It is commendable that organizations like the Administrative Staff College of India is trying to devise training programs to improve the failing communication between doctors and patients. But the result is doubtful, as the onus is equally on the lay public who do not seem to have an inclusion in the target audience. Doctors need it no doubt, but they are unfortunately much alone in the blaming game when things go wrong. It needs two to communicate; and the question is, who represents the other? The media, politicians, police, judiciary rarely speak publicly in support of doctors when things go wrong. Of course, privately, in view of their personal needs, they are extremely supportive! The onus almost always is on the doctor to ‘prove’ his innocence.
The fact is that a doctor-patient relationship of purity, trust, and loyalty has now a thick wall. The bricks of this wall comprises of sharp lawyers; insurance; faulty government social programs; expensive treatments; irresponsible media; tax burdens on hospitals; difficult laws; costly medical education; doubtful pharmaceutical business practices; ambition and greed; long settling time for doctors; patients expectations of the highest possible service in the shortest possible time at the minimum possible cost; hugely understaffed and overworked government hospitals; weak Primary Health Care Systems leading to a dependence of quacks (who our politicians embrace for the sake of votes); ambiguity regarding the parallel system of doctors like Ayurveda; a media looking for TRP ratings; and so on and so forth. The list is endless. The health systems are in a state of a most complicated mess and simplistic programs conducted in the confines of idealized environment of beautiful buildings cannot untangle the mess. It would require a large-scale war like effort from the governments, doctors, judiciary, police, and the media, of course, to bring our health systems to some level of sanity.
The private sector suffers from ever increasing investments, the struggle to remain afloat, and get ‘returns on investment.’ The pressure from the government laws, taxes, media, lawyers, insurance companies, shareholders apart from the patients demands has led to an alarming increase in practices which are nonacademic, irrational, illogical, and sometimes plain unethical. There is a huge work going in the overloaded, understaffed government hospitals. However, the public health systems in their way of socialization have become inefficient and corrupt. Ironically, the hospital employees and doctors mostly have a higher salary on average than their private counterparts despite the poorer services.
The rural India is highly detached from adequate healthcare. With a weak primary health care system and a poor transport facility, health delivery in the villages has gone into the hands of uneducated quacks. The villagers who have no access to health care depend on them and nothing can stave off the dependency. Ironically, majority of Indian doctors are catering to a minority 20% urban population! It was unfortunate that the Bhore Commission in 1952 rejected the LMP (Licentiate Medical Practitioner) system in its entirety. The LMP system allowed trained ‘middle level practitioners’ to give good service in rural populations. The argument which won the day was for a professionally trained ‘basic doctor’ as the best person who can impact the health scenario of the country. The philosophy failed. It made solid recommendations which have remained Utopian as we are still struggling with the health parameters.
Ill-conceived insurance schemes increase the havoc to the health system. Insurance entering medicine if not thoughtfully applied destroys the system. Under the assault of insurance and the lawyers in the USA, medical care has become expensive, defensive, and extremely bizarre. The acute need for doctors in the country in terms of the doctor-population ratio has seen a meteoric rise of private medical colleges with huge fees. The colleges for most part run poorly bereft of proper infrastructure, academics, staff, or patient volume. A consequence of the high fee structure of medical schools is that medical practice becomes a model of business seeking ‘returns on investment’ starting with dowry, rather than service.
Safe deliveries, primary health care, encouraging doctors to go to rural areas, immediate newborn care, regular attendance of public doctors, good transport, conversion to residency system in the teaching hospitals, better private-public partnerships would go a long way if combined with public health measures like closed drainage systems, clean water, and immunization programs. The successful Polio programme is a huge example of the fact that our country can do it if it wills.
The public sector and government bureaucratic agents look at private practitioners with suspicion, dislike, and apathy. In our country, more than 75% of doctors are engaged in private practice and it would do well if the private-public partnerships are manged more effectively and with more trust. A better organization is the need of the day without cracking whips, strangling doctors, or educating doctors in the essentials of effective communication. Medical systems reflect the society in which they embed. Every power and knowledge system wants to exploit today, and medicine is no way different as a sign of our times. But, being an important and a noble profession, there should be some urgent reforms in the way the health systems of the country.
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