Snapshot of family medicine around the world

Discussion

While the United States, Canada, the United Kingdom, Australia, and New Zealand have many long-standing family medicine programs, much of sub-Saharan Africa has none. Scandinavian countries have among the longest training programs while countries as diverse as Canada, Lebanon, Brazil, Mali, and Laos each have 2-year programs. However, Canada, unique among high-income countries for such short training, is planning on lengthening training to 3 years.¹²

Cross-jurisdictional data sources are a challenge to aggregate. The nomenclature around family medicine, including names of the degrees along the pathways of training, are variable. The MBBS, MBBCh, and MD degrees can each represent basic medical degrees, while MD can also be a graduate designation equivalent to a PhD in family medicine (namely in the United Kingdom) or specialization (as in India). The final year of medical school, clerkship (known as Praktisches Jahr in Germany), in some countries is known as an internship or service year. Several countries require 1 to 3 years of community work before postgraduate training in family medicine. Diplomas (eg, PGDFM or GDFM in Asia) usually require minimal coursework and are sometimes completed online, but a diploma in family medicine in India requires a 3-year residency. A fellow could have finished a year of coursework or have completed work beyond residency. A master’s degree may be a short route to designation while an MMed in Africa and some Asian countries may be 4 years and a superresidency including PhD-type research. Table 1 summarizes pathways outside of clinical residency including a multiplicity of other conduits (often in Asian countries), such as research and continuing education courses, to qualify for a family doctor designation.

As we assess the impact of family medicine, our data engender more questions. When evaluating the impact of training, do we include shorter and more informal training? Where family medicine is less established, representing a small proportion of primary care, should we explore only micro-level outputs (eg, comparing early graduates to other established primary care providers) to glean the value of training rather than seeking overarching population-based outcomes? We must determine appropriate quality indicators in terms of value of primary care.¹³ In settings where the family medicine model represents a substantial proportion of primary care, collaboration with other institutions may lead to the development of appropriate parameters to measure health system performance resulting from the impact of primary care models within and between countries, such as the “control knobs” framework.¹⁴

There are several limitations to our approach. Our data are dependent on the collective memory of our informants and our editorial board and our interpretation of the interviews, and they are complicated by the variation in official terminology. We may be unaware of nascent or dormant programs, particularly those not represented in the peer-reviewed literature, especially in emerging contexts. Thus, the development of our board and pool of regional experts and fostering of partnerships with WONCA leaders will be critical for the ongoing goal of this project.

Beasley et al asserted that a challenge of developing primary care research was strengthening academic departments, enhancing links to outside researchers, and increasing funding to ensure the relevance of research to vulnerable populations.¹⁵ Family medicine is still a young discipline in many parts of the world, and growing it also means growing its scholarship. This includes advancing the understanding of our discipline and assessing whether its myriad pathways and forms represent one of family medicine’s most appealing qualities: the ability to adapt to the needs of local populations.