I am a practicing family doctor of over thirty years of experience.I am fond of writing on matters related to medicine and people. I know, the modern day medicine suffers from lot of deficiencies and often I think about these and want to share my thoughts with u out there.
That is why I have called my blog, 'my thoughts'
B.C.Rao
16 comments:
Here I am again. Yesterday I visited A high tech super speciality hospital on the outskirts of this city. I came back with mixed feelings. We do need these hospitals but how many can afford the cost?.The booming tertiary care has left the ailing primary care so far behind that it may never catch up
Primary care is supposed to be the backbone of the medical services in any country.Ask any medical student what he wants to become after qualifying? Not even one percent will opt for primary care.
At present it is the medical drop outs who opt for this because they have no where else to go.
Pathetic state of affairs is not it?
Though I have a fraction of your experience...and despite the fact that I am NOT a medical professional....here's my two bits on this issue.
I believe that our civic society (and that includes us citizens as well as our government/s whom we love to hate)should focus on the following in this order...as far as healthcare goes :
1) HYGIENE EDUCATION
2) COMMUNITY HEALTH
3) ADDING MICRO-NUTRIENTS TO BASIC FOOD
4) HEALTHY LIFESTYLE EDUCATION
5) PREVENTIVE MEDICINE
6) PRIMARY HEALTHCARE AT PANCHAYAT LEVEL
7) SECONDARY HEALTHCARE AT TALUK LEVEL
8) TERTIARY HEALTHCARE AT DISTRICT LEVELS (I remember my father telling me about how effective District Hospitals were in his young days...the "Civil Surgeon" was an extremely important district functionary)
9) SPECIALITY & SUPER-SPECIALITY HEALTHCARE AT STATE HEADQUARTERS
We must, as a society, understand that specialty healthcare is not just expensive in terms of the money spent on it...but a skewed focus on it is also far more expensive in terms of degradation of the overall "wellness" of the population who are deprived of the building blocks of good health due to such skewed priorities.
However, we must also accept responsibility for our own life priorities...which values commercial glamour,growth and prosperity, attractive packaging and hype far more than stolid,boring,basic,down-to-earth
functionality - be it in healthcare or in our daily lives.
And that's why the "GP" is an endangered species today....he/she is too primitive and unglamourous to be treated by...a situation a bit like preferring to buy your daily bread and eggs at the supermarket or neighbourhood mall rather than the corner kirana store.
I am not a Medical Doctor. I have been associated with the Pharmaceutical Industry in India and have first hand experience of availability of Medical Care to citizens in various Far East countries of Asia and the Scandinavian countries of Europe for over 45 years.
I am an acknowledged Strategic Thinker and take up assignments when I find interesting opportunities.
1. Socialist Pattern of providing Primary Medical care does not work efficiently ~ reasons are many ~ (a)Lack of 'committed' qualified Doctors
(b) The aspirations of people, however poor they may be, for glamorous Medical Care Centers.
"Possible" Solutions:
(a)Established Charitable Trusts to set up facilities at grass root level, instead of joining the rat race in the cities.
(b) Social Service Organisations, like Rotary, Lions etc to take up such projects in rural areas, instead of holding "Medical Camps"
I haven't come across any project to even get Blood Groups identified in rural areas by any organisation.
2. Hygiene Education: Has no value when proper toilet facilities are not available in many schools, be it in the cities or villages. Answer is: Yes, Hygiene Education but with 'facilities' on the spot.
I am glad that you have set out to put down your rich experience as a medical practitioner and also ,I am sure,as a citizen of this time and place.I would be happy to visit your site.M.S.Thimmappa.
Good feeling to get some response. This brings me to the issue of what ails primary care. On paper we have an excellent set up of primary,secondary and tertiary care in place under public [governament] funding and supervision [what Anirvan is writing about].These are the most disliked places to visit by the ailing.The abject poor have no other option but to go to these places.
The quality of care offered in these places is dismal and they naturally attract the worst.
most, who can pay even little will go to private primary care and not to govet run PHCs, because they get some returns though far from satisfactory.
A medical graduate is exposed to institution based doctors who are specialists and his inputs in the formative years of medical school life is from these.
He is not aware of the type of life and the richness of quality that one can get by being a GP.
He only sees and hears the non glamourous part of being a gp [there are many, like long hours of unorganised work, no hospital attachment, no peer guidance, competition from quacks, lack of status etc]
Many donot know that one needs special qualifications to become a good GP.There is a PG qualification board [DNB]for family medicine/General pracice which prepares the young doctor to become a good GP.
There are a few who are doing this.
yours truely did it 20 years ago and some of you hopefully have seen the results!
To conclude though there is alot to dissuade there is lot that is attractive and one can make a good quality living by being a GP even under these trying conditions.
Have you observed lately that there is a lot more of koels singing in the early mornings around 5am?
This is because koels who resemble Crows lay their eggs in the nest of crows and the crows who are otherwise very intelligent donot distinguish these from their own and incubate these too!
Crows have abundant food available thanks to our habit of throwing garbage all over and offering food to them as they are supposed to represent our forefathers!
Crow population of Bangalore has increased and naturally the population of Koel too!
Venky here. fantastic!! If anybody needs to have a blog spot, it is you. I am looking forward to reading more of "your" thoughts.
Neither primary not tertiary healthcare is truly good in our country. Isolated pockets are simply shouting from the rooftops about themselves in the latter group. They really are not catering to the health needs of our country. They are simply filling up a vacancy that exists in that area, and in an even greater hurry, want to cater to medical tourism, and not our people!! So why bother. No country can do well in the absence of good primary healthcare, privately provided, or the government. We too will metamorphose into that over time out of necessity.
Venky, good to get you to write. Before I go furthur into the morass of present day medicine, a bit more about Koels [Kogile in kannada]
In the avian world it is the male that is better looking and male Koel is a sleek bird with shiny black plummage with agreenish white beak and a crimson red eye.The call of the male koel is music to Indian ears [wetern ears consider it as harsh!]and the kuooo kuoo sound made repeatedly in the early hours is perfect wake up call. How ever the female's is a different story.She is a rather ugly bird spotted with brown and white plummage, very shy and makes kind of kik kik sound as though offended by the male's call!
First time I sighted her I wondered how ugly! Now I am a bit more tolerant and may be for the male koel she is beutiful and human eyes neednot be the yardsticks to judge avain beauty!
Leela, pl put up about your Humming bird story on the page.
Practice Experience
More often than not these days [waning practice due to my getting old and inefficient?], I get some time between patients. How then will I occupy myself in this period of forced leisure? In the early years of practice when faced with similar situation [ young and inexperience was the cause] I read and could read non-stop for hours. Now I find it hard to concentrate and cannot read for more than ten to fifteen minutes at a time. So if you are under the impression that I occupy myself preparing for the next issue of the FPA journal you are sadly mistaken. In fact I have come to detest reading medical literature unless it is forced on me such as in times when I am foxed with a problem or when I have to meet a deadline [like publishing the FPA Journal on time] or when I have to send an article for review and beat a deadline.
This however doesn’t apply to general reading which I still enjoy. I often re read the olden goldies as I call them. Books by P.G.Wodehouse, Henry Cecil and John Mortimer are all time favourites. So are the mystery books by Agatha Christie and P.D.James.
Lately I have found another and more absorbing pastime. This is putting a golf ball into a cup strategically placed sideways at a convenient distance. Let me explain to the golf ignoramus, putter is a specially designed golf club [stick] to push or roll the round golf ball towards the hole on a specially designated area called the green. The floor area unoccupied by the clutter of furniture in my consulting room serves as the green and the tea cup as the hole.
When immersed in this activity, I sometimes fail to notice the arrival of the patient in the waiting room. I take the precaution of closing the intervening door. The poor man or woman thinks that I am engaged in the serious business of examining a patient. The tapping sound made by the golf ball hitting the cup or missing it and hitting the wall heard by him outside only confirms his belief. After waiting for what he thinks a reasonable time and to remind me that he is waiting he gives a discrete cough or a meek tap on the door. This usually succeeds in waking me up and I hurriedly place the equipment in a corner and call the patient inside.
You will be surprised that hardly any one asks me what has happened to the patient who was inside. They are so relieved that I am available and their anxiety to unload their problem is so urgent that most don’t ask me. But when some do I show them the putter and demonstrate my pastime. It doesn’t surprise me that most who do are children and one youngster wouldn’t let his mother tell me about his illness unless I first allowed him to play with the putter and the ball. He after the consultation was over picked up the golf ball and before his mother could stop him ran to the car expecting me to give him a chase! I had to with great difficulty restrain the mother from retrieving the ball. I wanted the boy to keep the trophy as it would be another addition to my collection of stories which ended happily.
Each for his own pastime!
More about medicine later!
I have occasionally heard similar things in the U.S. (about the increase in specialists doctors). But the numbers don’t quite tell the same story (at least as measured between 1980 and 2004). I looked up data in the Statistical Abstract of the U.S. (which obtained its data from the American Medical Association) and essentially I found the portion of specialists among doctors increased from 45% to 47%. Specialists is defined as all fields excluding GP, Family medicine, Pediatrics, ob-gyn, and internal medicine.
The general care model in France is pretty interesting. There the pharmacist is the first point of contact for mild aliments (for instance, a cold, a rash, soreness, even birth control). Pharmacists have more legal authority to prescribe than in other countries. However, when they are not sure they are quick to refer people to their primary care doctor.
I live in the U.S. and we have an on-going debate about how to contain our healthcare costs (16% of GDP at this point, up from 14% in 1993 and very high compared to other industrialized nations). I think the basic problem is many demand the expensive procedures and specialists (where cost is high but additional benefit is minimal) and bear little of the costs because of insurance coverage. For example, my dentist applied a densentizer to my teeth after my dental cleaning (to dampen the sensitivity of the teeth which become more sensitive after a cleaning!). The insurance covered the $25.00 cost, but really I do not need that (never had sensitivity problems before)….so next time I asked that they not use it. The quickest way to stop such spending, is to provide insurance for basic things, but force consumers to share the cost for the high cost-low benefit procedures. Of course, defining low benefit is a very, very subjective thing, which we can debate some other time.
My hummingbird story As requested…
Last summer we put out a hummingbird feeder and to our pleasant surprise within a week a ruby-throated hummingbird began visiting us regularly from July to late September. These little ones are famous for the long-non-stop journey across the gulf of Mexico each fall to their winter homeland in Mexico. This summer for some reason we did not have a regular hummingbird visiting our feeder until this week. We are guessing that they are fueling up for the journey in a few weeks.
(Speculating on reasons why they were not regular visiting the feeder this summer—unusually dry summer, the sugar concentration in the feeder was lower for most of the summer. I only increased it after reading that I had not been over sugaring it (as I had first thought).)
Humming birds consume enormous energy to stay stationary. The wings have to flap nonstop. Amazing such small birds travel such long distances.
You are right, they need to have concentrated sugar solution.Are you sure your neighbour is not provoding a better quality and they go there and not visiting your feeder?
Anu too has kept a feeder and gets them to visit her back yard!
Dr Venky’s comments are well taken. I am aware that all is not well with them [tertiary care hospitals]. All of them are vying for a share of the creamy layer pie. This constitutes about 5% of the nation’s population. Bangalore has a higher percentage and thus more competition. I wouldn’t have been this disgruntled had this been healthy. It is far from it and occasionally borders on the ridiculous and cheating the gullible.
To give few examples.
The farce of annual medical examinations: Most multinationals have built it into the employee benefits. This examination includes a host of tests most of them unnecessary. A normal lipid profile will remain normal for years and so is the chest x-ray and ECG. Why do them each year? Why expose the young man to harmful radiation every year by doing a chest x ray? Who benefits? Obviously the hospital which does the test and this is the reason they have sales and marketing departments to canvass this kind of farce.
Then there is this CT and MRI testing. All head aches [am I exaggerating?] end up getting one or both of these in a hospital setting. To detect one possible cause we in this poor country end of doing 1000 MRIs! Which turn out to be normal
One more example is TMT [treadmill excercise testing]. This is another goldmine. If one were to be unfortunate enough to end up in one of these institutions with any king of chest pain, mark my word, unless there is strong suspicion of an impending heart attack, a TMT is done.
Now comes the interesting part. This test can be interpreted as positive when there are definite criteria but even then there is a high percentage of false positives. But there are a large number which are negative but can be interpreted as positive. The patient is then advised admission and will end up getting an angiogram [an invasive procedure with some risk]done and the cardiologist if considerate will then leave him [patient] alone. If not the patient will end up getting a stent put or worse a CABG done. There is so much money involved that ethics has taken a back seat. There have been many occasions in my practice when I have to actively intervene and prevent this from happening.
Thankfully I have my friend who is an excellent and ethical interventional cardiologist and I take his help when faced with this decision and in most cases my suspicion that the patient’s TMT is normal has proved right.
Does this mean screening for disease is not required at all? Far from this one has to do it on a selective basis and when to and how to I will write some time later. In the meantime most important advice the companies can give and force their employees to do is to eat and drink in moderation, exercise daily and not use tobacco at all. I forget we are a democratic country, how can any one force any one elase to do any thing that is good and constructive?
We are thus helpless against high pressure salesmanship and money power. The only way is to educate people and that is one of the aims of this blog. Doc Venky, do you agree?
The feel of the supreme
I have learned
to look on nature, not in the hour of thoughtless
youth; but hearing often the still, sad music of humanity,
not harsh or grating, though of ample power
to chasten and subdue. And I have felt a presence that disturbs me
with the joy of elevated thoughts: a sense of sublime,
of something far more deeply interfused,
whose dwelling is in the light of stars and the setting sun,
the round ocean and the living air, the blue sky
and the mind of man.
Adopted from Wordsworth.
Recommended reading
Those who want to read a good book should buy or borrow Vikram Seth’s ‘Two Lives’. Seth is the author of another famous novel, an international best seller, ‘a suitable boy’. This book [two lives] deals with the eventful lives of an Indian man and Jewish woman set in the pre and post second world war England and Europe. Well researched and fascinating.
B.C.Rao
You are precisely right in your diagnosis about unnecessary procedures. If a doctor runs a few more expensive diagnostic tests, it means a few more dollars for them. And patients so easily agree because a third-party insurer is paying. We have become consumers of health care as much as we are patients (or perhaps more). That is why I think here in the U.S., things have to change to make the insured more sensitive to the price of such non-essential things.
Today's " thoughts" is indeed very refreshing!The other side of modern practice who else but you can tell us with such authority and which I am sure benefits many visitors to your blog.I remembered Dr. B.M.Hegde,whose writings also I love although people might think that Hegde has gone to the other extreme.M.S.Thimmappa
Very rich experience of 3 decades of sincere practice is really motivating & introspcting to a doctor like me.
I agree with you that we know less in medicine than what we know!
Pl continue with thought-inspiring messages & anecdotes.
Regards,
Dr.Ganesh Dhakappa.
Your 3 decades of medical n social experience is very thought-inspiring n motivating to a doctor like me. Pl keep up the same
Regards,
G.D.
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