Role models in Family Medicine lacking in India

Friday, January 18, 2013

by Rajni Pandey


Dr Raman Kumar

President
Academy of Family Physicians of India (AFPI)

Dr Raman Kumar is President, Academy of Family Physicians of India (AFPI). He has been actively involved in the development of academic family medicine in India for a long time. He has also been working for the education and rights of the primary care physicians in India.

Dr Raman Kumar

Dr Kumar is a graduate (MBBS) from Patliputra Medical College, Dhanbad. He was awarded DNB (family medicine) in 2005. He has worked as senior resident in general medicine department at Deen Dayal Upadhyay Hospital, New Delhi for three years. He has fellowship in occupational and industrial health from Maulana Azad Medical College, New Delhi.

A Fellow of Indian Medical Association – College of General Practitioners (IMA CGP), Dr Kumar has actively worked for the popularization of FCGP (Fellow of the College of General Practitioners) programme among young physicians. He has authored the introductory chapter of the book ‘Family Medicine’ published by IMA CGP. His main areas of interest are acute care, palliative care, occupational health and migrant health research.

In an exclusive interview with AalaTimes, Dr Raman Kumar shares the origin and objectives of the Academy of Family Physicians of India and how the organization is going to bring family medicine into the mainstream of the Indian healthcare industry.

How and when did the Academy of Family Physicians of India come up and what have been some of its major contributions so far?

The Academy of Family Physicians of India was founded in the year 2010 by some of the residency trained family physicians, who were trained in the speciality of family medicine. We have family doctors who are general practitioners having MBBS degree. Over the world, the family medicine has evolved as a speciality, as a discipline of medical science and in India too we have training called Diplomat of National Board (DNB) in family medicine, which currently has around 200 seats.

As an academic body, we are trying to promote the discipline of family medicine, which is a concept where doctors provide comprehensive healthcare across all age groups, all organ systems and all genders.

Why do you think family medicine and primary care, as a medical speciality, has not developed in the country in a big way?

Primarily, we have problem with our medical education system. MBBS doctors are supposed to become primary care doctors if they do not go into a postgraduation specialization. We have a very limited number of opportunities for postgraduation in India — for a total of 40,000 of MBBS students, there are only around 15,000 of postgraduate seats available in India. So, the rest of doctors are supposed to go into the primary care setting. They may go into government job or open their own clinic or they may work as resident medical officer in hospitals. The whole MBBS training is based upon the tertiary care system, our medical education system is not based in community settings.

In most of the developed nations such as Canada, UK, US — medical education is imparted in community setting as well. So, doctors who are working at district hospitals or community health centres can become faculty in medical education system but in our case only specialist doctors who have a postgraduate qualification can become faculty in medical colleges. So, most of our medical students are inclined to see them as their role models, they do not know whether doctors who are working in primary care setting or community setting can also be their role models. Therefore, the primary reason for this is lack of role models in our education system.

Distressingly most of our young doctors are not fruitfully engaged with the healthcare system as majority of them spend several years sitting idle, practicing multiple-choice questions for getting success through postgraduate (MD/MS) entrance examinations, in spite of very limited chance of success.

In a US study, only 2 per cent of all medical students expressed interest in practicing primary care. What’s the scenario like in India?

The US has a different scenario. They have three times more postgraduate seats as compared to undergraduate seats. Fifty per cent of the postgraduate seats are in the area of family medicine and generalist disciplines. It is because of the excess number of postgraduate training seats that the US is able to attract medical graduates from developing countries. Majority of foreign medical graduates, including the Indian ones, join family medicine residency training in the US, while majority of the local graduates are able to get more glamorous branches of medicine.

We are the second most populous country in the world; we have densely populated communities living in rural, sub-urban and urban areas. Here, it is not the problem of earning money or anything like that; probably, it is the issue of lifestyle. Since most of the doctors come from urban background, they are not comfortable in working in rural environment. In India, majority of the doctors who come from the public health education system are from various sections of the society, many would be interested in working in the primary healthcare system if right opportunities are available there. But unfortunately we don’t have vocational training in primary care, which is why students are actually not aware of this discipline at all. We expect that by default they will become primary care doctors but somehow we are training them for tertiary care only.

Why do you think not many medical graduates want to opt for family medicine / general practice?

Lack of an equal opportunity for career progression as compared with specialist counterparts is one of the main motivating factors for medical graduates not opting a career in primary healthcare. Family medicine is a clinical branch. Of the many postgraduate specialisations only few are clinical branches, where you can work as practicing doctors. In many other medical branches such as pharmacology (which is generally lab based) or para-clinical branches, you don’t have direct connection with patients, or diagnose patients, so despite being a doctor, you don’t have a direct link with patients. In family medicine you will get opportunity to treat patients, take care of patients, this is what most young doctors aspire to do when they first enter medical colleges. So, if they are given opportunity to take care of patients, practice clinically, enhance their level of skills, they will definitely opt for this opportunity.

What needs to be done to make family medicine a popular choice of medical specialisation among young doctors?

First we have to introduce this concept in MBBS curriculum itself. If you see the current curriculum of MBBS students, it is not mention there, so we teach everything but we do not teach family medicine, which is very important. All over the world, family medicine is included in undergraduate level training. But our doctors are not exposed to this concept during their formative years. If they are not introduced to this concept initially, how we can expect them to opt for this in their postgraduation years.

So, the first step should be to introduce the concept of family medicine in the primary curriculum of MBBS as a separate subject. Family medicine is a horizontal speciality, where vocational training enables doctors to take care of a wide variety of clinical conditions. Family medicine needs to be encouraged as a competency based training towards preparing multi skilled and competent primary care physicians.

What’s been the most important change since you joined the medical profession?

In the last 20-30 years, most of the healthcare developments have centred around the tertiary healthcare system. We have large speciality hospitals coming up, lots of growth happening, and we have big hospitals like Apollo, Fortis, Max etc. But there is also a growing desire and aspiration among people for personalized and comprehensive healthcare system. Many times people go to a hospital and get confused which doctor they should consult first, as one person can have many problems. Therefore, every hospital should have at least one primary care doctor who can guide patients for their treatment.

Why do you think people rush to specialists, before consulting general practitioners, even for minor illness? Should consulting family doctors before specialists be made mandatory?

People go directly to the specialists even for minor illness such as headache. Specialists have a very different way of working. Access to specialist care is itself a very expensive thing. For even minor problems, people spend lots of money by visiting specialists, which can be saved if they consult a general physician or a family physician.

It should be made mandatory because we need a system of screening, referral of patients, where people first go to a primary healthcare centre and only when there is a referral they should go to a specialist or to a big hospital. This will require time but it’s a requirement of the healthcare industry and the healthcare in general, because healthcare in India is getting very expensive and even the insurance companies cannot bear the cost of non-necessary procedures and treatments.

How has the field of family medicine as a career developed over the years?

We have only two-three career options or tracks in medical profession — people can either go into teaching or academics or direct practice. But the academic career option is currently not open for family physicians in India because to become a faculty you need a postgraduation qualification.

Earlier, there was no postgraduation system available in family medicine, so our primary care doctors could not became faculty. But now we have DNB and MD in family medicine, which has been started recently by Calicut Medical College. The Govt of India is supporting all the medical colleges in the country who are willing to start the department of family medicine. The AIIMS like institutions have also started the department of community and family medicine (CFM). So, in due course of time, we will have faculty posts available at all medical colleges in this discipline as well. Independent practice is always available to qualified family medicine specialists.

How do you think the country can bridge the huge gap between demand and supply of qualified medical practitioners?

This is very tough as most of the medical colleges or institutes in India are located in the southern part — Maharashtra, Tamil Nadu, Karnataka etc. The government is already devising schemes for opening of medical colleges in every district. The government is also planning to open more medical colleges in the 12th Five Year Plan, which will bring some rationalization in healthcare in the country.

Do you think the friendly neighbourhood family physician is becoming an endangered species?

Yes. It is indeed because most of the doctors nowadays prefer to go and work in big hospitals. Also, it is very difficult to sustain individual clinics these days because of the urban area issues such as real estate prices, market competition, low income etc. Many patients prefer to go to hospitals directly rather than going to a primary care centre or community centre.

What should be done to attract doctors to rural India? Do you support the idea of compulsory rural service?

Most of the young doctors resist this kind of forceful tactics. We are promoting family medicine in a way that if a doctor works in a district hospital or a community health centre and while working there if he or she gets an opportunity to earn a qualification, majority of the students would be interested to work there.

Traditionally, we think that advanced medical education can be imparted at large hospitals only, but we are trying to emphasis on the medical education regulators that medical education can also take place at district hospitals, CHCs (community healthcare centres) and PHCs (primary healthcare centres) as well.

We should have a clear career path defined for progress in this field as well. If you are a MBBS doctor working in a primary healthcare centre, your experience does not count, you cannot become professor or faculty of your own discipline.   There is a need to link medical education system both at undergraduate and postgraduate levels with the community based healthcare delivery system.

What could be the reasons of the troubled doctor-patient relationship in the present times? What should be done to make this relationship more cordial?

Our healthcare system nowadays is becoming more and more technology based. Whenever you go to a doctor, they prescribe you tests, write prescription or procedure. There is very less communication between the doctor and the patient. So, one is lack of communication. Doctors here are not supposed to explain what they are doing; our system is not like other western countries where the entire procedure has to be explained by the doctor to the patient and the patient has full right to decide and discuss the consultation. So, the communication gap is one part and the second part is the more technology based healthcare system.

What should be done to create a sense of security among doctors? Do you think hiring bouncers to protect doctors is an answer?

Security is an equal concern of all ordinary Indian citizens not just the doctors. Most of the doctors who have security issues in rural areas are from urban background. Many of them do not have any exposure of smaller districts, or village they have been assigned. During their training process, they should spend considerable time at the actual site of practice so that they can feel accustomed with that area and they will also have an opportunity to develop some kind of relationship with the local community.

In the pursuit of keeping pace with the technology, have we lost touch with the patient?

This is very true. Especially doctors in the government hospitals are overloaded with patients; in 2-3 hours, they consult 200-300 patients. So, it is not possible to give proper consultation time to each and every patient. Minimum consultation time, which we need to give a patient, is not less than 15 minutes but in many countries they have consultation time of 30-45 minutes. And, of course, lack of communication is another reason for this gap.

What has the Academy of Family Physicians of India done for popularizing the family medicine discipline?

It is because of the advocacy of AFPI that MD in family medicine has been initiated at various medical colleges in India. We also provide online guidance and career counselling to prospective students and trainees of family medicine. AFPI has started the first scientific journal of family medicine in the name of Journal of Family Medicine and Primary Care (JFMPC). JFMPC is now a popular academic forum for trainees, faculty and practitioners of family medicine and primary care in the South Asia region. We have also initiated a forum called ‘Spice Route’ for young and future primary care physicians of the South Asia region. We are encouraging young doctors to take up leadership role to develop primary healthcare in India.

Tell us about the 1st National Conference on Family Medicine and Primary Care, which AFPI is going to organize.

We are going to organize the 1st National Conference on family medicine and primary care at India International Centre, New Delhi on 20th and 21st April 2013. The theme of the conference is “Preparing multi skilled and competent primary care physicians — consensus on family medicine in India”. We have invited reputed international faculty from countries such as US, UK, Australia, Hong Kong, Nepal, Pakistan, Sri Lanka etc. Faculty from leading medical institutions in India is also participating. We are involving various stakeholders from public and private sector.

What’s your message to the budding doctors?

First of all, students need to understand family medicine. Many students consider family medicine as family planning or public health. They do not understand the concept because it is not introduced in the undergraduate level of medical education.

Family medicine is a clinical branch, where you will take care of the patients. Family medicine specialists are skilled to provide care for up to 90 per cent of health related ailments in a given community. One doctor can do deliveries, administer vaccination, treat hypertension, diagnose a heart attack and can also manage trauma care.

In Nepal, they have a very interesting branch called MD in General Practice and Emergency, where one doctor is trained to do anaesthesia, the same doctor can do deliveries, natal care and other surgical procedures. We are talking about doctors who have practiced a higher level of skills as compared to traditional general practitioners.

Family medicine is going to grow as a speciality and there would be various opportunities in the years to come. Upto 60 per cent of the specialist posts are vacant in NRHM (National Rural Health Mission) where family medicine doctors are most suitable to work. Most medical colleges will have independent family medicine departments in due course of time where young doctors will have opportunity to become faculty. In the private sector also, many new ventures of clinic chains such as NationWide of Bangalore are coming into the market, who would be scouting for specialists in family medicine.

by Rajni Pandey

Categories: INTERVIEWS

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11 Comments »

Comment by prof. Manoj Sharma
2013-01-19 07:46:18

One would like to know as to how much of gerontology /geriatrics is understood and taught during family physician courses does thesyllabus contain this aspect . How much of basics of oncology is understood by the family physicians as many a time it is the delay and ignorance of the family physicians that the delay in referring the cancer patient to a proper treatment centre happens. It is the overlooking by him that early recurrence becomes incurable
However
Once again this is the family physician who if educated and oriented properly can do miracles in early diagnosis, recognition of the post treatment recurrence of cancer and also cancer prevention through his clinic.Post treatment care is the one who can reduce tensions in over burdened cancer centres.

One of the greatest examples is the follow up techniques at the Centre of Excellence, Cancer Institute Adyar , Madras , where due to great cooperation of family physician the Institute has developed best follow up in the world for all class / socio-economic status.LABOUR AND DEDICATION INTENSIVE THOUGH .

Letter to FP on receiving the patient
Letter to FP after completion of treatment of cancer patient.
Letter to FP if the Institute is not getting desired follow up from the patient
Letter to FP if there is some post treatment problem and patient is unable to come.
Letter to FP on further management of patient if the patient had a radical treatment or is being sent with prescription of pallative care or supportive care

Indeed a well oriented Family Physician ZINDABAAD , AT LEAST FOR ONCOLOGISTS

 
Comment by Dr Raman Kumar
2013-01-19 08:21:13

Geriatrics, palliative and end of life care form the important components of family medicine training world over. Early diagnosis of cancer is part of comprehensive evidence based clinical prevention package. In countries like Canada, once diagnosis is established patients are returned back to family physicians for administration of chemotherapy in the local setting. The current curriculum of MD/DNB family medicine has been prepared by specialist doctors and requires further rationalization. Family physicians can no longer function just as traffic police. As a state Tamil Nadu has the best public health delivery system with many innovative schemes for public good.

 
Comment by Prof.Alexander John
2013-01-19 09:42:52

As has been rightly stated the crux of the matter is that most of our colleagues do not have the correct perspective of the subject and therefore are unable to ‘teach’ their students the same, without which they will never get excited about taking this as a career option.I dont think money is the major issue -if you are a good doctor you will have many patients and the volume of business will bring enoug revenue.

I do not think anyone needs to be convinced that this is the need of the present era for any developing or developed country.
The concept of a family physician will find many takers. But then who is qualified to be a family physician – In my opinion all doctors are primarily Primary care physicians. However they should be trained to be competent to handle all basic health related requirements of all members of a family and the communities they belong to. The patient will learn to like this again as they have done in the past. Many are already fed up of going to a different doctor for every part/ system of the body.

The curriculum should be revised, the scope of training in family and community medicine should be widened and centres of excellence in this field developed.

Above all the department of Community and Family medicine should be very much involved in clinical work along with whatever they are doing now and this will attract many young doctors to this speciality.The case of CMC,Vellore is a testimony to this – some of their top students are specialising in this department year after year.And thereafter doing some excellent work all over the country and abroad.

 
Comment by prof. Manoj Sharma
2013-01-20 05:51:42

No doubt the syllabus and curriculum needs drastic changes even at the MBBS levels and post graduate levels including oncological sciences as a subject at PG and modification of clinical approach in a comprehensive manner for cancers in all the specialities .
Leaving administation of cancer chemotherapy at FP level can only be achieved when the FP is educated and trained in medical oncology otherwise it will be a tool of killing rather than tool of curing in Indian settings, almost amounting to quackery.

Is there any harm in being a traffic police , seeing the crowd of sick people from different ailments?
The role of FP increases in Indian scenario because there is no patient information system available either during or post treatment period to a majority of Indian patients who can be categorised as illiterate or uneducated . This is specially so when latest developments of e developed countries are straightaway transferred to most back ward in our country and when he / she is not able to handle , it turns into disastrous consequences.
Taking super-specialist’s role at FP level with the time framed teaching syllabus may not be possible and there is no harm in remaining a FP who contributes more significantly to the health care needs of the masses than superspeialist can do. Only thing is that FP can further enhance his role as a subtle health educator ( cancer educator if I may desire so) by distributing health information material to his patients when they visit his clinic.Or display videoclippings in his waiting area on various health instructions.

 
Comment by Dr Raman Kumar
2013-01-20 11:45:58

@ Prof Manoj Sharma

Sir, we are by no means supporting any sort of quackery. We are talking about models of care, which have been shown to be safe internationally, through evidence based assessment. Our system must evolve and grow up. Many skills which are considered to be specific domain of so called super specialists are being taken up by even non physicians care providers such as nurse practitioners and para medics. One example is thrombolysis by para medics in ambulance in cased of acute MI in UK. It is a pity that 90% of our MBBS graduates and other doctors cannot read and report an ECG, which is a basic skill.

Restricting practice of common clinical skills through licensing means that we are depriving a large section of Indian population of quality medical care. “Clinical gate keeping” is the essential function of family physicians. Given the population and high level of morbidity, the trained family medicine specialist in India have to practice a higher level of clinical skills as well. So that majority of services are provided at the door step. People do not have travel from rural, remote and undeserved areas to the metropolitan cities. The scope and skill set of specialist in family medicine has to have a strong horizontal component which traverses though several specialties and sub – specialties. Some amount of discomfort among other professionals, (who consider these skills to be their exclusive license and domain) is inevitable.

The skills of doctors have to be determined by the community needs. What is common and what is essential/ emergency for a given population / community should determine the skills of family physician. It cannot remain seller’s market for ever. As professionals, we should not misguide and blackmail the society in the name of safety, while attempting to protect our own trade union interests (exclusive license). We have claimed to have reached international standards in tertiary care and I see no reason why our countrymen do not deserve an international quality primary health care.

The other day I was looking at the numbers of “Super Specialists” in USA, UK, Australia, New zealand and Europe. I have done this exercise on Google search and I request others to repeat it. If you search in Google, the number of “super specialist” in these countries is “ZERO”. In fact there is nothing like a SUPER SPECIALIST. This term was discovered not so long back in INDIA (It happens only in India) and exclusively used by our Indian colleagues, who claim to possess higher level of knowledge, which are in fact narrow / vertical / rare vocations skills. This term is a creation of corporate hospitals as a tactical marketing tool, which gives perception of high quality of care. This was conveniently adopted by our beneficiary colleagues. A good amount of quackery is practiced even at tertiary care level.

As a group of professionals, I can assure that we are not looking for right to administer chemotherapy. I was just referring to an example in Canada. In the era of evidence based medicine, where all practice standards and international guidelines are freely available on internet, we are for scientific and evidence based medical care at all levels of service delivery (primary, secondary and tertiary). Patients care and rights are supreme. Services should be transparent and public should have a choice to opt.

 
Comment by Avinash Chilukuri
2013-01-23 05:04:15

The intension to promote primary care physicians in media is important. Over the last 30 years there has been lost of private sector investment in secondary and tertiary care. There has also been a shift of population to semi urban and urban areas with increased incomes and poor lifestyle. The government has invested a lot on communicable diseases. But over the coming decade there will be rise of lifestyle diseases suc as CVD, diabetes, depression, obesity, copd, alcohol/drugs.

So primary care physician are needed not only in needed in rural but also in urban cities/tows.

He important issues are making primary care work equally rewarding for doctors to pursue, and a working model with the community and other HCP’s and insurance providers which is sustainable, evolving and beneficial to the society

 
Comment by SANTOSH
2013-01-23 10:06:54

A Family Physician is a multicompetent specialist , expert in managing the common ailments affecting the community. The focus is not organ/age/gender based, rather its the incidence and prevalence of the ailment in the community- commonness of the disease.At the end of my MBBS I was not competent to manage even a fever, while I could confidently diagnose a Lateral Medullary Syndromme! Therefore it is very important to widen the scope of learning and practice for medical graduates and post graduate level training in a broad speciality like Family Medicine must become mandatory for new graduates to practice as Family Physicians.Even the older doctors must have opportunities for practice based learning and accredited programmes coordinated by Family Physicians involved in the academic stream.

 
Comment by Alka Ganesh
2013-01-26 10:02:53

It is good that DNB continues to run the family medicine course, and gives a lot of incentive to institutions to run the course. However, it needs to help them to improve the courses, not by penalizing them or by laying down impossible curricula; rather, a core group of experienced trainers from India and overseas, may be empowered to train instituitions on how to run the courses, till such time as there are enough trainers emerging through the system to take on that role, perhaps in 8 to 10 years. Most young doctors who join DNB fam med course do so because they could not get into other courses. These students need encouragement and training.
I would also suggest that the vast number of current GP’s who have an MBBS or a specialist diploma/degree, should be given an opportunity to improve their knowledge and skills by enrollling in specially designed distance education, or part time short courses. Once there is a critical mass of well-informed, enthusiastic, empowered, GP’s with good communication skills, faith in themselves, and an optimistic view of their important role in the health care system, then , there will be a complete turnaround by society and the medical profession in their attitude towards primary care physicians.

 
Comment by Dr bharati borah
2013-01-28 21:13:29

the concept of primary care in India has been introduced in wrong way , the govt of India has been changing there approaches every time with not much changes or achieving targets both in rural & urban sector. I really appreciate Dr Raman Kumar to have this effort to start with community based multi iskilled primary physician ,so that majority of population will have the services at door step . The qackery system in the rural sector , due to non availability of qualified Doctors has made people to suffer more .I can assure u sir not at least 50% of our Doctors serving the PHC’S & CHC’S etc don’t know properly CPR or BLS etc, which in contrast in USA or other countries done by paramedices .therefore its time to have changes with uniformity in the system with greater effort in the community behavioral changes approach , to train the existing doctors in the system along with introduction in the graduation course about family medicine , even tho people have the concept about family medicine as master of all jack of none .

 
Comment by Dr.G.R.Banerjee
2013-04-02 13:00:15

Dear Dr.Raman Kumar,
First of all I want tell you that I am from from your Patliputra Medical College. I had finished my internship in the year 1981.But since your interest in Family Medicine and Occupational Health is same as mine. I had done MPhil in Health & Hospital Management from BITS, Pilani. I did my AFIH and also Family Medicine from Christian Medical College, Vellore.I want know about other doctors from our college who are in Family Medicine.
Regards
grbanerjee

 
Comment by ashutosh
2013-09-29 22:54:26

Sir,I got selected in dnb with good rank n wana pursue Family medicine ,please please tel me what are good colleges in north for this course,what are future job prospects in this branch..thanks in advance..

 
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