July 2017 News Updates

by Dr. Sajad Ahmad

It has been a while since I have written about any progress or new updates, a lot has been going on for the past six to eight months. We had an amazing July this year, more about that later.

At the end of last year, some of us started to engage with Khyber Medical University on how we could be of help in promoting Family Medicine. The interest had been mutual, a discussion of those few months saw the foundation of a separate panel on family medicine flourish at Khyber Medical University’s 8th Annual Health and Research Conference held on the 25th of April 2017. Family Medicine was discussed in detail by the secretary of health and options and discussion surrounding its promotion, trailing health centers, as well as the training of future family physicians, was discussed in detail.

Many insights were discussed in the panel dedicated specifically to Family Medicine by our Dr. Asma Kazmi representing APHCP.

The momentum from this did carry on, slow and steady, but this resulted in the formation of a focus group. Participation was encouraged from all over Pakistan with Ayub Medical College (Abottabad), Shifa (Islamabad), Fatima Memorial, University of Health Sciences (Lahore), Agha Khan University (Karachi) as well as the unflinching support of the World Health Organisation EMRO has been a key to the progress so far. It has been a great honor and privilege for APHCP to be a part of this team and help shape the future of Family Medicine in Pakistan.

The discussions from the initial focus group and after exchanging ideas and discussion in hundreds of emails in countless chains and telephone calls we flew to Pakistan in early July to participate in a two-day consultatory workshop held by Khyber Medical University under the auspices of World Health Organisation. The two-day event was attended by participants from all the four provinces including representatives from Kashmir and Gilgit Baltistan.  The attendance of Health department has been the key in taking the proposals forward. Presented by Family Medicine academics, senior examiners, PMDC, Family Physicians from both within Pakistan and the United Kingdom had the opportunity to suggest a way forward for the future. The two-day consultation concluded with the formulation of a concept note, a list proposals for the health department to carry out.

It has been an enormous privilege to be part of the team to help in laying the foundation of this wonderful speciality in Pakistan. Although some elements of Family Medicine are present in scattered forms in other provinces, Khyber Pakhtunkhwa, Balochistan and Gilgit Baltistan in particular lacks a setup to towards training generalists doctors. This in-spite of the facts that Four Medical Training Institutes of the province are recognised for Membership of the  College of Physicians and Surgeons of Pakistan in Family Medicine.

I believe more can be achieved in Khyber Pakhtunkhwa,  I believe there is a lot of potential for change towards better primary health care while keeping the costs of providing service down, I believe we can train our doctors working in the basic health units and provide them with the skills of family medicine. I believe we, working together can create a structure of primary health care that will complement the subspecialties of medical care already in existence. To do this, we need ownership, for, without it, we would be lost.

 

 

 

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FAMILY MEDICINE: A SAVIOUR OF ILL HEALTHCARE IN KHYBER PAKHTUNKHWA AND BEYOND

By Dr Sajad Ahmad

Pakistan can benefit from family medicine as a speciality, in this latest editorial written for KMUJ, I discuss some of the basic arguments for a better primary healthcare system.

You can read the full article on KMUJ’s website here

if the above link doesn’t work, click here http://www.kmuj.kmu.edu.pk/article/view/16910/pdf

THIS ARTICLE MAY BE CITED AS: Ahmad S. Family medicine: A saviour of ill healthcare in Khyber Pakhtunkhwa and beyond. Khyber Med Univ J 2016; 8(4): 165-166

Google Scholar citation: Ahmad S. FAMILY MEDICINE A SAVIOUR OF ILL HEALTHCARE IN KHYBER PAKHTUNKHWA AND BEYOND. Khyber Medical University Journal. 2017 Feb 25;8(4):165.

Primary Healthcare reforms in Pakistan.

by Dr. Sajad Ahmad,

Pakistan as a country needs to a lot more  to improve its healthcare. We have been raising the profile of family medicine together with a better system for the implementation of a modern primary healthcare. It is clear that to achieve the WHO millennium goals politicians need to come up with a clear exhaustive policy which needs to be followed through to the end.

You can read one of the articles I recently wrote for MEJFM here. You can also search for the article on google scholar.

Web linkhttp://www.mejfm.com/November%202016/Pakistan.htm

Citation : Ahmad S, Qidwai W. Primary health care reforms in Pakistan: A mandatory requirement for successful healthcare delivery. MIDDLE EAST JOURNAL OF FAMILY MEDICINE.;7(10).

 

A collapse and 1122

By Sajad Ahmad.

So I am standing in “The book shop”, a newly launched bookstore, welcomed and awaited good news after the last shut its doors to customers a few months ago in Peshawar, Pakistan.

I am trying to find books when I hear a loud thud, an elderly woman had collapsed on the floor hitting her head and back on the table behind her, her daughter panicking, (this is in Peshawar) they tried to sit her up, my adrenaline surge pushes me forward, I shout, “leave her laying down! I am a doctor” and then a thought comes to my mind, I am unsure of the services available here, I try to speak to the elderly lady, she is unresponsive with a vacant look. Next, I check her breathing, there is a very slow effort, suddenly she starts to gasp and lets her breath out. Panic sets in, her pulse barely palpable. I keep my hand on her pulse and suddenly I feel it stopping, “lay her flat”, I shout, while at the same time saying she needs CPR, I attempt and after a few compressions, I feel her responding moving her eyes, again.

She starts to breath better, her pulse becomes stronger.

The next moment I shout out, call for an ambulance, call 1122, it’s the equivalent of 999 we have come to know in U.K. I am unsure if this will work in Peshawar! I explain, now that the lady is more stable, I am a doctor, but don’t work in Pakistan and am here on a holiday. I am unsure of the services here.
We gradually help the lady to a chair, two guys from the shop are waving books to fan the lady. She feels somewhat better.

Next, I start taking a detailed history and ask for a paper and pen to write it for the family, I think the doctors in the hospital would need it.

I don’t recognise the names of the medications, they are trade names, and I am used to the UK system of generic drug names, here is a learning outcome for me!
The next thing I see, is the efficient paramedic from the 1122 service, arrived, taking no longer than 10 minutes in Peshawar traffic!

I hand over to him with details, giving the written sheet, and my phone number to the family.

I hope she recovers, I have hope that Peshawar is on the way to reforms. Well done 1122!

APHCP Presents at Ayub Medical College – Abbottabad.

No matter how much we talk about the importance of modern primary health care, a concept of family medicine, it is nothing but a drop in the ocean. Many of us know that Family Medicine as a concept still needs to be nurtured in Pakistan. It was in the middle of the year we started planning our talk at Ayub Medical College at Abbottabad. A city named after Major James Abbott (1), It grew from a small district in January 1853 to the second largest city in Khyber Pukhtunkhwa Province of Pakistan. With a current population of above one million souls (2) many have come to this beautiful site, an existence in the foothills of Himalayas, doctors have often struggled to provide health care.

Primary health care like anywhere else in Pakistan is provided by multiple sources. Ranging from private providers to specialists often treating multiple specialties in their private clinics. However, it was the earthquake of 2005 that saw a major burden on the already over-stretched health care system in Abbottabad. Many volunteered from the west, Orthopedic specialists, General Surgeons, and even Physicians, but of great pride is the involvement of Family Physicians in a disaster situation (3).

Pakistan as a country desperately needs a better system of primary health care, it needs the concept of trained family physicians, generalists specializing in the generality of medicine. That, we believe should be the way forward.

It was natural for us to plan one of our talks in the second largest city in Khyber Pakhtunkhwa province after our talks in Peshawar earlier, this time, the venue was Ayub Medical College at Abbottabad, the city of pines as its lovingly known. The planning for the talk was the culmination of discussions with the Dean and Associate Dean of Ayub Medical College. The Associate Dean, Dr. Umer Farooq arranged and hosted the event.

On 21st September 2016 We arrived at Ayub Medical College, the venue of our talk. Presented by two of our core committee members Dr. Abdul Jalil Khan coming back to his alma mater and Dr. Moeen Ashraf.

We were very warmly welcomed by the team of Community Medicine Department.

“It was very emotional to meet my great teachers Professor Huma Jadoon (head of department), Professor Saleem Wazir, Dr Umer Farooq (Associate Dean, AMC), Professor Dilawar, Professor Nisar Sb and Professor Aziz-un-Nisa (Dean, AMC).” ~ Dr A Jalil Khan

The talk was attended by final year MBBS Students, House officers, Trainee Medical Officers and the faculty Members. It has been a source of great pride, as Dr. Jalil stated, “I was really pleased to see my class fellows and other fellow students now sitting in the faculty seats especially Dr. Aftab Khan, Dr. Owais Khan, Dr. Zeeshan and Dr. Inaam. I am really thankful to Dr. Yousaf Aziz (pediatric Surgeon in Kuwait) who also attended our talk”.

Our aims and objectives of these talks have always been to promote family medicine as a specialty. The discussion we have had so far with the health professionals in Pakistan has concluded that a comprehensive primary care may be one of the better solutions to improve the health care system in Pakistan. For primary health care to be promoted in any capacity would require funding, training of general practitioners is the core foundation of any modern primary health care system and is directly related to the funding it receives. We have seen first hand how the inequality in the health care budget and lack of prioritization have led to the sprawling of specialists hospitals. But the lack of investment in primary health care still burdens the same hospitals (4) which ironically were set up to cope with the disease burden in the first place.

The talk at Ayub.

It all began with a brainstorming session, a scenario we placed to the medical students, asking them to come up with ideas how to improve the health care system. The purpose for this was to let the audience think differently, by challenging the common perceptions , the ideas we already have ingrained in our subconscious. and then began the talk, delivered by Dr. Abdul Jalil Khan and Dr. Moeen Ashraf.

The first part of the talk, “The Story” was meant to share an experience of being transformed from a student at Ayub Medical College into a career GP and Family Physician in U.K. The life of a GP in United Kingdom’s National Health Service (NHS), the variety, the challenges and most importantly the trust of community in this speciality.

The second presentation which was the main theme of the talk “Family Medicine as specialty and it’s Future” was delivered by Dr. Moeen Ashraf. Here came the advice to the students on current models of training that is offered across the developed world especially U.S.A, U.K, and Australia. Dr. Ashraf also discussed what is currently available in Pakistan in regards to the availability of training.

The last part of the talk “Why Family Medicine” was delivered again by Dr. A Jalil Khan. It was concentrated on the importance of a comprehensive primary care and how we might adopt it in Pakistan.

The talk was concluded by the closing remarks from the Dean, Professor Aziz-un-Nisa who acknowledged the importance of a comprehensive primary care. She mentioned how the specialist outpatient clinics are overcrowded by patients presenting with primary care problems. She agreed that developing a family Medicine specialty will not only train future Family physicians but will also run the filter clinics and improve the triage system in tertiary Hospitals.

References: 

1. Wikipedia. James Abbott (Indian Army officer): Wikipedia; 2016 [cited 2016 14th October]. Available from: https://en.wikipedia.org/wiki/James_Abbott_(Indian_Army_officer).

2. Wikipedia. Abbottabad Web: Wikipedia 2016 [cited 2016 17th October]. Available from: https://en.wikipedia.org/wiki/Abbottabad.

3. Newmark J. A month as a GP in the earthquake area of Pakistan. British Journal of General Practice. 2006;56(524):224-5.

4. Ahmad S. Letter to the editor (How to extend GP training and improve urgently and emergency primary care). Br J Gen Pract. 2016.

Awareness Talks on Introduction to Family Medicine

Talks at Medical colleges in Rawalpindi and Wah Cantt, April 2016

An article reviewing recent awareness talks by Dr Kashif Sohail MRCGP

I visited Pakistan in April with a plan to deliver talks on Family Medicine to raise awareness about speciality in medical colleges under the banner of APHCP (aphcp.com) and RAHII (www.rahii.org).

One week prior to these talks I had meetings with Principal of Rawalpindi medical College ( RMC ) and       Wah Medical College ( WMC ). Both institutions were enthusiastic to be part of awareness campaign.

Prof. M. Umar Principal RMC and Department of Medical Education arranged for me to present to final year medical students at RMC on 19th April. It was my first visit to new block of RMC and was a great feeling.

WMC principal Prof Waseem-ud-din arranged my presentation for house officers, PGT’s and faculty staff for 20th April.

AIMS : These talks were arranged to raise awareness among the medical community including staff and students in order to promote family medicine in Pakistan.

Presentation at RMC- 19TH April

Family Medicine awareness session was arranged in CPC hall and audience was mainly final year medical students.

Before starting my talk I asked the audience if they have heard of family medicine as a specialty before today’s talk ; surprisingly none of them nodded in yes and that showed how important was this to make them aware of family medicine. They listened keenly about family medicine as it was a new subject for them.

 

Presentation at WMC – 20TH April

Wah Medical College holds CPC meeting every Wednesday morning starting at 8 am and I was supposed to present during one of these meetings. I met couple of times with Principal of WMC, Prof  waseem-ud –din before hand and shared potential presentation points and also discussed possibilities regarding primary care model in wah cantt.

Here audience was mixed including all the faculty staff and junior trainees and house officers. Talk went very well and there was a good question answer session in the end. Few doctors showed interest in more information regarding membership exams in family medicine.


Conclusion:
 Talks were very well received and appreciated by the audience and head of both medical colleges and it was decided to arrange follow up talks as well.

There is a lot of potential for improvement of family medicine and Pakistan can benefit a lot from promoting family medicine training and also by including in the curriculum.

Potential Solution: 

Introduction of family medicine departments in colleges will create awareness and interest in medical students and house officers towards specialty. It was also discussed to consider the possibility of having family medicine outpatient clinics in hospitals in first phase and to start health checks of local population to screen for cvd and diabetes etc

PMDC should either declare it mandatory or at least encourage further training post MBBS before practicing independently and provide some incentives for those who are willing to opt for further training route in family medicine.

Those doctors who complete 18 to 24 months hospital rotation following MBBS could then be considered eligible for MCPS exam in family medicine. And after passing MCPS they can be allowed to work independently.

Those who pass MCPS and if they are willing to consider FCPS than  CPSP should arrange to provide some training in BHU / RHC for  at least 6 months and then as an incentive CPSP could consider to send them abroad for 6- 12 months for  training in family medicine.

This can work as an interim measure till Pakistan start producing its own family medicine doctors.

Rescue 1122 an excellent initiative in KP

On  Thursday 18th of February 2016 a group from the association had the immense pleasure of meeting Dr Asad Ali director general of rescue 1122 service in Khyber Pakhtunkhwa (KP) at Peshawar. We were given an extensive tour of the central head quarter which was followed by a presentation and detailed review of the services that are now available to the citizens of Peshawar and surrounding areas.

It was the fateful day of 28th of Oct 2008 when the lives of 337 families along with the thousands more changed. In a single bomb blast that erupted in the most densely populated area of Peshawar, The Meena bazar, frequented by women and children 137 people lost their lives with 200 or more injured (1). This was the day when rescue services in Peshawar were tested to its capacity. Peshawar has three main government hospitals, all already overwhelmed with patients due to the lack of an effective primary health care system were put to the test. It was this event that triggered a reaction from the local government.  A domino effect which culminated in the establishment of the first ever comprehensive rescue service for the citizens of Peshawar, its a shame that such had to be thought of only when we were plagued by terrorism, but nevertheless it is a service that is highly valued and has begun providing care in the best form that Peshawar would have ever seen.

Rescue 1122 “The leading Humanitarian service of Pakistan”(2) is a comprehensive humanitarian service, its roots were sown in Punjab, and that is where the trainees, the fire squad, the paramedics and other team members receive their training as well. The majority of the service provider in KP have received their training from the training institution in Punjab.

It is certainly a breath of fresh air that the Ambulances respond to emergencies, sent through calls received at the Headquarter call center, where trained triage staff and a supervisor covers the in-comings 24 hours a day 7 days a week, ambulances have a response time of under 10 minutes to most of the emergencies, may that be traffic accidents, strokes, cardiac emergencies or the menace of our society, terrorism. It is commendable that they have achieved this even in the busiest and congested cities in Pakistan (3).

Finding an ambulance, let alone one with a trained technician and equipment has always been a rarity in the past, it is surprising how much we as a nation are capable of achieving when we put our efforts and sincerity to it, the association’s (aphcp) main bias is towards providing health care, and that is where most of our questions and interest were. There are at present 28 ambulances and 12 stations all across Peshawar, the ambulances are fully equipped with defibrillators, spinal boards and facilities to triply immobilize patients, the days of dragging a patient from the arms and legs across an accident site are long gone, it was certainly a happy moment for us when we found out that the ambulance technicians now board and triply immobilize all patients, with giving special attention to the airway, they can intubate!

Each ambulance has two technicians and one driver, something that is even a rarity in the U.K were it is mostly only a pair.

There has been some anecdotal evidence and stories / feedback from people in Peshawar, how many have called the rescue 1122 service because of emergencies in their homes, and they have pleasantly found the ambulance along with technicians in under ten minutes, some even claiming that the response time was 3 minutes!

With the availability and ease of service has come misuse from the people, many telephoning and asking for food delivery, perhaps this will change with time and education, it does need a positive portrayal in media and it does deserve encouragement, it is with services as these that we become a caring nation, a nation that can achieve great feats.

The service has taken 5 years to reach its current status, and it is improving and expanding by the day, it has received the vision and dedication of its director general Dr. Asad Ali Khan and his dedicated team, it is now providing safety courses, BLS and other life support courses to organisations, it will in the future begin to deliver health and safety overviews and by law will change things for the better, safety in workplace, safety at public places are all in its vision for the future, it provides specialized urban search and rescue services, the services are most commendable, and we hope to see more improvements in this as well as in the rest of the elective and acute health sector in KP. Perhaps the establishment of a well equipped and highly skilled Family Medicine Physicians are needed to link the chain.

 

Rescue 1122 Punjab    Rescue 1122 KP 
1. 28 October 2009 Peshawar bombing wikipedia2016 [updated 29 January 2016; cited 2016 23 february]. Available from: https://en.wikipedia.org/wiki/28_October_2009_Peshawar_bombing.

2. : Punjab Emergency Service [cited 2016 23rd February ]. Available from: http://www.rescue.gov.pk/.

3. Ali Z, Shah SAA, Hussain A. Growing Traffic in Peshawar: An Analysis of Causes and Impacts. South Asian Studies. 2012;27(2):409.