The other day, I read Dr. Devi Shetty’s editorial on how to fix Indian’s broken healthcare system without spending big money. Dr. Shetty pointed out to couple of reasons and fixes but the most important one was that the India has inadequate number of doctors and hence should increase seats for post graduates from current 14,000 to same as of that of seats for graduates i.e. 50,000.
Unfortunately Dr. Shetty is prescribing a solution that is only going to exacerbate India’s problems. This obsession with specialists is costing our country dear. In the west, in both Europe and US, the first port of call for a household is a family physician. Approx 70-80% of ailments in daily life can be managed by a MBBS doctors. We need specialists only for chronic problems or specialists fields like orthopedic. Ailments like fevers, throat infections and food poisoning can be addressed by MBBS doctors. This grossly undermines MBBS degrees and affects future earnings of graduate doctors and thus forcing all of them to pursue post graduate degrees. The only options left for MBBS doctors are residencies or preparation for post graduate entrance exams. In the process, post graduate degrees are becoming very expensive due to skewed demand and supply. There are very few MBBS doctors who setup an independent practice.
What India needs is a band of general physicians. This will lower the cost of healthcare and will also increase the reach of doctors as they would be willing to go out and set up clinics in different areas. The pyramid structure of low skilled workers to high skilled workers cannot be turned upside down or square. We need physicians who are ready to visit patients at their homes and build long term relationships as a trusted friend. We need MBBS doctors who have been trained as GPs.
This trend of specialists being first port of call has also lead to some other social trends. One obviously is increased cost of medical care. The consultation fees for specialists being significantly higher than that of MBBS doctors. The extra-ordinary demand for specialists time has led specialists to stop making home visits which is being aped by MBBS doctors and AYUSH doctors.
One of the quintessential scenes in Indian movies used to be of doctor carrying his bag to patient’s house. Unfortunately this practice has stopped totally. Today the doctors take it as below their dignity to visit patient’s home. Unfortunately this severely restricts the reach of doctors especially in rural areas. The rural areas are dominated by unqualified RMPs whose only USP is providing 24*7 doorstep service. These RMPs have edged out Allopathic and AYUSH doctors who have now stopped making home visits.
Thanks to rampant commercialization of healthcare services, and the information asymmetry between doctors and patients/attendants the trust between doctors and their patients is breaking down. I recently visited a village near Palwal in Haryana. I was told economy of hysterectomies and how it enriches doctors and RMPs.
It is easy to fix the supply side problems. Currently the medical students study for 4 years and then undergo internship for a year. We can adopt the US model where the students undergo intensive training of three years in basics like anatomy, diseases, pharmacology, microbiology etc. with two years of internship. This will help us achieve right balance between knowledge and skills and equip the doctors to function as GPs.
However it is difficult to fix the demand side problem. In England and in US, the pressure to go to a primary physician before consulting a specialist comes from the system or regulations. In England its mandated by National Health Scheme while in US, its enforced by insurance companies who typically reimburse OPD costs. In India, in absence of regulatory mechanisms and due to social trends, people take consulting a specialist as badge of honour. It has its own snobbish value attached to it.
Indian government needs lot of political will and administrative efficiency to address it.