The influence of Resilience, Burnout and Job Satisfaction on Team development in the primary care setting : the Singapore experience

doi:10.21203/rs.3.rs-2079225/v1

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Research Article

The influence of Resilience, Burnout and Job Satisfaction on Team development in the primary care setting : the Singapore experience

https://doi.org/10.21203/rs.3.rs-2079225/v1

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Background

Team-based care is associated with improved quality, cost and access of care and team functioning plays an important role. However, team development may be affected by team member burnout, resilience, job satisfaction, and workplace characteristics. Team-based care was introduced in the National Healthcare Group Polyclinics (NHGP) through the teamlet care model, where small teams consisting of two family physicians, a nurse and care coordinator provided care for a fixed panel of patients, with improved care continuity, comprehensiveness and integration of care. This study aimed to assess burnout, resilience and job satisfaction amongst different healthcare professionals working in NHGP teamlets, and to determine the association with team development.

Methods

A cross-sectional survey study was conducted recruiting all teamlet members. Survey measures included the Team Development Measure (TDM), Maslach Burnout Inventory Human services survey (MBI-HSS), Connor-Davidson Resilience Scale 2 (CD-RISC 2) and War, Cook and Wall’s Job Satisfaction scale. Scores were compared amongst professional groups and the relationship between TDM and the other scores were explored using correlation analysis and multivariable linear regression.

Results

A total of 88 family physicians, 31 nurses and 27 care coordinators completed the survey, giving an overall response rate of 82.3%. Family physicians reported the highest burnout scores in all three MBI subdomains. There were no significant differences in TDM, resilience and job satisfaction scores amongst the health professions. Multivariable linear regression revealed that lower depersonalisation scores, higher job satisfaction scores and social interaction outside of work were significantly associated with higher TDM scores.

Conclusions

The association between depersonalisation, job satisfaction and social interaction outside work with TDM scores could inform the development of future interventions aimed at improving team development. Steps should be taken to address the higher levels of burnout experienced by family physicians.

Team development

Resilience

Burnout

Job satisfaction

A team-based approach is recognised as fundamental to providing comprehensive and coordinated care for patients with chronic conditions.^1,2 Team-based care has been found to improve the quality of care for patients with chronic conditions and reduce healthcare utilisation.^3,4 Studies have found higher rates of depression screening, adherence to diabetes care bundles, reductions in emergency department, hospitalisation attendances and reductions in primary care visits for patients managed by team-based approaches.³

In 2015, National Healthcare Group Polyclinics (NHGP), developed a chronic disease care model named the “NHGP teamlet”, providing team-based care and care continuity for patients with chronic conditions through small teams in a large polyclinic setting. The development of the NHGP teamlet model was informed by “building blocks of high performing care” that included (1) team-based care, (2) empanelment, (3) data-driven improvement, (4) population management and (5) stratification of chronic conditions for allocation of resources.^5,6

Each teamlet comprises of two family physicians, one care manager and one care coordinator. Care managers are nurses trained in chronic disease management, while care coordinators are ancillary staff who support preventive care such as providing advice for preventive health screening and following up with patients who missed or defaulted their planned clinic appointments. Each teamlet focuses on its patients’ medical, functional, psychological and social needs to provide individualised, holistic and integrated care while optimising resource allocation. The empanelment of patients to a teamlet supports care continuity and fosters a good doctor-patient relationship over time. It also facilitates goal-setting and shared decision-making by patients and healthcare providers, which are essential in chronic disease management.⁷

Good interprofessional collaboration between teamlet members is required to support provision of comprehensive and coordinated care for each patient. Important competencies of an inter-disciplinary team have been identified in previous systematic reviews. These include having appropriate leadership, common team values, a team culture, good communication and transparency in roles and goals.⁸ All NHGP teamlets attend a team-based training course after the teamlet is formed. The course is interactive and incorporates adult learning pedagogy, focusing on helping teamlet members gain role clarity, improve communication, foster cohesion, improve work processes and develop team goals.

Teamwork in healthcare teams is challenging. Team members frequently come from different backgrounds with different knowledge, attitudes and expectations. Teamwork is emergent and dynamic as team members react to each other’s words and behaviour and coordinate their efforts in response to changing work demands. Furthermore, the local primary care environment in the polyclinics is fast-paced with rising attendances over the years.⁹ The Team Development Measure (TDM) was developed to assess team functioning in primary care teams. A previous study found that while team-based training improved TDM scores in teamlets with poorer scores, there remained heterogeneity in scores between teamlet members by professional groups and between teams.¹⁰ Another study found that nurses had a negative perception of teamwork when compared to physicians, possibly attributed to hierarchical differences which hindered them from participating as full team members.¹¹

Burnout is described as “an erosion of the soul caused by the deterioration of one’s values, dignity, spirit and will.”¹² It is a threat to the primary care workforce. Symptoms range from fatigue, disinterest in patients, to physical symptoms and absenteeism. Studies have found that higher self-reported burnout was associated with lower perceptions of team development.^11,13 A study conducted amongst family physicians working in Singapore polyclinics in 2011 showed that 55% of them seriously considered changing job at least once over the past few months and scored high on the emotional exhaustion scale of burnout.¹⁴ The 2017 Medscape Lifestyle Report showed that the percentage of burnout had increased from 2013, with family medicine among the top three specialties affected in the United States (US).¹⁵ Burnout rates in US family physicians were up to 54.4% with higher rates in residents, fellows and early career family physicians.

Resilience gives us the ability to thrive in the face of adversity and indicates how well one is equipped to bounce back after stressful events. Job satisfaction is a feeling of fulfilment that a person derives from their job.

To our knowledge, few studies have been conducted to investigate factors associated with team development in a primary care setting. We investigated the relationship between resilience, job satisfaction, burnout and team development among teamlet members. Identifying differences between healthcare professions will support further understanding of health profession-specific issues, while identifying factors associated with team development will support further efforts in improving team dynamics and development of high functioning teams.

Design

This cross-sectional survey study was conducted over four weeks in July 2021. The survey was conducted anonymously using Research Electronic Data Capture (REDCap®).¹⁶ The study was approved by the National Healthcare Group Ethics Review Board (NHG DSRB Ref: 2019/01156).

Setting and participants

In 2021, the National Healthcare Group Polyclinics (NHGP) had six polyclinics serving the central and northern parts of Singapore and forms the primary healthcare arm of the National Healthcare Group. Polyclinics are large publicly funded clinics providing a comprehensive range of primary care services in Singapore, with an emphasis on providing care for chronic conditions. Approximately 6.7 million visits were made to polyclinics in 2019. Each polyclinic has five to six teamlets with a total of 31 teamlets across all clinics. All teamlet members (Family Physicians, Care Managers and Care Coordinators) were invited to participate in the study via electronic mail. Interested participants would click on the survey link to proceed with the survey. Participation was anonymous and participants’ place of practice was assigned a random code to prevent identification of participants. Upon completion, participants were reimbursed with a token of appreciation (SGD $10 Voucher).

Items in the questionnaire

The questionnaire consisted of six sections. The first section comprised of questions related to socio-demographic, professional and workplace characteristics, including years of work experience, employment status, presence of co-location of the team, preferred mode of communication, and whether there was social interaction among teamlet members outside of work.

The second section consisted of the Maslach Burnout-Inventory Human services survey (MBI-HSS), a validated 22-item questionnaire which has been widely used for measuring burnout of medical personnel.¹² It measures three dimensions of burnout: Emotional exhaustion (EE) (Cronbach’s alpha 0.90), Depersonalisation (DP) (Cronbach’s alpha 0.79) and Personal accomplishment (PA) (Cronbach’s alpha 0.71). Responses were given on a 7-point Likert scale, ranging from 0 (never) to 6 (every day). Burnout was defined by the updated Maslach-recommended criteria of high EE (≥ 27) and high DP (≥ 13) or high EE and low PA (≤ 31).

The third section included the Connor-Davidson Resilience Scale 2 (CD-RISC 2).¹⁷ It has two statements about resilience namely “I am able to adapt to change” and “I tend to bounce back after hardship”. These were scored on a 5-point Likert scale, ranging from 0 (not true at all) to 4 (true nearly all the time).

The fourth section consisted of the War, Cook and Wall’s Job Satisfaction scale, a measure of job satisfaction.¹⁸ It measures the employee’s satisfaction with the intrinsic and extrinsic facets of the job. The scale consisted of 10 items. Responses were given on a 7-point Likert scale, ranging from 1 (extremely dissatisfied) to 7 (extremely satisfied).

The fifth section included the Team Development Measure (TDM), which is a 31-item questionnaire with a Cronbach’s alpha of 0.97.¹⁹ It measures four domains of team development: Communication, Roles and Goals, Cohesion and Team Primacy. A 4-point Likert scale measure was used for each item ranging from 1 (strongly disagree) to 4 (strongly agree). The raw scores of the TDM are transformed to a scale of 0-100, where 0 is the lowest possible score and 100 the highest possible score. These scores are further categorised into team development solidification phases, which include initial development, in place and firmly in place.

Analysis

Data was extracted from the REDCap® database. Continuous variables were summarised using mean and standard deviation while categorical variables were summarised using proportions. Pearson correlation analysis was used to analyse the correlation between TDM and other scores. Multivariable linear regression analysis was used to examine the association between TDM scores with participant characteristics, workplace characteristics, resilience scores, MBI scores and job satisfaction scores. Data was analysed using Statistical Package for Social Sciences (SPSS) version 24 with the significance level set at p < 0.05.

A total of 88 Family physicians, 31 care managers and 27 care coordinators completed the survey, giving an overall response rate of 82.3%. Fifty-five per cent of Family physicians and 44% of Care coordinators were 35 years old and below while 41% of Care managers were between the ages of 36–45. More than 70% of the participants worked in NHGP for ten years or less and more than 85% were working full-time. The most common mode of communication was “face to face” among Family physicians (56.8%) and Care Coordinators (51.9%). Social interaction with their teamlet members outside of work were reported by 44.3% of Family physicians, 58.1% of Care managers and 59.3% of Care coordinators. (See Table 1)

Table 1

Participant characteristics
	Family Physicians (n = 88)	Care Managers (n = 31)	Care Coordinators (n = 27)	p-value
	N (%)	N (%)	N (%)	p-value
Age group
≤ 35	49 (55.7)	8 (25.8)	12 (44.4)	0.045
36–45	25 (28.4)	13 (41.9)	6 (22.2)
46–55	9 (10.2)	7 (22.6)	4 (14.8)
> 55	5 (5.7)	3 (9.7)	5 (18.5)
Length of service with NHGP (years)
≤ 10	70 (79.5)	24 (77.4)	19 (70.4)	0.61
> 10	18 (20.5)	7 (22.6)	8 (29.6)
Employment status
Full Time	75 (85.2)	31 (100.0)	27 (100.0)	0.01
Part Time	13 (14.8)	0 (0.0)	0 (0.0)
Mode of communication
Face to Face	50 (56.8)	15 (48.4)	14 (51.9)	0.70
Non F2F/Others	38 (43.2)	16 (51.6)	13 (48.1)
Social interaction outside work
No	49 (55.7)	13 (41.9)	11 (40.7)	0.24
Yes	39 (44.3)	18 (58.1)	16 (59.3)

Table 2 describes the mean and standard deviation of the variables of interest among the different healthcare professionals in the teamlet. There were no significant differences in TDM, resilience and job satisfaction scores among the teamlet members. Mean emotional exhaustion (EE) and depersonalisation (DP) scores were statistically significantly higher among family physicians (EE 25.8 ± 12.6, DP 10.1 ± 6.6) when compared to care coordinators (EE 15.1 ± 12.1, DP 5.5 ± 5.4) and care managers (EE 15.1 ± 9.2, DP 4.8 ± 4.4). Mean personal accomplishment (PA) scores were highest among care managers (38.6 ± 6.4). Burnout was detected in 6.5% of care managers, 14.8% of care coordinators and 31.8% of family physicians (p = 0.08).

Post-hoc analysis found a statistically significant difference between family physicians and care managers (p < 0.0167) for all three domains of MBI. Emotional exhaustion and Depersonalisation domains were statistically significantly different between family physicians and care coordinators. (p < 0.0167)

Table 2

Mean and standard deviations of the variables of interest among the different professions
	Family Physicians	Care Managers	Care Coordinators	p-value
	(n = 88)	(n = 31)	(n = 27)
	Mean (SD)	Mean (SD)	Mean (SD)
TDM Score	66.2 (14.2)	66.7 (12.8)	64.0 (11.7)	0.70
Resilience Score	5.6 (1.3)	5.7 (1.3)	5.6 (1.6)	0.95
MBI
Emotional Exhaustion	25.8 (12.6)^1,2	15.2 (9.2)¹	15.1 (12.1)²	< 0.001
Depersonalisation	10.1 (6.6) ^1,2	4.8 (4.4)¹	5.5 (5.4) ²	< 0.001
Personal Accomplishment	34.2 (7.8) ¹	38.6 (6.4) ¹	35.6 (8.4)	0.02
Presence of Burnout
Burnout, N(%)	28 (31.8)	2 (6.5)	4 (14.8)	0.08
Not Burnout, N(%)	60 (68.2)	29 (93.5)	23 (85.2)	0.08
Job Satisfaction Score	4.8 (0.8)	5.0 (0.6)	5.2 (0.8)	0.79
^{1, 2} Post-hoc comparisons using a Bonferroni correction were significant

Correlation analysis between TDM and other scores found a positive significant moderate correlation between job satisfaction (r = 0.47), personal accomplishment (r = 0.40) and resilience (r = 0.37) with TDM scores. EE and DP were significantly negatively correlated with TDM scores (r of -0.21 and − 0.24 respectively). (See Table 3)

Table 3

Correlation analysis between TDM and other scores
	r (p-value)
Resilience Score	0.37 (< 0.001)
MBI
Emotional Exhaustion	-0.21 (0.01)
Depersonalisation	-0.24 (0.004)
Personal Accomplishment	0.40 (< 0.001)
Job Satisfaction Score	0.47 (< 0.001)

Table 4 shows the multivariable linear regression analysis examining the association between TDM scores with participant characteristics, workplace characteristics, resilience scores, MBI scores and job satisfaction scores. Age more than 55 years (OR -13.03, 95% CI -19.77 - -6.28, p < 0.001) was negatively associated with TDM scores while presence of social interaction outside of work (OR 7.1, 95% CI 3.96–11.46, p < 0.001), lower depersonalisation scores (OR -0.50, 95% CI -0.95 - -0.06, p < 0.03) and higher job satisfaction scores (OR 6.60, 95% CI 3.64–9.56, p < 0.001) were positively associated with TDM scores after controlling for other independent variables.

Table 4

Factors associated with Team Development Measure Score
	B	95% Wald Confidence Interval
	B	Lower	Upper	Sig.
Age group
≤ 35	REF
36–45	-0.70	-4.95	3.54	0.75
46–55	-5.73	-11.84	0.39	0.07
> 55	-13.03	-19.77	-6.28	< 0.001*
Length of service with NHGP (years)
≤ 10	REF
> 10	4.47	-0.33	9.28	0.07
Profession
Doctor	REF
Care Manager	-4.04	-8.85	0.77	0.10
Care Coordinator	-1.59	-6.41	3.23	0.52
Mode of communication
Face to Face	REF
Non-F2F/Others	-0.12	-3.85	3.62	0.95
Colocation
Partially/No colocation	REF
Fully Colocated	0.28	-4.63	5.19	0.91
Social interaction outside work
No	REF
Yes	7.71	3.96	11.46	< 0.001*
Resilience Score	1.96	0.48	3.45	0.01*
MBI
Emotional Exhaustion	0.25	0.01	0.50	0.05
Depersonalisation	-0.50	-0.95	-0.06	0.03*
Personal Accomplishment	0.17	-0.12	0.47	0.25
Job Satisfaction Score	6.60	3.64	9.56	< 0.001*

Main findings

This study investigated the relationship between resilience, job satisfaction, burnout and team development among teamlet members. Family physicians reported the highest burnout scores across all three domains of the MBI. There were no significant differences in TDM and resilience scores among Family physicians, Care managers and Care Coordinators. Age more than 55 years were negatively associated with TDM scores while presence of social interaction outside of work, lower depersonalisation scores and higher job satisfaction scores were positively associated with TDM scores after controlling for other independent variables.

Burnout, Depersonalisation and Job satisfaction

More than half of physicians and one-third of nurses in the United States experience symptoms of burnout.²⁰ Those working in front line disciplines like family medicine are at a higher risk for burnout.²¹ The prevalence of burnout among teamlet family physicians in our study was 31.8%, lower than the reported prevalence of 80.7% among residents from Singhealth residency in a local study in 2018. A more recent study by the Singapore Health Services (SHS) cluster in 2019-2020 showed that 62.0% of the survey respondents in the Medical group experienced a high burnout score.²² However, the latter studies used a different definition of burnout as having a high subscore on any MBI subdomain whereas our study defined burnout according to the updated Maslach-recommended criteria of high EE and high DP or high EE and low PA.²³ The marked heterogeneity in burnout definitions in the literature contributing to variability in published prevalence burnout estimates had been reported in a systematic review, highlighting the importance of developing a consensus definition of burnout.²⁴ The Medscape National Physician Burnout & Suicide Report 2020 found that 46% of family physicians in the United States had burnout.²⁵

Studies have shown that burnout among physicians is caused by a myriad of factors. These range from heavy administrative burden, pressure to learn new technology, long working hours, time pressure during consults, to a lack of alignment regarding values, mission, and purpose.^21,26 In November 2021, Singapore’s Ministry of Health released statistics showing that about 1500 healthcare workers resigned in the first half of 2021, compared with 2000 annually before the Covid-19 pandemic.²⁷ The two-year average attrition rate was 9.8% in 2021. A qualitative analysis of e-diary data involving more than 600 healthcare workers in Singapore in mid-July to mid-August 2020 showed that the most commonly shared theme was the cumulative burnout from being overworked and emotional exhaustion.²⁸ This study was conducted during a time of heavy infection control restrictions, stringent quarantine and contact tracing measures during the pandemic. Not being able to take adequate leave and allocate time for self-care contributed to experiences of burnout in certain local institutions. The lack of appreciation at work also affected the morale of healthcare workers, especially among female nurses. Conversely, morale boosters described in the study included a devotion to service, being motivated and inspired by strong leadership and supportive colleagues. Leadership that went the extra mile for both staff and patients were lauded. Staff also derived assurance and job satisfaction from working with highly competent peers that they respected.

Burnout rates in care managers were lower (6.5%) when compared to a study involving nurse practitioners and physician assistants in the United States (22.6%).²⁹ The study by SHS in 2019-2020 revealed that 71.3% of nurses had high burnout scores in at least 1 MBI subdomain, 36.0% had high burnout scores in at least 2 MBI subdomains and 16.8% had high burnout scores in all 3 MBI subdomains.²² While burnout in care coordinators in the primary care setting is less studied, our study showed that 14.8% of teamlet care coordinators had burnout, lower than that reported (18.0%) among non-clinical staff working in primary care settings in the United States.²⁹ The proportion of nurses in Singapore public hospitals who resigned in 2021 was 7.4%, reaching a five-year high. The increase was higher for foreign nurses in the public sector, with 14.8% resigning.³⁰ The pandemic has indeed taken a toll on nurses, creating a nursing crunch that may stay in the coming years.³¹ A possible reason why burnout rates in our study was lower could be due to the different practice environment and working schedules. In our polyclinic setting, nurses have a fixed work schedule with no on call or overnight shifts. Working in integrated teamlets delivering patient care as a team helps to foster camaraderie and promote better relationships and emotional support between members, which is crucial during times of crisis like during the pandemic.

Our study also showed that lower depersonalisation scores and higher job satisfaction scores were associated with TDM scores after controlling for other independent variables. Depersonalisation can be described as the development of a callous and cynical attitude towards the recipients of one’s services.³² The three burnout dimensions of EE, DP and PA usually do not develop simultaneously. The sequential order of these concerns the development of burnout and may be relevant for early recognition and preventive interventions. Golembiewski et al argues that depersonalisation is experienced first as some level of detachment is needed when providing medical services.³³ Eventually detachment leads to depersonalisation and triggers emotional strain. Other researchers like Leiter and Maslach maintain that emotional exhaustion develops first as a response to chronic job stress, which then leads to depersonalisation to cope with the stressors.³⁴ These subsequently lead to a feeling of reduced personal accomplishment.

Social connectedness

Our study showed that the presence of social interaction outside work was positively associated with better team development. Social connectedness, especially in the form of teamwork, addresses the psychological needs of friendship, a sense of belonging and adds meaningfulness to one’s work.³⁵ Positive and rewarding human connections are known to be beneficial to mental well-being and can reduce burnout.³⁵ When team members discover meaning in their work through interaction with other members involving trust, respect and confidence, believing the best in one another and tolerating mistakes, they can inspire each other and enhance teamwork. ³⁶ In contrast, a study among healthcare professionals showed that loneliness was positively associated with somatisation, emotional detachment and dehumanisation.³⁷ Social interaction is a social exchange between two or more individuals which form the basis for social structure, group dynamics and conformity. These interactions can be categorised into accidental, repeated, regular and regulated. A previous study showed that small increases in social cohesion had large influences on better productivity even when interactions were not work related.³⁸ This highlights that it is the strength of the relationship that matters. Our study results are therefore not surprising.

It is likely that social interaction outside work starts with positive social interaction at work. Structural strategies to provide opportunities for socialisation may help to foster meaningful, high-quality social connections among teamlet members. In the newer NHGP polyclinics, there are designated “huddle rooms” with computers, projectors, notice boards and white boards to facilitate inter-professional discussions, planning of upcoming patient visits, team projects and initiatives. These huddles could be as short as five minutes before the start of a clinic session to get a glimpse of what is expected for the day. Longer sessions lasting up to an hour to discuss complex patients during working hours may also be planned. This gives the teamlet members a sense of unity, a channel for open discussion and feedback, and ensures that every member is on the same page. Teamlet leaders who encourage informal interactions such as out of hours social gatherings or team-building activities can further help to foster the development of more positive social relationships among members.

The strength of this study is that this was the first Asian study to investigate the relationship between resilience, job satisfaction, burnout and team development among members of a clinical care team in the primary care setting. In addition, this study included various professions to explore interprofessional perceptions of team development.

There are limitations to our study. Firstly, as team development, resilience, job satisfaction and burnout are self-reported measures, they represent the participants’ perceptions and could be affected by momentary emotional states and increases in workload, which were evident during the pandemic when this study was conducted. Secondly, this was a cross-sectional design which precluded inferences of causality. Thirdly, our study examined teamlet members’ recollections of experiences which may affect the accuracy of data collection due to potential recall bias.

This study analysed teamlet members’ team development, resilience, job satisfaction and burnout quantitatively. We found that presence of social interaction outside of work, lower depersonalisation scores and higher job satisfaction scores were positively associated with TDM scores after controlling for other independent variables. Further studies will be required to provide a better understanding of meaningful work, sustainable coping and social connectedness in relation to team development.

Funding

This research was supported by the Singapore Ministry of Health’s National Medical Research Council under the Centre Grant Programme (Ref No: NMRC/CG/C019/2017) and the FY2020 National Healthcare Group-Lee Kong Chian Medicine Clinician-Scientist Preparatory Programme Award (Ref No: CSPP-20006). The funding bodies had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication

Acknowledgements

The authors would like to thank Dr Ronald Stock for his kind permission to use the Team Development Measure (TDM) questionnaire and Sabrina Lee Poay Sian for helping with the collection of data using REDCap®.

Ethics approval and consent to participate

This research project was approved by the National Healthcare Group, Singapore—Domain Specific Review Board on 21 February 2020. NHG DSRB ref no.: 2019/01156

Informed consent to participate in the study was obtained from all participants in the study.

All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Competing interests

The authors declare that they have no competing interests.

Funding:

Authors' contribution:

1. QCT CHANG: Principal Investigator, collected the data, wrote the manuscript and oversaw the conduct of the project

2. KWS WONG: Conceived and designed the project, advised on drafting and revisions

3. HL KOH: Statistical analysis and interpretation of data

4. ES LEE: The key adviser for the project and advised on drafting and revisions

All authors have read and approved the manuscript.

Acknowledgement:

Author Information:

Qi Chang Tricia CHANG¹, Kay Wye Sabrina WONG¹, Hui Li KOH¹, Eng Sing LEE^1,2

¹National Healthcare Group Polyclinics, Singapore

²Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore

Email of corresponding author (Qi Chang Tricia CHANG) : [email protected]

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No competing interests reported.

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The influence of Resilience, Burnout and Job Satisfaction on Team development in the primary care setting : the Singapore experience

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