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“It is much more important to know what sort of patient has a disease than what sort of disease a patient has". Sir William Osler MD (1849 - 1919)
Family Physicians, a term synonymous with general practitioners are the backbone of healthcare around the developed world. General practitioners also known as family doctors have been the first port of call for patients since the beginning of times. With the advent of specialisation, the term general practice is gradually being replaced by family medicine in much of the developed world. Similarly, doctors working as general practitioners are now known as family physicians in many places around the world.
In the west, family physicians provide continuity of care to their patients. Illness and health are managed in a holistic manner through shared decision-making (1), these have become the core principles of family medicine. With the increase in chronic diseases, care is managed by different specialities, this has led to the potential fragmentation and deterioration in the continuity of care (2).
Family physicians provide healthcare to the entire family, they see patients from the time they are born to the time chronic diseases take hold, in the community palliative care is provided by them. Patients with poor mobility, the elderly and those not being able to visit the health centres are visited at home by family physicians. Primary healthcare provided with the principles of comprehensiveness, coordinated, encompassing holistic approach, patient centred with shared decision-making results in better value care. This results in a better community care, better value, and decreases the burden of costs on the health system (3).
World association of family doctors (WONCA) considers family medicine as an academic and scientific discipline, with clinical activity, research, education all oriented towards primary healthcare (4).
While many Middle Eastern countries have started a move towards a modern primary care incorporating family medicine as a speciality (5) and hence improving healthcare, Pakistan has unfortunately made no move towards a reformation in its healthcare policies. The only move towards the implementation of the speciality was made by Pakistan Medical and Dental Council (PMDC) issuing a notification in 2014 to all medical colleges directing the examination of the final year medical students in the speciality, this, however, has yet to bear any fruit.
Many factors play a part in the development of a healthy nation, Pakistan has its own challenges, broken health systems, ghost medical centres, lack of workforce and training has played its part in the failure of achieving WHO’s Millennium development goals. WHO described targets of policy reforms that strengthen health systems, together with ownership by the governments with aims for regulation of funding, and workforce (6). Pakistan currently spends 0.9% of GDP on healthcare (7). This insufficient budgetary expenditure coupled with poor health governance and inadequate training more specifically in the primary health care is compounding the difficulties in coping with the disease burden exponentially.
Apart from the increase in the budgetary expenditure and financial policy change, it is also imperative to bring in urgent primary health care reforms in order to contain the constant haemorrhaging and burden of resources at secondary and tertiary care level. Both communicable and non-communicable disease screening, health promotions, chronic disease management (8), a patient-centered holistic primary health care approach are needed to strength the delivery of health care (9). This approach practised widely in the west has proven to be more cost-effective and has shown to improve the disease outcomes, in turn reducing the disease burden on the society while achieving better results for the patients.
Pakistan is in desperate need of Family Medicine as a speciality to be at the centre of health care delivery (10). There has been some move towards establishing academic programmes in Family Medicine, some Universities have been offering diploma programmes in the speciality (14). Although these lack the clinical element, a step towards an academic programme would be beneficial for our primary care workforce in providing a better quality of care in many BHUs. There is evidence that stand-alone teaching like diploma programmes without any clinical contact improves knowledge but would not necessarily improve attitudes or skills. Comparing this to a clinical programme there is an improvement in skills, attitudes, behaviour (11) and will so improve clinical outcomes for the vast number of patients. The college of physicians and surgeons Pakistan (CPSP) offers clinical degree, MCPS as a basic qualification and FCPS as specialist training on a four-year programme, its uptake is poor due to the lack of future job prospects and unattractive salary packages. The training programmes are mainly available to doctors in Karachi and Lahore (12), Khyber Pukhtunkhwa lacks any formal training apart from the basic MCPS training accreditation at Ayub Medical College Abbottabad, Hayatabad Medical Complex, Khyber teaching hospital and Lady Reading hospital Peshawar (13). Unfortunately, the current MCPS training also lacks any clinical rotation in family medicine due to the unavailability of accredited family medicine centres.
In Khyber Pakhtunkhwa the autonomy granted to the government hospitals can be seen as an opportunity for the initiation of a clinical Family Medicine departments, aligned and accredited for training by the medical university it can prove as a fertile ground for the teaching and training of career medical officers, and family physicians, these can become the core foundation of a primary health care revolution, with time the concept can be expanded to other hospitals and local community clinics where homegrown family physicians with better training and specialisation can be the saviours of our basic health units (BHUs). An initiation of a diploma programme as a minimum step, as is being offered in other universities in Punjab and Sindh Province (14) can be of some benefit for improving patient care while introducing concepts of holistic care, health promotion and shared decision making as effective tools of Family Medicine. These if modernised, with an increase in budgetary commitments from the government, better salary packages for doctors can be a turning point in achieving the WHO’s millennium developmental goals and far beyond.
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