A few weeks ago, I was interviewing Dr. Ashoka 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 health care 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 thus far expressed their interest in enrolling for a PG course in family medicine.
The unjustified 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.
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 fewer nuclear families: all ingredients that allow 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 postcolonial 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 surprising, and dismaying, observation is that a nation such as India, which can benefit so much from the primary care model, has never really conceptualized the primary care physician as a specialist, unlike many western nations. The general practitioner (GP) has been relegated to a position at the bottom of the medical ladder, with the higher rungs occupied by "specialists". 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, has never been appreciated. The rampant specialty cult in the country thus stripped family practice of its prestige and allure. 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. The fact is that a fresh MBBS graduate is in desperate need of further years of supervised training to be able to establish a strong family practice. The outcomes of such a culture are obvious: large-scale irrational prescribing, injudicious referral of patients, sub-ethical practices and soaring healthcare expenses.
Unless we include family practitioners in the faculties of medical colleges, the message of primary care cannot be affirmed.
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, but would fall short in addressing it fully and completely. The unjustified 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 -- much more will be needed to give it the prestige it needs to be at par with other specialties. A family medicine PG program 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 to acquaint 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 tertiary care institutions in an environment focussed on primary care.
It's also unfortunate to note that family practitioners find no faculty positions, and are barred from teaching in medical colleges. Unless we rectify this and include family practitioners in faculties, 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 at par with 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 the education system. The earlier this is realized , the better.