Sunday, July 06, 2008

Doctors as bottlenecks - and patients as solutions !

One of the problems with any healthcare system anywhere in the world is that there are too few doctors and too many patients. This is as true in the US as it is in India. This means that patients have to suffer . Not only are there long waiting lists, they get to spend only a few minutes with their doctor during their clinical encounters. This makes for unhappy patients – who will often vent their anger on the doctor if there is a mishap or bad outcome.

The standard kneejerk reflex to this problem is train more doctors. If we have 1 doctor for every 1000 patients ( or whatever the magic number is, depending upon the author), all our problems will be solved ! Actually, this is not true. Churning out more doctors just ends up creating more clinical work, because doctors create their own demand ! Also, even if you do have more doctors, most of them will end up working in large cities, so that the poorer neighborhoods and the villages still remain underserved. We need to understand that we cannot solve this problem by regulating the supply of doctors – we need to look for alternative solutions !

The Aravind group of Eyecare Hospitals has taken an innovative approach. They realized that a lot of what the doctor does can be done by someone else, so they have taught non-doctors to perform the doctor’s tasks. Thus, routine clinical procedures , such as checking the intraocular pressure, which are usually performed by ophthalmologists in other hospitals ) are now done by trained assistants, thus freeing up the doctor to focus on his patients.

I think we can go one step further – and get the patients to take on many of the roles which the doctor plays today . Now this does not mean that I think we should teach patients how to do surgery !

Let me explain. One of the key tasks of a doctor (and a very time consuming one, if done properly) , is taking a medical history, where he listens to the patient and tries to figure out what the medical problem is. Traditionally, this history is taken at the clinic by the doctor; and in busy clinics, the medical history is taken by an assistant and then reviewed by the doctor.

This is not the best model, because often the patient forgets important information during the stress of the consultation; or may not have access to important medical details or records ,because he has forgotten to bring them.

Why not allow patients to fill in their medical history online, at home, before coming to the
clinic ? We do this routinely in our practice. Our patients have to fill out a structured form at - which ensures they will provide me with all the information I need to formulate the right treatment plan for them.

A very clever program called Instant Medical History ( allows patients to take their own history at home ! Branching logic enables patients to progress quickly through adjustable questionnaires from an extensive medical knowledgebase and provides the patient and the doctor with a very well organized and complete history – thus saving the doctor a lot of time and ensuring that no information is left out. Equipped with this, the doctor can then confirm the important medical features and get on with the clinical examination ! You can watch a video of how this works at

We can even go one step further ! Most patients have simple problems for which they do not even need to visit a doctor. Many problems are self-limited; or will get better on their own. All the doctor needs to provide is some hand-holding and reassurance – and a lot of the time, this does not need a trip to the clinic !

Does the patient really need a face to face visit ? Can the problem be resolved by a phone call ? email ? a web visit ? This allows many more patients to make much more efficient use of the doctor’s time ! But what if the problem is serious and is missed because the patient did not visit the doctor ? This is a valid concern ; and the good news is that clever triage programs can help to ensure that patients can manage simple problems for themselves with self-care . An excellent example of such a free program is available at !

Just like supermarkets make their customers do all the work ( select their products and put them in the cart), clever technology can allow patients to do a lot of the routine work which doctors do today. Not only will this free up the doctor’s time; it will also give patients much more control over their own medical care; and allow doctors to concentrate on key clinical tasks. Patients are the largest untapped healthcare resource – let’s make the most of them !

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