The family doctor: Catalysing change in family medicine

In the coming decades, Singapore will be faced with significant healthcare challenges, including the twin threats of infectious diseases and a rapidly ageing population. As Singapore’s first academic in family medicine, Prof Helen Smith plans on taking on some of these big research challenges.

Based at NTU’s Lee Kong Chian School of Medicine (LKCMedicine), where she is Professor of Family Medicine & Primary Care and Director of the School’s Primary Care Research Network, Prof Smith is studying novel ways of delivering primary healthcare, using pharmacological or psychological methods or those relating to service organisation.

As Co-Director of the Centre for Primary Health Care Research and Innovation, Prof Smith is leading a collaboration between LKCMedicine and the Singapore National Healthcare Group (NHG) to provide seed funding for research into chronic diseases and health promotion, among other initiatives.

In this interview with Pushing Frontiers, Prof Smith shares her views on the integral role of community-based medical services in a national healthcare system, which has become ever more essential during the COVID-19 pandemic.

Q: What is the role of family medicine and primary care in a healthcare ecosystem?

A: Primary care is usually the first point of contact that people have with healthcare services. When organised well, it provides comprehensive community-based care throughout life, sometimes described as “cradle-to-grave” care.

As generalists, family doctors do not focus on one organ or system but on the whole person. Patients can present with any condition—from minor or acute to severe or chronic—and the majority of a person’s healthcare needs are managed very well in primary care. However, for help with a difficult diagnosis or an investigation or procedure only available in a tertiary facility, the family doctor will refer the patient to a specialist colleague, in a triage role often spoken of as “gatekeeping”.

Family physicians and general practitioners take a holistic approach to problems; they are attentive to the psychosocial impact of ill health on the person as well as its physical impact. There is good international data showing that family medicine and primary care improve the quality of healthcare and patient outcomes in cost-effective ways.

Q: What were some of the challenges faced by family medicine and primary care doctors during the COVID-19 outbreak, and how did they respond?

A: In the very early stages of the outbreak, many patients presented at clinics with symptoms such as a cough or a higher-than-normal temperature, which might be caused by COVID-19 but are also symptomatic of many other frequent illnesses, including the common cold. Some patients presented with concerns generated by fake news or misleading information.

Very quickly, referral pathways were established and initiatives such as SASH—swab-and-send-home, a testing programme with clear criteria for eligibility—were initiated. Over 800 Public Health Preparedness Clinics (PHPCs) trained and equipped to deal with respiratory illnesses, which had been established in previous years to deal with the haze (a recurrent air pollution crisis caused by regional forest fires) and the 2009 H1N1 influenza pandemic, were re-activated to work with the polyclinics.

Clinics also adopted new ways to manage and monitor patients with other illnesses, including those with chronic problems. For instance, doctors reverted to telephone consultations to protect patients from being exposed to COVID-19-positive patients—an approach that appeared to be valued by patients for its convenience and cost-effectiveness. Thus, the novel coronavirus might become a catalyst for practice redesign, with in-person healthcare becoming the second rather than the first option for patient care.

In addition, doctors developed professional groups for information sharing and hotlines to support stressed healthcare workers.

Q: How will your appointment as the first professor of family medicine and primary care in Singapore support the advancement of this specialty? 

A: Traditionally, research has taken place in teaching hospitals and specialist centres. However, we increasingly recognise that such research does not always address the questions that are important in family medicine: management of minor illnesses, multi-morbidity and preventive healthcare, as well as the organisation of public healthcare. Such topics need to be investigated in real-world settings.

Research can improve service delivery and the health of our patients, while at the same time benefitting healthcare providers. Participating in research encourages us to reflect on our practice and explore questions arising from patient care. In addition, developing new skills, discussing ideas and collaborating with colleagues is fun and provides another dimension to the lives of professionals.

Q: What are your current research interests?

A: I have evaluated novel ways of delivering health services and “new technologies” in primary healthcare over many years, using pharmacological or psychological methods or those relating to service organisation.

In one example of my current research, we are completing an evaluation of a tele-dermatology service aimed at improving the management of skin problems in primary care. The service allows patients with skin problems that cannot be diagnosed by a primary care physician to have an immediate virtual consultation with a dermatologist at Singapore’s National Skin Centre. Patients benefit from timely advice delivered in an environment they are familiar with, and from being able to start their treatment without delay.

Another evaluation project aims to assess the benefits of pharmacogenetics testing in primary healthcare settings. Adverse drug reactions are a common cause of hospital admissions and it would be preferable if patients underwent pharmacogenomic testing prior to prescription rather than after developing the adverse reaction. As doctors in primary care are well placed to conduct pharmacogenomic testing, we are evaluating the potential and patients’ acceptability of a medical support system that guides drug prescriptions in primary healthcare.

Q: How has your appointment at LKCMedicine supported your research?

 A: I very much enjoy being part of a young medical school where I have been able to build research collaborations without being bound by tradition. LKCMedicine recognises the importance of translational research and partnerships between academics and clinicians to bring together different skills and perspectives in the design and execution of excellent research.

I have a long-standing interest in respiratory disease, and one of the LKCMedicine initiatives I am delighted to be part of is TARIPH, The Academic Respiratory Initiative for Pulmonary Health. TARIPH aligns academic expertise across Singapore to better understand the local respiratory disease burden and improve lung health, and I can contribute with my expertise in understanding patients’ journey to seeking healthcare and patient-related outcome measures.

Excellence in research goes beyond academics and clinicians. Patient and public involvement in medical research is also important, and is an area that is still in its infancy in Singapore, but my team has been developing a novel way of engaging patients in discussions about research. I am currently planning to establish a Lived Experience Group—a patient group willing to contribute to the projects within my research group and beyond.

Q: You are the Director of the Primary Care Research Network and Co-Director of the Centre for Primary Health Care Research and Innovation at the medical school. Tell us more about the network and centre.

A: The Primary Care Research Network I established in the south of England in the 1990s was the first of its kind and was cited as an example of good practice in the UK Department of Health’s Strategic Review of Primary Care. Subsequently, similar research networks were replicated throughout the UK, and I became the Foundation Chair of the UK Federation of Primary Care Networks and later co-founded the International Federation of Primary Care Networks, an organisation under the umbrella of the World Organisation of Family Doctors.

Similar to the UK networks, the Primary Care Research Network initiative at LKCMedicine aims to develop research capacity amongst family doctors who deal with a mix of cases that are quite different in terms of diagnoses and severity-level from diseases addressed in hospital- and specialist-based research.

Setting a different focus, the Centre for Primary Health Care Research and Innovation promotes innovative research and evaluation to strengthen the contribution of family medicine and primary healthcare to the well-being of patients and their carers. Among other initiatives, the Centre provides seed funding for research into ​chronic diseases and multi-morbidity, and new ways of promoting health and self-management. The Centre, which is a tie-up between LKCMedicine and NHG, also enables collaborations and the development of pilot data to justify bids to external research funding bodies.

Q: Could you share with us your vision of how family medicine and primary care should be practiced in Singapore?

A: Efforts led by the College of Family Physicians Singapore and the Ministry of Health have already achieved much in family medicine and primary care in Singapore, but there are some major challenges ahead.

To provide good care for our rapidly ageing population, we need to move from reactive care to more integrated and proactive care for individuals with multiple chronic conditions. This transition requires family doctors to develop new clinical skills and calls for changes to the way healthcare is organised, funded and delivered. Formal evaluation of new approaches to primary healthcare delivery will not only benefit Singapore but would also be of interest to other countries facing similar challenges.

I hope to contribute to the development of a robust evidence base for high quality care in the generalist setting in Singapore, and also help train a cadre of family medicine and health service researchers. My wish is to see the professional standing of family medicine increase, aided by the introduction of mandatory postgraduate training and organisational changes including patient empanelment, use of a universal electronic patient record and the development of multidisciplinary teams even in the smaller practices.

The article appeared first in NTU’s research & innovation magazine Pushing Frontiers (issue #17, August 2020).

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