off record
Shaukat Ali Jawaid



Emerging new tends
in primary healthcare


General practitioners are generally considered as the backbone of healthcare delivery system in any country and they are also the first one to be contacted by the patients. They play an important role in provision of primary health care but gradually PHC will be slipping out of their hands. Eventually they will be replaced by Medical Assistants and Nurse Practitioners in the days to come.

GPs always complain of unbridled quackery wherein they have to compete with these quacks and they have all along been requesting the government to eliminate quackery. Punjab Health Care Commission has also launched a campaign against quackery but little does everyone realize that quackery cannot be eliminated unless and until we ensure accessible and affordable primary health care universally. Ideally a couple of GPs should join hands and start a joint family medicine practice in properly staffed and equipped premises where all the essential primary healthcare services including comfortable waiting areas for the patients are available. It will not only ensure standardized primary health care but the GPs, Family Physicians will also work without any un-necessary stress and strains, will be able to avail holidays thereby improving their own quality of life as well. However, unfortunately this has not happened.

Added to this is the unprecedented manifold increase in the private medical and dental colleges established in the private sector during the last ten years most of which are just functioning as “Diploma Mills”. As regards the quality of education, teaching and training imparted in most of these institutions is far from satisfactory. After graduation, most of them do not find themselves competent enough to compete and settle in general practice while Government cannot provide jobs to every fresh medical graduate.

Even in United States, until 1920, majority of the medical graduates used to settle in General Practice and this went on till the middle of the 20th century. A new specialty, Family Medicine was established in 1969 in USA after these medical graduates had completed a three years residency programme in family Medicine.1 In the fast changing scenario, even United States is losing its main source of primary health care physicians. The number physicians entering residency programme in internal medicine and general pediatrics has drastically reduced. Between 2001-2010 as many as 69,850 physicians were entering internal medicine as compared to just 51,352 in sub-specialties but from 2011-2015 this number has reduced to 36,303 in internal medicine and 33,944 in sub-specialities.1 Authorities in United States project that there will be a shortage of over twenty thousand primary care physicians by 2020.2

The emerging new trend shows that these primary healthcare care physicians are being replaced by Nurse Practitioners (NPs) and Physicians Assistants (PAs). According to reports there were two lac twenty two thousand (2, 22,000) licensed Nurse Practitioners in United States in 2016 and 83% of them were trained and working in primary care. There has been almost 30% increase in primary care Nurse Practitioners since 2010.3 Regulations regarding nurse practitioners vary in different States in USA, in some they have to work with a physician while in others, they are allowed to do independent practice.4 However, Physician Assistants (PAs) are licensed to practice Medicine under physician’s supervision. There were 91,836 Physicians Assistants in the United States till 2016 of which 28% were certified in primary care. A large number of these PAs practice with medical specialists. Studies have also shown that these NPs and PAs provide the same quality of primary care as primary care physicians and their number is also increasing unlike the primary care physicians whose number if decreasing every year.3

In Pakistan the reluctance of the surgeons to manage diabetic foot ulcers has forced Baqai Institute of Diabetes & Endocrinology to train physicians in minor surgery of diabetic foot and they have also started training programme for Diabetic Foot Care Assistants (DFCAs). So far they have trained one hundred twenty six diabetic foot care assistants besides training Diabetic Educators (DEs) who are going to play an important role in the diabetes care in Pakistan. BIDE has now also requested the Ministry of Health, Government of Pakistan to recognize the services and degrees of these Allied Health Care Professionals (AHCPs) which includes diabetic foot care assistants, diabetes educators and podiatrists.5

Yetanother important development which is going to affect the provision of primary healthcare is the increasing number of girl’s enrollment in medical colleges. The number of boys getting admission and graduating is just about 30% as compared to 70% girl’s majority of whom is likely to give up this profession due to various reasons. Hence, unless some effective measures are taken, the authorities might find it difficult to find human resource to staff the healthcare facilities offering tertiary and secondary care in the big cities. Females cannot practice independently in small towns and villages as such the population will have to be served by these Allied Health Care Professionals in the days to come. It is high time that the GPs, Family Physicians take note of these emerging new trends and plan accordingly.


  1. Dalen JE, Ryan KH, Alpert JS. Where have the Generalists Gone? They Became Specialists, Then Subspecialists. The Amer J Med 2017; 130(7):766-768.
  2. 2 Kaiser Family Foundation. Tapping nurse practitioners to meet rising demand for primary care. Issue brief: January 2015. Available at: http://kff.org/Medicaid/issue-brief/tapping-nurse-practitioners-tomeet-risingdemand-for-primary care. Accessed August 24, 2018
  3. 3.Naylor MD, Kurtzman ET. The role of nurse practitioners in re-inventing primary care. Health Affairs (Millwood) 2010; 29(5): 893-899.
  4. 18. Kaiser Family Foundation. Total number of physician assistants by gender, September, 2016. Available at: http://kff.org/other/stateindicator/total-physician-assistants/?currentTimeframe¼0. Accessed August 24, 2018
  5. BIDE has so far trained 126 Diabetes Foot Care Assistants. Proceedings of NADEP Diabetic Foot CON 2018. Pulse International September 1, 2018.
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