Historical Evolution and Present Status of Family Medicine in Sri Lanka

Abstract

Sri Lankan health system consists of Allopathic, Ayurvedic, Unani, and several other systems of medicine and allopathic medicine is catering to the majority of the health needs of the people. As in many other countries, Sri Lankan health system consists of both the state and the private sector General practitioners, MOs in OPDs of hospitals and MOs of central dispensaries, provide primary medical care in Sri Lanka. Most of the general practices are solo practices. One does not need postgraduate qualification or training in general practice to start a general practice. There is no registered population for any particular health care institution in the state sector or in the private sector and there is no strict referral procedure from primary care to secondary or tertiary care. Family doctors have been practicing in Sri Lanka for well over 150 years. The first national organization of general practitioners was Independent Medical Practitioner (IMPA)'s organization which was founded in 1929 and the College of General Practitioners of Sri Lanka was founded in 1974. College conducts its own Membership Course and Examination (MCGP) since 1999. Family Medicine was introduced to undergraduate curriculum in Sri Lanka in early 1980s and now almost all the medical faculties in the country have included Family Medicine in their curricula. In 1979, General Practice/Family Medicine was recognized as a specialty in Sri Lanka by the postgraduate institute of Medicine. Diploma in Family Medicine (DFM) and MD Family Medicine are the pathways for postgraduate training in Sri Lanka. At present 50 to 60 doctors enroll for DFM every year and the country has about 20 specialists (with MD) in Family Medicine. The author's vision for the future is that all the primary care doctors to have a postgraduate qualification in Family Medicine either DFM, MD, or MCGP which is a far cry from the present status.

Introduction

Sri Lankan health system consists of Allopathic, Ayurvedic, Unani, and several other systems of medicine that co-exists. Of these systems, allopathic medicine has become dominant and is catering to the majority of the health needs of the people. As in many other countries, Sri Lankan health system consists of both the state and the private sector.[1]

Primary care physicians

In the state sector, medical officers (MOs) in outpatient departments of hospitals and MOs in central dispensaries provide primary medical care. MOs of outpatient departments of private hospitals and full time and part time general practitioners/family physicians provide primary medical care in the private sector. Part time general practitioners are MOs who are attached to the ministry of health and work in hospitals but work as general practitioners after office hours. Most of the general practices are solo practices. Any doctor who has completed internship and has gained full registration with the Sri Lanka medical council is eligible to start a general practice wherever he or she wants. One does not need postgraduate qualification or training in general practice to start a general practice. There is no registered population for any particular health care institution in the state sector or in the private sector and there is no strict referral procedure from primary care to secondary or tertiary care. Patients are free to select which doctor to consult or which hospital to get admitted whenever they fall ill.

History

Family doctors have been practicing in Sri Lanka for well over 150 years but they have remained as private general practitioners and have never been included in the government health service.[2] General practitioners in the earlier years were not vocationally trained but had only the experience gained by a few years of work in the government health service which has hospital-based curative and community-based preventive health services. Therefore, the doctors who embarked in general practice had to adapt themselves to the individual/family/community-oriented practice on their own.[3]

The first national organization of general practitioners was Independent Medical Practitioners’ Association (IMPA) which was founded in 1929.[4] This was a medico political body attending to the interests of the general practitioner, and it had little or no academic aspirations.

The first academic college of family physicians/general practitioners in the world was created in USA in 1947. Britain followed closely in 1952, Canada 1954, Australia 1958, Philippines 1961, Singapore 1971, Malaysia 1973, New Zealand 1974, and Sri Lanka 1974.[5]

College of general practitioners of Sri Lanka

The College of General Practitioners of Sri Lanka was established in 1974 and incorporated by an act of parliament.[4,5,6] The College of General practitioners of Sri Lanka is the second academic college of the medical profession in Sri Lanka. The first college was the Ceylon College of Physicians which was founded in 1967. The World Organization of National Colleges and Academies of Family Physicians (WONCA), which was founded in 1972, accepted Sri Lanka to the membership in 1978.[5]

The primary aim of the college is academic – the establishment and development of standards and the active promotion of postgraduate and continuing medical education of general practitioners and teaching undergraduates.[5]

The College Membership Course and Examination (MCGP) began in 1992 and college is actively involved in continuing professional development programs which includes orations, academic sessions, clinical lectures, seminars, symposia, and workshops.[6] Fellowship is awarded for distinguished members with remarkable contribution to service, education, and research.

College journal “the Sri Lankan family physician”

In 1979, College first published its journal “The Sri Lankan Family Physician”.[4] It publishes original articles, reviews, and case reports dealing with the medical and allied sciences as well as lectures and orations delivered to the college of general practitioners and proceedings of symposia and seminars held under the auspices of the college. The primary objective is continuing medical education for family physicians and it also serves as record of the activities of the college. It's a refereed journal and is indexed in international indexes and is often cited in publications both local and international. This has provide a forum to family physicians for publication of their work – a very important requirement for the continuing development of any discipline.[4]

Family Medicine as an academic discipline

An academic discipline has certain qualifying features – a unique field of action, a defined knowledge, an active area for research, training which is intellectually vigorous, and learning objectives for students.[7] All these could be found in Family Medicine. It is a discipline characterized by its breath, which embraces knowledge content from all the specialties at a certain level and holds it all together with the special skills and attitudes needed for providing person centered, comprehensive, primary health care for people in their own environment, namely the family, home, and community, on a continuing care basis.[3]

Undergraduate education

In 1952, the Royal College of General Practitioners recommended that all medical schools should have a department of General Practice.[8] In the USA, the term Family Medicine was used in place of general practice to emphasize family-oriented care, a trend that has continued the world over. Family Medicine thus gained academic recognition and was accepted as the 20^th clinical discipline in the USA in 1969.[8] UK and USA were the first to have departments of Family Medicine in medical schools. Canada, Australia, and the Netherlands followed the trend. In the Asia Pacific Region, Singapore had its first department of Community, Occupational, and Family Medicine established in 1987 in the National University of Singapore and in Malaysia, Family Medicine teaching was introduced through a Department of Primary Care Medicine in early 1990s.[9]

Family Medicine was introduced to undergraduate curriculum in Sri Lanka in early 1980s when Faculty of Medicine, University of Colombo started sending their students to general practices on three half day sessions.[2,4,6,8] In 1993, the newly established medical faculty of the University of Sri Jayawardenapura included Family Medicine in the undergraduate curriculum and the Department of Community and Family Medicine was created. In 1994, the Faculty of Medicine, University of Kelaniya also created the Department of Community and Family Medicine.[2,4,6,8] Both these Universities now have independent departments of Family Medicine.

At the faculty of Medicine, University of Kelaniya where the author is the head of the Department of Family Medicine, the training program consists of lectures during the third year and one month attachment to the Family Medicine clinic during the fourth year. Students get training in history taking, clinical examination, patient management, and practice management during this attachment. One student is present during a consultation inside the consultation room. Students learn by observing the doctor and actively take part in history taking, clinical examination, and procedures under the supervision of the teacher. Doctor discusses the plan of management with the student. Students get hands on experience in writing prescriptions, referral letters, and investigation requests. In addition, there are small group discussions on management of common reasons for encounter and common problems encountered at a primary care setting almost every day. Students visit general practices and outpatient department of the nearby teaching hospital during the attachment as the exposure to other primary care settings is also important. Continuous assessments are held at the end of the third year and the clinical attachment. Summative assessment is held at the end of the fourth year.

Recently, Family Medicine has been introduced to the curriculum of the medical faculties of other universities in the country although there are no separate departments.

Post-graduate education

In 1979, General Practice/Family Medicine was recognized as a specialty in Sri Lanka by the postgraduate institute of Medicine. The first board of study in General practice and Family Medicine was appointed in 1980.[3,4,5,6]

Diploma in Family Medicine

One year long full time face to face course of studies leading to a Diploma in Family Medicine (DFM) was launched in 1981 and it is tailored for the needs of general practitioners and first examination was held in 1982.[3,4,5,6] Since then, every year DFM examinations have been held. At present, about 60 doctors enter this course through a selection examination. Course consists of approximately 250 teaching sessions (lectures) which are held during the weekend and about 150 clinical sessions covering almost all the disciplines in the field of medicine during weekdays. The components of the examination are modified structured essay paper, multiple choice question paper, objective structured clinical examination, objective structured practical examination, and log diary examination. Fifty to sixty doctors enroll for this diploma every year following a selection examination.

Diploma in Family Medicine, India

In late 1990s, the college of General practitioners of the Indian Medical association (CGPIMA) collaborated with the PGIM Sri Lanka to have a training program and a postgraduate DFM examination under the auspices of the PGIM, in India. The first DFM examination was held in Chennai in 1999.[4,6] Thereafter, DFM examinations have been held almost every year in India and there are more than 300 diplomates in India. The examination format is similar to the DFM examination held in Sri Lanka.

Successful candidates are eligible to present themselves for the MD (Family Medicine) by thesis.

Diploma in Family Medicine online course

The online DFM, one of the pioneering online distance education courses in the field of Medicine in Sri Lanka, was introduced in 2008.

This is a 2-year, part time course in which the study materials and interactions are conducted online to supplement the Clinical rotations. This course has been designed to meet the needs of doctors especially in peripheries of the country who are unable to undergo training in the full time 1 year face to face the DFM training program.

MD Family Medicine

MD Family Medicine by thesis was introduced in late 1980s. Initially, the research was to cover a minimum period of 1 year but subsequently this minimum period was increased to 2 years.[4,6] Those who are successful at the exam are eligible for board certification as specialists in Family Medicine. MD by thesis is opened to Indian candidates also and first examination was held in Chennai in June 2011 and four Indians were awarded the degree.

MD by clinical training and examination which is a 2-year full time course leading to board certification was introduced in 2000. The training program consists of clinical rotations in hospitals for 15 months, attachment to a university department for 5 months, and 4 months of training in family practices. In addition, trainees have to write a dissertation based on a research carried out on a topic related to Family Medicine. Components of the exam are written examination (structured essay questions), clinical examination (10 OSCE stations), and research dissertation viva.[9]

The future

Family Medicine has gained recognition among doctors and undergraduates gradually and that is evident from the number of doctors who sit for the selection examination to gain entry to DFM course and caliber of applicants to join the academic departments in Family Medicine. About 250 doctors compete to gain entry to DFM course every year and it is graduates with first classes or second classes and distinctions who gain academic posts in university departments.

Ministry of health has started family clinics in a few hospitals and it now releases its MOs to follow MD (clinical training program). Even though the ministry of health has not identified the role of specialist in Family Medicine in the ministry of health that in the future Family Medicine will become a recognized specialty in the ministry as well. The role for these specialists, what the author suggests, is to place them in hospitals where there are no secondary care specialists. Those are the district hospitals, peripheral hospitals, etc., They will be able to improve the quality of medical care provided to inpatients, outpatients, and follow-up patients with chronic diseases. They will be able to manage patients to a greater extent in those hospitals and reduce the referral rates to secondary care hospitals. They will be able to conduct continuous medical education programs, journal clubs, case discussions, etc., to update knowledge of the MOs in those hospitals and thus become clinical heads in these institutions.

Medical officers hardly enter full time general practice now since they have the freedom to engage in general practice after hours. They can enjoy the privileges of the government service and engage in family practice also.

The author's vision is that all the primary care doctors (full time/part time general practitioners, MOs in outpatient departments of hospitals and central dispensaries) should have a qualification in Family Medicine either DFM, MD, or MCGP which is a far cry from the present status.