Table 3 Results from survey and focus groups

Broad scope and context of practice

It is difficult to become a good family doctor because it is such a wide field.

1

65.18%

7.04%

"GP is the most difficult specialty, because of the great scope of work, similarly, neurosurgery, because it is difficult to regulate something in microsurgery, brain. Then goes traumatology. It is also difficult specialty. […]" (FG6-Y6)

Students from the 3 study years considered GP as a specialty with wide field and a broad scope of practice, making it a difficult specialty.

However, compared to year 1, more students in year 4 and 6 disagreed with the statement that GP provides most health care needed by patients .

4

66.03%

13.86%

6

68.88%

12.06%

The family doctor is able to provide most of the health care patients require.

1

43.33%

19.63%

"Family doctor is a very important profession as a family doctor. He provides treatment to everyone, irrespective of age, gender. Also a family doctor not only treats but helps his patients psychologicallygiving them consultations." (FG2 - Y1)

4

37.23%

33.69%

6

38.41%

31.75%

Lower interest or intellectually less challenging

In Kyrgyzstan working as a family doctor is not very attractive.

1

37.04%

29.26%

“GP is boring. You must be a super unlucky fellow to be him.” (FG5-Y4)

Most students from year 4 and 6 perceived FM as unattractive and with limited career possibilities. They were very critical towards the professional GP and repeatedly stated it was office work and boring. In their view, GP can only manage minor problems, and have to refer their patients to specialists. Year 6 students however modulate this view since about half of them do not agreee with the statement of referral to specialits.

Year 1 students, although acknowledging that FM is unpopular and highlighting the lack of development perspective, had however a better image than older students (NB: about a third of year 1 students had a neutral answer to these statements).

4

66.30%

13.59%

6

69.84%

8.25%

Family doctors have limited career possibilities.

1

46.67%

17.41%

“For me, GP/FM is office work. You cannot become rich here; there is no career development.”(FG5-Y4)

4

71.20%

10.87%

6

75.87%

8.89%

Family doctors are only able to manage minor health problems.

1

37.78%

28.52%

“Why is GP/FM not attractive? Because family doctor has a lot of knowledge, but he cannot cure a patient completely, still he will have to send the patient to a specialist.” (FG4-Y1)

4

58.43%

17.66%

6

60.95%

18.09%

When treating patients family doctors should at an early stage request additional support from a specialist.

1

53.70%

15.93%

“From my experience, he [GP/FM] just directed me to a specialized doctor...” (FG4-Y1)

4

57.61%

17.93%

6

54.60%

23.17%

The only task of the family doctor is to refer patients to the appropriate specialist.

1

34.45%

35.18%

" Sometimes I think that GP just direct to a specialized doctor, since in the city a cardiologist doesn’t see patient without a referral from a specialized doctor. Many people just come and say: “My child is ill, give me a reference” and GP provides reference without examining a child... " (FG6-Y6)

4

42.66%

35.87%

6

32.70%

48.26%

Access to specialists should be controlled and coordinated by family doctors.

1

45.93%

18.89%

"Visiting a family doctor first must be mandatory." (FG2 Y 1)

4

52.99%

24.73%

6

55.87%

21.27%

Influence of role models and society, other professionals and family

The majority of teaching staff at university do not know what family medicine is about.

1

8.15%

56.29%

"Training of the staff. They absolutely do not know who GPs are, they just say that we study according to the Bologna system and at the end of studying we will be GPs. But these are absolutely different things. Starting from the first year it is necessary to explain"(FG6-Y6)

The focus groups revealed that the key positive influencers are the parents who practice family medicine and the rare professors who practice family medicine. Other professors and colleague on the contrary dismiss FM as shown in the survey.

Students therefore only have rare role models within the society and family.

students who learned about the family physician’s work at an early stage or whose close relative is a family physician demonstrated a better attitude and more interest in family medicine.

Students reported that some teaching staff appeared not knowing what FM is about.

Most importantly, most comments about FM and the reform made by professors, FD, students and alumni are negative.

4

21.74%

43.21%

6

28.57%

38.42%

How were the comments about Family Medicine you heard while studying at KSMA?

positive

negative

"Administration of the KSMA and our professors disrespectfully treat a new curriculum. We often hear their negative responses. They contributed to our negative perception of GP specialty". (FG6-Y6)

Professors

4

13.58%

42.67%

6

17.14%

47.62%

Family physicians

4

16.57%

39.94%

6

21.27%

44.13%

Hospital physician

4

19.30%

29.62%

6

27.30%

29.21%

Students

4

7.07%

68.21%

6

6.34%

78.41%

Alumni

4

5.98%

59.78%

6

4.76%

73.02%

THEMES

SURVEY

FOCUS GROUPS

SYNTHESIS BY THEME

Items from survey

study year

scale

Quotes from focus groups

agree

disagree

Lower prestige

Family doctors are poorly valued in our society.

1

32.97%

35.19%

“We often hear: “He’s the son of this surgeon”, but never: “He’s the son of a family doctor.” (FG2-Y1)

Students from the 3 study years recognized that FM is not prestigious. They perceived it as poorly valued by the society but also by other medical doctors. They considered that specialists are more needed than GP. However they also think that GP should be more prestigious.

When evaluating prestige of the profession in comparison with other spialties in the focus group discussion, GP/FM profession ranked at the lowest.

This low ranking was justified by the low salary this profession gets, the poor working condition, not recognized as a specialty and lack of professional development opportunities.

4

69.30%

10.33%

6

80.31%

8.57%

Family doctors are poorly valued by other medical doctors.

1

27.03%

35.92%

"As for GP – work is not seen. No one will remember the doctor".(FG5-Y4)

« Honestly many people think that family doctors are not doctors » (FG2-Y1)

4

62.50%

11.14%

6

76.19%

7.62%

In Kyrgyzstan narrow specialists are more needed than family doctors.

1

44.44%

20.37%

“If a person wants to be a man of importance, hold a position specialty plays an important role. To be an oncologist is prestigious. To be a family doctor is not prestigious”. (FG3-Y6)

4

47.28%

22.56%

6

41.27%

26.03%

A family doctor should have the same prestige as a specialist.

<

52.59%

10.37%

"GP – great knowledge, it is difficult but not prestigious."(FG-Y6)

“I agree with everyone. Profession of a family doctor is not popular now and it needs to be made competitive. In order to motivate students to become a family doctor, the officials have to provide good working and living conditions in order residents not to think how they will work, where they will live and what they will eat.” (FG1-Y4)

4

63.04%

13.31%

6

66.99%

11.42%

Low remuneration

Family doctors should receive a higher salary than narrow specialists.

1

26.29%

26.66%

"Well, as for the question of what encouraged us to choose a carrier of a specialized doctor I can say that I was such a romantic freshman. I want to be this or that, maybe even a family doctor. But later I concluded that in the real world I must have a well-paid job to guarantee a comfortable life for my family and me. This is the main motive for choosing the specialty which can ensure a decent standard of living. Unfortunately I will get less satisfaction from this specialty than the one I really like." (FG3-Y6)

The issue of remuneration is key in this profession and it is perceived by students of the 3 study years as much too low, not even allowing to live decently. It is thus a major obstacle to choosing FM

Whereas year 1 students do not have a clear opinion about how GP should be payed (about 5 % are neutral with regard to the statement and the rest are shared between agreement and non-agreement), most year 4 and 6 students consider that GP should be better paid, even more than specialists.

4

48.37%

14.40%

6

63.49%

15.24%

Medical school influences

Everyone should receive training in family medicine, no matter what specialty he/she choose later.

1

54.45%

28.52%

"We must know everything a family doctor does. Even if we are going to be specialized doctors, we should know everything. Even our relatives can ask us for medical help".(FG4-Y1)

The opinion of the 1st year students that each student must complete a course in GP/FM at post-graduate level whatever specialty will be chosen testifies to their awareness and understanding of the current needs of the health care system. This stands in contrary to 4th and 6th students, who are less aware of FM reform.

Generally, FM lectures are perceived as boring and this also linked to the teaching staff being unsufficiently informed and trained about the role of GPs says the students. The undergraduate training fails to stimulate interest of students towards FM. However year 4 students report some lectures who helped them to understand what FM is about.

4

24.45%

60.06%

6

17.46%

68.26%

Lectures/trainings during yr1 have increased my interest in FM

4

9.24%

60.59%

"When the lecture began we all complained that there was no reason to have this lecture. We couldn’t even imagine who a family doctor is, but after the lecture it became clear. It is especially important to communicate with a patient, not only give a prescription, but also discuss whether the patient can afford to buy the medicine. I realized that communication is sometimes more useful than medications".(FG4-Y1)

6

7.62%

68.89%

Lectures/trainings during yr1 helped me to understand what FM and FD are

4

45.11%

26.36%

6

31.11%

40.32%

Lectures/trainings on general practice during yr5 have increased my interest towards FM

6

7.93%

68.89%

"FM lessons are superficial, boring, not interesting. The teaching staff is not ready for teaching FM. Probably the problem is in the teaching staff who does not understand the work of GP. And we need optimism and patriotism". (FG6-Y6)

The family medicine lectures/training during yr5 helped me to understand what family medicine is.

6

42.54%

30.16%

The lectures/trainings during yr5 gave me a comprehensive view on family medicine

6

30.15%

40.00%

Post-graduate training

Two year residency prepares the students sufficiently for the most common medical situations they will encounter later.

6

47.62%

27.94%

“Why should we waste two years?” (FG5-Y4)

“I think this is not fair for non-government-subsidized students. We pay money, study for many years; we are made to have two years of FM residency. This is an impairment of students’ rights.”(FG1-Y4)

“But here in Kyrgyzstan we pay for our residency training and get no money during this period.”(FG3-Y6)

Core education takes six years plus two years of FM residency. In addition, one extra year of training if we want to become a specialized doctor”. (FG2-Y1)

“What can we do? We will have 2 years FM residency training; it is not the end of the world. (FG6-Y6)”

From the survey results, a majority of 6th year students agree that two years PGME is enough for FM and that it prepares students sufficiently. However, during the focus groups, they express great reluctance toward the 2-year postgraduate training in FM since the residency is unpaid and will be costly for their families.

When discussing the post-grad training, students thought they would all have to become GP and disagreed with that. This misunderstanding may have caused their negative attitude towards the two-year residency training in family medicine.

As for 1st year students, the focus group revealed that they are better informed of the ongoing reforms in the KR health care system and in medical education in particular, they have a more positive attitude to the post-graduate training in GP/FM and were fully aware about the 2 year post-grad training that would follow the 6 years of studies.

Two year residency is enough for family medicine.

6

48.25%

31.74%