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 Table of Contents 
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 6  |  Page : 1274-1278  

Do family physicians suffer an identity crisis? A perspective of family physicians in Bangalore city


Department Family Medicine and Community Health, Bangalore Baptist Hospital, Bangalore, Karnataka, India

Date of Web Publication30-Nov-2018

Correspondence Address:
Dr. Leeberk Raja Inbaraj
Department of Community Health, Bangalore Baptist Hospital, Bangalore - 560 024, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_149_18

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  Abstract 


Background: The need of the hour in Indian healthcare is well-qualified, competent family physicians, but there is an overwhelming importance given to specialized medical care. Family physicians feel that they do not get the recognition they deserve. This study was undertaken to explore the views and perceptions of family physicians and residents about their specialty. Materials and Methods: This cross-sectional study was conducted among 110 doctors who are undergoing family medicine (FM) residency and practicing family physicians in Bangalore. The questionnaire was developed with domains on patient or family relationship, balancing breadth and depth in practice, comprehensive nature of patient care, career flexibility, and patient advocacy. Data were analyzed using SPSS version 17.0, and P value less than 0.05 was considered as statistically significant. Results: The majority of the participants (55.5%) felt that there is poor acceptance among the people about FM doctor as a specialist. A significant proportion (39.1%) of them indicated that thought of “Jack of all trades and Master of none” bothers them much. More than 90% of respondents felt a sense of pride being family physicians. FM practitioners (28.4 ± 3.1) had a good perception score when compared with residents (27 ± 3.6) (P < 0.05). There was a significant difference among FM residents and practitioners on being pride of FM physician sense of belonging to larger community FM physicians. Conclusion: FM residents go through more identity crisis when compared with practitioners. This can be addressed well by incorporating FM curriculum in undergraduate medical training and strong FM department where students have role model as mentors and take FM as specialty as their preferred choice.

Keywords: Family medicine, identity, perception, role model


How to cite this article:
Raghavendran S, Inbaraj LR. Do family physicians suffer an identity crisis? A perspective of family physicians in Bangalore city. J Family Med Prim Care 2018;7:1274-8

How to cite this URL:
Raghavendran S, Inbaraj LR. Do family physicians suffer an identity crisis? A perspective of family physicians in Bangalore city. J Family Med Prim Care [serial online] 2018 [cited 2018 Dec 9];7:1274-8. Available from: http://www.jfmpc.com/text.asp?2018/7/6/1274/246456




  Introduction Top


Family medicine (FM) is a clinical specialty which is devoted to comprehensive healthcare for people of all ages and provides continued care for the individual and the family across all ages, genders, diseases, and systems of the body. The concept evolved as a model to cater to the growing demand of the people for personalized, continued, and comprehensive care.

In the United States, the specialty of FM was created in 1969 to fulfill the generalist function in medicine, which suffered with the growth of subspecialization after World War II.[1] Since its creation, the specialty has delivered on its promise and provides personal, front-line medical care to people of all socioeconomic strata and in all regions of the United States.[2]

General practice (as it is termed in the United Kingdom) is a key element of all healthcare systems in Europe and is recognized by health service providers as being of ever-increasing importance. International evidence indicates that health systems based on effective primary care, with highly trained generalist physicians (family doctors) practicing in the community, deliver care that is both more cost-effective and more clinically effective. In the United Kingdom, general practice has been a fundamental element of healthcare provision since the inception of the National Health Service in 1948. Structured training programs for postgraduate residents in general practice have been in place since early 80s.[3]

Family physicians deliver a range of acute, chronic, and preventive medical care services while providing patients with a patient-centered holistic care. Knowledge of family physicians not only includes clinical medicine but also emphasize on the epidemiology of area of practice, human development, and human behavior. The six core competencies of a family practitioner include primary care management, person-centered care, specific problem-solving skills, comprehensive approach, community orientation, and holistic modeling.[4]

FM has a history of struggling with its identity due to overlap in scope of practice with general internal medicine, general pediatrics, psychiatry, and obstetrics–gynecology. In addition, the discipline also has a strong tradition of promoting social consciousness. These contrasting points of view often result in a tension between professional identity within mainstream biomedicine and identity with a counterculture movement.[5]

Family physicians typically carry two types of identity, one as a physician, an identity they share with other physicians. Second is identity as a family physician. This identity emerges mainly during residency training and is constructed through actions within contexts of practice where routines and environments are refined to create ongoing improvement in the fit between thoughts and the world where these thoughts are expressed.[6]

In one of the focused group discussion among FM residents across Belgium, Canada, and France, three cardinal points were discussed. Discussion was on the relationship built over time between physicians and patient; the capacity to solve a variety of problems at the primary care level and the integration and coordination of the patient's care. One of the key findings of this study was that during their residency program, residents constantly felt low appeal of being a primary care physician and a strong divide between primary care and specialized medicine in day-to-day practice.[7]

In another study conducted in Spain among medical students, it was noted that students feel FM practice as monotonous, superficial, and lacks intellectual stimuli. It was also low appeal for them as the working environment in community was not great with very low pay and the majority preferred to be a specialist and work in cities.[8]

FM has been recognized in India as a distinct academic specialty for a long time.[9] In India, the traditional medical curriculum encourages learning extensive factual knowledge with focus on hospital-based and disease-centered medicine that is deficient in problem-solving skills. There is less emphasis for rational and cost-effective management of the common medical problems. In contrast, FM training is based on problem-solving skills in primary care environment with rational use of investigations and cost-effective management. Through FM training, students are likely to learn how they can apply their clinical knowledge gained in tertiary care to primary and secondary care context and understand the importance of FM.[10]

We are now at a time when there is more interest in the development of FM across the country. But, at the same time, there are still many challenges that a teacher and a trainee in FM face. First, we lack role models, and second what a family physician trained in India is expected to do. This question is being debated with different people having different opinions.[11]

Although the need of the hour in India is well-qualified, competent family physicians, there is an overwhelming importance given to specialized medical care. In this context, family physicians feel that they do not get the recognition they deserve. There seems to be a crisis of identity among them. Nevertheless, there is a dearth of published reports on what the perceptions of the family physicians in India about themselves. This study was undertaken to explore the views and perceptions of family physicians and residents about their specialty.


  Materials and Methods Top


A cross-sectional study was conducted in Bangalore among doctors who are undergoing FM residency and practicing family physicians in Bangalore. Assuming 50% of the doctors would have positive identity with 10% relative precision and using the formula 4PQ/d2, the sample size was calculated as 100 (d = 10); however, 110 doctors were included in the study. The questionnaire was anonymized, and questions were framed on the following domains:

  • Patient–family relationship
  • Balancing breadth and depth in practice
  • Comprehensive nature of patient care
  • Career flexibility
  • Patient advocacy.


The questionnaire was sent out as an online link and data were imported into MS Excel 2003 and analyzed using Statistical Package for Social Sciences (SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). Answers to questions on the Likert scale were expressed in proportions. Questions with positive stem were given scoring of 1–5 on the Likert scale and vice versa negative stem. Independent sample t-test was used to test the significance in scoring between various categories and Chi-square test was used to study the association between perception and years of experience. A P value less than or equal to 0.05 was considered as statistically significant.


  Results Top


A total of 110 doctors responded to the questionnaire, among which 55 were FM trainees and the rest (55) were practicing family physicians. Almost all of them (98.2%) and the majority (69.1%) felt strongly that having a professional relationship with patients is one of the most important aspects of their work as a family physician. They truly believed that they were able to connect better to patients and involve them in management plan. A large proportion (85.5%) which also includes a majority of the residents felt that they were comfortable in managing a wide array of conditions. Among respondents in this study, 87.3% of them felt that flexibility in building their own practice appeals to them and will recommend future generations to take up FM as their choice of specialization. More than half of them (55.5%) felt that there is still poor acceptance among people about FM doctor as a specialist.

In contrast, 45.5% of doctors felt that their patients do accept them as specialist and visit them regularly. Although more than half of the doctors (60.9%) responded that they are not concerned about being considered as “Jack of all and master of none,” a significant proportion (39.1%) of them indicated that the thought bothers them much. More than two-third (40%) of the residents too felt the same way about their specialty. More than 90% of respondents felt a sense of pride being a family physician, and a similar number felt that their professional identity is strengthened by being in a larger group of family physicians [Table 1].
Table 1: Designation of the participants and their perceptions in various domains

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Professional identity score ranged from 19 to 34 with a mean of 27.7. FM practitioners had positive identity toward their profession with a mean score of 28.4 [standard deviation (SD) 3.1] when compared with residents who had a mean score of 27.0 (SD 3.6) and this difference in the mean score was statistically significant (P < 0.05) [Table 2]. Among the residents, 85.5% felt that they feel they belong to a larger community of family physicians, whereas most of the practitioners (96.4%) had a good perception on belonging and his difference was statistically significant (P < 0.05). Similar difference (61.8% vs 25.5%) was observed for having overall pride about being family physician (P < 0.05) [Table 3].
Table 2: Comparison of perception score between residents and practitioners

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Table 3: Association between various perceptions and designation

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  Discussion Top


The majority of participants in the study value the core principle of FM – connecting to patients and establishing good rapport with them. In the modern era of medicine, there is a trend toward subspecialization; good proportion of residents in the study preferred to work in the extended branch of FM such as diabetes and women's health compared to traditional practice. Similar outcome was also noted in the study among residents reported from Spain.

Our study reveals that a significant number of residents feel that FM has poor acceptance; this could probably be explained by lack of promotion of FM in corporate and teaching hospitals. It is a fact that residents during the training look up to the practitioners of the other specialties as their role models which may lead to demotivation and sense of insecurity about FM as specialty.

The majority of FM residents felt that they were not experts in any field, as perhaps FM as a specialty caters to a wide variety of disease conditions. This highlights the need for FM training in undergraduate medical curriculum and showcasing role model faculties in FM during their residency programs and undergraduate years and empowering them in future. Another observation through this study is that as years of practice increase, practitioners are more comfortable in managing various illnesses and also uncertainty in clinical presentations much better.

Over the past few years, with establishment of Academy of Family Physicians of India and association with World Organization of Family Doctors, there has been more awareness about FM compared to a decade ago. Since then, more and more practicing family physicians are active in medical forums, conferences, and social media which has led to more recognition among the peer groups, and our participants in this study also felt the same and been valued in the community.

Limitations

As the focus was more on identifying some important domains in professional identity, we did miss out on independent variables such as age, gender, and area of practice.

Professional identity is one of the key aspects in all specialties and helps build a strong platform; in our next phase of study, we are planning to have separate focus group discussions for residents, faculties, and practicing family physicians along with structured questionnaire.


  Conclusion Top


As a specialty, FM has evolved over many years and in recent times, more promising career for future generation. Various studies across the globe had highlighted the importance of FM training in undergraduate curriculum; if we can incorporate in our undergraduate training program, it will increase the awareness among trainees and the number of trainees choosing FM as their career choice will increase.

With this study, we did identity some important aspects of training; incorporation of these findings in our training modules will help us develop strong foundation for FM training in India and produce high-quality trainees for serving our country. Our goal of Universal Health for All will only be achieved if more trained family physicians come into practice.

Acknowledgement

The authors thank Dr. Ramakrishna Prasad and Dr. Jaya Bajaj for their contribution in developing the questionnaire.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stevens RA. The Americanization of family medicine: contradictions, challenges, and change 1969–2000. Fam Med 2001;33:232-43.  Back to cited text no. 1
    
2.
Family Medicine Interest Group. History of family medicine. Available from: http://fmignet.aafp.org/online/fmig/index/family-medicine/defining-the-speciality/history-scope-resources.html. [Last cited on 2017 Jun 07]  Back to cited text no. 2
    
3.
The evolving role and nature of general practice in England, Kings Fund Report 2011. [ Available from: https://www.kingsfund.org.uk/sites/default/files/field/field_related_document/gp-inquiry-report-evolving-role-nature-2mar11.pdf. [Last cited on 2017 Jun 07].  Back to cited text no. 3
    
4.
The European definition of general practice/family medicine. Available from: http://www.woncaeurope.org/sites/default/files/documents/Definition%203rd%20ed%202011%20with%20revised20wonca%20tree.pdf. [Last cited on 2017 Jun 07]  Back to cited text no. 4
    
5.
Stein HF. Family Medicine's Identity: Being Generalists in a Specialist Culture? Ann Fam Med 2006;4:455-9.  Back to cited text no. 5
    
6.
Rodríguez C. Pawlikowska T, Schweyer FX, López-Roig S, Bélanger E, Burns J. Family physicians' professional identity formation: A study protocol to explore impression management processes in institutional academic contexts. BMC Med Educ 2014;14:184.  Back to cited text no. 6
    
7.
Beaulieu MD, Dory V, Pestiaux D, Pouchain D, Rioux M, Rocher G, et al. What does it mean to be a family physician? Exploratory study with family medicine residents from 3 countries. Can Fam Physician 2009;55:e14-20.  Back to cited text no. 7
    
8.
López-Roig S, Pastor MÁ, Rodríguez C. The Reputation and professional identity of family medicine practice according to medical students: A Spanish case study. Aten Primaria 2010;42:591-601.  Back to cited text no. 8
    
9.
Kumar R. Why family medicine is a good career choice for Indian medical graduates? J Family Med Prim Care 2014;3:1-2.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Sankarapandian V, Christopher PR. Family medicine in undergraduate medical education in India. J Family Med Prim Care 2014;3:300-4.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Abraham S. Practising and teaching family medicine in India. Fam Med 2007;39:671-2.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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