These days,the old doctor sitting by the bedside with the affectionate address and the black doctors bag is a sight which now exists only in grandmothers tales. The general practitioner (GP) or family physician is now an extinct profession. There are many theories about the extinction. Some say the medical generalist lost out to peer pressure of medical specialisation becoming the ticket to money and glory. Others say the loss of ethics in medical practice drove the GP out of business,as did faulty health policies. But the bottomline remains. The family physician,who was the first line of medical defence for many Indians,is now gone. However,India is a late entrant to a league that includes all developed nations. As early as 1965,an article written in CA (A Cancer Journal for Clinicians) pointed out how the number of GPs in America had almost halved between 1958 and 1964. The article said in 1950 50 per cent of medical graduates chose general practice,in 1964 only 18 per cent did. Figures are less easy to come by here but India is going through a similar phase where specialisations associated with glamour and money are the flavour of the day in the medical profession. As Dr Vikas Malhotra,associate professor ENT at Maulana Azad Medical College says,This effectively reduces the patient to a conglomeration of heart,lung,eyes,ears and limbs rather than a single human being who has to be treated as a whole. I feel the need for a GP all the time because a lot of my patients come with comorbidities (patients with several disorders or diseases in addition to the primary disease). I am forever sending them to a specialist because it is beyond me to develop an integrated treatment plan. All the other doctors I send the patient to are also specialists,so even they are unable to make the plan. This is hardly an ideal situation. Policy deficit could be one of the many reasons which has resulted in the death of the GP. Dr Mohan Rao of the Centre for Social Medicine and Community Health and Jawaharlal Nehru University feels that the pressure to over-prescribe medicines and send people for unnecessary tests is forcing people away from general practice. Changing social values mean that patients do not like it if their doctor sends them away without a long prescription or tests. Many of my friends working in private hospitals tell me that they have set targets for diagnostic tests and one of them once told me do not refer patients after the 20th of the month. Such is the rot that my teacher of obstetrics saw my wife only after she had paid for an ultrasound. She chose not to undergo the test, said Dr Rao. He recounts the story of how his GP of many years told him one day that he had decided to give up general practice because it is impossible to do so without compromising high ethical standards. I have since been looking for a GP. Do you have one? he says. A slow decline There were aspects of earlier medical education that lead to the growth of GPs. One was the dearth of postgraduate medical seats and the other was the tradition of house jobs which allowed fresh MBBS doctors to rotate from one department to another,picking up basic skills of all specialities. This was the ideal recipe for a good GP. Eventually as government jobs became prized rarities,a new regulation limited every person to just two house jobs. Gradually,the GPs died a slow death in India. However,doctors still cite the UK system as the model of general practice where a medical graduate needs to pass an examination to become a GP. In that system,specialists do not entertain patients referred by a GP. Looking towards family medicine Dr K S Reddy,president of Public Health Foundation of India says: Earlier when PG seats were limited,MBBS graduates felt confident enough to tackle most common ailments. However,now the emphasis of training has shifted and their ability to tackle common ailments has dwindled. They feel more comfortable in a hospital environment. There is no doubt that the days of the MBBS GP are over. The way forward is emphasis on an MD programme in family medicine. The other alternative should be linking of medical colleges to district and community health centres so that students start getting comfortable in a community set up. Encouraging MD family medicine programmes is a stated policy of the Medical Council of India and the Union Ministry of Health and Family Welfare. However,the ground reality is that not one such programme has seen the light of day. This despite the fact that there are huge vacancies for specialists in health centres run under the National Rural Health Mission. Dr Anand Zachariah,professor of medicine at Christian Medical College,Vellore,who is the course organiser for a PG diploma in family medicine run by the hospital,is also in favour of linking up medical colleges to district and primary health centres. That will serve the dual purpose of training and also tiding over the manpower limitations. There is also a need for incorporation of a greater amount of family medicine component in the present MBBS curriculum. The third requirement is to extend distance learning to bridge the gap between policy and practice, he says.
