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Family medicine

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For the journal, see Family Practice (journal). For the House episode, see Family Practice (House).

Family medicine (FM), formerly family practice (FP), is a medical specialty devoted to comprehensive health care for people of all ages. The specialist is named a family physician or family doctor. In Europe, the discipline is often referred to as general practice and a practitioner as a general practice doctor or GP. This name emphasizes the holistic nature of this speciality, as well as its roots in the family. Family practice is a division of primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body.[1][2] Family physicians are often primary care physicians. It is based on knowledge of the patient in the context of the family and the community, emphasizing disease prevention and health promotion.[3] According to the World Organization of Family Doctors (WONCA), the aim of family medicine is to provide personal, comprehensive, and continuing care for the individual in the context of the family and the community.[4] The issues of values underlying this practice are usually known as primary care ethics.

Scope of practices

Family physicians in the United States may hold either a M.D. or a D.O. degree. Physicians who specialize in family medicine must successfully complete an accredited three- or four-year family medicine residency in the United States in addition to their medical degree. They are then eligible to sit for a board certification examination, which is now required by most hospitals and health plans.[5] American Board of Family Medicine requires its Diplomates to maintain certification through an ongoing process of continuing medical education, medical knowledge review, patient care oversight through chart audits, practice-based learning through quality improvement projects and retaking the board certification examination every 7 to 10 years. The American Osteopathic Board of Family Physicians requires its Diplomates to maintain certification and undergo the process of recertification every 8 years.[6]

Physicians certified in family medicine in Canada are certified through the College of Family Physicians of Canada,[7] after two years of additional education. Continuing education is also a requirement for continued certification.

The term "family medicine" is used in many European and Asian countries, instead of "general medicine" or "general practice". In Sweden, certification in family medicine requires five years working with a tutor, after the medical degree. In India, those who want to specialize in family medicine must complete a three-year family medicine residency, after their medical degree (MBBS). They are awarded either a D.N.B. or an M.D. in family medicine. Similar systems exist in other countries.

Family physicians deliver a range of acute, chronic and preventive medical care services. In addition to diagnosing and treating illness, they also provide preventive care, including routine checkups, health-risk assessments, immunization and screening tests, and personalized counseling on maintaining a healthy lifestyle. Family physicians also manage chronic illness, often coordinating care provided by other subspecialists.[8] Many American Family Physicians deliver babies and provide prenatal care.[9] In the U.S., family physicians treat more patients with back pain than any other physician subspecialist, and about as many as orthopedists and neurosurgeons combined.[10]

Family medicine and family physicians play a very important role in the healthcare system of a country. In the U.S., for example, nearly one in four of all office visits are made to family physicians. That is 208 million office visits each year — nearly 83 million more than the next largest medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty.[11]

In Canada

In Canada, aspiring family physicians are expected to complete a residency in family medicine from an accredited university after obtaining their M.D. degree. Although the residency usually has a duration of two years, graduates may apply to complete a third year, leading to a certification from the College of Family Physicians Canada in disciplines such as emergency medicine, palliative care, and women's health, amongst many others. In some institutions, such as McGill University in Montreal, graduates from family medicine residency programs are eligible to complete a master's degree and a Doctor of Philosophy (Ph.D.) in Family Medicine, which predominantly consists of a research-oriented program. Physician Assistants in Canada are working in the field of family medicine to fill in the gaps in the healthcare system where there may be a lack of physicians. Physician assistants are advance practice clinicians who are trained in the medical model and practice autonomously under the supervision of a licensed physician. They diagnose illness, develop and manage treatment plans, prescribe medication, perform procedures as well perform and assist in surgery.”[12]

In the United States

History of medical family practice

Concern for family health and medicine in the United States existed as far back as the early 1930s and 40s. The American public health advocate Bailey Barton Burritt was labeled "the father of the family health movement" by The New York Times in 1944.[13]

Following World War II, two main concerns shaped the advent of family medicine. First, medical specialties and subspecialties increased in popularity, having an adverse effect on the number of physicians in general practice. At the same time, many medical advances were being made and there was concern within the "general practitioner" or "GP" population that four years of medical school plus a one-year internship was no longer adequate preparation for the breadth of medical knowledge required of the profession.[14] Many of these doctors wanted to see a residency program added to their training; this would not only give them additional training, knowledge, and prestige but would allow for board certification, which was increasingly required to gain hospital privileges.[14] In February 1969, family medicine (then known as family practice) was recognized as a distinct specialty in the U.S. It was the twentieth specialty to be recognized.[14]

Education and training

Family physicians complete an undergraduate degree, medical school, and three more years of specialized medical residency training in family medicine.[15] Their residency training includes rotations in internal medicine, pediatrics,[16] obstetrics-gynecology, psychiatry, surgery, emergency medicine, and geriatrics, in addition to electives in a wide range of other disciplines. Residents also must provide care for a panel of continuity patients in an outpatient "model practice" for the entire period of residency.[17] The specialty focuses on treating the whole person, acknowledging the effects of all outside influences, through all stages of life.[18] Family physicians will see anyone with any problem, but are experts in common problems. Many family physicians deliver babies in addition to taking care of patients of all ages.

In order to become board certified, family physicians must complete a residency in family medicine, possess a full and unrestricted medical license, and take a written cognitive examination.[19] Between 2003 and 2009, the process for maintenance of board certification in family medicine is being changed (as well as all other American Specialty Boards) to a series of yearly tests on differing areas. The American Board of Family Medicine, as well as other specialty boards, are requiring additional participation in continuous learning and self-assessment to enhance clinical knowledge, expertise and skills. The Board has created a program called the "Maintenance of Certification Program for Family Physicians" (MC-FP) which will require family physicians to continuously demonstrate proficiency in four areas of clinical practice: professionalism, self-assessment/lifelong learning, cognitive expertise, and performance in practice. Three hundred hours of continuing medical education within the prior six years is also required to be eligible to sit for the exam.[20]

Family physicians may pursue fellowships in several fields, including adolescent medicine, geriatric medicine, sports medicine, sleep medicine, hospital medicine and hospice and palliative medicine.[21] The American Board of Family Medicine and the American Osteopathic Board of Family Medicine both offer Certificates of Added Qualifications (CAQs) in each of these topics.[22]

Shortage of family physicians

While many sources cite a shortage of family physicians (and also other primary care providers, i.e. internists, pediatricians, and general practitioners),[23] the per capita supply of primary care physicians has actually increased about 1 percent per year since 1998.[24] Additionally, a recent decrease in the number of M.D. graduates pursuing a residency in primary care has been offset by the number of D.O. graduates and graduates of international medical schools (IMGs) who enter primary care residencies.[24] Still, projections indicate that by 2020 the demand for family physicians will exceed their supply.[24]

The number of students entering family medicine residency training has fallen from a high of 3,293 in 1998 to 1,172 in 2008, according to National Residency Matching Program data. Fifty-five family medicine residency programs have closed since 2000, while only 28 programs have opened.[25]

In 2006, when the nation had 100,431 family physicians, a workforce report by the American Academy of Family Physicians indicated the United States would need 139,531 family physicians by 2020 to meet the need for primary medical care. To reach that figure 4,439 family physicians must complete their residencies each year, but currently, the nation is attracting only half the number of future family physicians that will be needed.[26]

To address this shortage, leading family medicine organizations launched an initiative in 2018 to ensure that by 2030, 25% of combined US allopathic and osteopathic medical school seniors select family medicine as their specialty.[27][28] The initiative is termed the “25 x 2030 Student Choice Collaborative,” and the following eight family medicine organizations have committed resources to reaching this goal:

The waning interest in family medicine in the U.S. is likely due to several factors, including the lesser prestige associated with the specialty, the lesser pay, and the increasingly frustrating practice environment. Salaries for family physicians in the United States are respectable, but lower than average for physicians, with the average being $225,000.[29] However, when faced with debt from medical school, most medical students are opting for the higher-paying specialties. Potential ways to increase the number of medical students entering family practice include providing relief from medical education debt through loan-repayment programs and restructuring fee-for-service reimbursement for health care services.[30] Family physicians are trained to manage acute and chronic health issues for an individual simultaneously, yet their appointment slots may average only ten minutes.[31]

In addition to facing a shortage of personnel, physicians in family medicine experience some of the highest rates of burnout among medical specialties, at 47 percent. [32]

Current practice

Most family physicians in the US practice in solo or small-group private practices or as hospital employees in practices of similar sizes owned by hospitals. However, the specialty is broad and allows for a variety of career options including education, emergency medicine or urgent care, inpatient medicine, international or wilderness medicine, public health, sports medicine, and research.[33] Others choose to practice as consultants to various medical institutions, including insurance companies.[citation needed]

In India

Family medicine (FM) came to be recognized as a medical specialty in India only in the late 1990s.[34] According to the National Health Policy – 2002, there is an acute shortage of specialists in family medicine. As family physicians play a very important role in providing affordable and universal health care to people, the Government of India is now promoting the practice of family medicine by introducing post-graduate training through DNB (Diplomate National Board) programs.

There is a severe shortage of postgraduate training seats, causing a lot of struggle, hardship and a career bottleneck for newly qualified doctors just passing out of medical school. The Family Medicine Training seats should ideally fill this gap and allow more doctors to pursue family medicine careers. However, the uptake, awareness and development of this specialty is slow.[35]

Although family medicine is sometimes called general practice, they are not identical in India. A medical graduate who has successfully completed the Bachelor of Medicine, Bachelor of Surgery (MBBS), course and has been registered with Indian Medical Council or any state medical council is considered a general practitioner. A family physician, however, is a primary care physician who has completed specialist training in the discipline of family medicine.

The Medical Council of India requires three-year residency for family medicine specialty, leading to the award of Doctor of Medicine (MD) in Family Medicine or Diplomate of National Board (DNB) in Family Medicine.

The National Board of Examinations conducts family medicine residency programmes at the teaching hospitals that it accredits. On successful completion of a three-year residency, candidates are awarded Diplomate of National Board (Family Medicine).[36] The curriculum of DNB (FM) comprises: (1) medicine and allied sciences; (2) surgery and allied sciences; (3) maternal and child health; (4) basic sciences and community health. During their three-year residency, candidates receive integrated inpatient and outpatient learning. They also receive field training at community health centres and clinics.[37]

The Medical Council of India permits accredited medical colleges (medical schools) to conduct a similar residency programme in family medicine. On successful completion of three-year residency, candidates are awarded Doctor of Medicine (Family Medicine).[38][39] Govt. medical college, Calicut had started this MD (FM) course in 2011. A few of the AIIMS institutes have also started a course called MD in community and family medicine in recent years. Even though there is an acute shortage of qualified family physicians in India, further progress has been slow.

The Indian Medical Association’s College of General Practitioners, offers a one-year Diploma in Family Medicine (DFM), a distance education programme of the Postgraduate Institute of Medicine, University of Colombo, Sri Lanka, for doctors with minimum five years of experience in general practice.[40] Since the Medical Council of India requires three-year residency for family medicine specialty, these diplomas are not recognized qualifications in India.

As India's need for primary and secondary levels of health care is enormous, medical educators have called for systemic changes to include family medicine in the undergraduate medical curriculum.[41]

Recently, the residency-trained family physicians have formed the Academy of Family Physicians of India (AFPI). AFPI is the academic association of family physicians with formal full-time residency training (DNB Family Medicine) in Family Medicine. Currently there are about two hundred family medicine residency training sites accredited by the National Board of Examination India, providing around 700 training posts annually. However, there are various issues like academic acceptance, accreditation, curriculum development, uniform training standards, faculty development, research in primary care, etc. in need of urgent attention for family medicine to flourish as an academic specialty in India. The government of India has declared Family Medicine as focus area of human resource development in health sector in the National Health Policy 2002[42] There is discussion ongoing to employ multi-skilled doctors with DNB family medicine qualification against specialist posts in NRHM (National Rural Health Mission).[43]

Three possible models of how family physicians will practise their specialty in India might evolve, namely (1) private practice, (2) practising at primary care clinics/hospitals, (3) practising as consultants at secondary/tertiary care hospitals.

In Japan

Family medicine was first recognized as specialty in 2015 and currently has approximately 500 certified family doctors.[44] The Japanese government has made a commitment to increase the number of family doctors in an effort to improve the cost-effectiveness and quality of primary care in light of increasing health care costs.[45] The Japan Primary Care Association (JPCA) is currently the largest academic association of family doctors in Japan.[46] The JPCA family medicine training scheme consists of a three-year programme following the two-year internship.[44] The Japanese Medical Specialty Board define the standard of the specialty training programme for board-certified family doctors. Japan has a free access healthcare system meaning patients can bypass primary care services. In addition to family medicine specialists Japan also has ~100,000 organ-specialist primary care clinics.[45] The doctors working in these clinics do not typically have formal training in family medicine. In 2012 the mean consultation length in a family medicine clinic was 10.2 minutes.[47] A review literature has recently been published detailing the context, structure, process, and outcome of family medicine in Japan.[48]

See also

References

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  2. ^ "Family Medicine Specialty Description". American Medical Association. Retrieved 2 June 2020.
  3. ^ "Definitions, What is Family Medicine?". American Academy of Family Physicians. Archived from the original on 22 November 2008. Retrieved 17 July 2009.
  4. ^ "Global Family Doctor". Wonca Online. Archived from the original on 20 March 2012.
  5. ^ "Choosing a Primary Care Provider". Medline Plus Medical Encyclopedia. Retrieved 30 June 2009.
  6. ^ "Certificates/Longevity". AOBFP. Archived from the original on 30 December 2010. Retrieved 25 August 2012.
  7. ^ "Principles | About CFPC | The College of Family Physicians Canada". Cfpc.ca. Retrieved 2012-10-28.
  8. ^ "Family Medicine, Scope and Philosophical Statement". American Academy of Family Physicians. Retrieved 17 July 2009.
  9. ^ Nesbitt TS (Jan–Feb 2002). "Obstetrics in family medicine: can it survive?" (PDF). The Journal of the American Board of Family Practice. 15 (1): 77–9. PMID 11841145.[permanent dead link]
  10. ^ Kinkade S (April 2007). "Evaluation and treatment of acute low back pain". American Family Physician. 75 (8): 1181–8. PMID 17477101.
  11. ^ "Facts About Family Medicine". American Academy of Family Physicians. Retrieved 17 July 2009.
  12. ^ https://www.insideottawavalley.com/news-story/9525182-physician-assistants-could-provide-help-with-perth-s-doctor-shortage/
  13. ^ "B. B. Burritt Honored as Health Advocate". The New York Times. October 25, 1944. Retrieved 2017-05-16. Bailey B. Burritt, known as "the father of the family health movement"... {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
  14. ^ a b c Pisacano NJ. "History of the Specialty". American Board of Family Medicine. Retrieved 2009-06-30.
  15. ^ Adams B (March 17, 1995). "Primary Care: Will more family doctors improve health care?". CQ Researcher. 5 (10).
  16. ^ "All providers in pediatrics category".
  17. ^ "Patient Brochure". American Board of Family Medicine. Retrieved 30 June 2009.
  18. ^ Martin JC, Avant RF, Bowman MA, Bucholtz JR, Dickinson JR, Evans KL, et al. (Future of Family Medicine Project Leadership Committee) (Mar–Apr 2004). "The Future of Family Medicine: a collaborative project of the family medicine community". Annals of Family Medicine. 2 Suppl 1: S3-32. doi:10.1370/afm.130. PMC 1466763. PMID 15080220.
  19. ^ "Certification Policies". American Board of Family Medicine. Archived from the original on 10 January 2016. Retrieved 30 June 2009.
  20. ^ "Maintenance of Certification for Family Physicians (MC-FP)". American Board of Family Medicine. Archived from the original on 3 January 2011. Retrieved 30 June 2009.
  21. ^ "Fellowship Directory for Family Physicians". American Academy of Family Physicians. Retrieved 30 June 2009.
  22. ^ "Certificates of Added Qualifications". American Board of Family Medicine. Retrieved 30 June 2009.
  23. ^ Halsey A (June 20, 2009). "Primary-Care Doctor Shortage May Undermine Health Reform Efforts". The Washington Post. Retrieved 12 November 2012.
  24. ^ a b c "Recent Supply Trends, Projections, and Valuation of Services" (PDF). Testimony Before the Committee on Health, Education, Labor, and Pensions, U.S. Senate. United States Government Accountability Office. Retrieved 12 November 2012.
  25. ^ "2009 Match Summary and Analysis". American Academy of Family Physicians. Retrieved 17 July 2009.
  26. ^ "Family Physician Workforce Reform". American Academy of Family Physicians. Retrieved 17 July 2009.
  27. ^ "AAFP Hosts Launch of 25 x 2030 Student Choice Collaborative". American Academy of Family Physicians. Retrieved 25 July 2019.
  28. ^ Kelly C, Coutinho AJ, Goldgar C, et al. (February 2019). "Collaborating to Achieve the Optimal Family Medicine Workforce". Family Medicine. 51 (2): 149–158. doi:10.22454/FamMed.2019.926312. PMID 30736040.
  29. ^ "Family Physician Salaries Continue to Rise at Rapid Clip". AAFP. Retrieved 2016-06-17.
  30. ^ Bodenheimer T, Grumbach K, Berenson RA (June 2009). "A lifeline for primary care". The New England Journal of Medicine. 360 (26): 2693–6. doi:10.1056/NEJMp0902909. PMID 19553643.
  31. ^ Stange KC, Zyzanski SJ, Jaén CR, Callahan EJ, Kelly RB, Gillanders WR, et al. (May 1998). "Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians" (PDF). The Journal of Family Practice. 46 (5): 377–89. PMID 9597995.
  32. ^ "Physician burnout: It's not you, it's your medical specialty". American Medical Association. 3 August 2020. Retrieved 7 July 2020.
  33. ^ "Practice Options". Family Medicine Interest Group. Archived from the original on 15 September 2010. Retrieved 30 June 2009.
  34. ^ Abraham S. "Practicing and Teaching Family Medicine in India" (PDF). Society of Teachers of Family Medicine. Retrieved 12 November 2012.
  35. ^ Beswal G (July 2013). "Family Medicine: A Solution for Career Inequalities among Doctors in India". Journal of Family Medicine and Primary Care. 2 (3): 215–7. PMC 3902674. PMID 24479085.
  36. ^ "Welcome To National Board Of Examination". Natboard.edu.in. 2012-10-17. Retrieved 2012-10-28.
  37. ^ Bulletin of Information for Diplomate of National Board in Family Medicine (New Rules)
  38. ^ Minimum Qualifications for Teachers in Medical Institutions Regulations - 1998, table 1.
  39. ^ Postgraduate Medical Education Regulations 2000, schedule A.
  40. ^ "News Letter" (PDF). Indian Medical Association. 6 February 2009. Archived from the original (PDF) on February 17, 2010.
  41. ^ Zachariah P (September 9, 2009). "Rethinking medical education in India". The Hindu. Retrieved 12 November 2012.
  42. ^ "National Health Policy 2002". Ministry of Health & Family Welfare, Government of India. Archived from the original on 4 November 2010.
  43. ^ "Academy of Family Physicians of India".
  44. ^ a b Takamura A (September 2016). "The new era of postgraduate certified general practice training in Japan". Education for Primary Care. 27 (5): 409–412. doi:10.1080/14739879.2016.1220235. PMID 27658321.
  45. ^ a b Takemura Y (2003). "Family medicine: What does it mean in Japan?". Asia Pacific Family Medicine. 2 (4): 188–192. doi:10.1111/j.1444-1683.2003.00094.x.
  46. ^ "About Us". Japan Primary Care Association.
  47. ^ Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, Holden J (November 2017). "International variations in primary care physician consultation time: a systematic review of 67 countries". BMJ Open. 7 (10): e017902. doi:10.1136/bmjopen-2017-017902. PMC 5695512. PMID 29118053.
  48. ^ Kato D (April 2019). "Building primary care in Japan: Literature review". Journal of General and Family Medicine. 20 (5): 170–179. doi:10.1002/jgf2.252. PMID 31516802.
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