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Wikipedia

Family medicine

January 08, 2023

For the journal, see Family Practice (journal).

Family medicine[note 1] is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body.[2][3] The specialist, who is usually a primary care physician, is named a family physician.[note 2] It is often referred to as general practice and a practitioner as a general practitioner. Historically, their role was once performed by any doctor with qualifications from a medical school and who works in the community. However, since the 1950s, family medicine / general practice has become a specialty in its own right, with specific training requirements tailored to each country.[4][5][6] The names of the specialty emphasize its holistic nature and/or its roots in the family. It is based on knowledge of the patient in the context of the family and the community, focusing on disease prevention and health promotion.[7] According to the World Organization of Family Doctors (WONCA), the aim of family medicine is "promoting personal, comprehensive and continuing care for the individual in the context of the family and the community".[8] The issues of values underlying this practice are usually known as primary care ethics.

Family medicine
FocusPrimary care, preventive healthcare
Significant diseasesHypertension, URTI, arthritis, diabetes, mental health, pneumonia, AOM, back pain, dermatitis[1]
SpecialistFamily physician
Family medicine physician
Family physician (right) reviewing a case with nurse (left) in clinic
Occupation
NamesPhysician
SynonymFamily doctor
Occupation type
Specialty
Activity sectors
Medicine
Description
Education required
Fields of
employment
Hospitals, clinics, emergency departments, long-term care

Scope of practice

Family physicians in the United States must hold either an M.D. or a D.O. degree. Physicians who specialize in family medicine must successfully complete an accredited three or four year long 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.[9] 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.[10]

Physicians certified in family medicine in Canada are certified through the College of Family Physicians of Canada,[11] after two years of additional education. Continuing education is also a requirement for maintenance of certification.

The term "family medicine" or "family physician" is used in the United States, Mexico, South America, many European and Asian countries. 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.

General practice is the term used in many other nations, such as the United Kingdom, Australia, New Zealand, and South Africa. Such services are provided by general practitioners. The term primary care in the UK may also include services provided by community pharmacy, optometrist, dental surgery and community hearing care providers. The balance of care between primary care and secondary care - which usually refers to hospital based services - varies from place to place, and with time. In many countries there are initiatives to move services out of hospitals into the community, in the expectation that this will save money and be more convenient.

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 counselling on maintaining a healthy lifestyle. Family physicians also manage chronic illness, often coordinating care provided by other sub-specialists.[12] Many American Family Physicians deliver babies and provide prenatal care.[13] In the U.S., family physicians treat more patients with back pain than any other physician sub-specialist, and about as many as orthopedists and neurosurgeons combined.[14]

Family medicine and family physicians play a vital 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.[15]

In Canada

Education and training

In Canada, aspiring family physicians are expected to complete a residency in family medicine from an accredited university after obtaining their Doctor of Medicine 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 of Canada in disciplines such as emergency medicine, palliative care, care of the elderly, sports and exercise medicine, and women's health, amongst 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.

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.[16]

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.[17] 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.[17] 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.[17]

Education and training

Family physicians complete an undergraduate degree, medical school, and three more years of specialized medical residency training in family medicine.[18] Their residency training includes rotations in internal medicine, pediatrics,[19] 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.[20] The specialty focuses on treating the whole person, acknowledging the effects of all outside influences, through all stages of life.[21] 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.[22] 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.[23]

Family physicians may pursue fellowships in several fields, including adolescent medicine, geriatric medicine, sports medicine, sleep medicine, hospital medicine and hospice and palliative medicine.[24] 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.[25]

Shortage of family physicians

Many sources cite a shortage of family physicians (and also other primary care providers, i.e. internists, pediatricians, and general practitioners).[26] The per capita supply of primary care physicians has increased about 1 percent per year since 1998.[27] 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.[27] Still, projections indicate that by 2020 the demand for family physicians will exceed their supply.[27]

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.[28]

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.[29]

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.[30][31] 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 lower than average for physicians, with the average being $225,000.[32] 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.[33] Family physicians are trained to manage acute and chronic health issues for an individual simultaneously, yet their appointment slots may average only ten minutes.[34]

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.[35]

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.[36] Others choose to practice as consultants to various medical institutions, including insurance companies.[citation needed]

United Kingdom

History of general practice services

The pattern of services in the UK was largely established by the National Insurance Act 1911 which established the list system which came from the friendly societies across the country. Every patient was entitled to be on the list, or panel of a general practitioner. In 1911 that only applied to those who paid National insurance contributions. In 1938, 43% of the adult population was covered by a panel doctor.[37] When the National Health Service was established in 1948 this extended to the whole population. The practice would be responsible for the patient record which was kept in a "Lloyd George envelope"[38] and would be transferred if necessary to another practice if the patient changed practice. In the UK, unlike many other countries, patients do not normally have direct access to hospital consultants and the GP controls access to secondary care.[39]

 
Lloyd George envelopes at Whalsay Health Centre 2012

Practices were generally small, often single handed, operating from the doctor's home and often with the doctor's wife acting as a receptionist.[40] When the NHS was established in 1948 there were plans for the building of health centres, but few were built.

In 1953, general practitioners were estimated to be making between 12 and 30 home visits each day and seeing between 15 and 50 patients in their surgeries.[41]

Current practice

Today, the services are provided under the General Medical Services Contract, which is regularly revised.

599 GP practices closed between 2010–11 and 2014–15, while 91 opened and average practice list size increased from 6,610 to 7,171.[42] In 2016 there were 7,613 practices in England, 958 in Scotland, 454 in Wales and 349 in Northern Ireland.[43] There were 7,435 practices in England and the average practice list size in June 2017 was 7,860. There were 1.35 million patients over 85.[44] There has been a great deal of consolidation into larger practices, especially in England. Lakeside Healthcare was the largest practice in England in 2014, with 62 partners and more than 100,000 patients. Maintaining general practices in isolated communities has become very challenging, and calls on very different skills and behaviour from that required in large practices where there is increasing specialization.[45] By 1 October 2018, 47 GP practices in England had a list size of 30,000 or more and the average list size had reached 8,420.[46] In 2019 the average number of registered patients per GP in England has risen since 2018 by 56 to 2,087.[47]

The British Medical Association in 2019 conducted a survey for GP premises. About half of the 1,011 respondents thought their surgeries were not suitable for present needs, and 78% said they would not be able to handle expected future demands.[48]

Under the pressure of the Coronavirus epidemic in 2020 general practice shifted very quickly to remote working, something which had been progressing very slowly up to that point. In the Hurley Group Clare Gerada reported that "99% of all our work is now online" using a digital triage system linked to the patient's electronic patient record which processes up to 3000 consultations per hour. Video calling is used to “see” patients if that is needed.[49]

In 2019 according to NHS England, almost 90% of salaried GPs were working part-time.[50]

England

The GP Forward View, published by NHS England in 2016 promised £2.4 billion (14%) real-terms increase in the budget for general practice. Jeremy Hunt pledged to increase the number of doctors working in general practice by 5,000. There are 3,250 trainee places available in 2017. The GP Career Plus scheme is intended to retain GPs aged over 55 in the profession by providing flexible roles such as providing cover, carrying out specific work such as managing long-term conditions, or doing home visits.[51] In July Simon Stevens announced a programme designed to recruit around 2,000 GPs from the EU and possibly New Zealand and Australia.[52] According to NHS Improvement a 1% deterioration in access to general practice can produce a 10% deterioration in emergency department figures.[53]

GPs are increasingly employing pharmacists to manage the increasingly complex medication regimes of an aging population. In 2017 more than 1,061 practices were employing pharmacists, following the rollout of NHS England’s Clinical Pharmacists in General Practice programme.[54] There are also moves to employ care navigators, sometimes an enhanced role for a receptionist, to direct patients to different services such as pharmacy and physiotherapy if a doctor is not needed. In September 2017 270 trained care navigators covering 64,000 patients had been employed across Wakefield. It was estimated that they had saved 930 GP hours over a 10-month trial.[55]

Four NHS trusts: Northumbria Healthcare NHS Foundation Trust; Yeovil District Hospital NHS Foundation Trust; Royal Wolverhampton NHS Trust; and Southern Health NHS Foundation Trust have taken over multiple GP practices in the interests of integration.[56]

GP Federations have become popular among English general practitioners.[57]

Consultations

According to the Local Government Association 57 million GP consultations in England in 2015 were for minor conditions and illnesses, 5.2 million of them for blocked noses.[58] According to the King's Fund between 2014 and 2017 the number of telephone and face-to-face contacts between patients and GPs rose by 7.5% although GP numbers have stagnated.[59] The mean consultation length in the UK has increased steadily over time from around 5 minutes in the 1950s to around 9·22 minutes in 2013–2014.[60][61] This is shorter than the mean consultation length in a number of other developed countries around the world.[60]

The proportion of patients in England waiting longer than seven days to see a GP rose from 12.8% in 2012 to 20% in 2017.[62] There were 307 million GP appointments, about a million each working day, with more on Mondays, in the year from November 2017. 40% got a same-day appointment. 2.8 million patients, 10.3%, in October 2018, compared to 9.4% in November 2017, did not see the doctor until at least 21 days after they had booked their appointment, and 1.4 million waited for more than 28 days. More than a million people each month failed to turn up for their appointment.[63]

Commercial providers are rare in the UK but a private GP service was established at Poole Road Medical Centre in Bournemouth in 2017 where patients can pay to skip waiting lists to see a doctor.[64]

GP at Hand, an online service using Babylon Health's app, was launched in November 2017 by the Lillie Road Health Centre, a conventional GP practice in west London. It recruited 7000 new patients in its first month, of which 89.6% were between 20 and 45 years old. The service was widely criticized by GPs for cherry picking. Patients with long term medical conditions or who might need home visits were actively discouraged from joining the service. Richard Vautrey warned that it risked 'undermining the quality and continuity of care and further fragmenting the service provided to the public'.[65]

The COVID-19 pandemic in the United Kingdom led to a sudden move to remote working. In March 2020 the proportion of telephone appointments increased by over 600%.[66]

Patient satisfaction

85% of patients rate their overall experience of primary care as good in 2016, but practices run by limited companies operating on APMS contracts (a small minority) performed worse on four out of five key indicators - frequency of consulting a preferred doctor, ability to get a convenient appointment, rating of doctor communication skills, ease of contacting the practice by telephone and overall experience.[67]

Northern Ireland

There have been particularly acute problems in general practice in Northern Ireland as it has proved very difficult to recruit doctors in rural practices.[68] The British Medical Association collected undated resignation letters in 2017 from GPs who threatened to leave the NHS and charge consultation fees. They demanded increased funding, more recruitment and improved computer systems.[69]

A new GP contract was announced in June 2018 by the Northern Ireland Department of Health. It included funding for practice-based pharmacists, an extra £1 million for increased indemnity costs, £1.8 million because of population growth, and £1.5 million for premises upgrades.[70]

Ireland

In Ireland there are about 2,500 General Practitioners working in group practices, primary care centres, single practices and health centres.[71]

Australia

General Practice services in Australia are funded under the Medicare Benefits Scheme (MBS) which is a public health insurance scheme. Australians need a referral from the GP to be able to access specialist care. Most general practitioners work in a general practitioner practice (GPP) with other GPs supported by practice nurses and administrative staff. There is a move to incorporate other health professionals such as pharmacists in to general practice to provide an integrated multidisciplinary healthcare team to deliver primary care.[72]

India

Family medicine (FM) came to be recognized as a medical specialty in India only in the late 1990s.[73] 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.[74]

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).[75] 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.[76]

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).[77][78] 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.[citation needed]

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.[79] 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.[80]

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[81] There is discussion ongoing to employ multi-skilled doctors with DNB family medicine qualification against specialist posts in NRHM (National Rural Health Mission).[82]

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.

British model

A group of 15 doctors based in Birmingham have set up a social enterprise company - Pathfinder Healthcare - which plans to build eight primary health centres in India on the British model of general practice. According to Dr Niti Pall, primary health care is very poorly developed in India. These centres will be run commercially. Patients will be charged ₹200 to 300 for an initial consultation, and prescribed only generic drugs, dispensed from attached pharmacies.[83]

Japan

Family medicine was first recognized as specialty in 2015 and currently has approximately 500 certified family doctors.[84] 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.[85] The Japan Primary Care Association (JPCA) is currently the largest academic association of family doctors in Japan.[86] The JPCA family medicine training scheme consists of a three-year programme following the two-year internship.[84] 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.[85] 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.[87] A review literature has recently been published detailing the context, structure, process, and outcome of family medicine in Japan.[88]

See also

Notes

  1. ^ Less commonly referred to as family practice
  2. ^ or, more informally, family doctor

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Further reading

  • William G. Rothstein (1987). American Medical Schools and the Practice of Medicine: A History. Oxford University Press. ISBN 978-0-19-536471-2.

January 08, 2023
family, medicine, journal, family, practice, journal, note, medical, specialty, within, primary, care, that, provides, continuing, comprehensive, health, care, individual, family, across, ages, genders, diseases, parts, body, specialist, usually, primary, care. For the journal see Family Practice journal Family medicine note 1 is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages genders diseases and parts of the body 2 3 The specialist who is usually a primary care physician is named a family physician note 2 It is often referred to as general practice and a practitioner as a general practitioner Historically their role was once performed by any doctor with qualifications from a medical school and who works in the community However since the 1950s family medicine general practice has become a specialty in its own right with specific training requirements tailored to each country 4 5 6 The names of the specialty emphasize its holistic nature and or its roots in the family It is based on knowledge of the patient in the context of the family and the community focusing on disease prevention and health promotion 7 According to the World Organization of Family Doctors WONCA the aim of family medicine is promoting personal comprehensive and continuing care for the individual in the context of the family and the community 8 The issues of values underlying this practice are usually known as primary care ethics Family medicineFocusPrimary care preventive healthcareSignificant diseasesHypertension URTI arthritis diabetes mental health pneumonia AOM back pain dermatitis 1 SpecialistFamily physicianFamily medicine physicianFamily physician right reviewing a case with nurse left in clinicOccupationNamesPhysicianSynonymFamily doctorOccupation typeSpecialtyActivity sectorsMedicineDescriptionEducation requiredDoctor of Medicine M D Bachelor of Medicine Bachelor of Surgery M B B S Bachelor of Medicine Bachelor of Surgery MBChB Doctor of Osteopathic medicine D O Fields ofemploymentHospitals clinics emergency departments long term care Contents 1 Scope of practice 2 In Canada 2 1 Education and training 3 In the United States 3 1 History of medical family practice 3 2 Education and training 3 3 Shortage of family physicians 3 4 Current practice 4 United Kingdom 4 1 History of general practice services 4 2 Current practice 4 3 England 4 3 1 Consultations 4 3 2 Patient satisfaction 4 4 Northern Ireland 5 Ireland 6 Australia 7 India 7 1 British model 8 Japan 9 See also 10 Notes 11 References 12 Further readingScope of practice EditFamily physicians in the United States must hold either an M D or a D O degree Physicians who specialize in family medicine must successfully complete an accredited three or four year long 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 9 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 10 Physicians certified in family medicine in Canada are certified through the College of Family Physicians of Canada 11 after two years of additional education Continuing education is also a requirement for maintenance of certification The term family medicine or family physician is used in the United States Mexico South America many European and Asian countries 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 General practice is the term used in many other nations such as the United Kingdom Australia New Zealand and South Africa Such services are provided by general practitioners The term primary care in the UK may also include services provided by community pharmacy optometrist dental surgery and community hearing care providers The balance of care between primary care and secondary care which usually refers to hospital based services varies from place to place and with time In many countries there are initiatives to move services out of hospitals into the community in the expectation that this will save money and be more convenient 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 counselling on maintaining a healthy lifestyle Family physicians also manage chronic illness often coordinating care provided by other sub specialists 12 Many American Family Physicians deliver babies and provide prenatal care 13 In the U S family physicians treat more patients with back pain than any other physician sub specialist and about as many as orthopedists and neurosurgeons combined 14 Family medicine and family physicians play a vital 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 15 In Canada EditEducation and training Edit In Canada aspiring family physicians are expected to complete a residency in family medicine from an accredited university after obtaining their Doctor of Medicine 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 of Canada in disciplines such as emergency medicine palliative care care of the elderly sports and exercise medicine and women s health amongst 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 In the United States EditHistory of medical family practice Edit 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 16 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 17 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 17 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 17 Education and training Edit Family physicians complete an undergraduate degree medical school and three more years of specialized medical residency training in family medicine 18 Their residency training includes rotations in internal medicine pediatrics 19 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 20 The specialty focuses on treating the whole person acknowledging the effects of all outside influences through all stages of life 21 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 22 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 23 Family physicians may pursue fellowships in several fields including adolescent medicine geriatric medicine sports medicine sleep medicine hospital medicine and hospice and palliative medicine 24 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 25 Shortage of family physicians Edit Many sources cite a shortage of family physicians and also other primary care providers i e internists pediatricians and general practitioners 26 The per capita supply of primary care physicians has increased about 1 percent per year since 1998 27 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 27 Still projections indicate that by 2020 the demand for family physicians will exceed their supply 27 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 28 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 29 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 30 31 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 American Academy of Family Physicians American Academy of Family Physicians Foundation American Board of Family Medicine American College of Osteopathic Family Physicians Association of Departments of Family Medicine Association of Family Medicine Residency Directors North American Primary Care Research Group Society of Teachers of Family MedicineThe 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 lower than average for physicians with the average being 225 000 32 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 33 Family physicians are trained to manage acute and chronic health issues for an individual simultaneously yet their appointment slots may average only ten minutes 34 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 35 Current practice Edit 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 36 Others choose to practice as consultants to various medical institutions including insurance companies citation needed United Kingdom EditHistory of general practice services Edit The pattern of services in the UK was largely established by the National Insurance Act 1911 which established the list system which came from the friendly societies across the country Every patient was entitled to be on the list or panel of a general practitioner In 1911 that only applied to those who paid National insurance contributions In 1938 43 of the adult population was covered by a panel doctor 37 When the National Health Service was established in 1948 this extended to the whole population The practice would be responsible for the patient record which was kept in a Lloyd George envelope 38 and would be transferred if necessary to another practice if the patient changed practice In the UK unlike many other countries patients do not normally have direct access to hospital consultants and the GP controls access to secondary care 39 Lloyd George envelopes at Whalsay Health Centre 2012 Practices were generally small often single handed operating from the doctor s home and often with the doctor s wife acting as a receptionist 40 When the NHS was established in 1948 there were plans for the building of health centres but few were built In 1953 general practitioners were estimated to be making between 12 and 30 home visits each day and seeing between 15 and 50 patients in their surgeries 41 Current practice Edit Today the services are provided under the General Medical Services Contract which is regularly revised 599 GP practices closed between 2010 11 and 2014 15 while 91 opened and average practice list size increased from 6 610 to 7 171 42 In 2016 there were 7 613 practices in England 958 in Scotland 454 in Wales and 349 in Northern Ireland 43 There were 7 435 practices in England and the average practice list size in June 2017 was 7 860 There were 1 35 million patients over 85 44 There has been a great deal of consolidation into larger practices especially in England Lakeside Healthcare was the largest practice in England in 2014 with 62 partners and more than 100 000 patients Maintaining general practices in isolated communities has become very challenging and calls on very different skills and behaviour from that required in large practices where there is increasing specialization 45 By 1 October 2018 47 GP practices in England had a list size of 30 000 or more and the average list size had reached 8 420 46 In 2019 the average number of registered patients per GP in England has risen since 2018 by 56 to 2 087 47 The British Medical Association in 2019 conducted a survey for GP premises About half of the 1 011 respondents thought their surgeries were not suitable for present needs and 78 said they would not be able to handle expected future demands 48 Under the pressure of the Coronavirus epidemic in 2020 general practice shifted very quickly to remote working something which had been progressing very slowly up to that point In the Hurley Group Clare Gerada reported that 99 of all our work is now online using a digital triage system linked to the patient s electronic patient record which processes up to 3000 consultations per hour Video calling is used to see patients if that is needed 49 In 2019 according to NHS England almost 90 of salaried GPs were working part time 50 England Edit The GP Forward View published by NHS England in 2016 promised 2 4 billion 14 real terms increase in the budget for general practice Jeremy Hunt pledged to increase the number of doctors working in general practice by 5 000 There are 3 250 trainee places available in 2017 The GP Career Plus scheme is intended to retain GPs aged over 55 in the profession by providing flexible roles such as providing cover carrying out specific work such as managing long term conditions or doing home visits 51 In July Simon Stevens announced a programme designed to recruit around 2 000 GPs from the EU and possibly New Zealand and Australia 52 According to NHS Improvement a 1 deterioration in access to general practice can produce a 10 deterioration in emergency department figures 53 GPs are increasingly employing pharmacists to manage the increasingly complex medication regimes of an aging population In 2017 more than 1 061 practices were employing pharmacists following the rollout of NHS England s Clinical Pharmacists in General Practice programme 54 There are also moves to employ care navigators sometimes an enhanced role for a receptionist to direct patients to different services such as pharmacy and physiotherapy if a doctor is not needed In September 2017 270 trained care navigators covering 64 000 patients had been employed across Wakefield It was estimated that they had saved 930 GP hours over a 10 month trial 55 Four NHS trusts Northumbria Healthcare NHS Foundation Trust Yeovil District Hospital NHS Foundation Trust Royal Wolverhampton NHS Trust and Southern Health NHS Foundation Trust have taken over multiple GP practices in the interests of integration 56 GP Federations have become popular among English general practitioners 57 Consultations Edit According to the Local Government Association 57 million GP consultations in England in 2015 were for minor conditions and illnesses 5 2 million of them for blocked noses 58 According to the King s Fund between 2014 and 2017 the number of telephone and face to face contacts between patients and GPs rose by 7 5 although GP numbers have stagnated 59 The mean consultation length in the UK has increased steadily over time from around 5 minutes in the 1950s to around 9 22 minutes in 2013 2014 60 61 This is shorter than the mean consultation length in a number of other developed countries around the world 60 The proportion of patients in England waiting longer than seven days to see a GP rose from 12 8 in 2012 to 20 in 2017 62 There were 307 million GP appointments about a million each working day with more on Mondays in the year from November 2017 40 got a same day appointment 2 8 million patients 10 3 in October 2018 compared to 9 4 in November 2017 did not see the doctor until at least 21 days after they had booked their appointment and 1 4 million waited for more than 28 days More than a million people each month failed to turn up for their appointment 63 Commercial providers are rare in the UK but a private GP service was established at Poole Road Medical Centre in Bournemouth in 2017 where patients can pay to skip waiting lists to see a doctor 64 GP at Hand an online service using Babylon Health s app was launched in November 2017 by the Lillie Road Health Centre a conventional GP practice in west London It recruited 7000 new patients in its first month of which 89 6 were between 20 and 45 years old The service was widely criticized by GPs for cherry picking Patients with long term medical conditions or who might need home visits were actively discouraged from joining the service Richard Vautrey warned that it risked undermining the quality and continuity of care and further fragmenting the service provided to the public 65 The COVID 19 pandemic in the United Kingdom led to a sudden move to remote working In March 2020 the proportion of telephone appointments increased by over 600 66 Patient satisfaction Edit 85 of patients rate their overall experience of primary care as good in 2016 but practices run by limited companies operating on APMS contracts a small minority performed worse on four out of five key indicators frequency of consulting a preferred doctor ability to get a convenient appointment rating of doctor communication skills ease of contacting the practice by telephone and overall experience 67 Northern Ireland Edit There have been particularly acute problems in general practice in Northern Ireland as it has proved very difficult to recruit doctors in rural practices 68 The British Medical Association collected undated resignation letters in 2017 from GPs who threatened to leave the NHS and charge consultation fees They demanded increased funding more recruitment and improved computer systems 69 A new GP contract was announced in June 2018 by the Northern Ireland Department of Health It included funding for practice based pharmacists an extra 1 million for increased indemnity costs 1 8 million because of population growth and 1 5 million for premises upgrades 70 Ireland EditIn Ireland there are about 2 500 General Practitioners working in group practices primary care centres single practices and health centres 71 Australia EditGeneral Practice services in Australia are funded under the Medicare Benefits Scheme MBS which is a public health insurance scheme Australians need a referral from the GP to be able to access specialist care Most general practitioners work in a general practitioner practice GPP with other GPs supported by practice nurses and administrative staff There is a move to incorporate other health professionals such as pharmacists in to general practice to provide an integrated multidisciplinary healthcare team to deliver primary care 72 India EditFamily medicine FM came to be recognized as a medical specialty in India only in the late 1990s 73 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 74 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 75 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 76 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 77 78 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 citation needed 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 79 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 80 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 81 There is discussion ongoing to employ multi skilled doctors with DNB family medicine qualification against specialist posts in NRHM National Rural Health Mission 82 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 British model Edit A group of 15 doctors based in Birmingham have set up a social enterprise company Pathfinder Healthcare which plans to build eight primary health centres in India on the British model of general practice According to Dr Niti Pall primary health care is very poorly developed in India These centres will be run commercially Patients will be charged 200 to 300 for an initial consultation and prescribed only generic drugs dispensed from attached pharmacies 83 Japan EditFamily medicine was first recognized as specialty in 2015 and currently has approximately 500 certified family doctors 84 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 85 The Japan Primary Care Association JPCA is currently the largest academic association of family doctors in Japan 86 The JPCA family medicine training scheme consists of a three year programme following the two year internship 84 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 85 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 87 A review literature has recently been published detailing the context structure process and outcome of family medicine in Japan 88 See also EditATC codes Anatomical Therapeutic Chemical Classification System Classification of Pharmaco 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192 doi 10 1111 j 1444 1683 2003 00094 x About Us Japan Primary Care Association 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 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 PMC 6732569 PMID 31516802 Further reading EditWilliam G Rothstein 1987 American Medical Schools and the Practice of Medicine A History Oxford University Press ISBN 978 0 19 536471 2 Retrieved from https en wikipedia org w index php title Family medicine amp oldid 1127684224, wikipedia, wiki, book, books, library,

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