In my childhood in Bombay in the Forties every middle-class family had a family doctor. His (sometimes her) knowledge about the family covered everyone in it, visitors and relatives. The doctor was an intimate part of the family and knew everything about it, salary increases, promotions, examination marks of the children and so on. While doctor’s bills were to be settled every month, in many cases like mine, a family with many small children could not settle for months though the fees were small even by the standards of those days. The doctors’ response was invariably sympathetic and understanding. Bills were always settled, mostly by installment much after they were due. There was a compounder, (a pharmacist) who ground and mixed the medications prescribed by the doctor. This made the medicines very low in cost. Very rarely and in the most complex and stubborn cases would the doctor call for pathology, X-rays and other such expensive aids to diagnosis. These doctors had an encyclopedic recall of their patients’ medical history. In one clinical session of possibly five hours (300 minutes) these doctors might see as many as 150 patients. Each patient would wait for long to get to see the doctor but came out satisfied and with renewed faith in his family doctor. Fifty years later I remained “my child” to our still-living family doctor of my childhood. Family doctors (like schoolteachers) never forgot their patients.
All this is in stark contrast to the situation today. There are hardly any general practitioners, except in some remote towns and villages and slum areas. Those that are there are dedicated, hardworking and very considerate of the fees that they charge their poorly off patients. But it is the rare urban doctor who charges less than Rs 50 for a call, many times Rs 150. Indeed, recently one such general practitioner charged Rs 600 for a call in a five-star hotel room.
There are no general practitioners, only medically trained people, most of whom do not remember their patients from visit to visit. Medical practice has changed dramatically. There are much fewer general physicians. Medical education is expensive and the capital costs of becoming a doctor and then setting up private practice are very high. Increasingly it is paid for by borrowings. Just amortizing those costs over the patients seen over the years, results in high fees and for many patients to be seen.
The widespread availability of diagnostic tools (pathological laboratories) and equipment (like ultra-sound, CAT-scan, and so on) is a boon for speedy and good diagnosis. In many cases they are also crutches, as doctors use them to bolster their inability to diagnose from experience or to demonstrate their thoroughness to patients. Their financing is also usually based on borrowings. Hence the attempt is to maximize utilization of equipment. Patients are sent for tests that are not strictly necessary. The suspicion is widespread that many medical practitioners have a nexus with such diagnostic suppliers and get a cut for each patient they send for investigation.
Unfortunately there is no independent regulator who will investigate such situations. No doctor will blow the whistle on his colleague who indulges in such practices. The self-regulatory body that is supposed to do so has usually been hands-off regarding such complaints. In any case since patients cannot get other doctors who are willing to stand up and give evidence, they rarely complain.
The pharmaceutical industry has also grown at a tremendous pace. In India it is highly competitive. The large number of licensed manufacturers results in some of them producing imitations of popular drugs or fakes that look alike but are very inferior to the real thing. Such drugs kill sick people or jeopardize their recovery. But even genuine manufacturers are said to corrupt the medical practitioner. To fight competition, many give rewards and incentives in cash and in kind to the practitioner who is a large prescriber of the company’s products. Clearly this might lead the doctor to excessive prescription of such drugs. In order to maximize earnings many doctors probably continue with the same medication long after it ceases to be needed.
The vast variety of drugs available, the combinations of different drugs and the large number of manufacturers of the same drug, lead to medical practitioners being largely ignorant about drug compositions, effects of ingredients, the dangers lurking behind each combination drug used by the patient and of drug interactions. Most get their information about old and new drugs from the medical company salesman and the literature that he distributes. This is a poor basis for prescribing drugs to patients since the medical salesman is no expert but is trained in the essential and positive features of the product that he is propagating. The medical literature that he leaves with the doctor is largely propaganda, not learning.
Despite these weaknesses in health care delivery and the commitment of the medical practitioner, life expectancy of children, pregnant women, lactating mothers and other adults have improved considerably. It is difficult to apportion the credit between clinical health care by nurses, doctors, nursing homes and hospitals and improved public health (safe drinking water, sanitation and hygiene, for example garbage clearance, immunization of infants against the most common diseases, special dietary supplements for pregnant and lactating mothers, hot mid-day meals at schools for children, special programmes to fight malaria, small-pox, polio, tuberculosis and the like). The likelihood is that it is the improvement in public health that has played a more central role.
There is no doubt that the clinician today has many more tools, techniques and drugs to deal with his patients’ diseases. It is likely that many practitioners are not very good at interpreting the results of such investigations. When they are, they might be treating the properly identified disease with too many powerful drugs in combination, leaving the patient worse off than when he began treatment. We must look for ways in which he can relate more to his patient, as he used to in past years.
Patients could be tied to specific doctors. Thus there would be a central point that knows the patient and his history of illness and can monitor all that is being done to improve his condition. Large numbers of past records to be carried by the patient from visit to visit may not be enough to familiarize doctors. They are unlikely to study all the papers patiently and absorb the information for meaningful conclusions. On the other hand, the doctor with a small tied group of patients is in a better position to remember the patient’s history.
We must reinvent the institution of the family doctor in some way. One way is to give him a machine tie-up. The family doctor is essential for good medical practice and sound doctor-patient relationships. The growth of commercial hospitals and private nursing and diagnostic centres is increasingly making medical practice mercenary, cut off from emotional bonding with patients, reducing coordination of patient treatment by different specialties while making treatment expensive and soulless. We have to find a more acceptable way.
This will require fundamental institutional reform of regulation of the medical profession, the pharmaceutical industry and the many other players in health care. Unfortunately, health care has enormous vested interests supporting these players, and policy-makers try to get out of the sector because it does not give the visibility that other sectors do.