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Apr-Jun2002-10(2)
EDITORIAL
General practice: many
problems, few solutions
Suhas Pingle
This issue of the journal deals with an important
aspect of health service provision: general practice. The contributors belong to
the small minority in the medical community who are committed to ethical
practice and are alarmed by current trends. They have grappled with some of the
current controversies in general practice. They have identified issues which
cause much discomfort within the medical community. They have analysed the
history of these tensions, but they have come up with few solutions. This is
because there are no simple solutions.
General practice in the
past
Ancient India did not have a formal public health
system. The ruling classes had access to royal vaids. The rest depended on local
health traditions based on household remedies. The foundations of modern
medicine in India were laid down by the British Raj more than 150 years ago. The
colonial health service commenced with the setting up of public medical colleges
and hospitals. Eventually this led to the dominance of a hospital-oriented,
urban-centred, health service, contrary to the needs of the public. This bias
continues today. By the end of the first world war, the various medical colleges
set up by the British Government were well established, aided by the arrival of
antibiotics and investigating modalities like X-rays. Graduates in modern
medicine started settling down in practice. The early 1930s heralded the
development of what is known as general practice, in metropolises like Mumbai.
General practitioners (GPs) played a key role in providing the poor urban
population with treatment for minor colds and coughs as well as serious
infections and other ailments. GPs came from a middle-class background with
proper qualifications to practice. They were known for being hard working, and
for their compassion for patients. They were not perceived as greedy; on the
contrary, they were often an integral part of their patients' families. A lot of
water has passed under the bridge since then.
Medical practice
today
Today, medicine has more than 50 medical
specialities. Medical practice has become increasingly dependent on modern
technology, hospital-oriented and dehumanised. The mushrooming of capitation-fee
medical colleges has given rise to a generation of half-baked doctors. At the
same time untrained, inexperienced, unregistered and unqualified practitioners
are practising modern medicine without fear of being caught and punished.
As for patients, today they tend to either
self-medicate or to approach a specialist directly, for even minor ailments.
There is also a change in the disease pattern, as lifestyle and metabolic
diseases become more common; such ailments will soon pose a bigger problem than
infectious diseases do, to the health services. Finally, the breakdown of family
and human relations has also affected the doctor-patient
relationship.
Unethical practices
Improving the ethics of medical practice is a
favourite topic of discussion both among doctors and lay people. One of the
articles in this issue deals in detail with 'cut practice', a 'custom' started
by insecure consultants about 50 years ago, which has spread like wild fire. In
today's society, to expect an individual doctor to be moral is like asking for
the moon. We must not forget that the majority of patients are happy to offer
'fees' for false bills and certificates. Even the Mahatma failed in his
experiment. Changing the situation will be a Herculean task involving a
sustained effort by GPs and consultants with their respective associations. In
fact, it should be a lifetime mission of all well-meaning people, including
consumer organisations.
The importance of general
practice
Ironically, the increase in specialisation, and the
attendant skyrocketing of health care costs, makes the GP more important today
than ever before. In the west, national health schemes recognise the importance
of the GP as a gatekeeper. In these countries, a patient cannot approach a
specialist directly. Modern medical practice must be GP-based if national
expenditure on health is to be brought under control. It is unfortunate that
general practice is seen as having little social relevance in the 21st century.
The General Practitioners Association of Greater Mumbai tries its best to imbibe
confidence and self respect in GPs by arranging CME programmes. It also tried to
negotiate a formal programme to keep GPs involved in the management of their
hospitalised patients; they were to be paid for their services officially.
However, this plan did not materialise.
The ideal GP
The ideal GP should have proper qualifications and
good experience. The patient has a right to ask for the GP's registration
certificate. GPs should continue to learn and update their knowledge by
attending CME programmes. GPs should be very good at listening and communication
skills. They should be ready to discuss the patient's medical problems in an
open manner. They should be available to their patients for emergencies. They
should be caring in nature. Their charges should be reasonable. On their part,
patients also should have faith in their GPs. They should not expect false bills
and certificates from them. If GPs are prepared to play the role of a teacher
and counsellor, and to do their bit for preventive medicine, they will do
immeasurable good service to society.
Dr Suhas Pingle, general
secretary, General Practitioners' Association of Greater Bombay. Email address:
gpagb@vsnl.com