Thursday, August 19, 2010

Healing the Sick Health Care System - Dr Nadkarni

This is Chap 1 from Dr Nadkarni's book, Healing the Sick Healthcare System.

The Health–care-system is very complex . It is a
system in which any person with any perceived illness seeks
medical assistance to get rid of his illness, even if the perceived
illness is false, in the sense that it may not be a true organic
illness. The primary needs of the individual are food, clothing and
shelter. Health and education come next in order. Food, clothing
and shelter are considered most essential for the survival of an
individual. Yet every need under these heads cannot be
considered as essential. While rice, chapatti and dal maybe
considered most essential, the same cannot be said about
‘pickles’, ‘papad’ and ‘pista’, ‘badam’ and such dry fruits could
legitimately be considered as luxuries. Kashmiri chicken in five
star hotel certainly cannot be called a necessity. Same is true
about clothing. While shirt and pant or ‘saree’ can be considered
as most essential, designer shirt or silk saree would come under
items of luxuries. Most people do not realize that all the health-
care needs are not necessarily essential or vital for the survival
of an individual. There are some essential services but there are
other services which can be called desirable but not absolutely
essential and yet other services accepted by the society could
easily come under the term of luxuries. Most of the cosmetic
surgeries belong to this last category. Even many of the so called
preventive measures for long life such as use of a particular oil
in food could also be considered as not essential, if not luxuries.
Therefore, one has to realize that in health–care–system, there
are essential services, there are desirable services and there are
medical services which can be termed as luxuries.
In actual clinical practice the health professional is not just
a man of science. There is an admixture of art and science and
commerce in the actual clinical practice. Also there are three tiers
in the services provided under health-care system. Primary
health care service which is offered in the dispensaries and
primary health centres usually by a single doctor. These doctors
treat the patients who come to the dispensary for their
elementary diseases. The patients are not admitted in these
primary health-care centres. These doctors also treat the people
to prevent diseases. Preventive medicine has become a very
important aspect of the management at the primary health level.
Immunization, Vaccination, Counselling during the pregnancy,
Advice on diet and Hygiene for the family are all essential parts
of the primary health care of the society. Thus, primary health
care is one of the most essential health care services needed by
the society. Yet this is the most elementary aspect of the health
care and needs very simple equipments, investigations and
simple medicines. The doctors in these primary centres need to
have patience, a lot of sympathy and a great ability to discern
between simple and major illness. Thus, there is a lot of art and
some science at this level. ‘Medicine is an art’ applies particularly
to this primary health-care system.
At the other end of the spectrum are extremely serious
patients who are at a risk of losing their lives or at the risk of
being crippled. The medical science has progressed a lot and
many of such illnesses can be treated effectively now-a-days.
Some patients can be cured and life of many others can be
prolonged or made comfortable. But all this cannot be done
without profound knowledge of the science of medicine and many
high-tech equipments and sometimes use of newer drugs which
could be quite costly. In short, the management of serious
organic disease requires use of modern equipments and
medicines and the profound scientific knowledge of the body–
systems involved in the disease. Science plays a very major role
and the art of medicine is often sacrificed by the specialists who
offer these services. These medical services are offered only at
tertiary medical centres. They cost a lot and can be managed
only by expert consultants / specialists and super specialists.
All the intermediate groups of diseases i.e. those which
cannot be treated in dispensary or at home and yet are not so
serious as mentioned above are all treated at the secondary level
of the health-care-system. Nursing homes, private hospitals or
Taluka and District level hospitals in the public sector offer these
services. Standard equipments and standard drugs are mostly
sufficient and the medical professionals are specialists of basic
level or general specialists. A good admixture of art and science
is needed at these centres to satisfy the patients.
Apart from these, there are plenty of ailments for which the
patients seek the medical advice. Due to the modern pace in life
there is an immense increase in the psycho-somatic disorders.
The real ailment is 'tension or stress' but this emotional
imbalance is manifested in bodily illness. Some of these psycho-
somatic illnesses turn into organic diseases but many of them
remain non-organic in nature. Headache, backache, inability to
work, flatulence (gases) and many such vague symptoms are
instances of psycho-somatic diseases without any organic
changes in the body. Diabetes, hyper tension, heart disease etc.
are also phycho-somatic diseases but they cause organic
changes in the body and, therefore, become organic diseases
requiring major treatment. The first type i.e. non organic type of
psycho-somatic illness needs more of psychological treatment
while even in the second type, psychological treatment could
help a lot. In addition there are many ‘imagined’ illnesses. All
these except the organic diseases mentioned above could be
called as ‘non essential’ health care needs. Lot of art is required
in treating these diseases. But a lot of commerce also enters into
this field and even the patients are willing to spend exorbitantly
for getting rid of their ‘non-essential’ diseases.
Medical professionals are not saints and they have entered
the profession specifically to earn. They belong to a relatively
more intelligent strata of society and are highly educated.
Therefore, their expectation of earning is also legitimately high.
This legitimate demand of the medical professionals cannot be
termed as commercialization and the society must learn to
accept it as due compensation for the service rendered.
Therefore, commerce enters into the field of medicine at all
levels. Commerce enters in the medical field from the primary
level to the tertiary level and is most conspicuous in the
management of the psychosomatic illnesses mentioned above.
For the clinical practitioners, at any level, a fine balance has to
be achieved between art, science and commerce so that the
health professionals are not denied their legitimate dues while at
the same time, they are not allowed to commercially exploit the
patients who are too anxious to get well. There is no doubt,illegitimate demands are raised by some doctors and such
demands must be termed as ‘over commercialization’. This over-
commercialization needs to be curbed.
There are many systems of medicine practiced
simultaneously in every part of our country. Ayurvedic system of
medicine is the most ancient system in the country and is
respected by the masses even today. Hence, it is recognized by
state as well as central government and plenty of Ayurvedic
medical colleges churn out a lot of Ayurvedic practitioners. Even
in this system there are general practioners and specialists.
Same is true about Unani system. Started nearly 1500 years ago
in the middle east, it is more popular among Muslims and is
recognized by the governments. Homeopathy came in much
later. First founded in Germany, Homeopathy became rapidly
popular all over the world, as also in India and is now recognized
as a system of medicine like the other two faculties. Each of them
is governed by their own medical council and each separately
register their practitioners. Knowing the importance of Allopathy
as a more scientific system or, at any rate, the presently most
practiced system, all the above faculties have incorporated some
elements of allopathy in their training course. Even if it happens
to be very inadequate, it offers their practitioners a legal right to
practice allopathy simultaneously though they are not registered
nor governed by allopathy State or Indian Medical Council.
Indian Medical Council was established at the centre in
order to establish a standard of education in the allopathic
system. The council is expected not only to prescribe and
maintain the standard of medical education but is also expected
to oversee and regulate the functioning of the practitioners of
allopathy in India. In order to do so, the council had to first
prescribe the standard of education and prepare the curriculum
for various courses for graduation and post-graduation. The
council then had to define the exact role, the health-care
professionals are expected to play. Every practitioner, therefore,
must register under the Indain Medical Council.
But the council has the most insufficient infrastructure
amounting to almost nil to actually supervise the conduct of their
health-care-workers. Broadly the council depends on complaints
by their associates or by the public at large individually or through
government channels and then decides whether the person
actually is maintaining the standard or not. Even if the council
finds the behavior of the doctor sub-standard, it has very limited
powers. It can either warn the doctor or de-register him. Once a
person is de-registered, he or she cannot practice in the
allopathic system of medicine. But the legal system of the country
is so peculiar that once de-registered that person no longer is a
qualified doctor coming under the ambit of the medical council.
Therefore, for any malpractice, if he continues to do so, the
council cannot deal with him as he is no longer a member of its
body! Only the department of law and the police under them can
deal with such culprits and take necessary action against them.
The council is helpless. With meager knowledge of the
regulations under which the doctor is supposed to practice and
with such over-burden of duties to maintain the law and order in
the society, it is no wonder that the police also take no action and
various doctors who are de-registered by the council or spurious
(unqualified) doctors are practicing in the country in abundance.
The results for the society are obviously disastrous.
Thus, it will be realized that the structure of the health-care
system in India is haphazard. There is no clear-cut pattern in the
health care system in the country. Different categories of doctors
practicing their own systems of medicines-allopathy,
homeopathy, ayurvedic, unani and what not-all practice in their
own way without the control of the government and without any
co-ordination among them. The government has formed bodies
to control the practice of the doctors in each of their special
systems separately, Thus, just as the Medical Council of India
was formed to regulate and control the behavior and standard of
allopathic doctors. similar bodies were formed for homeopathy,
ayurvedic, unani etc., But there is no central body to have an
overall control over the health-care professionals in the whole
country. Each of there bodies supposedly try to maintain the
standard in their own system of medicine. The role of respective
councils of other systems of medicine was to regulate the
professional conduct of the health-care doctors in their respective
systems. But what is true of Indian Medical Council, is
substantially true for every other council like Ayurvedic,
Homeopathic, Unani ect. The role of the council is thus limited to
prescribing the curriculum for the courses of their respective
systems and to prescribing rules and regulations for the college
management to see that good standard is maintained in the
medical education. Here again the maximum the council can do
is to de-recognize a particular college or university. Political and
money pressure. coupled with incompetence of the inspecting
teams of the council, sufficiently dilute even this power of de-
recognition and sub-standard colleges continue to produce sub-
standard doctors.
But health is a concurrent subject and the state
government has a bigger role to play in the health-care than the
central government. Therefore, the state governments have
formed their own Medical Councils like say Maharashtra Medical
Council for the state of Maharashtra. Strangely these state
councils are not subordinate to the Indian Medical Council but
are completely independent bodies formed and regulated by the
state governments. Therefore, even if the medical course or
medical college is not recognized by Indian Medical Council
because it is not maintaining the standard expected by it, the
state medical council has its own right to recognize such a
different course or such a college and the graduates coming out
from such institutions are eligible to practice in that particular
state. They can not practice outside their own state, if not
recognized by Indian Medical Council nor can they go abroad
because other countries recognise only Indian Medical Council.
In a way it is not an altogether undesirable situation for a vast
country like India with a population of more than hundred crores.
It is not justifiable to have only one standard of health care
system for the whole country as social and economic conditions
in various parts of the country or in different states can be
extremely dfferent. A particular standard which can be
maintained by very wealthy states may be an impossibility for
another state which is comparatively very poor. It may be noted
that western Europe with a population of about thirty five crores
is divided into several independent sovereign countries and each
country has its own standard of medical education and its own
rules. Similarly in U.S.A. with the population of about thirty five
crores there are 48 states and under their constitution each state
not only has its own medical council to define the system in its
own state but such a medical council is also entitled not to
recognize the qualifications of the medical professionals from
other states. Such ‘outsiders’ are made to appear for their own
test before they can practice in that particular state. Therefore, it
is absurd to think of one universal system for a country of
hundred crores of people whose social and economic conditions
differ as widely as between different countries in Europe or
different states in U.S.A.. I, therefore, said that the independence
of such medical councils of each state is not so undesirable.
However, it may be noted that there is no regulatory or co-
ordinating mechanism between Indian Medical Council and State
Medical Councils, which is the matter for worry.
Even besides the medical professionals working in these
recognized systems of medicines, there are any number of
faculties of medicines which are practiced by the so called
doctors of these unrecognized faculties. They are bone healers,
acupuncturists, electro Magnetic Medical system and what not.
Unfortunately the political leadership in various regions
encourages these systems and the present government virtually
takes no action against these 'doctors'. The people at large do
not clearly know whether they are recognized professionals or
Even within the allopathic system the role of each
professional ought to be properly defined and regulated. There
are M.B.B.S. doctors who are supposed to be ‘basic’ doctors.
They were the backbone of the society in the form of general
physicians or family physicians. They treated the patients
primarily irrespective of which part of the body was affected and
irrespective of the age/sex of the patients and refered the
patients to a particular specialist only when the disease appeared
to be more serious. Now there are not only specialists (M.D. &
M.S.) but there is a plethora of super specialists. (D.M. & M.Ch.)
Specialist is defined as a person who knows more and more
about less and less. The recent advances in medical technology
have undoubtedly contributed to the development of the super
specialists. For example, in an organ as small as an ‘eye’ where
an ophthalmologist is a specialist of eye disease, there are now
super specialists who look at ‘retina and posterior segment’ of the
eye, super specialists to look at the ‘cornea’ only and super
specialists who deal with the tumors of the eye only. While the
role of super specialist is becoming clearer and clearer, the
respective roles of a basic doctor and a specialist are becoming
hazier and hazier. Even the distinction between the various
systems of medicine is getting obliterated. Eighty percent of the
general practitioners now hold non-allopathic degrees like
Ayurvedic or Homeopathic or Unani. But all of them, without
hesitation, prescribe allopathic medicines and treat their patients
allopathically. Similarly many allopathic pharmaceutical
companies are manufacturing Ayurvedic drugs and their
representatives are freely canvassing these drugs to the
allopathic doctors. In short, their practice goes far beyond what
was officially taught in their respective courses. In a way,
therefore, 80 percent of the patients are being treated by 80
percent of non-qualified doctors. I emphasize that even qualified
doctors become ‘non-qualified’ when they transgress the limits of
the systems they were taught.

1 comment:

  1. I would like to read this post, but stalled at halfway.. maybe Dr should change to a wider template and better paragraphing of this post. I end up copy and paste the content to microsoft words, preparing to read it. thanks for the post.


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