In recent times, the medical profession in the country has been going through a period of considerable anxiety. A historical snapshot of the evolution of the profession of doctors engaged in healthcare should be helpful in putting in perspective the present existential issues confronting the profession.
Concern for personal health is a part of the biological instinct for self-preservation in all life forms. Humans, as they stepped on to mother earth several millennia ago, have been specially equipped with a powerful ability to experiment with their natural surroundings. Consequently, the human species learnt, by trial and error, the possible use of nature’s bounties for preserving own health and/or relieving suffering amongst fellow human beings.
That was the beginning of healthcare. Several human clusters, living in different parts of the world, evolved their own systems of medicine in India, China, Egypt, Greece, Rome and possibly other locations. In view of limitations in scientific knowledge at the time, a divine hand was often invoked to explain practical outcomes, positive as well as negative.
It must be acknowledged, however, that significant progress was indeed made in providing welcome cure or relief to some of the affected patients at that time. That was the global scenario until 500 to 600 AD.
The industrial revolution in Europe provided the tools for accelerated scientific inquiry and research into biological sciences including healthcare. That is how the modern system of healthcare, also known as allopathy, came into existence. Although progress was slow initially, it started to pick up speed during the first half of the last century. That growth trajectory has been continually accelerating since.
As a consequence, the profession of modern medicine has grown both in the range of services provided as well as the precision with which these can be executed. The variety of professional expertise exhibited by individual doctors has spawned a number of different specialist services.
Alongside there has been a considerable growth in support services like those of Nursing and Technologists. More recently, the need for focussed skillsets has given rise to different specialist groups within these support services as well. Over the last seven decades or so the evolution of healthcare services has been truly phenomenal. From a service delivered by “loners” in the past, modern medical practice has evolved into a partnership of a group of service providers endowed with complementary skill sets.
In recent times, however, the following developments have cast a shadow on the profession which could adversely affect the professional activities of doctors in particular.
1). For quite some time now the government of India has been debating plans for a wholesale change in the architecture of the practice of modern medicine in the country. These proposals have the potential to impact every single facet of the professional activities of doctors; from the basic structure of the profession to the curriculum of medical education.
Basic principles that constitute the foundation of everyday practice such as the contours of quality control that inform the use of pharmaceuticals and/or procedures to address a particular clinical situation are being questioned. Briefly stated, it is an assault on the professional space that doctors need to practice their skills honestly, as well as to continue to innovate for the larger good of all humanity.
As part of this exercise, a wholly unnecessary controversy is often created by pitching different schools of medical practice against one another. As indicated earlier, history is witness to the fact that allopathy itself has herbal roots as much as any other school of medicine. Further, allopathy has avidly adopted solutions of proven health benefit irrespective of the source from which these may have came.
It needs to be emphasised one more time that the soul of modern medical practice is evidence-based medicine; nothing else matters. The only caveat, therefore, is that properly structured scientific evidence, not just anecdotal evidence, must be brought forward in support of claims made for any medicament, device or practice before it can be accepted for general application in allopathy.
It is more than likely that the entire global community of doctors, not just from our country, will lap up any evidence-based solutions that offer hope for prevention, amelioration or cure of disease irrespective of the source of that knowledge. In fact, this argument was appreciated a long time ago in our country when the Indian Council Of Medical Research (ICMR) was established in 1949. Amongst its several other activities, ICMR has been actively supporting individual research projects that set out to gain from the available knowledge base of traditional medicine. Likewise, there have been several initiatives of Central as well as State Governments in the country in pursuit of similar goals.
In a further push to this objective, a Postgraduate Institute of Indian Medicine was established within Banaras Hindu University in 1963 under the leadership of Prof. K. N. Udupa. The ICMR took its own initiative to the next level in 2004 when the ICMR-National Institute of Traditional Medicine was established at Belagavi, in Karnataka. Further, the Central Council for Research in Ayurvedic Sciences has been conducting research in several centres spread across the country. Many of the projects at these centres have been supported by institutions like the ICMR, CSIR, AIIMS, IIT, NIPER etc. Several publications have put out the results of these studies. Surely the shortest route to productive gain would be to commercialise identified products or practices that have gone through scientific scrutiny and encourage more studies to examine other possibilities. Yoga is an example of the ancient practice that has been shown to have health benefits and it is accepted today in allopathic practice in many parts of the world as well.
There is thus no need for a confrontation between ayurvedic practices and allopathic medicine; the two could and should complement each other. The problem arises when dogmatic beliefs are favoured over scientific evidence.
Surely, scientific evidence supporting clinical benefits offered by ayurvedic formulations will only enhance the position of that school of medicine. Contrariwise, any resistance to seeking supportive scientific evidence can only impact adversely wider acceptance of such products or practices. It may well be that flying machines existed in the past, but any flying machines that are put into use today must conform to modern scientific standards. Of course, it would have helped greatly if some kind of detail about the ancient flying machines were available for scientific scrutiny today. Maybe that could have helped to improve the design of modern flying machines. Unfortunately, that information is not available and we cannot fault anyone but ourselves for having failed to preserve that information if indeed it existed.
2). The government is justifiably concerned about the shortage of trained manpower for healthcare in the country. To fill this gap, it is argued that persons from different schools of traditional medicine could be trained to engage in the practice of allopathy. Given the state of existing knowledge and the minimum skillsets required, it seems wholly unwise to pursue that path. In fact, such an exercise is most likely to become counterproductive. Several decades ago, soon after gaining independence, pharmacists were permitted to prescribe some medicines to the general public for “non-serious common ailments”. The results have been disastrous; we continue to pay the price for that decision to this day. Then came the BAMS course. Although theoretically classed as being different from allopathy, in practice, it has turned out to be just a downscaled form of allopathic practice without the essential checks and balances built into the allopathic system. Consequently, the popularity index of such practitioners has not turned out to be a matter of envy.
Unfortunately, there is a common misconception that the poor and the disadvantaged do not need highly skilled persons for their healthcare needs and that their problems can be tackled by under-skilled persons. Unfortunately, that familiar refrain has already been discredited by practical experience gained in the country over the past 70 odd years. The wholly justified push for universal education as a means to uplift the poorer segments of society was pursued by recruiting poorly trained, even untrained, teachers. The result: poor education, falling class results and unemployable degree holders. Similar results are visible in many other areas of public activity. It is the considered view of this writer that the poor and marginalised need the services of highly skilled professional teachers (not under-skilled teachers) in order to help them step out of their existing handicaps. A highly skilled teacher is much more likely to be able to help many more students (within the same time frame) to overcome their current social handicaps than can be achieved by under- skilled teachers. The same is true for healthcare. That quality is, by definition, the most cost-effective way to gain progress is a truism that cannot be overemphasised.
In fact, whenever an alternate more efficient product or process is identified, the label of quality does inevitably shift to that product or idea in preference to any earlier alternative. If a doctor trained through a hybrid course is just as good as one who has gone through a regular course in medicine, the inescapable corollary is that the regular course is inefficient and needs to be replaced by the hybrid course for everyone! If on the other hand, the skillsets of trainees going through the hybrid course fall short of those gained through the regular course, the quality divide would amount to a fraud on the less privileged segments of society.
3). Public perception regarding the social standing of the medical profession in the country has taken a serious hit. Until very recently the profession was held in high esteem. Presently, however, public confidence in the profession has declined significantly and professional pride has taken a big hit. Things have come to such a pass that professionals today face a threat of physical violence from the very same individuals whom they wish to serve. Any attempt to dismiss these happenings as stray incidents would be suicidal; the warning signs must be addressed seriously.
In fairness, it needs to be said that the bond of trust between the doctor and patient in the country has been under strain for quite some time. From time to time many fellow professionals, as well as persons from the general public, have been raising red flags in this regard. That the profession has failed to respond to the warning signs is self-evident. In order to regain credibility and support from the general public, the profession as a whole needs to proactively reach out to the people and devise suitable means to provide effective and efficient healthcare for all segments of society as well as improve communication between the doctor and patient for better bonding.
Considering that the medical profession is beset with many uncertainties that affect outcomes; we can never guarantee results. What we offer instead is the commitment to always work in the best interests of any and every patient. That is why it is so important to restore trust in the doctor-patient interaction. In view of the foregoing, it is suggested that there is an urgent need for all doctors working in the field of healthcare in the country, to pull up our socks and work towards regaining the professional space essential for a healthy future of the profession as we know it. All of us young and old, men and women, generalists and specialists, commoners and academicians, whether working in the public sector or the private sector, need to come together to serve that common purpose. This is not the time to play the victim but to own responsibility and engage in strengthening the profession. Any dithering that may allow the moment to pass could make it difficult to retrieve the situation in the future.
Unfortunately, medical professionals in the country are split into a number of professional bodies that do not interact with one another even on core issues of common concern. True to the national characteristic each prefers to remain sheltered in their separate kingdoms. There is a need to bring all these organisations onto a single platform to debate and strategise on issues affecting the entire profession. The statutory structure of IMA offers a natural advantage for a common platform. Unfortunately, the IMA has been in professional hibernation for too long. Therefore, it needs to take a leap to rise to the occasion and devise a mechanism for all professional bodies to join hands for a common purpose. Likewise, all professional bodies individually and together with medical academia should collectively rise to the occasion and join in the struggle for survival. Anyone could take the lead. Healthcare as one of the three legs of the tripod that supports life (the other two being food and environment) that touches the lives of every individual sooner or later. The responsibility to carry forward such an important profession lies with each one of us. There are no “rajas” and “runks” in this; united we stand or divided we fall. For too long the community of doctors in the country, have remained silent spectators, almost by choice, believing that the fire is too far away from their own homes. For too long doctors have tended to seek comfort in the belief that they hold an impregnable position within their personal glasshouses. For too long individual doctors have sought protection for own selves through feudal dispensations unmindful of consequences for the rest of the profession.
Sycophancy has played havoc in this country and the medical profession has failed to stand out as an exception. Failure of the MCI to adhere to standards of quality and ethics let down the profession and triggered the subsequent adverse fallout, which is what the profession is struggling with today. That experience should be a constant reminder to all of us at all times.
In most advanced countries the medical profession is sustained by a fairly powerful professional organisation that stands up for the entire profession. Unfortunately, in this country, we are yet to find that institutionalised space. The need of the hour is for everyone to engage in drafting a comprehensive vision document that provides for (1) uncompromising professional freedom, (2) excellence of service that is inclusive in depth as well as range, (3) robust and independent academia and (4) a transparent oversight mechanism for the entire profession. Surely we can do it. Complacency and self-pity are not an option; it will be suicidal. Let us get on with the job; where there is a will there is a way.
The author Dr. R P SAPRU (MD, Ph.D.(Edin), FAMS, FIMSA, FICA, FICP, FISC, FCSI) is a Cardiologist and Retired Head Department of Cardiology, PGIMER, Chandigarh