Sankaran Pillai was always confused. Whenever he had a bad cough he visited his local GP (general practitioner), who gave him a cough syrup and tablets for a few days – he felt better, and remained better for the next few weeks. The diagnosis would vary from a bad throat to pharyngitis, to bronchitis (when he couldn’t sleep at night because of the cough), to allergic bronchitis, and of late as it got worse, even asthmatic bronchitis.
Visiting the GP
Sankaran Pillai accepted this as a way of life. At least one trip to the GP every month enabled him to work reasonably for the next few weeks. He worked as a salesman with a pharmaceutical company selling antibiotics. He believed (like many GPs do too) that the first thing to do when you have a bad cough is to take an antibiotic course. He never questioned his GP when he prescribed one, never questioned why he was falling sick every month, and never dared question his GP why the diagnosis was changing every month!
Sankaran Pillai’s sleep was also disturbed by cough at least twice a week (if not more often), but could he ask his GP why this was happening? He mustered up the courage one day to ask this very question. The GP replied, “You work so hard, Sankaran. What do you expect? Relax and meditate a bit. You will sleep better”. Sankaran dared not ask more questions, but wondered to himself – does hard work cause insomnia? It was difficult to understand that. He thought the harder he worked, the more tired he would get, the better his sleep. But how could he question the learned doctor. One more question and the GP would have asked poor Sankaran to leave the room immediately. After all, there were at least a dozen more patients waiting outside, all looking so miserable, that Sankaran would have felt guilty to deny them their time with their ‘trusted’ GP.
Sankaran had a cousin Radhika, who had a different view altogether. Radhika detested doctors who didn’t answer questions, and told Sankaran in plain speak, “You need to meet a specialist. Don’t waste time with GPs. I only meet specialists for my health problems. They charge much more, but they give me the right diagnosis at least.”
Then the specialist
So a specialist was met. The diagnosis was asthma. The treatment needed an inhaler. The inhaler contained steroid. It had to be taken regularly for at least 3 months. Sankaran balked. Asthma?? Inhaler?? Steroid?? Regular treatment even when well??? No way. But Radhika had her way. She got him to follow the specialist’s advice. Sankaran had never slept better in the past 10 years, than he slept the next 3 months. But when he went for follow up, the busy specialist told him, “continue the inhaler and come again after 3 or 4 months”. “Or you can just meet your GP”. Sankaran was confused. His GP had got it all wrong, and now he was to go back to him?
And now back to the GP?
The specialist said, “Asthma is such a simple disease to manage. Approximately 100 million suffer from it in India. It doesn’t need a specialist. I have so many patients with complicated lung conditions that I need to see, and a long waiting list for appointments. You can really follow-up with your GP, and if things get complicated in the future, we could possibly meet again. In all likelihood they won’t. You should be fine.”
For Sankaran and Radhika this specialist, for all practical purposes, was their new GP. But he wasn’t agreeing to be so, easily.
This is where the problem lies. And a solution doesn’t seem to be in sight. I strongly believe that at least 50% of the patients I see in a specialist practice today can be easily managed by a competent GP. But it doesn’t happen. Why?
Asthma is just one of the many diseases that can easily be managed by a competent GP. Others include diabetes, epilepsy, depression, migraine, COPD to name just a few. Many of these diseases are believed to be specialist-diseases in our country.
There are fewer and fewer competent GPs setting up practice today. In South Mumbai itself (one of the better areas for health care in this country), the number of new GPs (trained in allopathy) setting up practice in the last 15 years has been close to zero. And the reasons are manifold:
- Who wants to be just a GP?
- You’ve spent a lot of capitation money (private medical colleges) and worked so hard. Now just a GP?
- How many diseases and guidelines are you going to update yourself on as a GP?
- I will always be a ‘lower end’ doctor, not the hospital-based specialist with the badge and white coat. People may not trust my opinion unless I am competent and good at communication. The latter is never (or rarely) taught in medical school in India. You learn what you hear. If you hear bad doctor patient communication from senior colleagues/teachers, you learn that only.
- Medicine to an extent has become a glamorous branch. When I visited my daughter’s school a year ago to counsel the 9th and 10th graders on pursuing a medical profession (those who were interested), three girls were interested (and mind you all three) wanted to become cardiovascular surgeons only! Barring the fact that I am not aware of a single female= cardiovascular surgeon in Mumbai (not that a female cannot become one), the issue remains – first the girl needs to get into a good medical school, then she needs to graduate, and while she graduates she could decide whether she is medically or surgically inclined, or not clinically inclined at all – maybe wants to work with a research organisation or a pharmaceutical firm. If she is surgically inclined, she needs to specialise in general surgery, and after she post-graduates in general surgery, only then (and only then), can she start thinking about a seat (not always easy) and a career in cardiovascular surgery. I am not for a moment dissuading girls to take up this branch, but just to understand the road to cardiovascular surgery training.
- Finally, the cost of real estate in metropolitan cities has soared in the past years. It is hard for a GP to earn an income even close to that of a specialist, unless his overheads are really low, and/or he owns his own laboratory/investigation facility. Income and expenditure – it always boils down to that.
The result of the above issues is that we have a number of specialists in various branches of medicine, both in the hospital, and in post-graduate courses across the country. But show me the number of graduate doctors in allopathy actually expressing a desire to be a good GP, or to be a geriatric physician (someone who looks after only elderly patients > 60 years of age – another badly under-represented specialty in India), and I’m sure the numbers will be really low. 10.2 % of the world’s population is expected to be above the age of 60 by 2025. India’s ageing population has significantly increased as well in the past few years, and we are really ill-equipped and poorly trained to look after these patients well, as Atul Gawande has so elegantly brought out in his new book, Being Mortal.
I believe that things can change in the future if the following occurs:
- Hospitals encourage GPs to manage their out-patient departments (OPDs) to a certain extent. That way the GP will be enthused to be a hospital based GP – adds importance to his regular general practice too.
- More GPs do courses in family medicine practice – that brushes up their knowledge, and permits them to add-on a degree, for good reasons. Their value is more appreciated as well.
- GP groups are formed which focus on a motto “how to keep you away from a hospital”. Preventive health care becomes the focus, with GPs actually helping their patients to lead better lifestyles – something we know leads to less morbidity, and less hospitalisation.
- Lay people, patients and the media ask doctors more questions about common diseases. In India the doctor is often God incarnate – someone not to be questioned too much. This ideology needs to change. We need more responsible media. Today, it’s more sensational media, sadly.
With Corporate Hospitals mushrooming across the country, I wouldn’t blame the specialist for not (and often at times) over-utilising the facilities of the hospital he works at. After all, it is a business, like anything else, when a management that doesn’t understand medicine runs it. So a bad GP could make you keep coming back without proper guidance, improving his ‘business’, and a bad specialist can make you spend loads of money to maintain the bottom-line of the hospital he works at.
What matters in the end is not your diagnosis, or the number of investigations and treatments you received. What matters is how well you lived your life. And your doctor should help and guide you live it better, in the most sensible way possible. That’s all that matters.
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Dr. Sujeet Rajan
The writer is a Respiratory Physician at Bombay and Bhatia Hospitals in Mumbai.[/column]