Wednesday, September 1, 2010

Advice for building a new primary care based health system for Armenia: How "knowing the future" can inform our actions now

This is a guest post written by Heidi Chumley, MD. Dr. Chumley is Senior Associate Dean for Medical Education at the University of Kansas School of Medicine.

Recently, my husband and I (both family physicians) and our colleague (a health systems researcher in our family medicine department) visited Armenia as guests of the Kansas National Guard and USAID. Our mission was to learn about the evolving Armenian health care system, develop relationships, and move towards an end goal of providing assistance to Yerevan State Medical University as family medicine continues to develop in Armenia. We knew a little about their health care system before we visited, as our colleagues had made two prior trips.

After the collapse of the Soviet system, the Armenian government endorsed the development of a primary care based health care system and chose family medicine as the discipline to provide that base. We knew they were interested in learning about the family medicine curriculum in medical school, residency, and after residency in the US and specifically at the University of Kansas. So, we prepared our presentations about family medicine training, packed our bags, and worked with the US embassy and YSMU to set up a schedule. We met with officials of YSMU and their department of family medicine, a representative from the ministry of health, and the chair of the department of family medicine at their “NIH”-equivalent. During the course of these meetings, we learned of their two major strategies: 1) retrain "narrow specialists" (their term for physicians who restrict treatment to patients based on age, gender, or organ system) in a one-year program with a national curriculum and 2) begin 2-year family medicine residency programs. Over the past decade, they had retrained 1200 narrow specialists as family physicians. Also, there are 2 government-sponsored family medicine residency programs, training a total of 9 residents per year.

As you might suspect, when there has been no family medicine before in a country seeking to develop family medicine, there are no family physicians to lead the movement. There are narrow specialists who have learned about the value of primary care, endorsed that system, and are working together with other narrow specialists to provide as broad training as possible. This reminded me of what might have happened in the US as family medicine became a specialty. Visiting Armenia was like being granted a rare opportunity: a glimpse into our past, with a known future, poised at an important moment in time. It gave me a chance to reflect on what happened in the US that led us to a specialty-centric health care system and what decisions may affect whether or not Armenia is able to transform to a family medicine based health care system. At our exit meeting with the director of USAID in Armenia, we mentioned that the best way we could help would be to outline pivotal decisions that will either be made or just come to be as if a conscious decision was made. I've scripted those insights into concrete “dos” and “don'ts” based on knowledge of what transpired in the US health care system. Here is my advice, for what it is worth:

· Don't train your primary care doctors in a system where they only rotate with narrow specialists.

· Do train your narrow specialists in primary care settings to help them keep a sense of probabilities.

· Don't make family medicine training shorter or less prestigious.

· Do shorten procedurally based specialty training when possible, creating a system where new narrow specialists continue to develop their procedural skills under a proctoring system funded by private practices seeking new partners instead of the government.

· Do provide a sufficient number of government sponsored family medicine residency positions to produce the physicians needed to provide care for the population.

· Don't provide government sponsored narrow specialty residency positions at a number greater than what is needed for the population.

· Do set goals or metrics for how much a family physician should be able to manage (80% to 90% of what walks in the door).

· Don't enable a system that supports narrow specialist to narrow specialist referral.

· Do a national educational campaign on primary care concurrently with the improvement in the training of primary care physicians.

· Don't pay narrow specialists more than primary care physicians.

· Do follow outcomes and reward improved health of a population.

· Don't financially reward overuse of services.

· Do seek to become a nation in the top 10 of all nations on important health care outcomes.

· Don't spend 8 times as much as the other nations and remain below 40 other nations on health care outcomes.

I was also struck with this amazing reality: only a country as economically blessed as the US could even fathom conducting health care as we do. It is irresponsible of us to hold up our version of western medicine as a model. It won't work except in a society where the people have too much.

In fact, it doesn't work in our society for the people who don't have too much. It often doesn't even work that well for those who do.


Kollisch said...

Thanks, Heidi, for your keen observations and sage recommendations. I had the privilege of working in Kosovo periodically from 2001-2007, after their ethnic war and their "release" from the Soviet approach. The parallels are striking - most notably the tension between the Kosovars wanting to do the right thing (family medicine!) for the population, and also wanting to emulate the nutty USA system (if it is the USA, it must be good, right?).
So I can endorse your "do's and don'ts".
I'd add, perhaps, one more: "If U.S. family docs want to help, don't just provide training and supplies. Do try to support the establishment of SYSTEMS of care - patient flow, medical records, respect for nurses, teamwork, etc. - and a focus on measureable outcomes which recognize the population as well as the individual."

Unknown said...

Thank you for your observations. Here in Brazil he have problems like Armenia. Goverment start a "family medicice health care program" without specific training in what the world call real famile docs!
Best Regards

Marcelo Levites
Director of Brazilian Society of Family Medicine(

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