THE COST OF RECONSTRUCTING HEALTH-CARE PYRAMID IN INDIA – CAN YOU SACRIFICE HALF CUP TEA PER WEEK?!

This is a thought provoking article. So, I am starting with few pre-requisites:

• If you are busy and cannot complete reading this in one shot, please don’t start!
• These suggestions on modus operandi are just a beginning. As many ideas as possible need to be added to make it is a collective venture.
• Criticisms of every type are welcome. But, when you have any objection to any point, please suggest a remedial measure to improvise or to overcome the fault. Don’t just pelt a stone and be happy about participation!
• This discussion should shape into a tag and should propagate till it reaches a logical conclusion. The longer it is in air, better the chances of reaching helping ears. So, please keep commenting!

With the premise, let me start. This piece is a sort of continuation to my earlier article – Resurrection of MBBS and Family medicine: Can it check quackery in India? (Link: http://www.docplexus.in/questions/97117a2c-8318-4d81-8dde-65c0ce12ec95/resurrection-of-mbbs-and-family-medicine-can-it-check-quackery-in-india)

Few basic statistics as per PWC data on Indian Health-Care (year 2012) to begin with:

• 1.3 beds per 1000 population with 70% from private hospitals: about 7 lakh beds in private hospitals in India.
• About 10.5 lakh practicing Doctors of Modern Medicine registered in India with medical council. Please don’t use the term “Allopathy”; it is not same as what we practice. We are trained in “Modern Medicine” which is NOT Allopathy!

Indian Health-Care pyramid is skewed! I don’t see any need to elaborate on this. The bottom of this pyramid is infested with quacks – anyone untrained in medical care or trained in a different form of medicine but practicing Modern Medicine

If we want to reconstruct Health-Care pyramid in its proper perspective, these quacks should be replaced by qualified doctors. Anyone getting trained in their respective variant of medicine, be it AYUSH or Modern Medicine should practice in their own field. Unfortunately, neither the legal system nor the government feels the need for this!

In such a situation, we have the onus of restructuring the pyramid on our own without support from government. It is possible only through involvement of more and more MBBS doctors at the base of pyramid. The question is: HOW?

The chief reason for MBBS graduates not pursuing practice are:

• Lack of confidence: the training imparted in medical colleges during MBBS is no way helpful to establish clinic practice at present! One can count multiple reasons for it, but the end result is same. Barring few brave ones, most of the MBBS pass-outs are not confident of succeeding in clinic practice.
• Social Constraints: In the bargain of elevating the status of a specialist, we have deliberately denigrated MBBS as “just MBBS”. It is extremely myopic of such people. There was no need to kick down our own brethren to establish superiority of “specialization”. But unfortunately, it is built that way. Slowly, “just MBBS” has become a social taboo. This needs atonement!
• Finance: With lack of confidence and social taboo, there comes another devil to face- MONEY! Middle class students are drained out with fees and additional expenses by the time they finish MBBS. In an age when their BE/BTech peers are earning in six-digits, these bright brains are morally depressed for asking their parents for daily needs. It is humiliation of highest order. There is no way they would dare taking another loan for starting a clinic, success of which is uncertain.
• Lack of professional support: “Just MBBS” gets hit by even specialists! Caustic criticisms, unsavory remarks, hateful tone of speech are all very common. But, not many would try to help them imparting with what is needed for MBBS practitioners.

The list may go endless. Somewhere, we need a beginning to stop these. Here are some of suggestions: Please add to them.

First and foremost is finance. Don’t even think of help from government. They detest educated people and tax-paying population! Whatever is needed should be practical and should be on our own.

The proposals would be simple:

• Each private hospital should contribute at least Rs.1000/- (one thousand) per bed to a corpus. With 7 lakh beds, it should be 70 crore rupees.
• Each specialist professional body (like API, IAP, FOGSI, SSI, CSI etc) should contribute a minimum of Rs.500/- per member towards this corpus. This would amount to another 25 crores. Each non-specialist professional body run by MBBS doctors (Family Physicians Forum) can also contribute to this corpus.
• Each doctor of Modern Medicine should contribute Rs10/- per week (cost of half tea!) towards this corpus. With 10 lakh such practitioners it would be additional 50 crores per year.
• If this continues for a period of just 3 years, a cumulative corpus of 400 to 500 crore rupees can be generated.
• We should identify 4 or 5 reputed banks of national spread. IMA or any important medical body can moderate this. The entire amount would be under their custody with supervision from apex professional body.
• Each MBBS student should be encouraged to become a student member of IMA for an extremely nominal amount. When they finish MBBS, all such members should be entitled to avail loans of about 5 lakhs per doctor at extremely low interest (under 5% per annum) from these banks for starting clinic. EMI repayment should start from one/two years after the date of disbursement.  The rules of disbursement and loan recovery will be with banks, supervised by IMA. Also, IMA should act as guarantee for all such doctors.
• By 3 years, this will be self-sustained system. IMA can receive 1% interest per annum from banks for administrative purposes and for executing the process.
• This arrangement would encourage many MBBS doctors to dwell into practice. They should strongly feel that specialization is not essential or mandatory for being a good doctor and for serving the society! With time, the pyramid gets better and better!
• The entire handling of money would be done by banks in a professional way. No professional body would be directly involved. Detailed rules can be formed using the legal committee of IMA with banks to ensure simple yet thoughtful rules. Banks have to be accountable for IMA and other professional bodies. A committee of eminent doctors can be formed for this purpose to work on honorary basis. Since the reputation of banks is at stake with doctors, they will not dare foul play!

1. Each professional body should contribute to welfare of these MBBS doctors. There is no fear of losing practice. The referrals would be so good that each specialist or subspecialist would end up seeing more meaningful patients. Thus, individual consultation can go up with more attention given to each patient.
2. How can they contribute? Each specialist professional body should have online support forum in their website. Algorithms should be created for specific symptoms or problems with clear indication of how to manage and when to refer. These should be available in simple print versions also. Specific upgradations should be done to these algorithms as and when guidelines change. In addition, each specialist professional body should conduct specific CMEs meant for MBBS practitioners on periodic places at various places using locally available specialists. This would bring up tremendous rapport amongst them.
3. IMA should encourage student membership for all MBBS students right from 2^nd year. Monthly talks on practical aspects of clinic practice including legal hurdles, tips for good practice, medical ethics, government norms and everything a practitioner needs should be elaborated in these lectures with active participation from students.
4. Mentorship programme should be started by IMA. In this, any doctor willing to mentor one MBBS student should be enrolled into a database. Students should be offered an opportunity to stay with the said practitioner for a period of 6 months during practice hours to learn the nuances of practice, body-language, communication skills, art of practice and anything that helps practice on long run.
5. Active legal and indemnity insurance support should be provided by IMA to all MBBS practitioners at a very nominal cost. This works out due to good volumes.

This is an incomplete list. Huge modifications are possible. The biggest advantages of these steps are: government not involved at any point; no involvement of MCI is sought; no demand for change in curriculum- these are anyway not possible to achieve by mortal humans like us! These suggestions appear do-able!

Of course, this involves active participation of IMA as liaison office to collaborate and facilitate the overall process. This is the only hitch because we have never seen IMA standing firmly for the cause of doctors! However, some income generation and power bestowed upon should encourage IMA to be more proactive. There is always a choice of parallel body with time!

This lengthy piece of write up is meant for strong criticism and suggestions. Please remember: don’t criticize without suggestions on overcoming your criticism!

We need to change; we need a start! Let us begin somewhere. Let this beginning happen at DocPlexus forum!

 Resurrection of MBBS and Family medicine, Can it check quackery in India?

It is a burning problem with no policy maker paying attention to.
Certain issues in India are beyond comprehension and logic. Realms of intelligent understanding fail to find a reason, let alone search for solutions!
How can AYUSH graduates be allowed to practice modern-medicine? (But remember: MBBS graduate writing an occasional Ayurvedic medicine get penalised by court!) A simple "devils rush in where angels fear to tread" promotion by esteemed governments!
Forget their validity, government support or political backing; AYUSH graduates practicing modern-medicine do great; in fact, fabulous! Many of them are more successful than MBBS graduates with same years of practice!
How can someone who does not even have any formal understanding of our pharmacology be more successful than someone who has studied our medications systematically for more than 4 years?
Some of the reasons that come to mind are:

1. AYUSH people know that their graduation is the end of academic journey for them. For most of them, it is a surrogate entry into modern-medicine. So, they start their practice preparations by 2nd year of AYUSH course by doing night duties or becoming a helper to some busy practitioner. They gain their half-baked knowledge and full blown confidence from there!
2. AYUSH graduates are conservative! Most of them know their limits. Whenever something even remotely challenging is encountered, they wash their hands-off by generating massive fear in patients, thereby referring to a better place!
3. AYUSH graduates are over-cautious! They want to gain confidence of patients by fast relief. To achieve this, they indiscriminately use higher antibiotics, stronger analgesics, cocktail regimes and so on. Since they have no idea of scientific medicine or antibiotic resistance or ethical practice, they have no moral obligation either. "Ignorance is bliss" applies to them the best!
4. AYUSH graduates are over the top! They know what our ignorant masses want and they give "what people want"! One IM injection is mandatory for them! One AYUSH practitioner in my place is so busy that he does not even allow the patient to raise the sleeve of shirt; he gives injection into the deltoid region over the shirt of patient. And he has so many admirers for that quality!
5. AYUSH graduates pose inexpensive! Most of them charge under Rs.100/- per consultation with few paracetamol tablets, some weird colored cough syrup and an IM injection (usually diclofenac), all inclusive. Many of them do all this within 5 minutes! I have seen AYUSH graduates seeing (not consulting; they cannot!) around 100 patients per day on an average! But their cocktail prescriptions involving higher antibiotics cost quite an amount. Most of the patients do not understand the concept of "total expenditure" but are very satisfied with a doctor who charges less!
6. Since AYUSH doctors know only bits and pieces of pharmacology of modern-medicine, they rely heavily on medical reps of sub-standard pharma companies and local chemists. It is an extremely ugly nexus with of unethical brutes promoting each other! As with any other unethical nexus in India, this only gets stronger with time!

One can probably go on endlessly with this. Advantage of listing this is only when some punitive action can be taken or when it needs to be systematically countered. Otherwise, it is as good as yellow journalism!
How to counter this? We cannot trust government to help us. Most of the governments are against doctors of modern-medicine for unknown reasons! We have to find a solution ourselves!
We can start with some possible solutions. It cannot happen overnight. Lots of cumulative and continuous efforts are needed. But the beginning should happen somewhere too!

1. If some sort of forced discipline can be brought to qualification of duty doctors in hospitals and nursing homes, it would be a major boost. Any place employing non-MBBS doctors for treating patients with modern medical practices should be brought to the notice of patients. Awareness of patient community should be enhanced in this regard. They should be encouraged to force the hospitals to disclose the qualification of every doctor, including duty doctors, ICU resident, OPD/Ward assistant involved in treating them. Legal action against hospital should be threatened by patients for making non-MBBS doctors serve their medical needs. Every case of medical negligence should be evaluated for involvement of non-MBBS doctors.
2. The concept of ethical medicine and judicious use of antibiotics should be informed to public through mass-media, newspaper articles and public speeches. Protocols for approaching and treating routine OPD problems should be drawn and should accompany the prescriptions.One of the major ways to cut down the cost to patient is by bringing
3. the facilities together. A system should be developed where the overall profit sharing happens. Small centres with 3-4 consultation chambers with an attached pharmacy and a small lab should be established. Here, MBBS doctors would act as the back-bone of system with few on-call specialists. The MBBS doctors should charge less from each patient. At the end of month, cumulative profit from all the sources should be shared by all service providers. This way, everyone wins. The take-home at the end of month is higher for everyone. Of course, this involves some "taming down the ego", but is worth it for long run!
4. The nexus of bad pharma companies and AYUSH graduates practicing modern-medicine should be broken. Generics from reputed pharma companies dispensed by MBBS doctors through their pharmacy is very useful in this.
5. Every established General Practitioner should mentor at least one MBBS students per year in skills and art of general practice. Those who are unsure of competition can mentor MBBS students from outside place. Professional bodies like IMA should facilitate such mentoring. It is mutually beneficial for MBBS community. Technology can be of great use here. Some portal should act as liaison between those who can mentor and those who seek mentoring.
6. A good corpus should be generated by donations from hospitals and established practitioners to team up with few banks to provide loans for MBBS (not AYUSH quacks!) graduates at lowest interest possible to establish comprehensive clinics with pharmacy and lab. This will transpire to reducing cost of basic health-care with passing time.
7. Every MBBS doctor who wishes to make a career in general practice should be trained free-of-cost intensely for 6-12 months under some good hands. This can be non-government arrangement facilitated by professional bodies like IMA in collaboration with senior GPs and second-tier hospitals with a decent pay-package for service of MBBS graduate. Both the parties will be immensely benefitted.
8. A strong association of family physicians should be created attached to already existing professional bodies of specialties. It should be onus of all the specialists to support the association of Family Physicians in any way possible - financial to academic to legal to supportive and so on. The symbiosis will win than half-hearted fractionated fight.

I sincerely believe that there is no suggestion mentioned above which cannot be attained! It needs few good people with strong will power and dedication. And the best part of these suggestions are - they do not involve Government at any point!
It is not just the question of our survival but also the issue of restructuring the health-care pyramid of our country. Since we cannot rely on government or policy-makers to help us, it is high time to help ourselves. Unity is strength and we should strengthen the base of medical care by mutual support.
I would strongly seek criticism of the suggestions mentioned above with all possible corrective measures. Also, additional feasible suggestions are vehemently encouraged. If even an iota of idea flashes to anyone reading this, please take few minute to pen it down. It may be the most contributory suggestion for future! Please don't kill any positive measure you think which can potentially work!
We need a beginning; we need to be supportive; we need to fight a massive battle - not just for ourselves but for our children, our future, our masses and our final good!
Please be generous with whatever comments you have. All caustic ones are as welcome as compliments!