It’s time to have specialist clinicians only do their job! Rather than treat basic ailments that fall in their domain, we need to ensure that super specialists are brought in only when needed.
Why is this critical? India already has a shortage of allopathic doctors, with only one doctor per 1,597 as opposed to the World Health Organisation recommendation of one doctor per 1,000 population. The ratio of specialists to generalists is even less favourable, if compared to developed countries. The total yearly input for MBBS is 60,600 whereas for MD/MS/diplomas it is 30,253 and for super-specialties such as DM cardiology or MCH cardiothoracic surgery, the yearly input is only 2,771. This lopsided equation between demand and supply continues despite the aggressive increase in PG seats in the last few years.
The acute shortage of specialists in India is compounded by the medical structure whereby people reach super-specialists for treatment of basic ailments which can be addressed even by a good family doctor. For example, the first consultation for infertility with an infertility expert or for diabetes with a diabetologist is common. This happened as hospitals and doctors in the private space wanted to capture those who could pay. But today, the paying capacity of Indians has changed and so has health insurance coverage in India. The trend needs to be corrected now, so that specialists only visit complicated cases where the initial legwork and deep dive has been done by the primary or secondary care doctors.
Patient to benefit
Imagine if you have cervical neck pain. This can often turn you into a ping-pong as your diagnosis happens. You may be advised to seek a neurologist, then to an orthopaedic or even a neuro surgeon, depending on who you ask! This will deplete the patient financially and from a time perspective.
However, if the patient could access a system in which the generalists or primary care doctor had the guidelines and confidence of the system to assess and manage the patient better, almost 90 percent of the patients would not need to visit a specialist. At the very first instance, the primary doctor would assess the patient clinically, and aided by relevant tests, advise whether there is nerve compression or spine issue needing referral or diagnose the case as manageable by painkillers, physiotherapy and lifestyle modification.Similarly, cases such as lifestyle diseases, gynecological or
sexual problems can be managed in majority of cases by primary care doctors with increasing confidence. This comes from technological aids available to doctors – be it using standard protocols, good patient data, digital labs and imaging.
Globally too, the trend visible in medical practice is of improving the efficiency and creating a robust organised primary care. This is supported by strong referral systems for specialists. What’s more, even specialists agree that nearly 80 percent of all patients can be managed by primary care physicians, if supported by sound practice guidelines and referral systems. The primary doctor can investigate and check for preliminary readiness, as well as give symptomatic relief for even patients who would eventually need complex procedures and treatments. This frees up the time of the specialist to handle more complicated cases.
Learning from global practices
Two broad models of health management of population have been prevalent. The UK's NHS, which has an extensive government-owned primary network, which refers patients to specialists as per need. In comparison, the US does not have an extensive primary network, except a few free general or specialty-based clinics. These tertiary centres end up giving substantial primary care. In both countries, the government’s share of health expenditure is more than half.
The clinical and public health outcomes are better in the UK healthcare system despite the fact that the US is the highest spender on health per capita and as percentage of GDP. A report in 2014 had placed the UK among countries with top healthcare systems – especially with respect to effective care, access, efficiency and equity.
In India, where public health facilities aren’t doing what they are meant to do, private healthcare players have had to step up and sign up for a model similar to the NHS model. The hurdle from patients’ side is lack of trust in primary care doctors because of past two decades of specialist heavy approach in India. Also, the failure of the government to do its bit and the private players seeing little value in it have created an imbalance in the system.
Now, it is up to the government and the private players to think of primary care or clinics as funnels for specialist services. This would mean that health care providers will have to make people aware of their health needs, which they themselves may ignore or not be aware of. Also the private players will need to help form standard practice protocol and train general physicians to adhere to these, and they will need manpower to staff these clinics without taking away specialists’ time, as is the current practice. Hence more space, time and championing of family doctors at clinics and periphery would make best use of the specialist’s time.
The task is herculean as there is a rural-urban mismatch in availability of doctors. The push towards virtual medicine – be it telemedicine or electronic medical records, seamless sharing of data among healthcare providers is an important solution. It would also mean private players, with the government’s help, utilise the available RMTs, where trained allopathic doctors are not. These RMTs can be trained in diagnostic work. Most importantly, a referral tree should be created, with an incentive for general practitioners or specialists to refer the patient to appropriate level of care.
Ashish Gupta is the chief executive officer of Docprime.com.