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Background: To be recognized as a primary care physician (PCP), an Indonesian general practitioner (GP) has to fol- low a formal postgraduate training in primary care. However, 4 years since the regulation was published, the progress of the training is slow. There is a need to deeply investigate the doctors’ perspectives, particularly to explore factors associated with their willingness to follow this training. Aim: This study aims to explore the GPs’ views and perspectives related to the formal postgraduate training in pri- mary care that may influence their enrolment in PCP program. Methods: We conducted semi-structured interviews with a topic guide. The study took place in Yogyakarta from Jan- uary to December 2016. The participants were GPs practicing in Yogyakarta primary care clinics who were recruited using purposive-maximum variation sample design. The interviews were audio-recorded and transcribed. The data were analysed using interpretative phenomenological analysis approach. Results: Nineteen GPs participants were involved in this study. Three major themes were identified, namely unfamili- arity, resistance, and positivism. Almost all the GP participants were unfamiliar with the primary care training program. They were also pessimistic if the training could change the health service in the country while it lacked resources and infrastructures. However, exposure to the training brought positive insights that it could improve the doctors’ knowl- edge and skills in primary care practice. Discussion: The government intention to establish PCP training is currently on the right tract. However, information dissemination and more supports in primary care are also essential. Keywords: Primary care doctors, Training, Family medicine, Indonesia, Qualitative study Background essential health care without any financial barriers [ 2]. Then, in 2008, the WHO report emphasized that pri The World Health Organization (WHO) at the 30th - commemoration of the Alma Ata Declaration in 2008 mary care improvement consisted of four major pillars: urged its country members to rethink their primary care the health financing reform (universal coverage), health services . The narrative promises of this setting were service improvement, leadership, and policy reform . broadly explained, calling for high-quality care for all. In In response to the above WHO suggestions, the Indo- 2005, the WHO declared the essential need of universal nesian government has been implementing the uni- coverage for all people in the world, to help them afford versal health coverage policy-which is also known as Jaminan Kesehatan Nasional (JKN). This program was launched in January 2014 and was designed to expand *Correspondence: email@example.com 1 its broad coverage until 2019 [3, 4]. In line with the JKN Department of Family, Community Medicine and Bioethics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, implementation, the Indonesian government had also Radioputro 1st Floor, Jalan Farmako Sekip Utara, Sleman, Yogyakarta, prepared a structured formal postgraduate training for Indonesia general practitioners (GPs) to upgrade their skills in Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ekawati et al. Asia Pac Fam Med (2018) 17:10 Page 2 of 8 primary care. The training was stipulated in Medical Until this publication was written, very limited evi- Education Act number 20-year 2013 . In this regula- dence was available to explore the Indonesian doctors’ tion, the terminology of ‘primary care physician’ (PCP) perspectives about this formal postgraduate training. was introduced as a doctor having an equivalent posi- The local investigation about the GPs views related to tion as a specialist. To be recognized as a PCP doctor, the training was insufficient and were dominantly from the GPs have to follow a formal postgraduate train- news or media releases [15, 16]. Being intrigued by the ing in primary care conducted by 17 medical facul- debates, this study sought to deeply investigate the Indo- ties licensed by the Indonesian Ministry of Education. nesian GPs’ views on this training, specifically, what are The PCP curriculum content was designed according their arguments to follow or not to follow the govern- to international recommendations of family medicine ment intention to upgrade their knowledge and skills in training, consisting of advanced training for the GPs primary care. to have more person-centred care, continuity of care, community-oriented, holistic and comprehensive care Methods for their patients, leadership in general practice, and This research applied a phenomenology approach to primary care management [6, 7]. develop a comprehensive understanding of the GP par- The formal primary care doctor training for Indone - ticipants’ views . Consistent with this methodology, sian doctors is arranged with a workplace-based learn- the data collection was conducted using semi-structured ing methods (WBL)  developed by the Indonesian interviews to provide greater opportunities for the par- National Board of PCP (the representative members ticipants to express their views. of the 17 medical faculties). The WBL scheme aimed to This study took place in Yogyakarta from January to specifically train the future doctors to reflect and learn December 2016. A purposive maximum variation sam- medical cases from their practice settings. There are pling strategy was applied to ensure adequate encap- two sub-schemes in WBL methods: the first scheme is sulation of the participants’ perspectives. The GPs designed for those physicians who already graduated recruitment process was done in both private and public from the university and have had at minimum of 5-years primary care clinics from five Yogyakarta regions (Kulo - practice in primary care. This mechanism is also known nprogo, Sleman, Yogyakarta city, Bantul, and Gunung as the “Recognition Prior Learning” (RPL) model, in Kidul). The recruitment process is described as follows: which the doctors only need to accumulate credits by FME (first author) advertised this study in Yogyakarta taking a 6-month PCP training at assigned universities. general practitioners’ networks and mailing lists-with The RPL will be completed by 2030 to provide adequate more than 150 GPs members. The GPs who were inter - opportunities for the current GPs to join this scheme. The ested to join the interview, were advised to contact second scheme of WBL is the regular 2–3 years training FME, and FME then contacted back the GPs personally scheme, which is designed for newly graduate GPs with for the interview scheduling. Written informed consent less than 5 years practice experience. To do the training, was obtained from all GP participants, including their the junior GPs need to be registered as PCP residents at a consent that this research would be published in a jour- licenced university. nal board using their anonymous identity. All the inter- Unfortunately, until 4 years since the medical educa- views were held in a private room in the GP’s clinics. All tion act was published, the formal postgraduate train- the interviews were audiotape-recorded. Each partici- ing in primary care was not fully established. There had pant was given a small souvenir bag as a token of their been strong national debates related to this law from participation. the Indonesian Doctors Association [9, 10]. A juridical All the interviews were based on a topic guide. At the review was proposed by the Indonesian Medical Asso- beginning the GP participants were explained about the ciation and claiming that the practice skills had actually aims and any related information regarding this study. been included in undergraduate medical curriculum. Then, three main guiding questions were asked to them: Subsequently, the association notified the government to (1) their general views related the formal PCP training, take more consideration before the training was launched (2) their concerns related to the PCP training and (3) nationally . The Indonesian medical education experts their expectation for the training. Prompts were also constrained this claim by stating that the essence of pri- applied to explore more on the GPs views, such as: silent mary care practice was different from the undergradu - pause, and minimum engagement, (i.e. ‘what do you ate degree. They added that the PCP training would help think…’, ‘tell me more…’) . doctors to improve their skills [11–13] and would equip The interviews were transcribed and analyzed using them with an advanced focused clinical professional Interpretative Phenomenological Analysis (IPA) development (CPD) in primary care practice . approach for moderate scale participants. It is an Ekawati et al. Asia Pac Fam Med (2018) 17:10 Page 3 of 8 analytical method to deeply understand the participants’ Table 1 Maximum variation sample details views combined with the researcher analysis behind the Characteristic Number participants’ quotes. The steps of IPA analysis were sys - Gender tematically applied as had been suggested by Smith and Women 13 Osborn : (1) First, FME and MC (Co-author) read Men 6 all the transcribed texts independently, to be familiar Age with the participants’ views. (2) Notable quotes were 25–40 13 noted and discussed in three separate meetings. (3) The 41–55 4 quotes were then grouped into themes and superordinate 56–70 2 themes. Finally, (4) the emerging themes were discussed Practice setting and crosschecked amongst the other co-authors with pri- Rural 14 mary care backgrounds [12, 18]. Urban 5 Practice type Results Public 9 Nineteen GPs were recruited. Most them were females, Private 10 practicing in rural areas, aged 30–40 years, and having Practice duration more than 5 years’ experience practicing as a GP in pri- Less than 5 years 4 mary care practices. The participants had an equal pro - 5–10 years 7 portion of GPs who practiced in Puskesmas (Indonesian 10–15 years 3 Public Primary Care Clinics) and those who ran private > 15 years 5 practices. Ten GPs did not have any previous exposure Practice location to family medicine/primary care focused trainings, while Kotamadya 3 nine GPs in this study had exposure to family medicine/ Sleman 6 primary care courses. Eight of the participants had joined Bantul 3 the Universitas Gadjah Mada’s (UGM University-Indone- Gunungkidul 4 sia) Weekly Clinical Updates -family medicine postgradu- Kulonprogo 3 ate course for 1 year, and one GP participant was a Master of Family Medicine graduate from the university. The details of the participants are presented in Tables 1 and 2. The interviews went well. FME had no difficulties to a different recognition in front of their patients, as what have the interviews with the participants. All of them had been said by Doctor 6: “How is the position of the had also been informed that their participation would PCP doctors? Where are their positions? Would they not affect their relationships with the FME or other co- practice in the different clinic than us in Puskesmas? Do authors’ institution, now or in the future . we treat different patients?” (Doctor 6, urban practice). Three superordinate themes were identified as unfamil - While it was stipulated in the regulation that to iarity, resistance, and positivism. Unfamiliarity referred become primary care doctors the GPs should take a to the doctors who were unfamiliar with the PCP pro- formal postgraduate training, the doctors were unsure gram: about what it was, for whom, and if they would about the clarity of the training. They questioned if the have any compensation related to the training they would training was compulsory or a voluntary; and whether it have in the future. Resistance reflected the participants’ would require them to leave their practice and take an perspectives and pessimistic thought that the training on-campus training as similar to other specialist train- could improve the health system. However, some physi- ings. Unfortunately, with those questions, the doctors cians who had previous primary care training acknowl- felt that there was limited information available for edged that this training benefited their knowledge and them. Without adequate explanation and clarification, practice skills in primary care. their unfamiliarity resulted in doubts to go into training. “So, for the future of the training, I do not know Unfamiliarity about the length of the training. Do we have to Almost all doctors in this study expressed their unfa- take a 6-month training or is this just an alterna- miliarity related to the PCP terminology. They were tive? Do we have to also leave our practice? I want unclear about: who were the PCPs? and What made the to know about this. Otherwise, I could not decide PCP doctors different from current general practition - what is the best for myself ” (Doctor 13, rural prac- ers, as both kinds of physicians would work in the same tice) clinics. The doctors were also unsure if they would have Ekawati et al. Asia Pac Fam Med (2018) 17:10 Page 4 of 8 Table 2 Characteristic of each participant Name Practice setting Practice duration Experience of following a primary care/family medicine course(s) Doctor 1 Urban Less than 5 years No Doctor 2 Rural 5–10 years No Doctor 3 Rural > 15 years No Doctor 4 Urban 5–10 years No Doctor 5 Urban 5–10 years No Doctor 6 Urban Less than 5 years No Doctor 7 Rural > 15 years Yes (1 year) Doctor 8 Rural > 15 years Yes (1 year) Doctor 9 Rural 5–10 years Yes (1 year) Doctor 10 Rural > 15 years Yes (1 year) Doctor 11 Rural > 15 years Yes (1 year) Doctor 12 Rural 10–15 years No Doctor 13 Rural 10–15 years Yes (1 year) Doctor 14 Rural 10–15 years Yes (MSc in Family Medicine) Doctor 15 Rural Less than 5 years No Doctor 16 Rural Less than 5 years Yes (1 year) Doctor 17 Urban 5–10 years Yes (1 year) Doctor 18 Rural 5–10 years No Doctor 19 Rural 5–10 years No Resistance “I may not be good at patient care. However, I After expressing their unfamiliarity with the PCP pro- think this is the best I can do. We already have gram, half of the GP participants expressed their resist- adequate skills as GPs [from the undergraduate ance to take the postgraduate training program. This was education]. But, look, why couldn’t we treat the particularly expressed by doctors who felt that they were hypertensive patients well? [because] We only have competent enough already. They thought that they had captopril in our clinic. I also agree that maybe half mastered and had given their best performance, referring our patients are psychosomatic patients; we need a to the list of GPs’ competencies, such as health promo- long time to gain that information. We do not have tion and prevention. They thought that there were no time to do that. Even for the doctors; we do not further additional skills needed for primary care doc- have enough doctors here. Only one doctor practic- tors; as what had been said by Doctor 9: “We had given ing in the clinic, another doctor went to a meeting our best performance in primary care, in our undergradu- to health office” (Doctor 2, rural practice) ate curriculum we have been trained with the skills as a In addition, the GPs thought that the training would GP well. We had done the comprehensive care; we did the burden their economics situation. They argued that health promotion and prevention, we had also expressed their undergraduate training in medical school was long our objection to this training” (Doctor 9, rural practice). enough to get good salaries compared to engineers or These doctors also felt resistance and being pessimis - businessmen training. Furthermore, there were no such tic that their efforts to follow the PCP program would of a registrar’s salary in Indonesian medical training. improve their practice because of the limited resources available in primary care. The doctors argued that their “I am afraid that it would delay the time for the undergraduate skills were already adequate to tackle future GPs to be able to practice. You know that so the patients’ problems, but the facilities prevented far, we needed to finish our 4 years training in an them to perform well. They thought that the training undergraduate degree, after that we continued to would not result in any improvement unless the gov- another 2 years of clinical rotation. Not enough, we ernment improves the facilities. also had 1 year of the internship program. Now we Ekawati et al. Asia Pac Fam Med (2018) 17:10 Page 5 of 8 have to have another training to be able to practice? now, I feel that they need more my attention, I feel I cannot imagine. In another country, they have that I am responsible for their continuing medica- salaries for the residents, but here we pay the resi- tion, I should know that they have a risk of compli- dency with our money. See that engineers, business- cations, stroke, heart attack, which may burden their men they only need 4 years to work, we would need lives and families. I am feeling like a real doctor, who 8 years to practice, that is too long…why don’t we not only need trust from the JKN insurance but more just have a short course on this?” (Doctor 15, rural importantly from my patients and to manage their practice). conditions” (Doctor 14, rural practice). For this question, interestingly, when the GPs were Another GP in this study also promoted that the train- given a prompt to some GPs if she got a chance to follow ing could help the GPs’ practices during the implemen- another specialization training, with the similar situation tation of JKN as Indonesian Universal Health Coverage of no payment for the residents, the doctors replied with (JKN). He wondered if the GPs could perform well in the “Yes, I am interested. I want to pursue a specialist train- clinic, the unnecessary referrals could be avoided and the ing, that is my dream. I adore this specialization since I patients would receive a more appropriate care. was in Med-school” (Doctor 19, rural practice). “I think the training would be more beneficial for our This study also found an interesting argument that the graduate doctors. I experienced it in my clinic. There continuation of PCP program was constrained by groups are some newly graduate doctors working with us of doctors in the country. One GP commented this situ- and to be honest, they did not have a similar experi- ation that there were doctors who did not support this ence as I do. They loved to refer patients to second - PCP program exist. ary care, that may be right, but I have a different “iTh s is interesting, I know that this program is dis - opinion, this might also lead to unnecessary treat- rupted by other doctors, this is ridiculous. Some ment to the hospital. What I expect is they evalu- doctors didn’t like their colleagues to upgrade their ate the patients first, knowing their needs and treat skills. I also knew that some doctors who constrained them comprehensively” (Doctor 11, rural practice) this training were actually not practicing in pri- mary care, what are their problems? Some people in the Association also strongly debate this program. Discussion I think we just need to keep this going’ (Doctor 11, This study has identified interesting perspectives from rural practice). the Indonesian GPs about the PCP training that the clar- ity of the PCP information influenced the doctors’ views towards the training. It was mentioned that the doctors Positivism still questioned about the details of the training: such as Different perspectives were expressed by half of the doc - its contents, length, the different authorities of PCP doc - tors who already had more exposure to any family medi- tors and their future incentives compared to the current cine trainings. Doctors who practiced in the rural areas GPs. In addition, the practice supports and the medical expressed their gratitude as they already missed any association debates also challenged the doctors to opt in training in general practice and believed that the train- the training. Regarding this finding, the Indonesian gov - ing could improve their practice in primary care, as sug- ernment had actually disseminated information related gested by Doctor 19: “I am happy with the training. So far, to primary care doctors’ training. The Frequently Asked I’ve been practicing in rural areas, this is superb to remind Questions (FAQ), the training schemes, the PCP com- us of the skills in primary care” (Doctor 19, rural practice) petencies had been published . Some scholarships Some doctors told us more practical aspects of their to support the training were also offered . However, course experience helped them to appropriately man- seemed that the distribution and the clarity of those age their patients in primary care. A doctor expressed information inadequately reached the primary care his experience that his prescription to chronic disease doctors. patients changed significantly after he took his training in It also appeared at the result section (Resistance) that family medicine. After taking the training, he felt that he the doctors perspectives were framed with their current had another perspective on the patients’ care. Lately, he knowledge of general practice and accused its develop- considered more aspects in his patient care. ment by comparing the training with the facilities limita- “I felt significant changes in myself as a doctor, previ - tion in practice settings . The views that the doctors ously I only met my hypertensive patients and gave were admiring the other specialist trainings might the pills. I did not care about anything else. However, also show that they lacked abstraction and doubt the Ekawati et al. Asia Pac Fam Med (2018) 17:10 Page 6 of 8 prospects of PCP graduates compared to other speciali- training. The country still focused its primary care train - zation. Moreover, the medical association did not fully ing materials in undergraduate level  and the current support the training and published their objection . doctors have limited abstraction of family medicine as a Interestingly, it is showed that exposure to a formal unique specialisation. Therefore, massive considerations training could be a powerful strategy to change the doc- need to be taken by the Indonesian doctors and the gov- tors’ perspectives about the primary care practice. Half of ernment about the benefits of the developed primary the participants who already followed the formal train- care research and education, that the training could con- ing in family medicine had better insights of the train- tribute to improve the health system as well as to provide ing compared to the other doctors who didn’t not have a high quality health care for all people [14, 25] (Fig. 1). any exposures to family medicine courses. The doctors As shown in the above findings of this research dem - expressed that the training improved their practice per- onstrating that the current need for GP continuing spectives, from treating the acute care to a more compre- education programs, the Indonesian government’s inten- hensive and holistic care. From a disease-based treatment tion to upgrade the GPs quality with formal postgradu- to a more personal care for the patients, and how to ate training is currently on the appropriate decision [1, finally see the primary care as a macro system on its rela - 14, 26–29]. In addition to offering annual postgraduate tionship with secondary care [20, 21]. While the formal workshops, clear competence reviews and appropri- training seem to be suspended because of the national ate allocation of CPD credits for PCP courses/seminars/ medical association resistance, facilities improvement conferences are essential supports for the training pro- and supports for the trained doctors (such as: additional gram . The leadership from the government sectors incentives) could change the situation [22, 23]. and extensive information dissemination are also needed This phenomena of the Indonesian doctors’ reluctance to ensure the correct understanding of the GPs and to to the PCP training is in line with an article from Haq, balance the resonance of the medical association resist- Ventres  that stated that family doctor programs in ance . By these efforts, it is expected that the GPs can developing countries were lacking of recognition as a spe- better understand the values of the PCP training and its cialist training. In connection to this study finding, Indo - impact on patients and the healthcare system [27, 28]. nesia is now left behind from other Asia Pacific countries It is also strongly suggested that the government, GPs, for the establishment of family medicine as specialist and medical associations could create a plan together to Fig. 1 Practice supports, massive information dissemination, and leadership from both government and universities are potential to minimise the GPs’ resistance of PCP training in Indonesia Ekawati et al. Asia Pac Fam Med (2018) 17:10 Page 7 of 8 minimize the tension and provide assistances for GPs Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- who wish to take the PCP training. lished maps and institutional affiliations. Lastly, this research provided a foundation to further investigate the specialist doctors’ and other stakehold- Received: 11 April 2017 Accepted: 8 November 2018 ers’ views about Indonesian postgraduate training in pri- mary care, to explore the challenges and any initiatives which may endorse the recruitment of PCP trainee in References Indonesia. 1. WHO. Primary health care: now more than ever. Geneva: WHO; 2008. p. 1–120. 2. World Health Assembly. Social health insurance: sustainable health financing, universal coverage and social health insurance: report by the Strengths and limitations Secretariat. In: 58th World Health Assembly, 2005, World Health Assembly, This study was the first academic study to explore the Geneva. Indonesian GPs views related to the PCP training. It was 3. Indonesia, The Parliament of Republic and The President of Republic Indonesia. 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Asia Pacific Family Medicine – Springer Journals
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