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MANAGEMENT OF THE SICK HEALTHCARE SYSTEM
( By Dr.S.V.Nadkarni, M.S. )

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BILL FOR THE PATIENT IN MEDICAL COLLEGE HOSPITAL - For Teaching Economics of Healing

Medicine is an art based on a scientific footing. This basis is mainly the chemical and physical processes involved in the physiopathology of the body. The materialistic and western influenced attitudes plus the advances in modern technology, have made a medical teacher and a student feel that these are the only important sciences to be taught and learnt to become a successful doctor. He is thus being taught more and more details of the physico-chemical processes, or what may be termed as ‘organic’ changes, more and more of the detailed investigative approaches involving the great technological advances and is taught to plan his treatment on the ‘Sound Basis’ of these scientific facts. In terms of the best results, I have myself no doubt that some of these, if not all, have vitally contributed to the quality of medical treatment. And yet, this is the most important reason, in my opinion, for the education becoming unoriented to the practical needs of the medical graduates in our country.

For medicine, in its fuller concept, is an art based on the above-mentioned scientific footing. In actual practice, many other factors come into play in determining the care of the patient–the social factor, psychological factors, environmental factors, the religious biases, etc. But the most important and vital barrier to the effective practice of the knowledge learnt in the present way is the knowledge of Economics of Healing. In practice what to do and what should be ignored, which investigations are necessary and which can be avoided, and with what material difference,which equipments to buy and which would become burdensome, the choice between the best drug and the cheap drug, everything is determined by the socio-economic factors rather than anything else. But the graduate full of knowledge of physico-chemical processes often lacks the knowledge of the economic influences on the medical practice and fails to satisfy his patients and thus gets rapidly frustrated. He tends to blame the masses for their ignorance, being little aware of his own ignorance. What he has not learnt in the college covers much wider field than what he has.

The present set up of full-time ‘non-practising’ teachers and free treatment to all patients in the teaching hospitals makes this deficiency in teaching even more glaring. The entire cost of hospital, equipment and the treatment is borne by the government or some autonomous bodies, while neither the teacher, the student nor the patient becomes aware of the actual costs incurred in the whole process. This results in growing dissatisfaction among allwith ever increasing demands for equipments and facilities, which more often than not, contribute so little to the qualitative or quantitative improvement in the results. In short, neither the teacher, nor the taught and least of all the patient, ever even think about the cost involved in the so called modern methods and the relativebenefit derived out of this added expenditure. In actual practice as soon as the medical graduate goes out of the college, he is confronted, at every minute,with the cost involved and its relative or comparative benefit to his patient. This makes him unable to take decisions, especially the ‘cheaper decisions’.

Ultimately, some may learn, by themselves, the relative economic and medical values, but many swing to the opposite side and think that science taught in the medical college is meant to be forgotten and everything in practice is Art. This way the word Art becomes synonymous with pure commercialisation, cheating and fraud. Some of the graduates who are too good in their science and fail to learn the real art by themselvesi.e. the moulding of medical practice to these socio-economic factors, return back to the full time job and, in turn, not only continue to teach the pure science but fully ridicule any practical dilutions in practice.

Thus, the whole cycle of wrong emphasis leads to wrong choice of teachers, further emphasis on modernity and the society pays more and more, to receive less and less benefit in the poorer countries. The doctors trained by our college become progressively ineffective in treating our people, because the local people cannot afford such treatment. Strangely, the richer countries, already advanced, in such technologies and the relatively affluent people there can afford them. This mutual satisfaction between those masses and our doctors seems to be one of the most important factors, why ‘scientific doctors’ are draining to the west. Are we not training them for their needs, and not ours?

Secondly, the present pattern of ‘modern or technological’ approach is leading to ‘Office-type Doctors’ with a progressive deterioration of clinical judgement, which is being substituted by investigative procedures. I emphasize that investigative approach is used to substitute and not to aidclinical judgement. Again the result being same quality to the patient at a higher cost and the cause being non-economy-oriented medical education. My personal experience, after having worked innewer and smaller colleges and slowly shifting to the city of Mumbai, shows me clearly that by conscious efforts, clinical judgements can be improved and managements economized to half or even one-fourth.

The present mode of selection of senior teachers by the Public Service Commissions again shows the same lack of importance to ‘clinicians’ as teachers, and indifference to medical economics. Research and publications are the mainstay, but there is not a single ‘column or a confidential reference regarding the candidate’s ability to treat and teach.Result - unnecessary and elaborate modern investigations on the poor, advanced cases, long hospital stays, often at the cost of essential early treatment all for the sake of research and publications - for the sake of promotions - expensive nonproductive medicale education.

Clinicians who could teach, what I am advocating, are available in plenty, but they seek direct rewards in practice and would not turn to full-time teaching jobs, which become unrewarding both monetarily as well as job satisfaction-wise, as such a person is usually condemned as a ‘non-scientific teacher’ a dilutor, non-research-minded, non-progressive etc. And yet, some objective method ought to be found to find out, retain, encourage and promote such ‘clinical’ teachers, who treat well and yet economically. Such teachers automatically will teach students the art of clinical judgement. Today, there seems to be no way, for the Deans, Administrators, or Service Commissions to sort out such types of teachers. Can we find a way out?

The answer is not simple but a simple beginning can be made in this direction, which can expand later to cover the problems that I have posed. And the simplest way to start would be ‘to bill the patient’. Every patient, who is admitted to a medical college hospital, should receive a bill of expenses, at the time of discharge, irrespective of whether he pays it or not. This bill must be given to him by the resident doctor, so that all concerned would have seen it. The concept of the bill for the present is for medical education and hence the charges evolved can be only crudely accurate and need not be commercially accurate. They will give a comparative picture of the money spent over each patient over each disease, and would help to statistically evolve the comparative benefit derived to the patients or the masses through additional expenses for modernities.For a 600 bedded hospital with 15,000 admissions a year, this involves, making about 50 bills a day and the total extra establishment would not be much. Such a scheme will automatically make all money-conscious.The impact of additional space, personnel or equipment will be immediately reflected in the bill and the teacher and the taught would necessarily ponder over it–whether this was essential or not. Somemay now substitute clinical judgementsto investigations bringing the costs down. It would now be possible to sort out a better clinician as one who gives better results with lesser costs,and attempts could be made to retain and promote him or encourage him by offering larger responsibilities and/or monetary incentives. It would be necessary for making the scheme more educative, to arrange regular forums for discussions, seminars, monthly meetings, etc. where clinical results would be evaluated with the bills of expenditure.

Cost effective management

The positive concept of health is essentially due to the economic influences in the modern society. The need to keep productive, money earning population not only not-ill but fit, fit for skills and possibly fitterthan before, through the medical progress is a pure product of understanding of economic influences in modern society. Unfortunately, it is becoming necessary in our country to teach the medical profession, especially in medical colleges to distinguish between essential treatments and treatment for positive concept of health. For it will be correct and scientifically appropriate to charge fully for the latter and increase the direct income to the medical colleges, independent of the state or public money. Such accrual of direct wealth could make for a self-expanding medical education system and only such self-expanding medical education system and only such self-expanding colleges are likely to retain permanently their utilitarian character. Again the beginning is in introduction of medical economics and the first step is billing the patient and critical evaluation in periodical discussions, seminars, etc.

The answer is not that simple of course and involves many more basic changes in the system. While a lot of discussion centres round the content of medical education, extremely little time is spent over the need to select proper teachers, and still less to medical and hospital organisation in the utilitarian way. It is easily forgotten that the student learns from what he sees and not what he hears.Today, he is learning to do less and argue more (discuss is the euphemistic word), because that is what some of the teachers do. He cannot decide, without multitudes of reports, because that is what he sees. He fails as a house-surgeon, to talk and explain to his patients about the nature of illness and details of treatment and show sincere sympathies, but merely replaces them by ‘efficient Organic and technological’ approach, because that is what he sees in the hospital.

This would be only a beginning to give a social bias and practicality to our education system. Other aspects like social, religious, psychological, environmental, (rural and urban) factors, also might have to be brought home to the new students’ notice. Such an expansion of teaching of Art, will necessarily restrict the horizons in the knowledge of science and modern technology. A hue and cry would develop that our students would be unable to compete with others in the Western World, and would be found to be unfit there. It is for the educators here to decide, would it be better for the country or worse? It is for us to decide whether we train our students for foreign fitness or for internal fitness. This is what I call, ‘Indianization’ of Medicine.

Another common argument put forth is that these things need not be taught, and students would learn them automatically, when they go out in society, I have myself conceded this fact in the case of many. But it is at the expense of many more years, but more discomforting is the fact that a progressively larger number of students fail to learn this or accept and adapt to it without a sense of guilt or shame. Secondly, it is leading to wrong choice of clinical teachers. Let us also remember that commerce, business management, teaching, and politics are also being taught today and with advantage. Were not the former generations practising them and learning by themselves? Lack of natural inheritance in the new students in all fields today makes it imperative to include such aspects in the formal education.

I urge that these things should not be brushed aside, as politics, trade unionisms, or purely non-educative subjects; for they, more than the paper-definition of the contents of education, will determine the progress of medical education in India and its usefulness to the Indians. (The Indian Journal of Medical Education Vol. XIV No. 2)

(July-Dec. 1975)

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