Family Medicine at AIIMS (All India Institute of Medical Sciences) Like Institutes

AIIMS and its Mandate

AIIMS New Delhi was created in 1956 as an institute of national importance by an Act of Parliament.[1] Over several decades, AIIMS has evolved into the sole lighthouse of healthcare, attractive patients from all over India, especially from northern part. AIIMS epitomizes public sector academic tertiary care centre in India. Of late, AIIMS has been overburdened with patient care rendering it unable to meet its primary objectives. Recently, six AIIMS-like apex healthcare institutes (ALIs) have been established by the Government of India under the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY). The aim of this initiative is to rectify regional imbalances in the quality of tertiary-level health care in the country and attain self sufficiency in graduate and postgraduate medical education. These new AIIMS-like institutes are located in the states of Bihar (Patna), Madhya Pradesh (Bhopal), Odisha (Bhubaneshwar), Rajasthan (Jodhpur), Chhattisgarh (Raipur), and Uttarakhand (Rishikesh).[2]

Family Medicine (Academic Discipline of the Multi-Skilled and Competent Primary Care Physicians) at AIIMS

The new AIIMS-like institutions have commissioned a new department called “Community and Family Medicine.” One of these intuitions, AIIMS Bhopal, has identified the development of family medicine program as one of its primary objectives.[3] The MD in family medicine (post graduate) curriculum has been notified by the Medical Council of India (MCI) only recently. The Government Medical College, Kozhikode, has become the first medical college in India to start MD in Family Medicine. Interestingly, the family medicine component does not exist in the MCI-prescribed Bachelor of Medicine, Bachelor of Surgery (MBBS) course till date. The MCI regulation of the Graduate Medical Education states that “the Obstetrics and Gynaecology training will include family medicine, family welfare planning etc.”[4] Family medicine at AIIMS is likely to bring instant and much-needed academic recognition to the family medicine discipline in India. This model likely to be replicated elsewhere in India.

The regulation of medical qualifications and medical institutions has primarily rested with the MCI. The major focus of MCI regulations is on the staffing pattern, their qualification and facilities; and the recognition of institutions for various courses rather than the regulation of a standard curriculum. On the other hand, universities including AIIMS are primarily preoccupied with conducting examinations and appointing examiners for thesis and final university examinations, apart from awarding degrees. In most situations, trainee doctors are often left to themselves to learn and acquire competencies, skills, and knowledge. Most of this self-directed learning is based on peer's experience and work culture specific to the situation of the place.[5,6,7] In spite of best intensions, medical education in India has largely remained tertiary care based.

Family Medicine in India

Family medicine presents an extraordinary opportunity to the medical education system in India to reform itself. Embedding family medicine into the AIIMS model and incubating it with community medicine is a welcome initiative; however, future development of family medicine needs a cautious approach.

Family medicine is a recognized medical speciality in India since 1983, when the National Board of Examination (NBE) was formed through an amendment in the MCI Act 1956.[8] The initial curriculum of Diplomate of National Board (DNB) family medicine was derived from the syllabus of the Fellow of Indian Medical Association College of General Practice (FCGP) examination. Family medicine was not introduced as a fulltime residency training program until the late nineties. The National Health Policy 2002 emphasized the importance of family medicine and has identified it as a focus area of human resource development.[9] In 2005, full time DNB family medicine residency training gained momentum under the National Board of Examination (NBE), primarily to support the National Rural Health Mission (NRHM).[10]

Within the NBE system most of the family medicine training sites are operating at multi specialty community hospitals. A family medicine trainee is assigned to a guide, who is most often an internist or a consultant physician. The trainees are rotated through different clinical departments and are also given an opportunity for community posting. Currently 155 DNB family medicine seats are available under the NBE scheme for the January 2013 session.[11]

Family Medicine and Academy of Family Physicians of India (AFPI)

Even though the number of institutes offering DNB family medicine training has progressively increased over the period of last decade; young doctors are still unaware about the concept and the future prospects of family medicine in India. The primary reason for this unusual unawareness is the non-existence of a family medicine component in the MBBS curriculum and also the non availability of MD family medicine within the mainstream medical education system controlled by MCI. Interestingly no employment has been offered to DNB family medicine-qualified doctors by agencies such as NRHM, where family medicine doctors are best suited as multi-skilled and competent primary care specialists. More than 60% of the specialist posts at Community Health Centres (CHC) are lying vacant under NRHM.[12]

Since its conception the Academy of Family Physicians of India (AFPI) has floated a strong pro family medicine advocacy. At the initiative of the AFPI, a high level meeting was convened by the Ministry of Health and Family Welfare (MOHFW) Government of India in 2010 to discuss (a) the initiation of MD family medicine and (b) to create posts for DNB family medicine in NRHM.[13]

Family Medicine – Incubation with Community Medicine Department

The academic discipline and speciality of family medicine has evolved from the tradition of a generalist medical care. In most countries, general practitioners (GPs) and family physicians form the core faculty of medical education. In India, regulatory restrictions bar GPs, family physicians, medical officers (MOs), and other primary care physicians from becoming a faculty.[14] Only doctors with specialist qualification and work experience at tertiary level medical college hospitals are eligible to become a faculty within the mainstream MCI-regulated medical education system.

Although hosting of family medicine at community medicine/PSM departments is the best possible option available at the moment, it comes with a specific risk. Medical students and trainees may perceive family medicine to be the same as community medicine/PSM or a small component of it, while in practice they are two entirely different concepts.

Community Medicine/Preventive and Social Medicine at a Crossroads in India

Preventive and Social Medicine (PSM), Community Medicine (CM), and Community Health (CH) are synonymous to Public Health Education (PHE) in India. Community medicine came into existence under the influence of the Re-orientation of Medical Education (ROME) program of the World Health Organization (WHO) for Asian countries launched in 1977. The ROME scheme was planned to impart community-oriented training to medical undergraduates in primary health care.[15]

Over a few decades, community medicine/PSM has at best evolved as a medicalised form of public health in India. One of the major limitations in its approach towards evolution as authentic public health is the selective entry to licensed medical professionals only and at the same time barring experts from other knowledge discipline such as sociology, health economics, and political science etc. A pseudo scarcity of faculty exists all the time. In spite of the field work and health camps, a typical community medicine faculty operates from office at urban medical college and tertiary care hospital building; and also does not engage in regular clinical work. According to one report more than fifty percent of these departments are dysfunctional in terms of academic activities mandated to them.[7] They continue to exist in compliance to MCI guidelines towards recognition of the institute. This leads to visible lack of legitimacy and strength in action. Of late, many departments have started rectifying their focus and are working with enhanced attention to public health training; a few of them have started Masters in Public Health (MPH) program. Community medicine is at a crossroads in India and a lot of introspection and discussion is ongoing regarding its future direction.[16,17]

By default every family medicine faculty/trainee has to be a skilled clinician ideally located in a full time community-based practice. Family medicine is an independent academic discipline with a well developed body of knowledge and skill set.

Family Medicine in India – Challenges Ahead

For family medicine to develop to its true texture in India; two visible barriers are (a) training location (b) faculty eligibility which need immediate attention from medical education regulators. The scope of family medicine is determined by the local need of the community; therefore, it requires flexibility in operation and organization. National regulatory mechanisms do now allow regional and local flexibility. Tertiary care-based medical education and current eligibility criteria toward faculty positions have allowed a virtual monopoly of specialist doctors over medical education and service delivery; and at the same time also disfranchised the primary care physicians academically and professionally. While immediate benefit is expected from the association of family medicine at AIIMS, modelling family medicine at a tertiary care centre might pose difficulties at a later stage.

The beneficiaries of the current system are likely to resent and block the concept of gate keeping (which is an essence of family medicine) on unrestricted patient inflow from underserved, rural, and remote areas. Without removing these barrier, family medicine is at risk of being annihilated by the existing flawed medical education system.

Family Medicine is a Counterculture

Worldwide, family medicine has evolved as a counterculture to the rapid fragmentation of health care into ever growing lists of specialties and subspecialities. Internationally, there is growing demand for comprehensive health care. The value of family medicine lies in its integrative function in the health care system, which is often too complicated for a lay person to understand. In India, academic family medicine is in its nascent stage. To survive, progress, and prosper, the proponents of family medicine will have to challenge the existing fallacies within the medical education system in India. In due course of time, family medicine will grow, evolve and eventually develop its own identity.

Author's Note

The findings and conclusions in this article are those of the author and do not necessarily represent the official position of ILBS, New Delhi, India. Author is also the President of the Academy of Family Physicians of India (AFPI).