Family physician-the need of the hour
Anand K. Joshi
The recent Supreme Court ruling stating that paid medical services come under the purview of Consumer Protection Act has sparked off considerable medical and public debate. New laws, improvements and change are hallmarks of a progressive society. We must, however, expect friction between the upholding of the prevalent status and change brought about speedily. When changes are brought about by legislation, introspection and self-evaluation by concerned parties are worthwhile. When this exercise is carried out on the basis of knowledge and wisdom, it proves meritorious.
The changed public image of the medical profession
The commonplace images of dosage-indicator strips on hexagonal green bottles; of the doctor with black tubes attached to the metallic holder of a long stethoscope hanging around the neck as indicative of medical practice have now changed. Likewise the doctor-patient relationship is also undergoing subtle changes. But rather than excavating emotional memories of the practice of yesteryears, it is more meaningful to unearth the reasons for the change.
In the good old days, challenges to decisions made by medical practitioners were rarities. Whatever the doctor decided, it was considered final and irrevocable. Today the situation is different. The doctor’s diagnosis and the reasons behind it are questioned. The reasons for this are many and complex. But that this change has come about in fifty years after World War II – in a relatively short period – is certain.
Medicine vis-à-vis science
After World War II, there was an upheaval in the entire societal scenario due to rapid progress in science and technology. Medical science firmly embraced technology and the concepts of medical practitioners changed. Doctors – trained in the new discipline – failed to differentiate medical science from the art of medical practice.
If one looks at the history of medicine and science, it will be evident that their. basic nature and traditions are different. The concepts of science are value-neutral. In science the happenings in nature are neither good nor bad. All that matters is whether they exist and the laws that govern them. It was somewhat different in medicine. Even among the practitioners of modern western medicine there is a persistence of the tradition of ‘First of all, do no harm.’ A series of value systems has taken deep roots in clinical medicine.
Descriptions in pure science are bland, without reference to consequence to the affected person. They are different in clinical medicine. Science would describe a boil with references to the extent to which the temperature of that area is elevated, measurement of the area involved in inches or cm, and the fact that it excites the sensory nerves. A doctor would describe it by using terms like throbbing pain, sensitivity of the affected area to touch and the degree to which the individual was inconvenienced by it. These aspects are important to the doctor because medical science is person-oriented. The purpose here is not an attempt to undo the tangle between objective science and clinical science. Medicine has progressed because of advances in science. We do emphasise that the medical scientist cannot be purely objective as can a physicist or a chemist.
Technology vs. wisdom
Medicine has always welcomed technology. Various tests like examination of the blood, X-rays, ECG, CT scans, sonography . . . the list can go on . . . can be cited as examples. Diagnosis, based on the history and what was learnt using the six senses, has been aided by these new techniques to yield sharper distinctions. New standards have evolved. Uncertainties in diagnosis and the possibility of missing out on the probable cause of a particular patient’s illness have been minimised. Doctors and patients now believe that technology has now made near perfect diagnosis possible. The use of technology in medical practice has therefore increased enormously.
No test can give results with 100% accuracy. Every test has two aspects: sensitivity and specificity. Each of these may fall far short of perfection. For instance, the sensitivity of a particular investigation may be 90% and specificity 70%. This test may be fairly sensitive but not specific for a particular disease and could be positive in more than one disease. The lay belief that technology has banished uncertainty has not been validated. On the other hand, technology may blur evidence of fallibility – and this is an important issue. Results of most investigations need to be scrutinised with great care. Was the methodology sound? Was adequate control maintained over the quality of test procedures ? What does the result signify in the context of this particular patient’s symptoms and signs? Herein lies clinical expertise. Whilst computers have undoubtedly facilitated the work of doctors, many thinking gray eminences in medicine believe they can never replace them.
The belief that medical knowledge is value neutral and that the role of the doctor is that of an agent who will deliver it to the patient is gaining ground in lay minds. The influence of technology on society has spawned the do-it-yourself movement in almost all areas and medicine has not been exempted. The media reach medical information to lay persons with unprecedented efficacy. There is a common feeling among educated lay persons that they possess considerable medical information. What they may not realise is that there is a vast gap between mere possession of information and its wise usage by individuals with considerable expertise and specialised training.
Medical science has conquered several diseases. Life expectancy has improved and this calls for celebration. But this does not permit medical practitioners to conclude that their duty is done. Therapeutics is not limited only to disease and its treatment. ‘Healing’and ‘curing’-the important components of therapeutics – extend beyond the simple treatment of diseases. This is the important difference between the ‘science’and ‘art’of the profession. We need not only to attempt to eradicate disease but also to restore to the patient the state of health and happiness to the extent this is possible.
Medicine as commerce
After World War II, commercial values changed. With industrialisation, there was an increase in the number and variety of consumer goods. Money became the yardstick of success. The medical profession did not escape this avarice. Men with commercial mentality entered the medical profession in a big way. Five star hospitals have gained ground. New and increasingly expensive medical gadgets have become commonplace. The arithmetic of investments and revenues now dominates the medical marketplace. This is the basis of the sea change that has taken place in the medical profession.
A patient goes to a doctor with great expectation. He has faith that the doctor will cure his disease. But the nature of every disease is different and it is appropriate that this information is given to the patient. For every disease, there is an early, a middle and an end stage. Some diseases are self-limiting after their initiation whereas others are chronic and stay with patients. These variations constitute the natural history of the disease. Some diseases can be completely cured.When the disease cannot be cured, it is often possible to halt its progress and life can be made more comfortable This ‘remission’ of symptoms is a period of trough; after some time the disease ‘returns’, the severity of the symptoms increases. This is called ‘relapse’. The poorly informed patient, ignorant of the limitations of modern medicine, may not be willing to accept such a situation. The doctor who fails to emphasise the limits of his expertise does his patient a disservice. When the patient moves from doctor to doctor, spending considerable sums fruitlessly in quest of a cure, the error is compounded.
A quick fix
Even if the disease is ‘common’, its course may vary from patient to patient. If uninformed. the patient in whom the illness persists for a while may experience dissatisfaction at the fact that a similar ailment was cured in a friend or relative in a much shorter period. In the hustle and bustle of this day, no one can afford to remain ill for a long time. Because of this, patients tend to run to the doctor for every little symptom. Man is basically hardy, tough and can face a number of diseases with ease. But this natural gift to man is forgotten when he runs to the doctor for trifling reasons. If, within a day or two of treatment, he does not feel good, he rushes to another doctor. This rush from one person to another and the willingness with which one doctor takes up the treatment of a patient already under the care of his fellow-professional has led to a growing dissatisfaction of patients for doctors. Already we see the move from consulting the family physician to that of rushing to the specialist.
The family physician is in danger of extinction. The craze for a new drug or a new doctor is harmful to the patient both physically and financially.
The indicators of health
If one analyses the basis of health in society, it will be seen that only 10% of it is dependent on doctors, medicines and hospitals. Ninety percent of health relates to life style (smoking, diet and nourishment, exercise, mental status), social and financial state, environment (clean air and water) and measures for promoting public health. This vast segment, over which the medical profession has no control, is responsible for most diseases and deficiencies.
To take care of an individual’s health, two streams of health care infrastructure are employed. Of these the public health wing is the more important. Public health includes measures for the prevention of infectious disease. This is to be provided by the State and its various agencies like the municipality. Inefficient functioning of public health establishments is ruinous to the health of individuals. Because this health service ice is faceless, it is often not answerable in a developing country like India. When an epidemic of plague or malaria takes place, public health establishments are hardly ever legally taken to task. In developed societies, the managers and workers of the public health systems are answerable. The origins of the epidemic – where, how, why – are expeditiously investigated. There is an audit of public health systems. Unlike what obtains here, in developed countries, the health of individuals is an indictor of the health of the public health system.
Personal encounters between doctors and patients are the other aspect of the health care system in a society. The doctor is answerable for his therapeutic interventions on patients. These are of two kinds: one based on modern advances in medical technology and the other concerned with tender caring and mental support to the patient. It is with their fusion that medical therapeutics takes shape.
In the past fifty years, major changes have taken place in the medical profession as has been outlined above. Now, under the Consumer Protection Act, all paid medical services (why only the paid medical services are included is a moot question) are answerable to the Consumer Court. The purpose behind this legislation is to provide compensation to the patient in case of harm consequent to medical negligence. Will these objectives be fulfilled by mere legislation? In America, such provision to compensate patients suffering from medical negligence has existed for years and the serious effects of this on both the medical profession and the patients have been evident.
Because of the Act, the doctor-patient relationship will be adversely affected. Rather than looking at the medical difficulties of the patient, doctors will now view the patient as a potential litigant. The important aspect of ‘healing and caring’ suffers in this perspective. The situation is worse in the case of specialists offering inherently ‘risky treatment’ (e. g. neurosurgery) and the specialist becomes apprehensive. The doctor will start practicing defensive medicine. If a patient complaints of headache, the doctor may order x-ray of the skull, x-ray of the paranasal sinuses or CT scan of the brain and such other expensive investigations.
The patient also becomes dependent on the tests. And he begins to trust the tests more than the doctor. Doctors are now ordering 20 to 25 ECGs in a month for chest pain. To say that defensive medicine is not generated by laws related to compensation would be self-deception.
Two important questions arise: Can the average patient afford the increases in the cost of biotechnological tests? Are they cost-effective?
To get the plea against medical negligence admitted, Consumer Courts need attestation of the complaint by two experts from the same specialty as the doctor against whom the complaint is made. This is to avoid frivolous complaints. Some suggest placing limits on the earnings that lawyers can take home in medical negligence cases to reduce complaints.
Instead we need to examine whether the objective of justice for patients can be served by making the medical profession mor responsible (answerable) and whether the rift in the doctor-patient relationship can be narrowed.
Ever since science and medicine have come together, the doctor has adopted the role of a scientist. But a doctor is not just a scientist, rather he is a therapist who uses the base of science for helping his patients. The important touch of altruism has been overlooked in medical education. It is necessary to include medical ethics and humanities in the pre-degree and post-degree medical syllabus to achieve the above objectives.
The family physician has become a specialist. Today, with the resources of effective therapy and plethora of tests, it is unusual to find a doctor who has ground knowledge of the patient’s family, social, financial and hereditary history and knows the patient well. This is a great pity for such a family physician can play a vital role. He has the subtle vision of exactly where, when and to whom to refer the patient; which tests are to be ordered; which symptoms are to be taken seriously. The medical profession needs to introspect on this and ensure the continuation of the family physician whilst making it possible for the specialist and family physician to undertake continuous education.
When society asks the question, ‘Doctor, you too?’, the question implies, ‘We have been like this but you too?’ When the ‘values’ of society change, the ‘values’ of every segment of it also change. The medical profession does not remain an isolated exception. When every transaction in society (including education) is carried out on the principles of market forces and if commercial attitudes gain proficiency, it is not surprising to find them influencing the medical profession. One would hope that the medical doctor, with his considerable education and privileged position in society, would be able to overcome commercial temptations. This hope has yet to be borne out by observation.