|Year : 2016 | Volume
| Issue : 1 | Page : 4-6
Family medicine in Thailand: System, training, and obstacles
Public Health Curriculum, Surin Rajabhat University, Thailand
|Date of Web Publication||22-Dec-2015|
Public Health Curriculum, Surin Rajabhat University
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Wiwanitkit V. Family medicine in Thailand: System, training, and obstacles. Med J DY Patil Univ 2016;9:4-6
Family medicine is an important medical discipline worldwide. Basically, the family is the smallest social unit that everyone has to be a member. Family medicine is a specific discipline that focuses on family. The discipline deals with the medical practice at the family level, which is the interface between individual and community medicine. Family medicine skills are necessary for the general practitioner. Course content for training in family medicine has been developed worldwide. In different regions, the history, development, and problem are usually different. ,,,, In poor settings, the limited resources retard the development of the discipline and there are usually many problems in management (such as limited family medicine units and specialists). Hence, lesson learnt from each setting can be valuable and applicable for other settings. In Thailand, family medicine training has been in existence for a long time. The curriculum has evolved over a period of time. At present, there are about 6400 certified family physicians, that is, about one-fifth of overall physicians, practicing in all provinces of Thailand. However, bottlenecks in the system persist. The objective of this short article is to present the current situation of family medicine in Thailand. The overview includes history, present system, training, obstacles, and solutions. These inputs will be useful for those interested in family medicine and can provide ideas for research and development of the discipline in other settings.
In the past, in Thailand, the physician's job covered all aspects of medical and health care. He/she functioned as a nurse, pharmacist, laboratory scientists, and so on. Also, the physician was responsible for health care of families and communities besides individual patients. In the past, Thailand had limited individual practitioner working in rural setting who were usually not responsible for the family or had limited knowledge of the whole family (this is different from some South East Asian countries, such as the Philippines, where family physician concept is age old). However, advances in medical technology gave rise to different medical disciplines. The physician subsequently had a focused role and job. When the Western medical system reached Thailand in the past century, it spawned several new medical disciplines, specialties, and subspecialties. Family medicine is a rather new discipline in Thailand developing over the past three decades. A group of physicians in a medical university in a rural province of Thailand established a new Department of Family Medicine (Department of Family Medicine, Faculty of Medicine, Chiangmai University).  This was an actual challenge and the first adoption of the family medicine concept from the Western world to Thailand. Prior to the establishment of the first Department of Family Medicine in Thailand, there was no study on family in medical curriculum, family exposure was not given to the medical students, neither by Community Medicine Department nor Public Health Department; nevertheless, the study of family is partially mentioned in present course syllabus of community medicine and public health. Subsequently, the expansion and recognition of family medicine spread to all regions of Thailand. Presently, family medicine is a compulsory subject in medical curricula of all Thai medical universities and family medicine is a distinct specialty with specific syllabi corresponding with that of the Thai Royal College of Family Physicians. At present, Thai family physicians collaborate with international delegates via World Organization of Family Doctors (WONCAs). Presently, Secretariat of WONCA is located in Bangkok, Thailand.
Family medicine is a new specialty in Thailand. On par with other disciplines, family medicine is accepted as one of the highest forms of medical education in Thailand. The Thai Government approves and accredits the board and degree of family medicine issued by Royal College of Family Physicians. At present, the board certification of family medicine in Thailand is a PhD equivalent degree. The system of family medicine in Thailand is based on the family physician practice by family medicine specialist in specific family medicine care unit. However, the main problem is the lack of adequate numbers of family physicians. General Practitioner (M.D.), who has no specialty training, has to practice, without specific knowledge, as a family physician, and this becomes the problem that distorts the proper family physician system in Thailand. Nevertheless, there is an attempt by the government to provide education to upgrade the general practitioner to work in place of specialist in family medicine to serve the specific family medicine unit in communities, which will be discussed later.
In Thailand, the vision for the family physician system is the same as in developed countries that is, having the family medicine unit for attending to the health needs of the family. The family physician should have more roles in care of the family. Ideally, the patients should visit their family physician first before a visit to any other specialist; however, the general Thai people do not recognize the importance of family medicine and usually seek specialist care first. This results in overuse of resource by the rich. The declaration of the universal health coverage by the Thai government in the past decade can slightly help to promote the role of the family physician by setting specific family medicine unit system for each province. , According to the universal health coverage declaration, Primary Care Units (PCUs) are located in every district of Thailand. The aim of setting up PCUs as proposed by the universal health coverage project was to promote the system of family medicine in Thailand. The family physician can play a role as the director of the PCU (the other medical personnel cannot). This is the first time in Thailand that there is a specific family medicine unit. In the past, although there were many primary health care centers, general hospitals, teaching hospitals, and private clinics, there were no specific units for family medicine. In many settings, the administrators usually had general practitioners work for both primary health care and family medicine practice. With the concept of PCU, the rapid development of family medicine practice and training can be expected. At that time, to correspond to the setting of PCU, Thai medical council used a strategy to increase the number of family physicians by allowing of general practitioners and physician in other specialties to acquire family medicine board certification. This has resulted in many hybrid family physicians.
Family medicine is an important subject to be studied by all undergraduate MD students. Briefly, in Thailand, undergraduate MD education is a 6 years period study while graduate MD or specialist training is a 3 years period study. After undergraduate MD education, one can practice as certified general practitioner physician (this means the general practitioner is not the same as a family physician who has to pass the additional postgraduate MD education). The specific specialty training for family medicine is also available. The Royal College of Family Medicine in Thailand plays the main role in curriculum development and issuing of board certification to the graduate physician. In fact, family physician training was developed in 1999 for replacing the previously unsuccessful training in general practice.  The specialty training requires 3 years (with course work) or 5 years (without course work). The concept of the training system is based on the US concepts, which is similar to many countries in the Southeast Asia. Using the standard model from the US is the strength of training in Thailand; however, the weakness is a low preference for the discipline by MD graduates. , Each year, there are many family physicians certified by the Royal College of Family Physician (about 120 family physicians per year). Board certified physicians can work in several places, as director of PCU, as a specialist in a general hospital, as staff in universities, etc. Also, the board certification is equivalent to PhD recognition of the discipline, and continuous curriculum development will be the way for improvement of training. , Based on patient satisfaction levels, it is established that family physicians can provide a better primary care with higher levels of patient satisfaction, compared to other medical personnel. 
Since family medicine is a specific branch mainly relevant in primary care, the close relationship to the local alternative medicine system in Thailand can be seen. In fact, Thailand has just promoted the local Thai alternative medicine for a few years. At present, the syllabus for medical graduates in mainstream medical schools includes alternative medicine, and there are departments of Thai alternative medicine in some medical schools. Also, there are separate schools for alternative medicine in Thailand. Of interest, family medicine practitioners can practice alternative medicine in Thailand while those one who graduate from schools for alternative medicine cannot perform family medicine clinical practice (because medical students have to study alternative medicine, but alternative medicine students do not study and are not legally allow to practice modern medicine).
As already mentioned, the promotion of family medicine in Thailand is still an unfinished agenda. Compared to other specialties, the family medicine specialist is usually less recognized, in spite of the fact that family medicine board certification is approved as PhD equivalent to other more recognized board certification. This is only true for governmental setting. In private clinical setting, the recognition and salary is usually different. Hence, the family medicine is usually not a first choice for residency training by graduated MD. This is the same finding as other countries. , Biggs et al. suggested that, "medical school admission changes, loan repayment, and improved primary care reimbursement may help increase the number of students pursuing family medicine. " Also, the hybrid between a family physician and other kinds of specialists might deteriorate the concept of family medicine. Sometimes, a physician graduated in both family medicine and another specialty, he/she usually mainly practice in the field of another specialty that is more lucrative, without applying the concepts of family medicine. In addition, the role of family medicine sometimes overlaps with the general practice. In fact, the number of family physicians is about one-third of general practitioners who have no specialty in Thailand. The ratio of family physician to population is only 1:1000. Sometimes, general practitioners have to take the role of the family physician without in-depth knowledge, experience, and training. Although, there is a policy to train the general practitioner to be a specialist in family medicine not all general practitioners can be successfully trained and complete the certification process. Focusing on income, although family physician earns at the same level (low level comparing to private sector) of other specialists in governmental health sector, the family physician earns less than other specialist and nearly equal to general practitioner in private sector. This system is differing from western countries and countries neighboring Thailand.
In addition, since the current health care in Thailand includes private and public health care where a patient is not necessarily routed through primary care, a patient can directly seed care from the specialty unit. This can be problematic and lower the status of both the general practitioner and the family physician. To overcome the problem not only setting off more PCU but also regulation and promotion of primary care visit before meeting specialty and proper consultation system is recommended. It is also suggested that an important role of the academic Department of Family Medicine in the university is teaching, researching, as well as conserving the identity of family practice so as not to convert to general practice.  In addition, the general population does not fully know the role of family physician and, therefore, their services are not fully utilized. To cope with the existing problem, giving information on the role of the family physician to the masses is needed. In addition, a system to route the patient from general practitioners through the family medicine consultant as an intermediate step before further referring to other specialists is recommended.
| References|| |
Zuberi RW. Family medicine: A brief review of its history and concepts and its relevance to Pakistan. J Pak Med Assoc 1993;43:102-6.
Demarzo MM, Gusso GD, Anderson MI, de Almeida RC, Belaciano MI. Academic family medicine: New perspectives in Brazil. Fam Med 2010;42:464-5.
Abyad A. Family medicine in the Middle East: Reflections on the experiences of several countries. J Am Board Fam Pract 1996;9:289-97.
Abyad A, Al-Baho AK, Unluoglu I, Tarawneh M, Al Hilfy TK. Development of family medicine in the middle East. Fam Med 2007;39:736-41.
Christianson CE, Bistrovsky VF, Kogut BM. Family medicine in the Russian Far East. Fam Med 2007;39:742-5.
Kasemsant D. Family medicine: Old liqueur in new bottle? Chiang Mai Med Bull 1982;21:1-4.
Leesmidt V, Pannarunothai S, Chongsuvivatwong V. Implementing the universal health coverage: Which source of information is more reliable? Southeast Asian J Trop Med Public Health 2001;32:674-81.
Hughes D, Leethongdee S. Universal coverage in the land of smiles: Lessons from Thailand's 30 Baht health reforms. Health Aff (Millwood) 2007;26:999-1008.
Prueksaritanond S, Tuchinda P. General practice residency training program in Thailand: Past, present, and future. J Med Assoc Thai 2001;84:1153-7.
Biggs WS, Crosley PW, Kozakowski SM. Entry of US medical school graduates into family medicine residencies: 2012-2013. Fam Med 2013;45:642-6.
Saigal P, Takemura Y, Nishiue T, Fetters MD. Factors considered by medical students when formulating their specialty preferences in Japan: Findings from a qualitative study. BMC Med Educ 2007;7:31.
Jaturapatporn D, Dellow A. Does Family Medicine training in Thailand affect patient satisfaction with primary care doctors? BMC Fam Pract 2007;8:14.
Biggs WS, Crosley PW, Kozakowski SM. Results of the 2013 National Resident Matching Program: Family medicine. Fam Med 2013;45:647-51.
Clinical practice in academic medical center departments of family medicine. The Association of Departments of Family Medicine Task Force on Clinical Practice in US family medicine departments in academic medical centers. Fam Med 1997;29: 15-20.