Rethinking family medicine careers

Reforms are needed in career pathways for family medicine trainings in Pakistan

Rethinking family medicine careers

Family medicine is recognised as a speciality in many countries globally. However, in some regions, predominantly low- and middle-income countries, it is largely missing.

A number of studies in the South Asia region have shown lack of awareness among undergraduates about this discipline. As a result, many fresh graduates do not opt for family medicine as a career and spend years without a post graduate qualification. Other reasons for not choosing this specialty include a lack of role models, shortage of faculty and scarcity of post graduate qualifications. The structured training pathways in family medicine currently available i.e. a 2-year membership and a 4-year fellowship, carry no stipends. While a number of medical graduates consider popular specialities of medicine, surgery, gynaecology, a significant number remain outside the residency system due to lack of post graduate training positions. Such doctors can be considered for family medicine trainings.

In order to achieve this, reforms at both undergraduate and postgraduate levels are essential. Changes that need to be incorporated are listed below with details in subsequent paragraphs.

i) Establishing FM departments in medical institutions.

ii) Including FM in undergraduate curricula.

iii) Adding post-graduate qualifications offered by universities and degree-awarding institutions.

iv) Creating stipend posts for run through programmes in already existing post-graduate induction pathways.

v) Utilisation of existing general practitioners’ clinics as training sites.

vi) Flexible regulations for practicing GPs to join academic positions in order to deal with paucity of faculty.

vii) Ensuring mandatory FM qualifications for medical officers practicing in public and private sector facilities. This will allow provision of knowledge base and clinical skills to become safe and competent practitioners.

viii) Nationwide awareness campaigns to promote primary care/ family practice system.

ix) Setting up posts within public sector healthcare facilities for family medicine doctors.

x) Establishing national and provincial task forces to oversee implementation of the proposed reforms.

The concept of trained family physicians is non-existent, as family medicine is not an established speciality. The reasons for the under-development of this discipline include lack of postgraduate training, lack of job opportunities and poor monetary incentives. Undergraduate training mostly happens in tertiary hospitals with very little or no exposure to primary care. As a result, they do not acquire the required skills. Lack of exposure to family medicine in undergraduate years has made it a less popular speciality amongst medical graduates in Pakistan.

Over the last decade, there has been a greater emphasis on improving the education and training of family physicians and many institutions across Pakistan have started providing accredited postgraduate training programmes in family medicine.

The focus should be on developing skills in advanced consultation techniques, medical teaching and leadership that are key to improving patient care. General practitioners/ primary care physicians need to be equipped with the knowledge, skills and attitudes needed to provide comprehensive, continuous and appropriate healthcare to individuals and families.

The World Health Organisation’s Regional Office of Eastern Mediterranean (WHO-EMRO) has developed a regional professional diploma programme that has already been endorsed by experts in Pakistan. The curriculum is mapped to the competencies of family medicine/ general practitioner doctor as defined by the WONCA, the ACGME and those of the College of Family Physicians of Canada for the speciality of family medicine.

The concept of trained family physicians is non-existent, as family medicine is not an established speciality.

The 63rd session of the Eastern Mediterranean Regional Committee passed a resolution in which it urged member states to incorporate family practise approach into primary health care services as an overarching strategy towards Universal Health Coverage; strengthen the capacity of FM departments; and establish bridging programmes for general practitioners to achieve the target of 3 family physicians per 10,000 by 2030. Pakistan will require more than 70,000 trained family physicians to achieve this target.

Most general practitioners go directly into practice after completing their undergraduate training without any further education as few training programmes exist in the speciality. Existing GPs also need job capacity-building training programmes so that they can provide better-quality healthcare.

Reforming career pathway in family medicine involves enhancing various aspects of training, practice and support to attract and retain healthcare professionals in this speciality. Here are a few strategies that may help achieve this goal:

Enhanced training programmes:

Update family medicine residency programmes to incorporate more comprehensive training in areas such as chronic disease management, mental health, preventive care and telemedicine. Progressive increase in the number of fellowship and membership qualifications by the College of Physicians and Surgeons Pakistan, namely FCPS and MCPS trainees and training sites. Initiating MD and diploma programmes in family medicine from the platforms of medical universities will require strong coordination between the Ministry of Health, Pakistan Medical and Dental Council, Higher Education Commission and medical universities.

Flexibility in training:

Offer flexible training pathways to accommodate existing general practitioners, female doctors and full-time mothers etc.

Introduce family medicine cadre in the public sector and different tracks, such as rural medicine, global health, academic medicine, or public health etc.

Incentives to encourage rural general practice:

Provide incentives such as small loans, better salaries and additional resources for family physicians like linking with Sehat Sahulat Programme and introduction of capitation model of payment.

Integration of technology:

Provision and integration of electronic health records, telemedicine and other digital health tools into family medicine residency programmes to prepare physicians for modern practice settings.

Developing multidisciplinary primary care teams such as nurses, pharmacists, social workers and mental health workers to provide comprehensive primary care services.

Continuing professional development:

Provide CPD programmes to help family physicians stay up-to-date with latest evidence and best practises.

Mentor and peer support:

Establish mentorship and peer support groups for medical students and residents to provide guidance and advice throughout their training and early career.

Work-life balance:

To promote work-life balance, flexible and part-time working options and parental and study leaves should be introduced. This will help reduce burnout and improve retention rates among family physicians.

Advocacy and policy changes:

Advocate for policy changes at the local, provincial and national levels to implement family practise approach i.e. family physician-led primary healthcare.

Promotion of public awareness:

Increase public awareness on the importance of family medicine and the role of family physicians in providing comprehensive and continuous care for individuals and families.

By implementing these strategies, we can strengthen career pathways in family medicine, attract more healthcare professionals to the field, and ultimately improve access to quality primary care for patients.

The medical education system, consisting of health departments, degree awarding institutions, universities, medical colleges, regulatory bodies, medical educationists and various organisations, needs to work in partnership with family physicians and its academia. Active engagement of all stakeholders is crucial to achieve desired target of robust primary care system.

Dr Hina Jawaid is an associate professor in family medicine at Health Services Academy, Islamabad.

Dr Abdul Jalil Khan is an associate professor in family medicine at Khyber Medical University, Peshawar

Rethinking family medicine careers