|Year : 2016 | Volume
| Issue : 1 | Page : 51-55
State of family medicine practice in Lebanon
Mariana Helou1, Grace Abi Rizk2
1 Department of Medicine, School of Medicine, Lebanese American University, Beirut, Lebanon
2 Department of Family Medicine, School of Medicine, Saint Joseph University, Beirut, Lebanon
|Date of Web Publication||24-Jun-2016|
School of Medicine, Lebanese American University, Chouran, Beirut 1102 2801
Source of Support: None, Conflict of Interest: None
Background: Many difficulties are encountered in family medicine practice and were subject to multinational studies. To date, no study was conducted in Lebanon to assess the challenges that family physicians face. This study aims to evaluate the family medicine practice in Lebanon stressing on the difficulties encountered by Lebanese family physicians. Materials and Methods: A questionnaire was sent to all 96 family medicine physicians practicing in Lebanon. Participants answered questions about characteristics of family medicine practice, evaluation of the quality of work, identification of obstacles, and their effect on the medical practice. Results: The response rate was 59%, and the average number of years of practice was 10.7 years. Physicians complain mainly of heavy load at work, too many bureaucratic tasks, demanding patients, and being undervalued by the specialists. Most physicians are able to adapt between their professional and private life. Conclusion: Despite all the obstacles encountered, Lebanese family physicians have a moderate satisfaction toward their practice. They remain positive and enthusiastic about their profession. Until the ministry of public health revises its current health system, the primary care profession in Lebanon will remain fragile as a profession.
Keywords: Family medicine, physicians, primary care
|How to cite this article:|
Helou M, Rizk GA. State of family medicine practice in Lebanon. J Family Med Prim Care 2016;5:51-5
| Introduction|| |
Family medicine is a specialty that cares for the individual and the family and provides continuing and comprehensive care. The scope of family medicine encompasses all ages, both sexes, each organ system, and every disease entity. The first family medicine academic program was established in Canada, in 1967, then in the United States, in 1969. The family medicine program then spread to Latin America, Asia, Europe, and Africa. In Lebanon, the family medicine specialty program was launched in 1979. Over the last decade, there was a global shift from family medicine to other medical specialties, especially in Western countries. , In Canada, family physicians protested from being overloaded and lacking stature compared to their colleagues in other specialties.  In the US  and Switzerland,  family physicians were often underestimated and had low salaries, whereas in Britain and the Netherlands, family physicians faced poor work conditions and inadequate income. , In Australia, family medicine was described as a soul-destroying specialty.  Numerous international studies were conducted to identify the obstacles encountered by family physicians during their practice. The complaints were similar: High workload, ,, heavy bureaucratic work, , complex cases,  insufficient time to meet patients' needs,  unsatisfying income, , frequent phone calls from patients, , being undervalued, and often ignored by the specialists.  In France, 87% of primary care physicians found that professional requirements regularly interfere with their personal and/or family time. In rural practices, ,, primary care physicians complained of professional isolation, , substantial workload,  and complex patient profiles.  Family physicians suffer from work-related stress , with health repercussions: Poor sleep quality  and depression.  A study conducted in France showed that 21% of primary care physicians consider changing the way of practice, 18% consider getting further training, 13% hope to leave the profession for good, while 9% consider changing specialty. 
In 1998, a study was conducted on Lebanese physicians from all specialties.  This study included 388 doctors which constituted, at the time of the study, 5% of the number of physicians registered at the Lebanese Order of Physicians. The study showed a concentration of physicians in urban areas, with a predominance of women in primary care.
The health system in Lebanon, unlike Western countries, is lax with patients consulting directly a specialist of their choice, without the need or requirement to consult a primary care physician first. Patients are, in their turns, satisfied with this system because there is no third party payer for their consultations, and therefore they rather prefer to visit a specialist than to pay two consultations. On many occasions, some patients, especially in rural areas prefer to consult their local pharmacist rather than seeking a professional medical opinion. Furthermore, the surplus of specialists in Lebanon has made their access easier to patients which resulted in family physicians losing their primary role of being the first health care providers. To date, no study was conducted in Lebanon to assess the challenges that family physicians face. The goal of this study is to describe the practice of family medicine in Lebanon, identify the obstacles that family physicians face during their career, and assess the manifestation of these challenges on health care management.
| Materials and Methods|| |
The study was launched in 2010. Family physicians were identified from the roster of family physicians registered in the Lebanese Order of Physicians and from the roster of the Lebanese Society of Family Medicine. These rosters are comprehensive and are updated yearly. They include the physician's first and last name, work and home addresses, phone numbers, and E-mail addresses. The total number of eligible physicians identified from these rosters was 96, and they all accepted to participate in the study.
Each participant filled a survey with 44 close-ended questions. The survey was composed of seven sections that included personal data, characteristics of the medical practice, work quality, interaction with patients, communication with specialists, and impact of the work on their social life and their practice. The survey was administered in French and English and sent initially by E-mail. A pilot study was conducted with 8 randomly selected family physicians before the survey and was sent to all participants. Physicians who did not respond by E-mail were called on the phone or visited by a member of our team. The study was approved by the IRB of the Saint Joseph University.
Data were entered on Microsoft Excel, and the statistical analysis was performed using the SPSS program. Additional analysis was conducted using version 10 of the STATA software (Statacorp), with a 5% level of alpha significance. For the comparison between both sexes, we used the Chi-square test or Fisher test in cases of low numbers (qualitative variables), and the Student's t-test or Mann-Whitney test in cases of abnormal distribution (continuous variables). An ANOVA analysis of variances was then undertaken to compare groups.
| Results|| |
A total of 57 surveys were collected, giving a response rate of 59.3%. The average age of the participating physicians was of 40.7 years (minimum age 29, maximum age 59). 78.9% of them were married with a male predominance (56%). 86% of them received their degrees in general medicine from Lebanon. 98.2% of them received their family medicine degree from Lebanon, 52.6% from the University Saint Joseph, 45.6% from the American University of Beirut. Twenty family physicians hold a subspecialty degree (35.1%), 18 of whom are working with that degree (90%), and all continue to work as family physicians. Several subspecialties were mentioned: Geriatrics (5), emergency medicine (4), public health (3), nutrition (2), health management (2), pediatrics, occupational medicine, pedagogy, and tobaccology. The number of years of practice was on average 10.7 years, with a standard deviation of 7.14 years.
Two-thirds (63.2%) practice in an urban area, 7% in a rural area, and 29.8% in the mixed area. The average number of working hours per week is 17.1 h in a private clinic, 4.9 h in the emergency room, 4.4 h of administrative work, and 3.2 h of workers medicine. On a Likert scale from 1 to 5 with 1 being very rarely and 5 very frequently, the average response is of 2.6 for pediatric consultations, 2.2 for gynecologic consultations, 3 for geriatrics consultations, 1.8 for surgery consultations, and 2.9 for psychiatry consultations. Family physicians work on average 43.8 h a week (with a standard deviation of 13.5 h a week). Almost all of them (94.7%) conduct free consultations, which make up on average 20% of the total number of consultations. The percentage of patients referred to a specialist is 14.9%. 56% specified a constant monthly income from a stable source. 50 doctors answered the question related to their monthly income. 38% of them noted a salary between $1,000 and $3,000 per month, and 40% of them noted a salary between $3000 and $5000 per month [Table 1].
Subgroup analyses show that the average age of doctors rises along with the rise in salary. The average age is significantly higher in the group of physicians receiving a monthly salary exceeding $5000, compared to those getting a monthly salary of $1000 to $3000 a month (ANOVA test, P = 0.05). By analyzing variances, a significant association was demonstrated between years of practice and salary, P = 0.05 [Table 2].
Physicians who have graduated earlier than others tend to have a variable salary (changing from 1 month to another) rather than a stable one, but the difference is not significant, P = 0.26. No significant difference was found between the monthly income and the area of practice (urban/rural/mixed), P = 0.076. We noted, however, a slight rise in salary of physicians working in the urban area. Physicians perceive their income differently, on a scale of 1-5 [Table 3].
Only 45.6% of physicians hospitalize their patients under their care. The rest refer their patients to a specialist with two-thirds (66%) being able to consult their patients after being hospitalized. The workload is perceived by physicians as average to heavy; 54% of them answered 4 on a scale from 1 (little) to 5 (too much). The bureaucratic work takes an acceptable amount of time, and 70% rated it 2 or 3 on a scale of 1-5. Most physicians (98.2%) have never encountered medico-legal problems (56 out of the 57 physicians). The duration of a consultation in a private clinic is 28 min on average, with a minimum consultation time of 15 min, and a maximum consultation time of 60 min (SD ± 9.7 min). Most physicians find that this time is perfectly sufficient for patients and that they are almost always able to answer their patients' demanding needs. Physicians consider that their patients perceive their role as important; 49% rated it 4 on a scale of 1 (unimportant role) to 5 (highly important role). Most family physicians have good relations with specialists, with a majority of 4 and 5 answers, 5 corresponding to very good relation. However, 40% of them find themselves to be undervalued by physicians of other specialties.
Physicians find in general that work moderately interferes with their personal lives (42% of the answers ranged from 3 to 5, meaning they moderately agree); additionally, to the question of family life interfering with their professional lives, the answer was also moderate (31% of them answered 3-5, meaning they moderately agree). On a scale of 1-5 (1 being rarely, 5 being always), most of our physicians give a 3 for free time with family, 2 for free time spent on exercise/leisure, and a 3 for free time dedicated to social activities. Most of the physicians are satisfied with their practice, 50.8% answered 4 on a scale from 1 to 5, with 5 corresponding to maximum satisfaction [Table 4].
The physicians who are the most satisfied are those with an income ranging from $3000 to $5000 difference, not significant P = 0.065. The highest satisfaction scores come from the $3000-$5000 salary group, with a significant result P = 0.0094 [Table 5].
The level of stress felt during practice is moderate for most physicians in the study. Seventy-two percent of the physicians had rarely or ever regret their choice of family medicine. More than two-thirds of physicians (70%) would not have chosen another specialty than family medicine. The 30% that answered "yes" mentioned an array of other specialties, with dermatology at the forefront (10 over 16 answers, or 62.5%). Finally, 64% of them would not have chosen another career than medicine.
A gender-based analysis shows that the division of urban/rural practice is similar for both women and men. Men do more intrahospital work (P = 0.093), conduct more home visits (P = 0.0029), and have more clinic hours (P = 0.017). Comparing the average working hours, we see that men work more hours per week than women, with a significant difference (P = 0.0108). No significant difference was found between men and women's incomes, and income satisfaction was also similar. Men are significantly more satisfied with their medical practice than women (P = 0.011), with no difference in stress levels, or regret toward choosing medicine.
| Discussion|| |
There were 96 family physicians practicing in Lebanon at the time the study was conducted. This limited number shows that there are not enough family physicians to satisfy the need of a population of 4.3 million. The scarcity of family physicians may not be as problematic since many general physicians fulfill the role of the family physicians. The actual Lebanese heath care system allowing patients to consult a specialist directly without being referred by a primary care physician explains the fact that many family medicine doctors have a subspecialty diploma (35%) to attract patients who skip the primary care consultation to go to a specialist.
Our results show that most family physicians practice in urban areas while results from a previous study conducted on primary care physicians in Lebanon, found a concentration of primary care physicians in rural areas.  On one hand, this difference may be due to the fact that many of the physicians who did not respond to our study's questionnaire were those living in nonurban areas and were not easily reachable. On the another hand, this study focused on family physicians, whereas in other studies, primary care included a majority of general practitioners. These physicians are mostly present in rural areas in Lebanon, and this might explain our study results.
In this study, we found that family physicians work 43.8 h a week on average, similar to what other studies have shown. 38 h a week for Lebanese physicians,  and 52-60 h a week for general practitioners in France.  Working hours per week are divided with most of the time spend in clinics: 27 h for consultations. A study conducted in France shows that 33 h a week were given for consultations.  This difference is caused by the actual health care system in Lebanon, unlike the west, where doctors' consultations are not reimbursed by third party payers which encourage family physicians to favor administrative work at the expense of their clinic time. Furthermore, freshly graduated family physicians usually start with a relatively low number of patients as they are building their practice and are often tempted to accept hospital jobs where a fixed salary is guaranteed at the end of the month.
Almost all family physicians have answered yes when asked whether they conduct free consultations (94.7%), which make up around 20% of their total consultations. This is significantly more than what has been shown in other studies where an average of 10 free consultations a week is cited. 
The exact monthly salary of physicians in Lebanon, a developing country, is difficult to compare to physicians from other developed countries where similar studies have been conducted. In a study conducted in Lebanon in 1998, the average physician's income was $1873 a month. This was a national study that included rural and urban areas, general practitioners, and specialized physicians. The $1873 figure was an average with a large standard deviation ($133-$19,900).  Physicians in our study are, in general, moderately to well satisfied with their income while other studies have shown systematic dissatisfaction with the income. , The most satisfied family physicians are those that make between $3000 and $5,000 a month. This satisfaction is certainly not only related to salary but also to some other factors: Number of working hours, quality of work, and efforts put into the practice.
Despite all the obstacles encountered, Lebanese family physicians have a moderate satisfaction toward their practice, in contrast to other physicians in Europe or Canada. More than two-thirds of the physicians (71.9%) have never or rarely regretted choosing family medicine. Family physicians in Lebanon seem satisfied and feel good about their profession. They work extended hours while balancing between their practice and personal time. They show compassion with their patients offering significant free consultations. They maintain a healthy relationship with specialists, and they often supplement their income with administrative and hospital work. Despite the many challenges that Lebanese family physicians face, they remain positive and enthusiastic about their profession always trying to overcome these challenges.
The Lebanese family physicians are represented by the Lebanese Society of Family Medicine that was created in 1991. Its primary role is to establish guidelines for the family practice in Lebanon and to increase awareness of the Lebanese public and medical community regarding family practice. It has been actively working with governmental organizations, including the Ministry of Public Health to promote the profession and thrust family physicians as the backbone of primary care in the country. Until the ministry of public health revises its current practice of not requesting patients to consult primary care physicians first before they are referred to specialists, the primary care profession in Lebanon will remain fragile as a profession.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]