Needs assessment of general practitioners in Pakistan: A descriptive cross-sectional survey

ABSTRACT

Background:

With the growing and complex nature of medicine, it is imperative for physicians to update their knowledge and skills to reflect current standards of care. In Pakistan, 71% of primary care needs are met by general practitioners (GPs). GPs are not required to complete structured training and no regulatory mandates exist for continuing medical education. We conducted a needs assessment to evaluate the readiness for competency-based updating of knowledge and skills, and the use of technology by practicing GPs in Pakistan.

Methods:

A cross-sectional survey inviting registered GPs across Pakistan was administered online and in-person. Questions pertained to physician demographics, practice characteristics, confidence in knowledge and skills, and preferred modes of updating knowledge and barriers. Descriptive analyses were performed for GPs and patient-related characteristics and bivariate analyses to evaluate the relationship between parameters of interest.

Results:

Of the 459 GPs who responded, 35% were practicing for <5 years and 34% reported practicing for >10 years. Only 7% had a post-graduate qualification in family medicine. GPs reported needing practice in neonatal examination (52%), neurological exam (53%), depression screening (53%), growth charts (53%) and peak flow meter use (53%), interpretation of electrocardiograms (ECGs, 58%) and insulin dosing for diabetes (50%). High workload (44%) was the most common barrier to updating clinical knowledge. Sixty-two percent used the Internet on a regular basis.

Conclusion:

Most GPs have no structured training and encounter gaps in knowledge and skills in clinical practice. Flexible, hybrid, and competency-based continuing medical education programs can be used to update knowledge and skills.

Introduction

The World Health Organization (WHO) recognizes the role of primary healthcare in improving the overall health of the populace, especially in the developing world.[1]

Without a program of active learning, practicing doctors can only remain competent for a limited time after graduation.[2,3] With the growing and complex nature of medicine, it becomes more important for physicians to update their knowledge and practice to reflect current standards of care.[4] Evidence suggests that physicians who are far from an academic environment lack confidence in their clinical diagnosis,[5] thus making ongoing maintenance of competence necessary.

Pakistan is the fifth most populous country in the world with an estimated population of approximately 220 million.[6] However, it remains one of the lowest performers in health indicators in South Asia. The maternal mortality rate remains high, with a 1 in 140 chance of maternal death at each live birth. The under-five mortality rate is 81/1,000 live births and 44% of children under 5 years are stunted due to maternal and child malnutrition.[7] In addition, the prevalence of non-communicable diseases (NCDs) has steadily increased. At present, 51% of all deaths can be attributed to NCDs with coronary heart disease, lung diseases, diabetes, and cancers making the bulk of this burden.[8,9] Of NCD risk factors, high blood pressure affects 25.2% of adults, and obesity affects 5.5% of the population.[8]

In Pakistan, the acute and primary care needs of the public are mostly met by general practitioners (GPs) in the private sector. The GP in Pakistan is usually a practicing medical doctor with no formal post-graduate training.[10] Despite their thriving practices, GPs are found lacking in knowledge regarding basic diseases and drugs.[11-13] Family medicine, as a post-graduate specialty is still nascent, with one residency program at a private medical university since 1990.[10,14] Currently, only five accredited programs exist in the country, four in Karachi and one in Lahore.[15] In light of the above, empowering the existing GPs through competency-based, continuing medical education that updates their knowledge and skills can be a cost-effective way of improving the quality of care at the mass level.[16]

A needs assessment is an important tool used to facilitate the creation and evaluation of educational programs.[17,18] We report the results of a needs assessment of practicing GPs in Pakistan. This will allow us to develop an effective continuous medical education program that prioritizes their needs, understands barriers, evaluates readiness for a competency-based program, and explores the ease of using technology to update knowledge and skills.[19]

Materials and Methods

From February 2019 to September 2020, we conducted a cross-sectional survey inviting GPs across Pakistan who were licensed by the national regulatory body, the Pakistan Medical Commission (PMC).

Inclusion and exclusion criteria

We included all GPs working in primary care and who possessed a valid license to practice issued by the PMC. Those GPs who refused to participate for any reason were excluded from the study.

We used several avenues to ensure the participation of GPs across different work settings. These included 1) the database of the College of Family Medicine, a licensed organization; 2) doctors in Aga Khan Health Services Pakistan (AKHS-P), a sister organization with primary and secondary care facilities in urban and rural Pakistan; 3) pharmaceutical representatives who are in contact with GPs working in private settings; and 4) non-governmental organizations (NGOs) providing primary healthcare.

Ethical considerations

The study was approved by the Ethical Review Committee of the University (ERC 2019-0859-2681).

Survey instrument

We created a structured questionnaire that included items in five domains: 1) demographic information, education, post-graduate training qualifications, years in practice, and place of practice; 2) practice-related questions such as age and gender distribution of patients seen and common reasons for patient visits; 3) GP’s clinical skills including confidence in commonly used clinical skills in a primary practice; 4) avenues of upgrading knowledge including barriers faced in doing so; and 5) availability and ease of using technology.

We pre-tested the questionnaire with 10 GPs to correct any ambiguities and concerns. The results of the pre-test were not included in the final analysis.

We used Survey Monkey^® to disseminate the questionnaire to GPs. An online consent form was filled out by them before they could access the questionnaire. In addition, hard copies of the consent form and questionnaire were disseminated to GPs working in communities where emails were unavailable.

Access to Survey Monkey data was granted to a designated research administrator. Manually filled forms were entered into the database by the research administrator. Data were stored in a locked cabinet with access only to the research team.

Data analysis

We examined the raw data for missing entries. We used descriptive statistics for variable analyses. For continuous level data, we report means (±standard deviation [SD]) for normally distributed data and median interquartile range (IQR) for non-normally distributed data. For categorical variables, we report frequency and proportions. In addition, we used cross-comparisons and bivariate correlations to examine associations between variables of interest. Analyses were done using Stata/SE 15.1^®.

Results

We approached 499 GPs, of which 491 participated in the survey.

Demographic characteristics

Table 1 shows the demographic information of participating GPs and their practice characteristics. A higher proportion of female GPs responded to the questionnaire (female [54.2%] vs. male [45%]:χ²:4.06; P: 0.04). Of those responding, 382 (83.4%) were currently practicing. Twenty-seven percent of GPs reported graduating before 2000, showing an almost 20-year gap between terminal degree and practice. Only 7% of GPs had post-graduate training in family medicine. There was a positive relationship between the gender of GPs and their year of graduation (r_s = 0.13, P = 0.005). This depicts a progressive change in our society in recent times wherein more women are inclined to pursue a career in medicine.

Table 1.

General practitioner demographics and patient-related characteristics

Items	n (%)
(A) GP Characteristics (n=459)
Gender
Male	206 (45)
Female	249 (54)
Year of graduation
1981-1990	47 (10)
1991-2000	75 (16)
2001-2010	138 (30)
After 2010	177 (38)
Years in medical practice
0-5 years	159 (35)
5-10 years	69 (15)
>10 years	154 (33)
Not practicing at present	56 (12)
Never practiced	20 (4.3)
City of practice*
Karachi	224 (59)
Outside Karachi	71 (18)
Outside Pakistan	16 (4)
Type of practice†
Academic hospital	66 (17)
Government clinic	93 (24)
Not-for-profit organization	43 (11)
Private solo practice	136 (36)
(B) Patient characteristics
Patient population by age‡
Newborns and infants (0-1 year)	9.6 (0-70)
Children (1-10 years)	16.6 (0-70)
Adolescents (10-19 years)	17.7 (0-70)
Adults (19-59 years)	41.8 (0-100)
Elderly (60 years and older)	20.7 (0-80)
Patient population by gender‡
Male	44.9 (0-100)
Female	52.5 (0-100)

*City of practice and type of practice was analyzed for GPs currently in practice (n=382). ^†GPs reported practicing in more than one environment. ^‡Average% (min-max)

Clinical practice

As seen in Table 1, the majority of the physicians were practicing in Karachi (an urban setting); and the type of practice was majorly “private solo practices.” During an average week, the proportion of male and female patients was almost equal, with a large majority of patients being adults and elderly as compared to children and adolescents, with infants being least frequently seen.

The case mix seen in a typical week reflects the disease burden of Pakistan,[8] where most patient visits were for acute infections (38.4%) and NCDs (20.5%). Interestingly, mental health (2.54%) and women’s health issues (4.8%) were not reported as a large reason for patient visits.

Figure 1 shows GPs reported competency in select clinical skills. A large proportion reported requiring practice in the use of growth charts, screening for depression, and women’s health issues such as breast examination.

Figure 1.

Confidence in use of essential clinical skills

The additional list of clinical skills and GP’s confidence in practice is available in Table 2. We found a negative association between female GPs and their confidence in performing skills pertaining to women’s health such as routine vaginal exam (r_s = −0.54, P ≤ 0.01), breast examination (r_s = −0.60, P ≤ 0.01), and post-natal examination (r_s = −0.48, P ≤ 0.01).

Table 2.

Clinical skills assessment of general practitioners (n=291)

S. No	Skills	Very confident n (%)	Need practice n (%)	Not relevant n (%)
a)	Assessment and management of dehydration	183 (62.9)	89 (30.6)	19 (6.5)
b)	Counseling regarding breastfeeding and weaning	155 (53.3)	87 (29.9)	49 (16.8)
c)	Vaginal and speculum examination	38 (13.1)	99 (34.0)	154 (52.9)
d)	Male genital examination (including prostate)	73 (25.1)	100 (34.4)	118 (40.6)
e)	Male catheterization	100 (34.4)	74 (25.4)	117 (40.2)
f)	Female catheterization	78 (26.8)	71 (24.4)	142 (48.8)
g)	Antenatal examination	70 (24.1)	101 (34.7)	120 (41.2)
h)	Postnatal examination	71 (24.4)	107 (36.8)	113 (38.8)
i)	Counseling in the use of inhalers	175 (60.1)	96 (33.0)	20 (6.9)
j)	Chest X-ray interpretation	136 (46.7)	139 (47.8)	16 (5.5)
k)	Examination of neck lumps	166 (57.0)	102 (35.1)	23 (7.9)
l)	X-ray interpretation of joints	98 (33.7)	168 (57.7)	25 (8.6)
m)	Splinting	48 (16.5)	147 (50.5)	96 (33.0)
n)	Testing for visual acuity and visual fields	60 (20.6)	135 (46.4)	96 (33.0)
o)	Otoscopy and cerumen removal	40 (13.7)	139 (47.8)	112 (38.5)
p)	Incision and drainage of a superficial abscess	97 (33.3)	119 (40.9)	75 (25.8)
q)	Suturing	109 (37.4)	121 (41.6)	61 (21.0)

Views on continuing medical education

Table 3 reports GP’s views on continuing medical education. A large proportion reported interest in attending CME courses to update their knowledge and skills. It was heartening to see that almost 40% were planning to take a post-graduate qualifying exam in family medicine. The willingness to attend CME courses was not different between recently graduated GPs (0–5 years) and those with >10 years in practice (95 vs. 118; c²: 0.31; P: 0.57).

Table 3.

General practitioners’ (GPs’) views on continuing medical education

Items	n (%)
Willingness to take CME
Yes	280 (61.0)
No	9 (2.0)
Want to take a post-graduate exam in family medicine
Yes	180 (39)
No	109 (24)
Barriers to updating knowledge*
Difficulty in getting study leaves	151 (39.5)
High workload/long duty hours	168 (44.0)
Lack of facilities like computer/Internet	59 (15.4)
Long distance traveling	93 (24.3)
Lack of funds	105 (27.5)
Best training options
1-year course with some practical skills training	112 (24)
2-year structured training	158 (34)
4-year structured training	107 (23)
Ease of using technology for continuous medical education (n=459)
Internet access on the phone
Yes	284 (62)
No	5 (1)
Access to a computer with Internet
Yes	237 (52)
No	52 (11)
Frequency of reading clinical material on the Internet
Daily	151 (33)
Few times a month	135 (29)
Never	3 (0.7)

*GPs noted more than one barrier to updating knowledge

As seen in Table 3, GPs identified multiple barriers such as long work hours (44%) and difficulty getting study leaves (39.5%). They also reported a lack of academic guidance (7%), lack of family support (17%), and family commitments (14%) as other barriers.

As also seen in Table 3, the best training options considered by GPs to prepare them for clinical practice were a 2-year structured training program (Member of College of Physicians and Surgeons Pakistan [MCPS] or Diploma in Family Medicine). This was followed by a 1-year course with some practical skills training; and most recognized that 4-year structured residency training would provide them the best training to be effective in their clinical practice.

Ease of technology use

Although exploring the accessibility of technology for continuous medical education, as seen in Table 3, a large majority of GPs had internet access on mobile phones and reported access to computers with Internet connectivity. Daily Internet use was reported by 33%, whereas 29% used it a few times a month.

GPs reported using multiple avenues to enhance their knowledge [Figure 2]. These included using the Internet to improve clinical knowledge, discussing cases with senior colleagues, and attending CME sessions, conferences, and workshops.

Figure 2.

Frequency of modality used by general practitioners for updating clinical knowledge and skills. *Participants could select multiple options for this question

Discussion

Our study examined the needs of GPs who provide 71% of primary care in Pakistan.[20] Needs were highlighted in terms of confidence in various important clinical skills central to day-to-day primary care practice. We also investigated the methods used to update clinical knowledge and skills as well as the barriers to obtaining continuing professional education. Furthermore, we noted willingness on the part of GPs to advance their knowledge and take professional examinations. The availability and ease of using technology can be capitalized on to provide GPs an avenue to attain continuing medical education in a flexible and cost-effective way.

The current picture of family medicine

We found that only 7% of GPs had any post-graduate training in family medicine. This is in stark contrast to Kumar et al.’s[5] report of GPs in the Asia Pacific region, where 47% of GPs had completed a family medicine residency. In Pakistan, family medicine was added as a mandatory rotation at an undergraduate level in 2021. Because most of the medical education occurs in the inpatient hospital setting, GPs may not be equipped to provide the outpatient high-quality, comprehensive care that is required to boost the primary health system.

One-third of GPs in our study had been in practice for more than 10 years. Studies have shown a decrease in confidence levels of GPs who have been practicing for over 10 years.[21] We can see this in our participants where GPs were not confident with common skills in primary care such as interpretation of ECG and use of growth charts as well as neonatal examination. Thus, there is a need for organized continuing medical education programs for updating clinical knowledge and skills.[3]

GP clinical practice and gaps in knowledge and skills

Of those currently practicing, 36% of GPs reported having private, solo practices, whereas 17% were working in academic hospitals. Only 24% were working in the public sector, which is reflective of the health care infrastructure of Pakistan, where most health consultations by patients are in the private sector as compared to the public sector.[22] Similar trends in the private sector providing care were seen in the study done at Tabriz[2] where the majority (60%) of the GPs reported working in private practice followed by 14% of physicians working in the public sector.

The patient case mix is still predominantly focused on infectious diseases (38%), followed by NCDs (21%). This is in contrast to the changing epidemiology of morbidity and mortality in Pakistan where NCDs account for 51% of all deaths[8]; and in contrast to what we see in other countries of the Asia Pacific Region where GPs provide a significant amount of care for diabetes and hypertension.[5] This shows that in Pakistan’s largely fee-for-service model,[23] the focus remains on episodic care for acute issues rather than control of NCDs and preventive and promotive care. This again highlights the need to not only formally train GPs in the care of NCDs but also utilize episodic visits as opportunities for screening and prevention.

Most GPs reported needing practice in essential skills relevant to primary care practice. For example, more than half of GPs reported needing training and practice in ECG interpretation and insulin dosing for patients with diabetes, two skills necessary for decreasing morbidity and mortality due to the most common NCDs seen in Pakistan.[8] Continued training in ECG interpretation has been recognized as a need by GPs in other countries such as Ireland[24]; and based on the prevalence, experts consider management of hypertension and diabetes as essential for GPs.[2] Mental Health issues are a major health concern in our part of the world, and seeking support for mental health issues remains taboo. GPs can play a large role in the timely recognition and management of common mental health concerns such as depression and anxiety. Yet in our study, a large majority of GPs identified needing more practice in screening for depression. Training in the identification and management of depression and anxiety has been recognized by GPs in other countries across the Asia Pacific Region[5] and Iran.[18] What is also important is the ability to improve communication skills, attitudes, and behaviors necessary for successful primary care practice,[25] especially in dealing with mental health issues.

Barriers to professional development and avenues for learning

We focused on the barriers that this important healthcare workforce faces in updating their knowledge and skills. Similar to other primary care teams,[26] GPs reported a high workload (44%) and lack of study leaves (40%) as major hindrances. In addition, the cost of CME remains an important barrier.[5,26]

The preferred mode of learning remains diverse in the literature with many GPs opting for structured online programs,[21] whereas others prefer in-person live workshops.[5] Similarly, GPs in our survey reported multiple ways to enhance their clinical knowledge including using the Internet (47%), talking to senior colleagues (43%), and attending live sessions, workshops, and conferences (42%). Although the lack of Internet connectivity remains a concern in developing countries,[27] it was heartening to see that most of the GPs in our survey reported having Internet access on phones (62%) and computers (52%). Hence an online, flexible, blended-learning course, with a component of in-person skills training would be an effective method for updating knowledge and skills in Pakistan. This becomes, especially important during the COVID-19 pandemic where frequent surges with new variants make gatherings unsafe.

Strengths and limitations

A diverse group of general practitioners working in different clinical settings responded to our survey. This allowed us to assess their needs, skills, and confidence in multiple competencies central to primary care practice. Although we had representation from both rural and urban settings, a large proportion of GPs participating in our study was from Karachi, a large urban city, and their responses may not be generalizable to GPs working in other settings. Another limitation of our study is incomplete responses seen in 22.4% of our survey questionnaires; with these numbers being excluded in the final analysis. Similar participation patterns (incomplete responses) have been reported in research involving medical professionals.[5]

Conclusion

GPs remain the primary care providers for most communities across Pakistan. Training GPs in family medicine remains a pivotal goal in the Government’s commitment to “Health for All.” Our study highlights the barriers and possible solutions to achieving this goal by completing a needs assessment of the existing GP workforce. We find that a large majority of practicing GPs have no structured training in family medicine and report gaps in knowledge and skills in clinical practice. They identify a need for structured training and are interested in accessible avenues to update their knowledge and skills. What is heartening, however, is that our GPs are skilled in technology use. In this era, technology must be used to meet the professional development needs of physicians, especially in low-and middle-income countries. The access to technology and present practices of using the Internet for clinical knowledge make an online, blended-learning structured program a viable option to fulfill this need for a large group in the most cost-effective and flexible manner.

Our survey allowed us to recognize four key areas of GP professional development: Identifying their clinical needs, understanding barriers to ongoing professional development, evaluating their readiness for a competency-based program, and exploring their ease of using technology to update knowledge and skills. Using the results of our survey, we have created an online blended learning course “FamMed Essentials”, aimed to improve the clinical knowledge and skills of busy GPs within Pakistan. We hope that this will be the first step in upgrading the standards of primary health in the country by improving the quality of care provided by general practitioners in light of their needs outlined in our survey.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Abbreviations

AKHS- P, Aga Khan Health Services Pakistan; GP, General Practitioner; IQR, Interquartile Range; MCPS, Member of College of Physicians and Surgeons; NCDs, Non-Communicable Diseases; NGOs, Non-Governmental Organizations; PMC, Pakistan Medical Commission; WHO, World Health Organization

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.