Prologue
All healthcare requirements of the citizens were managed previously by doctors of
a different stream as ‘friend philosopher and guide’ available 24 × 7 from womb to
tomb. They were sincere to diagnose almost all the problems (if not solutions). We
all have experienced their care even at odd hours to be ‘People's Doctor’. Specialization
of medicine and its branches has become a trendy to produce experts who know more
and more about individual body parts. The family physicians have become an ‘endangered
species’. We are putting forward here an honest discussion about future of family
medicine in India as an academic discipline for students teachers, regulators, health
administrators and policy makers to consider.
Learning to Follow De-Learning
Historically, the health profession has been reflected as an honorable field and with
the health-seeker confidence and trust equated healers to a “Surrogate God”. Our ancestors
were able to think that medical profession in general and family medicine in particular
is for learning and not for earning. Step by step, this bondage has loosened to dislike
and at par with other professions. In the age of specialization and Super-specialization
(actually sub-specialization), the single-mindedness of our profession metamorphosed
in making headway from ‘learning’ to ‘earning’ for which one can blame the general
inflation, defeat of value-based education system. Likewise, patients now are remunerating
for the amenities and face value rather than empathy as well as care and competency
of doctors.[1]
We will have to learn the primary care to assess what may work in prevention of all
forms of morbidity, mortality and disability including those caused by injuries. People
at large move from pillar to post in search of a good doctor who will get time to
hear their innumerable problems related to their health and disease. In search of
care they are forced to visit specialist fully knowing well that specialists are expected
to know more and more about any organ-system only though even lay persons know that
disease may not be limited to part/s of their entire body.
We need empowerment of health care education with adequately trained multidisciplinary
resource persons (faculty) as facilitator of learning, updated infrastructure, the
systems approach in courses and curriculum, graded and shared accountability at all
levels, an improved environment of mutual respect for optimum effect. Our greatest
enemies are transference and indifference. We never get time to feel our patients
who are our next-door helpless neighbors. We have to cry with their pain and laugh
out loud sharing their joy.
Trust on the Family Medicine Postgraduates
From the time when Dr. Osler practiced Medicine and Healthcare in the early 20th century
a lot has changed in though the archetypes of clinical practice persisted eternally
through the ages. On the other hand the delivery of medical care has become delimited,
challenging and closely associated with industry; physicians and practices are being
held answerable.
Existing medical education emphasizes a lot of the clinical skills training but focus
is on the ethical and humanitarian side of medicine which is such a core and defining
aspect with impacts and influences all that is going to happen in the life of the
physician. Family medicine experts not only need to be aware of the complexities of
human diseases but also be sincere to learn the components of care to effectively
manage the patients and the downstream battery of activities which supports the same.
A cutting edge holistic knowledge has to be imbibed contextually and conceptually
where the ocean of wisdom will intermingle empathy, clinical skills, communication
skills, management skills for the primary care. The holistic approach to care a wide-ranging
crisis in the community, where our citizens live without prejudice for capacity to
pay, caste, creed or religion, help us grow as strong nation.
At the end of this discussion we will value: An move towards care from heart and not
from brain; Community orientation; Learning Contextually and Conceptually; Family-centered
care; A lifelong learner on the roads to truth and facts with creativity; Research
and Publication; Wise persons who know their limitations; Legal issues in Medical
Practice; Add life to years through promotion of primary care; Out of the box solutions.
One point of caution at this stage that, as family Medicine expert, we will have to
change the paradigm to prepare us to deliver a panorama of ‘Health care’, and not
only the telescopic piecemeal services of ‘Medical care’.
An Approach from a Noble Profession to the Patient
The expectations from the Family Medicine post-graduates are in the main an approach
from a noble profession to the patient. Being a good listener will help you achieve
a greater depth of understanding and be more effective healer of human suffering.
Every single health care provider has some basic approaches to any health seekers.
He must lend his fullest concentration to hear problems the patient (history) and
apply skills carefully to justify the history (clinical acumen). Doctors are expected
to attend and provide meticulous care, once they agree to manage the patient with
relevant explanations and facts related to the illness and its management in the languages
and expressions that the patient and their caregivers can understand; too much jargon
can satisfy the ego of the physician but there will be failure of communication if
the receiver are unable to follow what was told. The doctors must have updated knowledge
and equipment in their possession, as per their level of care. The primary care personnel
must be able to anticipate further complications and timely referral as per natural
history of the disease with detailed maintenance of data. Doctor's responsibilities
run parallel with their rights to turn away a patient before definitive management
by providing basic care for the problems as per protocol of standard medical practice.
A superior unconventional way is coming up in different parts of India as ‘group practice’
so that one of the regular healthcare providers is always available as well as more
than one can share their opinion regarding single case scenario.[2]
Value a Community Orientation
Family medicine experts need community placement during their training period that
is gold mine to acquire knowledge and skill about the ‘hemodynamic’ of their own society.
Armed with this they will be able to ‘know how’ the special effects of non-microbial
risk factors in the pathogenesis and salutogenesis that prevail as the hidden agenda
in their population in the hinterlands. They should learn the art of ‘First responders’
and train to the last man on the road the ‘do-s’ and ‘do not-s’ in any form of pre-hospital
set-up during the golden hours and platinum hours that have a colossal bearing on
the outcome of any illness from ‘womb to tomb’ and from the headache to head injury.
Think Beyond Koch's Postulate and Magic Bullet
In the contextual and conceptual learning model, the learning will include a transparent
knowledge on the natural history of disease as we have to correctly trace the patient
in front of us. Each individual is different and diseases have diverse expressions
of pathogenesis according to the genetic predisposition to the risk factor/s and risk
correlates. In the era of epidemiological transition we have to learn by heart that
‘A stitch in time saves nine’. For example if each of us can counsel each day one
chronic alcoholic citizen to stop consumption of alcohol, then a huge burden of alcohol-related
diseases and social disorders (including road traffic injury and domestic violence)
will come down to reasonable level. Not all disease has a microbial origin and not
all health problems have a pharmacological answer.
Principles of Family-centered Care
It has been sorrowfully observed that Family medicine training by and large have evaded
the learning in true family set up with brilliant exceptions across the country. That
correct knowledge, positive attitude and true practice should have included setting
the priority with special health care needs, learning by doing that that family-centered
care and cultural competence work together, reaping the benefits of collaboration
with caregivers with the core competence on psychosocial issues with an impact on
morbidity, disability and mortality. We have to promote at individual levels that
the support, encouragement and healing touch from caregivers promotes earlier recovery.
A lifelong Learner for Truths and Facts
We hope to get newer generations of health care professionals with a passionate learning
of Family Medicine who will practice updating till the end of life. They are expected
to get lessons in perseverance to get time to know the historical transition of Clinical
Practice Guidelines and/or Treatment Protocols for better prognosis in the era of
Emerging and re-emerging diseases. Particular attention is expected for those morbidity,
disability and mortality where the health problems spurt from multifaceted risk factors
and need multidisciplinary approach to solve.
The problem in DNB (Family Medicine) program is that the students are like uncared
orphans. Hardly anybody cares whether they are learning or not, whether they are passing
out to get the degree or not, whether they are getting placements or not! DNB residents
often report informally about their frustration as they are being exploited for cheap
labor by the hospitals in the existence of minimum academic atmosphere and training
infrastructure.
Still they should follow different learning paradigm such as, self-directed learning,
problem based learning, hands-on-supervised learning, presentations, journal club,
seminars, among others. The facilitators of teaching-learning should keep an eye on
the log books, portfolio learning, projects, reflections that will help the DNB residents
toward self-assessments. Everything will move around empathy and Ethics of care on
the foundations of evidenced based health care. The concern of the doctors will be
reflected at every step with improved patient experience of a coordinated evidenced-based
care based on learner-centred approach to gain clinical expertise with respect for
patient values.
They should show their creativity in their service to the mankind getting optimum
resources from Facilitators, textbook and other knowledge repositories, research publication
and others.
Research and Publication
“The illiterate of 21st century will not be those who cannot read and write, but those
who cannot learn, unlearn and relearn.”: Alvin Toffler
A large pool of scientific evidence is being generated globally on issues related
to reduction of morbidity and mortality and promoting health. There are many important
issues like interaction between risk factor that act simultaneously; spectrum of problem
from womb to tomb, iron supplementation; role of micronutrient for prevention of acute
diarrheal diseases and acute respiratory infections; rationale of food fortification,
complementary foods; safe delivery practices and micronutrient supplementation in
childhood, health benefits and risks of lifestyle modifications; antenatal care and
child survival among others.
Research is basically the continuation to innovate in the philosophy of Altruism (paying
back to the society) in a journey towards an unknown truth. We have to internalize
that research does not mean getting ‘Nobel’ or any recognition. For reasons unknown
doctors rarely devote their lives in basic research, yet they have to realize that
research help us keep updated. Keep a sincere footprint on the roads you have travelled
by publishing what did you think or do in past and present (and future).[3]
Researches are also needed on special emphasis to the process evaluation in the health
service with impact analysis on the innovations in search of predictable models that
will envision good quality, low cost, non- profitable and sustainable health care.
The deliberations by the invited leaders will lead to creating the “Consensus Document
for Health Care Sustainability in Developing India” which will encompass the National
Recommendations by the Experts.
Wise Persons Know Their Limitations
Family medicine specialist being a generalist treat patients of both genders at all
stages of life. A significant role of family medicine specialists is to refer their
patients to organ specialists as and when the need arises. Patients, because of their
long-term association with family medicine specialists, always prefer to maintain
their follow-up with their own neighborhood doctor for the ease of comfort, less travel
and more personalized approach. This requires family medicine specialists to keep
their knowledge and skills upgraded in the advancing medical field. As their specialization
is cross-cutting across boundaries, patient and their caregiver have unlimited expectations
from the family physicians. So there is eternal need to humbly accept the quintessential
responsibility that the society places on their expertise which further necessitates
them to keep updating the resource pool. Daily dealing of patient as a ground level
situation throws them multiple challenges often which are not linked to each other.
These challenges need to be confronted in-spite of the busy clinic schedules, mistime
urgent calls and administrative and clerical entanglements in the midst of personal
family commitment (doctors also have a family-that patients often forget). A genuine
and concerned physician will not shy away from accepting their limitation and dive
in the pool of vast knowledge that can be availed by attending Continued Medical Education
Programmes, conferences, seminars and training sessions. Such investments are worth
to make as they not only upgrade them in skills and technology but also provide them
the larger platform to share their concerns and hiccups in daily patient management
arena.
Beyond Grades/Marks of Formative and Summative assessments backed by liberation of
mind we have to update daily with the self-assessment on ground situation by showing
the skills and competence in real life. Even in our toughest stressful hours we have
to mind our language and empathetic communication. There is always a scope of improvement
for better to be turned into the best with our authenticity.
Issues in Medical Practice
Family medicine trainees need to be well-versed in the legal concepts governing the
practice of medicine. We can never assure ‘cure’, but definitely we can ensure ‘care’.
Patients want to experience a flawless and seamless care.
Value and price
We have to think of ‘Good for most’ and not ‘Best for many’ to assure the health and
well-being through a respectful professional tie in the milieu of updated standard
of practice. This high-quality service honors strength, culture, tradition, expertise
of everyone bringing in relationship with the hope believe and trust that medical
science has metamorphosed from ‘Knowledge based’ to ‘Skill based’. Further we have
to think of the ‘Good for most’ and not ‘Best for many’.
Responsible citizen
We should be the best friend at worst times with the triple role – Healer, Teacher
and Preacher as only the doctor are permitted to enter the bedroom of home and mind.
Family Medicine Training to be Streamlined at Any Cost
Classical Facilitator (Teacher) - Learner (Student) prototype to move in student-centered
outcome-based medical education are gaining grounds in different educational institutions
over the world; Empowerment with logical reasoning to explore unending potentialities;
Profession for learning – not for earning; Knowledge is power if you hone it; Need
based training; Utilizing the immense potentialities of trained Family Medicine trained
personnel of India; Sharing of expertise across the country.[4]
We can invite practitioners of repute, with an academic inclination, for guest lectures.
The students are exposed to novel yet practical as well as difficult approaches in
medicines to widen their horizons of learning experience. Encourage them to observe
basic skills like bedside electrocardiogram or echocardiogram performed by nurses
and paramedical staffs. All clinical teaching need not be done by consultants as the
senior residents can guide them as near-peer mentor to gel well. This will help these
budding professional to become future medical educators with a moral, social, professional
obligation and they cannot remain bystanders in this crucial situation.
Faculty Deployment: Challenges Ahead
With the inception of Departments of Community Medicine and Family Medicine at the
newly established All India Institute of Medical Sciences (AIIMS) across the country
a sincere and genuine dialogue is required, forwarding faculty development in family
medicine.
However as per the post graduate regulation of MCI specifically maintains that family
medicine is a separate and distinct specialty from social and preventive medicine/community
medicine. As per the MCI regulations only persons with qualification in family medicine
and general medicine are eligible to become faculty in family medicine.
The bone of contention lies in the fact that National Board of Examination has initiated
Diplomat National Board (DNB) in Family Medicine long before the newly established
AIIMS have been entrusted to teach and train ‘Family Medicine’ to Department of Community
Medicine and Family Medicine. A legitimate corpus of half a thousand DNB (Family Medicine)
postgraduates has been produced by this period. These DNB (Family Medicine) postgraduates
had passed through rightful inroads in the recruitment as Medical Specialists in the
Central and state government health care delivery jobs also apart from being utilized
by Corporate houses and overseas recruiters. Further, these DNB (Family Medicine)
postgraduates are confident of their knowledge and skills that is markedly different
when compared with the postgraduates in Preventive and Social Medicine or Community
Medicine. They have equivalency claims to be recruited as ‘Faculty’ in ‘Family Medicine’
in the medical institutes wherever ‘Family Medicine’ teaching and training has been
initiated.
In addition, a bulk of Member of the Royal College of General Practitioners (MRCGP)
have been serving Indian citizen in different corners of the country providing health
care at grass-root levels as well as providing training for aspiring MRCGP examinees.
All over again, MRCGP qualified personnel have genuine claim to get the respectable
equivalence with DNB/MD in Family Medicine (in line with other overseas qualifications).
This will help them to join in academics as well as Central and State government health
care delivery jobs when our country in true shortage of ‘Faculty in medical institutions’
and ‘Trained Medical Specialists’. We hope that the regulatory bodies will share our
genuine concern and move forward with the issue. They hope that wisdom should usher
by the grace of almighty so that steps will be taken by the policy makers to help
our health care learners can be skilled in primary care, a prime concern for World
Health Organization among others to improve national health parameters all over the
globe.
The Health Secretariat of Government of India has already sent circulars to all the
Medical Colleges to launch post-graduation courses in Family Medicine, under the aegis
of MCI, across the country. Government Medical College, Kozhikode, Calicut had already
started MD (Family Medicine) course, few more MCI recognized institutes are on the
pipeline to apply for starting the course. But the gray zone have not cleared yet
whether DNB (Family Medicine) postgraduates and/or MRCGPs can be recruited as faculty
members for MD (Family Medicine) course.
So the divide has cropped up whether these DNB (Family Medicine) and MRCGP can be
made equivalent qualification with the postgraduates in Preventive and Social Medicine
and Community Medicine in getting Faculty positions in newly established All India
Institute of Medical Sciences (AIIMS) across the country.
Stand on your feet: Never stand on the shoulder of giants
India is on crossroads of steps forward with International financial support as well
as the government both accommodating of investment driven growth in the Health Care
Industry. The academic institutes and existing healthcare systems both are equal when
it comes to trailing such growth opportunities where sustainability is an important
part of this progress story with sustainable growth. Academic leaders, health administrators
and policy makers are welcome to this nation building forum where the discussions
will lead to a consensus for guiding the regulatory bodies will be able to operate
in a conducive atmosphere.
Future Lies in Present
A rat race has begun from the last few decades of last millennium towards specialization
losing the notion that, we are supposed to treat a person not their organs. On the
contrary, we shall put special emphasis on the basic concept of health promotion with
a wide-ranging outlook even in the absence of any health problem. Health care providers
are confused- not interested in learning and practice this non-glamorous field - ‘Everybody's
responsibility has become Nobody's responsibility’. History move spirally. In recent
times the role of primary care physicians has been rejuvenated globally from Alma
Ata declaration with special trainings modules with or without downstream degrees.
We have to unite our voice that we should also be trained in the wholesome care with
extensive comprehension of health and disease in the ground situations.[5] In the
undergraduate medical education we affirmatively propose that Medical Council of India
should update the medical course and curriculum to add Family Medicine along with
newer generation of topics like Emergency Medicine, Injury science, Psychology, and
components of First responder training for pre-hospital care, the science and art
of Counseling and Empathy, Basics of Capacity building and manpower management among
others to provide a strong foundation of primary health care at entry level. We have
to spread our ‘Wings of fire’ with the expectations beyond boundaries to raise the
slogan to ‘Add life to years through promotion of primary care.’
The practice of medicine is an art, not a trade; a calling, not a business; a calling
in which your heart will be exercised equally with your head.” - William Osler