RETIREMENT SPEECH

FARE WELL SPEECH ON RETIREMENT(30/04/2015)

Dear Colleagues,students and friends,

Thank you for giving me such a farewell on this day.I would also place on record my gratitude for the love and care given to me during my tenure as Principal.

As principal of Govt Medical College,Kozhikode for a reasonably long period of almost 6 years, I feel humble and satisfied. I am the 26^th principal of this institution and is second to the legendary Dr Ananthanaranan Sir as far as duration of tenure is considered.

I joined this institution as an MBBS student in 1975. I studied for Diploma in Chest diseases and MD in General medicine in this college itself. In 1985 I started my carrier as a Tutor in Chest Department. When I was elevated to this post many of my relatives and friends advised against accepting it saying that this will create more head ache than any thing. I thought otherwise. I considered it as an opportunity to serve my Alma mater. I was ready to take any pain for that. I thought I will use my MBA knowledge to build a good cadre and to look at improvements in infrastructure and academics. Dr.C.B.C. Warrier was my mentor and my role model.

How I rate my tenure is a big question I ask myself. My main aim and ambition is to do something good to my institution. I tried many things, succeeded in some, failed in others. That's quite natural. Many people fail in their goals, but this should be evaluated by others, not me. I have always felt that our college is a wonderful institution and  with some discipline among the ranks, we can do wonders. During this tenure I have learnt the fact that one man alone cannot do wonders. I concentrated on improving academics first and then infrastructure. I know that knowingly or unknowingly I have ignored many areas. I am leaving those areas to my successor, hoping he or she will do what I could not and even better than me. I appreciate the cooperation of my colleagues, especially the senior teachers, students and the office staff who stood with me. I know that there are people who oppose me too. I felt that people who were denied personal favour became my enemies. I never permitted even my friends to gain unusual favours from me. That makes a lot of enemies, but it also gave me energy to fight.

Calicut Medical college is ranked as the fifth best all over India. This rank shows our quality. This rank is the result of our hard work. I thought of building this campus like that of NIT Calicut, but that could not be materialized. I even wanted to improve the casualty service, but that too is incomplete .The dream project of PMSSY is still away from us, but history takes years to complete. Therefore I do not worry about what is not complete; I focus on what is complete. I do not have a completely rigid style. At times I am cordial, at other times, excited. I use these qualities to achieve my goals. Most people may not recognize this and fail to understand me and my style. Anyway I am always ready to work overtime and I recognize people of that caliber. I have given opportunity to every department. But there is a complaint that I help only few departments. I know that certain department got preferential treatment and the reason is that those who work hard and use the given opportunity get further support. Those who blame are those who do not use these opportunities. Regarding government funds, there is no special way to attract the same. If we take a project and take it as our own personal project, then you will get it. I have always had good rapport with ministers, secretaries and director. That was a bonus for me. There are still many things to become reality such as PMSSY project, oncology institute, lecture theatre complex, residential facilities for PGs and the staff, and the paramedical hostel which are all sanctioned. It is the duty of all of you to support the project and make it come true. We need a few more improvements, such as a protected campus, an improved casualty and residential services. Restriction for visitors in the hospital, a good restaurant/canteen within the hospital etc. are urgent necessities. New house surgeons quarters and mortuary should be built. There are a few specialties we have to concentrate on soon, such as Emergency Medicine, Critical Care Medicine, Neonatology, Medical and Surgical Oncology, Cardiac and Neuro anesthesia, Sports medicine, Endocrinology and Diabetology. One should always have a good vision and a good team to work with. The rest will come on its way.

 I request my colleagues, juniors and students to take care of our college as this is our own prestigious institution.

Dr C Ravindran

ARTICLE ON FAMILY MEDICINE

J Family Med Prim Care. 2012 Jul-Dec; 1(2): 81–83.

doi:  10.4103/2249-4863.104925

PMCID: PMC3893973

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

Raman Kumar

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).

References

1. About AIIMS (All India Institute of Medical Sciences) [Last cited on 2012 Sept 15]. Available from: http://www.aiims.edu/aiims/aboutaiims/aboutaiimsintro.htm .

2. Pradhan Mantri Swasthya Surakha Yojana (PMSSY), MOHFW Government of India. [Last cited on 2012 Sept 15]. Available from: http://www.mohfw.nic.in/index4.php?lang=1 and level=0 and linkid=96 and lid=852 .

3. Primary and Secondary Objectives of AIIMS. [Last cited on 2012 Sept 15]. Available from: http://www.aiimsbhopal.edu.in/academics_and_research.aspx .

4. Medical Council of India Regulations on Graduate Medical Education. 1997. [Last cited on 2012 Sept 15]. Available from:http://www.mciindia.org/RulesandRegulations/GraduateMedicalEducationRegulations1997.aspx .

5. Medical Council of India Rules. 1957. [Last cited on 2012 Sept 15]. Available from:http://www.mciindia.org/RulesandRegulations/IndianMedicalCouncilRules1957.aspx .

6. Medical Council of India Salient Features of Postgraduate Medical Education Regulations. 2000. [Last cited on 2012 Sept 15]. Available from:http://www.mciindia.org/rules-and-regulation/Postgraduate-Medical-Education-Regulations-2000.pdf .

7. Lal S, Kumar R, Prinja S, Singh GP. Postgradate teaching and evaluation in community medicine. Indian J Prev Soc Med. 2011;42:221–4.

8. Notification No. V 11015/17/83-ME. (Policy) Government of India MOHFW (Dept. of Health) New Delhi, Dated the September 19^th. 1983. [Last cited on 2012 Sept 15]. Available from: http://www.natboard.edu.in/dnb_matter.php?notice_id=4 .

9. National Health Policy (India), MOHFW Govt. of India. 2002. [Last cited on 2012 Sept 15]. Available 

FAMILY MEDICINE-MY PERSPECTIVE

FAMILY MEDICINE- MY PERSPECTIVE

I loved practicing in rural areas. After my graduation I worked for 18 months in a rural hospital where there was no electricity, no oxygen supply, no ambulance etc. It was a family practice treating all diseases and attending labour. I left that place when I was selected for postgraduate course. Once in specialty practice in Medical College I have completely ignored my earlier carrier. When I became Dean of the college I was trying to strictly implement referral system in order to reduce the patient burden so that those who deserve tertiary care may get it. But soon I could understand that this could be a distant dream, as every body wanted to consult specialists. Nobody has confidence in primary health centers. This I thought will disintegrate the health care system. This also will lead on to unnecessary investigations and unnecessary medication which in turn will add to the cost of medical care.

What we need in this scenario is a global approach, a family or community approach. I remember fondly my former Principal Secretary to Govt. who asked me to chart a programme to link primary, secondary and tertiary cares. He sent me to CMC Vellore where a good family medicine department is functioning. He also made arrangement for an interaction with Dr Peter Kuling, a family practitioner from Canada. It was indeed an eye opener for me. We need to strengthen the primary care. For this a strong base of family practice and adequate number of primary care physicians are needed. This really motivated me to initiate the first MD course in Family Medicine in the country. I am really proud of that and still believe that this is a humble beginning and in future Calicut Medical College will be remembered for this.

The American Academy of Family Practice (AAFP) defines family medicine as a medical specialty which provides continuing, comprehensive health care for the individual and family. The scope of family medicine encompasses all ages, sexes, organ systems and diseases. Family Medicine ( FM) aims to provide initial, continuing and comprehensive care, while centering this process on the patient-physician relationship in the context of the family. It is not a patient but the family is treated by a family physician. Primary care physician always aims at relationship building, continuity of care, and seeing the impact on a patient’s health. They focus on disease prevention and health promotion, and when referral is needed, Family physician remains the coordinator of patient care. This leads to decreased chances of inpatient care, higher patient satisfaction, and increased cost-effectiveness.

FM training programs address a large breadth of topics: adult medicine, pediatrics, maternity care, gynecology, care of the surgical patient, musculoskeletal and sports medicine, emergency care, mental health, community medicine, skin, diagnostic imaging and nuclear medicine, and management of health systems. Family physicians have greatest flexibility regarding practice of any specialty.

The first purpose is social change. Many diseases, especially chronic ones like diabetes and heart disease, afflict the poor more than any other group. Chronic diseases are the embodiment of the extreme inequality present in this society. They can be improved with conscientious and thorough care on the part of health professionals dedicated to the underserved and prepared to advocate on their behalf. This ethos is promoted by many FM programs, which emphasize the physician’s responsibility to the community and the family as well as the individual patient. Many FM residencies are located in areas of need and specifically aim to produce primary care physicians to improve health care outcomes in these areas.

Philosophically, I believe that FM is the best platform for delivering primary care.  People live in families and communities, and rarely do illnesses affect only one person.  Patients often come to the doctor with family members, and thus building trust by treating the entire family, offering anticipatory guidance to family members when they come as patients as well as caregivers, and better understanding the dynamics at home through multiple visits are powerful assets when delivering primary care as a family physician.  When that primary care for the family is fragmented through multiple physician practices, the benefits of true primary care can be lost.

 
Practically, it is seen that most FM residents spend nearly 50 percent of patient-care time in the outpatient setting.  Meanwhile, most internal medicine primary care residents typically spend 20 to 25 percent of their time in outpatient care. 
 Family physicians in rural India, has a lot to do like moving from the pediatric ward, OB ward, and adult medicine wards with ease each morning, and then see patients of all ages in outpatient clinic in the afternoon. As a primary care doctor, it seems as though the vitality of one’s practice is often proportional to the breadth of one’s practice.

Finally, as we all know, the health care system in this country is broken, especially, when it comes to the coordination of care.  The broad clinical training one receives in family medicine, as well as the strong new emphasis many family medicine residencies are placing on team-based care; there is a unique position for family doctors to help lead the revolution that is stealthily underway in primary care.