Discussion

This study reported on the qualitative analyses of respondents’ written comments on expectations on FMSs: part of a larger national study on the perception of the Malaysian public healthcare professionals on FMSs (PERMFAMS). In spite of more written comments by the hospitals’ PHCPs, the numbers of subthemes coded were about similar in the PHCPs’ comments from the three different health facilities. As the coding strategy decided to provide quantitative weightage to the subthemes of expectation, such results indicated that non-hospital-based PHCPs had given broader expectation in a more concise manner compared with the hospital specialists who had elaborated their expectation mainly on clinical performance of FMSs. As this was a study on expectations on FMSs, it was not surprising that most expectations were directed towards improvement in clinical roles and functions, and the attributes of FMSs.

Among the different categories for the clinical roles and functions, we noticed that there were different expectations of FMSs from the three different categories of PHCPs. PHCPs at the health clinics wished FMSs to focus on clinical duties and be available for patients at health clinics. The availability of FMSs had become an issue in some of the clinics when the FMSs were also involved in administrative jobs that often required them to attend meetings. Family physicians’ availability was an ongoing challenge and expectation elsewhere.14 Family physicians functioning within the Canadian long-term home services team could be disrupted due to their unavailability, irregularity or unpredictable presence.14 Thus, the presence and function of primary care physicians are increasingly being recognised within an effective healthcare system especially through their gate-keeper role to the more expensive hospital care.

PHCPs at the health clinics expected FMSs to organise more teaching and training sessions to update them on current medical knowledge. This aspiration was rightly expressed in view of FMSs often being the only resident clinical specialists at the health clinic level. However, meeting this expectation would often pose the challenge of finding suitable time for the staff without interrupting the operations of the clinic or taking out staff on weekends. In addition, with the busy clinic schedule of the FMSs, organising well-structured training with clear learning objectives for the different categories of clinic staff might be too demanding. Nevertheless, an active learner would be more likely to be an enthusiastic teacher.15 Hence, looking outwards and having an external conversation with other FMSs may encourage mutual learning and teaching opportunities for the FMSs and their staff.16

Health offices’ PHCPs expected FMSs to be more active team members and to take up leadership roles to foster stronger teamwork relationship among the multidisciplinary members. This observation by the closest health partners at the primary care level and immediate managing health offices of the FMSs and their clinics10 would be an invaluable feedback. Effective multidisciplinary teamwork, leading to an integrated approach of primary medical care delivery, is a crucial element for success. In this set-up, GPs were almost always considered to be the leaders.17 Good leadership would bring focused effort, clear direction, regular organisational adjustment and meetings that would maintain the cohesiveness of the health clinics.4

As expected, the hospital specialists generally expected the FMSs to supervise their staff performance, especially the medical officers, when providing treatments and referring patients to the hospitals. This expectation followed from the hospitals’ specialist experience in receiving inadequate prehospital care and posthospital follow-up management of the patients by the medical officers. Thus, FMSs were highly expected by hospital specialists to improve management of patients, in their own respective disciplines, before referring to them as well as to continue posthospital care leading to reduced workload at the hospital specialist clinics. These are indeed great expectations and challenges for the family medicine specialty. To achieve this, FMSs are required to have a wide knowledge base in medicine and to keep these many pairs of knowledge-shoes shining.18–21 Quite a number of these expectations included more consultation and better communication between FMSs and the hospital specialists. Referrals that meet expectations could be learnt and would be achieved faster through more bidirectional dialogue and mutual respect plus understanding between FMSs and the hospital specialists.22 ,23 Collaborative care between these two sectors has its inherent difficulties and needs more than a formal encounter.24

The next major PHCPs’ expectation was of FMSs to self-improve. FMSs were unanimously expected by all the PHCPs from the three healthcare facilities to consolidate their medical knowledge and skills and to keep acquiring new medical updates. Keeping up-to-date in knowledge and expertise is important, ever more so in engaging healthcare interactions with educated patients and in supporting their self-management behaviours and skills.25 Knowledge and skills improvements are almost always related to better care of patients at the clinic level.26 ,27 Providing continuous medical education to other staff would be an important part of task delegation and successful collaborative care for patients with a complex disease profile such as chronic diseases and multiple comorbidities.16 ,28 These educations were rightly expected for better quality medical care to be delivered by the FMSs and PHCPs, and a more active information transfer methods were preferred than a passive ones. 29 In addition to this, PHCPs at health clinics expressed an almost equal number of expectations for the FMSs to improve on their personality, attitudes and behaviour in managing clinic issues and when dealing with staff. These included communication skills that showed mutual respect towards the staff, to listen and understand matters at hand before judging them. In English general practices whose staff reported a better team climate and team effectiveness using the team climate inventory (assesses perceptions of staff members of how people work together, how frequently they interact, whether teams have identified aims and objectives, and how much practical support and assistance are given towards new and improved ways of doing things). It was shown that quality of care, patient satisfaction, continuity of care and access to care were better.30 Physicians who had good interpersonal behaviour such as empathy and communication skills did improve patient satisfaction and adherence to therapy.31 For these attributes to be translated into effective teamwork, it would require all team members to practise these behaviours, not just the FMSs.17 These roles and responsibilities were also expected of the Canadian family physicians in running a cohesive and effective geriatric healthcare team.14

With the prevalent positive perception on FMSs, it was expected that many did express an expectation to have more FMSs at the primary medical care. The higher expectation came from PHCPs at the health offices and clinics, wishing that there was at least an FMS at every health clinic and even to have more than one FMS at the bigger or busier health clinics. However, the more realistic expectation for the near future is to have more FMSs at the district level to allow more visits to be made to other clinics without resident FMSs. Some PHCPs hoped that their current FMSs were to stay longer at the current posts indicating that FMSs turning-over or reposting to other clinics might be too fast to be desired.

There were more direct and clear expectations of FMSs to not get involved in administrative duties at the health clinics so as to be able to focus on clinical duties. However, some expectations did reveal that FMSs, being the only medical specialists at the health clinics, could not disassociate themselves from staff issues and practice management. FMSs in this country and family physicians worldwide are in fact trained in managing a health clinic.32 As a clinical discipline that is community based, family medicine is indeed a unique specialty positioned between public health and hospital care. Therefore, it was not surprising that many PHCPs at the health clinics and offices expected FMSs to get involved in administrative works and community health programmes, to investigative fieldwork during an outbreak and even to manage public health issues. Thus, this study showed that there were still misconceptions on this specialty's clinical functions, and confusion on roles between the FMS and the public health physician.

Of the many expectations reported, the priority areas for FMSs to improve on are their clinical competency, and personal and professional attributes.21 FMSs do need to pay attention to medical updates, be cognisant about latest evidence and practise effective medical care in congruence to the clinical practice guidelines.33 This is then followed by being available more often at the clinic for the patients and clinic staff, by having an efficient appointment system,34 ,35 and by applying evidence-based medicine in managing or referring patients by themselves or through their medical officers.2 ,36–38 Having an appropriate length of consultation time with each patient would help in a better clinical assessment of patients, decision-making and adherence to guidelines.39 Becoming an efficient clinician only is apparently insufficient and FMSs need to show a more caring attitude when dealing with clinic staff, and to always be thoughtful of their professional conduct when acting as a leader or as a team member.17 This, in turn, would create a good team climate leading to better chronic diseases management, preventive care services, patient satisfaction, continuity of care and access to specialist care.30

At higher levels, FMSA could organise relevant continuous professional development programmes on a regular basis consisting of scientific conferences, seminars or forums bringing together hospital specialists or experts to further understand essential updates in primary care medicine.40 Being the current main caretaker of this specialty in the public service, BPKK could work closely with the FMSs to improvise primary medical care. The Ministry of Health, through BPKK and state and district health offices, could do more by increasing FMS posts, allocating more resources that are in proportion to the workloads at each health clinic, as well as offering more opportunity for further training and promotion of the FMSs. Universities or training colleges that provide family medicine residency programmes should look into a more effective curriculum that could deliver the crucial clinical knowledge and incorporate desired skills in future FMSs.41 To be able to produce such FMSs, universities or training colleges need to have more capable academic staff, dedicated clinical site supervisors for curriculum implementation and regular formative and valid summative assessments.