Maladies of the Health Care Sector: A Reflection

The objective of the Indian Graduate Medical Training Program as per the Graduate Medical Education Regulation (GMER) of the National Medical Commission (NMC)[1] is as follows: “The undergraduate medical education program is designed with a goal to create an “Indian Medical Graduate” (IMG) possessing requisite knowledge, skills, attitudes, values and responsiveness, so that she or he may function appropriately and effectively as a Physician of first contact of the community while being globally relevant” Today, the status of the IMG, commonly referred to as General Practitioner or simply GP, is far removed from what it was intended to be. Before elaborating on the IMG’s status, let us take an overview of the present scenario of medical practice. Recently, a postgraduate resident presenting a case in our monthly clinical meeting projected a long list of investigations carried out for the evaluation of his case. When questioned about the justification of each of these investigations with reference to the case, he could not give a valid reply. It was pointed out to him that prior to listing out the investigations, he has not mentioned a provisional clinical diagnosis. The importance of a clinically established differential and provisional diagnosis, being the basis of deciding the relevant investigations required to arrive at a definitive diagnosis in any case, was explained to him. Clinical examination has become a lost art. There are occasions when a patient is directly sent for ultrasonography without any clinical examination. Sonography is considered to be the third or extended hand of the clinician. Unfortunately, it has become the primary hand of many physicians. In modern medicine, it is the corporatization, driven by advancing technology, which has generated various complexities. Many hospitals, mostly in the private sector, have a standard operating procedure of carrying out a battery of laboratory tests in patients irrespective of their clinical status. The requirement of such extensive investigations is often justified overtly as practice of defensive medicine and covertly to meet financial targets. A report published in BMJ has commented that many doctors in India employed in the “profit driven” corporate hospitals are pressurized to prescribe irrelevant and “risky” tests and procedures to meet revenue targets.[2] The art of medicine has been sacrificed at the altar of commercialization of healthcare. The medical graduate today hardly has any social standing. India, having the largest number of medical colleges in the world, has only 4.1 medical graduates per 100,000 population, among the lowest in the world.[3] The erstwhile ‘family doctor’, a graduate, became almost a family member and referred to as Doctor Uncle is now an extinct species. He was available whenever required either in his chamber, often a separate room in his house, or for a home visit in an emergency. How many of us have had the good fortune of experiencing such a family doctor? He was the historical version of the IMG who actually justified the role assigned to the IMG by the NMC in the GMER. Unfortunately, today, the specialist has replaced the GP as a physician of first contact. To make matters worse, some specialists with a tunnel vision sometimes refer patients to another specialist if the symptoms deviate from their own domain. This kind of team work sometimes becomes a gargantuan money spinning machine. To cite an example, a pregnant lady visits her gynecologist for her routine checkup and complains of fever and cough and gets referred to a physician for the fever. The problem of this lady can be easily managed by a single MBBS general practitioner, provided the GP is competent enough to handle basic health problems, irrespective of domain. In a country like ours with a diverse population where majority are located in rural or semiurban areas, we require a higher number of well-trained graduate general practitioners rather than specialists. The mad rush for postgraduation has resulted in a horde of specialists mostly crowding the cities. The IMG, who spends precious time in coaching centers, ignores internship to secure a PG seat and misses the opportunity of acquiring clinical skills. He then finds himself ill-equipped to play any meaningful role in the health care system. Hence, there may be a need for ensuring a graded health care service with a bottom-up approach from efficiently functioning graduates to specialists and superspecialists. The delivery pyramid should have a wide base of skilled IMGs imparting comprehensive basic health care. They should be trained accordingly. Opportunities for them in urban and rural areas with adequate and respectable resources need to be provided. A compulsory physical service of 2–3 years by the IMG as a medical officer preferably in the public sector may be mandated prior to appearing for NEET (PG). The specialists, in their turn, should play their respective roles with professionalism and ethics expected of them. Data availability statement NA. Authors contribution HB - Entire conceptualization, drafting and revision.