A cross-sectional survey on medical education needs of general practitioners and family medicine: Delhi, Himachal Pradesh and Tamil Nadu, India.

BACKGROUND: In India, most physicians pursue a specialist's degree resulting in a dearth of general practitioners (GPs). To provide primary care across populations and support universal healthcare coverage (UHC), there is a need to develop a core educational foundation for generalists and family medicine in undergraduate and post-graduate training.
METHODOLOGY: A cross-sectional survey was conducted as a part of a medical educational needs assessment (ENA) with a focus on family medicine. Respondents included practicing physicians, residents and medical students in Himachal Pradesh, Delhi and Tamil Nadu. Descriptive and bi-variate data analysis (Pearson's Chi square, independent t-tests and analysis of variance [ANOVA]) was performed to summarise data and determine significant differences between demographic groups of respondents.
RESULTS: Three hundred and sixty-one surveys were completed. From which, 80.7% (284) of respondents felt that family medicine would be beneficial/very beneficial to the Indian health system. Respondents were split over whether family medicine programmes should be integrated within the existing bachelor of medicine and bachelor of surgery (MBBS) programmes (149/42.5%) or created as a separate post-graduate level specialty (131/37.3%). Overall, 84.2% (292) and 85.4% (294) agreed/strongly agreed that family medicine would benefit specialists and decrease the health disparities. Challenges include lack of information about family medicine and patients' use of specialists for primary healthcare needs.
CONCLUSIONS: There was a positive response to expanding education for generalists and development of family medicine as a specialty in India. Mechanisms to support policies and programmes need to be further explored to ensure successful implementation across the country. Interest in skills-based courses can be an opportunity to provide GP and family medicine training while broader system-level changes are considered. Copyright:

Introduction

India continues to struggle to provide equitable healthcare access to its population and ranks 143 out of the 184 countries for health-related sustainable development goals.[1] The Indian medical education system has been fragmented into specialties with general practice not being recognised as a “career”.[23] As providers of comprehensive primary care, general practitioners (GPs) and family physicians can play a significant role for India's progress towards universal healthcare (UHC).[4] As a first step towards increasing equitable access to primary care, changes must occur within the medical education infrastructure to ensure that physicians are adequately prepared to work in primary and secondary healthcare settings.[5-7]

Materials and Methods

Ethics

Procedures followed were in accordance with the ethical standards of the study institutions’ ethical review boards and with the Helsinki Declaration of 1975, as revised in 2000. The protocol was approved by the Society for the Protection of Ethical Clinical Trials (SPECT) in New Delhi, India and the Institutional Review Board at the collaborating US-based health system. All research staff completed ethical training through the Collaborative Institutional Training Initiative (CITI, USA). Informed consent was obtained prior to data collection from all research participants. Data were not linked to respondent names or other identifying information.

Overview

The educational needs assessment (ENA) was an international collaboration including a large urban health system based in the United States of America and a hospital system based in New Delhi, India. The research team included principal investigators from each institution and local staff. The ENA used a mixed methods approach including: 1) compilation of secondary data resources on current policies and programmes related to general practitioner and family medicine education and practice in India; 2) qualitative interviews with policymakers, health administrators, medical faculty, and senior physicians; and, 3) development and implementation of a cross-sectional quantitative survey focused on medical education, family medicine, medical practices and policies, and Continuing Medical Education (CME). The current article is focused on the outcomes from the survey.

The overall objective of the medical education needs assessment (ENA) was to describe the current situation within medical undergraduate and post-graduate training programmes in India.[8] Specific aims of the survey were to: 1) identify knowledge, perceptions, and barriers related to expansion of family medicine and generalist education and practice; and, 2) identify short- and long-term steps to increase support for family medicine and GPs in medical education and public and private practice.

Research sites and population

Survey data were collected in New Delhi, Kullu and Mandi in Himachal Pradesh, and Vellore in Tamil Nadu [Figure 1]. The study was designed to ensure representation from a variety of regional and sociodemographic areas and a broad range of persons involved in medical education and practice. The survey respondents included medical faculty, practicing physicians in private and public facilitates, residents, and medical students.

Figure 1

Map of India. Available at: https://geology.com/world/india-satellite-image.shtml

Sampling strategy and sample size

Health facilities including hospitals, clinics, and medical schools were mapped within the targeted research sites. Utilising a stratified approach to include both private and public academic and medical facilities, study institutions were selected. We estimated a total of 1,200 medical students and 4,300 physicians in the assessment sites based on an average of 0.725 physician/1,000 population. With a 95% confidence level and.05 confidence interval, the sample size was calculated at 360.

Research instrument

The survey instrument was developed based on the specific aims of the study, secondary data from literature on medical education in India, and findings from the qualitative phase of the needs assessment. The survey instrument was piloted using a ‘cognitive interview’ approach to determine saliency of items to respondents, review wording of items, and appropriateness of the response options.[9]

Data collection and management

Eligible respondents were invited to participate in the interviews. Survey data were collected by Indian team members. All data were collected in English. Survey data were collected on Personal Digital Assistants (PDA tablets) using the REDCap (Research Electronic Data Capture) data entry system.[10] REDCap is a secure web-based application for building and managing online surveys and databases. Through REDCap, investigators at both the U.S. and Indian institutions had immediate access to the data as it was collected. This allowed for monitoring the data collection process and identifying issues in real time. Prior to data analysis, data were cleaned, scales were created, and descriptive data was used to screen for missing cases and outliers.

Data analysis

Descriptive data analysis was performed to summarise demographic characteristics of the respondents and numbers/percentages of responses to separate items. For continuous variables, means and standard deviations were calculated. Bivariate analysis including Pearson Chi square for categorical variables and independent t-tests and ANOVA for continuous variables were used to assess significant differences in responses between groups including research site, education of respondent, and gender. Data were analysed using SPSS version 25.

Results

Demographics

A total of 361 surveys were completed. Over half of respondents were male (207/57.3%). Mean age was 27.3 years (SD 8.7). Approximately one-third of respondents had post-graduate degrees (e.g. MD, MS, DNB, DM) and approximately one-third were students. [Table 1] A larger percentage of respondents from Vellore (50/62.5%) were students compared to Himachal Pradesh (24/35.3%) and Delhi (58/27.2%) [χ2 = 31.24; ].

Table 1

Cross Sectional Survey Demographic data (n=361)

Site	New Delhi	59.0% [213]
	H. Pradesh	18.8% [68]
	Tamil Nadu	22.2% [80]
Gender	Male	57.3% [207]
Age [Mean]		27.3
degree	MBBS	69.3% [250]
	MD	13.9% [50]
	MS	8.3% [30]
	DNB	3.9% [14]
	DM	1.9% [7]
	Other	2.8% [10]
Current Employment	Government agency	0
	Medical school	46.8% [169]
	Public hospital	41.0% [148]
	Private hospital	9.4% [34]
	Public clinic	1.1% [4]
	Private clinic	1.7% [6]
Current position/status	Administrator/Division Head	1.1% [4]
	Medical Registrar/Officer	8.2% [30]
	Professor	1.7% [6]
	Practitioner	8.9% [32]
	Resident	16.0% [58]
	Intern	23.2% [84]
	Student	36.5% [132]

Medical education

Survey respondents were asked a series of questions about their experience and perceptions of various aspects of medical education. Over 80% (289) attended a public medical school and 7.8% (28) had received some education outside of India. Over 20% (73) had participated in a rural posting and 12.1% (43) had experience working in a Primary Health Centre (PHC).

Overall, 38.8% (139) felt their education 'somewhat prepared’ them for practice and 61.2% (219) felt that they were prepared/very prepared. However, respondents with MBBS degrees (127/51.0%) compared to those with post-graduate education (92/84.4%) were less likely to state that they were prepared/very prepared (χ2 = 40.48; ).

Respondents rated their education experiences in relation to theoretical knowledge (247/68.8%), practical experience (254/70.8%) and access to non-medical courses [e.g. medical psychology] (78/27.2%) as ‘good’ or ‘very good/excellent’. Utilising a scale of these three items (”educational experience”), those respondents with MBBS rated their education experience lower compared to respondents with graduate degrees (t = -2.00 [CI -0.788—0.007]; ). And while 69.8% (249) of respondents agreed/strongly agreed that rural postings were an essential part of undergraduate medical education, those respondents with a MBBS (189/76.5%) were more likely than those with post-graduate degrees (60/56.6%) to agree/strongly agree (χ2 = 14.18; ). In addition, 57.8% (200) of respondents agreed/strongly agreed that medical schools should actively recruit more students from rural areas of India.

Family medicine

Overall, 15.2% (54) of respondents stated they were not familiar with family medicine; however, 80.7% (284) felt that family medicine would be beneficial or very beneficial as a part of Indian medical education. Respondents were closely split over whether family medicine programmes should be part of existing MBBS programmes (149/42.5%), created as a separate post-graduate level specialty (131/37.3%), or included in both MBBS and post-graduate education (71/20.2%).

Respondents were very favourable towards expansion of family medicine within the Indian medical education and health system. Overall, 84.2% (292) and 85.4% (294) agree/strongly agreed that family medicine would benefit specialists and would decrease health disparities. Less than half of respondents felt that urban (151/43.1%) and middle- and higher-income residents (168/48.0%) would not have confidence in a family medicine physician. Respondents overwhelmingly stated that there is a need for awareness campaigns about family medicine for health providers (343/96.3%) and communities (345/97.2%).

Medical practices and policies in India

Overall, 65.0% (192) of respondents agreed/strongly agreed that current government policies would not support development of family medicine. All respondents agreed/strongly agreed that primary, secondary, and tertiary care systems in India need to be improved to provide better access to care. And, a vast majority also agreed/strongly agreed that the Indian health system needs more trained medical staff (352/98.9%), improved health facilities (355/99.4%), and up-to-date medical equipment (354/99.2%), and that practicing physicians need to be a part of healthcare decision-making at the National level (349/97.7%). Respondents with post-graduate degrees were more likely to strongly agree that there is a need for infrastructure changes to increase the number of physicians working in rural areas and that health priorities are determined by political and economic pressures. MBBS respondents were more likely to strongly disagree that the National government provides adequate support for healthcare [see Table 2].

Table 2

Percent responses to survey items related to medical practice, health infrastructure and policies

Medical Practice, Health Infrastructure and Policies		Strongly Agree	Agree	Disagree	Strongly Disagree	X2/P
Current government policies would not support development of Family Medicine in India.	MBBS	9.2% (19)	54.6% (113)	34.8% (72)	1.4% (3)	X2=5.17 P0.160
	Post Grad	5.7% (5)	62.5% (55)	27.3% (24)	4.5% (4)
Infrastructure changes (e.g., roads, schools) are essential to increasing physicians’ willingness to work in rural areas.	MBBS	44.6% (111)	53.8% (134)	1.6% (4)	0	X2=10.79 P0.013
	Post Grad	60.6% (66)	36.7% (40)	1.8% (2)	0.9% (1)
The National government provides adequate support for healthcare in India.	MBBS	2.4% (6)	25.8% (64)	60.1% (149)	11.7% (29)	X2=16.26 P0.001
	Post Grad	10.2% (11)	14.8% (16)	56.5% (61)	18.5% (20)
More practicing physicians need to be a part of healthcare decision making at the National level in India.	MBBS	47.0% (116)	51.8% (128)	0.8% (2)	0.4% (1)	X2=6.22 P 0.101
	Post Grad	53.6% (59)	41.8% (46)	3.6% (4)	0.9% (1)
Healthcare priorities are determined by political and economic pressures.	MBBS	35.3% (85)	52.7% (127)	11.2% (27)	0.8% (2)	X2=12.08 P0.007
	Post Grad	50.5% (52)	46.6% (48)	1.9% (2)	1.0% (1)
The primary, secondary, and tertiary care system in India needs to be improved to provide better access to care.	MBBS	50.4% (125)	49.6% (123)	0	0	X2=1.09 P0.298
	Post Grad	56.4% (62)	43.6% (48)	0	0
Physicians need to receive more equitable remuneration.	MBBS	29.1% (71)	66.4% (162)	4.5% (11)	0	X2=6.40 P0.094
	Post Grad	39.4% (43)	59.9% (62)	2.8% (3)	0.9% (1)
The Indian health system needs more trained medical staff.	MBBS	44.9% (111)	53.4% (132)	1.6% (4)	0	X2=1.80 P0.406
	Post Grad	45.0% (49)	55.0% (60)	0	0
In general, the Indian health system needs improved health facilities.	MBBS	57.5% (142)	42.1% (104)	0.4% (1)	0	X2=5.17 P0.160
	Post Grad	54.5% (60)	44.5% (49)	0.9% (1)	0
In general, the Indian health system needs up-to-date medical equipment	MBBS	57.1% (141)	41.7% (103)	1.2% (3)	0	X2=5.17 P0.160
	Post Grad	57.3% (63)	42.7% (47)	0	0

MBBS=Bachelor of medicine and bachelor of surgery

Continuing Medical Education (CME)

Overall, 87.7% (308) of respondents agreed/strongly agreed that CME courses were available to them at their place of work. Respondents in Delhi (172/83.9%) were less likely to report availability of CME than respondents in Himachal Pradesh (63/92/7%) and Tamil Nadu (73/93.6%) [χ2 = 54.43; ]. Students (119/92.3%) compared to practicing physicians (189/85.2%) were also more likely to report available CME programmes [χ2 = 17.04; ]. When asked about five specific course topics, the level of perceived need was highest for trauma/injury (344/96.3%) and critical care (336/94.1%). However, most respondents also stated that diabetology (290/81.5%), non-invasive cardiology (175/77.3%), and disaster medicine (270/76.1%) were needed areas for CME. There were significant differences by site for perceived usefulness of five areas for CME training [Table 3]. The preferred method for delivery of CME was live didactic sessions compared to online modules. Female respondents and post-graduate respondents were more likely to prefer live didactic sessions. Preferred days and time and frequency of CME course offerings varied by place [Table 4].

Table 3

Percent responses related to perceived usefulness of continuing medical education topics by site

	Site			X2/P
	Himachal Pradesh	Delhi	Tamil Nadu
Critical Care	92.6% (63)	92.8% (194)	98.8% (79)	X2=11.46 P0.075
Trauma and Injury	98.6% (67)	94.2% (197)	100.0% (80)	X2=12.43 P0.014
Diabetology	82.4% (56)	85.6% (179)	69.6% (55)	X2=30.84 P0.000
Non-invasive Cardiology	85.3% (58)	80.3% (168)	62.0% (49)	X2=25.21 P0.000
Disaster Medicine	74.0% (49)	83.2% (174)	60.3% (47)	X2=23.97 P0.001

Table 4

Percent responses to items related to delivery of continuing medical education (cme) programmes by gender, education, and site

	GENDER		EDUCATION		SITE
	MALE	FEMALE	MBBS	POST-GRAD	HIMACHAL PRADESH	DELHI	TAMIL NADU
Preferred Method of Delivery
Live didactic sessions	74.3% (150)*	83.1% (128)	75.0% (186)*	85.2% (92)	77.9% (53)	79.3% (165)	75.0% (60)
Online modules	43.5% (87)	36.8% (56)	39.8% (98)	42.5% (45)	44.8% (30)	37.0% (77)	46.8% (36)
Preferred Time
Daytime (Monday to Friday)	37.6% (76)†	52.3% (80)	40.2% (99)*	52.3% (57)	35.3% (24)	44.2% (92)	50.6% (40)
Evenings (Monday to Friday)	42.5% (85)*	29.6% (45)	37.8% (93)	34.9% (37)	26.5% (18)	41.0% (84)	35.4% (28)
Weekends	56.9% (111)	49.7% (75)	56.6% (137)	47.1% (49)	68.7% (46)‡	43.8% (88)	66.7% (52)
Preferred Frequency of Sessions
Once a week	30.3% (61)	36.6% (56)	35.8% (88)	26.9% (29)	26.5% (18)*	32.0% (66)	41.3% (33)
Once a month	55.2% (111)	52.3% (80)	51.6% (127)	59.3% (64)	52.9% (36)	58.7% (121)	42.5% (34)
Once every 3 months	14.4% (29)	11.1% (17)	12.6% (31)	13.9% (15)	20.6% (14)	9.2% (19)	16.3% (13)

*P<0.05; †P<0.01; ‡P<0.001

Discussion

This medical ENA documents current experiences with the Indian medical education system, perceptions of family medicine, potential facilitators and challenges to expanding the role of generalists and family medicine practitioners to support primary care, and interests in relation to content and delivery of continuing medical education programmes.

Overall, there was a very positive response to family medicine being implemented in India; however, what remains an issue is how to integrate family medicine into the current medical education system of MBBS programmes and post-graduate specialist training. If family medicine were to be implemented through the MBBS program, there would clearly be a need for measures taken to improve that educational experience for students as MBBS physicians were more likely to feel that their education did not fully prepare them for practice. However, MBBS physicians more highly valued experience of working in rural posts.

The benefits of general practice or family medicine were recognised by respondents. At this time, specialists are overwhelmed by patient load and often do not have adequate time with each patient. Respondents felt that family medicine could benefit specialists and at the same time also decrease disparities in access to healthcare in India. At the societal level, generalists and family medicine can support India's goal for UHC and improve healthcare overall. While less than half of respondents felt that urban and/or middle- and higher-income individuals might not have confidence in family medicine practitioners, this still points to a significant issue in terms of improving use of primary care and decreasing use of specialists among certain population groups. There remains an urgent need to garner support for family medicine among policy makers, health practitioners, and the general public.

The development of family medicine, changes in medical education, and the institutionalisation of strong primary care in India need to be supported at the highest governmental levels. The survey data suggest that MBBS physicians both perceived less need for structural change but also perceived a general lack of structural support for healthcare. While seemingly contradictory, these data could indicate some level of scepticism as to whether structural change can make a difference.

CME can be an opportunity to provide family medicine training while broader system-level changes are being considered. Restructuring the health system and developing and implementing medical curricula are medium- to long-term goals. However, in the interim, steps can be taken towards improving primary care practice and supporting medical students and physicians. There was strong demand for CME courses to enhance knowledge and improve practice. Unfortunately, CME courses are not equally available across regions of India and issues such as lack of space and time relegated for CME need to be addressed, particularly outside of urban areas. Data also indicate different levels of interest in specific topics by region – this is important to consider as CME and other training programmes are developed. And while long-distance learning is one way to alleviate some of this lack of access, many physicians prefer face-to-face courses. This could be due to inexperience with long-distance learning or the need for high quality long-distance learning modules and programmes. There could also be a role for integrated face-to-face and long-distance learning through training-of-trainers or short in-person workshops followed by web-supported educational modules. Some pilot programmes indicate that India is well placed to take advantage of long-distance learning opportunities such as telemedicine.[1112]

The findings from this study are very timely – in early July 2018, citing the importance of family medicine, the Supreme Court of India granted the Academy of Family Physicians of India permission to approach the Medical Council of India (MCI) to request amending the ‘Post Graduate Medical Education Regulations 2000’ to start new post graduate courses or create post graduate seats in the discipline of family medicine or general practice.[13] However, subsequently on 26 September 2018, a bill was passed to replace the Medical Council of India with a National Medical Commission.[14]

This dissolution of MCI has been considered as a major step to bring profound change in healthcare in India. Data from the current needs assessment suggest that improvements in generalist education and expansion of family medicine should be a part of these reforms.

Limitations of the study include that the participants were not chosen randomly but by their availability. This could bias the data in terms of who made themselves available for the survey. Given the diversity and size of India, these data may not be generalizable beyond the sites where the study was conducted. However, these data provide important information to support generalist education and broader introduction of family medicine within medical schools in India.

Conclusion

The significance of generalists and family physicians as providers of comprehensive primary care is a crucial evolution required for India's progress towards Universal Health Coverage as deliberated by the various stakeholders who participated in the study. To date, irrespective of efforts made by the National Rural Health Mission (NRHM), the Indian Medical Association, and the National Board of Accredited Examination, post graduate diplomas in family medicine have not been recognised by academic institutions. This issue can be resolved with due diligence by approving family medicine as a specialty. Such a step will provide a new cadre of physicians who can support primary care, decrease the patient load for other specialists, decrease health costs, and provide a holistic approach to disease prevention and treatment. It is only by moving in this direction that India can achieve the Sustainable Development Goal (#3) – ‘Ensure healthy lives and promote well-being for all at all ages’ – and make accessible healthcare available to its diverse population.[15] Studies conducted in developed nations have shown that if reasonable healthcare reforms are coupled with a greater supply of primary care physicians as per the population ratio, the mortality rate can be lowered[16] However, 60% of primary health centres in India have only one doctor, while about 5% have none, according to the Economic Survey 2018-19, tabled in the Parliament on July 4, 2019.[17] This is more alarming for India as reports show that the infant mortality rate (IMR) and maternal mortality rate (MMR) are higher in PHC's where doctors are not available.[18] This situation can be stabilised if a well-trained cadre of medical doctors, including family physicians, are placed in these deserted health centres with upgraded facilities. This will be one step towards addressing continued high rates of IMR and MMR in underserved populations.

The most recent advancement made by the newly elected MCI is the release of a fresh MBBS curriculum titled “Competency-based UG Curriculum for the Indian Medical Graduates.” This curriculum is to be implemented beginning in August 2019 across India.[19] Unfortunately, the new MBBS curriculum has not only ignored the recommendations of the Government of India's National Health Policies of 2002 and 2017, but it seems to have completely eliminated the very discipline of family medicine from the medical education system of India.[20] If this scenario is not corrected as soon as possible, India's system will be severely limited in the long run. Our study data indicate respondents’ favourable perceptions and attitudes regarding family medicine and the importance of the discipline to the Indian medical education and overall health systems. These data can be used in conjunction with other studies in India and the region to provide evidence required by policy makers and medical education administrators to revaluate the value of family medicine in an era of UHC.

Criteria for inclusion

The manuscript has been read and approved by all authors. All authors meet the requirements for authorship. All authors believe that the manuscript represents honest work.

Financial support and sponsorship

Grant funding to conduct this project was provided by Pfizer Independent Grants for Learning and Change.

Conflicts of interest

There are no conflicts of interest.