The Principles and Practice of Family Medicine

Anna Maria

DNB Resident, Kauvery Hospital, Trichy, Cantonment

Family Medicine

It is an independent academic discipline and specialty of medical science that developed as a counterculture in response to rapid fragmentation of medical care into specialty and sub specialty care in the much of the developed world. It encompasses a spectrum of care and services to meet the entire needs of the community.

The family medicine practitioner acts as the first line of contact with the healthcare system and can address a wide range of health issues, either through direct care or through referral to other specialties, thereby maximizing the cost-effectiveness of the healthcare system. For most health problems, family medicine practitioners serve as an entry point for individualized healthcare. Providing comprehensive care for most specialties for all ages is the hallmark of family medicine

Family physicians possess unique attitudes, skills, and knowledge which qualifies them to provide continuing and comprehensive medical care.

Family medicine is based on continuity of care and creates a long-term relationship between patients and doctors.

It employs a patient-centered approach rather than a systems- and disease-based approach as seen in specialty care.

The scope of family medicine is broad and includes care at various stages such as pregnancy, newborn care, child care, treatment of acute and chronic adult life diseases, and end-of-life care.

The practice of family medicine is largely preventative care. In the absence of good family medicine practice in a community, there is an increased incidence of lifestyle-related diseases and patients often present in advanced stages of illness.

Chronic conditions such as asthma, hypertension, and diabetes can be actively managed in primary care, reducing hospitalizations and preventing acute exacerbations of these conditions.

Family medicine physicians are also strong health educators and they can help mitigate the gap between patients and healthcare providers, thus empowering patients to take part in their healthcare.

Family medicine physicians often have a longitudinal relationship with the patients and often are more trusted by patients than other healthcare providers. By virtue of this trustful physician-patient relationship, family medicine doctors can be strong advocates for their patients and they can facilitate communication within a medical team.

Their specific roles and responsibilities can be summarized as follows :

  • Promote health and prevent disease in the family and community;
  • Manage common diseases in all age groups across different clinical specialties and utilize the limited resources in primary care;
  • Appropriate referral to specialists by correctly identifying the red flags and symptoms;
  • Provide continuity of care by involving in two-way referral with the specialists;
  • Provide home and palliative care;
  • Provide community-focused care with a multidisciplinary approach;
  • Should be aware of the associated socio-cultural and environmental issues related to health;
  • Provide effective health education to the family and the community.

History of Family Medicine Specialty

While family medicine evolved since 1950s and 1960s in USA and UK to its present form today, it gaining rapid momentum in the middle east, Africa, Latin America and South Asia during recent decades. The term ‘family physician’ originated in USA, where it was deemed necessary to distinguish between family medicine and traditional general practice

The fragmentation of medicine into subspecialties has produced advances in our understanding of diseases. Advances were made by subspecialists who were concentrated in hospitals, with expertise in single organs, systems or diseases, in the performance of specific procedures or in the use of expensive and advanced equipment. It is precisely the development of these subspecialists and their concentration in hospitals that gave rise to a demand in the community for a physician, who was caring and accessible and who was also more expert and better trained than the general practitioner of those days, but who could act as the patient’s guide, protector, philosopher and friend. This led to the emergence of family practice as the natural inheritor of the ancient traditions of general medicine.

Family medicine in India

In India there is a growing recognition and value for family medicine and It has been realized that competent primary care physicians form the back bone of health care delivery system and could play a vital role in fulfilling the human resource requirement of National Rural Health Mission NRHM – (gradually evolving into the National Health Mission – NHM).

The forum for development of academic family medicine was founded in 2010 in the name of Academy of Family Physicians of India (AFPI) Family medicine is a MCI recognized specialization and has been notified at serial no 06 of schedule II of Post Graduate Regulation 2000 of Medical Council of India. As per Medical Council of India notification MD (Family Medicine) can be awarded as post graduate qualification by Indian universities.

However, in spite of being a primary specialty and discipline of national importance, family medicine has not yet been introduced in MBBS curriculum by the MCI. Majority of medical students and even senior faculty are not aware about the benefits of this post graduate training in this field. Also, there are no designated teachers of family medicine at MCI recognized medical colleges at present. AFPI is actively advocating for inclusion of family medicine in MBBS/ UG curriculum and at least 50% more PG seats in family medicine. The stated position of AFPI is that all medical graduates in India deserve a post graduate qualification, faculty eligibility and opportunity to become consultants in their own respective discipline. There are less post graduate seats in Family Medicine in India as compared to UK and USA, which has led to under development of family medicine in India.

Recognition of DNB Family Medicine by Medical Council of India/Government of India

Family medicine was originally recognized as a medical specialty in India in 1983 when the MCI Act 1956 was amended. DNB family medicine, awarded by National Board of Examination (NBE), is a MCI recognized qualification since then. Family medicine exists at serial no 30 in the list of recognized specializations and post graduate qualifications in the original notification of NBE dated 19th September 1983.

In India, the first postgraduate course in family medicine was launched in 2011 at the Government Medical College in Kozhikode, Kerala. A three-year residency program in Family Medicine is required by the MCI to award the Diplomate of National Board (DNB) or the Doctor of Medicine (MD) in Family Medicine. The primary objective of a postgraduate course in family medicine is to educate specialists in family medicine to provide quality healthcare to the community and advance the medical course through research and education. As per National Board of Examination, after qualifying the final examinations the candidate should be able to function as a junior consultant (specialist) in Family Medicine. He/she should be able to render health services to the community by providing health care to all members irrespective of age, sex, culture and socio-economic background. He/she should be able to decide for appropriate referral in order to provide secondary/tertiary health services when necessary. He/she should be clinically competent and should be able to take personal responsibility for rendering comprehensive and continuing care of his patients in their own family settings. In many developed countries, family medicine is recognized as a distinct specialty, and training is provided through structured postgraduate residency program. However, awareness of the specialty of family medicine is low among undergraduate students in India. Interestingly, the Indian Parliament has passed the National Medical Commission (NMC) Act in 2019. The NMC replaces the MCI Act and aims to facilitate the delivery of quality primary care as well as promote family medicine as a discipline. In addition, family medicine has been included in the foundation course of MBBS and is set to be introduced in all medical institutions in India, although the current MBBS syllabus makes no mention of it.

The author’s advice to Family Medicine practitioners!

1. You will always be in demand

A family doctor advocates treating the patient as a whole, not just their illness. This always puts the patient’s need as the focus as it should be. Therefore, as a family doctor, you can provide treatment to more than 80% of illnesses in a community setting, which makes family physicians essential to the medical eco-system.

2. Start your own clinic

Healthcare professionals with family medicine fellowships are perhaps best equipped to start clinics and work in community hospitals. A family medicine fellowship not only prepares a medical professional with the necessary clinical skills, but also equips them with managerial and administrative skills. Family medicine offers healthcare professionals independence and gives them the opportunity to excel in their medical practice.

3. You’ll always have an opportunity to learn

The desire to learn something new is essential for every physician as you’ll need to stay updated with the latest advancements in the industry to complete the education requirements to maintain your medical license. Owing to the recent advancements in the healthcare sector, family medicine experts will never run out of opportunities to learn, which will result in them being in high demand, both in the public and private sectors.

4. Build a long-lasting relationship with your patients

Family doctors are different from other specialists, as the patient chooses to consult the same doctor for a long time, sometimes for decades. Providing quality care is a hallmark of the family medicine specialty, which recognizes the importance of a unique interactive relationship based on respect, trust, and continuous care.

5. Help patients avoid future health concerns

The way forward

Departments for family medicine should be set up in medical colleges all over India. The necessary steps should be taken to incorporate the family medicine curriculum into the undergraduate MBBS curriculum. The number of medical colleges offering postgraduate residency training in family medicine should be increased. Public healthcare institutions and organizations should be educated regarding family medicine. A comprehensive curriculum for family medicine needs to be developed to meet the current health needs of the community. The health system should focus more on primary care and family medicine to provide people with affordable, accessible, and quality healthcare. A primary care-based health system is required for the epidemiological and nutritional transition as well as the impact of urbanization on health. In order to improve rural health services in India, sufficient numbers of rural family doctors are also needed, which can be achieved by improving and expanding family medicine specialty in India.

Conclusion

India is experiencing a rapid increase in population every year and the majority of the population lives in rural locations. Access to affordable, quality healthcare in rural India has been a challenge. Family medicine practitioners can play a big role in providing easily accessible, low-cost, high-quality healthcare to not just rural populations but also in urban centres where the wait time for specialists may be very high. However, family medicine is still not considered a specialty in India, and awareness about family medicine among the public and health stakeholders is low. A well-trained family health practitioner who can provide integrated healthcare is urgently needed to improve the current healthcare system in India. The importance of a family physician providing comprehensive care both in the hospital and in the community is often underestimated. The transition to universal health coverage for all requires a change in the healthcare system that places more emphasis on the practice of family medicine.

Anna-Maria

Dr. Anna Maria

DNB Resident

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