Dr Girish Gadkari, Mumbai-based family physician, obesity and cardiac lifestyle care consultant, recently released a book called, ‘My Family Doctor’. In the book, Dr Gadkari chronicles his journey to becoming a family physician but also shines the spotlight on how the concept of a Family Doctor is diminishing in these times of super specialisation.
The GP, to put in succinctly, is in eminent danger of becoming an extinct species. From difficulty in finding a place to practice, especially in Mumbai where starting off with a clinic of one’s own is prohibitively expensive, to the new mindset which bypasses the family doc, there are a number of reasons behind this decline, Dr Gadkari explains in his book.
“The number of General Physicians is dwindling. Nowadays, everyone is specialising and becoming MDs,” says Gadkari, who has been practising as a family physician since 1972. He believes that it is mainly because both patients and medical students believe a specialist is a better option than a GP. “This mindset needs to be changed. That’s why I wrote the book.”
Dr Gadkari suggests some measures to redeem the situation, one of which is, “Builders of large housing societies earmark space for a gymnasium and swimming pool. It should be mandatory for them to also make available spaces for a small clinic and rent the space to two doctors, who can function on a shift system. Having a doctor on call will not only benefit the residents of the society, but also the doctors, who won’t have to invest heavily in buying a place to start their practice.”
Dr Avinash Supe, Dean, Lokmanya Tilak Municipal Medical College, agrees that the concept of family physician is going down. “Students can afford to go for specialisation and they go for it. There are 32,000 MBBS seats in India overall. Of those who pass the examinations every year, 7,000-8,000 relocate abroad, 20,000-22,000 opt for post graduation and the rest enter general practice,” he says.
Dr Ramnik Parekh, immediate past president of Federation of Family Physicians’ Associations of India (FFPAI), disagrees that the concept of family physicians is dying, but accepts that medical students don’t prefer to be family doctors. “There are two main reasons. Firstly, there is glamour associated with specialists, apart from a much higher income. Secondly, real estate in Mumbai, especially South Mumbai, has become so expensive, that it is impossible to buy a place to practice. There are enough seats in medical colleges for specialisation and students opt to specialise.”
The effect of high real estate prices on the GP can be seen only in big cities, and it is not the case in smaller cities, says Dr Gustad Daver, Director of Professional Services and Consultant Surgeon, Hinduja Hospital. “However, society has started thinking that for every problem, you need to go to a specialist. Hence the demand for specialists is increasing and the demand for General Practitioners goes down. Patients are also not generally ready to pay well to GPs. Therefore younger doctors prefer to go for specialisation as it increases the demand for them and they can settle down in practice faster.”
Dr Ulhaas Chakraborty, a resident doctor, agrees the demand from patients for family doctors has decreased. “I know people among my own acquaintances who go to cardiologists or endocrinologists. They are educated about their bodies and want cutting edge treatment.
They directly go to the specialist whom they would eventually have to go to anyway,” says Chakraborty. He adds that society’s relationship with law has also played a role in this scenario. “Society has become more litigant now. If a family doctor prescribes a medicine and God forbid, something goes wrong, then the question that will be asked is: did you consult a specialist? Doctors refer to other specialists so that everything seems legally right.”
Kamran Dalwai (19), a MBBS student, says it is a matter of poor returns for both doctors and patients. “After putting a lot of time, effort and pain studying for an MBBS degree, the returns are not good – both monetary returns and the sense of satisfaction. Specialising in one subject and understanding it in more detail gives us that sense of satisfaction. Similarly, patients won’t come to you if you’ve done only MBBS. They think an MD will have more knowledge. It works both ways.”
According to Dr Amita Nene, Consultant Chest Physician, Bombay Hospital, innovations in medical technology have also affected the scenario. “When you are an MBBS, you know a little about every part of the body. Nowadays, medical science advances so much so quickly that you have to update yourself constantly. It is impossible to be updated about research in all the fields. Hence, doctors prefer to specialise in one field,” she says.
Says Chakraborty, “You do an MBBS, then an MD in internal medicine, which is a broad specialisation, then you specialise in a sub field such as cardiology. You have chest pain and you go to a cardiologist, he can tell you whether you are suffering from cardiac pain or a non-cardiac pain such as gastroenteritis.
The things that were considered the province of the GP are now taken over by the specialist. All this is towards greater specialisation in patient care. It is good per se but it is more expensive for a patient and maybe more intensive.” Says Daver, “Multiple problems are treated by different specialists, but this in turn increases the cost of treatment. GPs can take care of patients based on the advice given by the specialist. This will actually make it easier, more comfortable and cost effective for the patient.”
Parekh believes that the current fast pace of life is adding to this trend of consulting specialists. He says, “Patients want to get well quicker. They wrongly believe that a specialist charges more so he will cure them faster.” Dr Rashmi Sharma, an ayurvedic doctor specialising in Anatomy, says it is not different in her field either. “Patients want instant results. They don’t believe in family doctors.”
However, Nene states that the the proliferation of specialists is not an alternative to having a family doctor. “Family physicians form the most crucial base of the healthcare pyramid while specialists are updated on the ever-changing facets of contemporary medicine.
Family physicians are expected to make reasonable primary diagnosis and triage patients accordingly, while the specialist prescribes and oversees cutting edge treatment. The two have different roles and cannot replace each other,” she says. Parekh too makes a case for the need for family doctors, “People have not understood that a family doctor is a different type of doctor. He is a friend and guide. The family doctor is more familiar with early symptoms of a disease, compared to a consultant who is more familiar with the later stages of diseases.”
The current trend of consulting specialists directly, says Daver, is detrimental for the entire system. “First, a patient should go to a GP who will treat them for minor ailments or properly guide them. For example, if a patient is suffering from diabetes, a GP can help them manage the problem. If it becomes very severe, only then they need to go to an endocrinologist. In the US and UK, you have GPs trained specially in family practice and basic management of diseases. They will refer the patient to a specialist, if necessary.” Agrees Supe, “It is good if the concept of family physician comes back. Simple problems can be solved by family physicians in a cost effective way.”
So what can be done to change the trend? Says Parekh, “The situation can’t be changed unless society starts paying family doctors better. Society argues that doctors don’t give proper service, but if society wants doctors to be more humane, society should create appropriate conditions. For instance, the government gives tax incentives to companies that invest in the development of backward areas.
Do doctors get any sort of tax breaks? No.” Suggests Daver, “Provision should be made to give MBBS doctors special training in family medicine after their internship, in the form of a diploma. They will then be more confident and be more acceptable in their locality. This in turn will reduce the burden on the specialists to enable them to take care of major medical problems.”
Excerpt: from chapter on referral Fees Or commission in Medical Profession
The issue of giving and accepting referral fees is open to debate as there seem to be divergent opinions. This practice is considered unethical by many. But some argue that if the referred doctor is not charging the patient extra but sharing a part of his standard fees with the referring doctor willingly as gratitude, there is nothing wrong with it.
Therefore, if certain compulsions make a doctor accept these fees, a view has been expressed that it may be used for “patient benefit” and not “doctor benefit”. The doctor can pass on that money to his patients who need help for life saving or costly treatment; like chemotherapy, kidney dialyses, cataract surgeries, knew or hip replacements or some cardiac surgeries.
One can also help the domestic help for the education of their children or even buying decent spectacles. These patients will bless the doctor. I believe that the blessings one receives from the poor and needy patients go a long way in one’s life. Not only the doctor, but his family also gets blessings from such patients and indirectly from the Almighty. If one can’t part with the full amount, one can keep 25% to 50% aside from the collection for the needy patients.
Some years back this story was narrated to me. A referring doctor had collected about Rs. 50,000 for a coronary bypass surgery from the cardiac surgeon, but handed the full amount to the patient, who happened to be his close relative. This should happen to other patients also who may not be relatives of a referring doctor!
Just a few days back, I visited one of my close friends from my college days. One of my friends, who is also a General Practitioner, accompanied me to his place somewhere in suburbs of Mumbai. This friend of ours had a fall in Dubai and had suffered internal bleeding from the brain (subarachnoid hemorrhage). He was hospitalized in Dubai for almost a month. When he was brought to Mumbai, his family called his Family Doctor home to check him and decide future course of action. I was told by his wife that the doctor concerned was their regular family doctor for about 20 years.
They had never visited or consulted any other doctor besides him. His advice was the final word for them. They had judiciously consulted specialist doctors as per his advice when referred by him in the past. However after examining my friend the doctor advised hospital admission to my friend, which was inevitable. The family also agreed to his suggestion. However there was conflict of interests.
The Family Doctor suggested, rather insisted on two hospitals in the area which were not suitable for a case like my friend’s. As the condition of my friend was quite precarious, the family suggested a better hospital which was quite renowned and well equipped. They could easily bear the expenses. This suggestion somehow annoyed the doctor.
After collecting his visit fees, he just walked out of the house without any discussions. Since that episode, he stopped interacting with my friend’s family. The only comment we got from our friend’s wife was ‘Our doctor would not have received the cut from the renowned hospital. He could have earned a lot as commission from other two hospitals.’ One can draw a conclusion from this that this rampant unethical way of ‘earnings’ are known even to a common man. The story does not end here. Our friend’s wife has been searching for a decent GP, but has not succeeded yet.
My Family Doctor, by Dr Girish Gadkari, published by Shroff Publishers and Distributors,
Price: Rs 200