P K Sasidharan
Dean Faculty of Medicine, University of Calicut, Kerala
We are passing through a turbulent period in Health care and medical education. Lack of a comprehensive Health Policy and the consequent elimination of family doctors and even generalist doctors, the unchecked proliferation of Single System Specialists and the lack of a referral system together had made, treatment of diseases a costly and complicated affair. This is happening when our society is reeling under the pressure of communicable diseases and lifestyle disorders’- the double burden. The burden is only increasing in spite of all the technological advances, because “we ignore health care and manufacture diseases”.
As a responsible citizen and as a medical teacher I share some thoughts here. But my request is it should not be misinterpreted as against any speciality and specialists. What is urgently needed in the society is more family doctors who would act as friend philosopher and guide to all members of a family irrespective of age and gender.
A certain number of families must be registered with each family doctor as is practiced in all countries with proper health care. Patients should not have the right to seek help from specialists without a referral by the family doctor, which is essential to check all the unhealthy trends existing. They can have the freedom to choose between the family doctors. Even specialists can have the option to register as family doctors, if they are very particular. Specialist should be basically someone with research interest, and there should be a mechanism to ensure that doctors do not specialize to earn more money and other material benefits. As compared to specialists, the family doctors should get maximum salary and perks because their job is more important for the society and more difficult too. Our concept about family doctor is infantile and distorted; even a very important decision making persons in medical education had once expressed the opinion that we need more MD General Medicine people to practice as family doctors.
The fact is our MBBS training should aim at producing only family doctors for which the curriculum has to be modified rather than producing more MD Medicine doctors to work as family doctors. Before they become eligible to register as full-fledged family doctors, they should undergo a period of apprenticeship under senior family doctors. MD General Medicine, and MD Paediatrics is to practice as specialists in the application of clinical skill, to solve diagnostic problems without a bias for any system, and also to manage multisystem illnesses and complicated problems conservatively; they should be acting as the second level of referral to avoid unnecessary investigations and procedures. Ideally they should only be referring patients to the people who specialize in interventions and major surgical procedures. In short we need to set up a strong referral system and prepare guidelines for the public and doctors alike on the Do’s and Don’ts in the case of illnesses. Needless to say there should be a strong Health Policy aimed at improving Health care in the community to reduce the disease burden and to set priorities in fund allocation.
The move by the government to start a new Modern Medicine course is unfortunate when we already have more than enough doctors. We actually have a problem of shortage amidst plenty; why they are not available to the society is because they are not trained for it or we do not have a policy. Sometimes they do not have the aptitude or do not get adequate motivation from the authorities who are busy producing specialist doctors. What we should do is to modify the MBBS curriculum to produce family doctors by default rather than opening new avenues in Medical Education industry. After some years, they will fight for condensed MBBS as had happened in the past. Therefore It is ridiculous to start a new course(BRMS) and new medical colleges to overcome the deficiency of doctors in rural areas.
We should have the common sense to ensure that we produce doctors primarily for our country and to solve our health problems and not for enabling them to seek job elsewhere. We should evolve some mechanism to ensure that only students with the right kind of aptitude be selected for MBBS.
To ensure that they go back to their own rural areas there can be reservation for students from rural areas and should give a bond to work in their home places and we should offer more salary for rural service. We should produce specialist doctors only in limited numbers for research work and to practice special techniques at predetermined centers, but even that should not enable such doctors to have a superior status in the profession. Superiority should be based on the social value of the service and not based on degrees. It is even prudent to think of a radical change to abolish the structured “Super specialty” courses to end the unhealthy trends existing now. It is more than enough to have the certificate courses or at the most DNB alone for any specialization after PG qualification. No other country in the world has a similar situation as is happening in India in the field of medical education. We probably are at the peak of unhealthy practices, to give an example there are rumours that some “Doomed universities” are able to pay the heavy salary of one super specialist teacher with just the interest of huge kickbacks collected for a single Super speciality seat.
Our activities in research and patient care should be strictly society oriented, with awareness of our social structure and concern for cost effectiveness, and never doctor-oriented or industry-oriented. Unfortunately research in Medicine today is often misplaced and misdirected and finally it is often meant to satisfy the market interests only. It is for finding ways and means to produce new diagnostic techniques, new therapeutic options, or for producing artificial organs or for techniques to predict the future probability of getting diseases at the time of birth itself. But the sad reality is everyone has overlooked the fact that all diseases, including cancers and genetic disorders, result only from problems in Diet, Lifestyle and Environment. Instead of directing our human resources and financial resources to address the basic problems in these three areas, we waste all our resources on diagnosis and treatment and the only genuine prevention now practiced is vaccination.
Unless we have a strong and comprehensive, society oriented Health Policy and a strong referral system, doctors become part of several ‘wrongs’ knowingly and unknowingly and there is no point blaming individuals. All research should be directed to find out the root cause of diseases and the value of research is to be assessed only by the number of persons positively benefited, by the outcome of the study, in a cost effective manner. It is distressing to see the way young researchers and even Nobel prize winners in Medicine are moving now, they all finally end up promoting newer styles of sophisticated consumerism in Disease care. In short, more often than by chance, those who do research to satisfy the greed of the industries in Medicine alone get recognition from everywhere.
I have great hope in the young generation of medical students and doctors, they have tremendous potential but they have to be guided and nurtured properly to make them society friendly. The wrong trends in medical education, health care and wellness industry has to be checked with a long term plan.