History of Family Medicine
Historically doctors used to be generalist practitioners. However, during the past fifty years, technological and scientific advances have brought exciting prospects in medicine. The fragmentation of medicine into subspecialties has produced advances in our understanding of diseases. Generalist mode of practice languished, while spectacular 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.
In USA, the American Academy of General Practice (AAGP) was established in 1947 to give voice to the decreasing number of generalists. A series of events after that paved the way for family medicine to become an accredited, board-certified, professional specialty. In 1966, three landmark reports were released by commissions that had been appointed to study the problem of declining generalists. These include:
The Folsom Report
Concluded that “ every American should have a personal physician to ensure the integration and continuity of all medical services.” It also stressed the importance of preventive medicine, the use of community resources and the importance of caring for the patient as a whole.
The Millis Report
Focused on graduate medical education and determined that family medicine needed to be a board-certified specialty.
The Willard Report
Recommended residency training programs for family medicine and specified the establishment of a board to oversee certification. The American Board of Family Practice was established three years later in 1969.
International developments in the rest of the world
In 1952, the British College of General Practitioners was formed. Then in 1958, The Royal Australian College of General Practitioners was established. The family medicine counterculture was particularly strong in America and the general practitioner community worked towards a new general practice and even changed the name of the discipline from “general practice” to “family medicine” to reflect a renaissance in its culture.
Since then the movement has become worldwide. In India, though the General practice associations have existed in form of IMA College of General Practitioners (IMA CGP) and Federation of Family Physicians of India (FFPAI) represented by traditional old GPs. The forum for development of academic family medicine was only founded in 2010 in the name of Academy of Family Physicians of India (AFPI).
Changing Nomenclature
New disciplines need new terminologies, especially when the older terminology implied lower levels of specialized training and competence as well as lower status. The different historical backgrounds to medical practice in each country have produced different terminologies for family physicians and family medicine. The term ‘family physician’ originated in USA, where it was deemed necessary to distinguish between family medicine and traditional general practice
Three alternatives to the term ‘general practitioner’ have been proposed (a) Personal physician (b) Primary physician and (c) family physician. The term ‘Primary Physician’ was used in the report of the Citizen’s Commission on Graduate Medical Education (1966) chaired by Dr. John Millis. The adoption of the term ‘family physician’, by the American Academy and the Canadian College, promoted the universal use of this term to describe the new specialist.
The health policies of several developing countries including that of India are profoundly influenced by WHO’s concept of primary health care (Health For All – HFA) movement for basic and minimal health care services.
For a country like India term ‘Primary physician’ or ‘primary care physician’ are also more suitable and appropriate terms where family practice takes on a strong community orientation in the context of a national primary healthcare program. This term covers wide range of primary care providers including urban GPs, rural physicians, medical officers, emergency physicians, occupational physicians, doctors employed in military and public sector enterprises etc. These doctors often provide undifferentiated clinical and preventive services to the communities they serve.
In the UK, the term ‘general practice’ continues to exist by custom and statute but with a much higher level of acceptance and prestige. In Australia, the term ‘general practitioner’ is still in use, but the state-funded training program is called the ‘family medicine program’. In Europe, the term ‘medicine generale’ is in use.
The current practitioners of family medicine in India
By convention the term ‘family doctor’ should be understood as referring to the following: (a) Family physician in private sector (b) General practitioner in private sector (c) Medical officer in public sector (d) Faculty in family medicine (e) Family Medicine Specialist – evolving concept (f) General duty medical officers (GDMO) – Generalist physicians working as first contact care providers in various organizations in public and private sector
A family physician has postgraduate training in Family Medicine. A medical officer is a generalist in the public sector, without postgraduate training. A general practitioner is qualified private practitioner without postgraduate training.
Family medicine in India
Family medicine has been a recognized specialty since 1983 by an amendment in Medical Council of India Act (MCI Act). Since 2005, the NBE (National Board of Examination) has been promoting family medicine as a special human resource need for National Rural Health Mission (NRHM). The National Board of Examinations is an autonomous organization functioning under the Ministry of Health & Family Welfare, Govt. of India. The prime objective of the Board is to conduct post-graduate examinations of high and uniform standard throughout the country in different specialties. National Board of Examinations is keen to encourage family medicine as a specialty programme since it serves the needs of society by providing comprehensive and continuing care of the patients in their own settings.
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.
Various policy deliberations and discussions have supported the concept of family medicine in India. These include (a) Bhore Committee Report (b) Bajaj Commission (c) Reorientation of Medical Education (ROME) (d) Mehta Committee Report (e) Prime Minister’s National Knowledge Commission (f) the National Health Policy 2002 (g) Taskforce for development of human resource for National Rural Health Mission (h) Planning Commission’s Steering Committee on Health in 12th Plan (i) Pradhan Mantrai Swastha Surakhas Yojana (PMSSY) by establishing department of Community and Family Medicine at new AIIMS like institutions. (j) Medical Council of India’s Vision 2015. The national consultation convened by NHSRC, NRHM Government of India in April 2013, has proposed required skill set for family medicine specialist to be employed as specialists at Community Health Centre. The report is available online.
Medical Council of India Recognition to Family Medicine Specialty
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 the MBBS curriculum by the MCI. As outcome; majority of medical students and even senior faculty are not aware of the benefits of this vocational training. Also, there are no designated teachers of family medicine at MCI-recognized medical college at present. AFPI is actively advocating for inclusion of family medicine in MBBS/ UG curriculum and at least 50% of PG seats in family medicine. The stated position of AFPI is that all medical graduates in India deserve a postgraduate qualification, faculty eligibility and the opportunity to become consultants in their own respective disciplines. There are less postgraduate seats as compared to UK and the USA because of underdeveloped family medicine in India. The vocation of primary care specialist should be developed to the fullest possible potential at par with other specialties.
Recognition of DNB Family Medicine by Medical Council of India/ Government of India
DNB family medicine, awarded by National Board of Examination (NBE) is a MCI recognized qualification since 1983, the year; NBE came into existence through an amendment in the MCI act. Family medicine exists at serial no 30 in the list of recognized specialization and post graduate qualification in the original notification of NBE creation dated 19th September 1983.
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Family Medicine in India: Recent developments:
Calicut Medical College Kerala has become first institute to start the MD family medicine program in India. Earlier only DNB family medicine training was available at National Board of Examination-affiliated institutions. Under PMSSY, all recently established AIIMS-like institutions have started the Department of Community and Family Medicine; which is a welcome change. AIIMS Bhopal has declared developing family medicine as one of its primary priorities. Information about family medicine seat availability in the DNB system can be obtained from following link: Click Here >