A recent article published on CodeBlue titled “Are We Still Practising Family Medicine? — Concerned Specialist” raises an important concern.
Family Medicine Specialists (FMS) should not gradually become doctors who simply see more patients, run more disease-specific clinics, perform more procedures, and absorb work from hospitals while having less time for continuity of care, prevention, teaching, supervision, quality improvement, and leadership.
I agree with the article that new responsibilities must come with the right resources. At the same time, the discussion should be placed within a wider question: what kind of health system does Malaysia now need?
Health systems are usually designed around the problems, population structure, technology, resources, and social conditions of their time. A model that worked well 20 or 30 years ago was not necessarily a bad model; it was built for the needs that existed then, probably with some projection of future demand.
The problem is that the context keeps changing. Populations age, disease patterns shift from infectious diseases towards chronic conditions and multimorbidity, technology changes how care can be delivered, industries and workplaces change, environmental and climate risks increase, and economic pressures affect both patients and health services.
The World Health Organization (WHO) has highlighted that countries in the Western Pacific are already facing demographic, epidemiological, socioeconomic, environmental, and technological transitions.
These include ageing populations, rising noncommunicable diseases, persistent communicable diseases, climate-related risks, inequities, changing health-seeking behaviour, and workforce shortages (World Health Organization [WHO] Regional Office for the Western Pacific, 2023).
Therefore, reform or transformation should not be seen as an attack on the existing system. It is adaptation to a changing population and a changing operating environment.
This is where it is useful to be clear about what primary health care (PHC) actually means. PHC is much broader than Family Medicine or primary care alone. Since the Alma-Ata Declaration, PHC has included promotive, preventive, curative, and rehabilitative services, together with referral systems, multidisciplinary teams, community participation, and action across sectors (WHO, 1978).
The Astana Declaration later explicitly added palliative care and reaffirmed that PHC should provide promotive, preventive, curative, rehabilitative, and palliative care across the life course, with functional referral between primary and other levels of care (WHO, 2019).
That is important because PHC should not be framed as prevention versus treatment. A good PHC system needs the whole continuum. WHO describes comprehensive care as health promotion, disease prevention, diagnosis, treatment, rehabilitation, and palliative care delivered across time and settings (WHO & United Nations Children’s Fund [Unicef], 2020).
Therefore, the concern should not simply be that “more curative work means less Family Medicine.” The more useful questions are: Is the work appropriate for primary care? Is prevention still protected? Is the workforce capable of delivering it safely? Are there clear referral pathways? And does the rest of the health system support it?
Different specialties also have different roles. This does not mean one specialty is more important than another. A practical principle is that leadership should follow function, competency, and accountability.
Family Medicine Specialists should provide leadership in primary-care clinical services. Public Health Medicine Specialists should lead population-health functions, such as population health assessment, epidemiological surveillance, programme evaluation, population-level risk assessment, and health-system planning and evaluation.
Other clinical specialists should lead where disease-specific, organ-specific, life-course-specific, or procedural expertise is required. Where these functions overlap, leadership should be shared or coordinated.
The same principle should apply to PHC reform itself. The starting point should be population health needs, inequities, disease burden, service gaps, and health-system performance.
The strategic and technical stewardship of reform should therefore sit with the functions responsible for population-health management, epidemiology, priority setting, resource allocation, programme design, and evaluation. But that does not mean reform should be planned in isolation.
Family Medicine, Public Health Medicine, hospital specialties, nursing, pharmacy, allied health, health managers, policymakers, and communities all see different parts of the system. Their engagement is essential to identify real operational problems, understand unintended consequences, determine what is feasible, and make sure important concerns are not missed.
WHO similarly recommends that PHC reform begin with assessment of population health needs and system performance, followed by stakeholder engagement to identify gaps, priorities, and feasible entry points for reform (WHO Regional Office for the Western Pacific, 2023).
In simple terms: population health needs should set the direction; technical expertise should guide the priorities; and stakeholder engagement should make the reform workable.
The CodeBlue article is also right in its assertion that the Family Medicine field is broad. FMS see patients across different ages, diseases, and stages of life. Their strength is specialist generalism: dealing with uncertainty, multimorbidity, chronic disease, prevention, family context, continuity, and coordination. But being broad does not mean doing everything.
The Malaysian Family Medicine training standards are clear that FMS should manage common primary-care problems, provide preventive and continuous care, recognise patients who need further investigation or specialised care, and refer appropriately. Their leadership role also includes clinical governance and shared care with secondary and tertiary services (Malaysian Medical Council [MMC], 2023a).
That means referral is not a failure of Family Medicine. It is part of good Family Medicine.
Comprehensive care does not mean the FMS must personally provide every service. WHO itself defines comprehensive care as responding to the full range of health needs through health promotion, prevention, diagnosis and treatment or referral, together with rehabilitation and palliation where appropriate (WHO & Unicef, 2020).
The same applies to FMS subspecialisation or special-interest services. Deeper expertise in areas such as geriatrics, mental health, diabetes, women’s health, or other common primary-care problems can strengthen primary care.
But the goal should be to deepen Family Medicine within primary care, not to recreate every hospital specialty inside Klinik Kesihatan.
Where advanced expertise is needed, the better solution may be shared care, joint clinics, visiting specialists, teleconsultation, specialist advice, or formal referral.
The reverse is also important: hospital specialties should not simply transfer work downward. Hospitals themselves have a role in strengthening PHC. Evidence from the Western Pacific shows that hospitals can support frontline care through training, supervision, clinical decision support, information technology, supply-chain support, and stronger referral systems (Freijser et al., 2023).
This is why the phrase “hospital medicine outside hospital” needs some qualification.
Some complex patients are very appropriate for Family Medicine. Multimorbidity, polypharmacy, ageing, chronic disease, and care coordination are exactly where generalist expertise is valuable. Other patients clearly need advanced diagnostics, procedures, or specialist judgement.
The correct boundary should therefore depend on patient need, risk, competency, technology, available resources, and specialist support, not simply on where that condition was traditionally managed.
As technology changes, some services that were once possible only in hospitals may safely move closer to patients. At the same time, new treatments and technologies may create areas that require even greater specialist depth.
Health-system boundaries therefore need to evolve, but they should evolve in a planned and governed way.
Prevention should also not become a question of professional ownership. Primary-care clinicians contribute through counselling, vaccination, screening, risk reduction, and early detection. Disease-specific specialists prevent complications and recurrence within their fields. Public Health Medicine contributes through surveillance, health protection, population risk assessment, policy, programme design, and evaluation.
WHO’s essential public-health functions include health promotion, disease prevention and early detection, surveillance, public-health emergency management, stewardship, multisectoral planning, and research and evaluation (WHO, 2025).
This is also where clinical public health becomes useful. It connects individual clinical care with population-level evidence and action. Public Health Medicine is particularly positioned to lead this interface because its training combines medical knowledge with epidemiology, surveillance, prevention, programme evaluation, policy, and health-system analysis.
At the same time, it depends on collaboration with FMS and other clinical specialists. Choi et al. (2022) describe clinical public health as structured collaboration between clinical and public-health professionals towards common health goals.
On resources, I strongly agree with the CodeBlue article. Changing scope without changing capacity is not meaningful reform.
If FMS are expected to take on more responsibility, the solution cannot simply be “add another clinic”. They need enough medical officers, nurses, pharmacists, allied-health professionals, administrative staff, diagnostics, medicines, equipment, physical space, digital systems, and access to specialist advice.
WHO’s Western Pacific workforce framework emphasises having the right number of health workers, in the right places, with the right skill mix, supported by multidisciplinary teams, referral linkages, training, and appropriate regulation of scope of practice (WHO Regional Office for the Western Pacific, 2024).
If major new responsibilities are introduced, this should be treated as formal service redesign. Training, credentialing, job descriptions, staffing, infrastructure, financing, referral pathways, clinical governance, and performance indicators should all change together.
Ultimately, the future should not be about protecting an old arrangement simply because it is familiar, nor changing it simply for the sake of change. The question is whether the current arrangement still fits the needs of today and tomorrow.
A strong Family Medicine service should manage increasing complexity within the appropriate scope of primary care while retaining continuity, prevention, generalism, and coordination. A strong Public Health Medicine function should continue to guide population-health assessment, priority setting, planning, and evaluation. Strong hospital specialties should provide advanced expertise and support the wider system rather than functioning in isolation.
The practical principle is: adapt the system when the context changes, develop each specialty within its function, collaborate where functions overlap, and provide the right care by the right team at the right level across the full continuum of promotive, preventive, curative, rehabilitative, and palliative care.
References
- Choi, B. C. K., King, A. S., Graham, K., Bilotta, R., Selby, P., Harvey, B. J., Gupta, N., Morris, S. K., Young, E., Buklis, P., Reynolds, D. L., Rachlis, B., & Upshur, R. (2022). Clinical public health: Harnessing the best of both worlds in sickness and in health. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 42(10), 440–444. https://doi.org/10.24095/hpcdp.42.10.03
- Concerned Specialist. (2026, September 21). Are we still practising family medicine? CodeBlue.
- Freijser, L., Annear, P., Tenneti, N., Gilbert, K., Chukwujekwu, O., Hazarika, I., & Mahal, A. (2023). The role of hospitals in strengthening primary health care in the Western Pacific. The Lancet Regional Health – Western Pacific, 33, 100698. https://doi.org/10.1016/j.lanwpc.2023.100698
- Malaysian Medical Council. (2023a). Specialty-specific requirements: Family medicine.
- Malaysian Medical Council. (2023b). Specialty-specific requirements: Public health medicine.
- World Health Organization. (1978). Declaration of Alma-Ata.
- World Health Organization. (2019). Declaration of Astana.
- World Health Organization. (2025). Governance for public health across the health and allied sectors: A report to guide country-level institutional capacity for essential public health functions underpinning multisectoral approaches.
- World Health Organization, & United Nations Children’s Fund. (2020). Operational framework for primary health care: Transforming vision into action. World Health Organization.
- World Health Organization Regional Office for the Western Pacific. (2023). Regional framework on the future of primary health care in the Western Pacific.
- World Health Organization Regional Office for the Western Pacific. (2024). Regional framework to shape a health workforce for the future of the Western Pacific.
The author is a medical specialist. CodeBlue is providing the author anonymity because civil servants are prohibited from writing to the press.
- The views expressed are personal and are intended to contribute to professional discussion on primary health care and health-system reform. It does not necessarily represent the views of any institution, employer, professional body, or CodeBlue.
