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.
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.
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.
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.
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 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.