A few weeks ago, I was interviewing Dr Ashok Prasad for a popular Indian medical news portal, and was grabbed by a remarkable point that he made. Though the interview was mainly concerning the state of mental healthcare in India, Dr Prasad stressed greatly on the role of primary healthcare in providing a foundation to effective psychiatric care, and the criminal under-emphasis that we see on primary care in India today. For me, it was like a trip back to the time when I penned a series of articles on the importance of family physicians in our healthcare system. Dr Prasad also expressed his disappointment over the fact that only two institutions in the country have so far expressed their interest in enrolling for a PG course in family medicine.
One of the central aspects of the primary healthcare model is community involvement, which means that the community participates actively in the provision of its own healthcare. Representatives elected from within the community serve to meet the healthcare needs of their people. This facet of primary healthcare is what makes it highly attractive and advantageous for the Indian population. India is a nation characterized by a vast and dispersed rural population, strong social ties and less nuclear families: the ingredients allowing for a tremendous success of primary healthcare with minimal expenditure. Arguably, the primary healthcare model is not only the most beneficial one in the Indian context but also the most economic one. For the very same reason, India was quick to, at least theoretically, adopt the primary healthcare model. Not just that, but we were also the first non-white post colonial independent country to institute reforms in mental health, the most important of them being the integration of mental health care with primary care services.
Today, after nearly 70 years of independence, one wonders at what actually went wrong with primary care in the country. More so, one is forced to consider if starting a postgraduate course in family medicine is the way out of it.
A dismayingly surprising observation is that a nation like India, which can benefit so much from the primary care model, has never conceptualised the primary care physician as a specialist since inception, unlike many western nations. A GP (general practitioner) was instead rendered to be a basic, minimum doctor, an obligatory qualification to be called a medical doctor, and the point from which the roads to ‘exalted’ specialties emanate. The diverse skill set needed to run a successful family practice, and the fact that a general grasp of different specialties makes a worthy specialty in itself, was never appreciated. The rampaging specialty cult in the country thus despoiled family practice of its glamour and prestige. A GP-specialist dichotomy is therefore a deep seated feature of our healthcare culture. This dichotomy is what has led us to believe that a simple and cursory overview of different specialties during MBBS is all it takes to run a family practice while, as a matter of fact, a fresh MBBS graduate is in desperate need of further years of supervised training to be able to establish a resolute family practice. The outcomes of such a culture are obvious: large scale irrational prescribing, injudicious referral of patients, sub-ethical practice and soaring healthcare expenses.
Increasing the number of PG (postgraduate) seats in family medicine, though a much needed step, would therefore be a solution at the surface of the problem and would fall short in addressing it fully and completely. The undue GP-specialty dichotomy is a problem with the medical culture in India, a deformity of perception which runs into the very core of our healthcare system – and much more would be needed to impart to it the glamour and prestige it needs to be at par with other specialties. A family medicine PG programme can be successful only when it is attractive to fresh graduates, which would require us to address certain fundamental deficits in our medical education.
One of those deficits is the lack of any significant mention of family medicine in the UG (undergraduate) curriculum. To expect graduates to be interested in family medicine without covering the importance of the same in their formative years would be downright futile. There is a dire need of acquainting young doctors with the concept of family medicine via the MBBS curriculum and eradicating the grotesque perception of it that has built up over the years. Also, UG students need to be trained for a considerable time outside of the tertiary care institutions in an environment focussed on primary care. Being a fresh graduate, I can hardly recollect of my clinical postings in primary care being given the due emphasis.
It’s also unfortunate to note that family practitioners find no faculty positions and are barred from teaching in medical colleges. Unless we rectify such an arrangement, where the faculty is entirely composed of specialists and devoid of family practitioners, the message of primary care cannot be affirmed. Not only do family practitioners need to be employed in medical colleges to spread the importance of primary care, they should also hold a prestigious chair in the healthcare system and have a prominent voice in the medical administration. Last but not the least they need to be remunerated equally as other specialists.
Changing the direction of a nation’s healthcare is no easy task – it takes fighting the predominant perceptions and relies heavily on changing its education system. The earlier this is realized, the better.
Note: An edited version of this article first appeared in Huffington Post India.
Dr Soham D Bhaduri is a medical graduate from Rajiv Gandhi Medical College, Kalwa, Thane, Maharashtra, and is currently working as a medical officer in Alibagh, Raigad, Maharashtra. He has a keen interest in matters involving healthcare and medical education, and has written for a number of renowned news portals and medical pages.