History of Family Medicine

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Dr Indhu A J

Family Medicine is considered to be the oldest medical specialty, family medicine is a practice devoted to providing comprehensive care to patients of all ages and backgrounds.The changes taking place in the field of medicine is inevitable and can be understood only if they are viewed from the perspective of history. Centuries ago patients tried to take care of themselves before resorting to healers. In the 17^th and 18^th centuries relatively few physicians were available to the general population. Most of them practiced in 3 different settings like by travelling along the country, by serving the urban centres or as personal attendants to the wealthy or aristocratic family. The Apothecaries Act in 1815 allowed Surgeons trained by apprenticeship and apothecaries dispense and sell medicines and also provide the medical needs of the poor and rural people. The qualifying examination was LSA (the Licentiate of the societies of Apothecaries), midwifery was later added.

In the 19 ^th and early 20^th centuries the vast majority of medical profession comprised General Practitioners, those practicing medicine, surgery, obstetrics. The surgeons and apothecaries were gradually integrated with the physicians to form the modern medical profession as per the needs of the people. Each family had its own doctor that enabled continuing care and family approach. This General Practitioner was an important person for families and communities.

The 20^th century is considered the era of specialization by scholars of the history of medicine^1,2. In 1910 Flexner³ presented a report that marked the beginning of decline of General medicine in favour of medical specialities and its disappearance from universities. He had already warned that care should be taken because the overall view of patient could be lost and that General Practitioners such as Osler, Janeway, Halsted^3,4,5 should not be ignored. There was a concomitant rise of specialists and superspecialists.Osler had already warned that “the good physician treats the disease; the great physician treats the patient who has the disease²". This resulted in fragmented patient care and gradually weakened the doctor patient relationship. There were different varieties of specialists, different varieties of diseases but no one to give a complete care to the patient. This decline of General practitioners created a public concern that led to the movement to create the specialty of Family Medicine.

As the father of modern Hippocratic medicine, William Osler^4,5 shifted the foundations of 19^th century medical education from classes to bedhead of patients, bringing with him study and humanity in doctor- patient relationship. Family medicine had three major influences: social, humanistic medicine; scientific, academic medicine and the development of primary care.

In the 1940s generalist began to initiate steps to elevate general practice to “specialty” status. The model of neighbourhood health centres⁶ in the USA was also an influence, as was the Karkian model in Phoela(South Africa)in the 1940s which led to community oriented primary care. The American Medical Association was set up in 1946, and the American Academy of General Practice was founded in 1947, the first scientific society of family physicians.

Ian R McWhinney: The Father of Academic Family Medicine outlined the philosophical basis, principles, and knowledge of this clinical discipline. He started his first academic department of family medicine located in the University of Western Ontario in 1968. He was an intellectual force behind the patient centred clinical method of approach to the patient. He was instrumental in transforming FM worldwide by his visionary writings and research.

In the second half of the 20^th century, even though there were scientific and technological advances there were lots of shortcomings like lack of comprehensive care, high costs, and lack of holistic approach. The specialty of Family Medicine appeared in the 1960s and spread to various countries in the 1970s⁷.It was decided to initiate steps to improve the profession, the working conditions and give necessary training so that a practitioner could handle the needs of the population with ease.

The Royal college of General practitioners (RCGP) is the professional body for General Practitioners in the United Kingdom founded in 1952 in London, England, It drew up its first document on postgraduate training in 1965, entitled “special vocational training in General Practice”⁸.

In the 1960s WHO report 1963: “Training of family physicians for family practice” which recommended a post graduate study programme specifically designed to meet the needs of the General Practitioner.

The MILLIS commission report (1966) entitled “the Graduate Education of Physicians”⁹ became the forerunner for the development Family Practice residency programmes in USA. The conclusion of Millis Report: Family Practice needed to be a Board Certified Specialty.

The European Union of General Practitioners /Family Physicians(UEMO) works in the interests of the GPs/FPs and have specific training periods ranging from 2 to 6 years.

WONCA- World Organization of Family Doctors, a global non-profit professional organization representing family physicians and general practitioners from all the regions of the world was founded in the year 1972 at the fourth World Conference of General Practice in Chicago. It has official collaborations with the World Health Organization (WHO) representing family doctors and Family Medicine.

The main activities are to improve the quality of life of all the people through defining and promoting its values, and maintaining high standards of care in general practice/ Family Medicine. According to 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 community¹⁰.

Family Medicine in India

Family medicine came to be recognized as a medical specialty in India only in the late 1990s¹¹.In India a medical graduate who has completed MBBS course (Bachelor of Medicine, Bachelor of Surgery) and registered with Indian Medical Council or any state medical council is considered a general practitioner. Unfortunately, the trend in India is that, specialty and super specialty hospitals are flourishing and medical care has become fragmented, the numbers of traditional General Practitioners are decreasing. The patients had to visit multiple health providers for various issues leading to frustration, dissatisfaction and increase in costs was a concern.

The National Health Policy 2002 by the Government of India identified “FM” as a focus area of human resource development¹². The FM specialty has started to develop in response to the fragmentation of medical care. Several other policy documents by the Government have talked about developing FM training program’s which includes - The Mehta committee report, NHRM task force on human resource in health and planning commission‘s 12^th plan paper on health forecasted requirement of 15000 family physicians per year¹³. Now the Government of India is promoting the practice of Family Medicine by introducing three year residency programmes leading to Diplomate of National Board (DNB) in Family Medicine at teaching hospitals or Doctor of Medicine (MD) in Family Medicine at accredited medical colleges. Government Medical College, Calicut had started MD (FM) course in 2011.AIIMS institutes have also started a course in community and family medicine recently. 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 curriculum¹⁴.

The Academy of Family Physicians (AFPI) of India is a professional academic organization¹⁵ in the year 2010,registered as a non-profit society in India¹⁶. AFPI has been founded with the aim of promoting family medicine and primary health care¹⁷. There are several state chapters in this organization and membership base across India.AFPI is a full member of WONCA ( World Organization of Family Doctors). The academy is working towards empowering primary care physicians in India for better health outcomes¹⁸. The Journal of Family Medicine and Primary Care is a peer- reviewed indexed journal published by the academy , established in January 2012 with quarterly issues. FMPC (National Conference on Family Medicine and Primary Care) is an official academic event of AFPI conducted every two years. Post graduate updates are also held along with the National conference to facilitate the students to upgrade their knowledge and skills. AFPI has instituted an oration award in the name of Dr.Padmanabhan, a public health expert and a great supporter of Family Medicine. AFPI has supported equal professional opportunities and career ¹⁹ progression for primary care physicians at par with any other specialty²⁰.

References

[1] "Choosing a Primary Care Provider". Medline Plus Medical Encyclopedia. Retrieved 30 June 2009.

[2] "Family Medicine, Scope and Philosophical Statement". American Academy of Family Physicians. Retrieved 17 July 2009.

[3] Nesbitt TS (Jan–Feb 2002). "Obstetrics in family medicine: can it survive?" (PDF). The Journal of the American Board of Family Practice. 15 (1): 77–9. PMID 11841145.

[4] Kinkade S (April 2007). "Evaluation and treatment of acute low back pain". American Family Physician. 75 (8): 1181–8. PMID 17477101.

[5] "Facts About Family Medicine". American Academy of Family Physicians. Retrieved 17 July 2009.

[6] Adams B (March 17, 1995). "Primary Care: Will more family doctors improve health care?". CQ Researcher. 5 (10).

[7] "Patient Brochure". American Board of Family Medicine. Retrieved 30 June 2009.

[8] "Certificates of Added Qualifications". American Board of Family Medicine. Retrieved 30 June 2009.

[9] "Family Physician Workforce Reform". American Academy of Family Physicians. Retrieved 17 July 2009.

[10] "Global Family Doctor". Wonca Online. Archived from the original on 20 March 2012.

[11] Abraham S. "Practicing and Teaching Family Medicine in India" (PDF). Society of Teachers of Family Medicine. Retrieved 12 November 2012.

[12] National Health Policy. 2002. [Last accessed on 2015 Dec 14]. Available from: http://www.mohfw.nic.in/WriteReadData/l892s/18048892912105179110National%20Health%20policy-2002.pdf

[13] Report of the Working Group on Tertiary Care Institutions for 12th Five Year Plan Planning Commission of India. 2012. [Last accessed on 2015 Dec 14]. Available from: http://www.planningcommission.gov.in/aboutus/committee/wrkgrp12/health/WG_2tertiary.pdf .

[14] Zachariah P (September 9, 2009). "Rethinking medical education in India". The Hindu. Retrieved 12 November 2012.

[15] "Academy of Family Physicians of India". Health Market Innovation

[16} "Academy of Family Physicians of India (AFPI) has prepared more than one thousand doctors who are committed to provide their services in the field of family medicine and primary healthcare". EThealthworld.

[17] "About Us". Academy of Family Physicians of India. Archived from the original on 6 November 2014. Retrieved 27 October 2014.

[18] Kumar, Raman (1 January 2012). "Empowering primary care physicians in India". Journal of Family Medicine and Primary Care. 1 (1): 1–2. doi:10.4103/2249-4863.94438. PMC 3893943. PMID 24478991.

[19] "Doctors with MD/DNB (Family Medicine) to be appointed at CHCs, sub-district hospitals Indian Medical Times"

[20] "Role models in family medicine missing in India". India medical times.

Editor's notes

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Dr. Indhu A J

MBBS,DNB(Family Medicine),FICM
Consultant Critical Care,Lourdes Hospital,Ernakulam
Consultant Physician,Vijayalakshmi Medical Centre,Ernakulam