What ails family practice in India

Sudharsan Muniyappan is currently pursuing the three-year DNB (Diplomate of National Board) in family medicine.

This bright, young doctor presents an anomaly. A 2011 study of young interns in south India showed that nearly 95 per cent preferred one of four specialities: medicine, surgery, obstetrics and gynaecology, and paediatrics. Family medicine did not seem to make the cut.

Muniyappan is not surprised though. “Family medicine is not a part of the MBBS curriculum. Young doctors are therefore unaware of the speciality, and the few who do know about it are sceptical about prospects.”

Unlike in many other countries where it is recognised and promoted as important, family medicine remains marginalised academically and professionally in India. Lack of employment opportunities, poor social standing and no academic growth contribute to this marginalisation. This is especially disheartening as several policy initiatives have consistently highlighted the importance of family doctors in any robust healthcare system.

On paper

Way back in 1946, the Bhore Committee had in pre-Independent India recommended strengthening the healthcare system with a “social physician” at its heart. It suggested a three-month course on preventive and social medicine for them.

Again in 1983, the Medical Education Review committee called for “...a cadre of suitably trained manpower” that can deliver “comprehensive and integrated healthcare at the family level.” Importantly, family medicine was recognised as a speciality that year.

So where did we go wrong? Santanu Chattopadhyay, CEO of NationWide — The Family Doctors, has an explanation: “In India we are excellent at theory. There is no emphasis on practice.” The Government is too focused on tertiary care, he adds, as borne out by the 2002 National Health Policy’s observation that postgraduate courses are “overwhelmingly in favour of clinical specialisations”.

The policy favoured earmarking one-fourth of all post-graduation seats for family medicine and public health. A decade later, in 2013, Raman Kumar, Founder-President, Academy of Family Physicians of India (AFPI), filed an RTI on the status of family medicine courses in India.

Kumar says the Medical Council of India admitted it had no definition of family doctors and no curriculum for the specialisation either at the UG or PG level. “The current situation is such that this discipline will never be developed,” Kumar despairs, pointing also to the complete lack of representation of family doctors in the MCI, constituted by specialists.

Only a handful of institutions such as Christian Medical College, Vellore, Calicut Medical College and a few AIIMS departments currently offer specialisations in family medicine.

CMC’s distance education course in family medicine gives preference to doctors working in needy sectors or Government setups, a college official said. The course addresses multiple concerns, including upgradation of knowledge, irrational prescribing and unethical practice.

Art of medicine

Aside from the many institutional barriers, family medicine practice is weighed down by several professional limitations. Kumar says that running a clinic is akin to opening a shop; “Lack of resources, high real-estate prices and absence of insurance coverage for GPs make it difficult.” The government sector too offers few employment opportunities. According to the Journal of Family Medicine and Primary Care , although applications for DNB in family medicine have shot up thanks to the National Rural Health Mission, more than 60 per cent of the posts at community health centres remain vacant.

Chattopadhyay believes the solution lies in direct state intervention in primary healthcare. This, in turn, could spur the development of a cadre of family doctors with a focus on empathy, dialogue and discussion. “In medical school, the focus is on science, not on communication skills. Only the latter can turn medical practice into an art. In India, the art of medicine is not practised,” he contends.

GPs are seen as vital to restoring trust and confidence in India’s healthcare system. And for that, the educational and institutional system should heal itself first.

(This concludes the series on family doctors in India)

(This concludes the series on family doctors in India)

Also read: >GPs: The disappearing first line of defence

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