evidence of increased recognition of the importance of family medicine training for strengthening the primary healthcare system. In the Bahamas, the Government supports 15 residency posts in family medicine. The stated seven-year strategic plan’s objective, as enunciated by the Director of the UWI Clinical School in the Bahamas, is that a fully qualified and certified family medicine specialist will be posted in every government clinical service, in every community clinic throughout the archipelago.10 Within Jamaica, career path dialogue continues with the Ministry of Health. There is also discussion about the establishment of full-time residency posts because whereas the present format is ideal for persons who already work in primary healthcare (public or private) it is not suited to young graduates who do not have an established practice. The vision would be to have both full-time residents and residents in outside posts concurrently as each format fulfils a need. An obvious limitation of this study was the very low response rate. This may have been due to a number of factors, namely: lack of current contact information; practitioners being too busy to respond; lack of interest. Although we were not able to get the level of response which we had hoped for, those who responded gave in-depth analysis. With the restart of the programme evaluation tools have been developed to allow on-going analysis.

CONCLUSION This examination of the past programmes has informed the restart of the Family Medicine Programme at the University of the West Indies Jamaica Campus. We have built on the strengths of both previous models and sought to mitigate the weaknesses in developing a programme that meets the needs for training given resource limitations. This experience may be useful to those working in other jurisdictions with similar resource challenges.

Ethical approval Ethical approval for this study was granted by the University Hospital of the West Indies/University of


the West Indies Faculty of Medical Sciences (UHWI/ UWI/FMS) Ethics Committee.

Conflicts of interest The authors have no conflict of interest and have received no financial remuneration for carrying out this study.

References 1 Rakel R (2007) The family physician. In: Rakel R (ed) Textbook of Family Medicine (7e). Saunders Elsevier Publishing: Philadelphia, pp. 3–14. 2 World Organization of Family Doctors [internet]. Thailand: World Organization of Family Doctors; 2014. Available from: www.globalfamilydoctor.com/aboutWonca (accessed 23 August 2014). 3 McGahn A, Garrett E, Jobe A et al (2007) Responses to medical students’ frequently asked questions about family medicine. American Family Physician 76: 99–106. 4 University of the West Indies Department of Social and Preventive Medicine (1974) Growth and Development of Social and Preventive Medicine. UWI: Mona. 5 Segree W (2009) Family Medicine at Mona: Yesterday, Today and Tomorrow. Unpublished paper, 2009.

6 Williams-Green P, McCaw-Binns A and Paul T (2009) Distance learning – challenges and opportunities for postgraduate medical education. In: S Marshall, W Kinuthia, W Taylor (eds) Bridging the Knowledge Divide: educational technology for development. Information Age Publishing, pp. 321–35. Charlotte, NC. 7 Sackett D, Rosenberg W, Muir Gray J, Haynes B and Richardson W (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312: 71. 8 Chan M (2013) The Rising Importance of Family Medicine. Keynote address at the 2013 World Congress of the World Organization of Family Doctors Prague, Czech Republic 26 June 2013. Available from www.who.int/dg/ speeches/2013/family_medicine_20130626/en/ (accessed June 6 2014). 9 World Health Organization. Regional Consultation on Strengthening the Role of Family/ Community Physicians in Primary Health Care. 2011 October 19–21 Available from: www.searo.who.int (accessed June 6 2014). 10 Roberts R. Director’s Message. University of the West Indies, Nassau Bahamas. Available from: www. uwibahamas.com/roberts.php (accessed June 6 2014).

Correspondence to: Dr Aileen J Standard-Goldson, Department of Community Health and Psychiatry, University of the West Indies Mona Campus, Kingston, Jamaica. Email: aileen.standardgoldson@ uwimona.edu.jm Accepted September 2014