“The doctor came with his bag and his hat,
And he knocked at the door with a rat-a-tat tat!”
The picture of a family doctor that has been historically depicted via literature/visual media is of a kindly old doctor visiting his patients (which could be any member of a family), and treating conditions that would range from a critical cardiac event of a beloved grandparent to a peanut lodged up the nose of a little baby. This type of medical practice is fast disappearing from all the major cities of our country and is now restricted to smaller townships.
In the western countries family doctors remain the primary care givers and no specialist consultation can be advised without their prescription. This structured system of referral is somewhat ill defined in our fast-developing nation, where increasing number of patients (after educating themselves online) opt to seek specialist care for every malady, thereby increasing the burden on tertiary care centres.
The recent pandemic, however, has brought the community of family doctors back in focus as the bigger establishments were forced to curtail their routine procedures. We witnessed countless instances of family doctors risking their own health and coming to the aid of the sickly patients who were stranded in the remotest areas of the country owing to the quarantine rules.
General medicine (India)/ Internal medicine (USA): A person trained in internal medicine is known as an “internist” and takes care of adult patients only, usually treated in hospital and largely to inpatient care Many physicians trained in general medicine in India, however, engage in an independent single clinic practice (essentially a family practice).
Community Medicine or Preventive and Social Medicine is synonymous with Public Health Education in India usually dealing with population‑based interventions such as national programs.
Family medicine (FM) is a clinical medical specialty devoted to the comprehensive health care for people of all ages and genders, treating multitude of diseases involving all parts of the body. This branch was developed to counter the rapid fragmentation of medical care as is seen with specialty and subspecialty care in the developed world. In India, the branch is still in its infancy.
The oldest and historically the only form of medical practice simply came to be called as general practice. Doctors in those days would painstakingly amass a treasure trove of knowledge and experience over a period of decades, which they used to treat their patients.
The doctor had enough background of his patient’s previous medical experiences and often the medical histories of patient’s entire family. This familiarity resulted in greater trust towards the doctor and therefore the acceptance to both advised treatment and its outcome was higher. Such practitioners had a quality of enviable omniscience and commanded faithful following.
The medical counselling apart, it wasn’t uncommon for the family doctor to take on the role of a friend philosopher and guide for their patients. It is natural for a student of life sciences (physical, mental, social) to be looked upon as a mentor in the art of living. Poet Edgar Albert Guest says it best in his verse-
“He didn’t have to ask a lot of questions for he knew
Our histories from birth and all the ailments we’d been through,
And though as children small we feared the medicines he’d send
The old-time family doctor grew to be our best friend.”
Another factor in traditional type of medical practice was the consideration of the overall wellbeing of the patient rather than a targeted treatment of the disease (holistic approach v/s reductionist approach).
Specialty medical care offers a telescopic view of a specific aspect of a person’s health and often requires inputs from other specialists when multiple systems of a patient’s body are involved. The increasingly objective assessment of health parameters translates into a slew of investigations, all of which may not always be necessary but become a part of protocol for medico-legal reasons. This also increases the total treatment costs substantially.
Patients who are not so patient
In this fast developing, quick fix world with heavily marketed corporate tertiary care setups, average urban patients have abundant information at their fingertips and options to choose the course of their own treatment. There is pressure for instant diagnosis and one pill cures.
There is, thus, a greater temptation and tendency to seek the advice of a specialist even for the most basic healthcare needs, that can easily be diagnosed and treated at a primary level. This naturally puts tremendous load on tertiary care centres offering exclusive specialist care.
Family medicine in India
As one of the earliest civilizations of the world, our country is blessed with a rich history in the field of medicine. Our nation became the birthplace of formal surgical science and the ancient medical discipline of Ayurveda.
Every invasion that grappled our nation brought with itself its own health culture, because of which India today boasts of multitude of medical disciplines tending to its population of a billion people. The shamans of Indus valley tribes were followed by Rajvaidyas of ancient empires. Mughal invaders brought along their Hakims and the British, their doctors.
Through all these disciplines the entity of a family doctor remained infallibly constant.
While majority of the rural population in India today still visit one medical officer posted at their rural health centre, who often serves not only as the family doctor but a village doctor too; constant transfers and rotations break the rapport established by one doctor in his/her time. While the young officers are well versed in latest practice guidelines, they often lack clinical experience, and the opposite occurs with senior practitioners who fail to update their practice.
Family medicine was acknowledged as a specialty in India way back, in year 1983 by the amendment in Medical Council of India (MCI) Act 1956.
The 92nd report of department related parliamentary standing committee on health and family welfare published in 2016 recommended that the Government of India along with the state governments, establish well defined post graduate programs in Family Medicine. The National Health Policy mandates the popularisation of programs like MD/DNB courses in Family Medicine, as well as initiating multiple distance and continuing medical education options for established general practitioners in private and public sector to upgrade their skills.
The National Board of Examinations has pioneered post graduate program of Family Medicine, providing a career pathway into the horizontally community-based healthcare services instead of a hospitalist career. However, as observed 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), in his elaborate interview- despite these elaborate policies, separate Departments of FM do not exist at any of the Medical Colleges in India,
In his research published in Journal of Family Medicine, author Dogra V was hopeful in concluding that family medicine practice is slowly gaining momentum in India and should be looked upon as an opportunity to fill critical human resource gap at primary level.
Dr Raman Kumar strategized channelling the medical graduates of both allopathy and alternative medical disciplines (who anyways are viewed as the primary care givers) into being formally trained in the field of Family Medicine. “Once family practice clinics are sufficiently standardized, accredited and networked private insurance companies and plans will rush to provide outpatient care at clinics. They don’t have any option!” he declares.
The scope of family medicine encompasses all human healthcare needs in a community setting.
A doctor formally trained in Family Medicine not only diagnoses the condition afflicting a patient but also administers definitive primary and secondary level care to a non-critical patient.
This includes and is not restricted to providing emergency maternal and new-born care (vacuum assisted and caesarean deliveries, managing eclampsia), lifesaving anesthetic skills; urgent and emergent emergency and trauma care in a community setting, expertise in clinical audit, research, standardisation and quality accreditation, social and behavioral counselling, and end-of-life care.
The National Board curriculum in its post graduate program includes compulsory rotations in general medicine, surgery, obstetrics and gynaecology, paediatrics and neonatology and anaesthesia for all three years; including rotations in ophthalmology, NT, orthopaedics, psychiatry, dermatology including emergency medicine and casualty, in the second year and pulmonary medicine in the third year.
A practitioner qualified in the field of Family Medicine should also be adept in taking over the role of a manager, collaborator and health advocate; thereby deserving the sobriquet of Master of all trades!
Healer v/s practitioner:
In a recently delivered oratory lecture organised by the Doctors Fraternity Club, Sindhudurg, eminent Neurologist, Dr S. V. Khadilkar (Dean- Faculty of Medicine, Bombay Hospital), elaborated the need for practitioners to embody both aspects of medical practice- that of a humane healer as well as the hard wired, evidence based practitioner.
He also shed light on the driving factors that influence today’s youth to take up medicine, by sharing short video clips of medical students who were newly admitted into a prestigious medical college and were asked the reason for their career choice. The frequent responses were personal ambition, parental aspirations, passion for the subject, but rarely a sense of service towards the patient.
Societal norms greatly influence career choices among budding doctors who find it inadequate to restrict their practice to a traditional and rather unglamorous general practice.
Goel et al, in their 2018 review published by BMC Medical Education found that, the main motivating factors were scientific (interest in science, flexible work hours and work independence), societal (prestige, job security, financial security) and humanitarian (serving the poor) in high-, upper-middle and lower-middle income countries, respectively- which was comparable with Maslow’s hierarchy of needs theory of motivation. There were no studies found from low-income countries.
Dr Khadilkar, in his oration, finally described how a medico evolves from a library hopping student who is excited by the challenge of academic case to a seasoned practitioner who can see the human in the patient.
It wouldn’t be inaccurate to conclude that time spent in treating people (not just patients) and experience thus garnered instil the X factor that makes a good doctor, in a way that no curriculum can.
Featured Image: Deamstime