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FAMILY PHYSICIAN AND FAMILY MEDICINE - The Concept of Primary Care Physician, Specialist of Minor Diseases/Ailments, Mini Specialist Concept

VJ Ruparel

National Professor of Family Medicine-IMA-CGP. Examiner for FCGP and DNB (Family Medicine), Family Physician, Colaba, Mumbai 400 005.

THE ORIGIN OF FAMILY MEDICINE

The origin of family medicine can be traced to the evolution of mankind but, the speciality as we know today, a branch of allopathic medicine began its roots in early 19th century in United Kingdom. During that period the health care was practised by,

(a) "The Physicians"

Learned men, who had graduated from universities. They looked after the health of wealthy population, did not dispense medicine, they did not mix freely with other health professionals and labour class of society. They did not do any surgery. They formed Royal College of Physicians.

(b) "The Craftsmen, Barbers, Carpenters" etc.

They practised the art of surgery. They had formed Barbers Society which later became Royal College of Surgeons.

(c) "The Apothecaries or Tradesman"

They had ancestral knowledge of medicine or had worked as apprentice with senior colleague. They sold drugs and catered to the middle and the lower class of society. They later became general practitioners. Apothecaries Act was passed in 1915, which made it compulsory for all apothecaries to undergo 5 years of apprenticeship - covering Anatomy, Physiology, Materia Medica and Clinical Medicine. After appearing for the examination they were awarded Licentiate of Society of Apothecaries (L.S.A). Most of them also underwent MRCS (Membership of Royal College of Surgeons) examination and an examination in midwifery. All these 3 together equals MBBS of today. "Lancet" coined the term General Practitioner for them.

Early 20th Century was the beginning of golden era of general practice. The medicine was practised as a blend of Science and Art. There were few general practitioners, and fewer specialists. The general practitioners were known as "Family Doctor". (From Latin Doctor, meaning to withdraw from within, to educate). In India we inherited the British system (Allopathy, Modern Medicine) during British Rule.

THE AGE OF SPECIALISATION

Fragmentation in medical care had begun in 1892 with beginning of age related speciality paediatrics in Europe. But the momentum picked up in 1930. Midwifery and surgery combined gave speciality of Obstetrics and Gynaecology, further specialisation and fragmentation of medical care started.

(a) Organ system wise e.g. ENT, Ophthalmic.

(b) Disease wise e.g. Rheumatology.

(c) Symptom wise e.g. Pain Clinic.

(d) Time bound e.g. Emergency Care.

(e) Procedure related e.g. Endoscopy

(f) Part of organ e.g. Cornea specialist, Lens specialist and Retina speciality in Ophthalmology.

With specialisation and fragmentation still increasing, high technology medical care, is becoming impersonal. There is dissatisfaction in the society and the result is growing number of medico-legal cases. Doctor-society conflict are rising. The Society has begun to feel the need of good, qualified Family Physicians.

REVIVAL OF FAMILY MEDICINE A PRIMARY HEALTH CARE SPECIALITY

• In 1963, Indian Medical Association started a College of General Practitioners on the lines of Royal College of General Practitioners of England and Canada.

• In 1966, formal training for family physicians was enacted by law in USA. It was soon followed by similar provisions in Canada, Australia and other European countries.

• In 1977, FCGP (Fellowship of College of General Practice) examination was started by Indian Medical Association’s college of General Practitioners.

• In 1977 MNAMS (Membership of National Academy of Medicine) examination in general practice was started, it was later changed in 1982 to DNB (Diplomate of National Board) in Family Medicine.

 At home in Mumbai, the first DNB in family Medicine was acquired in Mumbai in 1992.

• In 2000, today, there are more than 100 doctors with FCGP qualification in Mumbai. 25 doctors with DNB (Family Medicine) Qualification.

HEALTH CARE PROFESSIONALS - Definitions and Health Care Differences

1. General Practitioner

A doctor who possess a basic MBBS qualification or equivalent from other pathies, offers primary health care to the individuals of any age or sex with any health or health related problem, medical, surgical or social. He has to compete with graduates of other systems of medicine and are dispensing allopathic drugs without basic understanding.

2. Specialist/Consultant

A doctor who after MBBS trains further and acquires post graduation qualification MS or MD. He normally restricts his practice either by age e.g. Paediatrics, Internist or Geriatrics; by sex Gynaecologist or by technique e.g. Surgeon. These group of doctors serve the purpose of super generalist to the target population. But they differ in that, they provide an episodic care mostly in complicated and unusual cases in a hospital setup.

3. Super Specialist

A group of doctors who have trained further after basic post-graduation and have further specialised in organ system, part of organ system or have mastered a specialised technique. They work in highly specialised centres and offer hitech medicine to select population.

4. Community Medicine Specialist

A doctor who after acquiring a basic graduate degree (MBBS) specialises in public health. He is a planner for health care of community, mainly looks after the health care needs of community, society, nation or world as per his posting. He does not offer individualised care.

5. Family Medicine Specialist/Family Physician

After basic graduation, he trains further and acquires a post-graduate qualification either FCGP or DNB (Family medicine). He offers a specialised care to the individuals. He is trained in family dynamics. Family is a smallest unit of society. He needs to be an internist and community Medicine specialist rolled into one. Like general practitioners he also offers primary health care to individuals of any age or sex with any health or health related problem. He is a doctor of the family.

To give you an example of how the health care differs viz. Tuberculosis. General Practitioner willdiagnose tuberculosis and initiate treatment. He will refer a complicated case to a physician, who in turn may refer to surgeon or a tuberculosis specialist. A family medicine specialist will also initiate treatment. He may manage minor complications, but his other role is preventive, he will initiate the family screening for tuberculosis in that patient. He will advice BCG to the non-immunised children in that family.

I have given an example of a very common disease. Thus family physician offers a comprehensive mode of treatment including preventive, curative, supportive and rehabilitative encompassing all aspects of the disease in tune with the WHO definition of health.

TEN PRINCIPLES OF FAMILY MEDICINE PRACTICE

1. Accessibility - Family physician practice/resides in the same area or neighbourhood of the community, he is planning to serve. Hence he is easily accessible at any given time for giving continuing and emergency medical care to the small, static community of his practice.

2. Comprehensive - Care offered is from womb to tomb, irrespective of age, sex or organ system affected. From birth to terminally ill, and after death, counselling to the family members is also a part of his practice.


3. Primary Care and Referral - The health care problem presented to him are undifferentiated and he initiates the process of differentiation, i.e. diagnosis and differential diagnosis, as against clear cut differentiated problems in a hospital settings. He should have readiness to deal with all types of problems and build a data base of

(i) What is curable?

(ii) What is tolerable?

(iii) What is normal?

(iv) What is preventable?

(v) What needs referral? When?

4. Friend, Philosopher and Guide - The Family Physician has to look at

1. Person as a whole (Mind, Body and Spirit)

2. Person as a part of Family, to understand effect and impact of disease on family and effect and impact of a family on disease.

3. Family as a smallest unit of the community.

5. Resource Manager - He must have knowledge of health care infrastructure in a given community set-up. Public, private and charitable. He must act as a resource manager for family and advise secondary and tertiary care according to family budget.

6. Community Knowledge - Acquire knowledge of community structure and, the community leaders. These can make or mar a practice. Many diseases, have origin in a family or community and health care practices of different communities are different.

7. National Health Care - He must be knowledgeable about national health care programmes and make use of every opportunity to get himself involved, and contribute in these programme.

8. Skills - He should acquire skills, aptitude and expertise for health.

9. Academic update - For all these, he must always keep himself updated by regular CME. He must modernise and update his practice form time to time.

10. Self-Care and Family Life - Most important he must learn to take care of his own health and hobbies, and to look after his own family.

POST GRADUATE QUALIFICATION

1. FCGP

FCGP is conducted by Indian Medical Association’s College of General Practitioners twice in a year. Eligibility is 3 years after completion of Internship. Minimum 50 hours of CME attendance is required. The Examination shall be in Two parts.

Part I : Theory consists of four papers

1) Medicine and Allied Sciences, 2) Surgery and Allied Sciences, 3) Diagnostic Medicine, Therapeutics and Toxicology, 4) Community Medicine and Practice Management and Medical Jurisprudence.

Part II : Clinical and Practical Examination

(a) Clinical Examination: One ‘long’ full case and Two ‘short’ Cases.

(b) Practical and viva voce.

- Spotting - 10 in numbers; clinical photographs, slides, instruments, X-Rays, ECG tracing, lab. report and pathological specimens.

- Viva Voce on the log diary submitted by the candidate.

The contents of the Log book are : 1) Personal profile of the candidate, 2) Educational qualifications, professional data, 3) Record of Case (Eight) history studies by him. Two Medical, Surgical, Paediatric and others, 4) Record of two family profiles, 5) Procedures learnt, 6) Record of Case demonstration Presentation, 7) Record of Participation in CME activities.

Application Forms can be obtained from The Controller of Examinations of IMA College of General Practitioners, IMA House, IP Marg, New Delhi 110 002 or from Local IMA Branches.

2. DNB (Family Medicine)

DNB (Family Medicine) is conducted by National Board of Examination, New Delhi. It is conducted twice in a year. It consist of two parts-

Part-I MCQs i) Basic Science ii) Clinical Sciences

Part-II Clinical Science as related to family medicine

1. Medicine and allied

2. Surgery and allied

3. Community medicine

4. Family Practice management

Practical examination will have four examiners

1. Physician

2. Another specialist either paediatrician, surgeon or a gynaecologist

3. Community medicine specialist and

4. Family physician

Eligibility is 3 years after completion of internship and 360 hours of CME attendance certificate. Candidate is also required to submit a log book and a thesis of a work done by him under a recognised postgraduate teacher. DNB is an MCI recognised postgraduate qualification.

For details write to The Registrar, National Board of Examination, Ansari Nagar, Mahatma Gandhi Marg (Ring Road) Post Box No. 4931, New Delhi 110 029.

3. MRCGP

This Examination is conducted by Royal College of General Practitioners of United Kingdom and Australia. This Examination has worldwide recognition. At present this examination is not conducted in India but it is possible to have examination centre in India.

TRAINING PROGRAMME FOR FAMILY MEDICINE

Institute of General Practitioners’ Association - Greater Bombay conducts one year of training programme. There are two centres for practical training. 1) Bombay Hospital, Mumbai 400 020. 2) KJ Somaiya Medical College, Sion, Mumbai 400 022. Only 20 candidates (on first come first serve basis) are admitted at each centre every year.

For details contact:

Convenor, Institute of General Practice, General Practitioners’ Association - Greater Bombay, 17, Mantri Corner, Gokhale Road (South) Mumbai 400 025.

I wish every family physician becomes the master of community based services, primary care physician, central/focal referral point and a mini specialist where he/she can acquire a niche in the society to help the patients and families and live up to the definition of "Friend, Philosopher and Guide".



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