Consultant Family Physicians (CFPs) are up in arms against the Health Ministry’s deliberate failure to place them in charge of primary care units in main hospitals in the country, but confining them to rural hospitals. In the event their services are undermined and if they are not allowed to discharge their duties in main hospitals, there is a looming danger of their being a brain drain of professional in primary care.
For these CFPs, serving a few patients who visit rural hospitals is a waste of their expertise. When considering the knowledge they’ve acquired after going through six years of rigorous training to become consultants, these professionals would wish to serve patients who throng primary care units, better known as Out Patients Department (OPD), at main hospitals. Patients visit these hospitals, which function in an organised manner, seeking quality treatment.
According to them the autocratic attitude of some administrators at the Ministry of Health has deprived patients the opportunity to receive quality treatment at an organised institute. This situation exists at these institutes because these specialists have not been appointed as Heads of Primary Care Units in specialist hospitals (base hospitals and above).
According to these sources, this issue had been brought to the notice of Health Minister Dr. Rajitha Senaratne who had patiently listened to their woes given instructions to place the CFPs in their due positions. But the minister’s instructions have been to no avail
Sri Lanka Association of Specialist Family Physicians (SLASFP) raised concern as to how a few Consultant Community Physicians, who hold senior administrative positions at the Ministry of Health, have taken a firm decision not to instate CFPs at main hospitals in the country. These CFPs are confined to peripheral and rural hospitals. For them, working in a rural hospital is a mere waste of knowledge when considering the training they’ve received abroad. These CFPs are not seeking facility or perks, but are making a plea to allow them serve the sick that come in numbers to OPDs in main hospitals.
A patient receives treatment
“All CFPs have been posted to rural and peripheral hospitals while Secondary Care Internal Medicine Physicians, widely known as Visiting Physicians (VP), have been assigned to oversee all OPDs in main hospitals. When these VPs have to manage the medical wards in these hospitals they have been assigned with an extra duty to work as VP-OPD,” a member of the SLASEF told the Daily Mirror on conditions of anonymity.
According to sources, when a VP is entrusted with the task to manage the OPD in addition to his medical wards, the quality of treatment cannot be guaranteed. “Unlike in other disciplines, to become a CFP we have to obtain a five-year post intern experience to qualify and sit for the selection exam for the Diploma in Family Medicine. Those who qualify through this exam have to undergo a year’s training where there are sessions seven days a week. Those who qualify are trained during the Diploma in Family Medicine as trainees. After the completion of one year, they are eligible to sit for the Post Graduate Diploma exam in Family Medicine. Those who pass this exam are eligible to sit for the selection exam for MD in Family Medicine. Those who qualify will become ‘Registrar in Family Medicine’. After this stage they have to undergo a three-year training period.
Those who complete this three-year training period successfully can sit for the MD in Family Medicine exam. Successful candidates will become Senior Registrars. The next step for them would be to undergo a one year training both in Sri Lanka and abroad. After these two years are completed they are eligible to function as Board Certified Consultants in Family Medicine. We have sacrificed eleven years since post internship to become a CFP. If these administrators undermine our discipline despite such a rigorous training and if our due posts are not given, brain drain will be inevitable as the United Kingdom has relaxed certain immigration rules to attract more foreign Family Medicine Specialists. There is a dearth of 10, 000 CFPs in UK,” sources said.
According to these sources, this issue had been brought to the notice of Health Minister Dr. Rajitha Senaratne who had patiently listened to their woes given instructions to place the CFPs in their due positions. But the minister’s instructions have been to no avail.
Services not obtained
“We had a few rounds of discussions with the Health Minister and these administrators. The Minister and Deputy Director General (Health Services) II, Dr. Amal Harsha de Silva agreed to our proposals and instructed these officials to instate us as Head of Critical Care Units in main hospitals. But all these directives have fallen on deaf ears. Unlike in rural hospitals, where the OPD turnover is less than 50 patients a day, more than 250 to 500 patients visit main hospitals to receive primary care treatment daily. The Government spent more than Rs.5 million to educate a CFP which was done by providing them with quality foreign training. These sessions helped them obtain the necessary knowledge to manage OPDs. But the money spent on us has gone in vain as our services are not obtained properly,” sources further alleged.
“There is a necessity to have Specialist Medical Officers in primary care. That’s why our discipline was included in appendix 1 in the service minute. In addition, the World Federation in Medical Education, which is a funded organisation of the WHO that maintains the standard of medical collages in the world, had stated that general practice of family medicine should be included in the six major subjects that should be taught at all medical colleges. The six subjects are surgery, psychiatry, gynecology & obstetrics, internal medicine and pediatrics. If these six subjects are not taught at medical colleges, the MBBS Degree they offer is not recognised. When family medicine is well recognised internationally, due to unknown reasons, the few administrators here do not want to give us our due positions,” sources complained.
According to these sources the Ministry should employ the CFPs to strengthen the primary care units in rural hospitals in order to prevent the specialist hospitals being over-crowded.
If anyone says that the Health Ministry has sidelined these Consultant doctors by not appointing them to main hospitals it is a baseless allegation.
- Dr. Sussie Perera
Meanwhile allegations have also been levelled against the Health Ministry for sidelining CFPs when formulating the Policy on Healthcare Delivery for Universal Health Coverage. This is a US $ 200 million World Bank project which is focused on strengthening the primary health care system in the country.
“This project is on primary curative care, but none of the Consultant Family Physicians was asked to for their opinion when formulating the policies. The Minister is unaware that our representation was not there when forming the frame work to which the Cabinet approval had been granted. On page 50 of the draft Essential (Health) Service Package it says that the CFPs have to train Medical Officers (MO) in primary care units for three months. It is only after the training period that they will be on par with the CFPs and these trained MOs should not refer any patient to a CFP for specialised opinion. However they can refer patients to a secondary or tertiary care specialist. We became specialists not to train MOs and once these MOs are trained for three months they are on par with a CFP. If the Ministry of Health can determine that the primary care medical officers, who received a three-month training, are equal to CFPs, why did they spent millions of rupees to train us to become Board Certified Specialists? There again, these administrators want to undermine our professional qualifications,” sources complained.
However Ministry of Health Organization Development Director Dr. Sussie Perera said that the reason why the CFPs have been deployed at rural hospitals is to strengthen the primary care units in those hospitals.
“If anyone says that the Health Ministry has sidelined these Consultant doctors by not appointing them to main hospitals it is a baseless allegation. We really need the help of these doctors to strengthen these family care units at small hospitals. Their services are essential to us,” Dr. Perera said.
Patients awaiting treatment
According to Dr. Perera, CFPs are needed to address the overcrowded situation at OPDs in specialist hospitals. “These CFPs have the responsibility of managing the divisional hospitals effectively and send the message across to the community that the nearest hospital for the patients possesses the best primary care units. Once the quality of the treatments given at these primary care units in divisional hospitals are proven, then the people in the area would not want to bypass these hospitals and visit specialist hospitals and spend their time and money. This will help to reduce the number of patients that visits main hospitals and aid in sorting overcrowding. We do not want the health system to be centralised, but what we want is the place to be regionalized,” Dr. Perera said.
If these MOs refer the patients that need secondary or tertiary care to the CFPs then the patient has to spend more time to go from one doctor to another
When asked as to why they have proposed to make these CFPs train the primary care MOs, which in turn will put the latter on par with the Consultants, Dr. Perera said that they have not yet taken any decision regarding who the trainers will be. However Dr. Perera added that once the MOs are trained there will not be a necessity to refer the patients to CFPs, and that trained MOs can direct patients straight to secondary or tertiary care doctors, if needed.
“There are 960 divisional hospitals and primary medical care units (PMCU) in the country. At this moment we have only 13 CFPs and this number is not enough to manage all OPDs in divisional hospitals. So that is why we want to train the primary care MOs to manage the hospitals where CFPs are not deployed. We want these doctors to set up model primary care units and ensure that the patients in their respective areas do not visit main hospitals. According to our concept, we do not want to harass the patient, but need to refer them to the right place without any hassle. If these MOs refer the patients that need secondary or tertiary care to the CFPs then the patient has to spend more time to go from one doctor to another. This procedure will not help our concept and this can once again lead the patients to seek treatment from specialist hospitals,” Dr. Perera added.
When asked as to who will be in charge of the OPDs at specialist hospitals, Dr. Perera said that as there will be a huge a scope for managing work, those who are engaged in the health administrative work will be appointed as Primary Care Clinical Managers.
SLASFP raised concern as to how a few Consultant Community Physicians, who hold senior administrative positions at the Ministry of Health, have taken a firm decision not to instate CFPs at main hospitals in the country
Responding to allegations levelled against the ministry officials for not getting CFPs involved when drafting the policies on the Essential (Health) Service Package, Dr. Perera said that although they were not involved in the first round, their officials were present at discussions from the second meeting on wards.
“Senior Professors in family medicine took part in formulating the policy. We have not sidelined them, but have obtained their proficient knowledge,” Dr. Perera emphasised.