|Year : 2016 | Volume
| Issue : 1 | Page : 1-3
Family medicine in India: Losing the way in spite of the map
Department of Community Medicine, Dr DY Patil Medical College, Hospital and Research Centre, Dr DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Web Publication||22-Dec-2015|
Department of Community Medicine, Dr DY Patil Medical College, Hospital and Research Centre, Dr DY Patil Vidyapeeth, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Banerjee A. Family medicine in India: Losing the way in spite of the map. Med J DY Patil Univ 2016;9:1-3
In 1946, the Bhore Committee suggested boosting up the healthcare delivery in India with a "social physician" as the key player.  Emphasis on preventive and social medicine was recommended for shaping up these social physicians. The concept was reiterated in 1983, the year when family medicine was recognized as a specialty in India, by the Medical Education Review Committee (Mehta Committee 1983). The Mehta Committee suggested a "cadre of suitably trained manpower" to deliver "comprehensive and integrated healthcare at family level." 
However, there is many a gap between theory and practice.  In spite of voluminous reports by expert committees recommending social physicians to deliver comprehensive health care to the community, the practice is tilted toward tertiary care. The government too is focused on tertiary care as evidenced by kick-starting more All India Institute of Medical Sciences (AIIMS) like institutions at cost of allocating enough resources for Primary Health Centres (PHCs). 
While the need for family medicine was felt in India to serve the health needs of the vast underserved (particularly rural) communities, in the developed countries like the USA, it evolved as a counterculture to challenge the rapid trends in super specialization and subspecialization.  The current American position is a "bellwether" of global social change.  Hence, it would be worthwhile to briefly consider the challenges that face family medicine in the USA today.
By the 1960's rapid advances in medical technology led to "dislocations wrought by science" a term used to sum up the USA medicine's emphasis toward specialism.  There was a felt need by the people for personal or family physicians to counter the culture of specialization and subspecialization. American Board of Family Practice was established in 1969 legitimizing family practice as a specialty within the hierarchy of the medical profession. A new type of generalist was envisaged to replace the aging cadre of general practitioners (GPs). Family physicians were expected to ensure success for the new discipline of family practice to capture the concepts of a personal physician, community medicine, comprehensive health, and primary care.
From the early optimism of 1969, in the USA, events did not unfold as envisaged. Unlike the UK, where GPs have a long history of being the first contact physician which ensures a definition of roles of the GP and the specialist or consultant, the USA did not have a comparative system. The GPs in the UK, being the first contact physician, provide the first-line care to the patients and families, referring to specialists as necessary. They also receive the patient back once specialist care is complete. This arrangement in the UK is ideal for the discipline of family medicine to flourish.
In the USA, on the other hand, the specialist system dominated. Physicians competed with each other in an open market for the patronage of the patients.  The role of the GP was ill-defined. General practice drifted to a less prestigious role with lesser remunerations compared to the well paid and highly regarded specialists. The option of a smooth transition from general to family practice was lost in the USA due to the lack of system of GPs at the forefront of primary care as in the UK. Market forces prevailed in the USA leading to direct access to the specialists. In a health care, market generalists were disadvantaged by not being recognized as having an important role. The lack of proper administrative structure for family practice or even for primary care has been a major barrier to the development of family medicine in the USA.
In India, on paper we have something similar to the British model of the National Health Service (NHS) in the form of a network of PHCs which are under charge of generalist medical officers. These generalists were envisaged to deliver comprehensive health care to families and communities particularly in the rural and tribal areas. This was conceptualized by Sir Joseph Bhore, an Englishman, who chaired the Bhore Committee before independence. The NHS in England, Bhore's native country, proved a fertile ground for GPs to grow professionally to a respected career and acquire leadership of the health system. On the other hand, in India where Sir Bhore introduced the concept of PHCs, the public health system and particularly the network of the PHCs are in a pathetic state in most parts of the country. Among the many problems facing the PHCs, is the low morale of the generalists who are in charge of these PHCs brought about by neglect of career planning and professional enrichment pushing them into a state of "professional exile."  Postindependence, we had a roadmap in the form of the Bhore Committee recommendations to promote family medicine in the country. However, over the years we have strayed from this map. This is due to many factors such as, breakdown of the public health system in the country; the phenomenal growth of the private healthcare industry and increasing specialization and subspecialization. With increasing market forces in medical services, we are going American way in spite of holding a map drawn by a Briton.
Given the low status of generalists in the country, few fresh medical graduates choose to become family physicians. The fact that family medicine became a recognized medical specialty in India since 1983 did not help matters immediately since the discipline did not have a residency training program in its early years. Full-time residency in family medicine started in the late nineties.  The national health policy 2002 stressed the role of family medicine in developing human resource for health. In 2005, full-time diplomate national board (DNB) in family medicine commenced with full-time residency under the national board of examination, to support the National Rural Health Mission.  Recently, MD in family medicine has been notified by the Medical Council of India. The Government Medical College, Kozhikode has become the first medical college in India to start MD in family medicine. However, family medicine is not included as a subject at undergraduate level. This is just one of the contradictions in the approach to promote family medicine in India.
Some time back, six AIIMS like Apex Medical Colleges have been established in different states to emulate the premier medical institute in the country-the AIIMS, New Delhi. In each of these AIIMS like institutes, the "Department of Community and Family Medicine" have been established. This clubbing of community medicine and family medicine is another contradiction in principle. This clubbing may give the impression that family medicine is same as community medicine or a small component of community medicine while in fact these two disciplines are disparate.  Besides, community medicine as a discipline is facing its own dilemmas and is at a crossroads.  Community medicine evolved from public health/preventive and social medicine (the changing names can also result in identity crises). The thrust area of community medicine ought to be statistics; economics; social sciences; demography; informatics; epidemiology; mother and child health; occupational and environmental health; and research methodology. There is not much core clinical work in the discipline. On the other hand, the thrust areas during a residency in family medicine should be core clinical subjects such as, medicine; surgery; obstetrics and gynecology; pediatrics; and psychiatry. Against this background "Community and Family Medicine Departments" in AIIMS like institutions is an incompatible marriage of a "teen" discipline of family medicine to an "aged" discipline of community medicine.
As compared to this ivory tower approach to Family Medicine in AIIMS like institutions, DNB residency in certain select community hospitals in rural areas can offer an excellent opportunity for training in family medicine according to the first person narration of those who have undergone such training. 
Thailand has lesser number of doctors per person than India. This is compensated by the higher number of health workers. Furthermore, family medicine is a compulsory subject in medical curricula of all Thai Medical Universities, and Family Medicine is a distinct specialty with specific syllabi corresponding with that of the Thai Royal College of family physicians.  Thailand has performed better on health indicators compared to India. 
Lessons from such countries can help India finds its way back and develop family medicine as a robust specialty in tune with its mission of providing comprehensive healthcare to population particularly in rural and remote areas as envisaged in the Bhore Committee report.
| References|| |
Stevens RA. The Americanization of family medicine: Contradictions, challenges, and change, 1969-2000. Fam Med 2001;33:232-43.
Puma MJ. Families. In: Detels R, McEwen J, Beaglehole R, Tanaka H, editors. Oxford Textbook of Public Health. 4 th
ed. Oxford: Oxford Medical Publications, Oxford University Press; 2002. p. 1569-86.
Beswal G. Family medicine: A solution for career inequalities among doctors in India. J Family Med Prim Care 2013;2:215-7.
Kumar R. Family medicine at AIIMS (All India Institute of Medical Sciences) like institutes. J Family Med Prim Care 2012;1:81-3.
Kumar B. Family medicine: A resident′s perspective. J Family Med Prim Care 2012;1:59-61.
Wiwanitkit V. Family medicine in Thailand: System, training and obstacles. Med J DY Patil Univ 2016;9:4-6 [In press].