Tuesday, July 21, 2009

Why more doctors are not the solution to India’s poor healthcare - The Peter Principle applied to Medical care

When most people talk about the sad status of healthcare in India, the standard knee-jerk solution is to build more hospitals; create more medical colleges and train more doctors and nurses, so that healthcare is easily available to the people. While this is a reasonable solution in medically under served areas such as the villages, this becomes a self-defeating policy when applied to cities like Bombay and Delhi, which is where most doctors prefer to practice.

Why doesn't having more doctors improve the quality of healthcare ? Logically, one would expect that the best way to fulfill increasing healthcare demands is to increase the supply of doctors. Unfortunately , this does not work in real life , because doctors create a demand for their own services – the more the doctors , the greater the demand.

I think this is an example of The Peter Principle being applied to medicine. The Peter Principle states - “ Work expands to fill the time available for its completion. “ The medical corollary would be – “ Medical demand expands to fill the pockets of available doctors. “

This is because specialists , as contrasted to generalists, have a very narrow focus. They work hard to create more work for themselves. This increases their perceived value to society; their sense of self-importance; and their income.
Let's see how this plays out in real life. Consider a Tier 3 city in India. This has a population of one million people who are being served 10 physicians. These physicians will also take care of heart problems , such as hypertension , angina and heart attacks - the bread-and-butter problems which every internist sees in daily practice. Now a cardiologist decides to set up practice here. Because he is a “ specialist”, and does have special expertise and equipment such as echocardiograms, the physicians are quite happy to refer their complex cardiac cases to him - and this is exactly the way things should be. Since he is busy and is doing well , a second cardiologist decides to set up shop in the same city. However , since there aren’t enough complex cardiac cases to keep two cardiologists happy, these specialists now start scouting for work and soliciting cardiac patients with simple problems. While these problems could easily have been handled by the physicians much more inexpensively, because the cardiologists cleverly project themselves as being better experts, patients with deep pockets prefer going to them rather than their regular doctor. Since cardiologists charge more than internists, they are seen as being better doctors in the public perception. Hospitals are quite happy to employ them, because they generate more income; and to protect their turf, the cardiologists start insisting that cardiac patients can only be admitted under their care, and not under the care of general physicians. Hospitals are more than happy to comply, because they need to keep their specialists happy - and the fact that this increases their income , is an additional incentive.

Over a period of about 10 years, the status quo changes. Because the new generation of young internists no longer sees cardiac cases, they are no longer capable or competent to handle these patients, who are then automatically sent ( or self-referred) to the cardiologist. As time goes by , the cardiologists become busier, and they end up monopolizing all the cardiac patients.

However, there aren't enough cardiac patients to keep all the cardiologists happy. This is when the Peter Principle kicks in, and cardiologists start creating more work for themselves. Rather than manage patients with angina conservatively, they start superspecializing, and performing invasive procedures such as cardiac catheterizations for angiography. At one end of the spectrum , they start doing more complex procedures such as angioplasty; while at the other end , they redefine normal cholesterol levels and normal blood pressure levels, so that practically everyone is either pre-hypertensive or hypercholesterolemic , and requires medical attention from a cardiologist.

By increasing the demand for their services, they setup a vicious cycle, so that no matter how many cardiologists are churned out, there will always be a need for more ! In fact, cardiologists often play a game of “one-upmanship” with each other, because they need to compete for patients and prove they are better than their colleagues. Thus, they will buy the nth generation stress test machine or the newest 64 slice colour CT scanner for visualising the coronary arteries – and then will hunt for patients who “need” these tests, to justify their purchases ! As George Bernard Shaw wisely said many years ago – Every profession is a conspiracy against the laity !

A specialist is one who knows more and more about less and less until he knows everything about nothing. Woe betide the man with chest pain because of a pulled muscle who goes to a cardiologist. Rather than make the correct diagnosis with the help of a careful history, he will subject the patient to a “ routine heart disease workup” involving an ECG, stress test and echo – not because the patient needs it, but because he is a cardiologist and needs to “rule out” a heart disease ! The real tragedy occurs when he finds an abnormality on one of his tests – an abnormality which may just be a normal variant, unrelated to the patient’s problem, but which then needs to be explored in greater detail, just
because “ it is there” !

Please note that I am not criticising cardiologists. They are just behaving as rational human beings, responding to the perverse economic incentives society chooses to provide them.

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