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Family Medicine and other specialties- the synergy that is needed for the current health care scenario in India


Prof. Dr. Sunil Abraham


The history of the growth of Family Medicine around the world has been one of struggles and overcoming challenges. Different specialties came up in response to the needs of the society and medicine, at different times. Some of the specialties emerged out of need to focus on certain age groups, organs, stages in life, procedures, diseases etc. From this has come the current milieu of specialisation and sub-specialisation. There is no question that we need excellent specialists and sub- specialists for dealing with the increasing complexity of medicine and the changes that are rapidly happening in the management of diseases. This certainly has made an impact on health by improving the diagnostic capabilities for more early and accurate diagnosis and also in offering cutting edge technology and treatment modalities which are more focused and with lesser side effects. However these developments do have their difficult side when seen from a patients’ perspective. It was this need of the patients that led to the demand from the society for generalist- physicians who would be patient- centred and wholistic in their approach.

The increasing focus on the diseases has left many patients frustrated and confused. People are realizing that even though they have doctors for their many diseases or organs, they do not have someone who is their personal doctor; the one whose focus is on them and who will journey with them through the cycle of life, during illness and even otherwise. They are missing the personal physician whose focus is to keep them healthy and proactively work with them as partners in this process. This fragmentation of care and frustration of patients along with the current suspicion of the medical profession has brought the doctor- patient relationship to an all time low in our country.

How can the single subject specialists and the Family Medicine specialists work together in this situation to improve the care of patients and also win their trust? In addition to increased access to competent, affordable health care, a network of well-trained family physicians will bring the following benefits to other specialists.

  1. The common and stable chronic diseases and minor illnesses will be managed by the family physicians, enabling the other specialists to focus on the complex and rare conditions that need their knowledge and skill. This will make their work fruitful and more professionally satisfying.
  2. Early diagnosis and appropriate referral by the family physicians will reduce the admission of patients who present with complications and are difficult to treat. In addition to the reduced morbidity and mortality, this will reduce the cost to the health care services of the country. The cost of early diagnosis of hypertension by a member of the primary care team by regular screening in the community, is certainly lower that the treatment of a complication of hypertension such as stroke or myocardial infarction.
  3. The current overcrowding of tertiary hospitals and medical colleges with patients who can be managed at the community health centres (CHCs) by competent family physicians can be avoided. The CHCs have become dysfunctional due to lack of appropriate generalists and this causes referral to the higher centres of patients who otherwise could have been managed there.
  4. The quality of care in the referral hospitals will improve.
  5. If patients are referred to a specialist by their family doctors with whom they have a long-term relationship and if the specialists asks for a certain treatment or investigation, the patients can confirm with the family doctor if this was appropriate. A professional relationship between the family physicians and the specialists will thus increase the trust of the patients and mitigate the atmosphere of distrust and anger that pervades our country now. A patient going to a single subject specialist often is going to a stranger with some apprehension. But a patient referred by his or her family physician goes with the background of a longitudinal relationship of trust and this will certainly be an advantage for the specialist.
  6. The specialist can send a feedback to the family doctor of the patient with details of investigations and management plan and this will enable the patient to enhance trust in the specialist and the medical profession. This practice of feedback to the family physician that referred the patient is mandatory in countries like Australia with a robust system of family medicine.
  7. Often the specialists may not have adequate time to discuss the disease and treatment plan with the patients or it might be too complex with involvement of a team of specialists. There could be changes in medications, treatment plan etc. that could leave the patient bewildered in the maze that modern medicine has become. Often the onus is on the family physician to see the big picture and explain to the patient and family about the disease and the treatment.

Considering all these, the relationship between the family physicians and other specialist should be that of trust, cooperation and synergy. That will not only help the growth of the medical profession and regain the trust of the society; it will also help the quality of care for the patients resulting in a win-win situation for all.

Case scenario 1

Ramesh, a 50 year old businessman had been coughing for the past 1 month and went to see a pulmonologist based on the information he got from the internet. He was a smoker and had been losing weight too. A chest Xray showed a shadow in the right upper zone. The pulmonologist was concerned that this could be a malignant lesion and advises a bronchoscopy. Ramesh had heard stories of unethical practices by the medical profession and became suspicious of his intentions. He goes to another pulmonologist for a second opinion and is advised the same procedure but the cost was higher in this hospital. He scouts around and finally gets the scopy done which showed tuberculosis. The hospital put him on many tablets and he goes home upset about his disease and worried about the stigma it carried. He had many questions about the disease, the medications, health of his family, work etc. He felt like a cog in the system and was not sure if he would get better. He longed for a doctor to sit with him, listen to him and explain things to him.

Case scenario 2

Rashid went to his family doctor as he hadm been coughing for the past 2 weeks and losing his weight too. He is a smoker and his family doctor had been advising him to quit for some time. His uncle died of lung cancer and he is worried if he also has cancer. A chest Xray showed a shadow in the right upper zone. He could not bring out any sputum and his family doctor advised him to see a pulmonologist since he would require a bronchoscopy. The doctor explained to him the need for the test, the possible outcomes and risks involved. He was referred to a skilled pulmonologist that the family doctor knew . Since Rashid had known his doctor for a long time and his whole family was being cared for by him, he completely trusted his advice and judgement. He came back with a report and letter from the pulmonologist addressed to the family doctor mentioning that he had tuberculosis. This was a devastating news for Rashid. His family doctor took time to explain the disease, the treatment involved, the side effects, precautions to be taken and a follow up plan. He also informed him the need to screen his family members and discussed concerns about his health, work etc. Rashid was happy that his disease was found out early and that he had someone to guide him through the maze of the complexities of modern medicine.


Prof. Dr. Sunil Abraham

MBBS, DNB (Family Medicine), DFM, FRACGP
Dept. of Family Medicine,
CMC, Vellore
Tamilnadu

Dr Sunil Abraham is professor and head, department of Family Medicine, Christian Medical College, Vellore. After completing his MBBS from Calicut Medical College, he worked for a year in a rural mission hospital in Umri, Maharashtra. This exposed him to the realities of health needs in India and the need for more generalists, even as he handled patients in a 45 bedded hospital. After working almost a year in internal medicine department in Christian Fellowship Hospital, Oddanchatram, in Tamil Nadu, he was convinced of the need and the Lord’s call to take up Family Medicine and joined the DNB Family Medicine course there and qualified in 1998. From the year 2000 he has been working in CMC Vellore, initially in the rural RUHSA hospital and from 2001 in the Low Cost Effective Care Unit, a 48 bedded unit for the urban poor. He worked as a GP in Melbourne, Australia for 3 years in a GP training practice. His areas of interest include teaching Family Medicine, Family Medicine for the urban poor and Whole Person Medicine. He is currently on the National Board of Examinations’ PG committee for Family Medicine and was member of the Medical Council of India’s expert committee on Family Medicine. He is married to Mary who is an ENT surgeon and has 2 daughters.
Email sunil.george.abraham@gmail.com




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