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Principles of

Practice and the Role
Dr Katrina Butterworth
in Nepal


Define what is General Practice

Gain an understanding of the role of General
Practice internationally
Appreciate the specific contribution that
General Practice makes to health care in

Question for discussion

What are the distinctive features of Family

(General) Practice?
What is the role of the generalist?

Principles of Family Medicine

First point of medical contact in health care

system regardless of age, sex, disease
In some countries gate keeper to secondary
Commitment to the person rather than type of
Patient centred

Principles of Family medicine

Manages both acute and chronic illness,

often simultaneously
Able to deal with undifferentiated complaints
early stages
Recognizes emergencies and manages
Able to tolerate diagnostic uncertainty,
remaining committed to the patient

Principles of Family Medicine

Consultation process is unique

Focused on ongoing relationship with patient
and family
Continuity of care is key

in some countries, GP maintains primary

responsibility for patient even after tertiary referral.
Co-ordinator of care.

Familiar with community and family context

knows whole family

Principles of Family medicine

Balance care of individual patients with

population health

In some countries co-ordinate immunization and

screening programmes

Every consultation opportunity for health

promotion as well as curative.
Manager of resources for both individual
patient and the community (planning of health

Principles of Family medicine

Ideally part of the community where their

patients live
Available for home visits
Involved in community networks of health
care provision

Definition by Oleson et al (BMJ

2000:320, 354-7)

GP is a specialist trained to be in the first line

of health care provision, providing initial care
Takes care of patients irrespective of disease
or any social or personal characteristics
Manages resources in health care system for
benefit of the patient
Involved in prevention, diagnosis, cure, care
and palliation integrating biomedicine,
psychololgy and sociology



Have a perspective of the whole and act as

communication centre.
Doesnt have to cover the whole field of
medicine but should recognize red flags
Knowledgeable about common conditions
(specialist doesnt always know more)
Able to live with uncertainty (skill all doctors
need, but many not good at)


Attitudes and skills are more important than
factual knowledge.
Only men who are themselves whole can
understand the needs and desires of other
men. Balance and wholeness are important!
Crosses clinical and social boundaries - interface
between clinical practice and counseling
Act as an interpreter to mediate between the
patients subjective experience and the scientific

Questions for Group

What are needs in Nepal?
What are the difficulties/distinctives
in Nepal?


Urban Growth (global - rural urban shift)

Lack of Human Resources and Poverty especially
Disparity of Access to Health care

Kathmandus doctor density was estimated to be 25 times more

than rural Nepals
20 year difference in life expectancy between rural and urban
Nepali population.

Need for Family Doctors - whole family, continuity

of care, appropriate referral and resource use (can
address 85-90% needs)

Why Focus on Primary Care?

Improves Health Indicators - Sri Lanka and Kerala

have best in South Asia (BMJ 3 April, 2004)
US Research found that increasing the number of
General Practitioners by 1 per 10,000 (33%)
decreases mortality by 70 per 100,000 (9% fewer
Increasing the number of specialists by 1 per 10,000
(8%) increases mortality by 16 per 100,000 (2%
more deaths).

Shi et al The Journal of the American Board of Family Practice (2003)

Better Outcomes
Care by a General Practitioner:
Reduces disparities in health (the gap
between rich and poor),
Reduces the effect of income inequality
Improves self-rated health
Starfield B, Shi L, Macinko J
Contribution of primary care to health systems and health.
Milbank Q. 2005;83(3):457-502

Patients with Primary Care

Doc Spend Less

After taking into account the patient's characteristics, health

insurance status, diagnosis, health perception, and smoking
status, study subjects with a primary care physician as their
personal physician "had 33% lower annual adjusted healthcare
expenditures and lower adjusted mortality,
The average total expenditure for those seeing primary care
physicians was $2,029 compared with $3,100 for those using a
specialist as a personal physician.

Franks P, Fiscella K. Primary care physicians and specialists as personal

physicians. Health care expenditures and mortality experienceThe
Journal of Family Practice August, 1998;47:103-104, 105-109.


Specialists tend to over investigate and over

treat (Iatrogenic morbidity)
Doctor may easily be working outside of his
field of expertise GPs deal with a broad
range of problems
Specialists tend to be less good at
communicating with their patients leading to
more errors.

The role of the MDGP in


Captain of the health care team especially in the

primary health care centres and the district hospital
Oversees mid level health care workers, who
provide much of the primary care (not enough GPs
to provide all the primary care)
Teaches, trains and supports
An excellent physician who can deal with the
majority of cases they see
Trained in essential life saving procedures e.g.
Caesarian section, appendicectomy, basic
orthopaedic skills

The role of the MDGP in


Vital part of the government strategy to

achieve maternal child health MDG goals
Integrate clinical expertise, a patient-centred,
socially aware approach and a public health
One or two fully trained GPs placed in the
Primary Health Centre and District Hospital,
are able to provide the sort of comprehensive
holistic service that the people need

Difficulties for General

Not everyone who calls themselves a GP is trained in its

specialty (especially in India)

Lack of specific UG and PG Family Practice medical
Vulnerability of living with uncertainty doctors feel need to be
seen to have all knowledge
Pressure of the immediate and urgent against health
promotion and prevention.
Balance of individuals (the patient in front of you) and the
population. Specifically, the patient and the wider family
needs, community needs of clean water, sanitation and better

Difficulties in Nepal

Lack of continuity of care.

To be where the people are lack of desired facilities for

personal and family well-being and growth
Difficult to see people in homes especially in rural areas.
Lack of gatekeeper role which best achieves equity of care with
appropriate use of resources.

Patients pick and choose doctors, difficult to build up commitment/

responsibility; fragmented care and inappropriate investigation.

Can still help patients choose and get appropriate care from
different parts of the system.

Inadequate referral people not seen at right level of care


2007 NSI retrospective study of Nepal

government district hospitals where an MDGP
doctor was present for five or more years during
the period 2053 62.
19 district hospitals were identified and in 12 of
these district hospitals, MoHP Annual Reports
showed that the presence of an MDGP doctor
was associated with more deliveries, more OPD
visits and more operations

2010 review of NSIs Rural Staff

Support Programme (RSSP)

Presence of an MDGP doctor - patient utilization

(Gulmi - OPD patients increased by almost 3
fold, the number of deliveries by over 2 fold and
the number of admissions by approximately 1.4
fold) and comprehensive emergency obstetric
care (CEOC) rose dramatically.
Community interviews - availability of MDGP
made a tremendous difference in the service
provided to patients; they were appreciated.


Good primary care is good for everybody.

Strengthening district health systems is the most

appropriate way to promote primary health care.
General Practitioners (GPs) are the most effective
doctors for providing primary health care.
There are appropriate and complementary roles for
Primary Care and Specialist Physicians.
Nepal, as a nation with limited resources and a large
number of poor people needs far more well-trained,
committed General Practitioners.