Slow Progress: Predoctoral Education in Family Medicine in Four Latin American Countries
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Vol. 35, No. 8 591
International Family Medicine
Slow Progress: Predoctoral Education in Family
Medicine in Four Latin American Countries
Lyndee Knox, PhD; Julio Ceitlin, MD, DPH; Ricardo G. Hahn, MD
Background: Many countries in Latin America are seeking to expand primary care services pro-
vided through their health care systems. Family physicians are an essential component of an effec-
tive primary care workforce, but we know little about the status of family practice training in Latin
America. This study examines predoctoral training in family practice in four Latin American coun-
tries and identifies factors affecting its incorporation into medical training institutions. Methods:
A Spanish language survey was mailed to the heads of all medical schools in Argentina, Colombia,
Mexico, and Panama (n=100), asking about the status of family practice training at the school and
factors perceived as facilitating or impeding its acceptance by the institution. Quantitative data
were analyzed for freque ncy, and qualitative data were analyze d for content and theme .
Results: Sixty-five of the 100 schools responded to the survey. Of these, only 34 (52%) provide
training in family practice at the predoctoral level, and only nine (14%) have established depart-
ments of family medicine. Barriers to inclusion of family medicine include lack of financial and
human resources, definition of family practice as a subject rather than a specialty, and a perceived
lack of interest among students. Discussion: Inclusion of family medicine into medical education in
Latin America has been slow. Unless strategies can be developed to increase training for family
physicians in Latin American countries, governments in the region will have difficulty expanding
primary health care services in their systems. Support is needed from governments, public health
officials, funding agencies and organizations, and the academic community to increase training of
family physicians in Latin America.
(Fam Med 2003;35(8):591-5.)
The introduction of family practice into Latin America also in the region at large. The introduction of the spe-
began in earnest in the 1980s, stimulated by efforts of cialty in Canada and the United States served as an
Latin American governments to develop cost-effective additional stimulus.
and efficient systems of care for their predominantly Building an adequate health care workforce in fam-
poor populations. Efforts to expand the family practice ily practice will be necessary to ensure the success of
workforce were further stimulated by the World Health both the Latin American governments’ efforts to ex-
Organization’s advocacy for primary care service mod- pand primary health care services and the survival of
els as a main strategy for delivering health services in family practice in the region. Development of this
developing nations.1 Activism by individual family workforce will depend in large part on the availability
physicians has also played an important role in advanc- of training.
ing the specialty. Individuals such as Julio Ceitlin, MD, Similar to their US counterparts, family physicians
DPH (Argentina), Pedro Iturbe, MD (Venezuela), and in Latin America complete 5 to 7 years of medical
Thomas Owens, MD (Panama) have done much to ad- school, followed by a 3-year residency in family prac-
vocate for the specialty not only in their countries but tice. Emphasis is placed on preparing physicians to work
in ambulatory care settings, training them to be capable
of responding to the majority of problems presented
by patients in the office. However, we know little about
From the Department of Family Medicine, University of Southern Califor- the degree to which family practice training has been
nia (Drs Knox and Hahn); and the University of Buenos Aires (Dr Ceitlin). incorporated into medical training in Latin America.592 September 2003 Family Medicine
In January 2000, family physician leaders in Latin toral level. Seven (11%) provide training at the post-
America established a task force known as the Grupo graduate level. Only 12 (19%) offer training at both
de Panama to monitor the progress of academic family predoctoral and postgraduate levels (Table 1).
medicine in Latin America.2 The group met again in In Argentina, eight (62%) of the 13 schools respond-
December 2000 with support from the AEQUUS Foun- ing provide training in family practice. Four (31%) of-
dation. This paper, written by two members of the task fer training at the predoctoral level, two (15%) at the
force and a third researcher from the United States, re- postgraduate level, and two (15%) offer training at both
ports the findings of the task force’s evaluation of levels. In Colombia, 11 (61%) of the 18 schools re-
predoctoral training in family medicine in the region. sponding provide training in family practice. Eight
(44%) offer training at the predoctoral level, and three
Methods (17%) provide training at both predoctoral and post-
Samples in four Latin American countries—Argen- graduate levels. In Mexico, 19 (61%) of the 31 schools
tina, Colombia, Mexico, and Panama—were used in responding provide some type of training in family prac-
the study. The countries were selected based on task tice. Eight (26%) offer training at the predoctoral level.
force members’ ability to identify and contact top ad- Five (16%) offer it at the postgraduate level, and six
ministrators in medical education in each country. (19%) provide training at both levels. In Panama, all
The Grupo de Panama research team (Julio Ceitlin, three schools provide training in family practice. Two
Argentina; Miguel Angel Fernandez, Mexico; Arnoldo (67%) offer training only at the predoctoral level, and
Bromet, Colombia; Thomas Owens, Panama; and one (33%) offers family practic e tra ining at the
Ricardo Hahn, United States) constructed a 14-item predoctoral and postgraduate levels (Table 1).
Spanish language survey that contained questions on
the existence and characteristics of family practice train- Predoctoral Training in Family Practice
ing in medical schools and factors that may have af- As a Mandatory Part of the Curriculum
fected inclusion of the training in the schools’ curricula. Predoctoral family practice training was mandatory
Members of the task force reviewed the survey for face in 74% of schools responding. In Argentina, four (67%)
validity and relevance of terms and concepts to their of the schools mandated training; in Colombia, all
particular country. schools mandate training; in Mexico, seven (50%)
Next, the team mailed the survey to all medical mandate training; and, in Panama, all three schools re-
schools (n=100) in the four countries selected for the quire training in family medicine (Table 2).
study, along with a cover letter requesting that the dean
or the dean’s designate complete and return the survey Faculty Resources Supporting Training
within 3 weeks by mail or fax. No effort was made to Survey respondents were asked to indicate whether
collect surveys from nonrespondents. their school included physicians with specialist train-
Quantitative survey data were entered into an Ex- ing in family practice on their faculty. Of the 34 schools
cel® database and analyzed for frequency using SPSS.® responding that provide predoctoral training in family
Qualitative survey data were analyzed by three review- practice, 30 (88%) report having a physician with spe-
ers. One member of the review team was an experi- cialty training in family practice on faculty. Five (83%)
enced qualitative researcher from the United States, and schools in Argentina, nine (82%) schools in Colombia,
the remaining two were practicing family physicians 13 (93%) schools in Mexico, and all three schools in
from Latin America. Two of the reviewers coded the Panama report having physician specialists in family
qualitative data for content and theme using methods practice on faculty (Table 2).
recommended by Miles and Hubberman.3 Disagree-
ments between the two reviewers were resolved by the
third reviewer. Table 1
Results Number of Schools Offering
Deans at 65 of the 100 medical schools responded to Training in Family Practice
the survey, for an overall response rate of 65%. Deans
at 13 (62%) schools surveyed in Argentina responded, # of Medical
Schools With FP # Providing Training
18 (75%) in Colombia, 31 (60%) in Mexico, and 3 Training at Any Level at Predoctoral Level
(100%) in Panama. Argentina (13) 8 (62%) 6 (46%)
Colombia (18) 11 (61%) 11 (61%)
Mexico (31) 19 (61%) 14 (45%)
Level of Training in Family Medicine Panama (3) 3 (100%) 3 (100%)
Provided by Medical Schools Total (65) 41 (63%) 34 (52%)
Forty-one (63%) of the 65 schools responding to the
FP—family practice
survey provide some type of training in family medi-
cine. Thirty-four (52%) provide training at the predoc-International Family Medicine Vol. 35, No. 8 593
Organization of Predoctoral Training (33%) school has established a department of family
in Family Practice in Medical Schools medicine, and two (67%) have established professor-
Respondents were asked to identify the organiza- ships in family medicine (Table 2).
tional structures supporting family practice training at
their institution. They were provided with the options Factors Affecting Inclusion of Training
of “department” (eg, the institution supports a depart- in Family Practice in Medical Schools
ment dedicated to the discipline—considered the high- Qualitative responses from the surveys were analyzed
est level of organization within an institution), “pro- for content concerning barriers/facilitators to the inclu-
fessorship” (eg, the institution supports faculty posi- sion of family practice at the respective institutions. The
tions specifically designated for family practice spe- majority (89%) of respondents reported substantial
cialists but does not have a department of family medi- barriers to the inclusion of training in family practice
cine), “c ourse work” (eg, the institution provides at their institution (Table 3).
courses in family medicine that may or may not be
taught by specialists in the discipline but does not have Lack of Resources for Teaching Family Medicine
faculty positions designated for the specialty or a de- Respondents reported a lack of financial support from
partment of family medicine), or “none” (eg, training their institutions for family medicine. Many also de-
in family practice occurs as part of other courses or scribed difficulty finding appropriate sites for clinical
curricula in the institution but has no formal structure training in the specialty, indicating that most sites as-
of its own). Using these criteria, 30 (88%) of the 34 sociated with their institutions were designed for sub-
schools with predoctoral training in family practice re- specialty training and were unable to support the conti-
port some type of formal organizational structure at their nuity experiences central to effective family practice
institution supporting the training. Of these, however, training. Respondents also cited a lack of skilled teach-
only nine (27%) have established departments of fam- ers of family medicine and limited curricular resources
ily medicine. Twelve (35%) have formed professorships as barriers.
in family medicine, and a few (4/12%) report no for-
mal organizational structure for family medicine be- Failure to Define Family Practice
yond providing a course dedicated to the topic (Table As a Legitimate Medical Specialty
2). Subspecialists’ and academics’ perceptions and defi-
In Argentina, only one (17%) of the schools offering nitions of family practice created a significant barrier
predoctoral training in family practice has established to the specialty’s inclusion. These professionals often
a department of family medicine. Four (67%) have pro- defined family practice as a set of “basic skills” learned
fessorships in family medicine. In Colombia, four by all specialists and subspecialists, rather than as a
schools (36%) have established departments of family specialty in its own right. In its most extreme form,
medicine, two (18%) have formed professorships, and respondents reported that their schools did not need to
three (27%) support family medicine at the course level. include family medicine in their curriculum because it
In Mexico, only three (21%) schools have established “was already [being] taught in their medical sociology
departments of family medicine. Four (29%) have and epidemiology” courses. Others reported that “fam-
formed professorships in family medicine, and one (7%) ily practice” was the domain of mid-level practitioners
is organized only at the course level. In Panama, one and not of physicians.
Lack of Demand for the
Specialty by Students
Several respondents reported
Table 2 a lack of demand for training in
family medicine among the stu-
Characteristics, Resources, and Organization dents. They attributed this to stu-
of Predoctoral Family Practice Training dent perceptions of limited job
opportunities for family physi-
Mandatory FP Specialists
Training on Faculty Departments Professorships Course cians and low prestige relative to
Argentina (6) 4 (67%) 5 (83%) 1 (17%) 4 (67%) 0 other specialties. Respondents
Colombia (11) 11 (100%) 9 (82%) 4 (36%) 2 (18%) 3 (27%) indicated that their schools de-
Mexico (14) 7 (50%) 13 (93%) 3 (21%) 4 (29 %) 1 (7 %)
Panama (3) 3 (100%) 3 (100%) 1 (33%) 2 (67%) 0 cided not to offer training in the
Total (34) 25 (74%) 30 (88%) 9 (26%) 12 (35 %) 4 (12 %) specialty because of this limited
demand.
FP—family practice594 September 2003 Family Medicine
Discussion trast to the progress family practice has made in other
In Latin America, health care services are delivered parts of the world, such limited progress has been made
through three separate systems: the public health ser- in Latin America.
vices, funded by the government and open to all citi-
zens; social security programs, which provide health Why Has Progress Been Limited?
care to the employed; and private health services, which A number of factors may be contributing to this slow
includes prepaid medical care and services purchased rate of progress. Most signific antly, in its ca ll to
from insurance companies. The public health services strengthen primary health care services in developing
and social security systems provide health services for nations, the Alma Ata Declaration fails to address de-
the vast majority of the population, with private care velopment of physician specialists in primary care, em-
providing service for less than 10% of individuals in phasizing instead the development of mid-level pro-
the region. In three of the countries studied in this re- viders. Consistent with this, the governments of the
port—Colombia, Mexico, and Panama—family prac- countries surveyed have failed to develop incentives or
tice has been designated as the main provider of pri- regulations that stimulate development of a primary care
mary care services in the social security system. physician workforce.
Despite the central role that family practice has been
assigned in these systems, and despite the potential that What Needs to Be Done
family practice holds for improving health care in the Government support, both financial and regulatory,
countries surveyed, progress incorporating predoctoral will be central to the expansion of training in family
training in family practice into academic institutions in medicine and to the development of a competent pri-
these countries has been slow. In Argentina, Colombia, mary care physician workforce. For this to happen, how-
and Mexico, only half (31) of the institutions respond- ever, internal advocates for family medicine must be
ing offer predoctoral-level training in family practice. developed. Future leaders in family medicine must be
Of these, only eight (26%) have established departments identified and provided with training in political advo-
of family medicine. Although the smaller country of cacy, in medical education, and in the curriculum change
Panama has made more rapid progress in including process. This training might occur through seminars
training in family medicine in its medical schools (3/ held at well-established predoctoral training programs
100%), similar to the larger countries, only one school in family practice in Canada, the United States, the
has organized family medicine at the department level. United Kingdom, and Europe.
Simila rly, le aders in family medicine in Latin
Stages of Development of Family America must work to convince governments, public
Practice in Latin America health officials, and the academic community of the
In 1982, Gayle Stephens, a prominent scholar in fam- contributions that family physicians can make to their
ily medicine, outlined three stages in the inclusion of health care systems and of the need for specialized
family medicine training into medical schools.4,5 He training in family medicine at all levels. This could be
suggested that the first, or political stage, is character-
ized by power struggles between the newcomer (fam-
ily medicine) and established disciplines to acquire
basic recognition of the specialty and the contributions Table 3
it can make to medicine. The second, or administrative
stage, is characterized by negotiations of conditions Barriers to Incorporation of Family
under which the new specialty will function in the medi- Medicine Into Medical Education
cal school and the acquisition of the basic resources
needed to educate students, including time, money, Category Barrier
Definitions/perceptions • Failure to see need or academic value
space, and human resources. Finally, the third, or aca- of specialty • Belief that content is already adequately
demic stage, involves the establishment of academic incorporated into subspecialty training—
boundaries, including the definition of how the new dis- family practice as subject versus specialty
• Rigid rules for curriculum change
cipline is distinct from and similar to existing disci-
plines and developing the methods and styles of train- Resources • Lack of money
ing for the specialty. It is during this stage that class- • Lack of time to provide continuity experience
• Lack of clinical training sites
room- and clinic-based instruction begins in earnest. • Lack of specialists to teach
Based on this model, predoctoral training in family • Lack of curriculum
practice in the countries surveyed remains in the early
Demand/student interest • Perception of limited job opportunities in
political and administrative stages of incorporation. specialty
It is discouraging and even disturbing to observe that • Low level of interest among students
20 years after the Declaration of Alma Ata, 1 and in con-International Family Medicine Vol. 35, No. 8 595
accomplished by physician leaders in the different Latin facilitate the sharing of these resources and their modi-
American countries partnering with international asso- fication for use in Latin America. Training fellowships
ciations such as the World Organization of Family Doc- for faculty members could be developed through col-
tors (WONCA), Pan American Health Organization laboration among medical schools in North America,
(PAHO), and the Inter-American Development Bank Europe, and Latin America. An Internet-based clear-
(IDB), to convene meetings of political and health sys- inghouse for training resources for family medicine
tems and medical education leaders. Topics of these could be established to provide easy access to the ma-
meetings should include discussion of the role and po- terials.
tential contributions of family medicine and other pri-
mary care disciplines in reformed health systems in The Need for More Information
Latin America. While this study provides information on four coun-
Models of how primary care can work together with tries in Latin America, it is not possible to generalize
other specialties and subspecialties also should be de- its findings to all the countries of the region. A com-
veloped and disseminated as part of national health re- prehensive survey of family medicine training in all
form efforts, which will decrease subspecialist opposi- Latin American and Caribbean countries should be car-
tion to the discipline. Similar efforts should be made to ried out to identify “best practices” in the diffusion of
identify and develop mechanisms to encourage collabo- predoctoral and other levels of training in family prac-
ration rather than fighting within the primary care dis- tice that can inform incorporation of training through-
ciplines. out the region.
Finally, an advisory group of leaders in academic
family medicine, such as the Grupo de Panama, should Corresponding Author: Address correspondence to Dr Knox, University of
Southern California, Department of Family Medicine, 1420 San Pablo Street,
be formed to assist medical schools in identifying, lob- PMB-B205, Los Angeles, CA 90033. 626-457-4220. Fax: 323-442-3070.
bying for, and obtaining funding to support the incor- knox@hsc.usc.edu.
poration of family practice training into medical edu-
cation in their countries. One existing source for this is REFERENCES
the IDB, which currently provides funding for curricu- 1. World Health Organization. Declaration of Alma Ata. International
lum change in medica l schools in Latin America. Conference on Primary Health Care, Alma-Ata, USSR, September 6–
Argentina’s Programa de Reforma de la Atencion 12, 1978. www.who.int/hpr/archive/docs/almaata.html. Accessed Janu-
ary 2002.
Primaria de la Salud en la Argentina (PROAPS) uses 2. Grupo de Panama. Estudio sobre ensenanza de la medicina familiar en
IDB funding to train physicians in family practice/gen- las facultades de medicina de America Latina. Buenos Aires: Grupo de
eral practice in four provinces in the country. Panama, December 7-8, 2000.
3. Miles MB, Huberman AM. An expanded sourcebook: qualitative data
Curricula specific to predoctoral training in family analysis, second edition. London: Sage, 1994.
practice in Latin America should also be developed and 4. Stephens G. The role of the medical school in the development of fam-
made easily available to educators from the region. ily practice. In: Stephens G, ed. The intellectual basis of family medi-
cine. Tucson: Winter Publishing Company, Inc, 1982:207-16.
Partnerships between professional associations in Latin 5. Stephens G. The integration of family medicine into today’s medicine.
America and associations such as the Society of Teach- In: Stephens G, ed. The intellectual basis of family medicine. Tucson:
ers of Family Medicine (STFM) and WONCA can Winter Publishing Company, Inc, 1982:183-94.You can also read
