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 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