WHERE IS THE FAMILY PHYSICIAN ?

There is nothing inevitable about the decline in general practice's fortune but if this trend is to be halted and reversed, it can be only through consistent and constructive leadership. Before a series of tests, try and see the family physician first.

"Professions arise in response to the recognition of a social need, and their continued existence is dependent on their success in satisfying the expectations raised by the state of knowledge which they proffer."
-Sir Harold Himsworth

MR. S, 28, a worker in a pappad manufacturing unit, suddenly complained of chest pain, sweating and mild body ache, while working. The proprietor immediately fixed up an appointment with a cardiologist, Dr. X. In the evening, Dr. X saw him after an ECG evaluation and advised him to come the next day with the results of his blood tests, to rule out cardiac problems.

Mr. S developed high fever the same night. After completing the tests the next day, he again met Dr. X and brought to his notice the fever that he had had. Dr. X after going through the reports suggested that he consult another senior physician after adding that he had no cardiac problem to worry about. On contacting the senior physician, it was learned that he saw only a limited number of cases per day and that he could see Mr. S only after two weeks. On the third day Mr. S came to my clinic with his reports. On clinical evaluation after eliciting a good history, I did a simple blood test, which revealed malaria. He was given tablets for three days and he recovered.

I have narrated the case to explain that a primary care physician or family physician should be the physician a patient must see first. The message here is that similar physical complaints may be manifestations of different diseases like malaria, heart problems or lung diseases. In this case, the choice of specialist was made by a lay man. Hence, the patient had to suffer for three days before a diagnosis was made and suitable treatment was given, not taking into account the monetary loss incurred by the individual.

By tradition, the doctor first consulted in an illness is known as a GP. He is also called the family physician or the primary care physician. By practice, even today the doctor responds to a patient's call either by treatment at his office or by visiting the home. The family physician will be a doctor to all the members of a family and will look after them throughout his practicing years, being involved in many important events in their lives, including births, marriages and deaths. He acts as a friend, counsellor as well as a doctor, especially in rural areas, and is an honourable member of the family. After qualifying, a new doctor must immediately forget most of what he has been taught or has learned about medicine and start again. It is found that more than 50 per cent of them eventually go into family practice, but it is unfortunate that the medical curriculum, even now, tends to concentrate on the diagnosis and treatment of obscure illnesses which a family physician may rarely encounter in the course of a long career. The present day hospital and medical college environment is too refined and unrealistic to be of continuous use to the prospective family physician.

Moreover the attributes which go to make a family physician do not appear in any text book. It is astonishing to note that for long, hospitals have failed to impress students with the fundamental attributes to enter family practice. The great qualities of a family physician are compassion, sympathy, understanding, faith, hope and affection.

GOING into a little bit of history of this speciality, the term GP came into use at about the beginning of the 19th Century in England. Prior to that, only three categories were present — physicians, surgeons and apothecaries. A hundred years ago a doctor was not a gentleman and was expected to enter through the back door, whereas his veterinary counterpart entered through the front door as he looked after the gentleman's horse. In 1827, the President of the Royal College of Physicians held that midwifery was an act foreign to the habit of a gentleman! In 1830, a Metropolitan Society of General Practitioners in medicine and surgery had been instituted. The GP at that time did everything. By the late 19th Century, teaching hospitals came up and were staffed by physicians, surgeons and obstetricians. But for the GP, hospital privileges were of little importance as he could do his surgery over the kitchen table or his obstetrics in the family bedroom much more safely than in the institution. As the hospital system developed, it was not really the possession of skills or a higher qualification that began to divide the profession but the question of whether or not the doctor had access to hospital beds. In 1948, the National Health Service of England formalised the separation of domiciliary and institutional services. Once the GP was excluded from the hospital, a marked deterioration in his status began. But later in March 1965, a Charter for the Family doctor services appeared and was produced by the British Medical Association. And now the real backbone of the NHS in England is the services of the general practitioner.

Meanwhile in the U.S. in 1962, the Association of American Medical Colleges noted that from 1900 to 1962, American medical graduates choosing general practice fell from 33 per cent to 18 per cent and projections for the following decade predicted the demise of the general practitioner. However, in a leading article, "End — or Beginning?" in The Lancet (July 24, 1965) it was stated that "there is nothing inevitable about the decline in its (general practice's) fortune; but if this trend is to be halted and reversed, it can be only through consistent and constructive leadership". During this period, a group of 10 general practitioners in the U.S. saw this rapid decline of general practice and were eager to keep up with the times yet preserve those precious attributes of the old generalist. They hastened to establish a movement to create the new specialty of family practice through an American Board of Family Practice (ABFP).

FAMILY practice is a horizontal specialty, much like paediatrics and internal medicine, and shares large areas of content with other clinical disciplines. It incorporates this shared knowledge and utilises it in a unique way to deliver primary medical care. It draws most heavily on internal medicine, paediatrics, obstetrics and gynaecology, surgery, psychiatry and preventive medicine. This establishes a cohesive unit, combining the behavioural sciences with the traditional biological and clinical sciences.


The ABFP defines the family physician to be one who serves the public as a physician of first contact and as means of entry into the health care system; assumes responsibility for his patients' comprehensive and continuing health care, acts as coordinator of his patients' health services; and accepts responsibility for his patients; total health care, including the use of consultants, within the context of their environment, including the community and the family or comparable social unit. The family physician performs two major functions which may be related entirely to individual patients but usually concern the family as a group. They are primary assessment and continuing care.

Primary assessment refers to the patient presenting to the doctor with previously undifferentiated, unknown illnesses or symptoms. The task of the family physician is to decide upon the severity of these symptoms, their prognosis and the way in which they affect the person's socio-economic conditions. This is one of the most difficult aspects of family practice. Assessment is made not only upon the information the patient presents to the family physician but is also related to the family physician's knowledge of the patients environment, his family, his work, his past medical history, his pattern of behaviour and the culture of the neighbourhood. Thus the roots the doctor develops in his community become important. After this assessment, the management of the problem is discussed with the patient and a mutually acceptable course of action is agreed upon. The term continuing care, is based on the knowledge of the social background of the patients over many years and for the chronic sick. It also means that the long term problems of people which may persist for months, years and sometimes for a whole lifetime can be managed.

Why do patients see a doctor? All patients consult doctors for some reason. Yet, it is very common to hear doctors speaking of unnecessary consultations, and patients who waste their time. Evident in all such phrases is the feeling that there was no reason for the patient's visit to the doctor. The truth lies either in the doctor's inability to discover that reason or because the patient has not learnt how to use the doctor. In most cases, the fault lies more often with the doctor than the patient. Thus a patient goes to a doctor for two reasons — to obtain recognition of his sickness, and to seek help in order to get better.

IN conclusion, the role and function of the family physician was described by Sir Theodore Fox, Editor of The Lancet in these terms: "his essential characteristic... is that he is looking after people as people and not as problems. He is what our grandfathers called `my medical attendant' or `my personal physician' and his function is to meet what is really the primary medical need a person in difficulties wants, in the first place, the help of another person on whom he can rely as a friend. Someone with knowledge of what is feasible but also with good judgment on what is desirable in a particular circumstance and an understanding of what the circumstances are".