Family medicine

Family medicine (FM), formerly family practice (FP), is a specialty devoted to comprehensive health care for people of all ages; the specialist is named a family physician or family doctor. In Europe the discipline is often referred to as general practice and a practitioner as a General Practice Doctor or GP; this name emphasises the holistic nature of this speciality, as well as its roots in the family. It is a division of primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body.^[1] It is based on knowledge of the patient in the context of the family and the community, emphasizing disease prevention and health promotion.^[2] According to the World Organization of Family Doctors (Wonca), the aim of family medicine is to provide personal, comprehensive, and continuing care for the individual in the context of the family and the community.^[3] The issues of values underlying this practice are usually known as primary care ethics.

Scope of practices

Family physicians in the United States may hold either an M.D. or a D.O. degree. Physicians who specialize in family medicine must successfully complete an accredited three- or four-year family medicine residency in the United States in addition to their medical degree. They are then eligible to sit for a board certification examination, which is now required by most hospitals and health plans.^[4] American Board of Family Medicine requires its Diplomates to maintain certification through an ongoing process of continuing medical education, medical knowledge review, patient care oversight through chart audits, practice-based learning through quality improvement projects and retaking the board certification examination every 7 to 10 years. The American Osteopathic Board of Family Physicians requires its Diplomates to maintain certification and undergo the process of recertification every 8 years.^[5]

Physicians certified in family medicine in Canada are certified through the College of Family Physicians of Canada,^[6] after two years of additional education. Continuing education is also a requirement for continued certification.

The term "family medicine" is used in many European and Asian countries, instead of "general medicine" or "general practice". In Sweden, certification in family medicine requires five years working with a tutor, after the medical degree. In India, those who want to specialize in family medicine must complete a three-year family medicine residency, after their medical degree (MBBS). They are awarded either a D.N.B. or an M.D. in family medicine. Similar systems exist in other countries.

Family physicians deliver a range of acute, chronic and preventive medical care services. In addition to diagnosing and treating illness, they also provide preventive care, including routine checkups, health-risk assessments, immunization and screening tests, and personalized counseling on maintaining a healthy lifestyle. Family physicians also manage chronic illness, often coordinating care provided by other subspecialists.^[7] Many American family physicians deliver babies and provide prenatal care.^[8] In the U.S., family physicians treat more patients with back pain than any other physician subspecialist, and about as many as orthopedists and neurosurgeons combined.^[9]

Family medicine and family physicians play a very important role in the healthcare system of a country. In the U.S., for example, nearly one in four of all office visits are made to family physicians. That is 208 million office visits each year — nearly 83 million more than the next largest medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty.^[10]

Family medicine in Canada

In Canada, aspiring family physicians are expected to complete a residency in family medicine from an accredited university after obtaining their M.D. degree. Although the residency usually has a duration of two years, graduates may apply to complete a third year, leading to a certification from the College of Family Physicians Canada in disciplines such as emergency medicine, palliative care, and women's health, amongst many others. In some institutions, such as McGill University in Montreal, graduates from family medicine residency programs are eligible to complete a master's degree and a Doctor of Philosophy (Ph.D.) in Family Medicine, which predominantly consists of a research-oriented program.

Family medicine in the United States

History of Medical Family Practice

Following World War II, two events shaped the advent of family medicine. First, medical specialties and subspecialties increased in popularity, having an adverse effect on the number of physicians in general practice. At the same time, many medical advances were being made and there was concern within the "general practitioner" or "GP" population that four years of medical school plus a one-year internship was no longer adequate preparation for the breadth of medical knowledge required of the profession.^[11] Many of these doctors wanted to see a residency program added to their training; this would not only give them additional training, knowledge, and prestige, but would allow for board certification, which was increasingly required to gain hospital privileges.^[11] In 1969, family medicine (then known as family practice) was recognized as a distinct specialty in the U.S.^[12]

Education and training

Family physicians complete an undergraduate degree, medical school, and three more years of specialized medical residency training in family medicine.^[13] Their residency training includes rotations in internal medicine, pediatrics, obstetrics-gynecology, psychiatry, surgery, emergency medicine, and geriatrics. Residents also must provide care for a panel of continuity patients in an outpatient "model practice" for the entire period of residency.^[14] The specialty focuses on treating the whole person, acknowledging the effects of all outside influences, through all stages of life.^[15] Family physicians will see anyone with any problem, but are experts in common problems. Many family physicians deliver babies in addition to taking care of patients of all ages.

In order to become board certified, family physicians must complete a residency in family medicine, possess a full and unrestricted medical license, and take a written cognitive examination.^[16] Between 2003 and 2009, the process for maintenance of board certification in family medicine is being changed (as well as all other American Specialty Boards) to a series of yearly tests on differing areas. The American Board of Family Medicine, as well as other specialty boards, are requiring additional participation in continuous learning and self-assessment to enhance clinical knowledge, expertise and skills. The Board has created a program called the "Maintenance of Certification Program for Family Physicians" (MC-FP) which will require family physicians to continuously demonstrate proficiency in four areas of clinical practice: professionalism, self-assessment/lifelong learning, cognitive expertise, and performance in practice. Three hundred hours of continuing medical education within the prior six years is also required to be eligible to sit for the exam.^[17]

Family physicians may pursue fellowships in several fields, including adolescent medicine, geriatric medicine, sports medicine, sleep medicine, and hospice and palliative medicine.^[18] The American Board of Family Medicine and the American Osteopathic Board of Family Medicine both offer Certificates of Added Qualifications (CAQs) in each of these topics.^[19] Recently, new fellowships in International Family Medicine have emerged. These fellowships are designed to train family physicians working in resource poor environments.^[20]

Shortage of family physicians

While many sources cite a shortage of family physicians (and also other primary care providers, i.e. internists, pediatricians, and general practitioners),^[21] the per capita supply of primary care physicians has actually increased about 1 percent per year since 1998.^[22] Additionally, a recent decrease in the number of M.D. graduates pursuing a residency in primary care, has been offset by the number of D.O. graduates and graduates of international medical schools (IMGs) who enter primary care residencies.^[22] Still, projections indicate that by 2020 the demand for family physicians will exceed their supply.^[22]

The number of students entering family medicine residency training has fallen from a high of 3,293 in 1998 to 1,172 in 2008, according to National Residency Matching Program data. Fifty-five family medicine residency programs have closed since 2000, while only 28 programs have opened.^[23]

In 2006, when the nation had 100,431 family physicians, a workforce report by the American Academy of Family Physicians indicated the United States would need 139,531 family physicians by 2020 to meet the need for primary medical care. To reach that figure 4,439 family physicians must complete their residencies each year, but currently the nation is attracting only half the number of future family physicians that we will need.^[24]

The waning interest in family medicine is likely due to several factors, including the lesser prestige associated with the specialty, the lesser pay, and the increasingly frustrating practice environment in the U.S. Salaries for family physicians in the United States are respectable, but lower than average for physicians, with the average being $159,564^[25] and ranging from $102,358 to $212,421,^[26] but when faced with debt from medical school, most medical students are opting for the higher paying specialties. Potential ways to increase the number of medical students entering family practice include providing relief from medical education debt through loan-repayment programs and restructuring fee-for-service reimbursement for health care services.^[27] Family physicians are trained to manage acute and chronic health issues for an individual simultaneously, yet their appointment slots may average only ten minutes.^[28] Physicians are increasingly forced to do more administrative work, and to shoulder higher malpractice premiums, thus forcing doctors to spend less and less time with patient care due to the current payor model stressing patient volume vs. quality of care. Things are starting to change as more insurance carriers consolidate. They are not stressing performance but more and more volume, thus increasing insurance company profit margins. Physicians are starting to shun insurance carriers to lessen the paperwork in order to focus more on patient care as they are originally trained to do.

Current practice

Most family physicians in the US practice in solo or small-group private practices or as hospital employees in practices of similar sizes owned by hospitals. However, the specialty is broad and allows for a variety of career options including education, emergency medicine or urgent care, inpatient medicine, international or wilderness medicine, public health, sports medicine, and research.^[29] Others choose to practice as consultants to various medical institutions, including insurance companies.

Family medicine in India

Family Medicine (FM) came to be recognized as a medical specialty in India only in the late 1990s.^[30] According to the National Health Policy - 2002, there is an acute shortage of specialists in family medicine. As family physicians play very important role in providing affordable and universal health care to people, the Government of India is now promoting the practice of family medicine by introducing post graduate training through DNB (Diplomate National Board) programs.

There is a severe shortage of post graduate training seats, causing lot of struggle, hardship and a career bottle neck for newly qualified doctors, just passing out of medical school. The Family Medicine Training seats should ideally fill this gap and allow more doctors to pursue Family Medicine careers. However, the uptake, awareness and development of this specialty is slow.^[31]

Although family medicine is sometimes called general practice, they are not identical in India. A medical graduate who has successfully completed the Bachelor of Medicine, Bachelor of Surgery (MBBS) course and has been registered with Indian Medical Council or any state medical council is considered a general practitioner. A family physician, however, is a primary care physician who has completed specialist training in the discipline of family medicine.

The Medical Council of India requires three-year residency for family medicine specialty, leading to the award of Doctor of Medicine (MD) in Family Medicine or Diplomate of National Board (DNB) in Family Medicine.

The National Board of Examinations conducts family medicine residency programmes at the teaching hospitals that it accredits. On successful completion of a three-year residency, candidates are awarded Diplomate of National Board (Family Medicine).^[32] The curriculum of DNB (FM) comprises: (1) medicine and allied sciences; (2) surgery and allied sciences; (3) maternal and child health; (4) basic sciences and community health. During their three-year residency, candidates receive integrated inpatient and outpatient learning. They also receive field training at community health centres and clinics.^[33]

The Medical Council of India permits accredited medical colleges (medical schools) to conduct a similar residency programme in family medicine. On successful completion of three-year residency, candidates are awarded Doctor of Medicine (Family Medicine).^[34][35] Govt. medical college, Calicut had started this MD (FM) course in 2011. A few of the AIIMS institutes have also started a course called MD in community and family medicine in recent years. Even though there is an acute shortage of qualified family physicians in India, further progress has been slow

The Indian Medical Association’s College of General Practitioners, offers a one-year Diploma in Family Medicine (DFM), a distance education programme of the Postgraduate Institute of Medicine, University of Colombo, Sri Lanka, for doctors with minimum five years of experience in general practice.^[36][37] Since the Medical Council of India requires three-year residency for family medicine specialty, these diplomas are not recognized qualifications in India.

As India’s need for primary and secondary levels of health care is enormous, medical educators have called for systemic changes to include family medicine in the undergraduate medical curriculum.^[38]

Recently, the residency-trained family physicians have formed the Academy of Family Physicians of India (AFPI). AFPI is the academic association of family physicians with formal full-time residency training (DNB Family Medicine) in Family Medicine. Currently there are about two hundred family medicine residency training sites accredited by the National Board of Examination India, providing around 700 training posts annually. However, there are various issues like academic acceptance, accreditation, curriculum development, uniform training standards, faculty development, research in primary care, etc. in need of urgent attention for family medicine to flourish as an academic specialty in India. The government of India has declared Family Medicine as focus area of human resource development in health sector in the National Health Policy 2002 <http://mohfw.nic.in/np2002.htm>. There is discussion ongoing to employ multi-skilled doctors with DNB family medicine qualification against specialist posts in NRHM (National Rural Health Mission).^[39]

Three possible models of how family physicians will practise their specialty in India might evolve, namely (1) private practice, (2) practising at primary care clinics/hospitals, (3) practising as consultants at secondary/tertiary care hospitals.

See also

• ATC codes Anatomical Therapeutic Chemical Classification System
• Classification of Pharmaco-Therapeutic Referrals CPR
• Family nurse practitioner
• General practice
• ICD-10 International Classification of Diseases
• ICPC-2 PLUS
• International Classification of Primary Care ICPC-2
• Primary care
• Referral (medicine)
• Walk-In Clinic

References