Subcontracting

In one of my recent blogs I had talked about a person who wanted treatment for TB in our center and Diabetes elsewhere and how I had asked him who takes care of him, if the different diseases are being taken care of at different centers. Over last few weeks, the number of patients who are on treatment for their various ailments from different practioners or institutions have been many. A typical example is this 50 year old man who was brought to us by his wife and daughter. He did not seem too keen to see us. He had a bipolar disease for the last 20 years on treatment form Patna, has a chronic alcohol dependent stage, for which he has been to many doctors, and he has a psoriasis, for which he is on treatment from a homeo-physician. We evaluated him and found that he is in moderate liver failure, due to the chronic alcoholism. We asked, what is that you expect from us? They wanted treatment for Psoriasis only. After going through the initial discussions we told him, unless he stops alcohol, his liver will not get better, unless his liver gets better, we cannot treat his psoriasis, and unless we know what he is on for his Bipolar disease we cannot plan his treatment at all. They were open enough to show the current treatment he was on, which was unusual. Most of the others, do not even tell us what they are on. They will ask, you tell what I should do!

This was not so a few years back. The current practice of “sub contracting off” different organs to different specialists has increased over last decade. It is not only in this part of the country, but all over. I was in my home town couple of years back, vising my 86 year old uncle. He was on 21 drugs per day, and he wanted me to look at his prescription. Being a patient with Diabetes, with Nephropathy (renal failure), Ischemic heart disease, early Parkinsonism, he was on treatment from a Nephrologist, Cardiologist, Neurologist, Diabetologist and a general physician. He was on different combinations of the same drugs, given by different practioners. This happening in a state where there is 100% literacy!

How did we reach here? There are many factors that have contributed to this specialized sub contracting of organ systems. Most significant of this is, the Bio Medical model which we the physicians have promoted. We have not adequately focused on the whole person but focused on the disease and organ systems and promoted this model through our education, our communication and media. Two, the specialization of knowledge which has become a “power” to mystify medicine and widen the gap between the common man and the specialist! Three, technology that drives specialization, and the cuts and commissions which are part of this system. Four, the health care structures which thrive on this technology driven, commerce focused, mystification of knowledge promoting, health care practice.

And the common man, over awed by the “Greek and Latin” we specialists speak and communicate in, the technology which is promoted as the answer to all problems, think that handing over different organs to different specialists is good Medicine.

Is it good Medicine? Where one specialist knows only one system issues and the other knows the other system? Is there a way in which we can move back to a more comprehensive way of practicing medicine, where by the person is not seen as a conglomeration of a few systems but an integrated whole? Where by, a General practioner (the old Family Doc) takes care of the integrated whole and asks support from the specialists for specific issues which needs attention. Efforts have been put in by many to bring back this model, but not much progress have happened. The stumbling blocks are, the power of knowledge, the lure of money, crumbling values in health care and systems which perpetuate these market supported directions!

What would it take to move from a fragmented approach to an integrated approach? What would it take to demystify knowledge? What would it take to use technology as support and not as the driver of health care? What would it take to change systems which perpetuate health care as a money spinner – an industry?

Suffered in the hands of many physicians – is that not true today too….