Dr. C. V. Alert, MB BS, DM. (Family Medicine), FCCFP.
Family Physician. Fellow, Caribbean College of Family Physicians.
There is no doubt that the ‘cutting edge’ management of the non-communicable diseases, the NCDs, in particular those with a cardiovascular and/or a metabolic component, is changing rapidly. Almost annually there are new evidence based guidelines for major diseases like diabetes mellitus and hypertension; many new drugs and/or classes of drugs have appeared, although many of them are not available here because of high costs. On the other hand, most Caribbean research, although limited, suggest that we are still struggling with basic tasks like screening for cardiovascular risk factors, controlling blood pressures and blood sugars, and advising patients on weight management.
Then along came Covid-19, and it began picking off vulnerable individuals. How can the Caribbean Family Physician identify and protect these vulnerable individuals, and how can we prepare for future infectious disease pandemics, while attempting to keep the NCD pandemic at bay?
The NCD pandemic has led to large numbers of Caribbean peoples suffering and even dying prematurely from these diseases, even before Covid-19 arrived. Even though there has been some attempts to upgrade the management of NCDs in the Caribbean, such as new disease management guidelines promoted by some individual Ministries of Health, and even The Pan American Health Organization (PAHO), in many cases there is little ‘active promotion’ so perhaps a small handful of primary care physicians even see these new guidelines; and no system is ever established for active surveillance to monitor or ensure compliance with any guidelines. Primary Care also suffers while attention, and resource allocation, is focused on Tertiary Care: Health Promotion and Disease Prevention are pushed to the proverbial back burner. Making optimal use of available, albeit limited, resources does not seem to be a priority of our health decision makers.
It is quite remarkable that Caribbean medical research often shows up significant deficiencies in Primary Care, such as treating diabetes and hypertension. We know that, when diabetes and/or hypertension are not appropriately treated, then the chances of that individual having a heart attack, a stroke or other complication of these diseases rises significantly. In Barbados, for example, over the last decade, the average monthly number of heart attacks and strokes are thirty and forty five respectively, and the average monthly deaths from both of these diseases is twenty (1). One approach to this situation is to try and prevent these diseases, or to treat them aggressively when identified: Primary and Secondary Prevention. The health decision makers try to ‘fix’ these deficiencies in our health care delivery by focusing on Tertiary Care, such as setting up Emergency Departments, building Cardiac Suites and opening Stroke Units. To justify the costs associated with a Cardiac Suite, for example, you must make sure that you generate large number of patients with heart disease (even though you soon run out of beds to admit them), so downplay primary and secondary prevention. [That is the equivalent of, in response to a leaking tap that is flooding the floor, deciding to buy a new mop instead of trying to stop the leak.] Tertiary care takes up a lot of human, financial and technical resources, serves a few people only, is difficult to sustain with ‘Caribbean health budgets’ – how often have we heard of an expensive piece of equipment just sitting down idly, while waiting on a technician or a part to come from overseas. If we fail to improve our Primary Care, we will have a tsunami of patients requiring treatment for the complications of uncontrolled diabetes and hypertension, for example: one can make a case, based on our current statistics that we are already at this point.
According to Sir William Osler, the father of Internal Medicine, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has”. This is one area in which the Family Physician has an advantage over the Tertiary Care physician. While the hospitalized patient lies down in bed all day long, the Family Physician’s management is guided by the answer to questions like: Does this person have an active lifestyle, or sits in front of a screen all day long? Does (or often how much) does this patient drink and smoke? Is this person a ‘fast food junkie’? These are all important as they represent areas in which behavior can (at least in theory) be modified, especially in a patient who was never informed that his/her health is linked to eating, drinking, smoking and (lack of) exercise, in addition to getting regular doctor visits (‘check-ups’) and adherence to medications when prescribed.
At the practical level, treating the patient rather than the disease means considering what’s important to the individual patient and keeping that in mind when deciding how best to proceed. Of course an important part of that is patient education, and family physicians must adopt many opportunities to educate Mr. John Public, using a wide variety of conventional and social media avenues, available today, in addition to offering further education during face-to-face encounters with the patient and his/her family.
The Family Physician in the Caribbean, in an environment of limited numbers of specialists particularly in the public service, and with many patients unable to afford private specialty health care, often needs to have some competence in areas including psychiatry, cardiology, endocrinology, ophthalmology, nephrology, pharmacology, as well as being able to counsel the patient and their families on behavior change.
Continuing Medical Education (CME), linked to the ability to practice medicine in some islands, must be structured to update and enhance the clinical skills of practicing physicians. Available evidence suggests that this need is greatest in Primary Care. And while the University of the West Indies has developed a post-graduate course in Family Medicine, many Caribbean countries show little interest in encouraging their Primary Care Physicians to upgrade their clinical skills. Then, on top of a basic background in Family Medicine, the Jamaican Chapter of the Caribbean College of Family Physicians (CCFP) leads the Caribbean in terms of the quantity, and possibly quality, of CME provision for practicing physicians, while BAMP in Barbados also does a fair job, although BAMP’s CME is not directed specifically at Family Physicians. In some islands CME is offered by the pharmaceutical industry, an industry whose agenda at best may intersect with National Health agendas.
So the father of medicine Sir William Osler makes a strong point: we need to treat the patient, not just the disease, even while our knowledge of disease processes and their treatment is being advanced. Nowadays the Tertiary Care physician has to focus on ‘the patient in bed 9 who had a heart attack: what do his cardiac enzymes and cardiac catheterization show’? Our rotation of medical students during medical school, and even newly graduated doctors during their internship, has reduced exposure to Primary Care and instead focused on Tertiary Care. The Family Physician has to deal with the family and friends of the patient who had the heart attack. What can he eat? When can he resume sexual activity? Can he resume working, or does him employer need to recruit a new staff member? And what about the psychological state of the patient and his family?
The Family Physician must be prepared to listen to our patients, so, in addition to their concerns and questions, they are encouraged to bring in their blood sugar and blood pressure readings. We want to hear what is happening with their weight loss, i.e., how the diet and exercise are doing? What is happening with the medications: did they get all their medications, or did they stop taking some because of possible side effects or medication costs? We do know that some of the newer medications have favorable disease modifying properties, like cardio-renal protection, but invariably these newer drugs are costly, especially when compared to the ‘free’ older chronic disease medications on government formularies. Does the patient’s diet upset the family’s eating habits, or would the patient like to bring the entire family (especially the main cook) to have an interactive session with the dietitian?
There was a conference in Barbados in January 2023, put on by WHO/PAHO for Small Island Developing states (SIDS), titled “The NCDs and Mental Health”. However, long before the end of this 2-day conference most attendees were convinced that the NCDs and ‘mental health’ could not be logically separated, as each of these is intertwined with the other. However, most physicians who practice in Tertiary Care Institutions have little or no experience in Psychiatry or mental health issues. Mental health gets little attention in medical school undergraduate programs, and ‘Psychiatry’ is not mandatory in internship programs. Yet both physical and mental health issues co-exist in most patients.
The Family Physician then both has to take care of the mental health of patients, then guide them through the new protocols designed to minimize the effects of both the NCD and the Cavid-19 pandemics. We need Family Physicians 2.0: primary care physicians trained in Family Medicine, and committed to upgrade their skills to deal with challenges now and in the future.
References.
- Barbados National Cardiovascular Disease Registry Annual reports series, 2010-2018.