|Year : 2014 | Volume
| Issue : 4 | Page : 237-243
Being a family physician: Experience of general physicians working in rural and urban healthcare centers in Iran
Setareh Abdoli1, Samereh Abdoli2
1 Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
2 Nursing and Midwifery Care Research Centre, Nursing and Midwifery Faculty, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||16-Oct-2014|
Faculty of Medicine, Iran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Background: The family physician program in the form of a referral system is one the best administrative strategies, especially in rural and low populated regions (under 20,000 people) of Iran in 2006. Objectives: This study was conducted with the aim of general physician's experience as practicing in family physician program. Materials and Methods: This study was a qualitative study using conventional content analysis. The data were gathered by in-depth interview with 12 family physicians working in rural and low populated urban health and treatment center in a province located in west of Iran in 2011. Findings: The findings highlighted that five main themes and 12 subthemes reflected the general physician's experience as family physicians. They were: The physician's lost identity (physician: Belittled and physician: Shattered in the system), the physician left in the system (physician: Extorted and lacking supportive environment), passive and thoughtless practice (learning, a faded element, and scientific practice on the verge of demise), the unstable foundation of the program (insufficient groundwork, lack of comprehensiveness, and the change in the program's nature during practice), and sparks of success (satisfaction with need-based practice, proper distribution of general physicians within the country, and effective management of chronic diseases). Interpretation and Conclusions: The findings indicated serious challenges in family physician program. Ignoring these problems may lead to medical and financial resources wasting. So a permanent progressing program needs solving defects of the valuable program in Iran to improve healthcare in rural and low-populated regions.
Keywords: Family physician, Iran, qualitative study
|How to cite this article:|
Abdoli S, Abdoli S. Being a family physician: Experience of general physicians working in rural and urban healthcare centers in Iran. Int J Health Allied Sci 2014;3:237-43
|How to cite this URL:|
Abdoli S, Abdoli S. Being a family physician: Experience of general physicians working in rural and urban healthcare centers in Iran. Int J Health Allied Sci [serial online] 2014 [cited 2019 Sep 20];3:237-43. Available from: http://www.ijhas.in/text.asp?2014/3/4/237/143063
| Introduction|| |
Health is the heart of social, economic, political, and cultural developments of all human communities, and enjoys an exceptional importance in development of infrastructure of various social sections.  The ultimate goal of health and medical systems in any country is to promote the level of population's health so that they can participate in the economic and social activities. 
To this, the system of referral classification avoids repeated and unnecessary visits to the professional sectors, and wasting human and financial resources. It provides an appropriate means for controlling care expenses, and increases conformity between general physicians and specialists. Ignorance of referral system can separate the chain of health and medical services and increase their expenses, harm their quality and quantity. 
The family physician program in the form of a referral system is one the best administrative strategies, especially in the countryside and low-populated regions of Iran. In the program, general physicians (after graduation from a 7 years academic program) have to work as family physicians in rural or urban area based on their preference. They are responsible to manage the local patients and refer them when it is a necessity, to the appropriate specialists.
The family physician program, making an allowance for the costs, started its activity in 2006 by presenting the medical insurance services cards for all the residences of villages and cities with population under 20,000 people, and providing medical care in the form of health and medical systems.  Since the referral system is the basis for health organization, and its background and culture existed in the villages, the program was decided to be put into practice in the villages first. 
This program was designed to increase villagers' constant access to health and medical services, reduce their commute to cities, employ the educated resources, promote the health indexes, enhance the referral system, and decrease the amount of medical expenses and the number of villagers wandering in the cities. 
Among the health and medical systems of the world, Cuba is one of the countries that have a health system similar to Iran's. In a study titled "Cuba: On the Road to a Family Medicine Nation", Gilpin mentioned the Cuban population's satisfaction of the program.  In an article in Cuba, 1992, Brown also considers the program to be a better one compared to the health system in US. 
Although there is information on patient satisfaction of the quality of medical care services provided in the program,  there are still few studies concerning the general physicians' experiences who work in a family physician program. Bearing in mind that the family physician program is a fundamental step and an immense transformation in the health and medical system of Iran, as a family physician, the first researcher conducted this study with the goal of understanding the experience of family physicians in the program. This study can give the policy makers such perspective to be familiar with general physicians' experience and help them to develop the program. The aim of the study was exploring general physicians' experience working in the family program in rural and small urban in Iran.
| Materials and methods|| |
The present study was a qualitative study of content analysis type. Purposeful sampling was used in the qualitative studies.  Thus, the participants, who were selected via purposeful sampling, included the family physicians who worked in rural and urban health and treatment centers located in west of Iran.
As there are no fixed rules or criteria for the number of participants in the qualitative studies, in this study, sampling continued until data saturation. Twelve family physicians (four male and eight female) from the health and medical centers of urban (three people) and rural (nine people) areas with diverse employment statuses (one officially employed, four contract employed, and seven program resources) participated in the study. The age of the participants ranged from 28 to 38. Six were married and six single, whose experience as a family physician varied between 3 months and 6 years. The study environment was the rural and urban centers, where participants were present as the family physicians.
Potential participants were informed that participation in the study was voluntary and they could withdraw at any time, their confidentiality would be maintained, and that no individual would be identified in any publications arising from the study.
The data collection was done using unstructured interviews since this method provides the interviewer with more detailed and profound information.  Each interview was started with the open question of "As a physician, what is your experience regarding working as a family physician?" and depending on the responses from the participants, the interview would move on to obtain deeper information. Before each interview, the objective and conditions of the interview would be explained to the participants on the phone or in person, and their approval of the voice recording would be obtained. The time of interviews varied between 20 and 40 min.
The purpose of data analysis of qualitative studies is to organize the data and prepare a structure and extract data meanings. , The conventional content analysis method was used in the present study. Consequently, the interviews were written on paper during the first 24 h and read again to be encoded during which titles about the subject under study were written down. This stage was repeated several times by the authors until the titles on the margins of the texts could cover all the aspects of the interview. Then all these titles were written on encoded papers and classified. A title was chosen for each group containing all the titles on the inside. The differences between two researchers in the coding process were solved through discussion. Finally, these groups were put into bigger classes whenever possible.
The interviews were tried to be done deeply to maintain data accuracy and reliability, while the codes from each interview was referred to the participants and colleagues familiar with qualitative research for confirmation or correction.
Limitations of the study
The study was a small one and its generalization should be taken into more caution.
The findings of the present study were categorized under the following five categories.
The physician's lost identity
The physician's lost identity includes the subcategories of "physician: Belittled" and "physician: Shattered in the system". They often saw themselves as belittled entities that have lost their professional role in the family physician program.
The physicians believed that the physician has become merely a bridge for reference and his role as a therapist and counselor have been forgotten. This matter heightened so much that the patients would visit the family physician only to reduce the costs and getting their cards stamped, which was followed by disrespecting the physician.
"I asked my patient what his problem was for me to write a referral. He responded with swearing and asked me 'who are you to know about my problem? Stamp the card so I can go'. What do you think my being a physician means? As a family physician you feel like a small piece that everyone tramples once and the only thing missing is your respect as a family physician. I only feel humiliated". - Female, 27 years old.
One of the other female physicians says:
"Not only is my character as a physician questioned, but I'm also not here for what I was trained for. I don't feel good at all. I'm here merely for my financial needs. I have no other motivation". - Female, 33 years old.
One of the physicians likened herself to a scarecrow in the system and talked about her feeling of humiliation that she has never experienced during her practicing years:
"I'm a scarecrow here; I have no respect before the patient or the people in charge. I have never been this humiliated during all my practicing years, and to be honest, my only feeling as a physician is humiliation, that's all". - Male, 35 years old.
Physician: Shattered in the system
Many of the participants believed that the family physician program would eventually shatter and destroy the physician. Those physicians who were practicing for long within the program would bluntly speak of "being destroyed", a phrase that surely depicts their lost identity.
"The social and scientific demise to the physicians in this program is irreversible. People who are immanent as a physician in this program benefit from all social advantages and forget the entire scientific knowledge". - Male, 40 years old.
The time and money the society spends on training these physicians, and the years they spend on becoming a therapist and physician in the most difficult conditions, in the end goes to waste. One of the physicians states with pity:
"It's hard to continue in this system. Physicians either can't keep on for some reason or turn to another profession. It is a shame that all the time and energy finally ends here and gets vanished". - Female, 30 years old.
The physician left in the system
This category includes the subcategories of "physician: extorted" and "lack of supportive environment". The physicians explained how they are left in a system under extortion without any support.
The participants spoke of extortion caused by minimum wage and heavy workload. One of them said:
"It is a program that extorts the physician to the fullest, a program that leaves the physician without any support in an unknown land". - Male, 27 years old.
One of the other physicians portrays the disproportion between the wage and workload this way:
"In some centers the workload is massive. There are no limitations for number of patients in these centers. The physician chart is a two-person one, but one physician manages it, and receives no extra income for the added work. This is really not a befitting wage. For this amount of money the physician is practically wandering between the insurance company and the health center". - Male, 38 years old.
Lack of supportive environment
The physicians often would not receive any help from the local people and the organization, and likened themselves to shields for all the present shortcomings in the system.
"The physician is the only person who is held responsible for the shortcomings, the one who is expected to carry the workload without receiving any support from the system. He is in fact the shield for all troubled, and yet not supported at all". - Female, 33 years old.
One of the other physicians adds
"This program only introduces a person to the health system as the family physician to carry the responsibility of centers and clinics, to manage the personnel, and shoulder the blames. The physician has no limitation in patient visits, and there is always one person to blame for anything that happens in terms of management or medicine, and that person is the family physician". - Male, 40 years old.
The physician as a member of the health system needs support. But more often than not the physicians talked about the absence of a supportive environment:
"The organization shows no support for you as a physician. I have visited the center to get some support for my scientific practice and refusing to give into the patient's illogical requests, but unfortunately there was no such luck and all they did was questioning me". - Female, 30 years old.
Passive and thoughtless practice
The consequence of the physician's being left in the system without any support was providing passive and thoughtless practice. This category includes the subcategories of "scientific practice on the verge of demise" and "learning, a faded element".
Scientific practice on the verge of demise
The physicians explained how they give into the patient's satisfaction to decrease the system's pressure and gain their approval, and according to some of them, to escape the tension. Some physicians believed that this program has turned them into inactive entities:
"As a physician that you get to this point where you'd do what people expect only not to be under pressure. Here you listen to people's swearing if you want to practice scientifically and fundamentally. We are physicians, but we cause patients' fridges' to be filled with unnecessary drugs". - Female, 33 years old.
The participants said that the system makes them present fake statistics, threatening them with the legal leverage and deductions. They mentioned how they try to create a process, which they call "paperwork" or "false statistics", to reduce the tension and prevent their income deductions:
"I fill many forms and statistics monthly, and collect signatures from various sections which are often a formality. We cannot provide our genuine statistics although we are supposed to hand in some statistics; otherwise it will go out of our income, and that is why we create false statistical information". - Female, 29 years old.
Learning, a faded element
In addition to the scientific practice being on the verge of demise, learning was really insignificant in the family physician program. Utilizing the knowledge of their educating years was so obsolete that they would explain how they had lost studying after a while and were not involved with the new practices and patient's new problems.
"We don't learn anything in the system when patients with particular diseases would not visit us in the primary stage. The patients go around us, and we around practicing medicine. Even when we come across these patients after their treatments, they refuse to answer us about the basic information". - Female, 29 years old.
Another physician stated that:
"In this program, the physician is practically removed from the cycle of medical practice and learning. Most of the visiting cases are repeated and concern colds". - Male, 40 years old.
The unstable foundation of the program
The physicians mentioned that this program has been initiated on an unstable foundation. "Insufficient groundwork", "lack of comprehensiveness", and "change in the program's nature during the practice" were the subcategories derived from their words.
Successful implementation of a program requires a suitable groundwork which this program lacks according to the physicians:
"A proper groundwork for this program has never been laid out. People must be informed and educated on the fact that this program is meant to reduce the costs and referrals to specialists". -Female, 27 years old.
Another one of the physicians says:
"These problems root in diverse places, but maybe one of the most important problems is that people have not learned to think medically and hygienically. Patients do not acquire the needed awareness and culture and do not recognize the purpose of this program". - Female, 26 years old.
Lack of comprehensiveness
The physicians stated that the program's priority, hygienic coverage on big scales, and for target groups such as children, women, and chronic patients is very favorable; the truth is that despite the proper coverage for cases of women and children, there is no suitable coverage for population health records and mental patients.
"This program has been successful in family planning, mothers' health, and children's health; but shows no success in the case of mental health. As a matter of fact, one of the problems of this system is failing to observe the primary principles concerning mental health and health records of covered areas". - Female, 26 years old.
Another one of the physicians confirms absence of dynamisms and says:
"One of the problems of this program is the issue of health records. Due to lack of time and resources, the physician is not capable of completing the records single-handedly, and that causes a major part of this program concerning mental health to be left incomplete". - Female, 33 years old.
The change in the program's nature during practice
The physicians described the primary purpose of the program well. According to them, the theoretical principles on which this program was founded were right, but the program has changed its nature during the course of practice for several reasons. The fragmentation of this program is described as below:
"There is no doubt the program is good in nature. But how successful it is in practice and how satisfied the personnel and patients are with it can be argued. It is correct in nature but in practice it is where the problem rises." - Male, 38 years old.
One of the physicians describes this change in nature:
"As far as I know, it is as if all parts of the systems interact to make everything seem right, while it is not important to genuinely implement the program correctly". - Male, 35 years old.
Sparks of success
The physicians mentioned some positive and important points in the family physician program which would fall under the subcategories of "Satisfaction from need-based practice", "proper distribution of general physicians within the country", and "effective management of chronic diseases".
Satisfaction from need-based practice
Some of the physicians spoke of a type of satisfaction in their words that in spite of all the problems pleased them in heart. Serving a class of society they believed to have a key role in the production and agriculture industry, but lacking the most basic healthcare facilities was satisfying to them. One of the physicians explains her contentment:
"I feel like I'm working where people need me the most. These places are areas where the medical resources are the least, and these people lack medical care despite all their hard work. It feels good to help these people who need me more". - Female, 27 years old.
Satisfaction of practicing medicine sometimes initiated from being close and familiar with the local people. Some physicians talked of the positive effects of intimacy with locals in spite of their problems:
"I feel emotionally safe here. I have been here for a long time and gotten to know people, families, and their problems. This is very effective in my practice and the quality of my interactions and their trust". - Female, 33 years old.
Proper distribution of general physicians within the Country
The proper distribution of graduate general physicians all over the country, specially the remote regions, is one of the major advantages of this program. One of the physicians substantiated this merit and said that such a huge program requires time for integration and operating as a single unit:
"One of the merits of this program is the great recruitment of physicians. There are no clinics now found without a physician, even in areas that lacked physicians and had a need for them. This program caused the medical resources to be distributed throughout the country in a proper way. It was a great program on a massive scale and takes time to be adjusted". - Male, 35 years old.
Effective management of chronic diseases
The physicians considered providing care for chronic patients with diseases like diabetes and blood pressure in rural regions and low-populated towns as one of the most significant successes of the program.
"Follow-up visits and screening for chronic diseases like diabetes and blood pressure have been fairly successful. Throughout all the rural areas, we almost don't have a patient without a medical care". - Female, 26 years old.
Another physician says:
"Coverage for chronic diseases is acceptable. Before this plan the diabetes and blood pressure patients had no program of follow-up visits, but are now fully covered and informed on the matter". - Female, 27 years old.
| Discussion|| |
There is no doubt that the family physician program aims at providing basic healthcare for people in all parts of the country with a community-oriented approach. The findings of the present study showed that the physicians saw their identities lost in this program and expressed that with words like "physician, a belittled and destroyed entity". Although no qualitative study concerning the experiences of physicians when working as a family physician was found in the library query, quantitative studies in Iran and other parts of the world indicate a dissatisfaction of this profession among general physicians. ,
The findings showed that the physician tried to stabilize his status in the family physician system following his lost identity, an effort that requires an emotional and financial supportive environment. Unfortunately, they likened themselves to extorted entities in an unsupportive environment. They spoke of the large number of visitors, heavy workload, and unpaid incomes; and described the income to be unjust for the amount of work. In the study by Janati et al., (2010) the problem of the large number of visitors and failure to pay the incomes on time has been mentioned as shortcomings of the program.  Van Ham et al., (2006) in a study in Europe, named low income, long working hours, and little free time as concerns of the family physician program.  In a study in the US in 2000, the level of dissatisfaction was reported higher in family physicians than general physicians,  which is consistent with the findings of our study. In the study by Janati et al., in 2010 in the northern provinces of Iran, 74.4% of the physicians were not content with their delayed payment, and 71% considered the paid amount unfair. 
The physicians who participated in the study, lack of cooperation between people and physicians was among the program's problems that were similar to Janati et al., (2010) study. 
Furthermore, the participants of the present study believed that despite its success in covering the records of women and children, the program fails to cover mental patients' records and has lost its society orientation in that sense. Although there was no information found in the library query on the mental health records coverage in other parts of the country, a study by Reisi et al., (2009) showed that putting the family physician program into practice has had a positive impact on the mother-child health indexes in Iran.  Moreover, the study by Macinko et al., (1990-2002) in Brazil showed that implementing the family physician program decreased mortality rate in children under 5.  In another study in Cuba in 1994, Benjamin and Hendel found that implementing this program decreased the mortality rate in infants, which is consistent with the findings of the present study. 
The physicians saw the negative outcomes of the family physician program to be the absence of appropriate groundwork before putting it into practice, a groundwork whose basis is proper culture development and spreading awareness of the nature and purpose of the program among the locals. They believed that with proper and adequate justification before putting the program into practice on such a large scale, many of the obstacles and problems are preventable. In a study by Motlagh et al., (2009) in the northern provinces of Iran, they found that the villagers' level of awareness of the principles and regulations of the insurance cards in the family physician program was very low and required a well-sought education plan.  In another study, more than 90% of the physicians suggested a comprehensive information method regarding the correct way to use the rural insurance cards. 
Despite all the negative findings of the study, some participants spoke of their inner satisfaction of helping deprived people in remote regions, and believed that intimacy with local people over time helps stabilize their status as a physician in the rural background and its cultures and beliefs. Furthermore, they considered the need-based distribution of medical resources throughout the country as one of the most significant merits of the program which has been confirmed in another study. 
A number of the physicians believed that this program has employed a great part of the physician class in the country as well as spreading the medical resources throughout the country, and needs time to improve. They confirmed the improvement of medical facilities, medicine, office equipments, and payment over time.
On the other hand, the findings of the present study showed that the family physician has had a significant role in continuous follow-up checks on chronic patients. Likewise from the Clausena et al., (2000), and Caughey et al., (2010) studies, , it was found in our study that the physicians knew the management of chronic diseases such as diabetes and blood pressure to be successful.
| Conclusion|| |
It is as if accelerating the growing improvement of the program regarding its advantages, especially in managing the chronic diseases, required removing the present challenges. Emphasis on team approaches and using various members of the medical staff, specifically the community health nurses in rural health and treatment centers, and noticing the physician as a human being with all the existential aspects are of the crucial factors in the successful survival of the family physician program in Iran. In addition, it seems focus on community-oriented education in universities could help to provide different perspective for general physicians. As one of the participants said, "having removed all administrative problems, this program can be a master key for promoting the health and medical care system of Iran especial in rural and low populated regions".
| Acknowledgments|| |
The authors would like to thank all participants who assisted them to conduct the study.
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