I wonder

The last couple of decades has been a happening one in health care. Having had graduated in Medicine, 35 odd years back, my generation had the opportunity to be part of these happenings and taste both worlds. The world of health care of yester years and new world that is fast emerging around us.

There are innumerable “happenings” that have transformed health care, but I am reflecting on four happenings or in one sense, transitions. Transiting from one way of functioning to another. Transitions that has brought much celebrations for some, but a nostalgia for some others – me being one with nostalgia's! May be like the Jews who were on a journey from Egypt to the Promised Land, still carving for the meat and the food of the country that they had left, some of us still craving for the yester years! We are promised a new face and system of health care, in the new emerging India, but some of us still yearning for the context of old times….

One such transition is from Medicine being an art and science to one driven by technology. “I remember as a fresh MBBS doctor, spending a few hours with a patient, working up and coming to a possible diagnosis of “Malabsorption syndrome” with all the supportive tests proving it. I, feeling happy about being able to come to a diagnosis! The consultant whom I worked with walking into the ward, standing by the bed side, holding on to the patient’s hands, before even listening to my well-planned presentation, looking at the face of the patient, observing him for a few seconds, and telling me - “He has a malabsorption look, doesn’t he?”. I remember being totally amazed by these clinical observational skills and clinical acumen. I remember the same consultant after listening to the story of a patient with Nephrotic syndrome, just putting his hands on the ear lobe of the patient and responding – Amyloidosis of the kidney! A diagnosis made by the observation of the thickened ear lobes due to Hansen’s disease.”

These were the teachers who taught us Medicine. The art and the science combined. The art of seeing, listening, touching, and correlating with the scientific knowledge they had. Technology was used to support their art and science.

Sitting in an outpatient clinic a few months back along with another young doctor, over an hour or so, both us saw 10 to 15 patients each. In that one hour, I got up at least 10 times to examine the patients – a habit of putting the patient on the bed and doing quick examination, which had been taught to us as mandatory. The young doctor who was seeing patients on the other side of the table, never got up or put hands on any one. The quick history was enough, and the patient was off with a list of tests to be done.

Somewhere in the last decade or so, from art as the soft skills of clinical medicine, science as the logical thinking and evidence, and technology as the supportive element, we have moved into technology as the god of Medicine that we worship. The art and the science are only supportive to technology. But in that transition, the listening, the touching, the observing and the correlating has been pushed into the side lines.

A friend our family, admitted recently to one of the highly acclaimed corporate institutions in Delhi with acute gastro enteritis shared this story. In 48 hours, she ended up paying a bill of 50,000/- - Of course the insurance was there to pay. She had every possible test done including an ultrasound, but she was not touched by any doctor. Doctors came and went – looked at the papers, the x-rays and reports, but never touched her!

I wonder, when I grow old and need health care, what would I long for – being taken through a mill of tests or a listening ear, a touch, a careful observation and a comforting word?

This change has not happened in isolation. This has come out of another change – the change of relationships. Doctor patient relationship which was once sacrosanct, more of a covenant relationship has transitioned into a contractual relationship. This relationship changed over last few years, as health care knowledge expanded. Medical knowledge like many other fields of knowledge become a commodity to sell, and this sale and purchase is driving force of the health care industry. A service sector, that trained professionals to care for those in need using their knowledge, transitioned. It became a knowledge industry that sells its knowledge for a price. If you pay me, I will provide my knowledge against a contractual agreement.

As this expanded, there needed to be structures to support this model. Corporate models of health provision, where investment and return on investment as the bottom line emerged. This is today seen as the ultimate model of health care. Nations saw this as a good way to boost its economy. There are many who needs health care, there is enough knowledge to be sold. Create business vehicles that can sell knowledge and use that to sell health.

And the middle men walked in – the insurance sector – to be the middle man between a need and the commodity to be sold. But health care for the upper class had to be provided in contexts they feel comfortable. That led to the emergence of high-end hospitality systems to support the health care. Over time hospitality over took health and health care. And today even the poor in rural areas look up to 5-star hospitality centers in urban areas as the dream for them to get health and health care!

I remember my grand parents having a family physician who know every family member’s illness and was able to take care of the children and the elderly. But for an occasional referral for a technology supported intervention or surgery, most of the routine issues would be sorted out by that family doctor. A vestigial model, visible in some small villages even today!

But not too long away – a decade back when a patient would come to you, you talked more about illness and its effects and patients trusted your judgement. Money was required but that was a discussion which would not influence the clinical discussions or decisions much.  Today when a patient comes in, he or she comes in with a host of papers of other hospital visits already in hand, information of costs across various centers already known. The discussion goes around, what can you offer at what cost, and under-girding all these is a “can I trust this doctor?” question for the patient. For the doctor, “how much can I get from this patient or his insurance agency?” as the under-girding question. If the doctor is uncomfortable with these discussions the institutional structures will take care of this. One need to be willing to sell your knowledge to the institution, they became the middle man to buy your knowledge and reimburse you for the same.

For this model a compassionate covenantal relationship is no more required. What is required is a matter of fact, commercial contractual agreement and a detached conditional relationship, which ends once the contract is fulfilled.

When I fall ill, what I need is not one who knows everything about my illness and knows what to do only, but one whom I can trust. One who will not allow monetary issues to affect his or her decision making. Is it too much to expect?

The knowledge explosion also brought in another transition. A transition of knowledge from a broad knowledge of the whole body, systems and diseases, to becoming masters of specific systems and specialties. Medicine with the expansion of knowledge had no other way but to become compartmentalized. No doctor could know all what was happening in the various fields of medicine. So, for optimal utilization of knowledge, there needed to be professionals who can develop and expand on their areas of interest. This led to expansion of various specialties.

From being an MBBS doctor, who had a good standing in the society, the upward mobility led to MD/MS of various specialties and then the DM MCH of various super specialties. With this also came three transitions.

A transition from a common medical fraternity to class-based sub fraternities in medicine. In the upper class the so-called super specialists, in the lower most rung the GPs or MBBS graduates and the general specialists the middle class.  The pay packages also got readjusted based on “knowledge level” equated to the degrees you have, with super specialists earning most. Peoples expectations started changing. The more degrees one has, the more money charged, the better the knowledge and better the care and people started expecting specialists to care for common illnesses.

Every other patient who comes to our rural hospital with a tension head ache would have had a CT Scan done prior to coming. If not, they would ask for one. Last week, a patient who  can not afford regular care came and asked us – we were told that an MRI can help in getting a diagnosis for this chronic poly-arthritis my wife is going through, can you get it done for her. It took quite a bit of convincing with them to give up this dream of MRI!

This transitions also led to a compartmentalized care. Patients would get their diabetes managed by a diabetologist, peripheral neuropathy by a Neurologist, Nephropathy by a nephrologist, Cardiac illness by a Cardiologist. Visiting an elderly uncle of mine few years back, I was going through his 23-drug list. I found the cardiologist, the nephrologist and neurologist, along with his diabetologist all had prescribed their own special vitamin preparations for him – thus making his daily medicines to 23 plus!

In this compartmentalization of body between the various specialists, the mind and soul – the whole person is forgotten. Each specialist is concerned with that part of the patient’s body, no one remembers that the person who is in front of you has a mind, emotions, a soul and desires and fears.

I wonder, when my organs fail, do I want a specialist who understand my organs or a doctor who can listen to my worries and my fears along with taking care of my whole body and the organs too!

These transitions have left the emerging generation of Medical aspirants confused. To follow the dream of a upwardly mobile career ladder, the requirement is to join the rat race of knowledge acquisition to pass the entrance examination hurdles. This starts at 8^th to 9^th standard onwards. The boards examination and knowledge are sacrificed for preparation for the NEET – the 1^st hurdle.

Many aspirants – do not aspire, but they are fulfilling their parents’ aspirations. Recently talking to 18 young medical students from a good private Medical college in south, I was surprised. Only 5 out of the 18 wanted to be in Medicine. The rest are fulfilling their parents’ aspirations!

This crossing NEET barriers does not end with getting into MBBS. The moment you enter MBBS and once the reality strikes – you start the next race – preparation for PG NEET. Talking to a group of students from Government medical colleges in Delhi, most of them, by second year, had already registered into PG NEET preparatory coaching’s. The studies of MBBS is left to the minimum to clear the examinations. PG NEET is more important than MBBS examinations.

The one year of mandatory internship is where you pick up your soft skills, the hands-on skills and knowledge of practicing medicine under supervision. For most interns in government and many private colleges, internship is a time to get intensive coaching for NEET PG. Attendance for internship is signed off in the mornings and one is off to study. Basic skills and knowledge that is required to be a good doctor, is left for a day when they get into PG. And this cycle repeats itself during basic PG too – getting ready for the super specialty. For 100 MBBS seats there are only 40 PG seats and less than 10 higher specialty seats. These are fast changing with seats increasing every year, but many aspirants keep following the dream for many years. Their hope is that one day they will go up the ladder of medical education, in the meantime acquire knowledge to cross those barriers of NEET!

There was a time, not so long ago, knowledge acquisition was for the thrill of knowledge itself, to provide better care, to teach and train others and pass on the knowledge to build many others. Today in many institutions, knowledge is only a way to build and move up in their career and life!

One wonders, if such a generation becomes the foundation of the health care system of our nation, what would health care look like a few decades form now?

There are many more such transitions – may be another day I will visit a few more. But I ask myself – am I wrong in desiring for yester years, or should I just forget the past, move on to future – the promised land of a new health care system of the new India?