Few thoughts on Family Medicine

INTERVIEW: Dr. Sunil Abraham, Dept. of Family Medicine, CMC, Vellore

The government is giving a lot of focus on hospital care, tertiary care and ignoring the primary care.Shahid Akhter  |  ETHealthWorld  |  15 December 2015, 8:58 AM IST

Dr. Sunil Abraham, Dept. of Family Medicine, CMC, Vellore, talks to ETHealthworld about the role and importance of family doctors and how CMC is bridging the healthcare gap between the rural and the urban areas. 

1. Why are we lagging behind in primary care and family medicine? 

There are three reasons. One is the perception problem because the young doctors feel it's not a glamorous specialty. They think that you need to be a cardiologist, nephrologists or a radiologist to have a specialty that is accepted and have some esteem. Second is that people feel you make much more money in other specialties. Third is the policy problem because when we look at countries like the UK, Canada or the Scandinavian countries, they all have a good foundational family medicine. 

You cannot see a specialist without first being seen by your family doctor but this policy hasn't come to India yet. The government is giving a lot of focus on hospital care, tertiary care and ignoring the primary care. These are the reasons why it has not gone forward. 

There have been studies done in other countries. For example; a study done in US found out that in a population of 1000 people, only 1% get admitted in a tertiary teaching hospital. If you increase the duration of medical education in the community, they will learn about the common problems and where problems present to the doctor much earlier in the diseases and that is very important. We have tried doing this in CMC and it is making an impact. 

2. Why and how are the family physicians important? 

There are few issues that people face when they age like multiple diseases. The aged person may have diabetes, hypertension, COPD, muscular skeleton problems, depression, prostate problem etc. They need somebody who can manage all these problems otherwise it is very tedious for them to go from one specialty to another. 

Going to the hospital is becoming more of a harrowing experience because you have to go through the busy traffic, wait in line etc and elderly people may not be healthy enough to do that. They are also looking for people whom they know on continues long time basis. I see a great role of family physicians to give elderly artery care. 

3. How can the healthcare in rural areas be encouraged? 

I personally have worked in a very rural place with 1500 population. I know the realities of working in rural place and how challenging it is. The issues people face are schooling, support system and salary. The infrastructure and the support system in the rural hospitals are very poor. Salary is an issue because they make less money when you are in a rural place. 

Currently from the 50,000 MBBS seats, we have only 10,000 post graduate seats. The government should give a career path for family physicians that are trained to be given consultant post in the rural place and a salary incentive for them. The problem with the community health centers is that you don't have the right kind of doctors. You need more family doctors there who can manage 80-90% of the problems. This will be a solution to increase the healthcare in the rural areas. 

4. What is happening in Family Medicine in CMC? 

We have a department of family medicine for the past 6 years. We are only one of the two medical colleges in the whole country with department of family medicine. Currently we have 10 faculties and most of us work in the four to six bedded unit for the urban poor called the Low Cost Effective Care Unit. 

Some of us work in the urban Ambulatory Care Family Medicine Center where patients are given ambulatory care that means there is no place to get admitted but they can come as a one stop place for most of their medical problems, get the drugs there, give the investigations there and we have minor positions also being done there. 

5. Tell is about the Low Cost Effective Care Unit associated with CMC? 

The main CMC hospital is about 2300 bedded hospital. In 1982, it started a unit called the Low Cost Unit which is 46 bedded hospitals and is 1 kilometer away from the main hospital. Here, when the poor patients come for the first time, they pay 25 Rs as a lifetime registration fees and after that the consultations are free. 

We have 46 beds and all these beds are free. We ask them to pay for the drugs as we don't give out free drugs unless there's an emergency. We manage about 80-90% problems and they have access to all the investigations of the main hospital. 

We have consultants from the main hospital coming to us giving for giving free consultations if we ask them to. We have no other specialists; we have got 5 family medicine specialists and 2 community medicine specialists and few other junior doctors along with all our other staff that runs this space. 

6. How are you associated with Low Cost Effective Care Unit? 

There are two things that I am focused on when I sit in the OPD. One is to see patients of all ages. I manage problems across all disease patterns and all organs. We manage a breath of problems and the other thing is that our focus is not on the disease but on the person. My focus is the person, his issues, how I know him and this relationship is the foundation of family medicine. On a typical day I would see patient with multiple problems and also see people whom I have known for many years. 

Eat Healthy - Beat Diabetes

The World Health Day 2016 is observed worldwide with a theme – Beat Diabetes. Diabetes Mellitus is a chronic, metabolic disease characterized by elevated levels of blood glucose which will over time lead to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. The prevalence of diabetes has been steadily increasing and it has witnessed fourfold increase in the past four decades. About 350 million people have diabetes worldwide, and it is estimated that one tenth of the adults over 18 years have diabetes.
  

Diabetes occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin, a hormone that regulates blood sugar, gives us the energy that we need to live. If it cannot get into the cells to be burned as energy, sugar builds up to harmful levels in the blood. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels.

Types of Diabetes 

There are two major forms of diabetes. Type 1 diabetes is characterized by a lack of insulin production and Type 2 diabetes results from the body's ineffective use of insulin. Type 2 accounts for around 90% of all diabetes worldwide. A third type of diabetes is gestational diabetes. This type is occurring or diagnosed during pregnancy. Women with gestational diabetes are at an increased risk of complications during pregnancy and at delivery. They are at increased risk of Type 2 diabetes in the future.

Apart from these three types, IGT (Impaired Glucose Tolerance – high sugar values only after food; not at fasting and IFG (Impaired Fasting Glycaemia – high sugar values only at fasting; not after food) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to Type 2 diabetes if appropriate preventive measures are advocated in time. 

Causes

The causes of diabetes are a multiple and complex, but for Type 2 diabetes the increase is in large part due to rapid increases in overweight, including obesity and physical inactivity.  The cause is not known in Type 1 diabetes, but it is thought to be the result of a combination of genetic and environmental factors. Due to this multifactorial feature, diabetes is seldom an isolated entity and usually occurs along with other conditions like Hypertension, Dyslipidemia and Obesity. 

Complications 

Diabetes has become one of the major causes of premature illness and death, mainly through the increased risk of cardiovascular disease and chronic kidney disease. Cardiovascular disease is responsible for between 50% and 80% of deaths in people with diabetes. Lack of awareness about diabetes, combined with irregular treatment, can lead to complications such as blindness, amputation and kidney failure. The life threatening infections, hypo or hyperglycemia are the acute complications of diabetes.

Diabetes is not just a matter of health; its complications bring about substantial economic loss to people with diabetes and their families and to national economies through direct medical costs and loss of work and wages.

Treatment

Early diagnosis and prompt treatment is the cornerstone of diabetes management. Early diagnosis can be accomplished through relatively inexpensive blood testing. Once diagnosed, diabetes needs to be controlled well to prevent further complications. People with type 1 diabetes require insulin; people with type 2 diabetes can be treated with oral medication, but may also require insulin. Other co-morbid conditions and complications also need to be screened periodically and treated appropriately. 

How to Prevent

A large proportion of diabetes cases are preventable. Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes. Maintaining normal body weight, engaging in regular physical activity, and eating a healthy diet can reduce the risk of diabetes.
  

To help prevent type 2 diabetes and its complications, one should:

• Achieve and maintain ideal body weight according to the height.

• Be physically active – at least 30 minutes of regular, moderate to intensity activity on at least 5 days in a week.

• Eat a healthy diet of between 3 and 5 servings of fruit and vegetables a day and reduce sugar and saturated fats intake.

• Avoid tobacco use as smoking increases the risk of cardiovascular diseases.

The symptoms of diabetes include excessive excretion of urine, excessive thirst, constant hunger, weight loss, vision changes and fatigue.

If you are in doubt, check! Let’s beat diabetes together!