Spice Route India Newsletter
Dr B C Rao:In the sixties and seventies, a fresh medical graduate had three choices. Either one went abroad to the US or UK or one stayed back in India. Back then, US faced a shortage of doctors. We gave our entrance test [ECFMG] in our final year or during internship and went to US or UK. Many of us who came from poorer socioeconomic backgrounds and with family responsibilities, took to either government service or entered private practice and became GPs. I chose the latter. It may come as a surprise to many that PG courses were just beginning in our medical colleges, then. So, it was the question of making a living and meeting the family and social responsibilities that decided the career choice and so it was in my case too.
Dr B C Rao:In the sixties and seventies, we were a very poor nation with all pervading poverty. Doctors too were either upper poor or lower middle class going by today’s standards. Tertiary care was available mostly in government hospitals which were better managed and most patients went there for their specialist care. Very few private hospitals existed, with few mission hospitals being the exception. Most patients went to ‘their family doctor’ and they handled health issues across all specialties. Managing home deliveries, minor surgical procedures, doing house calls were routine. I remember driving [two-wheeler] 20 km to see patients at their homes. Usually there were three to four house calls which were often at night.
The 80s and 90s saw the emergence of the economy and began the flood of private enterprise and loosening of the license permit Raj. The Health sector was also not an exception. In the 90s ,began the major advent of private players into the health scene. Private medical colleges ,where admissions based on ability to pay ,rather than merit came up like mushrooms. So were the private tertiary care hospitals. This had a major impact on the health scene. The middle class and the wealthy who now had money to spend chose to be treated in the private hospitals and the public hospitals virtually became charity places meant for only the poorest of the poor. These private hospitals also attracted talented doctors from in and out of the country. Standards of care improved for a small section of the community at the cost of the vast majority.
The major shortcoming in the field of health care was the loss of the breadth of practice. Obstetricians gradually took over the care of the pregnant, Pediatricians took over the care of the children and the tendency of the middleclass to seek help from the organ specialist gradually increased. Family doctors were the cheaper alternatives to this class. Some of us survived because of the reputations built up and the ability to render better and quicker service than institution-based doctor, often cost effective. In the late 2010s many patients seem to have realized this and there appears to be a reverse flow of them to the FPs. But the comprehensive nature of practice, as I saw in the 70s seems to have been erased from urban India.
Dr B C Rao:If earning money is the sole objective, then, no enterprising youngster should opt for this profession, specialist or generalist. Specialists especially some in clinical branches certainly make more money than say a family doctor in private practice. This comes with a rider. Most specialists, especially those in private institutions work under pressure from the hospital owners who are entrepreneurs and not doctors. Earning certain amount of money on investment is their norm. Specialists are under pressure to generate income which as we are seeing, is leading to ordering avoidable tests and doing often unnecessary procedures. Thus, many specialists are trapped in this situation and are often victims of violence. In contrast, Family doctors do not work under such stress. As they work in the community, and see the same patients often year after year, their life though financially less than that of specialists [not universally true] is more rewarding and rarely one hears of violence against family doctors.
Dr B C Rao:There is a rich field of opportunities out there. There are large numbers of people who are dissatisfied with hospital-based care and are looking for doctors whom they can trust and are willing to pay. But unlike a paid job, here there is no assured income in the beginning years, till one gets established. How long will this take? Couple of years, may be but it is rarely a failure. The problem in urban India today is the cost of initial investment. The rentals are steep and overheads are heavy. Shared premises, equipment, manpower amongst two or more doctors, would be an ideal solution. Some risk is inherent in any undertaking of this nature. Once established there is no turning back and practicing in the community, enjoying the confidence and love of the families is a special feature of family medicine which is denied to other specialties. Of course, one needs to be skilled and jumping to practice without acquiring basic skills will only make such a family physician a referral clerk and that is no fun. Thus, shared practice [group practice] appears a possible option.
Dr B C Rao:50 years of practice is a very long time to recall many of these that have taken place. I have over 200 of these written over a period of ten years from 2007 to 2018. Those interested can go to my blog badakerecrao.blogspot.com
Dr B C Rao:One major disadvantage of family medicine is that the practitioners are distributed in far flung places with poor facilities for professional and social interaction. This professional and social isolation can be taken care of by the Spice Route movement. Periodic workshops and webinars can be held online. These seminars should not merely stress on clinical/system-based subjects which I often see, but also stress on problem solving in the family and community settings where most family doctors’ practice. Build a strong network and promote fraternity feeling amongst young doctors which will last a life time. Promote travel and visit to each other’s homes and practices, if need be by building a corpus meant only for this purpose. This ‘route’ should produce future leaders in family medicine.
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