Thursday, November 15, 2007

Past and present

As I age and spend the last years in my general practice, my worries about the future of new entrants to this branch of medicine and the quality of their practice seem to increase. One such worry is the loss of pediatric group of patients [children] to pediatricians. While I have nothing against pediatrics as a specialty, I am against paedricians seeing routine problems of children, especially their taking over the doing of basic immunization. This must be the preserve of GPs and pediatricians should see patients only when GPs refer. Lot of quality time of pediatricians is now wasted in managing routine problems in children when that should have been spent in handling difficult problems which can not be handled by GPs and which may need hospitalization. Of course one could justifiably argue the same with all specialties but I am particularly vexed with pediatricians because it is such a pleasure looking after children and we are being deprived of what is rightfully our domain.

Most of you must be reading and hearing about practice of evidence based medicine. This simply means doing something when you know that it is going to do good to the patient based on evidence. If one were to strictly follow this then often there would be conflicts with ones experience. Experience is individuals and evidence is collective. Let me give an example. It is well known that most of upper respiratory infections in child hood are viral in nature and don’t need antibiotics. That is evidence but the doctor’s experience over the years is that he gets results by giving all these children antibiotics. What must he do? Old habits die-hard and bad habits however old they are must be allowed to die so that our patients are spared from our unnecessary ministrations. More than any other branch of medicine family medical practice needs evidence based medicine to be practiced. There is a small aside to this. Today’s evidence may be to morrow’s blasphemy, remember the choice but mutilating treatment of gastrojejunostomy with gastrectomy [a major surgical procedure] for ulcer disease not so long ago, before the medical treatment for the germ Helicobacter came in and this common surgical procedure almost vanished?

I don’t exactly remember what was it that made them stop using my services, but I know it was something not very pleasant. Therefore to see her after 25 years, back again in my consulting room was a bit of surprise. 25 years ago she was a good-looking young woman and now she was one of those run of the mill middle aged. She was having episodes of breathlessness, attacks of syncope with spontaneous resolution and had come to me to find out what was wrong. She had already made the usual hospital and specialist rounds and had a file full of records with her. After listening to her and examining I could make a diagnosis of supraventricular tachycardia because she was having one at the time I was examining her and I could record it with an ECG. We discussed the various modalities of treatment including that of electrical ablation of the offending pathway. She went satisfied that at last a proper diagnosis was made and hopes of a permanent cure. Both of us had the prudence [age related wisdom?] not to dig up the past.


G.D. said...

My experience is not any different though. I may agree a paediatrician treating a child, but definitely not a surgeon treating Typhoid, Hypertension (with atenolol in an asthamatic with disastrous results!)etc.To some extent most of our "consultants" are glorified GPs in a way.

Anonymous said...

Dear pops,
I agree with you and most of the medical proffesionals reading your blog,would have the same opinion,but in the present age it is more about earning rather than following evidence based practice.If you analyse a good Gp gets more number of patients seen by the specialists nowadays and it is not so the other way round.

Anonymous said...

I read a fit analogy about unfair competition in a wonderful book titled 'Happiness'. Here it is-suppose all of us are watching football in a stadium. One person in the front suddenly stands up; others cant see. They wait for a while and then slowly begin to stand up. Now the situation gets so bad that everybody HAS to stand up to see ANYTHING. Everybody is standing, uncomfortable and doesnt enjoy the game so much.This is probably whats happening to medical practice now.
So In Mumabi Pediatricians started charging almost as much as Family Physicians and encroaching on their practice. If that was not enough, they handed out prescriptions to the accompanying parent for a small extra charge-under the pretext of limiting family germ load. Next they now hold seminars on behavioral problems in children. They have usurped the official machinery to test Learning Disabilities in Maharashtra State. Although they are neither trained nor know anything about psychiatric disorders, a good numbers treat them and actively discourage patients from seeking appropriate help. Some of them do a course in counseling and then settle in as Psychiatrists only. This is my experience as I am a Psychiatrist.
The only thing I say is-well if you are so keen in dealing with behavioral problems of children petition the MCI or your association and do at least a proper modification of the MD training program to include these patients. In residency these same persons shun mentally ill patients and Psychiatrists as though they were THE PLAGUE. Dito with neurologists. During residency, they are forever dumping even clearly neurologic cases to psychiatrists under one pretext of the other. But in private practice mental illness suddenly becomes a disease of the brain-therefore requiring expert neurological treatment!
This is nothing but unfair competition. Sad, that these specialists are abdicating their true responsibilities and engaging in hopeless and wasteful detours!