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Apr-Jun2002-10(2)
DISCUSSION
Changing trends in general
practice in Mumbai - a few stray thoughts
Arvind
Pednekar
Hippocrates, had he been living now - in India, in
Mumbai - would have been too confused to write his famous oath. Perhaps, he
would prefer to have nothing to do with it.
In the early 1950s and '60s, Mumbaikars,
irrespective of their class, had their own family doctor as an essential part of
their family. Nobody then, unlike today, had his or her own paediatrician,
physician, gynaecologist or surgeon. The Family Doctor (FDr) or General
Practitioner (GP) served families medically and socially. Patients, too, had
explicit faith in the FDr. This reciprocal relationship produced the best in the
FDr and the patients.
Since the 1970s onwards, with rapid
industrialisation, patients became financially affluent. For many patients,
employers offered medical perks along with other perks. Such facilities had an
abusive effect on the family doctor-patient relationship. The FDr was easily
by-passed and the help of other specialists was sought. And these other
specialists conveniently did not bother to involve the FDr. The need for the FDr
came into the picture only after the retirement of the patient when medical
perks disappeared. This scenario changed for the worse by the 1980s when general
practice started getting eroded by other specialities. Facilities to patients,
which were conventionally given by the FDr or GP, were given by these
specialists. Paediatricians were the leaders by snatching the immunisation
programme from the FDr. Ante-natal and post-natal care started to be given by
obstetricians and gynaecologists. Nowadays even non-medical personnel like
beauticians and dieticians have been guiding patients.
All this made it difficult for GPs to survive. The
famous scientist Abdul Kalam recently stated that to reach heights self-respect,
self-assessment and self-value has to be at their heights. Our senior GPs
perhaps never did any of these, and younger GPs, out of fear of competition with
seniors, never dared to change, resulting in doctors finding other sources of
income, medical, non-medical and even unethical. A big hue and cry was made by
the media regarding this last source of income. It is not to justify this in any
way, but one must not forget that the GP is part and parcel of society. He has
to flow with society's rules and methods. Our country's existing culture being
corruption, a GP falling prey to such temptations is not a surprise. Since the
medical profession is considered to be noble, this becomes unacceptable and thus
an issue for discussion
However, one must admit that in the past 20-25
years, a small percentage of GPs have shown a consistent interest in updating
themselves. These few GPs have intentionally distanced themselves from the
conventional practice of their seniors. It is observed that most senior doctors
have never updated themselves in medical knowledge, and not even in their
clinics where they spend most of the day. Buying medical books by a GP was never
heard of in the past. Medical book depots will vouch for this. As against this,
the above-mentioned small percentage of GPs are regularly exposed to books,
journals, seminars and CMEs. The GPA of Greater Mumbai singularly deserves
credit for infusing awareness in its members for such updating. The IMA and its
branches in Mumbai have taken a cue from the GPA and have started offering
various such programmes. Due to all this, the GPs of today are definitely well
oriented with modern technology.
Despite this, the liaison between GP and patient
seems to be getting commercialised. Financial affluence, as said earlier, tends
to get patients into doctor shopping. Add to this patients' exposure to media
advice offered by specialists and quacks. This media facility provides an
excellent opportunity to market the specialist, the benefit to the patient being
disputable. Thus specialists create their own way of marketing. Hippocrates, had
he been witnessing this, would be turning upside down in his grave.
Awareness of one's own health is seen to be gravely
lacking amongst patients in spite of efforts by GPs. Not having a family doctor
who has the full medical and social history of the entire family creates a great
hollow when a crisis occurs. Eventually, along with patients, the whole family
suffers. In such times, having a family doctor and not a specialist is
definitely advantageous. Luckily, in Mumbai there still exist a few family
doctors and a few family patients. Among them they share most cordial,
dependable and also a professional relationship.
The relation between a GP and other specialists has
changed dramatically over the years. Typical, the Mumbai scenario of GP-
Specialist relations is like this:
The young specialist will make all efforts to
remember birthdays, wedding anniversaries and even the colours liked by a GP who
refer him the cases. His rapport with the GP will be excellent all the time even
if it is not desired. A few years later, on establishing himself, all this
recedes (barring those few GPs who keep on referring). A decade later it comes
to "Hi, Long time no see." The GP has thus become a stepping-stone.
The GP too exploits the situation, willingly or
unwillingly. He gets easily carried away and later gets used to 'receipts'.
Eventually, to keep it up he creates references. Who started the ball rolling
and who is tossing it is a million-dollar question. However, no efforts on
either side are seen to stop this 'you scratch my back, I scratch yours'
attitude. In the modern days of management this self-marketing and
self-promoting is conveniently accepted by both.
To quote a different scene, I had the privilege of
a superb intellectual and professional liaison with a senior specialist;
incidentally he was my teacher too. On a domiciliary visit when this specialist
was called, after examining the patient he would ask me to offer my opinion
freely about the diagnosis and management, and invariably correct me very
politely, never in the presence of the patient and relatives.
Such was the rapport between GP and specialist. Now
in contrast, on my referring a case to a specialist with a covering note asking
for feedback, the specialist will ask the patient to inform me to telephone him.
Hospitalised patients get easily tossed form one specialist to another without
the GP being informed. The attitude of such specialists is: "What's the need to
inform?" Sadly it is only when a doctor himself or his relatives go through such
a terrible plight, causing financial drain, that they realise the need for a
family doctor. I had, and still have, such senior non-practicing doctors and
their relatives as my family patients, some of them are even my teachers.
Indeed, it is a pleasure and honour to be a family doctor to a
doctor.
The GP-hospital relationship is non-existent in
Mumbai. Hospitals, as a rule, do not believe in the GP- FDr concept, except for
inviting them as an audience for self-marketing occasions. Not a single hospital
in Mumbai has a small line on its case paper for the FDr's name. To gather
information about his patients in a hospital, the GP has to go through most
unpleasant hassles, right from the doorstep to the treating doctor. The GPA,
Greater Mumbai, sorted out this problem a few years back with positive
reassurances from hospitals. But this has remained on paper only. A facility for
admitting patients under the care of GPs is still unheard of.
Hopefully in the future, somewhere in this country there will be a hospital exclusively owned and managed by a GP and an FDr, and only when required would other specialities be called as visiting faculty. It is a dream, though.
Hopefully in the future, somewhere in this country there will be a hospital exclusively owned and managed by a GP and an FDr, and only when required would other specialities be called as visiting faculty. It is a dream, though.
We, the present GPs, must realise that we are
equally good in our own speciality as compared to any other speciality. And for
this, we must basically realise that general practice is a speciality which is
not easy to practice. It is not included in medical teaching at the
undergraduate level. It requires extraordinary skill to be available quickly, to
take decisions quickly and to have sufficient knowledge of all the specialities.
All this is self taught, self-developed. These qualities are not required by
other specialities. But one wonders, if this is so, why are our fees not on par
with other specialities? This could be attributed to the inferiority
complex of our seniors resulting in lower fees and lower respect in the eye of
patients.
The time has come for all GPs to revolutionise
their thinking and method of practice. The modernisation of clinics, and
updating knowledge, have to be on the cards. Only then will general practice be
placed on a high pedestal in society, which it rightly deserves.
Hippocrates perhaps then will write a better and
practical oath for the medical profession of today.
Dr Arvind Pednekar,
Consultant Family Physician and Geriatric Counsellor, Venus, 6, Nowroji
Vakil Street, Grant Road (W) , Mumbai 400007 E-mail:arvind01@hotmail.com