The Concept of Family MedicineFamily medicine is an independent academic discipline and speciality of medical science. Family medicine developed as a counterculture in response to rapid fragmentation of medical care during post second world war period into speciality and sub speciality care in the much of the developed world. The concept evolved as a concept of medical care to cater to the growing demand of the people for personalized, continued and comprehensive care.   

Thus Family medicine (FM) is a medical speciality devoted to comprehensive health care for people of all ages and provides continuing and comprehensive health care for the individual and family across all ages, genders, disease and parts of the body. It is based on knowledge of the patient in the context of the family and the community, emphasizing disease prevention and health promotion.  

While family medicine evolved since 1950s and 1960s in USA and UK to its present form today.  It has been gaining momentum in Middle east, Africa, Latin America and South Asia during last couple of decades. In India there is a growing recognition and value for family medicine. It has been realized that competent primary care physicians can form the back bone of health care delivery system and can play a vital role in fulfilling the Human Resource Requirment of National Rural Health Mission which is gradually evolving into the National Health Mission (NHM).

Definitions

Definition of Family Medicine Speciality: 
Family medicine is the academic discipline that both serves and leads the specialty of family practice. It organizes curiosity, systematizes observation, advances understanding, communicates knowledge, and challenges convention. The form of family practice follows the function of family physicians.

Definition of Family Practice
Family practice is the professional discipline that trains and sustains the doctors who practice the evolving arts and sciences of family medicine. Family practice is patient centered, evidence based, family focused, and problem oriented. It shares historical roots and a worldwide movement with general practice.

European Definition of Family Doctors
Family doctors are specialist physicians trained in the principles of the discipline. They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespective of age, sex and illness. They care for individuals in the context of their family, their community, and their culture, always respecting the autonomy of their patients. They recognise they will also have a professional responsibility to their community. In negotiating management plans with their patients they integrate physical, psychological, social, cultural and existential factors, utilising the knowledge and trust engendered by repeated contacts. General practitioners/family physicians exercise their professional role by promoting health, preventing disease providing cure, care, or palliation and promoting patient empowerment and self-management. This is done either directly or through the services of others according to health needs and the resources available within the community they serve, assisting patients where necessary in accessing these services. They must take the responsibility for developing and maintaining their skills, personal balance and values as a basis for effective and safe patient care. Like other medical professionals, they must take responsibility for 8 continuously monitoring, maintaining and if necessary improving clinical aspects, services and organisation, patient safety and patient satisfaction of the care they provide.

AAFP definition of family physician:
Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity. (1986) (2010 COD).

A physician who is educated and trained in family practice - a broadly encompassing medical specialty. Family physicians possess unique attitudes, skills, and knowledge which qualify them to provide continuing and comprehensive medical care, health maintenance, and preventive services to each member of the family regardless of sex, age, or type of problem, be it biological, behavioral, or social. These specialists, because of their background and interactions with the family, are best qualified to serve as each patient’s advocate in all health-related matters, including the appropriate use of consultants, health services, and community resources.

National Board of Examination (NBE) India definition of Family Medicine 

Family Medicine is defined as a specialty of medicine which is concerned with providing comprehensive care to individuals and families by integrating biomedical, behavioral and social sciences. As an academic discipline, it includes comprehensive health care services, education and research. A family doctor provides primary and continuing care to the entire family within the communities; addresses physical, psychological and social problems; and coordinates comprehensive health care services with other specialists, as needed.

History of Family Medicine Specialty 
Historically doctors used to be generalist practitioners. However during the past fifty years, technological and scientific advances have brought exciting prospects in medicine. The fragmentation of medicine into subspecialties has produced advances in our understanding of diseases. Generalist mode of practice languished, while spectacular advances were made by subspecialists who were concentrated in hospitals, with expertise in single organs, systems or diseases, in the performance of specific procedures or in the use of expensive and advanced equipment.

It is precisely the development of these subspecialists and their concentration in hospitals that gave rise to a demand in the community for a physician, who was caring and accessible and who was also more expert and better trained than the general practitioner of those days, but who could act as the patient’s guide, protector, philosopher and friend. This led to the emergence of family practice as the natural inheritor of the ancient traditions of general medicine.

In USA, the American Academy of General Practice (AAGP) was established in 1947 to give voice to the decreasing number of generalists. A series of events after that paved the way for family medicine to become an accredited, board-certified, professional specialty. In 1966, three landmark reports were released by commissions that had been appointed to study the problem of declining generalists. These include:

The Folsom Report 

concluded that “every American should have a personal physician to ensure the integration and continuity of all medical services.” It also stressed the importance of preventive medicine, the use of community resources and the importance of caring for the patient as a whole.

              

The Millis Report

 Focused on graduate medical education and determined that family     medicine needed to be a board-certified specialty.

The Willard Report 

Recommended residency training programs for family medicine and   specified the establishment of a board to oversee certification. The American Board of Family Practice was established three years later in 1969.

In 1952, the British College of General Practitioners was formed. Then in 1958, The Royal  Australian College of General Practitioners was established. The family medicine counterculture was particularly strong in America and the general practitioner community worked towards a new general practice and even changed the name of the discipline from “general practice” to “family medicine” to reflect a renaissance in its culture.

Since then the counterculture movement has become worldwide. In India, though the General practice associations have existed in form of IMA College of General Practitioners (IMA CGP) and Federation of Family Physicians of India (FFPAI) represented by traditional old GPs. The forum for development of academic family medicine was only formed in 2010 in the name of Academy of Family Physicians of India (AFPI).

Changing Nomenclature 
New disciplines need new terminologies, especially when the older terminology implied lower levels of specialised training and competence as well as lower status. The different historical backgrounds to medical practice in each country have produced different terminologies for family physicians and family medicine. The term ‘family physician’ originated in USA, where it was deemed necessary to distinguish between family medicine and traditional general practice

Three alternatives to the term ‘general practitioner’ have been proposed (a) Personal physician (b) Primary physician and (c) family physician. The term ‘Primary Physician’ was used in the report of the Citizen’s Commission on Graduate Medical Education (1966) chaired by Dr. John Millis. The adoption of the term ‘family physician’, by the American Academy and the Canadian College, promoted the universal use of this term to describe the new specialist. The health policies of several developing countries including that of India are were profoundly influenced by WHO’s concept of primary health care (Health For All – HFA) movement for basic and minimal health care services.

For a country like India term ‘Primary physician’ or ‘primary care physician’ are also more suitable and appropriate terms where family practice takes on a strong community orientation in the context of a national primary healthcare programme. This term covers wide range of primary care providers including urban GPs, rural physicians, medical officers, emergency physicians, occupational physicians, doctors employed in military and public sectors enterprises etc. These doctors often provide undifferentiated clinical and preventive services to the communities they serve. 

In the UK, the term ‘general practice’ continues to exist by custom and statute but with a much higher level of acceptance and prestige. In Australia, the term ‘general practitioner’ is still in use, but the state-funded training programme is called the ‘family medicine programme’. In Europe the term ‘medicine generale’ is in use.

Practitioners of Family Medicine 
By convention the term ‘family doctor’ should be understood as referring to the following: (a) family physician, (b) general practitioner, or (c) medical officer. A family physician has postgraduate training in Family Medicine. A medical officer is a generalist in the public sector, without postgraduate training.A medical officer is a generalist in the public sector, without postgraduate training.A general practitioner is qualified private practitioner without postgraduate training.

Family medicine in India
Family medicine is a recognized speciality since 1983 by an amendment in Medical Council of India Act. Since 2005 The NBE (National Board of Examination) has been promoting family medicine as a special human resource need for National Rural Health Mission (NRHM). The National Board of Examinations is an autonomous organization functioning under the Ministry of Health & Family Welfare, Govt. of India. The prime objective of the Board is to conduct post-graduate examinations of high and uniform standard throughout the country in 42 specialties including DNB is Family medicine. National Board of Examinations is keen to encourage family medicine as a specialty programme since it serves the needs of the society by providing comprehensive and continuing care of the patients in their own settings.

As per National Board of Examination, after qualifying the final examinations the candidate should be able to function as a junior consultant (specialist) in Family Medicine. He/she should be able to render health services to the community by providing health care to all members irrespective of age, sex, culture and socio-economic background. He/she should be able to decide for appropriate referral in order to provide secondary/tertiary health services when necessary. He/she should be clinically competent and should be able to take personal responsibility for rendering comprehensive and continuing care of his patients in their own family settings.

Various policy deliberation and discussions have supported the concept of family medicine in India. These include (a) Bhore committee report (b) Bajaj Commission (c) Reorientation of Medical Education (ROME) (d) Mehta Committee Report (e) Prime Minister’s National Knowledge commission (f) National Health Policy 2002 (g) Task force for development of human resource for National Rural Health Mission (h) Planning Commission’s Steering Committee on Health in 12th Plan (i) Pradhan Mantrai Swastha Surakhas Yojana (PMSSY) by establishing department of Community and Family Medicine at new AIIMS like institutions. (j) Medical Council of India’s Vision 2015.

Family Medicine in India: Recent developments:

Calicut Medical College Kerala has become first institute to start the MD family medicine program in India. Earlier only DNB family medicine training was available at National Board of Examination affiliated institutions. Under PMSSY, all recently established AIIMS like institutions have started department of Community and Family Medicine which is a welcome change. AIIMS Bhopal has declared developing family medicine as one of its primary priorities.

Family medicine seats availability in the DNB system for Jan 2013 Session (there are two session, other one starts in July). 

www.cet.natboard.edu.in/pdoofs/Seatsfordnbcet.pdf

Leading academies and colleges of family medicine in world 
www.globalfamilydoctor.com/AboutWonca/Regions.aspx