The Evolving Role of Physicians - Don’t Forget the Generalist Primary Care Providers

Abstract

The editorial "Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians" by Eyal et al describes non-physician clinicians’ (NPC) need for mentorship and support from physicians. We emphasise the same need of support for front line generalist primary healthcare providers who carry out complex tasks yet may have an inadequate skill mix.

We acknowledge the editorial “Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians,”¹ offering pertinent suggestions for healthcare provision in resource-constrained settings.

It is timely to reconsider the function and training of physicians in health systems where tasks and responsibilities are increasingly shifted to non-physician clinicians (NPCs). And it is essential to clarify the scope and boundaries of work of different healthcare providers.

Eyal et al describe mentorship and supervision of NPCs as one of the evolving roles of physicians. We want to emphasize this role in relation to mentorship and supervision of generalist primary care providers in non-hospital primary care facilities.

Eyal et al define NPCs as providers with more skills than nurses and less than physicians.¹ The examples provided show that their tasks are often highly specific, such as HIV-care, Caesarean sections, and hernia repair.

While spotlighting on specialized NPCs, generalist providers in primary healthcare (PHC) settings should not be forgotten. African countries have many generalist primary care providers who might not be considered as NPCs – probably many more than there are NPCs. The vast majority of outpatient consultations are delivered by generalist primary care providers in non-hospital PHC facilities.^2,3

Generalist primary care providers may or may not have skills comparable to NPCs. No matter their skill-level, their tasks are comprehensive and complex, often mirroring those of physicians such as taking a full history and doing relevant examinations and investigations for myriad complaints. They must analyse and decide who to refer, who and how to treat, when to follow-up, and equally important who can be reassured to go home. Additionally, they may shift between departments in the health facility such as child immunisation, antenatal care, HIV-care, tuberculosis (TB)-care, and surgical care.

PHC, as a gatekeeper, is unique in that it influences all other parts of the health system. In most countries, the quality of PHC will determine patient flow in health facilities through referrals and counter-referrals, and thus, health expenditure at more specialized levels of care. Therefore, effective PHC requires generalist primary care providers with a comprehensive skill mix to cover the wide-ranging problems presented.^4,5

Yet, generalist primary care providers typically do not receive training beyond basic nursing level. Many are nurses with a secondary-school based nursing education.^6,7 Their needs for mentorship and support are largely unmet.⁸

NPCs may be mentored by specialists, such as internists for HIV-care and obstetricians for Caesarean sections. Similarly, mentoring generalist primary care providers requires knowledge of comprehensive and holistic PHC.

We see a need to upgrade district hospital physicians in the core competencies of effective PHC delivery, which in many countries is a medical specialty.⁹ Fostering a medical PHC cadre, whether articulated as ‘family physicians,’ ‘community physicians,’ ‘district care physicians’ or ‘ambulatory physicians,’ can address mentorship and clinical supervision at the sub-district level of both NPCs and generalist primary care providers. This will benefit the entire health workforce, and expectedly lead to cost reductions as more comprehensive sub-district care delivery decreases the number of referrals to more expensive specialized care levels.⁴ The suggested changes would require reprioritization of the health budget as well as readjusting the responsibilities of generalist physicians’ and other providers’ around the actual needs of people and communities to fully support “primary care now more than ever.”^5,10

Ethical issues

Not applicable.

Competing interests

Authors declare that they have no competing interests.

Authors’ contributions

VKC and MS wrote first draft. MF and PC commented on draft and contributed to further development and discussion of ideas.

Authors’ affiliations

¹Aarhus University, Aarhus, Denmark. ²University of Rwanda, Kigali, Rwanda.

Citation: Cubaka VK, Schriver M, Flinkenflögel M, Cotton P. The evolving role of physicians - don’t forget the generalist primary care providers: Comment on "Non-physician clinicians in sub-Saharan Africa and the evolving role of physicians." Int J Health Policy Manag. 2016;5(10):605–606. doi:10.15171/ijhpm.2016.77