Dr. P K Sasidharan
What is General Medicine? What is Family Medicine? What exactly is Community Medicine?
Sharing a post made exactly six years ago on 7 th July 2018 – it is more relevant now
The interface between General Medicine, Family Medicine & Community Medicine
I realize that there is some confusion at all levels in understanding the real difference between the three departments, General Medicine, Community Medicine and Family Medicine; even the doctors in these respective departments are now confused and hence I write these clarifications.
What is General Medicine? In some countries it is known as Internal Medicine. They are true experts in Clinical diagnosis with fine-tuned clinical skill, working often in a hospital setting for giving care to all individuals (above the age of 12 years). General Medicine is thus for in- patient care (hospital care) including emergency care to all the sick patients (now they are called as hospitalist in some places). They are truly masters of clinical skill, with expertise in clinical diagnosis, without too much use of technology. Because they are the people with fine-tuned clinical skill, they are also important for imparting clinical skill to upcoming undergraduates and family doctors. They are needed in all hospitals where patients are admitted. Their number should not be outnumbering the family doctors. In India right now, due to the absence of family doctors, they are the only ones to help an undifferentiated patient and hence some people have confusion as to what is the difference between General Medicine and Family Medicine. At the moment we do not have enough General Medicine doctors too, all of them are transforming to cardiologists, neurologist, diabetologists, gastroenterologist, haematologist and what not. Yet many General Medicine specialists with a concern for the community, who understands the principles of community medicine, are effectively practicing as family physicians in the absence of family physicians in India. In a nation with empowered referral system General Medicine specialists should serve as the first referral point for family physicians.
They both are multspecialists
In a society like ours without family doctors, general medicine doctors are in great need and hence some general medicine doctors at least see family medicine as a competitive branch ruining their scope of practice. If all the doctors are working for a government controlled disease care, such a thought would not have arisen. It is the greed for private practice that invites such unhealthy attitudes. This is because most of the doctors in India are now doing private practice and are not really working for the government. When it comes to paediatrics, it is for giving similar care to all individuals below the age of 1 2 years of age.
What is Family Medicine? Since it is the marginalised sections that get diseases, naturally disease care facility should also be for them. The only way to make disease care people friendly and cost effective is 1) to reduce the disease burden by providing all the basic health needs, by creating awareness and empowerment for the health needs 2) to produce large number of primary care doctors (family doctors) as in Canada, UK and the Scandinavian countries. But unfortunately India does not even know what Family Medicine is; they tend to compare or identify it with Community Medicine and General Medicine. Family Medicine doctor is someone with clinical skill and the mind-set of the community Medicine doctors. They are for providing disease care at first contact in the periphery and to promote health in a microenvironment (the home).
Family Medicine doctors should be staying closer to the families for easy access and guidance, they must be in charge of a selected population in the nearby locality- say 500 – 1000 houses or 5000 persons – irrespective of age, gender or nature of disease (continuous and comprehensive care). People registered with each doctor have to be approaching that family doctor only for all their problems. They are doctors of first contact and would give not only continued and comprehensive care but would also coordinate consultation with specialists and will naturally become friend, philosopher and guide to the families registered with them. Their primary job is to treat all kinds of patients, provide palliative care, and end of life care, they will gain the insight to promote health and prevent disease, because of the very nature of their work and because of the mind-set instilled in them through a tailor made curriculum. If things are in order with a three-tier referral system and when they are available in large numbers, the need for too many specialist doctors will naturally diminish and majority of MBBS doctors would opt to become family doctors and then treatment will become cost effective. All the countries have policies to attract more doctors into this people friendly speciality. Their availability in large numbers would avoid unnecessary and costly cross consultations, and since the service is provided near their residence, it would avoid unnecessary travel and thus would even prevent the spread of communicable disease. In reality any one with a mind-set for service can become a family doctor, but he/she can be useful only if he has acquired good clinical skill, which is the basic tool to help the individuals with health problems who approach doctors. These individuals with diseases help them to have an insight and access to the society to address the social issues, because every disease is a symptom of a bigger disease in the society. They should alert the community medicine people to the social issues behind the disease, who in turn would have to devise strategies to reduce the reduce disease burden and prevention of disease in the society by several social interventions utilising all the departments. Of course they need to get adequate insight into such bigger issues before they practice this branch.
What is Community Medicine? Several authorities including doctors in administration do not really are aware of the difference between this and family medicine. Once the vice chancellor of a medical university asked me this question, as he was not very clear about the difference. To clarify that one must recollect the old name for that branch- it was once known as Social and preventive Medicine. It is inappropriate to call it as Community Medicine; this branch is not about medicines and drugs at all, they have greater things to do. They are meant to identify and treat the macro environment, the social aspects of diseases, they should occupy the interface between medical profession (especially the family doctors) and all other departments, for promotion of health and prevention of diseases. This is because every department has something to contribute to health and wellness; the PWD, the agriculture, the law, the education, the finance, the revenue, civil supplies— all should contribute to social health. These departments are unaware of their proactive role in health care because of the absence of dedicated Social and Preventive Medicine doctors. These doctors are needed only in the teaching hospitals and they will identify the social problems and give advice to family doctors, policy makers- In reality they will be the VIPs in a health care delivery system, they are demeaning themselves by not recognising their role – It is true they have to work in close association with family doctors and need to get inputs from them and even guide them to achieve social health. In the absence of family doctors in India, some right thinking people would have thought, genuinely so, that they are the only ones with some interest in social health and hence would have decided (wrongly so) to change the name to Community Medicine. In reality, the Community Medicine doctors do not have the clinical skill to provide disease care, as an MBBS degree is not enough for it and their PG training is not oriented to provide patient care. But they have a bigger responsibility of supervising the determinants of health, making policies for making all the basic needs available and accessible to people, based on inputs from the Family doctors (not from the Single System Specialists). Thus they have to work in close cooperation with the family doctors and policy makers.
What is a referral system? Unless the GP/Family doctor refers a patient the specialists/consultants should not have the right to accept a patient. This alone will bring in discipline in medical practice. The industry driven doctor- shopping in India can be controlled only with enforcement of a strict referral system. I do not know why the authorities are delaying the introduction of family doctors and a referral system in India.
