Ajeesh may be surprised to know that there is no proper course to train a GP in our country. Except the Dip NB (Family medicine) course of the National Board which is not very popular among doctors. What we do is to shout from rooftops about the importance of primary care service. It may be having commercial interests as well. Specialist practice is concentrated around towns / cities in huge capital intensive multi speciality hospitals. Providing basic health care at affordable costs to the public is a very important duty of the government. It is not something that doctors or private health care providers should be entrusted with. It is not correct to depend on the committment or compassion of a few doctors alone for this. Experts and medical teachers all over the world are now speaking of providing medical education in community settings to reduce the overemphasis on technology and equipments. Majority of health problems can be solved by the good old village doctor. What he does is to rule out serious illnesses and comfort the poor man. This helps to reduce the cost of health care. Those who need expert care are referred to specialist settings. But this arrangement may not be welcomed by the hospital promoters and some drug companies. It is true that private companies are the most active players in the development of new drugs. How to regulate them without hindering research is another major challenge.
Dear friends,Thanks for the comments. The history of medical practice in India is quite complex as suggested by Dr Vijayan, We had a totally unregulated system till the British entered. Thereafter the western scientific medicine started receiving support of the governments. It was eminently successful in controlling infectious diseases. After independence, there was no proper strategy. the British medicine continued to receive state patronage. Instead of developing suitable methods of teaching and developing indigenous systems like Ayurveda, Unani, Siddha etc, they decided to blindly ape the western systems and similar colleges were started.The duration of the course was artificially fixed as 4 and half years in line with that of MBBS. The German system of homeopathy was also treated at par with our indigenous systems. The importance of research was not realized at all. The importance of research in to the merits of traditional systems was highlighted by our former president A P J Abdul kalam. The development of modern medicine did not follow any proper plan or design either. More on this later
Some concerns raised by Ajeesh in his comment to my post on Malingering needs to be taken seriously. Being a non medical person, he has observed how doctors do wrong things to patients. But the situation is much more complex in reality. It has to be analyzed in the context of the way medical care is provided in our society. There are various models for providing health care. One is the U K kind of situation in which the general practitioner acts as the point of primary contact for all ill persons, except in an emergency. The G P is also the gate keeper, who decides which patients need to be referred to specialist services. Another style is followed in the U S A and some other countries, where the G P has no specific role. In our country there is no such strict criterion or demarcation. It is the sick person who decides which doctor he will consult. Often this choice is based on many factors. Proximity, his judgment about the gravity of the illness, cost, accessibility etc are important. For a problem which he thinks is minor, a local non specialist will be consulted. For a more serious problem, he may see a specialist in the nearby town. For a serious complaint, he may choose to consult a large hospital or medical college hospital. Studies have shown that only about 20 to 30% of symptoms seen in general practice have an organic basis. The G P is actually trying to rule out serious diseases by examination or tests. This is done with a desire to keep the costs as low as possible. The risk-benefit ratio has to be carefully understood in this decision. Sometimes the G P may miss serious illness. This will ruin his reputation and worsen the patients' outcome. Hence, to be on the safer side, he may over treat or over do investigations. The public is ignorant of the complexities involved in taking such decisions. The doctor is actually doing this on their behalf, but he is penalised for errors of omission. Committing errors of commission is a different matter altogether. The situation is further complicated by kickbacks some drug companies or labs offer. Competition from other doctors is also a concern for a G P whose livelihood depends on his practice income. Another complicating issue is the presence of alternate systems and hostile media who tend to blame the doctor for any negative outcome. It is the job of the government to come out with clear guidelines of duties and responsibilities of different categories of doctors. One way out may be to follow the U K system and ensure that patients contact specialists only through G P referrals. But this also can lead to problems in some situations, though it can reduce health care costs. The role of the specialist will be to confirm the suspicion of the referring G P or to rule out the suspected serious illness. If serious illness is detected, the patient is treated by the specialist. But the present system of administration in our country may not be able to bring about such a drastic change in the pattern of service delivery. The process of conversion from one system to another can bring up crisis situations which will result in antagonism of the public and media. I do not think our political leadership in any state or at the Center has the will or vision to think about major changes. The way drug industry is regulated in our country is another source for problems. This also need drastic measures. I am stopping here. Comments from the readers are welcome.
