The Flight From Primary Care in Psychiatry

To the Editor: I read with interest the article by Samuel F. Law, M.D., F.R.C.P.C., and colleagues in the December issue (1) and applaud the initiative. We would like to point out that primary mental health care is lacking in other Asian countries too, but for reasons other than political. In Singapore, an urban city-state in Southeast Asia with a population of 5.18 million, these reasons are rooted in a rapid development and expansion of health care services. A rapid shift to medical specialization and subspecialization and increasing health care consumerism for specialized care have drawn patients away from primary health care to readily available specialist care at tertiary centers. While initially not undesired, the shift has gradually taken a toll on primary care physicians. In psychiatry, the gradual erosion of expertise and clinical skills in dealing with mental health issues has left primary care physicians reluctant and sometimes unwilling to handle even minor psychiatric problems. The population also continued to seek help for mental health issues from faith healers and from the nonmedical community.

In Singapore, major efforts have been made to remedy the situation, with postgraduate training programs for primary care physicians and allied health professionals and the setup of general practitioner partnership programs that allow for a two-way flow of patients for more appropriate allocation of care. Additionally, public health efforts to reduce stigma associated with mental illness have also been expanded.

Beyond this, recent calls to review undergraduate training and the relevance of clinical training in psychiatry should be heeded. Much can be done during early medical training to provide necessary skills for lifelong learning and change the attitudes of our medical students for their future practice (2–4).