|Year : 2021 | Volume
| Issue : 4 | Page : 303-305
The future of medicine - A gathering storm?
Robbie K George
Department of Vascular and Endovascular Surgery, Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bengaluru, Karnataka, India
|Date of Submission||26-Nov-2021|
|Date of Acceptance||26-Nov-2021|
|Date of Web Publication||9-Dec-2021|
Robbie K George
Department of Vascular and Endovascular Surgery, Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
George RK. The future of medicine - A gathering storm?. Indian J Vasc Endovasc Surg 2021;8:303-5
The recent Vascular Society of India annual general body meeting had some spirited discussion on concerns raised by the younger vascular and endovascular surgeons. The concerns arise from the training support extended to nonvascular surgeons and the resultant encroachment into what has been vascular territory. We are all aware of the business model for the treatment of varicose veins and hemorrhoids that have become rampant in the metros. There are any number of companies that want to become service aggregators such as Swiggy or Zomato – with scant regard that the treatment be appropriate or proper. Young doctors and surgeons are increasingly under the financial pressure of corporate owners, and themselves, to cater to these demands. Many of these service providers would like doctors to become faceless technicians employed by the company, rather than having a relationship with the patient.
This microcosm of vascular surgery is being played out on a much larger scale across health care and will have an increasing impact on lives and livelihoods of patients and doctors.
| The Numbers Game?|| |
In 2018, India reached the WHO-recommended doctor–patient ratio of 1:1000 when doctors of modern medicine (MBBS) and traditional medicine (AYUSH) are included. This is indeed a great achievement, but perhaps, increasing physician numbers will bring its own set of problems.
In 1947, India had 1500 medical graduates each year. As of March 31, 2017, India had 1,022,859 MBBS doctors registered with the Medical Council of India and State Medical Councils. This year as of March, there are 83,175 MBBS seats available for the NEET entrance examination. At the very least, we can expect an additional 800,000 MBBS doctors to join the ranks of medicine within the next decade, while the numbers of those retiring from practice will be significantly lesser. This does not include doctors who are training overseas (estimated at 40,000) or the AYUSH stream (53,000 seats annually).
The number of medical colleges will continue to increase. Since 2014, the government has approved 157 new medical colleges, of which 6500 news seats have already been added with a further 10,000 to be added once this expansion is complete. This would bring the annual number of medical seats in India to nearly 100,000 each year.
There is a perceived shortage of doctors in India – a fact that is not borne out by the numbers. The total number of posts sanctioned for primary health-care centers is around 34,000 – a fraction of the total number of doctors. The actual shortage of MBBS doctors at PHCs has been estimated at 6.8%, with most of the shortage in the northern states. However, there is a significant shortage of specialists – pediatricians, gynecologists, and surgeons at the community health center level and in the smaller towns and cities of India. This is really where the health-care crisis lies.
The additional trend of licensing/permitting nonallopathic trained personnel (AYUSH, BDS, etc.) to practice medicine adds to the potential oversupply of physicians.
Oftentimes, a dramatic increase in the numbers of trainees dilutes the quality of training. A glaring example is seen in Engineering. In 2014–2015, there were 31.8 lakh seats on offer, with large numbers of seats lying vacant. At the same time, recent employer lead analysis has found that only 40% of engineering graduates were considered “employable.” Similarly, the poor salaries and opportunities for nurses and teachers in India are partially a result of an oversupply. The abysmal quality of fresher nurses is well known to anyone in health care. Many of these nurses receive their “training” in buildings devoid of patients.
The doubling of medical undergraduate seats was achieved by the stroke of a pen – essentially, the teaching facility and faculty requirements were reduced by half. Over the next few years, permission was also given for the opening of large numbers of medical colleges. At the same time, seats are available on payment of huge capitation fees. The impact of this dramatic expansion coupled with a postgraduate entrance system that relies on purely the clearing of theoretical examinations may well produce a large number of poorly trained doctors.
There are plenty of anecdotal reports of trainees entering superspecialty courses without basic practical skills and abilities either due to medical colleges with very few patients or due to lack of clinical work because the focus is on clearing the next NEET entrance.
| The Value of Health Care|| |
The lack of proper health care has long been a major problem. India has achieved dramatic improvements since Independence (infant mortality reduced from 150 to 50, life expectancy increased from 31 to 65, and maternal mortality reduced from 2000 to 200 per 100,000 births), but there is still a long way to go. Investment in public health care has been limited. The total investment on health care by the central and state governments comprises 1.4% of GDP in 2016–2017. This is less than the world average of 6% and can be compared to 10.30% in Brazil, 9% in the UK, and 16% for the USA.
The government has launched the National Health Protection Policy in 2018–2019 with the aim of providing cover of Rs 5 lakh per family per year for 10.7 crore poor and vulnerable families. As part of the National Health Mission under the Pradhan Mantri Rashtriya Swasthya Suraksha Mission, tariffs have been announced for various treatments. These tariffs can be considered to be reflective of what the government considers fair value and will likely form a base rate for tariff negotiation by insurers, both public and private. [Table 1] lists some of the tariffs of common procedures and some that would be specifically applicable to vascular surgeons. Whether these tariffs are sustainable in large metros or small cities is left to the judgment of the reader.
|Table 1: Selected payable tariffs under the Pradhan Mantri Rasthriya Swasthya Surakhsha Mission|
Click here to view
| The Prince and the Pauper|| |
India as a large developing nation has its own set of unique problems. We have a very large population which rightly expects quality and affordable health care. Within this population, there exist almost subnations. The “princes” – residents of posh areas such as Malabar Hill, Mumbai, or Jor Bagh in Delhi, have very little in common with the “pauper” residents of Alirajpur or Pujari districts (you probably have not heard of them – they are among India's poorest districts). The definitions of quality and affordability and the expectations, wants, and needs of the varying patient groups are almost planets apart. Yet as physicians, we are expected to provide the same degree of care at the same price point and are judged within the judicial system by the same yardstick. Ideally, it should be possible to do exactly that. Reality is always different. Realistically providing superlative, state-of-the-art modern care of a complicated thoracoabdominal aneurysm or a complicated cesarean section in Rs 9000 is unrealistic.
| Expectations and Reality|| |
Most people who enter medicine do so with an expectation of making a respectable living. Entry to medical school is extremely competitive, and entry to specialization degrees of MS/MD is even more arduous. It will take at least 12 years to become a fully qualified vascular surgeon – likely longer for most people. The more recent enforcement of compulsory government service following every qualification will extend this period very significantly.
At the end of this process, it is not unreasonable for doctors to expect that the work and skill be adequately remunerated. Seeing bright, hardworking, and talented young doctors still depending on their parents for financial support well into their thirties is disheartening. They continue working in the hope that they shall earn significantly better once they are fully qualified.
The reality may well turn out to be different for many. Many newly qualified superspecialists struggle to establish themselves adequately, especially in the metro cities. This has been a major challenge for cardiac surgeons, neurosurgeons, and urologists among others.
| The Future|| |
This coming together of factors can result in a variety of outcomes – some good and some not so good. Hopefully, there will be a significant increase in the number of adequately trained specialists in the smaller towns and cities and rural India with a resultant improvement in health. Health care would also, perhaps, become more affordable as the cost of medical services would fall as a result of competition.
When this is combined with a poorly paid government-supported health-care scheme, it will clash with the expectations of young doctors to earn commensurate to their efforts and abilities.
Competition would also bring with it the need for a more “customer-friendly” approach. This will have various manifestations including an expectation that doctors will always be available at beck and call. Most Indian doctors, at least in the private sector, already work long hours including weekends. This is only likely to worsen in the future.
The wider availability of specialists will contribute to the practice of doctor shopping. The pandemic of the (in) famous second/third/fourth opinion will worsen. When this is combined with the competition for practice, the impact on clinical decision-making can certainly be adverse.
It would be very unfortunate if all these were to translate into malpractice of doing unindicated procedures and investigations purely for financial gain.
The impact of these developments on an already fraught doctor–patient relationship in India can be terrible. The “prince” and “pauper” effect due to widely varying patient expectations will have its own impact on how the doctor–patient relationship evolves.
Hopefully, the good outcomes will outweigh the bad for society as a whole.
The impact on medicine as a profession may not be as agreeable.
Doctors may well respond to these changes by looking for greener pastures overseas.
If medicine becomes an unattractive career, it will be difficult to recruit the best and the brightest students into the profession – an outcome that will reveal its impact many years later.
Although rapidly dwindling, there still exists some respect for being a doctor and for what we do – the future for the young student entering his medical college with starstruck eyes is unclear indeed. Every young doctor would do well to consider the future and have a Plan B for survival beyond pure clinical practice.
| References|| |
Kumar R, Pal R. India achieves WHO recommended doctor population ratio: A call for paradigm shift in public health discourse! J Fam Med Prim Care 2018;7:841-4.
Deo MG. population ratio for India – The reality. Indian J Med Res 2013;137:632-5.
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