A family physician-led comprehensive primary care is the key to successful implementation of universal health coverage
Persuading general practitioners to get formal training in family medicine is one of the challenges of introducing family practice approach. Despite the challenges, a strong momentum, including a political one, exists to shift the balance from secondary to primary care and make family practice an integral part of the health system.
There is a need to re-position family physician at the centre of gate-keeping mechanism. This requires regaining trust of the public in primary care centres as most of the population believes that for any serious health issue the outcome of using such facilities would be a referral, hence bypassing primary healthcare accelerates the process (Family Practice in EMR, WHO).
A family physician-led comprehensive primary care is the key to successful implementation of universal health coverage (UHC). Due to a lack of exposure to primary care, medical students do not select family medicine as a career in Pakistan. Although most end up becoming general practitioners, sometimes by choice but mostly by default.
Before we proceed, we need to ask a few questions. Do our newly qualified medical graduates feel prepared to practice in primary care settings? During the undergraduate training, are we placing emphasis on a generalist’s approach to medicine, including communication skills, social and psychological aspects of medicine, rational prescribing, professionalism, team work, continuity of care and medical ethics? How organised and effective are the trainings in our clinical placements, particularly in relation to primary care?
In order to engage medical students, we need to provide a conducive environment for learning. The ongoing huge burden of non-communicable diseases, for instance, diabetes compounded by minimal to no awareness or signposting for diabetic foot or retinal screening, low mood symptoms (depression) accompanying chronic diseases amid financial constraints made worse by the pandemic, limited range of medication availability in public sector health facilities even for high priority conditions, irrational antibiotics prescription, inappropriately utilised family planning services, insufficient coverage of certain chronic conditions like rheumatological, high prevalence of drug addiction with absence of or limited rehabilitation services, etc, have impacts, not only on practicing physicians but also on trainees’ learning outcomes.
Poorly used clinical evidence and poorly captured clinical experience lead to missed opportunities, waste of resources and harm to patients. With only 14.3 percent medical students being aware of the discipline of family medicine and 18 percent choosing it as a career (PJMD,2020), it appears that part of the problem lies in defining medical and health education policy.
Implementing an undergraduate family medicine curriculum will not just increase the exposure of medical students but will also encourage them to adapt this speciality as a career. This will help in establishing community-oriented medical education.
Medical colleges have a responsibility to educate and equip their graduates and help them move forward into healthcare. General practice is a hub of diagnostic and management decisions, experience in undergraduate general practice must be considered a priority as it is directly related to future career choice (SAPC, RCGP UK).
Right now, 16 medical colleges in the country have a family medicine department, however only four have ‘regular’ undergraduate family medicine teaching as part of their curriculum.
Pakistan Medical and Dental Council (PM&DC) notification of 2014, stating family medicine to be made a compulsory subject/ department during the final year of MBBS has not been implemented. It is important to note that the existing MBBS curriculum requires that 20 percent of the time be spent in community-based education.
The Medical Education Committee at Pakistan Medical Commission (PMC) is already considering theoretical and practical training for family medicine at undergraduate medical curricula. Medical curricula in both developed and developing worlds have introduced family medicine as an integral component of undergraduate medical education. This isn’t the case in Pakistan where most medical colleges do not provide such exposure to their undergraduates – perhaps, due to lack of family medicine faculty. As a result, this speciality is less appealing for medical students.
Inclusion of family medicine in the undergraduate curriculum by the Pakistan Medical Commission (PMC) is under consideration. Khyber Medical University, Peshawar, is in the process of developing and implementing family medicine curriculum at the undergraduate level. Medical colleges in Khyber Pakhtunkhwa (KP) will then be encouraged to hire faculty and start family medicine departments.
The family medicine faculty can also provide clinical services in the neighbouring primary care centres, which can be used as teaching sites for medical students. This will be a key step towards community-oriented medical education and will increase medical students’ exposure to primary care.
The way forward is to include family medicine as a mandatory subject in all medical colleges in Pakistan. Every medical college should adopt primary healthcare centres and convert them into community training sites for their undergraduate and postgraduate medical and allied healthcare students. These centres should be led by a trained family medicine faculty that will also help in providing safe and quality healthcare to the population they serve.
Health system reforms are taking place, slowly but surely. The national task force, medical regulatory bodies, degree-awarding institutions and, above all, specialists are backing general practice training. Sustainable financing from the government for an essential package of health services is required to make primary care high performing.
At the same time, implementing an undergraduate family medicine curriculum will not just increase the exposure of medical students but also encourage them to adapt this speciality as a career. This will help in establishing community-oriented medical education which focuses on self-empowerment and change people’s attitudes and promotes healthy behaviours.
Dr Hina Jawaid is an assistant professor in
family medicine at the University of Health
Dr Abdul Jalil Khan is an assistant professor in family medicine at