Background
Family physicians take care of a varied range of patients with undifferentiated conditions over a long period of time. Their scope of practice is, therefore, defined by the human needs rather than specific disease conditions (Phillips and Haynes, Reference Phillips and Haynes2001). A survey in Europe and Britain showed that, out of 1000 adults in a community, within the span of one month, approximately 3 quarters suffered an episode of illness, 250 sought health care with only 1 person reaching a specialist. This underscores the importance of family medical practice. The roles of the family physician include clinic leader and manager, mentor and clinical teacher and researchers among others (Makwero et al., Reference Makwero, Lutala and McDonald2017). Key among the many roles of a family physician are caretaker, consultant, expert in clinical governance and community-oriented care, clinical supervisor and capacity builder, etc. However, the focus of these roles may vary by individual preferences as well as with experience. Senior family practitioners may prefer to take on more complex administrative oversight roles over clinical care or go into sub-specialization (Mash et al., Reference Mash, Ogunbanjo, Naidoo and Hellenberg2015).
Due to the long-term relationship with the patients (1), the family physician plays a critical role in preventing illness, managing common complaints, identifying emerging illness, managing chronic illness and acts as a focal point to link patients to other specialized services while still providing primary health care. This supports patients in navigating the complex healthcare systems (RevereHealth, 2018). Research into family medicine centers around clinical issues as well as educational issues so as to ensure excellent care is provided (Bowman et al., Reference Bowman, Lucan, Rosenthal, Mainous and James2017).
Family medicine as a practice in Saudi Arabia was started in 1980. By 2014, there were three cadres of health workers providing family practitioners health services to address the increasing and varied needs of the indigenous populace with the epidemiological transition of disease (Albejaidi, Reference Albejaidi2010). The scope of practice of family medicine practitioners (FMP) is not well-defined (Osman et al., Reference Osman, Romani and Hlais2011); additionally limited data exists on this practice (Albejaidi, Reference Albejaidi2010). It is with this background that we set out to explore what family physicians deem relevant and wish to prioritize among a broad range of common activities in daily practice with a view to provide information to support the national strategic vision of 2020 in Family Medicine (Al-Khaldi et al., Reference Al-Khaldi, Al-Ghamdi, Al-Megbil and Al-Khashan2017).
Methods
Study design and setting
The study was a cross-sectional survey of FMP in Saudi Arabia.
Study population
The study population was a conveniently selected sample of 415 individuals of approximately 700 FMP in Saudi Arabia (Almalki et al., Reference Almalki, Fitzgerald and Clark2011).
Data collection
The participants responded to an online questionnaire sent as an electronic link through email and distributed all over the country. Responses were collected between November 2018 and February 2019. The questionnaire was comprised of eight questions. The first five questions addressed demographic data, highest educational qualification, employer and duration of practice in a specific primary care center. The next 3 questions listed 20 activities usually done by primary care physicians, and asked them to rate their meaningfulness on a 5-point Likert scale; and select the top 3 they would like to spend the most time on and the top 3 they would like to spend the least time on. The Likert scale was graded as follows: ‘strongly not meaningful’, ‘not meaningful’, ‘neither meaningful nor non-meaningful’, ‘meaningful’ and ‘strongly meaningful’.
The questionnaire was adapted from Halvorsen (Reference Halvorsen, Edwards, Aaraas, Aasland and Kristiansen2013) based on activities regularly conducted by FMP (Halvorsen et al., Reference Halvorsen, Edwards, Aaraas, Aasland and Kristiansen2013).
Data analysis
Reliability test was conducted using Cronbach’s alpha test. Measures of central tendency and dispersion, as well as proportions, were used to summarize participant characteristics and proportions of participants that gave similar responses to the questions.
Responses on the 5-point Likert scale were summarized to a 3-point scale of meaningful (comprised of ‘meaningful’ and ‘strongly meaningful), neither meaningful nor non-meaningful and ‘not meaningful’ (comprised of ‘not meaningful’ and ‘strongly not meaningful). Proportions were used to summarize participant characteristics and proportions of participants that gave similar responses to the questions.
Each of the responses of the three activities that participants wished to spend the most time on or three the least time on were categorized into categorical outcome with three options; ‘would like to spend more time’, ‘would like to spend less time’ and ‘no opinion’ for those who did not select that option. Chi-square statistics were used to compare preference for time spent on these six activities by participant characteristics; a P-value of <0.05 was considered significant (Bruce, Reference Bruce2008). Data analysis was conducted using SAS version 9.2 (SAS Institute Inc., 2012).
Ethical considerations
Ethical approval to conduct this study was granted by the IRB committee of College of Medicine, Prince Sattam Bin Abdulaziz University. Return of the online, anonymous questionnaire was considered as consent to participate in the study
Results
Participant characteristics
Out of 700 FMP invited to participate in the study, 527 agreed to participate in the study and a total of 415 physicians returned completed questionnaires, with a response rate of 78.7%. The median age of the 415 practitioners interviewed was 35 years (IQR 32–38 years). The majority were male (59.3%; n = 246), had a Bachelor’s degree (42.4%), worked at the Ministry of Health (47%). (Table 1). The median duration of work experience since qualification was nine years (IQR 5–14 years).
Demographic characteristics of family practitioners in Saudi Arabia (n = 415)
Reliability and validity test
Reliability test was conducted using Cronbach’s alpha to test whether the data collected from the study was reliable. From the analysis, the Cronbach’s alpha was found to be 0.864, and thus was considered acceptable and further tests were conducted.
Perceived relevance of different roles by family practitioners in Saudi Arabia
More than half of all the 415 practitioners interviewed, felt that all the listed activities were meaningful to them. The majority (>80%) listed that the management of risk conditions, follow-up of chronic somatic illnesses, preventive health clinics, dealing with psychosocial problems, quality assurance, teaching and supervision, the management of medically unexplained symptoms and school health services were meaningful to them (Table 2)
Ranking of meaningfulness of specific duties by family practitioners in Saudi Arabia
Activities family practitioners would like to focus on most
Each practitioner interviewed was asked to identify from the same list of 20 activities, which 3 activities he or she would like to spend the more time on. The majority indicated they would prefer to spend more time managing health risks (57.6%), daily common complaints (55.7%) and follow-up of chronic illnesses (55.7%). The selected activities in the order of the most preferred to the least preferred are shown in Table 3.
Activities family practitioners in Saudi Arabia would prefer to spend time engaged in
As regards preference for spending time on recent everyday symptoms and complaints (infections, tendinitis, headache, dyspnea, chest pain, abdominal pain, etc.), 231 (56%) responded they would like to spend more time, 50 (12%) responded they would like to spend less time and 134 (32%) did not respond. There was a significantly higher proportion of male participants who indicated they would wish to spend more time on recent everyday symptoms and complaints compared to female participants. Responses for preference for more time, less time and no response were 65%, 31% and 62% for male participants and 35%, 68% and 39% for female participants (P = 0.3). Preference for time spent on ‘recent daily symptoms’ did not vary by other participant characteristics. Preference for time spent on ‘chronic care’ and ‘risk conditions’ did not vary by participant characteristics as shown in Table 4.
Activities family practitioners would like to focus on the least
Each practitioner interviewed was asked to identify from the same list of 20 activities, which three activities he or she would like to spend the least time on. The majority indicated they would prefer to spend less time engaged in terminal care activities (46.8%), emergency care (32%) and addiction medicine (23.4%). The activities that were least preferred are highlighted in bold font in Table 5.
Chi-square test between gender and activities spent more and less time on
Chi-square test between age and activities spent more and less time on
As regards preference for time spent on emergency care, 50 (12%) responded they would like to spend more time, 133 (32%) responded they would like to spend less time and 232 (56%) did not respond.
The proportions of participants who wished to spend more time on emergency care (n = 50; 12%) varied by educational qualification; these were 63%, 21%, 10% and 5% for Bachelors, Diploma, Board-certified and Fellowship holders, respectively. This was statistically significant (P = 0.01). Preference for time spent on ‘emergency care’ did not vary by other participant characteristics. Preference for time spent on ‘terminal care’ and ‘drug addiction’ did not vary by participant characteristics.
Discussion
FMP in Saudi Arabia ranked management of health risk conditions, follow-up of chronic illness and running preventive health clinics as activities that were most meaningful to them. The same order prevailed when ranking activities that they would have preferred to spend more time except for the management of recent everyday symptoms that were ranked third in place of preventive clinics. Male practitioners preferred to spend time on running daily clinics compared to female practitioners. Additionally, they would prefer to spend less time on emergency care, terminal care and addiction medicine. Additionally, those with Bachelor’s degree preferred to spend more time on emergency care compared to those holding other educational qualifications.
It is laudable that the activities ranked as meaningful by the family medical practitioners are aligned to the general prevailing conditions in the country. Among adults visiting primary care centers in Saudi Arabia, 38.3% we overweight and 27.6% were obese (Al-Qahtani, Reference Al-Qahtani2019). Additionally, among adults visiting primary healthcare centers in Riyadh, 21% and 12% had a Framingham risk score (FRS) of ≥10 indicating intermediate and 10-year risks for cardiovascular disease (AlQuaiz et al., Reference AlQuaiz, Siddiqui, Kazi, Batais and Al-Hazmi2019).
The model of family medicine practice is structured similar to that of primary health care and could be used to improve primary health care (Al-Khaldi et al., Reference Al-Khaldi, Al-Ghamdi, Al-Megbil and Al-Khashan2017). This is because it is centered on the needs and preferences of individuals and communities, addresses broader health determinants and provides comprehensive contextualized care throughout the lifespan of an individual (World Health Organization, 2019). By indicating their preference for attending to daily complaints of their patients which would be varied, family medical practitioners illustrated they were driven to care for the needs of their patients (Halvorsen et al., Reference Halvorsen, Edwards, Aaraas, Aasland and Kristiansen2013)
The variation in preference for time spent on emergency care by educational qualifications may point to differences in training program content and educational methodologies. As family medical practitioners in Saudi Arabia are frontline workers at primary healthcare centers, akin to middle-level healthcare workers in Africa, it is essential that training content and skills’ professional development course are standardized to enable them provide uniform care (Couper et al., Reference Couper, Ray, Blaauw, Ng’wena, Muchiri, Oyungu, Omigbodun, Morhason-Bello, Ibingira, Tumwine, Conco and Fonn2018). The absence of unified standards in family medicine has been cited as one of the challenges faced in the development of the practice of family medicine in the Arab world (Al-Kurashi, Reference Al-Kurashi2002).
It is challenging to infer why more male practitioners preferred to spend more time on managing daily complaints compared to female practitioners in the absence of information regarding what actual tasks they are involved in on a day-to-day basis. In the literature, male and female physicians with the same skill set and level of experience usually have different career progression rates, which may denote different role assignments (Maynard et al., Reference Maynard, Bloor and Jefferson2015). It is possible that our sample that had a majority of male participants, was biased or our sample was not representative of the population of FMP in the country (Ministry of Health, 2017).
Limitations
There were some limitations. In the literature, family medical practitioners have mentioned that challenges they face were workload, time pressures and meeting demands (Manca et al., Reference Manca, Varnhagen, Brett-MacLean, Allan, Szafran, Ausford, Rowntree, Rumzan and Turner2007). However, we did not collect information regarding what were the actual activities that family medical practitioners were involved in that were taking up their time in place of what they would prefer to do. Furthermore, we did not probe further to find out their reasons for preference of specific activities over others. Additionally, our sample was limited and there was a possibility of selection bias due to convenience sampling. Our inquiry was focused on a generic scope of service rather than a contextualized scope of service that addresses specific needs.
Conclusion
In conclusion, the activities that FMP find most meaningful correspond to the epidemiological patterns of disease in the country. These activities are also aligned to the World Health Organization’s goals for primary health care that intend to achieve universal health care and attain the sustainable development goals (World Health Organization, 2018). The variations in preference of managing medical and surgical emergencies by different cadres of family practitioners in the country reflect the varied format and duration of training of these practitioners who provide the same set of services on a day-to-day basis (Al-Khaldi et al., Reference Al-Khaldi, Al-Ghamdi, Al-Megbil and Al-Khashan2017).
We, therefore, recommend that training of family medical practitioners be comparable across qualification types and specific contextualized scopes of services to be offered by family practitioners be developed. Further studies that compare the actual activities that family practitioners are engaged in versus a specific scope of service, and probe further to find out reasons for preference for certain activities over other activities should be conducted.
Acknowledgments
The authors would like to thank the study participants. This publication was supported by the Deanship of Scientific Research at the Prince Sattam Bin Abdulaziz University, Al Kharj, Saudi Arabia
Funding
This study did not receive any specific funds.
Availability of Data and Materials
All data and materials supporting the conclusions of this study are included within the manuscript and available upon request from the corresponding author.
Authors’ Contribution
SAG designed the study and wrote the draft of the manuscript. MMA and MAB performed data acquisition. JAZ and KKA performed the analysis. All authors read and approved the final manuscript for submission.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Consent for Publication
Not applicable.
Ethics Approval and Consent to Participate
This study was ethically approved by the Institutional Review Board (IRB) of College of Medicine, Prince Sattam Bin Abdulaziz University. Return of the online, anonymous questionnaire was considered as consent to participate in the study.
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