A few weeks ago I was interviewing Dr Ashoka Prasad, a psychiatrist and campaigner for improving the rights of those with mental illness, for a popular Indian medical news portal, and was grabbed by a point that he made. The interview was mainly about the state of mental healthcare in India, yet Prasad stressed the role of primary healthcare in providing a foundation for effective psychiatric care, and the criminal under-emphasis of the importance of primary care that we see in India today.
Dr Prasad also expressed his disappointment that only two institutions in the country have thus far expressed their interest in offering a postgraduate course in family medicine.
India is a nation characterised by a vast and dispersed rural population, strong social ties, and less nuclear families: all features that mean a strong primary healthcare system would be highly advantageous for the population. Arguably, the primary healthcare model is not only the most beneficial one in the Indian context, but also the most economically sound one. For this reason, India was quick to—at least theoretically—implement a model of primary healthcare (long before the declaration of Alma-Ata). Furthermore, we were also the first non-white, post colonial independent country to institute reforms in mental health, the most important of them being the integration of mental healthcare with primary care services.
Today, after nearly 70 years of independence, we wonder what went wrong with primary care in India. More so, one can’t help but consider if starting a postgraduate course in family medicine is the solution.
It’s dismaying and surprising that a nation like India, which can benefit so much from the primary care model, has never conceptualised the primary care physician as a specialist—unlike many western nations. A GP (general practitioner) was instead intended to be a basic, bare minimum doctor—the point from which the roads to “exalted” specialties emanate. The diverse skill set needed to run a successful family practice, and the fact that a general grasp of different specialties makes a worthy specialty in itself, has never been appreciated.
This GP-specialist dichotomy is therefore a deep seated feature of our healthcare culture, and one that has robbed family medicine of its prestige. This dichotomy is what has led us to believe that a simple and cursory overview of different specialties during MBBS is all it takes to run a family practice—when, in fact, a fresh MBBS graduate is in desperate need of further years of supervised training to be able to establish a robust family practice. It’s not hard to see how this perception of family medicine contributes to other problems that ail the Indian healthcare system: large scale irrational prescribing, injudicious referral of patients, sub-ethical practice, and soaring healthcare expenses.
Increasing the number of postgraduate places in family medicine, though a much needed step, would therefore be a superficial solution to the problem and would fall short in addressing it fully. The harmful GP-specialty dichotomy is a problem of perception that runs through the very core of our healthcare system, and much more needs to be done to confer to family medicine the status it needs to be on par with other specialties. A family medicine postgraduate programme can only be successful when it is attractive to fresh graduates, which would require us to address certain fundamental deficits in our medical education.
One of those deficits is the lack of any substantial mention of family medicine in the undergraduate MBBS (bachelor of medicine, bachelor of surgery) curriculum. It’s futile to expect graduates to be interested in family medicine without covering its importance in their formative years at medical school. India urgently needs to acquaint young doctors with the value of family medicine through the MBBS curriculum and eradicate the poor perception of it that has built up over the years.
Undergraduate students also need to be trained for a considerable period of time outside of tertiary care institutions in an environment focused on primary care. As a fresh graduate, I can’t recollect my clinical postings in primary care being given due emphasis.
It’s also unfortunate to note that family practitioners find no faculty positions, and are barred from teaching in medical colleges. Unless we rectify such an arrangement, whereby the faculty is entirely composed of specialists and devoid of family practitioners, the importance of primary care cannot be affirmed. Not only do family practitioners need to be employed in medical colleges to communicate the value of primary care, they should also have a prominent voice in the medical administration. Last but not least, they need to be remunerated on a level with other specialists.
Changing the culture of a nation’s healthcare system is no easy task, and in this instance it will mean challenging the prevailing perceptions of family medicine and redesigning India’s education system. The earlier this is realised, the better.
Soham D Bhaduri is a medical graduate from Rajiv Gandhi Medical College, Maharashtra, India, and is currently working as a medical officer in Alibagh, India. He has a keen interest in writing about healthcare and medical education, and conducts physician interviews for GP CLINICS, an Indian CME journal for family physicians.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.