Saturday Nov 23, 2024
Saturday Nov 23, 2024
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Introduction
A Western medical doctor who has undergone further training to deliver medical care at primary care level based on concepts and principles of Family Medicine/General Practice is a General Practitioner/Family Physician. Family Medicine/General practice is the medical specialty which provides continuing and comprehensive care for the individual and the family. General Practitioners deal with physical, mental and social signs and symptoms in individuals, their families and the community to deliver quality promotive, preventive, curative, rehabilitative and palliative care in an ethical and professional manner based on the principles of family medicine which is the academic discipline which underpins general practice. It integrates biological, clinical and behavioural sciences to deliver healthcare in holistic manner.
The Family Physician of today is rooted in the historical ‘generalist’ commonly referred to simply as ‘A Doctor’. The reader is encouraged to reflect on who or what a medical doctor means to him/her at an individual, family and community level. In Sri Lanka, the terms general practitioner, private practitioner or family physician is synonymously used to identify a Western medical practitioner who may or may not deliver primary curative medical care based on the principles of family medicine. This implies that anyone with a medical degree (or not) is deemed fit by the medical regulators and the Sri Lankan public as qualified, trained and competent to deliver care to patients based on the concepts and principles of family medicine.
This basically allows every Tom, Dick and Harry (or to contextualise it to a Sri Lankan scenario every Silva, Perera and Fernando!) (Or put another way every Community Physician, Oncologist and Cardiovascular surgeon!) to engage in General Practice. This puts patients in harm’s way and gives genuine general practitioners a bad name and image professionally. This in turn leads to unnecessary medicalisation of health issues and leads to a disease-based approach to health care at an exorbitant cost for the individual and society. The outcome of this is patients expecting and doctors complicitly delivering disease care as opposed to healthcare when often it is clearly unnecessary.
Background
The concepts and principles of family medicine are as old as the field of medicine itself. Family medicine as an academic discipline is comparatively new. It was accepted as a distinct academic branch of medicine in the UK in 1952 and in the USA in 1969 and in Sri Lanka, it was recognised as a distinct clinical discipline in May 1979.
In Sri Lanka there is no historical record of self-employed Western medical practitioners during the colonial occupations by the Portuguese or even the Dutch. One of the earliest references to self-employed Western medical practitioners is in the year 1835 during the British colonial occupation. These records state that a Western medical practitioner named Dr. Misso ‘opened an exceedingly well-furnished dispensary in Pettah after spending twenty years in public service’.
Towards the end of the 19th century, many Ceylonese doctors who were products of the Ceylon Medical College (presently the Faculty of Medicine, University of Colombo) took to private practice and established independent clinics outside the State healthcare system in Colombo and Kandy gradually moving to other major towns and villages.
With the increase in their numbers, by the early part of the 20th century, there were quite a few general practitioners all over Ceylon. A logical development of the proliferation of those engaged in general practice was the formation of an association to look after their interest and ensure their continuous professional development. This led to the formation in 1929 of The Independent Medical Practitioners Association (IMPA) vibrantly existing even today.
The IMPA was a medico-political body with academic general practice as a subsidiary interest amidst the many professionally related issues it had to deal with at its inception and formative years. Nevertheless, in the 1960s the leaders of the IMPA identified the need for a separate entity to spearhead and dedicate itself as an organisation to the academic discipline of General Practice. This idea was the embryo which over the years developed into the College of General Practitioners of Sri Lanka, the apex professional and academic body of all grades of general practitioners in the private, state and academic sectors in Sri Lanka.
In 1969, Dr. A.M. Fernando attended the convention of the General Practitioners of Australia in Sydney. During this visit he experienced firsthand the benefits of a formal organisation dedicated to GPs and how it played a role in the continuous professional development of its members which in turn led to quality primary curative care to patients. He shared his experience with the IMPA membership who too were convinced of the benefits of such organisation and its advantages to the healthcare system of the country.
Dr. C.E.S. Weeratunge a General Practitioner and member of IMPA was appointed Secretary to the Ministry of Health in 1970 and having been convinced of the idea for the need of a organisation for academic family medicine he lost no time in facilitating the idea of a College for General Practitioners and converted it in to reality along with a team of colleagues spearheaded by Dr. G.M. Heennilame. The procedural and legal aspect of this venture commenced in 1972 and culminated on 19 August 1974 when under the able guidance of the Speaker of the House Stanley Thilakaratne and the Clerk of the House Sam Wijesinghe, Ronnie de Mel Member of Parliament for Dondra (later Finance Minister) presented the bill which was approved and brought in to the existence the College of General Practitioners of Sri Lanka (CGPSL) by an act of parliament.
The inaugural meeting of the founder members of the College was held on 6 September 1974 at SLMA House. The first general meeting was held on 18 February 1975. At this meeting all qualified doctors who were eligible for membership according to the Bill were enrolled, subject to the confirmation of the Council. In all 118 members were enrolled on that day.
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Major achievements
1. Establishment of the Board of Study in Family Medicine, at the Post Graduate Institute of Medicine (PGIM) of the University of Colombo
Through this academic activity the College laid the post graduate educational foundation for every single trainee in family medicine who went through the Diploma in Family Medicine Programme and all those who have gone through, are going through and will go through the MD in Family Medicine program in Sri Lanka.
It must not be forgotten that the entire effort in creating this Board of Study was shouldered by Members of the CGPSL. Of the initial 10-member board, five were Members of the CGPSL including the Chairman and Secretary of the founding Board. The stewardship of this pioneering board is considered the Golden Era which ushered Family Medicine as an academic disciple into the medical and post graduate medical education spheres in Sri Lanka and beyond. The CGPSL through the BoS successfully conducted the Diploma in Family Medicine (DFM) exam in Chennai, India in collaboration with the College of General Practitioners of the Indian Medical Association (CGPIMA). As such there are quite a few Indian Doctors with the DFM-Colombo qualification in Indian even today. To date this remains the only post graduate medical examination conducted in a foreign county by the PGIM.
2. Introduction of Family Medicine to the undergraduate medical curriculum
At the request of the CGPSL the Faculty of Medicine, University of Colombo began sending its students to General Practitioners in the Colombo area for three half-day sessions in 1980 to expose them to the discipline. The NCMC which was established in 1981 had a Department Family Medicine in 1983 where students were given formal theoretical and practical inputs into Family Medicine for the first time in Sri Lanka. Subsequently the Universities of Sri Jayewardenepura and Kelaniya established Departments of Family Medicine in the years 1993 and 1994 respectively. The University of Colombo established a Family Medicine Unit in 2002 and converted it to a Department of Family Medicine in 2018. The Universities of Jaffna, Rajarata, Eastern and Ruhuna have either commenced or are in the process of establishing either Departments or Units to teach Family Medicine.
3. International partnerships and collaborations
a) World Organization of National Colleges Academies and Academic Associations of General Practice – WONCA
WONCA commenced in the year 1972 and the CGPSL formally joined in 1978 at its 8th meeting held in Geneva, Switzerland though professional and academic contacts had been going on since 1976.
Earlier this year in conjunction with the 50th anniversary of celebrations of the CGPSL, the WONCA South Asia Regional meeting was hosted by the CGPSL in Colombo 3 to 5 May 2024 at the Shangri-La Hotel. Sri Lanka had twice previously hosted this conference (2005 and 2016)
This event was marked by the Philatelic Bureau of Sri Lanka issuing a commemorative stamp and first day cover marking the event.
Many members of the CGPSL play active roles in WONCA with great distinction.
b) Royal College of General Practitioners of the United Kingdom
The CGPSL established formal links with the Royal College of General Practitioners of the UK in March 1978 with the visit to Sri Lanka of the Dean of studies of the RCGP, Dr. J.S. Norell. This link was renewed in 2003 with the CGPSL taking a lead role negotiating with the RCGP to conduct the Membership exam of the RCGP in the South Asia region. The first MRCGP [INT]-South Asia exam was held in 2007 in Colombo. This exam is now held three times a year in rotation in Colombo, Chennai and Karachi.
4. Establishment of the North Colombo Medical College
When Dr. G.M. Heennilame first brought up the proposal of a private medical school in 1975 at a Council meeting of the CGPSL, he was ridiculed and had to face raucous laughter and cynical comments from his colleagues in the Council who did not allow him to continue his presentation. He re-presented his proposal in 1980 at the AGM having further refined it. The proposal won unanimous support from the general membership. Following this a memorandum was submitted to President J.R. Jayewardene. Health Minster Gamini Jayasuriya was instructed by the President to follow the matter up with the CGPSL along with Secretary Health B.C. Perera and the Director General of Health Services. A series of meetings with relevant officials took place and The President on the recommendation of his officials approved the long lease of the Thalagolla convalescent home with 5 to 10 acres of surrounding land in Ragama and designated the North Colombo General Hospital as the teaching hospital for the proposed private medical college.
The NCMC having produced about 300 doctors was acquired by the government in 1989 and the educational activities continued under state control. The CGPSL received financial compensation for the NCMC project in 2024. President Ranil Wickremesinghe decided to gift a piece of land within the city limits of Colombo to the CGPSL to put up its headquarters.
5. Membership program of the CGPSL
This is currently a two-year part-time post graduate diploma level program which leads to an examination consisting of MCQ, SEQ, OSCE, and Portfolio assessment. This diploma is a registrable with the Sri Lanka Medical Council. The introduction of a compulsory Mentoring Program for MCGP trainees by the Faculty of Teacher is considered a unique development in a medical educational program conducted by a professional college in Sri Lanka.
6. Mentoring in Sri Lankan General Practice
The aim of the mentoring program (commenced in 2013/2014) initiated by the Faculty of Teachers is to guide doctors and postgraduates trainees in their personal, professional and academic development as General Practitioners in Sri Lanka. It is hoped that once the College’s efforts in establishing a Register for General Practitioners in Sri Lanka at the Sri Lanka Medical Council succeeds this mentoring programme can be offered to prospective applicants as a part of their registration process and continuous professional development.
7. Introduction of Palliative Care training program
In the year 2009/2010 the College recognised the need for provision of quality palliative care at the community level. An MoU with the Institute of Palliative Care, Calicut, India which is a WHO collaborating centre for community participation in palliative and long-term care, provides training for medical and para medical staff. This led to the formation of an independent organisation named the Palliative Care Association of Sri Lanka under the auspices and guidance of the CGPSL.
The future
As Martin Luther King Jr. once said: “We are not makers of history, we are made by history.” Moving forwards, I am reminded also of what George Orwell said: “The most effective way to destroy people is to deny and obliterate their own understanding of their history.” For the younger members of our profession in Sri Lanka in particular, I urge you to be familiar with these events as you take our profession into the glorious uncertainties of the future.
As the apex professional and academic organisation of general practitioners in Sri Lanka the CGPSL must always strive to be relevant to our profession and members to equip ourselves with the knowledge, skills and attitudes to provide quality primary curative care to our patients. The key point to remember in our progression towards our centenary is we must not revolve as a scientific discipline but must evolve for the benefit of our patients.
Conclusion
The concepts, principles, knowledge, skills and attitude which Family Medicine imparts on its practitioners is the most suitable platform to get scientific advances in medicine to people who need it the most because of its simplicity/complexity and cost effectiveness. For me the word ‘doctor’ in the medical context is epitomised by the discipline of General Practice/Family medicine as it provides cares to undifferentiated care seekers not limited by the origin of the ‘problem’, organ system, gender, age or diagnosis.
Medicine is also a matter of income, geography and justice. Access to healthcare is still impeded in much of the world by neglect, by distance, by governance, by prejudice and fixed ideas of what is possible. These are the social and commercial determinants of health which we as professionals and lay people must work together to overcome…
Members of the CGPSL have stood for political correctness in the country and have spoken out and written on issues which affect the democratic system of government in Sri Lanka. Dr. R.M.L. Fernando (better known as Riley Fernando) created history, of sorts, in the early 1970s with an obituary notice he inserted in a leading newspaper on 24 April 1974. During that time the Government imposed an Island-wide curfew, banned all opposition meetings and sealed the Independent Newspaper group. Dr. Fernando decided to act against the looming dictatorship which was slowly being established in the country. His obituary notice created a sensation in Sri Lanka and interest, admiration and amusement abroad. The international press gave coverage to this now famous obituary which is reproduced below.
“O’cracy – The death occurred under tragic circumstances of D.E.M. O’cracy, beloved husband of T. Ruth, loving father of L. I. Bertie, brother of Faith, Hope and Justitia. Interred on Saturday, 20th inst. – Araliya Medura, Panagiyawatte, Anduruwala.”
(The writer is a Specialist Family Physician; Founder Head, Dept. Family Medicine, Faculty of Medicine, University of Colombo; and Past President, Sri Lanka Medical Association.)
As the apex professional and academic organisation of general practitioners in Sri Lanka the CGPSL must always strive to be relevant to our profession and members to equip ourselves with the knowledge, skills and attitudes to provide quality primary curative care to our patients. The key point to remember in our progression towards our centenary is we must not revolve as a scientific discipline but must evolve for the benefit of our patients