Need of Department of General Practice / Family Medicine at AIIMS (All India Institute of Medical Sciences): Why the apex medical institute in India should also contribute towards training and education of general practitioners and family physicians.

Family medicine or general practice is the practicing discipline of the majority doctors in India, however formal academic departments of general practice (or family medicine) do not exist in India, as it is not a mandatory requirement as prescribed by the Medical Council of India; the principal regulator of medical education. Currently India has capacity to produce more than 60,000 medical graduates per year, majority of whom are expected to become general practitoners or primary care doctors without under going any vocational training in general practice or family medicine. The 92nd parliamentary standing committee report (on health and family welfare) of the Indian Parliament recommended that Government of India in coordination with State Governments should establish robust postgraduate programs in Family Medicine and facilitate introducing Family Medicine discipline in all medical colleges. This will not only minimize the need for frequent referrals to specialist and decrease the load on tertiary care but also provide continuous health care for the individuals and families. The authors concur with the parliament of India and strongly feel that "Family Medicine" (community-based comprehensive clinical practice) deserves dedicated and distinct department at all medical colleges in India in order to availability of qualified medical doctors in the community-based health system. AIIMS, New Delhi, along with other newly established AIIMS, should rise to their foundation mandate of supporting excellence in all disciplines of medical science and to this historic responsibility; and not just remain an ivory tower of tertiary care based fragmented (into sub specialties) hospital culture.

AIIMS (All India Institute of Medical Sciences) and Family Medicine / General Practice

The AIIMS (All India Institute of Medical Sciences) New Delhi was created in 1956, as an autonomous institution through an Act of Parliament, to serve as a nucleus for nurturing excellence in all aspect of health care. AIIMS was established as an institution of national importance by an Act of Parliament with the objects to develop patterns of teaching in Undergraduate and Post-graduate Medical Education in all its branches so as to demonstrate a high standard of Medical Education in India; to bring together in one place educational facilities of the highest order for the training of personnel in all important branches of health activity; and to attain self-sufficiency in post-graduate medical Education. To develop a pattern of teaching in undergraduate and postgraduate medical education in all its branches so as to demonstrate high standard of medical education to all medical colleges and other allied institutions in India and to bring together in one place educational facilities of the highest order for the training of personnel in all important branches of health care. Teaching and research are conducted in several disciplines except that of family medicine/general practice.

The Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) scheme was announced on the 15th August, 2003 with the objective of correcting the imbalances in the availability of affordable or reliable tertiary level health care and also for improving facilities for quality medical education in the States. In pursuance of the said scheme, initially six All-India Institute of Medical Sciences (in addition to the AIIMS, New Delhi established under the AIIMS Act) one each in the States of Bihar (Patna), Chhattisgarh (Raipur), Madhya Pradesh (Bhopal), Odisha (Bhubaneswar), Rajasthan (Jodhpur) and Uttarakhand (Rishikesh) were set up up, broadly similar to the existing AIIMS, New Delhi. The Central Government has also taken a decision to set up in future (in the second phase) two more All-India Institute of Medical Sciences broadly similar to the existing AIIMS, New Delhi.

“Family Medicine” – is the academic discipline, medical specialty, and core domain of primary care physicians; it has been recognized as a distinct and separate medical specialty in India for the past three decades on papers. “Family Medicine” is and termed as “General Practice” discipline in the Europe for historical reasons. Family physicians or general practitioners play vital role in providing holistic and affordable health care to people. In India, there is an acute shortage of family doctors who are the experts of primary care, despite a pressing unmet population need. This crisis has resulted primarily from severe shortage of postgraduate training seats in contrast to countries like USA where post graduate residency seats are almost double the number of undergraduate medical seats; which causes lot of struggle, hardship, frustration, and a career bottleneck for newly qualified doctors. The community-based “Family Medicine” postgraduate residency/capacity building should ideally fill this gap and allow more doctors to pursue “Family Medicine” as professional avenue, thereby facilitating horizontal integration of newly qualified doctors, into the chronically starved health system. Despite repeated calls by respective National Health Policies (2002 and 2017), the development of “Family Medicine” specialty, in general, has remained unsatisfactory in India. Department of family medicine or general Practice does not exist at the apex medical institute of India – The All India Institute of Medical Sciences (AIIMS), New Delhi.

Why Family Medicine?

The Department-related Parliamentary Standing Committee on Health and Family Welfare (The Parliament of India) its 92nd report has stated following in 2016:

The Committee has also been informed by an expert during his evidence that the medical education system in the country has been devised in such a way that the concept of Family Physician has been ignored.

An expert who deposed before the Committee in her postevidence written submissions stated that “the target for the future should be to have PG opportunities for all medical graduates. To do this, the target should be to make 30%–50% of all seats in Family Medicine. Although the specialty exists on the Medical Council of India (MCI) list, the present rigid MCI framework (30 beds, separate department, 3 faculty members, etc.) has not allowed colleges to start this course. Furthermore, except in practice, there are few career options and young people are biased by the available career options when they opt for a specialty. The Central and State Governments should take a policy decision that wherever MBBS level posts are advertised, MD in Family Medicine will be preferred with a substantial salary advantage. Over time, the Medical Officers at all levels will be postgraduates, and this will enhance the level of primary care and decrease the load on tertiary care. Without this, Family Medicine is not going to get established.”

The Committee agrees with the suggestion that there is an imperative need to promote PG degree in Family Medicine because Family Medicine combines a broad set of clinical competencies, and therefore, family physicians are more equipped to manage most of the medical problems encountered at the primary level. The Committee recommends that the Government of India (GOI) in coordination with State Governments should establish robust PG programs in Family Medicine and facilitate introducing Family Medicine discipline in all medical colleges. This will not only minimize the need for frequent referrals to specialist and decrease the load on tertiary care but also provide continuous health care for the individuals and families.[1]

In the backdrop of global consensus on “Universal Health Coverage” several policy documents and directives of GOI had called for rapid revival of the holistic care concept of “Family Medicine.” Competent multi-skilled specialists in “Family Medicine” are optimally suited to be recruited as specialists at the Community Health Centres (CHCs) and Subdivisional Hospitals (SDH). An estimated 75 percent posts of the specialist posts are CHC are presently lying vacant in public sector health services across India.[2] Further, the concept of “Family Medicine” has received a strong emphasis in several policy discussions of GOI including the National Health Policy 2002 and National Health Policy 2017.[34] The theme of “Family Medicine” was previously supported by Mehta Committee Report, Prime Minister's National Knowledge Commission, NRHM taskforce on human resource development, Planning Commission's Steering Committee on Health in 12th National Plan (2012–2017).[5] According to a planning commission paper, India needs to produce 15000 family doctors (Family Medicine specialists) per year by 2030.[6]

In May 2013 Health Secretary, Department of Health and Family Welfare, Ministry of Health and Family Welfare (MOHFW), the GOI had advised all state across the country to start postgraduation in “Family Medicine” toward strengthening of specialist services at CHC and SDHs under the broader scheme of “Universal Health Coverage.”[7]

The GOI is promoting the induction of “Family Medicine” through Department of Community Medicine and Family Medicine under newly established the All India Institute of Medical Sciences (AIIMS). Earlier Family Medicine training was popularized through 3-year full-time Diplomate National Board (DNB) programs conducted by National Board of Examinations under Ministry of Health and Family Welfare.

Distinction of “family Medicine”

“Family Medicine” is recognized as a separate discipline with statutory status granted by notification under MCI act. Postgraduate regulation of MCI 2000 also clearly maintains “Family Medicine” as a distinct specialty from “community medicine and General Medicine”. As per the regulation for medical teacher's eligibility; persons holding MD qualification in “Family Medicine” or “General Medicine” are eligible to become faculty for the Department of Family Medicine.[8]

The National Board of Examinations under Ministry of Health and Family Welfare pioneered DNB (Family Medicine) training toward award of DNB long back, even before MD (Family Medicine) course started in India, and Family Medicine postgraduate training program is recognized by the amendment in MCI act/MOHFW notification and statutory in status since 1983.[9]

The National Board of Examinations as well has defined “Family Medicine” as separate medical discipline from “community medicine.” The National Board of Examination defined “Family Medicine” as a medical specialty concerned with providing comprehensive care to individuals and families by integrating biomedical, behavioral, and social sciences; academic discipline to include comprehensive health-care services, education, and research.[10]

“Report and recommendations” from the “National Consultation on Family Medicine Programme” 2013 convened by National Health System Resource Centre, National Rural Health Mission, and Ministry of Health and Family Welfare GOI also called for strengthening the Family Medicine program in India.[11]

Community Medicine Versus Family Medicine: Conventional Difference

In the international academic arena, the “Courses and Curriculum for Public Health” has equivalence to “community medicine” training in India. At the global level “Courses and Curriculum for General Practice/Family Practice” has equivalence to “Family Medicine” training in India.

Training in “Family Medicine” is patient-centered comprehensive clinical care across all age groups and organ systems, in contrast to training on the population-based program-oriented public health approach in “community medicine.” “Family Medicine” training provides person- and family-based clinical competency, consultation skills, and clinical research spread over cradle to grave in primary care in contrast to imparting the managerial skills for epidemiological research and national program in “community medicine.”

The training in “Family Medicine” demands expertise in catering womb-to-tomb patient care needs in both acute and chronic illnesses including emergencies and palliative care of all spectrums. Capacity building in “Family Medicine” needs to be supported by outpatients (including prehospital outreach care) and inpatients facilities at all levels to provide skills and competency to cater comprehensive health care at individual patient level.

Family Medicine at Department of “community Medicine and Family Medicine”

“Family Medicine” and “community medicine” are two separate and distinct medical specialties as per the Post Graduate Regulation of MCI 2000. However, these two departments have been combined into one at newly established AIIMS institutions. Undergraduate (UG) and postgraduate (PG) course curriculum for Family Medicine at the newly conceptualized Department of Community Medicine and “Family Medicine” (CMFM) at six newly established AIIMS is currently under preparation. At these departments faculty (including senior residents) with formal training and expertise solely in “community medicine” specialty have been recruited till date as revealed through information received under Right to Information Act. Faculty or “senior resident” with a core competency and holding recognized qualifications in “Family Medicine” have not been recruited at any of these newly established AIIMS.

Historically, the role of community medicine departments and faculty in India has been somewhat different from what it may appear in many parts of the world. It is neither purely “Public health” in spirit nor “Family Medicine” in clinical practice. At the new AIIMS across India established recently, all professionals trained only in “community medicine” have engaged themselves in drafting UG and PG courses and curriculum in the prototype of that of the Centre of Community Medicine (CCM), AIIMS, New Delhi. Yet, AIIMS, New Delhi, does not have a formally declared “Family Medicine” department or “Family Medicine” components embedded in their UG or PG education by CCM, AIIMS. Therefore, it is imperative that there is a clear gap in the “AIIMS, New Delhi CCM model” regarding “Family Medicine component of training.” Further, in the absence of any “Family Medicine trained faculty” in any of the new AIIMS, the faculty members will clearly fail to justify their role to be protagonist of “Family Medicine” in framing UG and PG courses and curriculum for the departments of CMFM at the six newly established AIIMS.[12]

The current expertise of existing resource pool in CMFM needs additional and continuous “capacity building” for “Family Medicine.” In both, the expert group meets, namely, AIIMS, Bhubaneswar (January 2013) and CMFM Conclave, Delhi (December 2013), recommendations were in this direction with optimum national and international collaboration.[13]

Newly established AIIMS institutes are also trying to establish “School of Public Health” as well. It is not clear, however, that how only with professional background of “community medicine” faculty would be able to develop (a) Department of Community Medicine and Family Medicine and (b) School of Public Health.

Initially, we welcomed Family Medicine being hosted with community medicine department; however, now we have apprehension that due justice may not be done to the development of Family Medicine and primary care education at AIIMS institution.[14]

Family Medicine at Other Medical Colleges in India

Although it is not a mandatory requirement by MCI, Christian Medical College, Vellore, is running Department of Family Medicine with “Family Medicine” experts trained in Family Medicine holding DNB (Family Medicine) and other international qualifications. Government Medical College, Calicut, has started the first MD (Family Medicine) with approval of MCI after pooling faculty from specialties.

International Status of Family Medicine

“Family Medicine” is an internationally recognized specialty for decades. “Regional Scientific Working Group on Core Curriculum on Family Medicine” under the aegis of the WHO Regional Office for SE Asia, New Delhi, had recommended to member countries as follows:[15]

Family Medicine should be recognized as a separate specialty in medicine

Immediate steps should be taken to incorporate the recommended core curriculum in Family Medicine into the existing basic medical curriculum

Department of Family Medicine should be established whenever/wherever possible

Provision should be made for training of teachers for Family Medicine

PG specialization in Family Medicine to be established wherever possible.

“Family Medicine” was recognized as a distinct broad specialty in the USA, UK, and most of developed countries long back in the sixties. These countries have strengthened “family Medicine” discipline in a quest to develop quality primary care workforce as an essential requirement toward regulating cost of medical services delivered though their respective universal health coverage (NHS of UK is an example).

Historical Development and Evolution of Other Specialties in India

Till the seventies in the past century, “Pathology” and “Microbiology” was taught from a single “Department of Pathology and Microbiology” and university examinations were also conducted as a single paper in UG/PG named “Pathology” and “Microbiology.” “Pediatrics” was part of “UG Courses and Curriculum for Medicine;” later on, these “Siamese twin” specialties have been separated. Now we should agree that Faculty of “Medicine” is not authorized to formulate “Courses and Curriculum” for “Pediatrics;” comparable situation is true for Faculty in “Pathology” not to formulate “Courses and Curriculum” for “Microbiology.” Similarly, Faculty of “Surgery” dare not to formulate “Courses and Curriculum” for “Orthopedics” after they have been separated by regulatory bodies. So logically, “Courses and Curriculum” for “Family Medicine” should have been formulated by persons who have been formally trained in the core competency of “Family Medicine.”[16]

Future Direction: Important Considerations

More than a thousand DNB (Family Medicine) doctors qualified from the National Board of Examinations are available in the health system. Their expertise should be given due consideration by recruiting them at the Departments of Community Medicine and Family Medicine at six newly established AIIMS under PMSSY from MOHFW, GOI. Induction of persons holding international qualifications such as MRCGP (UK) or Board Certification in “Family Medicine” from the USA for faculty positions should also be facilitated. As apparent from the past recruitment advertisements for at least at two institutes (a) AIIMS, Jodhpur and (b) AIIMS, Bhubaneswar indicates that persons holding DNB/MD Family Medicine qualification are not even been considered eligible toward faculty or senior resident positions. Additionally honorary lectureship/ faculty position needs to be awarded to practicing family physicians possessing requisite experience at accredited academic family practice sites.

The training of health care at all levels has metamorphosed from “knowledge-based” to “skill-based” approach. Without any formal or informal training in “Family Medicine,” it will be considered inappropriate to allow the faculty trained only in “community medicine” to formulate “Family Medicine” component for UG Courses and Curriculum at Departments of CMFM at six newly established AIIMS. This is necessary, so that the trainees of these departments identify themselves as family physicians or family doctors.

We urgently call decision-makers to formulate a roadmap of intake of “core faculty members” who are unambiguously trained in “Family Medicine.” This is required to do justice to the stakeholders of teaching and training of UG as well as postgraduate students at the Departments of Family Medicine. AIIMS, New Delhi, needs to appreciate “Family Medicine” (primary care) as a priority and should start department of Family Medicine. Simultaneously, all other medical colleges in India need to start a distinct departments of Family Medicine.

Without support and rectifications in the provisions of Medical Council of India, this cannot happen. The GOI, MOHFW, and respective state governments need to frequently reflect back to the regulators of medical education about their respective health system needs and health policies. Health system development and human resource in health can no longer remain captive of professional monopolies leading to adverse impact on population health.

Disclaimer

The opinions expressed in this article are solely of the authors and should not be attributed to any institution/organization; they have been affiliated in the past or at present.