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?