Tuesday, 9 August, 2022
HomeOpinionBring back the family doctor. India has too many specialists

Bring back the family doctor. India has too many specialists

Every town and city in India has a multi-speciality clinic or hospital. But where are our family physicians who can tell us ‘go to the doctor’?

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If you live in a medium-sized or larger town in India, chances are that you have a private medical clinic or hospital not too far from your home. Chances are that it will describe itself as a “multi-speciality clinic” and the reception area will have a long list of specialists who you could consult. Even the smallest clinics in my neighbourhood in Bengaluru have around a dozen specialists on their roster. Every conceivable specialisation — from neurosurgery to psychiatry, interventional cardiology to maxillofacial surgery — is available within a 5-kilometre radius from my home.

The only problem is that if a person has, say a bad headache, he or she would not know where to start and which of these specialists to consult. In the best case, it is quite possible that they would see one of the specialists, do the lab investigations or scans she recommends, only to find out that the ailment belongs in the domain of another specialist. This, at once, is inefficient, stressful for the patient, undermines trust in the system, affects health-seeking behaviour and impacts overall health outcomes.

Also read: Breathe new life into public health. Far too many Indians rely on Baba Ramdev, Akshay Kumar

Missing family ‘doctors’

We have a lot of specialists, but too few “doctors”. The shortage of general practitioners or family physicians has become one of the weakest links in India’s medical system: there are too few of them both in urban and rural areas, although for different reasons. The trend towards specialisation is likely to continue. Of the 54,000 new doctors who will graduate this year, at least 44,000 will become specialists after the expansion in the number of post-graduate seats. Worse, as Dr Raman Kumar, president of the Academy of Family Physicians of India has written, the Medical Council of India (MCI)’s new 890-page MBBS curriculum “does not even mention the words “General Practice” or “Family Medicine” or “Family Physicians” throughout the voluminous document (sic)”, leaving ”students in the road of no return of specialist and tertiary level hospitalist care.”

As Dr Kumar points out, almost all the training that an MBBS student gets is at tertiary hospitals, depriving them of valuable working experience in clinics and primary health centres. In other words, of the 80,000-odd students who will enter medical colleges after the NEET exams this year, very few will study family medicine as a subject and very few will have any experience of “general practice” as part of their practical training. Political economic factors are likely to continue to push governments to increase the number of post-graduate seats, such that most of the 80,000 will be able to become specialists a few years from now.

To be sure, India needs the specialists. But it needs general practitioners even more. There are a number of reasons why the composition of medical practitioners is skewed in favour of specialists: competitive pressures of over-concentration in urban areas, greater income potential, higher status among peers, greater prestige in society and patients’ demand, among others, drive the preference for specialisation. As the changes in syllabus and expansion of post-graduate capacity show, the medical education system is more sensitive to the preferences of medical graduates, than the overall needs of the health system. Clearly, the connect between the health ministry’s national goals and the MCI’s medical education priorities must become stronger. One simple way is to increase the MBBS intake — India needs a lot more doctors anyway — and simultaneously increase seats for family medicine at the post-graduate level.

Also read: Covid-forced break in medical education could have long-term effects on society, says IMA

Up-skilling the nurses

Such policy changes are necessary, but even if they were implemented tomorrow — and we are very far from that — it will take close to a decade before we see changes on the ground. What do we do in the meantime? We should upgrade nurses and qualified ASHA workers to “chartered nurses”, equipping them with higher skills and technology that will enable them to become the citizens’ first port of call. In addition to basic medical services, their primary function would be to act as health advisors, guiding anxious patients to the appropriate healthcare facility. Indeed, one of the most effective healthcare interventions is to advise the person to “go and see the doctor”.

With greater smartphone ownership, internet connections and inexpensive diagnostic equipment, it is possible for chartered nurses to “check” the patient using a basic technology kit, transfer the data to analysis hubs for interpretation, and advise the patient what to do next. With just over 2 million chartered nurses, every 100 families can have a designated chartered nurse. There are around 900,000 ASHA workers and 3.07 million registered nurses in India who can be trained, up-skilled and supported by a technological backbone to become chartered nurses.

In movies of a bygone era, doctors would be fetched when someone fell sick. For those of us fortunate to have access to them, house calls by the family doctor were common during my own childhood. While the world has moved forward and it might not be practical to design a national healthcare system based on doctors doing house calls, raising a force of 2 million chartered nurses is something that can be done in a few years. If the nurse can tell — using inexpensive, reliable, prompt diagnostics and analytics — whether the headache is nothing to worry about, or that the patient must immediately rush to the appropriate hospital, we will be able to reap the benefits of having so many specialists around.

Nitin Pai is the director of the Takshashila Institution, an independent centre for research and education in public policy. Views are personal.

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  1. Thought provoking article indeed. One solution may be to create a specialisation for family practice as some countries have.

  2. I second the views of the author. There can be more than proposed alternatives to reach there.
    I recently switched to Ayurvedic doctor as I wanted one doctor to be constant for my all the treatments except (accident, dentistry and eye specialist). Not that it is cheap but I know he knows me really well and does not make list of tests to done to find out whether I should be given anti-biotic or not.
    Gladly, I have observed that Ayrurvedic doctors are doing traditional practice are increasing.

    I honestly do not like hospitals, doctor for chest is different than for bladder, if that was not enough person who does gastroscopy is another. Wait when you go in hospital dietician is top up. If you are doing surgery then anesthesia and whole bunch of tests for fitness certificate. While I appreciate having such specialists but there must be some pragmatism for “tick boxes” and specialists should have at least basic knowledge of body than just make tail of doctors treating single patient.

    • The article is absolutely correct when it says that we need more doctors doing general practice, and I will add to it by saying that those doctors should also practice preventive medicine. My father is one such doctor who has been doing general practice after doing MD medicine. But, PATIENTS themselves are to blame for it. Everyone wants specialist only nowadays. Apparently MBBS followed by MD (Internal Medicine) is not enough for a lot of patients because even for the treatment of common ailments, they want a neurologist or nephrologist or diabetologist to treat them. So obviously, doctors of my generation arent going to waste their time doing general practice. You are getting what you are asking for.

      For the gentleman who says that investigations done for fitness for anesthesia are pointless: very few anesthetists will ask for unnecessary tests unless your medical history demands it or your behaviour suggests to us that you aren’t very honest about your medical history. As far as having “basic knowledge of the human body” is concerned: all of us have that basic knowledge. That is what we spent time doing for 5.5 years when we did MBBS before specializing further. Also, if you believe that anesthesia is a simple procedure, think again. When we give you anesthesia, we arent making you go to sleep. We are putting you into a medically induced coma. Following that we give you life support and keep you alive throughout the surgery and then we get you out of that coma. Do you want us to do a shabby job of that? If you dont want to wake up from the anesthetic, then fine, we will not ask for the relevant investigations. Just instruct your family members not greedily drag us to court when a complication occurs. When you believe you know more than a professional who has spent nearly a decade training to become that professional. When you believe that your 5 minute google search somehow makes you more expert than a decade of practical training, endless reading, passing a plethora of exams and seeing the same thing day in and day out, you can treat yourself. We would be happy to not have to deal with the likes of you.

  3. This Is a very well written article highlighting the one of the foremost problem of today but is highly ignored, another point I must add which I came across these days is trend of super specialisation a dr checks the patient only for the disease he came to him and ignoring the underneath problem he is suffering, for example a patient goes to a cardiologist for a chest pain and is also suffering from burning micturation or some other problem he will tend to ignore the other problem he’s having and this sometimes leads to severe complications.

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