training

Type of Training – Residency, Diploma, Fellowship and Masters

Length of Training –

Residency - 3 years; postgraduate diploma in family medicine – depends on institution; Master in family medicine program – 2 years

Year Family Medicine established – 2012

Number of family medicine residents graduating each year – unknown

Number of institutions that offer family medicine – 7 institutions offer on campus programs; 5 institutions offer distance learning programs.

o   Residency - 5 institutions (Kerala University of Health Sciences affiliated with Calicut medical college; another university affiliated with Chennai Christian medical college, National Board of Examinations; Government Medical College, Kozhikode; CMAI in collaboration with Tribhuvan University)

o   Diploma - 5 institutions (Institute of Health Management Studies in collaboration with Annamalai University; IMA College of General Practitioners; Apollo Medvarsity Online Limited, in collaboration with RCGP, UK; Pathfinder Health India in collaboration with University of Westminster and Rila; CMC Vellore)

o   Fellowship - 2 institutions (CMAI, CMC Vellore)

practice

Number of family doctors – 67,000 MBBS Doctors

Physician to population ratio – 13 MBBS doctors per 100,000 population

DALY: 27,316/100,000 individuals (due to all causes).

Life Expectancy:

• Females 2017: 70.0 years

• Males 2017: 68.0 years

Mortality rate 2017:

• Males: 209 per 1,000 male adults.

• Females: 136 per 1,000 female adults

Infant Immunization-HepB3: % of 1-year-old children recieved: 89%

College of Family Physicians (Y or N):

• Yes: Academy of Family Physicians of India (AFPI)

training

The undergraduate training is 5 years and 6 months in duration and this includes a mandatory internship for a year (Mash et al., 2015). The clinical rotations done during the undergraduate training ranges from 2 weeks to 2 months for clinical disciplines in the hospital, and 6 months is reserved for rural/community posting (Mash et al., 2015).  All training is centered on hospital-based specialists and public health experts. Family physicians or primary care doctors are neither a part of the faculty nor involved in the training (Mash et al., 2015). There are 479 medical schools that graduate a total of 67,000 medical doctors. Family medicine is not taught within medical schools (Kumar, 2018).

Graduates of MBBS without postgraduate training could start to practice as a general practitioner right away (Kumar, 2018). Due to widespread trend of specialization, not many MBBS graduates are interested in pursuing general practice as a career (Kumar, 2018). Some MBBS graduates would complete junior residency to gain some experience for 6 months to 1 year, but this training does not give any formal qualifications (Kumar, 2018).  Most MBBS graduates attempt to take the post grad entrance examinations, which are very competitive since there are only 10,000 practising clinical discipline spots (Kumar, 2018). The widely seen trend is that MBBS graduates would take up a short-term position and then prepare for the post-grad entrance examination (Kumar, 2018). If a graduate is unable to get into postgrad training after approximately 8-10 years then the graduate would start general practice (Kumar, 2018). Previously, graduates were more likely to start general practice (Kumar, 2018). Some work as resident medical officers, wards, in the ICU’s, emergency department, or work as support staff in the large number of private hospitals in the cities (Kumar, 2018).

The MD family medicine program was first started in a Government medical college in Calicut, Kerala in 2012 (Roshni, 2016). The Academy of Family Physician of India (AFPI) was founded in 2010 in India (Academy of Family Physicians of India, n.d.).

There are various types of postgraduate training in family medicine that are available: Residency, Diploma, Fellowship and Masters (Pati et al., 2015). It is not mandatory for medical school graduates to complete postgraduate training in order to practice as a family physician in India (Mash et al., 2015). The residency is a three-year program that is offered at 5 institutions (Kerala University of Health Sciences affiliated with Calicut medical college; another university affiliated with Chennai Christian medical college, National Board of Examinations; Government Medical College, Kozhikode; CMAI in collaboration with Tribhuvan University) (Pati et al., 2015). There are 155 residency positions for family medicine (Kumar, 2018).  A limited number of family medicine residency spots were introduced in the last decade (Mash et al., 2015). There are two main ways residencies are offered (Kumar, 2018).  First, is through Medical council of India, which runs family medicine residency programs through two universities they are Kerala University of Health Sciences affiliated with Calicut medical college, and another university affiliated with Chennai Christian medical college (Kumar, 2018). Second, is through the National board of examination, this institution is an evaluator, accreditor, and a university that operates all over India (Kumar, 2018). Currently, the training in residencies is not very structured and this varies depending on the place where the training is being offered (Kumar, 2018).  Residencies involve training in the form of apprenticeship, learning through modules, journal clubs, and case discussions (Kumar, 2018).  Nine months out of the three years is spent at a community posting and the remainder of the training happens in the hospital setting (Mash et al., 2015).

The other forms of teaching family medicine in addition to residency include distant learning opportunities like postgraduate diploma in family medicine, which is offered at Christian Medical College Vellore and in West Bengal (Kumar, 2018).  As of 2015, the diploma in family medicine is offered at 5 institutions (Institute of Health Management Studies in collaboration with Annamalai University; IMA College of General Practitioners; Apollo Medvarsity Online Limited, in collaboration with RCGP, UK; Pathfinder Health India in collaboration with University of Westminster and Rila; CMC Vellore), and the duration of diploma program depends on the institution (Pati et al., 2015). The students in these programs would meet 3 times for contact learning close to their work area. There are 250 positions for the diploma programs (Kumar, 2018).

The Masters in Family medicine program is a two-year program offered at 2 institutions (CMC Vellore, and The Tamil Nadu Dr. MGR Medical University) (Kumar, 2018). The fellowship is a 2-year program offered in 2 institutions (CMAI, CMC Vellore) (Kumar, 2018).

The duration of training received for family medicine is sufficient, but it has to be made more appropriate (Kumar, 2018). The training is focused towards a hospital based setting rather than a community center (Kumar).  The older generation of general practitioners who are now between 70-80 years old retire and then there are no doctors to replace them (Kumar).  Further, the older generation are not able to engage and train the current family medicine residents since they are not accredited to train family doctors (Kumar).

The concept of family medicine training has been debated for several years but it has not yet been implemented all across India since there are concerns about cost and the duration of training (Mash et al., 2015). There has been a recent policy surrounding the training of family physicians for community health centers with greater emphasis on both surgical and anaesthetic skills (Mash et al., 2015).  There are other initiatives focused on increasing the skills of the existing pool of primary care doctors through short-term courses that target important skill gaps like anaesthesia, obstetrics, and neonatal care (Mash et al., 2015).

practice

75% of the physicians in India are family physicians and there are a total of one million doctors (Kumar, 2016).  Family Medicine is the practicing discipline for a majority of the medical graduates in India and this includes medical officers in the government sector, family physicians, and general practitioner (Kumar, 2016).

The undergraduate qualification allows graduates to work in the public health system (Mash et al., 2015). Since newly graduated doctors prefer training for a hospital-based specialty there are a large number of vacancies that are filled up by AYUSH physicians (non-allopathic alternative system) (Mash et al., 2015). The role of postgraduate family medicine has been envisaged in policy, however designated posts are yet to be created within the healthcare system (Mash et al., 2015).

Majority of physicians’ stay and practice in India. Previously, many physicians preferred to practice in the Middle East (Kumar, 2018). This trend is now reducing since the Middle East now has its own medical system with stricter regulations for doctors trained outside UAE (Kumar, 2018). Previously the United States used to be a favorite destination for physicians to practice (Kumar, 2018).  Not many physicians prefer to go abroad due to the difficult working conditions such as in the UK because of European Union, which makes it difficult to find a job in the UK (Kumar, 2018).

The role of family physician is now weakening and there are more challenges that are arising. The first challenge is that there is no formal way of replacing the older doctors (Kumar, 2018).  Further the cost of starting a practice is a financial concern; hence there are not many new doctors in urban areas (Kumar). The people living in urban areas depend more on hospitals with out-patient department and not on family physicians (Kumar).  There exists a gap to be financially competitive to be in the market and setting up a practice (Kumar).  Currently, the role of family physicians in rural areas is better, however the challenge faced is that not many qualified physicians are in the rural workforce (Kumar).

Family Doctors don’t have a gatekeeping role, hence patients can visit a specialist without referral (Kumar, 2018).  The place in which people live determines the percentage of primary care issues seen by the family doctors (Kumar, 2018).  In an urban area like New Delhi, a large section of the population live in slums, hence the people go to the community practitioner but would not receive care from a family physician (Kumar). People with low socioeconomic status usually receive care from an unqualified practitioner (Kumar).  People with an insurance plan would directly go to the hospital (Kumar).

Family Physicians work as a solo practitioner currently, however in previous generations family doctors would start with a solo practice and then turn it into a nursing home (Kumar, 2018). The nursing homes would offer surgical care, emergency care, and would have around 10-50 beds (Kumar). The nursing homes were run/managed or owned by one family doctor (Kumar).  Later on other specialists would join the nursing home, which turns it into a group practice (Kumar). With the overcrowding present in urban areas there is less space available to continue this trend (Kumar). Further, it is difficult for small hospitals to survive once big hospitals are established due to the competitive prices offered by the big hospitals (Kumar).  Hospitals take care of 70-80% of the healthcare needs, hence the role of a family physician is now decreasing (Kumar).

The care received is comprehensive and continuous in the family medicine practices that are successfully established (Kumar).  There are between 100 to 1000 famous family doctors all over India, who are well-respected and trusted by their communities. These well-known doctors would offer continuity of care to children, parents, and elderly (Kumar). The concern that exists is that once these great family physicians retire there will be a gap in the care received by these communities (Kumar).

The people in India are not satisfied with the healthcare system available and there is a lot of negativity about the healthcare system (Kumar). This can be seen with the increased amount of violence against doctors, because they are right in between the healthcare system and the population (Kumar).  This shows the increasing frustration the people have with the failing health system, as it is not able to cater to their needs (Kumar).

It is hard to calculate the number of family doctors in India, the ratio of MBBS doctors to the population is 1.3/1000, and this is a good ratio since the recommended is 1/1000 (Kumar, 2018).

The model of primary care that exists is a vertical disease oriented model, since it is widely promoted by the government through initiatives focusing on HIV, polio, tuberculosis, mental health, and non-communicable diseases (Kumar, 2018).  There is a lot of fragmentation from the government itself (Kumar, 2018).

The requirements for continuing certification either vary by state or are not required at all (Kumar, 2018).  In some states physicians are registered for life, while in some others physicians need to re-register every 5 years (Kumar).