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

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High-Tech Modern Hospitals - Are they really usefull ?

At the time of independence, the country had very few medical colleges. Over the next 25 years, the number, was steady at around 105, and they turned out about 10,000 M.B.B.S. doctors every year. The main objective then was to provide a ‘basic doctor’ for the ‘basic’ medical needs of the population. So, most M.B.B.S. doctors opened their dispensaries and became ‘family physician’ advising the patients not only on their medical problems but equally often on their social and economic problems. But, with rapid expansion in medical knowledge, the tendency to specialize in one or the other branch of medicine increased so much, that nearly 80 to 90% of M.B.B.S. doctors
became ‘Specialists’ and their place, as family physician or basic doctor was mostly taken over by other faculties of indigenous medicine like Homeopathy, Ayurvedic, and Unani faculties.

But the last 25 years have seen further expansion not only in medical scientific knowledge but also, to a far more extent, in medical ‘Technology’. Newer and newer, electronic, ultra – sonic, and magnetic highly computerized equipments came into use in the medical fields, as modern diagnostic tools or therapeutic equipments, and this has resulted in a distinct change in the attitude and philosophy of modern medical professionals. The knowledge and especially the skills of the ‘specialists’ proved inadequate to properly utilize these ‘high-tech’ equipments and a new creed of ‘super-specialists’ was born. Cardiologist, nephrologists, Urologist, neo-natologist and what not! The number of the super-specialist branches and the super specialists is ever increasing, in both medical and surgical fields.

Naturally, it has resulted in establishment of more and more modern ‘High-tech super specialist’ hospitals or the general hospitals have opened new ‘super-specilaist’ sections in their general set-up. It is a common belief that this modern technology has 'revolutionized’ health-care, that it is contributing greatly to raise the average life-span of the population and in general offering a much healthier life to the society. How far is it true? The question appears silly on the face of it, but I would rather discuss it.

Specialists (and super-specialists – to a smaller extent) did exist in yester-years, but most of the M.B.B.S. doctors became general practitioners. Even those who specialized almost always had a few years of experience in general practice either beforeor immediately after obtaining the post-graduate qualifications. Most specialists preferred to combine general practice with specialist practice at least in the initial phase of their professional career, if they did not have G.P. experience before going for post-graduation. There were no further degree courses for super specialization and therefore, after practicing as specialist (say a physician) for 10 to 15 yrs, if he developed an inclination for a particular smaller branch, he gradually shifted towards it and became a ‘Super – specialist’ (say a cardiologist or neuro physician) at a mature age of about 40 or above. In general, therefore, these super – specialists had a much wider base of medical practice and a much deeper understanding of the social and economic circumstances of the general public they served.

But the situation has totally changed today. Medical education and especially the selection pattern for post–graduate courses in so peculiarly distorted that even the M.B.B.S. medical student refuses to learn the entire medicine fully before he obtains his degree. He plans carefully for his post–graduate ambition from the beginning. If he is interested is surgery he would prefer to concentrate on that subject only and study medicine, ophthalmology, obstetrics etc. only for passing marks. Immediately, a 3 years course for post-graduation and he is a qualified specialist. Even without any experience, immediately he competes for ‘super – specialist degree’ and if successful he is ‘super – specialist’ 2 years later at a tender age of 27 to 28. A lot of theoretical knowledge but no experience whatsoever in actual practising field and extremely narrow social and economic perspective of the very people whom he decides to serve in practice. He lacks, the broad vision of the super-specialists of yester–years, and developes a narrow and rigid attitude in his professional conduct. Barring his own (super) branch, his knowledge in other branches of medicine is almost as poor as that of a knowledgeable lay-man. In any case, he definitely refuses to accept any responsibility for any clinical problems for these ‘other’ fields – minor or major. No doubt, those who practise in small nursing homes and small institutions learn the hard-way through experience and come to terms with reality, but those who are attached to these High-tech institutions or ‘High – tech’ sections continue to live in their ivory towers. ‘(super) specialist is one who knows more and more about less and less’. But medical practice is not the treatment of one organ. It involves the treatment of the entire person, taking into consideration not only his clinical picture but also his social & economic circumstances. If an old lady developes an attack of paralysis, she will be treated by a neuro-physician. But what if she had high blood pressure or diabetes. Paralysis often affects, respiratory system or kindneys; who will treat these conditions? Who will do the dressings or operation, if she developes bed-sores due to prolonged stay in bed. Naturally for each of these ailments, separate super – specialists visit the patient separately. Sometimes the instructions are contradictory. Multiple doctors, multiple investigations, multiple medicines, and multiple procedures; naturally the expenses sky-rocket far beyond the capacity of the patient and the relatives.

Even otherwise, high-tech treatment has to be costly. All high-tech equipments are very costly ranging from a few lakhs to a few crores of rupees. One can not run such equipments with ordinary workers. Appointing skilled & trained technicians is a must. In our country of vast population, trained technicians are really scarce. Besides, they easily get lucrative jobs abroad after a few years of experience. Hence, they have to be paid high salaries, in an effort to retain them. Super specialist doctors, skilled technicians and costly equipments can not be managed except by ‘management experts’ who also must be well taken care of. Thus the whole set up is very costly; it can never be cheap. Politicians and social elites who continuously appeal from every conceivable platform that ‘modern medicine must be made affordable and should reach the poor masses’ are either fooling themselves or are hipocrats.

Expense apart, are these facilities not really useful? Have they not revolutionized medical treatment and made impossible into possible? The answer is yes and no. Today many conditions can be diagnosed at a very early stage which was not possible before. Formerly cancer cases were cured only when detected in first stage, today patient even in third and fourth stage sometimes need not lose hope. Age and existence of major associated illnesses, made it impossible to operate on many patients, with a curable surgical disease. Today, almost anyone can be operated upon despite any other associated disease (from infants to 100 year-olds). Very major operations were needed for kidney stones and pancreatic diseases. But endoscopic surgery now cures them in less than a week, fit enough to join duties. Ultra-sonography and endoscopy have no doubt revolutionized management of many diseases. In short, when the disease or the patient was in a more advanced stage of morbidity and occasionally for early cure of unmanageable diseases, super-specialsit treatment and high technology is very useful and is inevitable. But its impact on health management of he entire general population is very negligible – almost nil – because the total number of such patients really needing such treatment is very low in the whole population. Hence these super-specialties, have not contributed to the increased lifespan of the population nor have they contributed to reduction in the incidence, severity or complications of various major killer diseases. This has been proved statistically not only in our country but even in the developed countries of the world.

On the other hand, barring these few lucky patients perceptible harm can not be ruled out for many other unfortunate patients who happen to seek treatment in these high tech sections.

Multiple high–tech investigation show up lots of ‘lesions’ which were never seen before. Many of them are aberrations of ‘normal’ but are now diagnosed as ‘diseases’. Thus overtreatment is very frequently indulged in, resulting in major high-tech operations, like coronary angioplasty, bypass surgery or laparoscopic gall bladder surgery. Besides, complications arising out of these ‘modern interventional’ investigations or procedures are sometimes far more dangerous than the disease itself. Multiple super-specialists giving multiple advices at different times calls for a fine co-ordination among all of them, and that is not as easy as one may think. This often results in inordinate delays in instituting definitive treatments. But much worse, is the peculiar hostility the patients suffer in these ‘ivory tower’ institutions. With less social perspective and more pride-verging on arrogance – in their knowledge, the specialists are extremely intolerant to even suggestions for simpler alternatives, requested by patients and relatives. ‘This is my advice. Take it or leave it on your own responsibility’ is their attitude. So discussions are out of question. ‘The ivory-tower’ attitude soon percolates to all the staff in the hospital & they also become intolerant and arrogant. Soon the ‘Red-tape’ of public institutions tightens its hold even here and the patient or his relatives can not understand what is happening, why the delays, why the condition is not improving etc. Tension and panic, besides the high cost, take the toll of the family members in terms of their own health.

Yet the glamour persists and the conviction remains that the modern technology is very useful and life saving. So why should not the poor people get the same benefits? Thus superspecialty sections are established in all major public institutions. The up-gradation of J.J. hospital or the establishment of Renal Transplant Unit at Aurangabad at the cost of 2 crores, announced by the chief minister are but examples of this philosophy.

The government spends only about 2 to 2 1/2 % of its buget expenditure on health-less but not more. But, now, a major share of this meagre expenditure is getting diverted to ‘modern super-specialty' sections. The Bombay Muncipal Corporation, for example, spends more than 60% of its health budget on the three medical college hospitals, and even there, more than 50% is spent on super-specialty section. Thus, it is not unusual to find that in the hospital which takes pride in doing many open heart surgeries, the general patient has to buy gloves and catgut for his simple operation. Are we justified in diverting the money meant for common needs of common people to the specialized needs of a few?

Hygene, Nutrution and good drinking water along with preventive and primary health care are really what the common man needs. It is proved beyond doubt that the average life expectancy and general health of the society, as a whole, is improved by these measures, not only in our country but even in the developed countries. Hence, there is a real need to increase the expenditure on these, at least 5 fold. Diverting the funds, instead, from the present 2.1/2% expenditure is absolutely unjustifiable.

As individuals can expect real life-saving benefits but the society, as a whole, does not get any benefits, it is but right that these modern facilities become available in private sector where the individuals pay for their services. If they were to go to the general specialists first through their general practitioners, to ascertain whether their ailments could be treated in a simpler way and at a lesser cost with the same degree of success before going to the super-specialists, it would help them a lot in avoiding the harmful consequences of ‘modern therapy’ as well as the high costs. It would have also encouraged a healthy competition between the specialists and super-specialists with great benefits to the society. But, the recent applicability of consumer protection act to doctors has greatly hampered this competition. Also, the present medical education system which teaches such a lot with almost no experience is resulting in less and less competent G.P.s and general specialists. The society is paying its price for ignoring these vital factors.

It does not mean that there should be no super specialist sections in public hospitals for the poor and middle class. But, certainly, these should not be established or run by diverting the meagre funds allotted for general health services. These sections should be funded entirely through special insurance schemes, compulsory or optional, meant specifically for super specialities. Agreed that an individual can not spend a lakh of rupees for coronary bypass operation or for full cancer treatment. But, presuming that one in a thousand persons will need such treatment (actually it is much less) the cost per head would be only Rs. 100/- The centers thus raised are likely to be few but the returns can be even more costeffective, if no one was allowed a direct access to them. Everyone should be ma e to pass through dispensary to specialist and the super-specialisties would be involved only after the patient is refered to them by the specialists.

If, however, any patient wishes to have a direct consultation and treatment from super-specialists, he will have to bear all the charges as in the private sector including the doctor’s charges. This way, maximum benefit will reach the deserving poor, there will no misuse of the facilities by those who can really afford and public sector super-specialist doctors would also benefit. The decision to open up health insurance to private sector is the most welcome step in this direction

Marathi Article Published in Loksatta 2nd June 1997

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