J
Family Med Prim Care. 2012 Jul-Dec; 1(2): 81–83.
PMCID: PMC3893973
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).
References
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.
9. National Health Policy (India), MOHFW Govt. of India.
2002. [Last cited on 2012 Sept 15]. Available
