THAI EQUIVALENT OF THE FAMILY DOCTOR IS NON EXISTENTPeter B. Dunki Jacobs MD, PhD - July 03, 2020
Since 2011 Dr. Peter Dunki Jacobs is a retired Surgeon Consultant. He spent 30 years working in a Teaching Hospital and Trauma center in The Netherlands and ended his medical career as a Consultant Quality of Care and Innovation for a Dutch healthcare insurance company, ZilverenKruis Achmea.
Throughout his career he has seen healthcare from different inside perspectives as well as from a patients’ point of view. Peter and his spouse Louise reside in Thailand during European winter months.
First let’s zoom in on the role of a General Practitioner or Family Doctor in relation to over-treatment and the benefits of a GP system for the patient.
Value in healthcare is quality of care divided by the costs. Quality depends on treatment outcome and optimal patient experience. The value of care increases when complications and unnecessary treatment decreases.
General Practitioners (GP) or Family Doctors are the first point of contact for healthcare in the Netherlands. They provide referrals to all specialists and, if necessary, to a hospital. GP’s are the gatekeepers for the influx of patients to secondary or tertiary tiers of specialised and academic health care.
This system can have advantages and disadvantages for the individual patient, but from an economical viewpoint it makes hospital healthcare in the Netherlands much more cost effective compared to the United States.
Quality, efficiency, affordability and accessibility for all, are the pillars of the Dutch healthcare system.
Danger of over-treatment
Over-treatment isn’t just expensive, it can also harm patients.
A quick search on the internet soon reveals complaints from some American expats on how they dislike the Dutch healthcare system. They are used to getting immediate access to specialised care, which is a well known cause of over-treatment. Over-treatment is a globally pervasive problem, especially in American medicine, where the GP system or family physician organisation is less well developed than in the Netherlands.
According to Kaiser Health News, over-treatment in the United States ranges from duplicate blood tests to unnecessary knee replacements. Every year millions of Americans undergo screenings, scans and treatments that offer little or no benefits. Doctors have estimated that 21 percent of medical care is unnecessary — a problem that costs the US healthcare system at least $210 billion a year. Over-treatment isn’t just expensive, it can harm patients. (source)
The role of the GP is essential in decreasing over-treatment. In the GP system the patient benefits and is protected from unnecessary diagnosis and treatment that may be harmful. In fact, value of care is enhanced while costs are decreased.
Thai Healthcare system
The appreciation of primary care delivered by GP’s and Family Doctors shows cultural differences between countries and continents.
Thailand has a well-developed healthcare sector with secondary and tertiary care structures equal to those of many European nations, but by way of contrast the country offers very limited primary care services in the community.
There is no Thai equivalent of the Family Doctor, General Practitioner clinic, ‘huisartsenpost,' ‘Hausarzt Klinik’ ‘médecin de famille’, ‘allmänläkare’, ‘primary care physician’ or similar healthcare providers commonly seen throughout the Western world. Unlike citizens of Western (European) countries, Thai are not registered with any one healthcare provider and typically attend any hospital they choose when a clinical need arises.
More wealthy Thai living in major metropolitan centers this are likely to choose one of the many high-class private hospitals. In rural areas, and for less wealthy citizens living in the major conurbations, an extensive network of government hospitals allows access to healthcare at nominal cost. Small clinics do exist within the community but are mainly clinics of hospital specialists, who see patients in the evenings or weekends after completing their hospital duties.
Given the paucity of primary care in the community it is no surprise that the medical educational system in Thailand barely gives attention to specialisation as a Family Doctor. There is postgraduate training available in general practice, but a general practitioner is still regarded as a ‘second tier’ doctor and mainly works within a hospital. Family healthcare is simply not a well established concept within the Thai society and in Thai medicine.
From Chiangmai to Hua Hin
We reside in Chiangmai, the second largest city of Thailand, from the end of October to January when the climate in the north of the country is at its best. Cool nights and temperatures 30-32 Celsius with low humidity in the daytime. We play golf, enjoy the culture, the Buddhism way of life and the fabulous food of the North.
In January, as the smog is accumulating between the mountains, we head south to the costal region. This year we went to Hua Hin, with its beautiful beaches and numerous, splendid golf courses.
Here we met Haiko Emanuel at the Banyan Golf resort. Haiko Emanuel is one of the founding fathers of a local family healthcare centre in Hua Hin. Of course, when a doctor meets an investor in a medical clinic, the mutual interest is clear. We were invited to visit the recently opened clinic and learned about their goals, an interesting story worth sharing.
This unique family healthcare medical center in Hua Hin, a 3 hour drive south of Bangkok, began operating at the end of 2019 in a custom built facility within the Banyan estate, an impressive 200 hectares Dutch owned development with a resort, private residences and a golf course.
The Be Well Medical Center is the brainchild of recently retired Dutch General Practitioner, Dr. Daan van Groenewegen and his entrepreneurial friend Haiko.
Daan is the owner of the Driebergen Medical Centre (DMC) which served as a template for the Be Well clinical and business model.
The Hua Hin location was selected due to its popularity as a tourist destination for many Thai and overseas visitors and because it has a large resident expat community of Western retirees. Their patient population is around 70% Europeans, 20% Thai and 10% Americans and Australians.
Benefits of Primary Care
Good primary care can be a very cost-effective sieve. It saves patients the need of visiting a hospital altogether even though some will still need to see a specialist.
In the absence of a well developed primary care system the patient must decide for himself which specialist he needs to see. Often that decision is though to make for the individual patient, consider orthopaedics or rheumatology for a hand or knee problem; general surgery or gastroenterology for abdominal discomfort.
The knowledge and expertise of a family doctor can effectively direct these patients to the most appropriate specialist in the best facility, bearing in mind individual specifics such as financial constraints or personal beliefs. This is a process of shared decision making.
A common concern in elderly expats is the feeling that private hospitals may be over-treating them or overprescribing medication and diagnostic tests. This sense of unease can be exacerbated by language and cultural differences. A comfortable primary care centre can help allay these fears by providing an independent medical opinion.
Dedicated primary care teams, with an intimate knowledge of the patient’s unique circumstances built over time along with it the trust of the patient, is a new development in Thailand.
First 6 months (Covid-19)
The Be Well clinic began small, with an initial complement of two nurses, a physiotherapist and two doctors. The center was just finding it’s feet when, mid-January, Thailand became the first country outside of China to register a case of Covid-19.
Far from being derailed at such a delicate time in its development, the clinic embraced the opportunity by reaching out into the local expat community, for whom little information was being directly provided.
The clinic’s staff made educational visits to local schools and hotels to advise management, staff and pupils on recommended hygiene measures and gave people the opportunity to air their concerns. In this regard, the appointment of former senior cruise ship Physician, Chris Taylor as the clinic’s manager was fortuitous timing. His experience in public health and outbreak control proved to be invaluable at these seminars.
Dr. Chris became a regular guest on a local radioshow to discuss the latest developments and address the concerns of the expat community about the coronavirus.
The clinic designed and distributed educational posters and made a video for the general public showing correct hand washing techniques and explaining how to stay healthy during times of infectious disease outbreak. Taking these steps the Be Well Clinic was soon recognised as a reliable and trustworthy new healthcare provider in the area.
The interruption of tourist travel impacted business projections on one hand. But was mitigated by the prolonged stays of many of the European expats who, like Louise and I, would usually only winter in Thailand.
In many cases the extended stays necessitated the replenishment of chronic medications and generated the need for medical consultations. The clinic remained busy throughout the pandemic lockdown in Thailand.
Expansion within and outside of the clinic
Similar to the DMC model in The Netherlands, the Be Well Medical Center invites local medical specialists to run occasional clinics that address specific patient requirements. This program started in June with a monthly clinic for hearing problems, a common complaint amongst the clinic’s retiree demographic. The program is based on the Dutch system known as the ‘one and one half’ tier of primary care. (‘one and a half tier’ care is combines specific medical knowledge and diagnostics with easy accessibility and aims to provide sustainable care, red.)
In the case of the hearing assessment clinic, a visiting otorhinolaryngologist attends one day per month accompanied by audiology technicians. The team is equipped with audiometric devices and hearing aid fitting and servicing capabilities. Plans to run a similar ‘one and one half’ programs will be set up for orthopaedics and cardiology at the clinic.
Many expat retirees came to Thailand 15 to 20 years ago and have no intention of leaving. However with advancing years health deteriorates, sometimes to the point where a person can no longer self-care. The provision of sheltered, supportive resort-style care for these individuals is a newly developing sector in Hua Hin where organisations such as Prosana and Lotus Well are also taking part. A positive development in which the Be Well clinic is actively engaged and provides regular home visit clinics to meet the health needs of the residents.
The clinic’s business model is based on a membership program although it recognises that many of the residents in the clinic’s catchment area are holiday-makers, therefor non-members can also access their services. Membership entails an initial intake assessment of the patient’s medical history, an examination, an electrocardiogram and a series of baseline blood and urine tests, all of which are performed on-site in the clinic’s laboratory resulting in a complete and fast diagnostic assessment in a single visit.
Membership provides benefits that are unavailable to unregistered patients, such as discounted prices on medications, diagnostic testing and consultations. Members are eligible for a home visit services should they be unable to attend the clinic; a service that is also extended to guests staying in major local hotels but for reasons of staff safety it isn’t available to other non-registered patients.
Focus on Family and Doctor
The ethos of the Be Well clinic is to be the first port of call for a patient’s primary care needs with the aim to deliver high quality care without overenthusiastic prescribing or investigating.
What Be Well understands well is to place focus on both the word ‘family’ and the word ‘doctor’. Patients visiting the facility confirm that the clinics’ comfortable and welcoming approach is popular among the Western expat community of Hua Hin.
In perspective of disease prevention and quality of care I advised the Be Well Clinic to start with Life Style advise and Patient Related Outcome Measurement (PROMS) or Patient Related Experience Measurement (PREMS) in the near future. PROMS and PREMS feedback will increase Quality of Care within this unique Family Doctor system in Thailand.
It will most definitely be interesting to keep track of further developments in a for Thailand new healthcare set up.