|FAQS: FAMILY MEDICINE
|Year : 2016 | Volume
| Issue : 1 | Page : 3-6
Frequently asked questions about family medicine in India
President Academy of Family Physicians of India, Editor-in-Chief, Journal of Family Medicine and Primary Care, Dundahera, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||24-Jun-2016|
President Academy of Family Physicians of India, Chief Editor Journal of Family Medicine and Primary Care, 049, Crema Tower, Mahagun Mascot, Dundahera, Ghaziabad - 201 016, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Family medicine (FM) is an independent and distinct medical specialty in the developed countries such as USA, UK, Australia, and Canada since 1960s. FM teaching is imparted at undergraduate and postgraduate levels in countries such as Nepal, Pakistan, and Sri Lanka. Family practice is the practicing vocation of the majority doctors in India. The practitioners of FM include general practitioners, family physicians, FM specialists, and medical officers in the public sector. Medical students are largely unaware about FM career as this concept is not introduced at MBBS level. Faculty and senior doctors from other disciplines are also not able to answer the queries related to FM as they themselves also have gone through the same education system for last three decades, largely unexposed to the concept of academic family medicine. This article is a compilation of frequently asked questions, and their appropriate responses, presented here to dispel myths and misinformation about FM specialty. The answers are deliberated upon by Dr. Raman Kumar the founder president of the Academy of Family Physicians of India and the chief editor of the Journal of Family Medicine and Primary Care. This article was originally published as an interview in Docplexus, a popular online network and website for medical doctors in November 2015.
Keywords: Family medicine, family practice, human resource in health universal health coverage, Medical Council of India, medical education, primary care
|How to cite this article:|
Kumar R. Frequently asked questions about family medicine in India. J Family Med Prim Care 2016;5:3-6
| What is the Difference Between General Medicine and Family Medicine and Their Respective Practitioners According to You? How is it Different from Community Medicine?|| |
As per the postgraduate (PG) regulations of Medical Council of India (MCI) 2000, all three are different and distinct specialties.  General medicine is a British terminology for what is popularly known as "internal medicine" in the USA. A person trained in internal medicine is known as an "internist" and takes care or adult patients only. An internist is mostly also a hospitalist who is supposed to work as per fixed treatment protocol of inpatient care. In India physicians trained in general medicine often do single clinic practice in independent capacity which is a form of family practice.
Family medicine (FM) is a clinical medical specialty which is devoted to the comprehensive health care for people of all ages and provides continuing and comprehensive health care for the individual and family across all ages, genders, disease, and parts of the body. FM has been developed as a counterculture in response to rapid fragmentation of medical care during postsecond world war period into specialty and subspecialty care in the much of the developed world. The concept evolved as a concept of medical care to cater to the growing demand of the people for personalized, continued, and comprehensive care.
Community Medicine or Preventive and Social Medicine is synonymous with Public Health Education in India. Public health deals with population-based interventions such as national programs. Except for a couple of MD programs such as MGIMS and CMC Vellore majority of the Community Medicine Faculty and experts do not engage with routine clinical work and often engage themselves with prestigious Public Health Organizations such as WHO, National Health Programs, and teaching.
| What is the Difference Between General Practice and Practicing Family Medicine?|| |
General practice is the oldest form of medical discipline in the world. In the beginning, all medical practitioners used to be general practitioners only. Medical graduate not getting into any specialty training after MBBS traditionally used to proceed with general practice vocation. General practitioners often accumulate a wealth of knowledge through decades of practice. However, most often they do not have the opportunity for additional skill development and maintain competency with ever evolving and exploding science of today.
FM evolved from the historical tradition of general practice. In much of the developed world and in countries such as USA, UK, Canada, and Australia; FM is recognized as a distinct academic discipline, knowledge domain, and specialty vocational which is imparted through structured residency training. 
FM training offers fresh medical graduate an opportunity to prepare themselves clinically and academically for lateral movement into community-based health services as the undergraduate MBBS training is often imparted at the tertiary care hospitals. FM trained persons engage with academics and are eligible for faculty positions. They are also competent for research and are a good resource for community-based clinical as well as population-based research. Through structured vocational training, they are often capable of practicing additional clinical skills with sufficient confidence and competency.
In fact trained family physicians are able to provide care to 90% of the healthcare needs. In developed countries such as "diabetes" and "hypertension" are considered primary care diseases and managed in community setting, unlike India where these clinical conditions are still considered specialist domains.
| Do You Think that the Number of Family Physicians in India is Decreasing? If Yes, What are the Underlying Issues and Reasons for the Decreasing Number of Family Physicians?|| |
The number of traditional general practitioners is decreasing. In cities such as Mumbai, Chennai, Kolkata, and Pune the older generation of general practitioners are retiring in their 70s and 80s, while no one is opening new practices in their localities.  During the last 50 years, much of the medical care has fragmented into organ-based specialty domains. In India, this trend has become more prominent with arrival of "super specialist" and "super specialist hospital" culture during the last three decades.
Unfortunately, the medical education system in India has not reformed itself for the last six decades. Unlike most of the world, medical education is imparted at tertiary care hospitals (medical college hospitals) and by specialist doctors only. The role models of medical students are teachers who are by regulations specialist doctors only. Family physicians are not eligible to become medical teachers because of the lack of PG qualification and disabling regulations; their practices are not considered teaching locations. Therefore, medical students do not have any exposure to this wonderful and viable, lucrative career option, considering huge population and morbidity prevalent in the community. 
As an outcome while most newly qualified medical graduates spend years of dysfunction status waiting and toiling for numerically impossible PG seats, the community-based family practice space remains vacant and largely has been taken over by quacks and faith healers.
| How Important are Family Medicine and Family Physicians in the Present Era of Super Specialty Practice? Especially When You Consider the Overall Pressure on Healthcare in India?|| |
In the era of super specialist practice, FM, and family physicians are more relevant than ever. Today, there is no one doctor who is responsible for the whole person. People often find it frustrating when their small health-related questions are not answered by the treating doctors, as they have to visit multiple health care providers. This is more difficult for older persons with multiple health issues. People want solutions which only family physicians can provide, who are capable of generalist care. The entire health system is internally unstable for India as even rich countries find it difficult to cope up with ever increasing the cost of tertiary care facilities. Family physicians can provide quality and cost-effective healthcare. It is a win - win situation for both public and doctors. Family physician's close contact with society also strengthens the doctor-patient relationship. 
| Does Government Support Family Medicine Practice and Practitioners in India Like Some Other Countries Do?|| |
The National Health Policy 2002 by the Government of India identified "FM" as a focus area of human resource development.  However, implementation has been very slow. Several other policy documents by the government have talked about developing FM Training Programs - these include (a) Mehta Committee report, (b) NRHM task force on human resource in health, and (c) planning commission's 12 th plan paper on health forecasted requirement of 15,000 family physicians per year. 
| Are There Any Policy Decisions Which have Shown that Governments Want to Incorporate Family Medicine Practitioners in the National Health Schemes?|| |
Yes! Health Secretary, Government of India, has written twice to the state governments to incorporate FM Program within the National Health Mission. At one point, Government of India also offered funds through NRHM to start MD/DNB FM Training Program. NRHM also has funded state medical officers for training in FM through CMC Vellore affiliated PGDFM program.
| What are the Benefits of Implementation of Government Policy on Family Medicine?|| |
In spite of a National Health Policy (2002) supporting FM concept, separate Departments of FM do not exist at any of the Medical Colleges in India. Few seats of FM are available through National Board of Examinations (NBE) under Ministry of Health and Family Welfare. FM facilitates lateral movement of medical graduate into the community-based health system as it is a community-based specialty. The lack of PG seats in India is primarily due to lack of FM Training in India. Very few PG specialist training (MD/MS) are available for more than 50,000 MBBS graduates. This is a strange crisis where fresh medical graduate face a lack of career opportunities after MBBS completion where community-based health facilities both and urban and rural areas are depleted from medical personnel. There is a recent interest among policy makers and medical students about the concept of FM in India. There would be no need for compulsory rural postings if the government policy about FM is implemented. Lack of choice by recently qualified medical graduates for primary care vocations is primary due to absolute lack of career progression after initial engagement. FM system provides equal opportunity of career progression to primary care doctors with respect to academics positions, professional development, and access to research funding at par with other specialists.
| Should Doctors Start Taking Up Family Medicine as Their Specialty? Are There Any Recognized Postgraduate Courses Available with Medical Council of India?|| |
Yes! Why not? FM is a recognized PG specialty through both MCI and NBE. There are 200 DNB FM seats available through centralized entrance test. The first MD program in FM has started at Calicut Medical College, Kerala. The majority of Indian doctors who immigrate to USA and UK do FM residency there. In USA for every UG seat, there are 200 PG seats. Almost half of these are FM residency positions. The USA is able to attract and induct a large number of family physicians in her health system due to these additional FM residency PG seats.  Why it cannot be done in India? Our policy makers need to think on this issue.
The FM specialty has already started taking shape in India. The professional society of FM doctors is known as "Academy of Family Physicians of India." We also publish a peer-reviewed Journal of FM and Primary Care (FMPC) we also have established a national conference called National Conference on FMPC.
| What are the Different Pathways to Pursue Family Medicine If One has Already Pursued Other Specialization? What are the Employment Opportunities and Expected Income Resources after Pursuing Family Medicine as a Specialty?|| |
One can do short-term courses in FM. There are International Accreditation Programs such as MRCGP Int. The most important thing is to start practice with confidence and person should be always eager to learn more and update knowledge continuously. In the era of evidence-based medicine and information revolution, it is possible to keep yourself updated with all recent standard treatment guidelines and apply them into your practice. Going by the experience of the recently qualified PGs in FM, the income is at par with any other specialty. And if you start your practice early, there is no limit, as your patient contact grows, you can live an ethical and satisfying life.
| How Should New MBBS Graduates Start Practicing Family Medicine? Do You Suggest any Strategy or Guideline for Fresh MBBS Graduates Who have Started their Career in Family Medicine to Combat with Undesired Intrusion of Alternative Medicine Practitioners?|| |
Alternative practitioners occupy the whole of primary care space because MBBS graduate are not aware, educated, and mentored into FM practice. India is a huge country with morbidity; we should not be afraid of intrusion of alternative medicine practitioners. We should practice good quality, standard, and ethical practice at good and clean premises.
India produces 50,000 medical graduates per year now. Only a privileged few that is <10,000 will ever get a clinical PG specialty for career progression. Thousands of medical doctors stranded and are wasting their youthful lives preparing PG entrance test for 5-10 years. Above all this competition, strangely there is no campus interview for any medical qualification at any Medical Intuition in India. Salaries in corporate hospitals are very low for MBBS doctors in cities such as Hyderabad, Bengaluru, and Mumbai. In public sector also, eleven months low salary contract jobs are being offered.
One of the best options for medical graduates for today is to opt for FM career as it brings you closer to people. And did not we always dream to become a practicing doctor with patient touch?
Under the evolving scheme of Universal Health Coverage it is reasonable to expect that good financial compensation will be available for the family physicians to provide health maintenance (outpatient cover) through government sponsored insurances schemes. At present only hospital services are covered in the public funded insurance programs such as RSBY (Rashtriya Swasthya Bima Yojana). In future it is likely that like most other countries out patient care (prevention and health maintenance) will be covered. Private insurance companies are also bleeding by excursively covering tertiary care facilities. Once family practice clinics are sufficiently standardized, accredited and networked private insurance companies and plans will rush to provide out patient care at clinics. They don't have any option!
[TAG:2]I Think There is a Huge Requirement for Geriatric Medicine Trained Doctors and also Family Physicians are Best Point of Contact for Elderly Patients. Should New MBBS Students and Aspiring Family Medicine Practitioners Engage in Training for Geriatric Medicine?[/TAG:2]
FM covers antenatal care to palliative care and end of life situations. Care of elderly is part and parcel of FM practice; therefore, necessary skills should be acquired.
| Is there any Database of Family Physicians in India? Should there be One? Should the System be based on Geographical Distribution of Family Physicians and can the System be Linked to the Referral System?|| |
There is no such data available. The total number of doctors is supposed to be close to one million (ten lakhs). Out of them 25% could be specialist doctors. Rest are all FM practitioners. FM is the practicing discipline of the majority of medical graduates of India, which includes (a) Medical officer in the government sector, (b) family physicians, and (c) general practitioners.
This article was originally published as an interview in Docplexus. A popular online network and website for medical doctors in November 2015. www.docplexus.in.
| References|| |
India has More Specialists than General Practitioners ANS New Delhi; 29 October; 2014. Last Updated at 10:08 IST, Business Standard. Available from: http://www.business-standard.com/article/news-ians/india-
has-more-specialists-than-general-practitioners- 114102900164_1.html. [Last accessed on 2015 Dec 14].