Do you remember the old black & white Indian films in which every time a crucial character fell sick in the family, the familiar, all comforting doctor (General Physician)was called in to examine the patient and order rest, medication, or tests if necessary? Needless to say, in the past, communities reposed enormous faith in the easily accessible and affordable services of family physicians. However, the concept of the family doctor which was fading into oblivion is now gradually gaining ground in the backdrop of the Covid-19 pandemic, finds ARCHANA JYOTI.
Family doctor as a breed is fast becoming extinct. It is unfortunate because the medicine as seen and practiced by specialists and super specialists, is increasingly becoming myopic with a tubular vision; and the implications are profound,” says Dr. Rajesh Malhotra, Head of the JPN Trauma Centre, AIIMS, Delhi. Dr. Sumit Anand, Chief Medical Officer (CMO) at Municipal Corporation of Delhi (MCD), agrees. “The aspirations for high social status and prestige, and the demand of patients, who earn well and enjoy better lifestyles in urban areas, for medical specialists has triggered the drive in the medical fraternity for specialization and super specialization. As there is little motivation for young budding doctors to become family doctors as General Physicians, the concept of the family doctor is fading into oblivion.”
Both the experts, joined by many others from the fraternity, concur that, unlike the healthcare super specialists, family doctors usually share a long and therapeutic relationship with their patients. They are trusted more by their patients than other healthcare providers, as they are familiar with the case history of their patients and provide comprehensive care for treating various ailments for all the age groups in a family.
“Providing comprehensive care for most specialties to patients of all age groups is the hallmark of family medicine”, says Dr. Nita Radhakrishnan, Associate Professor of Pediatric Hematology-Oncology at Post Graduate Institute of Child Health, Noida
Family medicine practitioners serve as an entry point for individualized healthcare for most health problems.
They enjoy a distinct status in developed countries where patients can’t approach a specialist without the recommendation of a family physician. Unfortunately, this is not the case in India where a fast flourishing culture of corporate hospitals is making Family Physicians irrelevant. The Coronavirus pandemic, however, steered a shift in this trend with the focus again zooming on family physicians for providing healthcare at the grassroots level. “Family Physicians counseled patients about the role of preventive medicine, the importance of vaccination, and the usage of various preventive care measures to limit the spread of infection. They were also providing domiciliary care to the Covid patients and to all those who were exposed to Covid patients and were kept in isolation at home”, says Dr Malhotra while bringing home the point.
“Family doctor is not a new concept in India. Historically, family doctors used to be generalist practitioners who would act not only as health managers to families but also as their friend, philosopher, protector, and guide,” says Dr. Raman Kumar, President of the Academy of Family Physicians of India (AFPI). AFPI has been pushing for the revival of family physicians and popularising family medicine as a clinical specialty.
Family medicine is recognized in many developed countries where training is provided through organized residency programs. This should happen in India as well.
“Family medicine has been incorporated in the foundation course of Bachelor of Medicine, Bachelor of Surgery (MBBS) and is planned to be adopted in all medical institutes in India; however, the MBBS syllabus makes no mention of it. In medical schools in India, fully functioning family medicine departments should be established on an urgent scale. It is necessary to take the required measures to introduce the subject at the undergraduate level of the MBBS program and to generalize it across India,” rues Kumar.
A review article ‘Need of the Hour: Family Medicines published in a journal of Medical Sciences recommends that the number of medical schools in India offering postgraduate residency training in family medicine should be increased to meet the current health needs of communities.
“Of the 54,000 new doctors who will graduate this year, at least 44,000 will become specialists after the expansion in the number of post-graduate seats,” says Dr Raman Kumar.
He has written to the Medical Council of India (MCI) after he found that its’ new 890-page MBBS curriculum made no mention of terms like General Practice or Family Medicine or Family Physicians, leaving students little choice than the option for specialist and tertiary level hospitalist care.”
According to Dr. Kumar, MBBS students get all of their training at tertiary hospitals, which deprives them of valuable working experience in clinics and primary health centres.
Even as political and economic factors are likely to keep pushing the government toward raising the total number of post-graduate seats, family physicians would still be scarce as MBBS students continue to opt for specialization in the medical field.
Despite their contribution to managing a wide range of health problems, either directly or through referral to other specialists, family physicians in India continue to face an identity crisis. Irrespective of their role in optimizing the cost-effectiveness of the healthcare system by treating general healthcare ailments and guiding their patients towards specialized care in cases of acute ailments, Family Physicians are becoming outdated in India.
Doctors feel that this could be addressed if the Government pushes for the formation of Departments for family medicine in medical colleges across India, and the study material for family medicine is included in the MBBS curriculum. Besides increasing the number of medical colleges offering residency programs in family medicine, public healthcare institutions and organizations also need to be educated and updated on the subject.
There is a requirement for developing a comprehensive curriculum for family medicine to address the current health needs of communities. The healthcare system should focus more on primary care and family medicine to provide affordable, accessible, and quality healthcare to people.
India is experiencing a rapid annual increase in its population, a chunk of which lives in rural locations. Access to affordable, quality healthcare has been a challenge in rural India. Say the authors of the study published in the Journal of Medical Sciences, " Poor individuals are more sensitive to healthcare costs and more likely to delay treatment when ill, and this impact has increased over time for residents of rural and metropolitan areas. In addition, the financial burden of inpatient and outpatient treatment for rural families is consistently higher than for urban households, with significantly increasing expenditures per admission. As a result, higher out-of-pocket health spending exacerbates poverty."
Little wonder that the family medicine has been recognized and integrated into the primary healthcare system in varied contexts around the world. Canada, Australia, Norway, Brazil, Latin America, Nigeria, Ghana, Ethiopia, South Africa, China, Russia, Nepal, and several other countries have prioritized family medicine throughout the health system., Dr. V Sreenivas, Director, Academics, Academy of Family Physicians of India says as per a media report
Indian policymakers should see that the state invests significantly in family-doctor-centric primary healthcare, preventive public health, social development programs, the opening of new healthcare facilities, safe universal health coverage, investment in public health and primary care research and infrastructure development, including large-scale reforms in public health. They should put in serious effort to create a pandemic-free world for our future generations, he says.
Some of the specific roles and responsibilities of a family physician are:
l Promote health and prevent the spread of communicable diseases in families and communities;
l Manage common diseases in all age groups across different clinical specialties, besides utilizing the limited resources in the primary healthcare system;
l Making appropriate referrals to specialists by correctly identifying red flags in patient’s health via the study of their symptoms;
l Provide continuity in healthcare by involving two-way referral with specialists;
l Provide home and palliative care;
l Provide community-focused care with a multi-disciplinary approach;
l Learning by observation and sharing with others the association of socio-cultural and environmental factors with individual and community health;
l Provide effective health education to families and the communities.
DOCTORSSPEAK
Family doctors as a breed are fast becoming extinct. It is unfortunate because the medicine as seen and practiced by specialists and the super specialists is increasingly becoming myopic with a tubular vision, and the implications are profound!
A family physician is almost like a family member to the patient. He is conversant with the patient’s family history and knows his/her medical, social, and financial background. He is the one who can connect the dots, but the past history in today’s perspective and treats the disease as well as the person. The dwindling interest in a career as a family physician is manifest in fewer physicians practicing family medicine; this is causing difficulties in providing the appropriate health care. It also means a diminution of the art of clinical medicine as traditionally it relies more on clinical acumen, with the modern and expensive investigations relegated to special situations. He can triage the patient and seek the timely intervention of a specialist/ higher center in case of need.
The recent pandemic has brought to the fore the importance and the role of family physicians in providing healthcare at the very grassroots level. It ranges from counseling about the role of preventive medicine to explaining the importance of vaccination, prevention of the spread of prevention as well as providing domiciliary care to the Covid affected who have to be managed at home. Managing patients at home, and recognizing red flag signs with timely referral to hospitals saved lives at a time when hospital beds and specialist care were at a premium. A family physician was the primary caregiver as much as he/she was the healer you knew and had easy access to. We are now highly cognizant of the role family physicians can play in times of major healthcare crises and pandemics. Recent times have seen an escalation in the demand for family physicians all over the world. It is particularly true in countries like the United Kingdom where an appointment with a specialist may not be available for months on end. The disease itself, however, does not respect that. The family physician thus becomes the savior who is readily available, accessible, affordable and acceptable. Follow-up is no challenge and a teleconsultation session is less likely to be fraught with errors.
We need to nurture this breed of healthcare providers who can extend our access and reach to the remotest corners of the country, decongest our hospitals and offload, to some extent, the burden faced by our specialists and super-specialist healthcare providers.-------------------Dr Rajesh Malhotra, Chief, JPN Apex Trauma Centre, Prof &Head Department of Ortheopedics, AIIMS, Delhi
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As the first point of contact between the patient and the healthcare system, the role of the family doctor is enormously significant. A family doctor is literally a healthcare provider who takes care of an entire family by providing medical treatment to its various members ranging from newborn/neonates to bed-ridden and very old grandparents.
In this era of super specialization where doctors’ outlook is turning into tunnel vision and a patient with multiple ailments keeps wandering from one doctor to another, the role of family physicians with a panoramic vision becomes significant. They are the backbone of the healthcare system in the rural and suburban parts of India wherein they provide support for the implementation of various government health schemes.
Family Physicians are doctors who have been serving the majority of the Indian population, be it the patients living in the country's hinterlands or the patients receiving medical treatment at home. The biggest challenge before the Family Physicians is the general lack of understanding in the public about their role. The question “kis cheez ke doctor hai aap”, questions their professional identity as a whole. Besides this, the aspiration to achieve higher status and recognition in society, and the demand for specialized doctors from patients, who earn well and enjoy a good lifestyle in urban India, have triggered the drive for specialization and super specialization in the medical fraternity. This has dented the prospect of family doctors for budding healthcare professionals who then choose to go into specialized care.
In developed countries, patients can’t approach a specialist directly without the recommendation of a family physician. Whereas with corporate hospitals' culture building up in India, family physicians are facing an identity crisis. The government needs to be more sensitive in recognizing their contribution and bring more job opportunities for them. Housing the 2nd highest population in the world, India’s healthcare system can’t survive the extinction of family doctors.
Let’s recognize and pay tribute to their endless service to mankind. Without their support, we could not even have dreamt of fighting and winning the battle against the dreaded COVID Pandemic which shook the world in the 21st century.----------------------------Dr. Sumit Anand, Chief Medical Officer (CMO) at Municipal Corporation of Delhi (MCD),
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Indians need a defined network of referral pathways which we currently lack in our system. We do have a system of referral in government sector hospitals from wellness clinics to primary health centers to district hospitals to medical colleges to tertiary institutes. However, patients are also free to go to a specialist any time and in many cases, we feel a specialist consultation is vital. But the reverse is also true.
Family doctors who are the first line of defence in medical care in most countries have a wholesome approach to each disease and are able to resolve many primary care issues at their level. They also have a more holistic perspective as unlike specialists, they manage the health of other members of the same family and the community as a whole. So, the development of a referral network would help ensure adequate resource allocation and strengthening of primary care which is currently weak in our country.--------------Dr. Nita Radhakrishnan, Associate Professor of Pediatric Hematology-Oncology at Post Graduate Institute of Child Health, Noida
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Family physicians are general physicians who are committed to their patients regardless of their age, gender, and type of illness: they are responsible for comprehensive healthcare of patients with undifferentiated problems. The scope of their practice is not defined by diagnosis or health procedures but by the nature of human needs. The GP provides a vital role in steering for their patients the targeted treatment process while making them feel comfortable with the right advice and care during periods of uncertainty.
The family practice has a distinct clinical approach that requires special skills to identify concerns, focus on issues, negotiate plans, and help solve problems. The recognition, integration, and prioritization of multiple concerns and the synthesis of solutions are critical clinical competencies. Family doctors oversee one’s preventive care.
One of the most important functions of a family doctor is to educate patients about disease prevention and health maintenance. They are concerned with one’s entire being, including mental and emotional well-being. This could include assisting with techniques for stress relief, anger management, weight management, nutritional counseling, and fertility testing besides advice or advice on the best types of physical exercise for better fitness.
Focusing on the individual necessitates refined abilities to observe, communicate, understand, and care. Taking care of various patients and target populations necessitates activism and advocacy. Family medicine has the potential to reshape what it means to be a professional, a physician, and a general health care provider.--------------------------Dr Anil Kumar Chandna, EC member, Dental Council of India and Member, Delhi State Dental Council
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Family doctors were a bridge in the community—between the super specialty and the patients.
Family practitioners also called GPs used to see the body as a whole. But now we have moved to the scene where super specialists just see one part of the body without realising that body part itself is going wrong or somewhere else might be the reason for the cause of that ailment, given that body is interconnected.
We started seeing the body as a part and not the body as a whole. That’s where the utility of the family doctor is required. The family doctor was the one who knew not so much in detail but something about everything so that he/she could give remedial measures at the earliest. The family doctor could determine what is the cause of the sickness in his/her patient and after determining the reasons he could send the patient to the particular super-specialists. This saves time as well as unnecessary expenditure on multiple clinical tests.
With longevity at our hands, where we are at least going to survive more than 75 years of age we need to find or say the need of the hour is to have a family doctor who can take care of us. In the super-specialty world, where everybody wants to become a super-specialist, where is the time to talk to the patients in detail? For instance, a gastro doctor has no time to speak about neuro problems. But if we have a family doctor, the patients need not go through multiple tests and are not clueless about what is happening.
GPs are the need of the hour. A formula has to be worked out to ensure that we have a sufficient number of family doctors or say, general physicians. They are the first contact points for people. This will also lessen the burden on the AIIMS like institutes which instead of conducting studies and researches are overburdened by the patients who can be otherwise treated at the basic level itself i.e. by general practitioners at the primary level itself.-----------------------------------------Dr Rahul Bhargava, Principal Director, Hematology Department at Fortis Memorial Research Institute, Gurugram
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Family physicians form a major link between the patient and the entire healthcare system encompassing patients, healthcare providers, and doctors. They are the first link for patients to report and the last link to address their problems on a day-to-day basis.
Whereas a super-specialist is needed to provide the best up-to-date care, their number is limited, hence they cannot take full loads of patients. After treatment from a specialist, a patient will fall back to a family physician for subsequent care and support. There is a need to update the current knowledge of family physicians so that they can cater to some special services with confidence.
Family physicians will always remain an important part of the system; they know every family member of the patient at a personal level, and thus are a trusted bridge between the people and the public healthcare system. A family physician’s services are economical, long-lasting, and easily available even at district levels.-----------------------Dr Daljeet Singh, Professor and Head of Department of Neurosurgery, GB Pant Hospital, Delhi
