Doing more

In February 2011, I participated in an international elective in Zamboanga City, a large urban centre in the southern Philippines. Throughout my stay, I facilitated sessions at the Rural Medicine Conference of the Philippines; I taught a module at the Ateneo de Zamboanga University School of Medicine; and I completed a clinical rotation at the Zamboanga City Medical Centre. My primary goal was to learn more about practising family medicine in a resource-poor setting. Before arriving, I had read about the complexities of the Philippine health care system. The system is primarily modeled on the American system, while providing free basic health services. To better understand the role of family medicine in primary care delivery in the Philippines, I collected qualitative data with an informal questionnaire distributed to several Filipino medical students and family medicine residents. From these data, and from my brief personal experience, it appears that the Philippine health system must make efforts to further elevate the status of family medicine and primary care. This is supported by a body of evidence describing the status of primary care across many developing countries.¹

In the Philippines, patients can consult any specialist of the organ system that they believe is troubling them, without first consulting a primary care provider. This lack of a gatekeeper leads to important inefficiencies. One medical student summarized the trouble with this reality: I’ve known families who have been tormented by physician-hopping in the hopes of receiving better health care and explanation as to what their condition is. [They] were not satisfied [with] the service. But maybe that’s because they went to a renal and pulmonology specialist while the complaint was hemorrhoids.

A formal triage of undifferentiated symptoms by a primary care provider would arguably save time and money for such patients.

In the Philippines, family medicine graduates face the challenge of limited opportunity to practise comprehensive care, although they train with a wide knowledge base, comparable to that of Canadian family medicine programs. After graduation, family physicians generally follow 1 of 2 career paths. Those who choose to practise as generalists typically move to rural communities and serve as consultants to the Doctors to the Barrios—medical doctors functioning as general practitioners for the rural poor. Those who wish to stay in urban settings are often pressured into subspecialization, including extra training in such fields as dermatology, emergency medicine, or geriatrics. The residents suggested that this is a question of financial and professional survival. Generalists are perceived to have “less expertise.” In the survey, I asked residents about their postresidency plans. Overwhelmingly, they were planning to pursue subspecialty training for fear that they would be unable to carry the patient load necessary to make a living.

Another hurdle appears to be trainee perception of the field itself. I questioned medical students about why people choose not to pursue careers in family medicine. I suspect that their answers reflect the view of Philippine society, as demonstrated by limited self-referral to family physicians for undifferentiated problems. “Family medicine practice is not popular and not considered a high-profile profession compared to other medical fields,” wrote one student.

Another student explained: “Here, from what I know, patients [have greater] trust [for] physicians who are specialists,” and summarized the general perception of the field, “Others might find that other subspecialties are more rewarding. Family medicine is not quite popular here.” Overall, responses reflected the sentiment that family medicine could not offer trainees a fulfilling or sustainable career.

It is unfair to make generalized statements about the status of family medicine in the Philippines based on such limited, informal qualitative data. In fact, the Philippine Academy of Family Physicians has done great work to promote the discipline. Further, the Ateneo de Zamboanga University School of Medicine has become a model for community-based training and promotion of primary care. However, my experiences and data reveal a need to further integrate the role of family physicians as providers of primary care into the psyche of Philippine society.

Barbara Starfield and colleagues have shown us that the primary care model is an efficient and cost-saving method of delivering health services.² As an established profession in Canada, we need to support the efforts of our international colleagues in promoting our field and its values. We should support trainees who choose to practise family medicine and identify the factors that lead them to do so. Finally, we should continue to promote the well-established financial and health benefits of a universal primary care provider system to the general population. My elective reminded me of my good fortune to be able to practise my chosen passion of family medicine here in Canada, and has given me the determination to promote the field internationally.

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