ACTIVITIES AND ACHIEVEMENTS OF THE
MALTA COLLEGE OF FAMILY DOCTORS
Dr Mario R Sammut MD MScH DipHSc
Honorary Secretary, MCFD 1994-2003
This paper chronicles the history of the College until May 2003
The Malta College of Family Doctors is an autonomous academic institution founded in 1989 whose object is to encourage, foster and maintain the highest possible standards in family medicine in Malta, and to sustain and improve the professional qualifications of members of the medical profession in Malta who are engaged in family medicine (Ref.: the College statute, 1989 & 1996).
Origin & Development
The need for advancement of family medicine in Malta had been felt for a long time, but any such activities were not possible before the end of the ten-year medical dispute in August 1987. One exception was a 9-month intensive course for family physicians, conducted in 1987-88 by the late Prof. Douglas Johnson of the University of Toronto under the auspices of the University of Malta. Preparations for such course had been made by the Faculty of Medicine and Surgery prior to August 1997. In March 1988, three family doctors, namely Dr Denis Soler, Dr Wilfred Galea and Dr Ray Busuttil, were appointed to a General Practice Sub-Committee of the Postgraduate Medical Committee (PMC) of the University Faculty of Medicine & Surgery. Their remit was to devise a development plan for family medicine in Malta.
In their report presented to the PMC in November 1988, four areas were outlined for future development:
1. The development of a Department of Family Medicine within the Faculty of Medicine
2. The establishment of a programme of continuing medical education for family doctors
3. The development of a vocational training programme in family medicine
4. The setting up of a Malta College of Family Doctors
As a result of intensive lobbying by these three doctors, Dr Alistair Donald and Dr Edwin Martin, chairman and member of the International Committee of the Royal College of General Practitioners, were invited to Malta in November 1989 to assess the situation and offer their advice. These five gentlemen worked hard together to produce a charter for a proposed Malta College of Family Doctors, and the formation of the College in fact was formally announced by Dr Soler in the presence of Dr Donald and Dr Martin during a Postgraduate Medical Committee Meeting in November 1989.
A provisional Committee was set up to draw up a College Statute, and both were formally endorsed during the College's first general meeting on the 4th April 1990, with Dr Denis Soler as College President, Dr Wilfred Galea as Vice-President and Dr Ray Busuttil as Honorary Secretary.
The College made an impact in the early 1990's on the proposed reforms in primary health care services in Malta, before these were eventually shelved for political reasons. It had earned itself representation on the Family Doctor Scheme Council, which had been envisaged as the body to run the general practitioner service. The College's role was to be not only an advisory one, but it would have been responsible for the organisation of the compulsory refresher course for doctors joining the scheme. Its functions would have included also the evaluation of the suitability of practice premises, the accreditation of doctors for the receipt of the CME allowance, and the assessment of practices for the receipt of the good practice allowance.
In 1998 the College was invited by the Minister of Health to start discussions, together with the Department of Primary Health Care and the Medical Association of Malta, for the reorganisation of Primary Health Care. In 1999, the College President gave the College Council an overview of the ensuing document, entitled Reforms of the Primary Health Care Services. Three systems were to be proposed to the cabinet for a definite commitment by the government before one was developed. However the proposed reforms were turned down, reportedly due to financial reasons.
Education & Accreditation
There being no formal training in family medicine in Malta, the College launched a Continuing Professional Development Programme in September 1990, in the form of a three-evening meeting which to this day is held in each term of the academic year (Autumn, Winter and Spring). Other ad-hoc meetings are also organised. The year after, a system of accreditation of CME activities was initiated, with continuing membership of the College depending on the accumulation of sufficient credit units within this scheme. In 2002, 34 College members were accredited (i.e. 22% of the 153 College members as on 15th May 2003), 12 of which had maintained their accreditation status for the twelve consecutive years since 1991.
The credibility and status earned by the College in the first three years of its existence resulted in the Postgraduate Medical Committee of the University's Faculty of Medicine formally passing on to the College in 1993 the organisation of all postgraduate educational activities for family doctors. For a time, the College was also asked to act as coordinator of the whole CME calendar for the PMC.
In 2001, a Strategy for the College's CPD Programme was presented to the College Council, consisting of the following objectives:
· The presentation be improved as regards venue, publicity and refreshments;
· The academic content be improved according to the needs ascertained through research;
· The format of teaching be practice-based and informal, taking place in small groups;
The topics be not always clinically based, but should also include other topics like academic family practice and practice management.
Other academic activities of note were (and still are) organised by the College. Highlights of these activities include:
- 5-day Teachers' Course in Family Medicine held in March 1993, in collaboration with the Bedfordshire & Hertfordshire Faculty of the Royal College of General Practitioners (RCGP) (Figure 1);
- 5-day Family Doctor Training Seminar on Community Psychiatry co-organised in May 1994;
- Weekend Workshop on Counselling in Family Practice held in April 1995, in collaboration with the Primary Care Trust, Staines, UK, and the RCGP International Committee (Figure 2);
- 3-day Joint Seminar on Paediatrics and Obstetrics & Gynaecology co-organised in November 1996;
- 6th Congress & 2nd Summer School of the Mediterranean Medical Society, organised in Malta by the College on 5-10 September 2000;
- 9-day Teachers' Course in Family Medicine held in collaboration with the RCGP during 2002-3 (Figure 3);
- ICGP Brief Intervention Training Workshop on Smoking Cessation in General Practice on 18 October 2003.
The College over the years had repeatedly proposed to the relevant authorities the establishment of a separate Department of Family Medicine within the University Faculty of Medicine & Surgery. This would provide instruction in family medicine for undergraduate medical students, and was also envisaged to be involved, in liaison with the College, in the setting up and running of Postgraduate Vocational Training in Family Medicine.
Through such pressure from the College, the post of part-time lecturer in general practice within the Department of Public Health in the Faculty of Medicine was instituted on 1st January 1991 with the appointment of Dr Ray Busuttil.
Eight years later, during a meeting with a College delegation on the 3rd February 1999, the Dean of the University Faculty of Medicine & Surgery, Prof. Mark Brincat, announced plans for the set up of a Department of Family Medicine. Dr Denis Soler, as President of the College, was invited to chair an ad-hoc Advisory Committee on Family Medicine, whose main aim was to prepare an undergraduate and postgraduate programme for the new Department of Family Medicine. The Department was formally set up in April 2001 with the appointment of 7 lecturers (all College members), and Dr Denis Soler as Head of Department.
Communication & Links
In September 1990, the first issue of 'It-Tabib tal-Familja', the Journal of the Malta College of Family Doctors, was issued. Initially a humble four-page newsletter, this has now grown into a colour journal issued twice yearly, with 23 issues published by 2002. In 2000, the Journal was upgraded academically, with the appointment of three international peer reviewers, an international scientific advisory board to recruit papers from the Mediterranean region, and its renaming as ‘The Family Physician - It-Tabib tal-Familja’. Dr Jean Karl Soler, replaced the original editor, Dr Godfrey Farrugia, in 1993. In April 2005, Dr. Noel Caruana was appointed the new editor, and the journal was renamed "The Maltese Family Doctor".
Moreover, since 1995, a separate ‘MCFD Newsletter’ was introduced by Honorary Secretary Dr Mario R Sammut and sent to College members on a regular basis and keep them informed of local and international educational activities of interest. On the initiative of Dr Wilfred Galea, one of the College founders, an Internet Website was launched in February 1996, courtesy of Grazio Falzon’s ‘Malta Virtuali’ in the USA. In October 1996, the site exchanged its host for TheSYNAPSE Network here in Malta at http://www.synapse.net.mt/MCFD
On the international front, the College has over the years developed affiliations and links with the following organisations:
Royal College of General Practitioners (RCGP);
Canadian College of Family Physicians;
World Organisation of Family Doctors (WONCA);
WONCA Region Europe - European Society of General Practice/Family Medicine (ESGP/FM);
· European Working Party on Quality in Family Practice (EQuiP);
· European General Practice Research Network (EGPRN);
· European Network for Prevention and Health Promotion in General Practice / Family Medicine (EUROPREV);
· European Academy of Teachers in General Practice (EURACT);
Irish College of General Practitioners (ICGP).
The Malta College of Family Doctors has maintained the excellent relationship it has had with the Royal College of General Practitioners since its inception. A certificate dated 4 September 1990 presented to the Malta College by the RCGP through Dr Edwin Martin (the RCGP's Malta Fellow during 1990-3) gives evidence to this. This certificate states that the RCGP 'regards the Malta College as a sister body that will set the standards of education in family medicine in Malta and as the body which will, where appropriate, give accreditation to doctors undertaking approved training for family medicine'. The RCGP's help resulted in the Teachers' Course in Family Medicine in 1993 (Figure 1), the Workshop on Counselling in Family Practice in 1995 (Figure 2), the sponsorship of College representative Dr Philip Sciortino in an International Course for Teachers of General Practice in 1997-98, and another Teachers' Course in Family Medicine in 2002-3 (Figure 3).
The College also had close links with the Canadian College of Family Physicians, most especially with the late Professor Douglas Johnson who had given his unstinting help and support in all of the College's major projects, most recently in the development of the Specialist Training Programme in Family Medicine.
The College's membership of the World Organisation of Family Doctors (WONCA) was boosted in February 1996 when two Council members, Dr Wilfred Galea and Dr Jean Karl Soler, were appointed to the WONCA Working Party on Informatics. Moreover, in 1998 Dr J K Soler was appointed to the WONCA International Classification Committee. In October 1995 the College became a founder member of WONCA Region Europe - the European Society of General Practice/Family Medicine. Not only is the College President automatically a member of the ESGP/FM Council, but the College was also honoured by the ESGP in 1997 when two Council members were invited to chair sessions in its Prague Scientific Conference that year (Figure 4). Through the generous help of sponsors, the MCFD has maintained a regular representation to the yearly conferences organised by ESGP/FM.
Since 1994, the College has been affiliated to EQuiP, the European Working Party on Quality in Family Practice, and to the European General Practice Research Network (EGPRN), being a national college member of the latter. The College in fact hosted the EGPRW meeting in Malta in October 1996 (Figure 5), and in 1997 Dr Jean Karl Soler was appointed webmaster of the EGPRN website. In 1998, College representation was granted to EUROPREV, the European Network for Prevention & Health Promotion in Family Medicine, and Dr Mario R Sammut was appointed to the EUROPREV Coordinating Board in 1999. Moreover, a number of College members are affiliated with EURACT, the European Academy of Teachers in General Practice.
In 2001, relations were initiated with the Irish College of General Practitioners (ICGP) through a one-year Distance Learning Diploma in Therapeutics for General Practice organised by the ICGP for 14 Maltese family doctors, under the auspices of the MCFD. This was to be followed by another diploma course (in prevention and health promotion) during 2003-4, and in October 2003 by a one-day Brief Intervention Training Workshop on Smoking Cessation in General Practice also held in Malta and facilitated by facilitators from the ICGP and STAG - the Smoking Target Action Group.
Strategy: Past, Present & Future
The College in 1998-99 developed a Strategy for the Future of the Malta College of Family Doctors and of Family Medicine in Malta. The most important and urgent targets were identified as the accessing of members, a policy document, patient initiatives, the definition of standards, a patient charter, and a PR exercise. In fact, a Patient Charter, entitled 'You and Your Doctor', was presented to the College Council in March 1998.
A Family Doctor Directory, initially drawn up in 1994, was revised and updated during 1998, when it consisted of 269 full-time and 34 part-time family doctors. Such a directory was intended as just an interim step towards the College’s ultimate aim of establishing a proper Specialist Register of family doctors who have undergone Specialist Training in Family Medicine. Today the Specialist Register of family doctors is a reality!
After recommending a standard Data Set for Computerised Medical Records in 1996, the College started planning for the development of a full Computerised Medical Records System for family doctors. Its aim was to facilitate good quality continuing care, health screening through recall systems, the keeping and exchange of statistics, and the performance of research and audit. In 1998 the College signed an agreement with the Transition Project from the University of Amsterdam to use the Computerised Medical Records System - TRANSHIS, based on ICPC – the International Classification for Primary Care, and developed for family doctors by Prof. H Lamberts and Dr I Okkes (Figure 6). Transhis was launched during 2 workshops held in February 2000, with 17 doctors signifying their readiness to use the programme under the coordination of Dr Jean Karl Soler. By the end of 2003, Maltese users accumulated 3 full years of data on the system.
The College has always pushed for the creation of a culture for research in family medicine, as it believes that it is through research that academic credibility and status can be developed further. In fact in 1997 the College approved a Research Policy and Planning Document to promote research in Family Medicine in an organised way, to improve the status of the specialty, and enhance:
· the academic development and career prospects of family doctors,
· knowledge and information on family practice, enabling plans for its future, and
· the health and well being of the population.
Moreover, an International Course on Research in Primary Health Care, co-organised with the EGPRN, was held in Malta on the 3-7 June 1999 (Figure 7).
Although a Policy Document entitled 'The College - History and Future Development' was prepared for the College by (then) Honorary Secretary Dr Ray Busuttil in March 1993, this unfortunately was never published. Then, in line with the declared intention of the World Health Organisation to define a charter for General Practice/Family Medicine in Europe, a Policy Document on Family Medicine in Malta was drawn up and approved by the College in 1998. Its objective was to sensitise the public, the Government and University to the importance of family medicine, and to upgrade the status of the family doctor as a specialist in his/her own right.
The publication of this policy document was intended to serve as a springboard for the launch of a Specialist Training Course in Family Medicine, which however did not materialise. The International Committee of the Royal College of General Practitioners (RCGP), the European General Practice Research Network (EGPRN) and the Royal Society of Medicine, amongst others, had confirmed their willingness to help in its implementation. What had been needed to bring it to fruition is the necessary funding, together with the support of the University, the Department of Health and the Government.
In 2000, a memo regarding the introduction of a 3-4 year course in Vocational Training in Family Medicine was approved by the Director General (Health), the Medical Association of Malta and the College. In 2001, lists of criteria for the selection of twelve trainers and one coordinator for the course were approved by the College Council and forwarded to the Director General (Health). In 2003, an agreement on the subject was reached by the Health Division and the Medical Association of Malta, and a call for applications for a coordinator was issued in November 2003, to be followed by a call for applications for the posts of trainers in 2004 – the year of Malta’s accession to the European Union.
In 2001, the College Council agreed to the following strategic recommendations for the further development of the College:
· Marketing of the College through patient handouts, newspaper articles and multimedia presentations;
· Sub-committees to be set up regarding group practices, doctor-patient registration cards, and membership by examination;
· The introduction of membership/certificate courses;
· The seeking of strategic partner/s.
Other topics proposed included GP cooperatives, practice certification, a College archive, the Journal on CD, and small group meetings.
In May 2002, the College was invited by the Health Division to form part of the interim Specialist Accreditation Committee (SAC). In November 2002, during meetings of College representatives with the Minister of Health and the Director General (Health), Family Medicine was guaranteed specialist status in the forthcoming Health Care Professions Act. This was confirmed in correspondence exchanged with the Medical Association of Malta, where it was agreed that:
· Family Medicine is put at par with other specialties in the list of specialties;
Family doctors on the specialist list are nominated by the SAC on the recommendation of the MCFD.
In 2001, the College Council agreed to develop a two-year course leading to membership by examination (MMCFD). However, in 2003, the Council noted that other countries around the world are negotiating with the RCGP for certain concessions to allow local trainee GPs to do the highly reputable MRCGP International. Council thus agreed that the way forward for Malta should be for the MCFD to provide assistance (through a Teachers’ Group) for local candidates to prepare for the MRCGPI, rather than to reinvent the wheel by developing an expensive local course and examination.
In the General Practice Subcommittee’s 1988 Development Plan for Family Medicine in Malta, which had been presented to the Faculty of Medicine and Surgery’s Postgraduate Medical Committee, the four areas that had been outlined for future development have all been achieved as follows:
· The Malta College of Family Doctors was founded in 1989;
· A programme of continuing medical education for family doctors was established in 1990;
· A Department of Family Medicine within the University of Malta was set up in 2001;
· The development of a vocational training programme in family medicine was agreed to in 2003.
The Family Doctor in the European Union today is considered as a specialist and needs vocational training to practise as such. The College has gone beyond the 4 areas listed in the 1988 Development Plan to fulfil the aim of its 1998 Policy Document towards upgrading the status of the family doctor. In fact the new Health Care Professions’ Act passed through Maltese Parliament in 2003 ensures that Maltese Family Doctors too will benefit from the specialist status that they so richly deserve.
With thanks to Dr Ray Busuttil, Honorary Secretary 1990-94, for kindly providing details of the College's first years.