Wednesday, December 5, 2012

A shout-out to India's Generalists

A few years ago, the President of India’s National Board of Examinations went on record as saying that about 90 percent of India’s health needs could be managed by doctors trained in Family Medicine. About 5-7 percent could be managed by doctors trained in Rural Surgery. Only about 2-3 percent of India’s sick needed to see a specialist!

The trend, however, is for doctors to get more and more specialised. Many students begin training for the postgraduate entrance examination even while still studying for their MBBS. The message is passed on to them that even an MD or an MS is not enough these days. The buzzword is Super-specialisation.

As a result, the health-care delivery system in India has become dangerously inverted.

Ideally, India needs plenty of Family physicians and Rural surgeons. These are Specialised Generalists. They are equipped to handle most health problems. They are also trained to identify problems that need more specialised care, and refer patients accordingly.

Often, these Generalists have been specially trained in general care. The National Board awards DipNB degrees in Family Medicine and Rural Surgery. Sadly, these two courses have not yet gained the popularity they deserve.

It is also possible to choose to practice Generalist care even after specialisation. For example, I have been fortunate to have had the opportunity to work as a Rural Surgeon even after specialising in General Surgery. In addition to performing surgery I was trained to do (for example, open and laparascopic operations on the abdomen, surgery on the head and neck, thyroid, breast, etc), I had to do (because I was the only surgeon available) Urology (operations for kidney, ureter and bladder stones, intra-corporeal lithotripsy, PUJ obstruction, open prostatectomies, TURPs, etc), Pediatric Surgery (colostomies, neonatal intestinal obstruction, paediatric hernias and circumcisions, undescended testis, etc), Obstetrics and Gynaecology (Caesarians, abdominal and vaginal hysterectomies, surgery for rupture uterus, ectopic pregnancy, ovarian cysts, etc), Orthopaedics (open and closed reduction of fractures, amputations), ENT (tonsillectomies), and so on.

I have had to learn to do ultrasounds, and do simple ultrasound guided procedures like putting drains into liver abscesses, intra-abdominal collections and so on.

I have removed foreign bodies from the esophagus, ears, nose and even vagina.

I have had to give my own anaesthesia on occasion.

During some Caesarian sections, I have played the role of anaesthetist, obstetrician and neonatologist. I have given spinal anaesthesia, instructed a nurse to monitor the patient, started the Caesarian, opened the uterus, delivered the baby, put Green-Armitage clamps on the uterus to stop bleeding, and run with the baby to a side table where the baby could be resuscitated, then handed the baby to the nurses while I returned to close the uterus and complete the Caesarian.

Was that ideal? Hardly!

But under the circumstances, it was the highest quality of care available, because I was the only doctor around!

 As I watch medical education become more and more specialised, I cannot help being concerned. I realise that I too am contributing to the problem, and feel myself being forced down a path of further specialisation.

I am reminded of the old adage, “A Specialist is somebody who learns more and more about less and less, until he knows everything about nothing!”

I wonder if we are becoming more and more irrelevant to the real health needs in India.

Perhaps some amount of specialisation is needed in larger medical colleges, and in the cities. However, these are also the very places where young doctors are being trained. They learn a system of medicine which makes them irrelevant to the rest of Bharat, and fall into their place on the conveyor belt to specialisation.

I wonder if we are contributing to the vicious cycle that is tragically ruining the health ‘industry’ in India. As doctors become more specialised, we send a message to our patients that it would be better for them to see a specialist for their basic health problems. As a result, they insist on seeing specialists. Specialists are an expensive option! We have become experts at seeing health dangers when there are none. As a result, we over-investigate and over-prescribe. We are so afraid of litigation that we are unwilling to take risks, but quick to refer. We have developed tunnel vision, and see only the patient’s problem in our own field of specialisation. As a result, a patient has to see a large number of specialists for his various health problems. Investigations are repeated a number of times, many drugs are prescribed which interact with each other, and often, patients only get worse (and poorer!).

Perhaps, together with campaigning against medical corruption, we should campaign for specialised Generalists. We should appreciate them, honour them, and give them a high place in our medical fraternity. They are facing greater challenges and adapting better than many of us safely ensconced in our comfort zones.

Perhaps they should receive better incentives and rewards for the work they do.

Perhaps they should be offered special opportunities to keep abreast with developments in medicine, and to learn new skills.

Perhaps more specialists should spend time on a regular basis in generalist situations, keeping abreast of the real health needs of the country.

Perhaps some specialists should move permanently to rural India, to help address the inequality in distribution of health resources.

And, most importantly, perhaps we should allow Family physicians and Rural surgeons to play a greater role in training and impacting our young graduates and post-graduates. Would it not be wonderful if our students should spend a sizeable part of their training period working alongside these heroes?


  1. I wish at least 10% of our specialists have a similar attitude. The bottom line is in the present scheme of things, being known as a specialist, be it a cardiologist or a neurosurgeon is what one would prefer. And even that's what one's parents would like their children to be. Well, there are places like ours who would always benefit from some specialist who would be willing to be a generalist.

  2. As you are rightly commenting , yet you yourself took up superspecialisation in pediatric surgery- are you going to set the trend to go into generalist practice?

  3. Welcome to the 1st National Conference of Family Medicine and Primary Care FMPC 2013

    Dr Raman Kumar

  4. National Conference on Family Medicine and Primary Care 2013

  5. Bertrum AtputhasingamDecember 5, 2012 at 5:42 PM

    Very surprised to note your thoughts on hyperspecialisation-especially from you Pradeep!
    I am not the ideal person to comment on rural health in India but I agree Generalist needs to be Incentivised and should have targeted training.
    Extending the role of existing health carers in rural areas maybe one way forward but would require medical fraternity to accept we are not indespendible. With minimal added training nurses/health carers could do much more including initiating treatments and prescribing. Most labour ward skills including scanning and performing assisted vaginal deliveries could be done by non medics.
    Most countries are looking at moving away from traditional model of health care in rural communities. It will significantly improve patient centered, Safe, appropriate, timely and cost effective health care.
    UK system values/incentivice General Practitioners so much so we have trouble recruiting into other specialities.
    Hats off to India in Promoting rural surgery and family medicine. Keeping abreast with new development is so easy with current developments in IT!
    Will follow with interest the thoughts on your topic.

  6. Abraham, good question! The frank answer is...I don't know. I took up Pediatric Surgery because I felt it was a unique specialisation that would equip me in a very broad way. I was told that studying Pediatric Surgery would open more doors, without closing any....and I think that is true. I have acquired skills that could stand me in good stead even while operating on adults.

    Will I ever go back to a Rural surgery practice, or will I stay on in my superspeciality? Honestly, I really don't know at this stage!

  7. Bertie, thanks for your comments. I like the term 'Hyperspecialisation'. It reminds me of another term I have heard before, 'Educationally Obese'!

    I think you have raised a really valid point. I, for one, would really welcome empowering nurses and other paramedical staff to play an important role in health care delivery, and not just in rural India.

    However, I am aware that the greatest opposition to any such plans have always come from the doctor community. We are unwilling to work in rural India, and we are unwilling to empower others who are willing to go and work in such places. It is a classic case of 'having your cake and eating it too'!

    I would agree that perhaps a large amount of India's health burden could be handled by Paramedical staff, but would also add that when so many doctors in India have not benefited from training that empowers them, and equips them with the necessary skills to practise medicine with competence and confidence, I do not see (in the foreseeable future) a time when paramedicals are equipped and empowered enough to be able to take on such a role.

  8. Pradeep,
    I do agree with you.
    Being a "specialist" is different from offering "specialised "services. Even in OECD countries like Australia there are situations where generalists provide specialists services. As health care anywhere is a function of economy/social structures/market forces and even regulatory environment, what is offered by whom and to what extent depend on a lot of factors , out of which the technical skills of the surgeon is just one( though important).

    Creating and sustaining environment and systems for ongoing learning and skill development, keeping patient safety in mind is something we all could do..and we strive for where ever we happen to work.

    I am sure that the additional skills you have gained through your subspeciality training will help you to improve patient safety, wherever you decide to work.

    With all good wishes,


  9. Dr Sabu, Great to hear from you, and thanks for your very thoughtful comments.

    I agree that in some situations generalists need to provide specialist services. I would also agree that there are situations when specialists need to provide generalist care, for example, when specialists in each specialty are not available in the hospital.

    I think the prevailing health care environment in the country at present does not encourage either!

  10. The present day situation in India is so unfavorable for Family Medicine. As there are only very few people actually trained in Family Medicine, the ongoing training programmes like DNB is exclusively ran by specialists who do not have idea about this wonderful specialty. As far as I know the DNB Family medicine curriculum and examinations were set and ran by specialists from other fields.

    Thanks for your wonderful post.

  11. Dinesh, great point, and yes, you are absolutely right. I have myself watched confused specialists try to teach Family Medicine students, and the chaos that results, because they have no idea what Family Medicine is all about.

    However, I suppose that this situation will continue until such a time as there are sufficient Family Medicine faculty who are interested in training, and willing to take on this role.

  12. As much as we 'd like the world to be "equal"or egalitarian, it will never be. It doesn't work. You'll always have inequalities and injustices. Even the people with the best of intentions can't do anything about it. The system is broken. The world is broken and flawed. All this noble talk does nothing to change anything. only good for speeches.

  13. Really enjoy your writing and admire your work. Thought you might appreciate this article celebrating generalism

    1. Thank you! I did enjoy reading the article, and left with a greater desire to be polymathic....