One
A few years back I attended a meeting with the Head of the Department of General Practice in Melbourne’s Monash University. He asked me about the undergraduate medical training programme in Bangladesh. I went through the structure of the undergraduate training programme in various disciplines. I spoke about Medicine, Surgery, Obstetrics, Gynaecology, ENT and so on. He then asked me, ‘What about General Practice or Family Medicine? You haven’t told me about that’. I replied, ‘Prof, we do not have a General Practice or Family Medicine segment in our undergraduate training programme’. Without uttering a word, the professor stared at me with his eye wide open for a minute or two. One could see the sign of total disbelief in his face.

Are you sure? How could it be?

Yes, Prof.

So, for the GPs you only have post graduate training programme?

No, Prof, we don’t have that either.

That’s a bit odd!

Our conversation did not proceed much further. I am sure the professor found it difficult to comprehend how a fraternity of Medicine could develop and thrive without having its most important and very basic component like General Practice being trained neither in undergraduate nor in postgraduate levels.

The question is, has the fraternity been thriving towards excellence or towards its maximum potential?

Two:
On the 6th September 2009, Bangladesh lost one of its most talented frontline journalist Ahmed Faruque Hassan who was the deputy editor of Daily Jugantor. He happened to be very close friend of mine. He has been coughing for a while. That was not a surprising as he was a chain smoker. However, the cough accompanied fever at that time and he thought about seeing a doctor. On the fatal day, the fever and cough was complicated by a left sided chest pain. At night his colleagues discovered him listless on his working desk, forced him to go to a doctor. Faruque decided to consult a ‘Chest Specialist’ as all his symptoms were in the chest. 

He was eventually seen by a Chest Specialist. What happened during consultation and aftermath is any one’s guess. Apparently, he was sent for a chest x-ray and was prescribed some medication (antibiotics for ‘Chest Infection’).  However, he was allowed to come back to his office. Later at night his dead body was found in his office. He died of massive heart attack.

One could easily have asked Faruque’s family history, risk factors and explored more about his recent onset left sided chest pain. Having an index of suspicion and sending him for an ECG could have brought a different outcome. If he attended an appropriately trained General Practitioner/ Family Physician, he could have triaged properly and referred to a Cardiologist. Alas! That was not the case. If one consults a ‘Chest Specialist’ (in Bangladesh who is a Respiratory Physician in essence), it is only natural that the consultant does not often think outside his ‘box’ (Lungs in this case). It is common in any other discipline as well.

What option did Faruque have? He probably did not have a qualified Family Physician at his disposal. Do we have many of them anyway? One wonders how many Faruques are losing their lives in similar circumstances.

Three:
In the recent past we have lost another of our most talented journalist Minar Mahmud. He died in mysterious circumstances in an upmarket hotel room. It was alleged that he committed suicide as he had been suffering from severe Depression. Well, he might not have ventilated his feelings to anyone. In Bangladesh Clinical Psychologists are few and far between. The idea of consulting a Psychiatrist for a condition like Depression is a non-starter due to social stigma. It the Psychiatrists have to consult each and every patient with Depression, the real ‘psychotic’ patients would not have access to them. General Practitioners are easy going by dint of their training and their nature of job.  They should be easier to access as well for initial and ongoing management of such cases. However, do we have many suitable trained General Practitioners around? People like Minar Mahmud possibly had nowhere to go (except his family and mates).

Four:
During my routine phone conversation to one of my friends in Bangladesh, he asked me whom should he consult to quit smoking. I did not have a readily available answer. In our time smoking cessation was not a part of our undergraduate curriculum. Whom should he consult? An Internist? A Respiratory Physician? A Psychiatrist or perhaps, a Clinical Psychologist? Actually there is no need to run around to various specialists for smoking cessation therapy.  He should have consulted a family physician with appropriate training. But do we have many of them around?

Five:
It was good to see the Department of Psychiatry of BSMMU had recently organised a scientific seminar on ‘Updated Management of Erectile Dysfunction’. Except by the street Herbalists and the ‘Hekims’, ED (Erectile Dysfunction) is not something widely talked about in Bangladesh. 

Whether we talk about it or not, ED is a common problem that needs to be addressed if we were to help those patients to enjoy healthy sex life. ED is often a multifactorial condition that warrants multidisciplinary approach for management. 

In a culturally conservative society like ours, patients do not usually consults their doctor only for ED. It is rather mentioned as a co-existing condition while discussing other illnesses. Patients are often reluctant to volunteer to discuss the issue. So, the general practitioners are in the right position to explore the issue opportunistically and they are the appropriate co-ordinators of the multi disciplinary approach. 

Many of these patients can easily be managed in the general practice setting. Only a very few will need intervention by a psychiatrist or by another specialist. However, the Department of Psychiatry of BSMMU deserves appreciation as they have taken the lead while not many other professional bodies are coming forward.

We need a bunch of appropriately trained General Practitioners to identify the problem of ED and manage it properly. This will not only allow more and more patients to address their problem but also reduce the unnecessary workload to various other specialists (e.g. Psychiatrists). Not all ED patients can be treated by the Urologists or by the Psychiatrists, but all such patients can be investigated, initially managed and referred to the appropriate specialists by the GPs if and when needed.

Six:
I have mentioned some real and practical scenario of health care inadequacies in Bangladesh. Thousands of such examples could be sited to emphasise the need for more and more appropriately trained General Practitioners/ Family Physicians around us.

Surely, we have many General Practitioners rendering their services especially in urban areas. Many of them are highly experienced and competent. However, the GPs who are awaiting to specialise in other disciplines and who become GP because they could not specialise outnumber the competent ones by far. And yet, a vast majority of our population depends on them for essential health care need. Even there is no structured CME (Continuing Medical Education) or CPD (Continuing Professional Development) activities for the experienced ones for maintaining their skills, let alone to up skill them.

Many of us have a misconception that General Practice is all about sub-standard Medicine. If one looks at the state of health service in Bangladesh with a myopic view, it may appear the case. However, nothing could be further from the truth. While a specialist in any other discipline knows ‘many things’ about ‘something’ an appropriately trained General Practitioner knows ‘something’ about ‘everything (in Medicine)’. 

The readers may notice I have been qualifying the term ‘GPs’ by mentioning ‘appropriately trained’ before them. We do not have many of them around as there is no structured training programme for GPs in Bangladesh. If we are to excel in health care, we definitely need to improve the quality of our General Practice. After all, the GPS are the back bone of the health care delivery system. 

A General Practitioner has the most challenging job among all health practitioners. S/he is required to remove a foreign body from someone’s eye at one moment, deal with a patient crying inconsolably with a grief reaction the next moment. His/ her day may start with draining an abscess and may end with attending to a patient with acute chest pain. He or she has to deal with the issue at hand or to refer to an appropriate specialist. How on earth a lay patient would know whether his chest pain is of heart or lung origin or not? General Practice in fact is the most diverse of all specialties in medicine. Such a diverse and challenging discipline warrants and deserves its rightful place in the health care delivery system through its elevation to a specialty status.

The excellence in medical care in Bangladesh like any other country depends largely on the excellence of General Practice. To achieve this, the policy makers have to think about appropriate training and career pathway for the GPs. A measurable improvement in Health care could be achieved with only a little effort, if planned appropriately. General Practice is not about knowing very little about different body systems but about knowing a lot about all of them. A General Practice domain without postgraduate training programme and Continuing Professional Development stream does not have a place in health care delivery system in modern era. 

The good news is that such a training programme does not necessarily require a lot of resource or even need for fulltime hospital attachment. The programme needs to be community based and practice oriented. It is understood that Bangladesh University of Health Sciences (BUHS) has designed such a programme to upskill the new generation of General Practitioners/ Family Physicians. We can move towards excellence in Primary Health Care delivery if more and more of these programmes are readily available. 

The time has come to think outside the box.

(The author is a practicing Family Physician in Melbourne, a social activist and a freelance columnist) 

BDST: 1440 HRS, JUN 09, 2014