The Quiet Disappearance of the “Family Doctor”

When I grew up, we had one doctor who fulfilled almost all medical care needs of our family. The doctor had his clinic in the next building in the same compound. If I got hurt while playing, I would go confidently and directly to ‘Doctormam’ – Doctor Uncle in my mother-tongue – even if we had no money in our pocket. I never saw him hurried, he went about his work humming some barely audible tune under his breath.

·    For lacerations, he would carefully clean the area, apply tincture of iodine after telling me how brave I was, so I braced for the sting, then apply an ointment (Furacin) topped by cotton and sticking plaster. 

·    If the problem was a cut on the skin, say on the eyebrow, he would make me lie down on his examination bed, clean the wound and take a needle and thread and stitch and dress the wound carefully. Within a week, after one or two dressing changes, there would be a slight scar that would vanish as I grew up.

·    If the problem was a fever, after his examination and using a mercury thermometer, we would have to go to a cubicle net to the doctor’s cabin where a compounder dished out a mixture (we called it carminative mixture) in a translucent green glass bottle, on one side of which he would cut and stick a dosage indicator strip based on the doctor’s instructions.

·    If there was a dislocation or a fracture of an arm or a leg, the doctor would treat it in his clinic, with a Plaster of Paris cast, where appropriate. 

·    If the patient was too weak to visit the clinic, or there was some other reason that forced us to request a visit, he would visit our home within a few hours for a modest visit fee. He came carrying a doctor’s leather brief case packed with all tools of his trade.

Given the wide variety of ailments and conditions that our family doctor routinely treated, his ‘catchment’ area was a mere 20-25 surrounding buildings with around 300-500 households. It was sufficient to ensure that he was busy all the time. It was a rare day when his clinic did not have 3-4 patients waiting outside his cabin in the waiting area while he treated one during consulting hours.

Our doctor’s main work was running the maternity clinic attached to his consulting room, where patients came in for pre- and post-delivery consults, treatment and delivery. He always had 2-3 ‘sisters’ who would hang on to his every word and do his bidding.

Over a few years after our family doctor passed on, without our realising it, the model of medical practice changed. His son had become a “Gynaecologist” – he was no longer our “family doctor”. We then started going to different specialists for various problems. One big difference I barely noticed: We always had to go to these doctors’ clinics/ hospitals; they never visited us.  All Doctors (even GPs) had at some point simply stopped doing house calls, no matter how dire the patient’s need was. This is how it seems to me and came home to me forcefully in 2007: My father was diagnosed with an incurable, aggressive cancer with very poor prognosis – death within a few weeks. The treating surgeon in the hospital suggested we might consider taking him home to die (which I later learnt was not because of his empathy, but because he did not want his record besmirched by having a patient die under his care). We hired a hospital bed and brought him home. But he was in extreme pain and groaned if we touched him. So we first asked the treating doctor, then another doctor whose consulting room was very near where we lived, and finally my father’s GP of over 10 years, to come home and administer him morphine to relieve the pain. We told them to name their price, and that we would pick them up and drop them back.  They all refused saying that they did not do house calls. My father died in unrelieved excruciating pain for a few days while we watched helplessly. The medical profession did not help, and we could do nothing. Then we had difficulty getting a death certificate because he died at home and was technically not under the direct treatment of any doctor for the last few days before he died.

I think the late 70s and early 80s mark the period when the General Physicians with an MBBS degree, started quietly becoming less visible, to be replaced by a dazzling variety of specialists (at least in populous urban areas). In dental care, alone, for example, we now have specialisations that include paediatric dentistry, cosmetic dentistry (with a super-specialisation called “smile management”), 3D-printed prosthetics, maxillofacial surgery, and probably many more. Earlier, we had eye surgeons. Now, we have cataract specialists, retina specialists, squint specialists, paediatric ophthalmic surgeons, and so on. Left-eye doctor and right-eye doctor is no longer a far-fetched joke.

General Physicians (GPs) have not totally disappeared. In every batch passing out from medical school, perhaps 80% opt for further studies to become specialists of one kind or the other, and get an MD, MS or MCh degree. The remainder become General Physicians.

All who opt for specialisations now require 7-10 years to complete their medical studies. This naturally means (as compared to doctors with only an MBBS degree) foregoing income for about 3 years more. Also, the fact that they are so highly specialised means that to get enough patients to make it financially worthwhile, they have to cast their net wide – impossibly wide, which eventually pushes them into the arms of large corporate chain hospitals that have a brand name and recognition that can pull in patients.

If (say) 20% of doctors are MBBS doctors, why do I say that the Family Doctor has disappeared? It is because of how most of their practices have got reshaped completely, to be unrecognisable from the kind of practice of GPs before the late-70s. A few hypothetical examples follow.

·    If there is a patient with a cut requiring say, 3-5 stitches, today’s GP only cleans and dresses the wound, for which he may charge (say) Rs.800-1,000 and then refer the patient to a specialist – with whom there often is an allegedly hidden arrangement to get a cut out of the surgeon’s billing (which is why such a practice is commonly called ‘cut-practice’). The specialist will stitch the wound neatly, charge (say) Rs.5,000 or more, which price includes the stitching, dressing and one or more follow-up visits. The patient gets good treatment, the GP makes money from at least two sources, and the specialist acquires a patient at a fixed cost (not known to the patient). Sometimes, the patient gets reimbursed by his medical insurance provider, which further sweetens the deal: Net cost to patient is near-zero. Everyone is happy, except uninsured persons! Surely a Win-Win situation for all concerned!

·    If there is a patient with a fever or undiagnosed growth, now the first thing the doctor orders is a battery of blood, urine, and other diagnostic tests (sometimes scans and X-Rays too), whether needed or not. This practice has a beautiful euphemism: Defensive Medicine. They often recommend a particular pathological laboratory, and if the patient gets his tests done there, the referring doctor (allegedly) gets a cash referral commission from the lab. Thereafter, the MBBS doctor may refer the patient to a relevant specialist doctor (say an Endocrinologist or an Oncologist). By this referral, the MBBS doctor has successfully passed on his malpractice litigation risk to the specialist, who in turn has passed on the risk to an insurer through a malpractice insurance policy.  If the patient is medically insured, he bears only a small part of the total cost eventually. If the patient’s case is allegedly botched, the senior specialist’s financial risk is kept manageable through his malpractice insurance policy, which was hardly known in the time of ‘family doctors’. Here too, we can see a Win-Win situation for all parties, except uninsured doctors and patients.

·    If the specialist has signed a contract to work with a large chain hospital, he enjoys the brand recognition of the chain. But the doctors in such hospitals are under constant pressure to attract patients, fill beds, prescribe tests and otherwise generate revenue. Indeed, I know of a specialist doctor who closed his own practice and joined a corporate hospital as senior doctor. In a few years, his reputation among his patients and peers went from being a conservative doctor who recommended very few surgeries only where unavoidable to one who prescribes unnecessary tests, surgeries & unnecessarily long hospital stays.

·    Can you see any trace of a trusted “family” connection in this chain of relationships described? That, I’m afraid, has been lost for ever over the last half century. We can only get that if we are fortunate to have a doctor in the family, who also lives nearby. As a direct result of this lack of family connections, patients have become more untrusting and litigious, and doctors have become more defensive about exposure to possibly litigious patients or their family members – not exactly a fertile ground for trust to flourish.

So now, there are no family doctors who do home visits if needed (at least in populous urban areas), but there are uncounted doctors (GPs & specialists), healthcare service providers and health/ malpractice insurers. Each of them makes good money.

·    Do you think the model that medical practice has evolved into is a good thing as compared to the more genteel era of the ‘family doctor’?

·    Do you miss having a family doctor?

·    Do you have different thoughts/ experiences worth sharing?

Gender, Privacy and Ethics

Long back, I had blogged about why, when it came to procreation, people are seduced by technology to sally forth into uncharted moral and legal waters, instead of simply accepting the morally and legally acceptable solution called adoption.

We are now finding a similar set of dilemmas coming into focus thanks to the Pinki Pramanik case - that of the concept of gender and its intersection (or shall we say, collision?) with rights to privacy and our sense of right and wrong (ethics and morality). Here, too, a simple solution exists.

Pinki Pramanik thinks she is a lady. That should be enough for the rest of us to treat her as one. If our law allows ladies to be exempt from being punished for rape, that is a defect of our law - and anyone consistently claiming to be a lady should be allowed the benefit of such a law.

If our culture can tolerate, and indeed assign roles (however peripheral) to transgenders or cross-dressers in our culture, and give them the right to proudly say that they are hijras, and even give Shikandi (who thought she was a lady), the right to be treated in battle as a lady in the Mahabharata, there is no reason why, when it comes to a case like Pinki, she should be harassed and humiliated.  She should be treated as a person with due solicitousness - just as we treat the differently-abled in society.

If it is proved that Pinki has committed violence, she should definitely be punished for it. But, here again, the allegation is a private criminal complaint, and the only person who has the right (locus standi)  to prosecute Pinki for the offence alleged is her partner who alleges the violence. Hopefully, the decision will go though without the taint of the controversy about Pinki's gender clouding the decision, because that is really a non-issue. (In fact, just as I get ready to post this entry that has been a few days in the draft stage, comes the news that Pinki's partner has admitted to have been spurred to make the rape and masculinity charges by a person who was engaged in a bitter property dispute with Pinki). Whatever is the truth, what becomes clear is that Pinki's suffering was unnecessary and avoidable. She has fallen victim to the general intolerance of ambiguity in our Society. Everything has to be right or wrong; black or white - no space for grey!

In sports, at the international level, the case of Caster Semenya has brought out the difficulty of "proving" gender. Instead of learning lessons from that episode, we are going headlong into committing the same mistake, forgetting that mandated gender testing is an affront to the target's right to privacy and human rights.

On a slightly different note, Bidhan Barua's case - of his right to undergo gender-altering surgeries - has also got its fair share of headlines. Here too, the simple  solution as I see it, is to allow people like Bidhan do what he/she wants - like we do not raise eyebrows for cases of Botox shots for eliminating wrinkles and crow's feet.