An opening repartee in one of Richard Gordon’s “Doctor Series” books went something like this: “As evolution progressed the young depended longer and longer on their parents — this must make doctors the most evolved species of all”.
Do tarry a while to think. It is an acceptable tenet that while your friends in other disciplines joined well-paying jobs, looked after their families, drove themselves around and married while they were young, as a young doctor in incubus you “swotted” and scrounged around for the cheapest deals. The young doctor was expected to have a long and arduous maturation period like the proverbial good wine!
However, somewhere in the process of evolution, we are threatened with the loss of the friendly family physician, who used to treat all ailments with a fair degree of equanimity.
He was an important member of the family, who knew everything about everyone. He was invited to all important social functions at home. The most important seat was reserved for him though he came in inevitably late, bringing with him a faint smell of rectified spirit mixed with old cologne and an aura of goodwill.
He was the person to call in an emergency, the one to liaise with the specialist, the one to hold your hand and explain when things did not turn out the way they should have.
The absence of the family physician in the present scenario has a number of effects and causes. Information explosion has made knowledge easily accessible. Unfortunately, expertise and experience come from practice.
One is no longer happy to go to a “simple” general physician. One would have already had a tentative diagnosis ready and opt for specialist services like cardiology, nephrology or rheumatology.
Unfortunately, the exact diagnosis may often prove elusive. The patient is therefore stuck in an expensive medical facility while tests are carried out to establish the exact nature of the disease. Worse, medical insurance is not prepared to reimburse for “unknown” diseases. This, despite having paid one’s premium religiously over the years.
What makes the problem acute is that the person in charge is a very busy specialist whose time with you is limited and who may be treating a disease not quite in his specialty and for which specialists from other disciplines are called in. One has therefore lost the single most important person, the general physician, who would have liaised with different disciplines and been a source of information.
Witness what this has caused to the process of becoming a doctor. The fresh medical graduate knows too well that to succeed in life one has to become a specialist. The day the final MBBS exams finish is often the day to start studying for the postgraduate entrance tests. Who has the time to spend with patients? The “Holy Grail” is to be successful in the entrance tests — actual hands-on experience can wait!
Having “cracked” the exams, your marks will decide your discipline. One may have harboured dreams of becoming a paediatrician, alas, the marks will allow the candidate to enter a different field. Now if this leads to a disgruntled doctor, who looks at the work as a chore, who is to be blamed?
India has witnessed changes in the duration of postgraduate training as well. Earlier, one spent a year as an “intern” rotating through various disciplines. This had two great advantages. Someone who wanted to be a general practitioner had a good idea of all disciplines. Those who wanted to specialise could find out which suited them.
You then spent two years as a house surgeon in your chosen field and took your entrance test after being convinced that this was your calling. Two more years as a postgraduate trainee ensured that you had a total of five years of training in your discipline.
Most developed countries have increased the duration of the postgraduate courses. At present, an Indian postgraduate trainee would spend one year of internship poring over books and then only three years in training.
The British Health Service went through an exercise of reducing working hours to a 48-hour working week. They soon realised that in medicine you cannot have shifts. No amount of handover to the next shift can replace the trust built over hours with the patient. Their response has been to increase the duration of the internship to two years and postgraduate training to five or more.
That our hospitals still manage to churn out good specialists is a credit to the dedication of the students and their teachers. We have witnessed a population explosion but there has not been a corresponding increase in medical facilities. Despite this, a large number of patients get adequately treated. Unfortunately, the adequate routine medical practice never makes headlines. Hey, who wants to read about the gall bladder patient going home after an adequate treatment?
But then perhaps, the next generation preparing to choose a profession, does!
(The author is surgical gastroenterologist associated with CMRI and examiner and tutor for Royal College of Surgeons of Edinburgh)