Health Regulation Department Scope of Practice for

Specialist Family Medicine

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Introduction Health Regulation department (HRD) is responsible for regulating medical practice in the Emirate of Dubai, United Arab Emirates. Scope of Practice (SOP) refers to the activities that licensed Medical Doctors are educated, authorized and competent to perform as well as their decision making capacity. Such activities are established through the legislated definition of licensed medical practice, complemented by standards, limits, conditions and education and influenced by setting, environment and health needs of the population. This document is the result of a collaborative effort from specialists in family medicine, regulatory, legal experts and others from within both the public and private health care sectors of Dubai, which has provided a broad and enabling framework which supports Medical Doctors to make decisions about and within their scope of practice. The framework has been rigorously benchmarked against international best practice and provides mechanisms to ensure that specialist family medicine practitioners are competent and fit to practice their profession. The scope of practice for the specialist in family medicine is determined by the scope of human needs. There are, however, predictable points in the life cycle of the individual and family where the Medical Doctor fits uniquely into the experience of health and illness. These nodal points include pregnancy and childbirth, the newborn child, life-threatening and life-altering illness, loss and grief, and care at the end of life. The scope of practice for the specialist in family medicine is endorsed by HRD and should be read in conjunction with HRD Code of Conduct for Physicians. The American Academy of Family Physician (AAFP) defines the SPECIALIST Family Medicine as: a physician who is educated and trained in family practice, a broadly encompassing medical specialty. SPECIALIST Family Medicine possess unique attitudes, skills, and knowledge which qualifies them to provide continuing and comprehensive medical care, health maintenance, and preventive services to each member of the family regardless of sex, age, or type of problem, be it biological, behavioral or social. The family physician, is the best qualified to serve as the patients advocate in all health related matters, including the appropriate use of consultant, health services and community resources. The SPECIALIST Family Medicine must:: Provide primary, comprehensive and continuous health services to individuals, families

and communities Provide cost effective preventive, promotive, curative and rehabilitative health services to

individuals, families and communities Participate in improving practice management, quality of care and professional

development activities Participate in implementing evidence based practice guidelines, audit and continuous

medical education programs

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Competency Standards This document sets out the scope of practice for Specialists in Family Medicine (SFM). SFM have obtained a postgraduate qualification which entitles them tom practice Family Medicine in the country of education. This additional qualification further entitles to practice as SFM in the emirate of Dubai, United Arab Emirates. It is recognized that the role and responsibilities of the Specialist Family Medicine are broad and complex. The following sets out the competency framework within which Specialist in Family Medicine must be judgment-safe and competent. The indicators are neither comprehensive nor exhaustive but rather provide examples of evidence of competence. The following competency framework for the SFM has been organized into seven (7) domains of competence

Medical Expert Communicator Collaborator Manager Health Advocate Professional Development Professional

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Domain 1 Medical Expert: A specialist Family Medicine (SFM) is a general family doctor who integrates all roles to provide optimal, ethical and patient centered care. SFM is mandated to ensure primary care which is comprehensive, preventive, and continuous and community based care. Competency 1.1 Specialists in Family Medicine possess a defined body of knowledge and procedural skills, which are used to collect and interpret data, make appropriate clinical decisions, and carry out diagnostic and therapeutic procedures within the boundaries of their discipline and expertise. Their care is characterized by up-to-date, ethical, and cost-effective clinical practice and effective communication in partnership with patients, other health care providers, and the community. Such fields require from SFMs to attain sufficient knowledge, diagnostic expertise, judgment and skills in performing techniques and procedures to manage patients.

Indicator Sub Indicator 1.1.1 Demonstrate diagnostic and therapeutic skills for effective patient care by using evidence based medical practices

1.1.1.1 Select medically appropriate investigative tools, interpret the results of common diagnostic tests and demonstrate an understanding of their cost effectiveness, limitations and complications 1.1.1.2 Formulate a comprehensive patient problem list, synthesize an effective diagnostic and therapeutic plan and establish appropriate follow up 1.1.1.3 Generate a rational plan of diagnostic and therapeutic measures with use of information on cost benefit ratio

1.1.2 Access and apply relevant information to clinical practice

1.1.2.1 Elicit, present, and document a history that is relevant, concise, accurate and appropriate to the patient's problems 1.1.2.2 Perform, interpret the findings of present and document a physical examination that is relevant and appropriate 1.1.2.3 Retrieve, critically appraise and apply relevant information to clinical practice 1.1.2.4 Knowledge of normal body structure and function as expressed in a bio psychosocial model of human development 1.1.2.5 Knowledge of disturbed body structure and function 1.1.2.6 Be able to assess, diagnose, and manage patients with common and uncommon diseases in the appropriate setting. 1.1.2.7 Demonstrate an understanding of basic pharmacology and its application to clinical practice 1.1.2.8 Appropriate application of knowledge derived from critical appraisal of the literature

1.1.3 Demonstrate effective referral services with respect to patient care and education.

1.1.3.1 Demonstrate effective referral services in presenting well- documented assessments and recommendations in written and/or verbal form 1.1.3.2 Demonstrate knowledge of promotion, maintenance of optimal functioning in biological and psychological aspects 1.1.3.3 Establish a professional relationship and interact with the patient and parent, guardian or other caregivers in order to obtain a history, conduct a physical examination and provide ongoing care 1.1.3.4 Establish an atmosphere of open communication appropriate to the situation and convey interest, sensitivity, empathy and support 1.1.3.5 Recognize personal limitations and demonstrate a willingness to call upon others with special expertise and

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make referrals where appropriate 1.1.4 Demonstrate an understanding of medico-legal issues

1.1.4.1 Demonstrate an understanding of the epidemiology of such conditions 1.1.4.2 Demonstrate sensitivity to the patient's needs, modified according to the patient's age, gender and problem, and record this information by regions or systems 1.1.4.3 Demonstrate the ability to correlate, evaluate, prioritise and synthesise information, including the relevant ethical issues 1.1.4.4 Maintain confidential information as appropriate

Domain 2 Communicator: To provide humane, high-quality care, Family Medicine Specialists establish effective relationships with patients, other physicians, and other health professionals. Communication skills are essential to work as SFM and are necessary for obtaining information and conveying information to patients and their families. Furthermore, these abilities are critical in eliciting patients' beliefs, concerns, and expectations about their illnesses, and for assessing key factors impacting on patients' health. Competency 2.1 Specialist Family Medicine enables patient-centered therapeutic communication through shared decision-making and effective dynamic interactions with patients, families, caregivers, other professionals, and important other individuals. The competencies are essential for establishing rapport and trust, formulating a diagnosis, delivering information, striving for mutual understanding, and facilitating a shared plan of care. Poor communication can lead to undesired outcomes, and effective communication is critical for optimal patient outcomes. SFM is also responsible to communicate effectively to the public or media about medical issues whenever appropriate.

Indicator Sub Indicator 2.1.1 Establish therapeutic relationships with patients/families

2.1.1.1 Recognize that being a good communicator is an essential function of a SFM and understand that effective doctor- patient communication can foster patient satisfaction and compliance as well as influence the manifestations and outcome of a patient's illness 2.1.1.2 Establish relationships with the patient characterized by understanding, trust, respect, empathy & confidentiality 2.1.1.3 Demonstrate caring and empathy for patients and their families, & especially for those individuals who are vulnerable 2.1.1.4 Develop strategies for managing challenging communication issues such as obtaining informed consent, delivering bad news, identifying situations which could lead to angry exchanges, confusion or misunderstandings.

2.1.2 Obtain and synthesize relevant history from patients/families/ communities

2.1.2.1 Interact with community care-givers and other health resources to obtain and synthesize relevant information about the patient 2.1.2.2 Gather information not only about the disease but also about the patient's beliefs, concerns and expectations about the illness, while considering the influence of factors such as the patient's age, gender, ethnic, cultural and socioeconomic background, & spiritual values on that illness 2.1.2.3 Provide close attention to the impact of factors such as age, gender, disability, ethno-cultural background, social support, and emotional influences on a patient's illness

2.1.3 Listen effectively 2.1.3.1 Understand and demonstrate the importance of cooperation and communication among health professionals involved in the care of individual patients such that their roles are

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delineated and consistent messages are delivered to patients and their families. 2.1.3.2 SFM demonstrates respect for individual patients, families, colleagues and for their value systems

2.1.4 Discuss appropriate information with patients/families and the health care team

2.1.4.1 Deliver information to the patient and family in a humane manner and in such a way that it is understandable, encourages discussion and promotes the patient's participation in decision-making to a degree that is compatible with current surgical practice 2.1.4.2 Demonstrate skills in providing clear, concise and timely verbal and written communication as applied to consultation notes, sign over of patient care and management plans; communication with patients and families regarding informed consent, the medical condition, plan of treatment, prognosis, primary and secondary prevention, adverse events, medical uncertainty, & medical errors; and communication with other health care professionals regarding all aspects of patient care 2.1.4.3 Educate patients, families and health care professionals in formal and informal educational settings 2.1.4.4 Develop a discharge plan for hospitalized patients and learn to involve home care facility and other care-givers in the development of long-term community health planning. 2.1.4.4 Present the patient's problem(s) clearly, concisely and correctly, in the following ways: 2.1.4.4.1 verbally, in the clinical setting or formal presentation 2.1.4.4.2 in a written medical record (in standard/ problem oriented form) or consultation report 2.1.4.5 SFMs demonstrate an ability to support and counsel patients/families with chronic illness and/or impending death and provide bereavement counselling

Domain 3 Collaborator: As Collaborators, Specialist Family Medicine effectively works within a healthcare team to achieve optimal patient care. Competency 3.1 A Specialist in Family Medicine works in partnership with others who are appropriately involved in the care of individuals or specific groups of patients. It is therefore essential for them to be able to collaborate effectively with patients and a multidisciplinary team of expert health professionals for provision of optimal patient care, education, and research.

Indicator Sub Indicator 3.1.1 Consult effectively with other specialists and health care professionals

3.1.1.1 Develop an ability to work effectively and harmoniously with other health care workers 3.1.1.2 Participate in the interdisciplinary team meeting, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing specialty-specific expertise 3.1.1.3 Function competently in the initial management of conditions that, in major centres, fall within the Family Medicine Specialty.

3.1.2 Contribute effectively to other interdisciplinary team

3.1.2.1 Identify and describe the role, expertise and limitations of all members of an interdisciplinary team required to optimally achieve a goal related to patient care, a research problem,

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activities an educational task, or an administrative responsibility 3.1.2.2 Develop a care plan for a patient they have assessed, including investigation, treatment and continuity of care, in collaboration with members of the interdisciplinary team, the patient and the family 3.1.2.3 Effectively communicate with the members of an interdisciplinary team in the resolution of conflict, provision of feedback, and where appropriate, be able to assume a leadership role

Domain 4 Manager: As Manager, Specialists in Family Medicine are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system. Competency 4.1 Specialists in Family Medicine function as managers when they make everyday practice decisions involving resources, co-workers, tasks, policies, and their personal lives. They do this in the settings of individual patient care, practice organizations, and in the broader context of the health care system. They also take roles of leadership within the context of professional organizations and the health care system.

Indicator Sub Indicator 4.1.1 Utilize resources effectively to balance patient care, learning needs, and outside activities

4.1.1.1 Recognizes the structure, resourcing, and operation of the Dubai health care system, and function effectively within it, as well as being capable of playing an active role in its evolution 4.1.1.2 Understand knowledge of the definitions and role of audits, quality improvement, risk management, occurrence / incident reporting, and complaint management in a hospital and ambulatory setting 4.1.1.3 Utilize appropriate time management for effective patient care, administrative duties and continuous professional development activities. 4.1.1.4 Understand population-based approaches to health care services and recognize their implication for medical practice

4.1.2 Allocate finite health care resources wisely

4.1.2.1 Utilize resources to effectively balance patient care and health care economics

4.1.2.2 Understand the interplay between governments & the health care sector in allocating finite health care resources

4.1.2.3 Recognize the business and financial skills needed for a successful medical practice and/or academic career. Understand the advantages, disadvantages and relative costs of preventive and therapeutic health care programs

4.1.2.4 Understand the advantages, disadvantages and relative costs of care in different settings, including an appreciation of the various forms of health care provision, including hospitals, ambulatory clinics, home care, chronic care and rehabilitation facilities as they relate to quality assurance

4.1.2.5 Avoid unnecessary investigation and/or hospitalization 4.1.3 Work effectively and efficiently in a health care organization

4.1.3.1 Understand how to function effectively in health care organizations, ranging from individual clinical practice to local,

regional and national associations 4.1.3.2 Demonstrate an awareness of the need to continually balance

professional, personal, institutional and social commitments 4.1.3.3 Work to develop effective and efficient patient management

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strategies by avoiding duplication of services, involving other caregivers and obtaining appropriate patient information from other health care sources

4.1.3.4 Demonstrate conflict resolution skills and make clinical decisions and judgments based on evidence based for the benefit of individual patients and the population served 4.1.3.5 Delegate responsibility effectively to junior staff

4.1.4 Utilize information technology appropriately to optimize patient care

4.1.4.1 Utilize appropriate use of information technology. Understand population-based approaches to health care and their implication for medical practice and prioritization to access for services

4.1.4.2 Acquire the ability to access and apply a broad base of information to the care of ambulatory patients, and those in hospitals and other health care settings

Domain 5 Health Advocate: Specialists in Family Medicine must use their expertise and influence to advance the health and well-being of individual patients, families, communities, and populations. Competency 5.1 Specialists in Family Medicine recognize the importance of advocacy activities in responding to the challenges represented by those social, environmental, and biological factors that determine the health of patients and society. They recognize advocacy as an essential and fundamental component of health promotion that occurs at the level of the individual patient, the practice population, and the broader community.

Indicator Sub Indicator 5.1.1 Identify the important determinants of health affecting patients

5.1.1.1 Demonstrate an appreciation of health care needs. Appreciate the existence of global health advocacy and initiatives for elimination of poverty and disease (e.g. tuberculosis, malaria, Acquired Immune Deficiency Syndrome)

5.1.1.2 Recognize, assess, and respond to the psychosocial, economic, societal and biologic factors influencing the status of health

5.1.2 Contribute effectively to improved health of patients and communities

5.1.2.1 Encourage promotion of active family involvement in decision-making & continuing patients management 5.1.2.2 Adapt management accordingly and assess the patient's ability to

access various services in the health and social system 5.1.2.3 Demonstrate the ability to contribute effectively to improved

health of patients and communities 5.1.3 Recognize and respond to those issues where advocacy is appropriate

5.1.3.1 Apply the principles of quality improvement and quality assurance, to promote equitable health care

5.1.3.2 Educate patients and families about and promote the importance of long-term healthy behaviours and preventive health care (e.g. smoking cessation, screening tests, vaccinations, exercise, and nutrition)

5.1.3.3 Be familiar with the underlying research evidence and apply this understanding to common problems and conditions of such specialty

5.1.3.4 Respect and empower patient autonomy 5.1.3.5 Work collaboratively with other specialty and identify current "at

risk" groups and application of available knowledge regarding prevention to "at risk" groups

5.1.3.6 Intercede on behalf of their patients as the patient weaves his/her way through complex health care institutions and services

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Domain 6 Professional Development: This domain assumes primary responsibility for maintaining competence and fitness to practice as a Specialist in Family Medicine (self regulation). It includes a commitment of life long learning, as well as the creation, dissemination, application and translation of medical knowledge. Competency 6.1 Specialists in Family Medicine engage in a lifelong pursuit of mastery of their domain of professional expertise. They recognize the need for continuous professional development (CPD) activities and set example for others. Through CPD activities, they contribute to the appraisal, collection, and understanding of health care knowledge, and facilitate the education of their, patients, students and others.

Indicator Sub Indicator 6.1.1 Develop, implement and monitor a personal continuing professional development strategy

6.1.1.1 Recognize the importance of self-assessment of professional competence and acceptance of the responsibility for self-directed learning as a life long goal, to develop, implement and monitor a personal CPD strategy 6.1.1.2 Identify clinical problems and practice areas for research 6.1.1.3 Recognize and identify gaps in knowledge and expertise 6.1.1.4 Monitor the outcome of professional development

6.1.2 Facilitate learning of patients, residents/ students and other health professionals

6.1.2.1 Demonstrate the ability to teach medical students, residents, patients, colleagues and other health care professionals 6.1.2.2 Demonstrate an understanding of, and the ability to apply the principles of adult learning, with respect to oneself and others 6.1.2.3 Demonstrate an understanding of preferred learning methods in dealing with students, residents, and colleagues 6.1.2.4 Facilitate teaching of patients about their health problems directly or through the involvement of other professionals

6.1.3 Contribute to development of new knowledge

6.1.3.1 Specialists in Family Medicine will maintain a questioning and inquisitive attitude towards medical information and an appreciation of the necessity for ongoing research to develop new knowledge 6.1.3.2 Attend academic day to develop learning skills in evidence- based medicine, medical ethics, physical examination skills, acquisition of medical knowledge, etc. 6.1.3.3 Attend other available rounds to enhance learning

Domain 7 Professional: As a Professional, Specialist in Family Medicine is committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behavior. Competency 7.1 Specialists in Family Medicine have unique societal role with a distinct body of knowledge, skills, and attitudes dedicated to improving the health and well being of others. They are also committed to the highest standards of excellence in clinical care and ethical conduct, and to continually perfecting mastery of their discipline.

Indicator Sub Indicator 7.1.1 Deliver highest quality care with integrity, honesty and compassion

7.1.1.1 Display attitudes commonly accepted as essential to professionalism.

7.1.1.2 Evaluate one's abilities, knowledge and skills, recognize one's limitations and use appropriate strategies to maintain and advance professional competence

7.1.1.3 Acquire the training and experience to maintain competence as a Specialist in Family Medicine.

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7.1.2 Exhibit appropriate personal and interpersonal professional behaviours

7.1.2.1 Strive to heighten personal and professional awareness and explore and resolve interpersonal difficulties in professional relationships

7.1.2.2 Strive to balance personal and professional roles and responsibilities

7.1.2.3 Demonstrate ways of attempting to resolve conflict and role strain 7.1.2.4 Demonstrate a willingness to accept peer and supervisor reviews

of professional competence 7.1.3 Practice as specialist ethically with consistency

7.1.3.1 Know and understand the professional, legal and ethical codes to practice

7.1.3.2 Recognize, analyze and attempt to resolve in clinical practice ethical issues such as truth telling, consent, advanced directives, confidentiality, end-of-life care, conflict of interest, resource allocation, research ethics, interactions with the pharmaceutical industry

7.1.3.3 Understand and apply relevant legislation that relates to the health care system in order to guide one's clinical practice

7.1.3.4 Recognize and know how to deal with unprofessional behaviours in medical practice, taking into account local and provincial regulations

7.1.3.5 Know the basics of the principles of medical ethics including: "best interest" of the child, autonomy, beneficence and non-malfeasance, confidentiality, truth-telling, justice, respect for persons, conflict of interest, advanced directives and end-of-life care, and resource allocation

7.1.3.6 Know and be able to obtain informed consent 7.1.3.7 Know the ethical decision-making process and legal and ethical codes of professional behaviour 7.1.3.8 Demonstrate tolerance for ambiguity and uncertainty & the possibility of error in ethical decision-making; flexibility & willingness to adjust appropriately to changing circumstances

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APPENDIX 1 PRIMARY CARE SERVICES General Health Services Across the Life Span

1. The provision of continuity of care: the Doctor Patient Relationship. 2. The appropriate assessment and management of all acute physical or psychological

symptoms. 3. The management of chronic diseases: heart disease, diabetes, asthma, COPD,

epilepsy, Thalassaemia, sickle cell, G6PD Deficiency. 4. Screening for cancers: breast, cervical, bowel, prostate. 5. Screening for chronic diseases for example - diabetes, hypertension, G6PD,

dysliepedemia. 6. Health Education and Health Promotion. (the science and art of helping people

change their lifestyle to move toward a state of optimal health) 7. Provision of all adult vaccinations. 8. The assessment and management of Mental Health Disorders. 9. Continual liaison with other medical Professionals. 10. A Family Medicine Specialist with a Special Interest and relevant further

qualifications may also be involved in the delivery of more specialist medical care, for example Care of the Elderly, Pain Management, Sports, Sleep and Hospice Medicine.

Childs Health services

1. Assess, identify, treat and refer appropriately newborns with Infections or congenital abnormalities

2. Screen for congenital diseases in new born 3. Monitoring of growth, nutrition assessment and development during regular pediatric

wellness visits 4. Administer/ provide immunizations in accordance with most current guidelines 5. Assess and treat common childhood illness e.g. acute respiratory infection, otitis

media, skin rashes 6. Screen for chronic diseases and make appropriate referrals

Women's Health Services

1. Antenatal Care Antenatal clinic booking Referral of high risk pregnancy to Obs/Gyn physician Initial antenatal investigations Monitoring fetal growth and wellbeing Provide anti-D for Rh negative mothers Vaginal screening for group B beta haemolytic streptococcus Education of nutrition and breast feeding

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Supplementation of vitamins/folic acid

2. Delivery Care Referral of pregnancies to hospital for delivery

3. Cancer Screening Breast Breast assessment - Mammography for those 40-69 years every 1 - 2 yearly Referral of suspected cases Cervix Cervix assessment - Pap smear for those women within 3 years of onset of

sexual activity or age 21 then every 3 years Referral of suspected cases

A Specialist in Family medicine should be competent to use the followings appropriately: 1. Laboratory tests: Hematological test: Microbiological test Biochemical test Serological and viralogical test: All other diagnostic tests

2. Radio Diagnostic Services: X-ray, Ultrasound, MRI and CT scan.

3. Therapeutic and relevant Equipment: Nebulizer and Oxygen Therapy Suction therapy and ear wash Defibrillation therapy Nasogastric intubation and Urinary catheterization Expression of breast milk Stitching and ENT packs

4. Other services: ECG, Fluorescein eye stain, and PE FR Fundoscopy, Proctoscopy, etc.

References

1. Royal College of Physician and Surgeon of Canada, Can MEDS 2005 framework, http://meds.queensu.ca/medicine/obgyn/pdf/CanMEDS_2005_Framework.pdf

2. Department of Health and Medical Services, Dubai (2007); Dubai Residency

Program. 3. Department of health and medical services, Dubai, UAE: Job description card of

General Practitioner.

4. Department of Health and Medical Services, Dubai (2007); Senior House Officer Job Description.

5. Victoria, Queensland, Australia: World Organization of National Colleges,

Academies, and Academic Associations of General Practitioners/ Family physicians (1991); WONCA: the role of the general practitioner/ family physician in health care systems.

6. General Medical Council (1999): Management in health care: the role of doctors.

7. Good Medical Practice. RCGP Curriculum Statement 1 (2005); Being a General

Practitioner,

8. Dubai Health Authority (2008); Scope of Practice for Registered Nurse.

9. Web definition for Medical Doctor; http://en.wikipedia.org/wiki/Medical_doctor, accessed on 28/03/2010.