Economic discussion 6

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Address for correspondence: Dr. Yahia M. Al-Khaldi, Joint Program of Family Medicine Aseer, P. O. Box 2653, Abha - 61461, Saudi Arabia. E-mail: [email protected]

Challenges facing postgraduate training in family medicine in Saudi Arabia: Patterns and solutions Yahia M. Al-Khaldi1, Kasim M. AlDawood2, Adnan A. AlBar3, Sulaiman A. Al-Shmmari4, Mohammed A. Al-Ateeq5, Tariq I. Al-Meqbel6, Omar A. Al-Yahya7, Mohammed A. Al-Dayel8, Mohammed S. Al-Ghamdi9, Badr O. Al-Badr10

1Joint Program of Family Medicine, Aseer, 2Medical College, University of Dammam, Dammam, 3Medical College, King Abdul-Aziz University, Jeddah, 4College of Medicine, King Saud University, Riyadh, 5Family Residency Training Program, Academic Affairs, National Guard Hospital, Riyadh, 6Department of Postgraduate Studies, Ministry of Health, Riyadh, 7Department of Training, General Directorate of Health Affairs, Qassim, 8Security Forces Hospital, Ministry of Interior, Riyadh, 9Joint Program of Family Medicine, Jeddah, 10Health Affairs, Ministry of National Guard, Riyadh, Saudi Arabia

ABSTRACT objective: The objective of this paper was to show the challenges that are faced by the Family Medicine Training Programmes in the Kingdom of Saudi Arabia as well as suggests appropriate and practical solutions. materials and methods: This study was conducted from 2010 - 2013 using a semi-structured questionnaire to achieve the objective. The questionnaire was designed and completed by the investigators during their visits to accredit the training centres all over the Kingdom. It consisted of questions concerning the trainers’ and trainees’ opinions regarding all the aspects of training. Another tool used was the accreditation checklist, which contained a comprehensive list of training structures and processes mandatory for any training centre. The accreditation checklist and questionnaire were reviewed by the investigators after visiting all the training centres. The challenges were then classified manually and solutions were reviewed as well as approved by the members of the Accreditation Committee. results: Seventy-five training centres were visited and 250 trainees along with 75 trainers participated in this study. Twenty- five challenges were identified and classified under 6 major groups. The practical solutions to these challenges were discussed with participants and then approved by the investigators. Conclusion: This study showed that Family Medicine Training in the Kingdom of Saudi Arabia faces many different challenges. Early identification along with key solutions to these difficulties are extremely important in the efforts to produce a new generation of competent Saudi Family Physicians who can improve the quality of healthcare for the population of Saudi Arabia.

Keywords: Challenges, Family Medicine, postgraduate

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Original Article

intRoduction

Family Medicine Postgraduate Training in Saudi Arabia was started in the universities under the umbrella of postgraduate centres in a few Medical Colleges as Master Degree and Diploma in 1983.[1] In some health sectors,

for example Riyadh Military Hospital, the postgraduate training courses were established leading to MRCGP (UK) exam. Subsequently, Fellowship, Arab Board and Saudi Board in Family Medicine were introduced between 1988 - 1995.[1] By 1995, the Saudi Commission for Health Specialties (SCFHS) recognised the Saudi Board of Family Medicine as the highest ranking postgraduate certificate in Saudi Arabia in this field. The MRCGP qualified doctors played an important role in establishing Family Medicine Training Programmes in the initial stages. Ten years after the birth of the Saudi Board of Family Medicine, a few training programmes were established in the large cities of Saudi Arabia namely: Riyadh, Jeddah, Al-Khobar, Abha and Madina.

In order to meet the high demand of Family Physicians (FPs), the Ministry of Health (MOH) requested for a shorter diploma certificate in Family Medicine to be launched in 2006. The proposal was drafted by

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the SCFHS Scientific Board of Family Medicine and after conducting many workshops and forums, the curriculum of 14 months for Saudi Diploma in Family Medicine (SD-FM) was approved.[2] Postgraduate training for SD-FM started in 2008 in Riyadh and Jeddah and then in Abha, Qassim and Madina. Soon after, many training centres were inaugurated in most of the regions of Saudi Arabia. Nowadays, there are more than 70 postgraduate training centres of Family Medicine in Saudi Arabia, with a total capacity of 300 trainees per year.

Based on the training curriculum of Family Medicine, the trainee is expected to spend a total of 44 or 14 months of training to fulfil the requirements of the Saudi Board or Saudi Diploma respectively in Family Medicine. Both curricula were designed to meet the trainee’s practical and theoretical needs in Family Medicine in order to graduate as qualified and competent FPs. In addition to Family Practice, the curriculum includes different rotations in Internal Medicine, Surgery, General Paediatrics, Obstetrics and Gynaecology, Orthopaedics, Dermatology, ENT, Ophthalmology, Emergency Medicine, Community Medicine and Psychiatry.[2-3]

Compared to other specialties, Family Medicine is still at the beginning in Saudi Arabia, even though it attracts a sizeable number of medical school graduates than any other specialty. This situation poses many expected challenges that should be addressed and solved.[4-6]

Family Medicine is considered to be the most needed medical specialty in Saudi Arabia for many reasons. The foremost reason is the high demand for the services of FPs by the Saudi community, which is estimated to be 15,000 FPs. The shortage of Saudi FPs is severe as they represent less than 28% of the total physician power at the Primary Healthcare Centre (PHCC) level.[7] Other reasons include lack of qualified FPs in PHCCs, huge expansion of the number of PHCCs in Saudi Arabia, which is more than 2,000.[7] This shortage is expected to continue for a while, despite the increasing number of Saudi physicians who are applying to join this specialty every year.

During the past 10 years, the SCFHS has worked in collaboration with other health sector institutions to improve the Family Medicine training and practice. This has been achieved through increasing the number of training centres from 10 to 75, thereby increasing the capacity of the training programmes by more than 5 folds. Consequently, these rapid changes have significantly increased pressure on the different aspects of training and are the cause of many challenges. These difficulties or ongoing challenges should be

appropriately assessed, explored, discussed and overcome.

This paper was prepared to show the patterns of challenges that are faced by the Family Medicine Training Programmes in the Kingdom as well as suggest appropriate and practical solutions.

mateRials and methods

This study was conducted between 2010 - 2013. A semi-structured questionnaire was used to achieve the objective of the study [Appendix 1]. The questionnaire was designed and completed by the investigators during their visit to accredit the training centres all over the Kingdom. The questionnaire consisted of questions concerning the trainers’ and trainees’ opinions regarding all the aspects of training including: Healthcare settings, trainers, availability of different training facilities, cooperation of other health sectors, the difficulties they face during training in addition to their suggestions on how to overcome these difficulties. Another tool used was the accreditation checklist, which contained a comprehensive list of training structures and processes mandatory for any training centre. This document was designed by the Accreditation Committee of the Scientific Board of Family Medicine in Saudi Arabia. The checklist consisted of the following parts: Essential data about the training centre (total population served, number of trainers, number of doctors and nurses), availability of venue, diagnostic facilities, therapeutic services, supportive services, training facilities, preventive services, clinical guidelines, medical records and registers.[8]

The total annual capacity of all the training centres for both the Saudi Board and Saudi Diploma is about 200 trainees at different levels of training. During the study period, 75 training centres were visited and evaluated using the accreditation checklist. During these visits, more than 120 trainers and 250 trainees were invited to share their opinions regarding all the elements of training aspects as mentioned above.

After visiting all the training centres in Saudi Arabia, the accreditation checklist and the questionnaire were reviewed by the investigators. The patterns of challenges were classified manually. Solutions were reviewed and approved by the members of the Accreditation Committee.

Results

Table 1 depicts the profile of the Family Medicine Postgraduate Training Centres in Saudi Arabia. In 2013, there were 75 training centres, 150 registered trainers and 474 trainees throughout Saudi Arabia.

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Table 2 shows the different challenges reported by the trainees and trainers along with the suggested solutions. Twenty-five different challenges were identified and classified under 6 major classes i.e.: Health setting, trainers, trainees, health teams, patients and health sector challenges.

discussion

This study attempts to highlight the most important challenges encountered in Family Medicine Training and to suggest the practical solutions to these challenges.

PhCCs related challenges and solutions This study revealed many challenges related to PHCCs accredited for training in Family Medicine. They include inadequate space for training such as small consulting and teaching rooms, inadequate diagnostic and supportive medical services (radiology, laboratory facilities), lack of good medical library and

unavailability of clinical guidelines. Similar findings and observations were reported previously by Bin Abdulrahman and Al-Dakheel.[4] It was also observed, in another study conducted by Al-Khathami that teaching and library facilities were among the common barriers faced by trainees during Family Medicine Training in Saudi Arabia.[9]

To overcome these deficiencies urgent and long-term actions are needed. The urgent action plans include: Allocation of special consulting and teaching rooms for training, facilitating access to diagnostic and supportive services in nearby hospitals without the need of referral to the concerned specialists.

In regards to the unavailability of an efficient library, it was suggested to allocate one room in each training centre, which should be equipped with adequate number of computers, online access to electronic books, guidelines and relevant medical journals. Long- term solutions include: Designing and constructing ideal and model training centres, which meet the accreditation requirements with all the supportive health services and logistics required for training in Family Medicine. Additionally, it was advised to adopt international guidelines for common health problems, such as obesity, hypertension, asthma, dyslipidemia and acute respiratory and gastrointestinal tract diseases until national guidelines are established. These efforts would result in better quality of training and evidence- based quality health services for trainees and trainers

Table 1: Profile of Family Medicine Postgraduate Training Centres, Saudi Arabia - 2013

Number of training centres 75 Number of graduates since 1996 410 Number of health sectors sharing in training 6 Number of trainers 150 Number of trainees at different levels 474 Average of annual graduates 120 Average of annual capacity of training centres 200

Appendix-I: Checklist used by investigators visiting postgraduate centres in Saudi Arabia during routine accreditation visits

Items Methods of evaluation Results/Comments Availability of vision, mission and objectives of training program Looking for a clearly visible signboard Availability of an organizational chart of the training program Looking for it on the signboard There is job description for (director, trainers, trainees) in the program Reading documents Availability of policies and procedures at the training program Reading documents Availability of committees with job descriptions in the training program Reading documents Availability of a written annual action plan Reading documents Availability of written weekly schedules for all training activities (clinic, HDRC) Looking at timetables Presence of records for trainees and trainers Looking at records Presence of a portfolio with each trainee Observation during meeting with trainees There is regular meeting in the training programme Reading relevant documents Presence of clear process of academic supervision in the training program Reading documents, asking trainees/trainers/directors Presence of clear process of coordination with hospitals Reading documents Presence of memorandum of understanding with other health sectors (for Joint programme) Reading Memo of Mutual understanding (MOMU) Presence of programme for trainers development Looking for programme/asking trainers/directors Presence documented regular meetings with trainees Reading minutes/asking trainees Presence of clear process for evaluation of trainees Reading policy/procedures Presence of clear process for continuous quality improvement in the training programme Asking and looking for previous audits Presence of a clear process for administrative issue in the training programme Looking at policies and procedures Presence of effective leadership in the programme Observation during meeting with directors/trainers/ trainees Presence of efficient and homogenous teamwork in the programme Observation during meeting with directors/trainers/ trainees Presence of sufficient number of trainers with different experience Asking during meeting with trainers/trainees

HDRC: Half day release course

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Table 2: Patterns of challenges faced by Family Medicine Training and their solutions in Saudi Arabia - 2013

Healthcare settings (PHCCs/hospitals) related difficulties Solutions 1. Inadequate space for training (e.g. lack of adequate clinic/teaching

rooms)

2. Inadequate diagnostic facilities

3. Lack of internet for staff

4. Shortage of relevant medical reference/sources

5. Lack of clinical guidelines for common health problems

• Allocate adequate space (clinics for training with definite time table in every centre). • Each supervisor should have an office. • Allocate a room for a library which could also be used for small group teaching • One supervisor in each centre should be assigned for all academic and training activities • Provide each training centre computers with internet accessibility to relevant medical

references and clinical guidelines

• Coordination with the nearest hospital to provide direct access to diagnostic and supportive services

Trainers related difficulties Solutions 1. Inadequate numbers

2. Lack of experience in teaching

3. Busy trainers with other commitments

4. Quick/urgent (transfer/movement) from one place centre to another

5. Lack of trainees punctuality for training activities

• Provide all trainers with a manual containing the job description and any new regulation(s) • Focus on the future trainers since the first year of their training to get a new generation of

good trainers (trainees → trainers) • Give short and brief training of trainer (TOT) courses for trainers as well as prospective

trainers

• Conduct regular continuing professional development (CPD) courses/workshops for trainers on “teaching and learning” using adult learning principles

• Allocate time for training and office administrative work • Reduce service load for those working as trainers • Recruit non-Saudi trainers with good experience and qualification in training to share in

teaching load

• Provide significant incentives for distinguishable trainers • 2-3 trainers should available full time at each training centre to avoid shortage and act as a

substitute in case of any unexpected trainer transfer

• Conduct regular social/scientific meetings to resolve conflict, if any • Renewal of Training license should not be given unless the trainer attends some relevant

CPD activities (15 - 20 hours per year)

Trainees related difficulties Solutions 1. Weak up to date knowledge

2. Negative attitude related to punctuality, respect of seniors and colleagues

3. Lack of safety when practicing alone

4. Lack of proper documentation in patient’s files/records

5. Exam oriented more than practice oriented

6. Weak practice management (taking long time with patients, unaware about healthcare system, such as reporting, referral, etc.)

7. Social obligation (frequent excuse, absenteeism, late arrival)

8. Personality disorders (anger, difficult, manipulative)

• Implement valid selection exam including psychological assessment • Provide trainees with important and relevant few references to keep concentration and

focus.

• Concentrate on common health problems in Saudi Arabia • Train trainees on the appropriate use of clinical guideline • Give adequate orientation at the beginning of academic year and rotations • Make trainees aware about SCFHS bylaws and implement it when needed with documents • Conduct joint consultation at least three times per week per trainee. • Use case based discussion, mini-clinical examination and direct observation procedures as

often as possible.

• Active participation of the senior trainees, as trainers for their junior colleagues • Provide trainees with written feedbacks frequently • Trainers should conduct a short meeting at the end of a training clinical session to discuss

with trainees what they have learnt, what are their future plans and their knowledge about cases encountered

• Check records/files, prescriptions and relevant formats to ensure completeness and in the case of incompleteness, discuss it with trainees and in the event of similar reoccurrence provide formal warning

• Implement portfolio completion by trainees with weekly monitoring by academic supervisors • Trainees should have an annual plan for acquiring knowledge, skills and preparing for

exams

Health teams related difficulties Solutions 1. Staff unawareness of training process

2. Uncooperative health centre team members • Supervisors should brief and orient all staffs at the PHCC about the importance of their

centre being selected as a training centre for postgraduate studies

• Explain the role and value of training in improving the quality of health services, patient safety, well-being and satisfaction

• Reinforce that everyone should work as a team • Conduct regular meeting with the directors and technical supervisors of PHCC to

discuss important issues, such as patient flow, quality and safety of care, as well as results of audit

• Explore ideas, concerns and expectations of team members regarding the training process

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attending the training centres of Family Medicine. It was observed that all training centres depend on traditional medical records, which were old, unorganised with lack of problem list and use of different documentation methods. In this regard, it was very important to initiate the implementation of electronic medical record (EMR), which may solve many problems, such as lack of continuity, coordination and comprehensives healthcare in addition to reducing cost of health services as reported by Martin JC.[10]

Other important and common observations were unavailability of adequate number of offices for supervisors, trainers, trainees and other training activities such as group discussions, workshops and seminars in most of the training centres. This problem was due to inadequate number of rooms at the PHCCs. In this regard, it was recommended to construct extra rooms to make training environment healthy and attractive in addition to enabling training staff to be equally accessible to their trainees and patients alike.

trainers related challenges and solutions Trainers are considered the most important pillar of training. Trainers are responsible for planning, execution and evaluation of training activities in all training centres in Saudi Arabia as stated in the job description of trainers in Family Medicine.[11] In this study, it was noticed that the number of trainers was inadequate in most of the training centres, with inadequate or no vocational training in teaching. Many of them have other managerial and clinical loads with some instability due to urgent transfer or reallocation to another position or place. The present study showed two types of trainers: Old and new graduates. Primarily, old graduates with good managerial interest and clinical experience, but lacking teaching skills, literature research and practice of evidence-based

skills. Secondly, new generation of trainers with interest in training, good background in evidence-based medicine but lack teaching and managerial experience. This mixture of senior and junior trainers is a healthy phenomenon in Family Medicine Training despite the fact of the “generations gaps”.[12] Both could be made well-functioning through good and fair job descriptions designed considering the experiences and different roles of trainers (clinician, teachers and managers).

Developing short training of trainers (TOT) course focusing on learning and teaching for all trainers in addition to establishing a structured continuous professional development (CPD) programme depending on their actual needs, are the two recommendations that should be implemented as soon as possible. Regarding inadequate number of trainers, many short- and long- term solutions to overcome these challenges could be implemented. In all the centres, at least 3 trainers should be available to overcome any urgent and unexpected changes such as transfer, vacation, or illness. Non-Saudi FPs with postgraduate qualification in Family Medicine, who are interested or have good experience in training could be recruited and trained to fill some gaps in this regard. Another solution includes allocating training jobs, which could be used to recruit expert academic teachers from outside for short or long periods, as needed. The grade and salary of Consultants/Trainers, who meet the Family Medicine Trainer criteria should be significantly higher than the other Family Medicine Consultants.

For all doctors involved in teaching, it is strongly recommended to give different incentives such as: Financial, reduction of other workloads, awarding of appreciation certificates and academic honorary titles, especially for those with outstanding performance. Lastly, it is recommended to have periodic social meetings for trainers and trainees. Such events may help to strengthen social bonds.

Table 2: (Continued)

Patients related difficulties Solutions 1. Number of patient may be inadequate (low flow)

2. Huge number of patients (high flow)

3. Lack of variety of presenting problems where majority of cases seen are upper respiratory tract infection, diabetes mellitus, hypertension and obesity

• Implement simulation clinic with simulated patients when needed • Trainers and trainees to coordinate with other clinicians to keep a balance regarding health

services needs and training requirements

• Trainees should rotate among training centres in different health sectors Health sectors related difficulties Solutions

1. Relevant authorities may be unaware about the training program requirements

2. Relevant authorities may be uncooperative

• Explain the training program to the relevant authorities indicating the important roles of the concerned sectors

• Active involvement of health sectors in planning, execution and evaluation (Joint Programs) • Advance coordination with the relevant health sector (choose good coordinators) • Establish and approve strategic partnership between different health sectors • Conduct frequent meetings with the concerned people • Provide different incentives for individuals and organizations who show cooperation • Implement and activate of Joint Programs • Regular meeting of different program directors and regional committees

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trainees related challenges and solutions Individual trainees can make training attractive or they can make it painful for all. Programme Supervisors and Trainers reported many observations related to trainees. They include poor competency, unsafe practice when practising alone, poor punctuality, unnecessary prolonged consultation with patient, and focusing on final passing examination rather than clinical practice. Furthermore, they make inappropriate use of medical records and lack awareness of healthcare system, particularly ethical and reporting issues.

A small number of trainees were reported to withdraw from the training programme when they create problems during training. Despite being few in number, they tend to destroy professional relationships and also try to manipulate the system.

To overcome the above mentioned challenges many solutions were suggested. First and foremost was establishing a valid selection criteria for admission to the Saudi Board of Family Medicine Programme, which should also include a psychological assessment. Such an approach will help exclude most of the applicants with behavioural problems and negative attitudes.

It was observed that most of the trainees join the training programme after internship immediately without any experience in Family Medicine. This phenomenon may contribute significantly to a negative attitude and behaviour of some trainees. In this aspect, it would be preferable that applicants spend at least one year at a training centre, which will enable them to be exposed to actual Family Medicine practice. Opinion of senior FPs who have worked with these young physicians should be sought before acceptance in a Postgraduate Training Program in Family Medicine.

Another important suggestion is to give selected candidates adequate orientation, which should include details of training programme (objectives, contents, methods of assessment, few relevant references, different bylaws, regulation, policies and procedures) in addition to issuing a training contract, which includes job description.

Regarding problems related to poor competency of trainees, some important actions related to formative assessment and improvement may be implemented. They include, direct and indirect clinical supervisions, particularly during clinical work, workplace based assessment tools, such as case-based discussion, mini-clinical examination, and direct observation procedures. This approach may help in enabling active participation of trainees, identification of weakness areas and immediate feedback to trainees by the trainers. In addition, this process may

assure patient safety and better quality of healthcare including documentation and reporting.[13-14]

In many training centres, there are senior and junior residents of different residency levels. This mixture could be utilised efficiently by appropriately distributing tasks at the clinics, emphasizing supervision of the juniors by the seniors, and finally have one daily session for supervisors and all trainees to discuss some interesting cases, give feedback and to get reflections from trainees.

Finally, implementation of portfolio to attain the objectives of the training programme with frequent mentoring by the academic supervisors must be assured.

health teams related challenges and solutions Teamwork is one of the important characteristics of a new model of Family Practice, which could deliver high-quality healthcare for individuals and their families.[15] In Saudi Arabia, the workers involved in teamwork at healthcare settings have different levels of educational and professional backgrounds, which may affect equally the health services and the training quality.

Most of the members responsible for running healthcare services at PHCCs do not provide any significant contribution to the training programme and even lack awareness about training in Family Medicine. These factors may lead to a conflict of interest between the two parties (team responsible for health services and the team responsible for training) which eventually may lead to failure of the training process all together.

In this regard, many solutions could be applied to overcome the difficulties in this area. In each Training Centre of Family Medicine Practice, a Committee may be formed consisting of the technical supervisor, director of the centre, academic supervisors of the training centre and trainer in each centre. This committee would be responsible for the distribution of workload in the centre, making services and training schedules as well as solve any conflict.

This Committee should meet frequently on regular basis to discuss all issues related to the training and health services in addition to solving any problem that might arise. All health team members of the health centres should be aware about the importance of Training in Family Medicine and about their vital roles in the training process.

Patients related challenges and solutions One of the biggest challenges faced by the Family Medicine Training Programmes is the availability of a broad spectrum of cases and services that should be covered to master most of the skills necessary to graduate as a medical expert in Family Medicine.[6,14]

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In this aspect, many challenges were identified; they include very low or very high flow of patients and lack of variety of cases with regard to gender, age and different types of cases. To deal with such an important issue, the following suggestions may be helpful: 1. Trainers should tailor clinical teaching according to

the types of cases 2. There should be more trainers at peak hours to

manage high flow of patients 3. One room should be allocated in each centre to

conduct simulation clinics in order to overcome the lack of variety of clinical cases

4. Train candidates on “how to deal with uncertainty and difficult patients in Family Practice”

health sector related challenges and solutions In Saudi Arabia, Postgraduate Training in Family Medicine is conducted in six different health sectors. These belong to MOH, Ministry of Defence, Ministry of National Guard, Ministry of Interior, Ministry of Higher Education and the private sector. Each one of these sectors has its own different agenda, priorities, policies and procedures. It has been observed that the senior administration and decision-makers in most of the health sectors have inadequate background about the training process in Family Medicine and its importance, which may abort or obstruct training anytime. However, it has also been noticed that this variety and diversity of health sectors enriches the training in many ways. Some sectors have good infrastructures, and others have well established curative and preventive programmes, whereas some other sectors may have good number of qualified trainers. In order to get the best from all sectors, some vital recommendations may be issued in this regard. In each region or city, a Joint Programme of Family Medicine can be established to represent all health sectors participating in training. Through Joint Programmes, many advantages could be achieved such as exposure of trainees to different settings, experience and appropriate utilisation of educational as well as clinical facilities. Furthermore, this may reduce the shortage of trainers in some health sectors and lead to coordination between different sectors when conducting academic activities such as Half Day Release Course, Community Medicine Course, Research and Evidence-Based Medicine Courses. In order to make Joint Programmes more efficient, mutual understanding and willingness to collaborate among all sectors should be secured. Frequent meetings should be conducted by a committee of well selected team members from each sector with unified vision with clear understanding and written action plans.

conclusion

This study showed that Family Medicine Training in Saudi Arabia faces many different challenges. Early

identification and solution of these difficulties are extremely important in the efforts to produce a new generation of competent Saudi FPs, who can improve the quality of health care for the population of Saudi Arabia.

acknowledgements

The authors are grateful to all regional committees supervisors, program directors, trainers, and trainees in all centers in KSA for their valuable input, and suggestions which helped us to execute and publish this research project. They also appreciate the valuable comments of Professor Riaz Qureshi on the manuscript.

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How to cite this article: Al-Khaldi YM, AlDawood KM, AlBar AA, Al-Shmmari SA, Al-Ateeq MA, Al-Meqbel TI, et al. Challenges facing postgraduate training in family medicine in Saudi Arabia: Patterns and solutions. J Health Spec 2014;2:61-7.

Source of Support: Nil, Conflict of Interest: None declared.

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