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research articleSilver service - 25 yearsof activities by the Malta Collegeof Family Doctors (1990-2015)Dr Mario R SAMMUTINTRODUCTIONThe Malta College of Family Doctors is an autonomousacademic institution that was formally set up in 1990 withthe object to encourage, foster and maintain the highestpossible standards in family medicine in Malta, and tosustain and improve the professional qualifications ofmembers of the medical profession in Malta who areengaged in family medicine.ORIGIN & DEVELOPMENTThe need for advancement of family medicine in Maltahad been felt for a long time, but any such activities werenot possible before the end of the ten-year medical disputein August 1987. One exception was a 9-month intensivecourse for family physicians, conducted in 1987-88 by thelate Prof. Douglas Johnson of the University of Torontounder the auspices of the University of Malta. Preparationsfor such course had been made by the Faculty of Medicineand Surgery prior to August 1987. In March 1988, threefamily doctors, namely Dr Denis Soler, Dr Wilfred Galeaand Dr Ray Busuttil, were appointed to a General PracticeSub-Committee of the Postgraduate Medical Committee(PMC) of the University of Malta’s Faculty of Medicine &Surgery. Their remit was to devise a development plan forfamily medicine in Malta.In their report presented to the PMC in November1988, four areas were outlined for future development:(1) The development of a Department of FamilyMedicine within the Faculty of Medicine;(2) The establishment of a programme of continuingmedical education for family doctors;(3) The development of a vocational training programmein family medicine;(4) The setting up of a Malta College of Family Doctors.As a result of intensive lobbying by these three doctors,Dr Alistair Donald and Dr Edwin Martin, chairman and6VOLUME 04 issue 02 September 2015member of the International Committee of the RoyalCollege of General Practitioners, were invited to Maltain November 1989 to assess the situation and offer theiradvice. These five gentlemen worked hard together toproduce a charter for a proposed Malta College of FamilyDoctors, and the formation of the College in fact wasformally announced by Dr Soler in the presence of DrDonald and Dr Martin during a Postgraduate MedicalCommittee Meeting in November 1989.A provisional Committee was set up to draw upa College Statute, and both were formally endorsedduring the College’s first general meeting on the 4thApril 1990, with Dr Denis Soler as College President,Dr Wilfred Galea as Vice-President and Dr Ray Busuttilas Honorary Secretary. Picture 1 shows members of theCollege Council and guests in 1994.PLANS & POLICIESThe MCFD made an impact on the proposed reformsin primary health care services in Malta in the early1990s, before these were eventually shelved for politicalreasons. It had earned itself representation on the FamilyDoctor Scheme Council, which had been envisaged asthe body to run the general practitioner service. TheCollege’s role was to be not only an advisory one, butit would have been responsible for the organisation ofthe compulsory refresher course for doctors joiningthe scheme. Its functions would have included alsothe evaluation of the suitability of practice premises,the accreditation of doctors for the receipt of the CMEallowance, and the assessment of practices for thereceipt of the good practice allowance.After recommending a standard Data Set forComputerised Medical Records in 1996, the Collegestarted planning for the development of a fullComputerised Medical Records System for familyThe Journal of the Malta College of Family Doctors

doctors. Its aim was to facilitate good quality continuingcare, health screening through recall systems, thekeeping and exchange of statistics, and the performanceof research and audit. In 1998 the College signed anagreement with the Transition Project from the Universityof Amsterdam to use the Computerised Medical RecordsSystem - TRANSHIS, based on ICPC – the InternationalClassification for Primary Care, and developed for familydoctors by Prof. Henk Lamberts and Dr Inge Okkes(Picture 2). Transhis was launched during 2 workshopsheld in February 2000, with 17 doctors signifying theirreadiness to use the programme under the coordinationof Dr Jean Karl Soler. By the end of 2003, Maltese usersaccumulated 3 full years of data on the system.The MCFD has always pushed for the creation of aculture for research in family medicine, as it believes thatit is through research that academic credibility and statuscan be developed further. In fact the College approveda Research Policy and Planning Document in 1997 topromote research in Family Medicine in an organisedway, to improve the status of the specialty, and enhance: the academic development and career prospects offamily doctors, knowledge and information on family practice,enabling plans for its future, and the health and well being of the population.The College developed a Strategy for the Future of theMalta College of Family Doctors and of Family Medicinein Malta in 1998-99. The most important and urgenttargets were identified as the accessing of members, apolicy document, patient initiatives, the definition ofstandards, a patient charter, and a PR exercise. In fact,a Patient Charter, entitled ‘You and Your Doctor’, waspresented to the College Council in March 1998. AFamily Doctor Directory, initially drawn up in 1994, wasrevised and updated during 1998, when it consisted of269 full-time and 34 part-time family doctors. Such adirectory was intended as just an interim step towards theCollege’s ultimate aim of establishing a proper SpecialistRegister of family doctors who have undergone SpecialistTraining in Family Medicine.Although a Policy Document entitled ‘The College- History and Future Development’ was preparedfor the College by (then) Honorary Secretary Dr RayBusuttil in March 1993, this unfortunately was neverpublished. Then, in line with the declared intention ofthe World Health Organisation to define a charter forGeneral Practice/Family Medicine in Europe, a PolicyDocument on Family Medicine in Malta was drawn upThe Journal of the Malta College of Family Doctorsand approved by the College in 1998. Its objective wasto sensitise the public, the Government and Universityto the importance of family medicine, and to upgradethe status of the family doctor as a specialist in his/herown right. The publication of this policy documentwas intended to serve as a springboard for the launchof a Specialist Training Course in Family Medicine,which however did not materialise at that stage. TheInternational Committee of the Royal College ofGeneral Practitioners (RCGP), the European GeneralPractice Research Network (EGPRN) and the RoyalSociety of Medicine, amongst others, had confirmedtheir willingness to help in its implementation. Whatwas lacking to bring it to fruition was the necessaryfunding, together with the support of the University,the Department of Health and the Government.In 1998 the MCFD was invited by the Ministerof Health to start discussions, together with theDepartment of Primary Health Care and the MedicalAssociation of Malta, for the reorganisation of PrimaryHealth Care. In 1999, the College President gave theCollege Council an overview of the ensuing document,entitled Reforms of the Primary Health Care Services.Three systems were to be proposed to the cabinet for adefinite commitment by the government before one wasdeveloped. However the proposed reforms were turneddown, reportedly due to financial reasons.In 2001, the College Council agreed to the followingstrategic recommendations for the further developmentof the College: Marketing of the College through patienthandouts, newspaper articles and multimediapresentations; Sub-committees to be set up regarding grouppractices, doctor-patient registration cards, andmembership by examination; The introduction of membership/certificatecourses; The seeking of strategic partner/s.Other topics proposed included GP cooperatives,practice certification, a College archive, the Journal onCD, and small group meetings.In 2001, the College Council agreed to develop atwo-year course leading to membership by examination(MMCFD). However, in 2003, the Council noted thatother countries around the world are negotiating withthe RCGP for certain concessions to allow local traineeGPs to do the highly reputable MRCGP International.VOLUME 04 issue 02 September 20157

Council thus agreed that the way forward for Maltashould be for the MCFD to provide assistance (througha Teachers’ Group) for local candidates to prepare forthe MRCGP[INT], rather than to reinvent the wheel bydeveloping an expensive local course and examination.CPD PROGRAMME AND JOURNALThere being no formal training in family medicine inMalta, the College launched a Continuing ProfessionalDevelopment Programme in September 1990, originallyin the form of a three-evening meeting, with educationalevents to this day being held in each term of the academicyear - Autumn, Winter and Spring - under the directionof a team currently led by Dr Philip Sciortino. Other adhoc meetings are also organised (Picture 3). A systemof accreditation of CME activities was initiated in 2000,with continuing membership of the College dependingon the accumulation of sufficient credit units withinthis scheme.The credibility and status earned by the Collegein the first three years of its existence resulted in thePostgraduate Medical Committee of the University’sFaculty of Medicine formally passing on to the Collegein 1993 the organisation of all postgraduate educationalactivities for family doctors. For a time, the Collegewas also asked to act as coordinator of the whole CMEcalendar for the PMC.In 2001, a Strategy for the College’s CPD Programmewas presented to the College Council, consisting of thefollowing objectives: The presentation be improved as regards venue,publicity and refreshments; The academic content be improved according tothe needs ascertained through research; The format of teaching be practice-based andinformal, taking place in small groups; The topics be not always clinically based, butshould also include other topics like academicfamily practice and practice management.Highlights of early academic activities organised bythe College include: 5-day Family Doctor Training Seminar onCommunity Psychiatry co-organised in May 1994; 3-day Joint Seminar on Paediatrics and Obstetrics& Gynaecology co-organised in November 1996; 6th Mediterranean Medical Congress &2nd Mediterranean Summer School of theMediterranean Medical Society, organised in Maltaby the College on 5-10 September 2000;8VOLUME 04 issue 02 September 2015 Brief Intervention Training Workshop on SmokingCessation in General Practice co-organised with theIrish College of General Practitioners on 18 October2003 (Picture 4).In September 1990, the first issue of ‘It-Tabib talFamilja’, the Journal of the Malta College of FamilyDoctors, was issued a humble four-page newsletter withDr Godfrey Farrugia as editor (Picture 5). Dr Farrugiawas replaced as editor by Dr Jean Karl Soler in 1993,with the newsletter being converted to a colour journalin 1995 and upgraded academically in 2000 with theappointment of three international peer reviewers, aninternational scientific advisory board to recruit papersfrom the Mediterranean region, and a change in nameto ‘The Family Physician - It-Tabib tal-Familja’. In 2005,Dr Noel Caruana was appointed the new editor, and thejournal was renamed ‘The Maltese Family Doctor’. In 2012,the College Council relaunched the journal under thename of the ‘Journal of the Malta College of Family Doctors(JMCFD)’ which is being issued three times a year withProf. Pierre Mallia as Editor (Picture 6).The JMCFD is available online together with otherresources useful for College members on the MCFDwebsite at www.mcfd.org.mt/jmcfd. An MCFD websitehad been launched in February 1996 through the initiativeof Dr Wilfred Galea, one of the College founders, courtesyof Grazio Falzon’s ‘Malta Virtuali’ in the USA. In October1996, the site exchanged its host for TheSynapse Networkhere in Malta, and subsequently was transferred to thecurrent URL www.mcfd.org.mt by Dr Renzo De Gabriele.The website was later reconstructed by Dr KennethVassallo and is currently maintained by webmaster JanWillem van Avendonk.INTERNATIONAL COLLABORATIONThe Malta College of Family Doctors has maintainedthe excellent relationship it has had with the Royal Collegeof General Practitioners since its inception. A certificatedated 4 September 1990 presented to the Malta Collegeby the RCGP through Dr Edwin Martin (the RCGP’sMalta Fellow during 1990-3) gives evidence to this(Picture 7). This certificate states that the RCGP ‘regardsthe Malta College as a sister body that will set the standardsof education in family medicine in Malta and as the bodywhich will, where appropriate, give accreditation to doctorsundertaking approved training for family medicine’. Besidesa Workshop on Counselling in Family Practice in 1995(Picture 8), the RCGP’s help resulted in a 5-day Teachers’Course in Family Medicine run with the Bedfordshire &The Journal of the Malta College of Family Doctors

Hertfordshire Faculty in 1993 (Picture 9), the sponsorshipof College representative Dr Philip Sciortino in anInternational Course for Teachers of General Practice in1997-98 (Picture 10), and the following other teachers’courses: 2002-3: 9-day Teachers’ Course held incollaboration with RCGP (Picture 11); 2004: 10-day RCGP-MCFD Teachers’ Course(Picture 12); 2006: 5-day MCFD-RCGP Teachers’ Course Moduleon ‘Mentoring & Appraisal’ (Picture 13); 2006: MCFD-RCGP Assessment Workshop.These were the first steps in preparation for the localintroduction of specialist training in family medicine.Over the years the College developed affiliations andlinks with other important organisations: the Canadian College of Family Physicians, mostespecially with the late Professor Douglas Johnsonwho had given his unstinting help and support inall of the College’s major projects; the Irish College of General Practitioners, throughthe provision of distance learning programmes andthe organisation in Malta of a Brief InterventionTraining Workshop on Smoking Cessation inGeneral Practice during 2003; the World Organisation of Family Doctors –WONCA and the European Society of GeneralPractice/Family Medicine - WONCA Europe withits various network organisations: the EuropeanAssociation for Quality in General Practice/FamilyMedicine - EQuiP, the European General PracticeResearch Network – EGPRN, the EuropeanAcademy of Teachers in General Practice/FamilyMedicine – EURACT, and the European Networkfor Prevention and Health Promotion in GeneralPractice/Family Medicine – EUROPREV.The College’s membership of the World Organisationof Family Doctors (WONCA) was boosted in 1996 whentwo Council members, Dr Wilfred Galea and Dr Jean KarlSoler, were appointed to the WONCA Working Party onInformatics. Moreover, in 1998 Dr Soler was appointed tothe WONCA International Classification Committee. In1995 the MCFD became a founder member of WONCAEurope and automatically a member of the WONCAEurope Council, and the College was also honoured by theWONCA Europe in 1997 when two Council members (DrDenis Soler and Dr Mario R Sammut) were invited to chairsessions in its Prague Conference that year (Picture 14).The Journal of the Malta College of Family DoctorsWhile the MCFD obtained affiliation with EQuiP in1994 with whom it was ably represented by Dr AnthonyP Azzopardi, local ties are especially strong with the otherthree WONCA Europe network organisations - EGPRN,EURACT and EUROPREV. No less than three workshopsof EGPRN have taken place in Malta in 1996 (Picture 15),2004 and 2013, with EGPRN research-methods coursesalso held in Malta in 1999 (Picture 16) and 2004. FormerMCFD Council Members Dr Anthony Mifsud and Dr JeanKarl Soler were instrumental in the organisation of theseactivities in the role of Malta’s national representative toEGPRN, with Dr Soler also being elected Chairman ofEGPRN in 2013.In 2008, EURACT held its Spring Council Meetingin Malta in 2008 (Picture 17) and also played a role inthe organisation in Malta of courses and a workshopas follows: 2007: 5-day MCFD-EURACT-RCGP Teachers’Course (Picture 18); 2008: EURACT-MCFD InternationalWorkshop on Lifelong Learning in FamilyPractice (Picture 19); 2009: 5-day MCFD-EURACT Teachers’Course.In his role as Malta’s national representative toEURACT since 2004, former MCFD Honorary SecretaryDr Mario R Sammut facilitated the participation oflocal family doctors in various EURACT teachers’ andassessment courses abroad, and in 2013 he was electedas Honorary Secretary of EURACT.Dr Mario R Sammut also spent 14 years (1999-2013)as a member of the Coordinating Team of EUROPREV,and on behalf of the MCFD was the local coordinator ofthe EUROPREV survey on the attitudes and knowledgeof GPs in prevention and health promotion held in 2000and of the EUROPREVIEW Patient Study to elucidatethe beliefs and attitudes of patients regarding preventiveservices and lifestyle during 2008-9.UNDERGRADUATE AND POSTGRADUATETEACHING IN FAMILY MEDICINEThe College over the years had repeatedly proposedto the relevant authorities the establishment of a separateDepartment of Family Medicine within the UniversityFaculty of Medicine & Surgery. This would provideinstruction in family medicine for undergraduate medicalstudents, and was also envisaged to be involved, inliaison with the College, in the setting up and runningof Postgraduate Vocational Training in Family Medicine.VOLUME 04 issue 02 September 20159

Through such pressure from the College, the post of parttime lecturer in general practice within the Department ofPublic Health in the Faculty of Medicine was instituted on1st January 1991 with the appointment of Dr Ray Busuttil.After further lobbying by the MCFD, the Dean of theUniversity Faculty of Medicine & Surgery, Prof. MarkBrincat, announced plans for the set up of a Departmentof Family Medicine during a meeting with a Collegedelegation on the 3rd February 1999. Dr Denis Soler, asPresident of the College, was invited to chair an ad-hocAdvisory Committee on Family Medicine, whose mainaim was to prepare an undergraduate and postgraduateprogramme for the new Department of Family Medicine.The Department was formally set up in April 2001 withthe appointment of 7 lecturers (all College members), andDr Denis Soler as Head of Department.After his retirement in 2013, Dr Soler was replacedby Dr Philip Sciortino as Head and the departmentpresently consists of 8 part-time lecturers who provide anundergraduate teaching programme of lectures, tutorials(face-to-face and electronic) and community placementsfor medical students in their 4th year. The Department ofFamily Medicine also runs a postgraduate MSc in FamilyMedicine, with the first cohort of candidates graduatingin 2009.Since 2001, MCFD members have participatedthrough distance-learning in Diplomas in Therapeutics,Prevention and Women’s Health, and a Certificatein Diabetes all held by the Irish College of GeneralPractitioners (Picture 20). Then, during 2004-7, MCFDCouncil Member Dr Jean Karl Soler facilitated theparticipation of College members in the University ofUlster’s distance-learning Diploma/MSc in Primary Care& General Practice (Picture 21). Last but not least, in2005-7 the MCFD organised an inaugural Diploma inFamily Practice coordinated by Prof. Pierre Mallia that wassuccessfully completed by twenty-seven local doctors andwas given recognition by the Medical Council of Malta(Picture 22). Kindly sponsored by St Philip’s Hospital, itconsisted of eighteen assessed modules and was the firstdiploma offered by the College and the first formal postgraduate diploma in family medicine organised by localdoctors for local doctors.SPECIALIST STATUS AND TRAINING INFAMILY MEDICINE, THE MMCFD AND THEMRCGP [INT]In 2000, a memo regarding the introduction of a 3-4year course in Vocational Training in Family Medicinewas approved by the Director General (Health), the10VOLUME 04 issue 02 September 2015Medical Association of Malta and the MCFD. In 2001,lists of criteria for the selection of twelve trainers and onecoordinator for the course were approved by the CollegeCouncil and forwarded to the Director General (Health).In 2003, an agreement on the subject was reached by theHealth Division and the Medical Associat

6 VOLUME 04 issUE 02 sEptEMbEr 2015 the Journal of the Malta College of Family Doctors Dr Mario r saMMUt rEsEarCh artiCLE Silver service - 25 years of activities by the Malta College of Famil