Changing cultures within medicine

K. S. Jacob
care and service.

Medicine continues to be a valued career choice in India. However, the many changes in society over the past few decades have made it a less attractive option today. The changes in the social and financial climate have also resulted in major shifts within medicine. The changed culture within medicine appears pervasive and, in many ways, irreversible. Medicine today looks less of a vocation and more of a business opportunity.

Many recent changes, some subtle and others more obvious, have had a significant impact on the practice of medicine. Even subtle shifts within society have had a major impact on the traditions of medicine, with some catastrophic and others no less monumental.

Prevention versus cure

Prevention is less fashionable than cure: employing urgency-driven curative medical solutions, instead of long-term public health policies, is common. Diarrhoea, potentially a killer disease among the vulnerable and often caused by unsafe water and poor sanitation, is commonly treated with antibiotics with no provision to address the root causes. This is also true for the relationship between tuberculosis and poor housing or chronic malnutrition and inadequate nutrition. Much of the effort of today’s champions of public health ends up in provision of curative services, albeit at the small hospital or clinic. They succumb to the constant demand for better curative services. Such services thwart public health efforts by treating diseases and preventing death (reducing their impact on social consciousness), which should have been prevented in the first place using public health strategies. Cynics would argue that there is less money to be made through public health interventions.

Curing a disease is more glamorous than healing an illness: The medicalisation of distress has lowered the threshold for seeking help from physicians. About a third of people who visit physicians do not have a demonstrable medical disease. Many visit doctors when they are in distress or are unable to cope with life’s incessant demands. However, recent advances in technology have made diagnosis and cure attractive and profitable for hospitals and medical practitioners. Physicians are taught to focus on underlying structural and functional defects and they often tend to disregard the human context of illnesses. Many physicians, with their focus on disease and cure, get irritated with patients who present symptoms with no obvious medical causes as determined by expensive laboratory investigations. They dismiss the patients’ concerns and rarely focus on the illness or practise the art of healing.

The clinical-technology divide: Clinical assessment forms the bedrock of medicine. However, the phenomenal improvement in medical technology, while revolutionising the practice of medicine, has come at a price. It has also changed medical traditions. There is a naive belief that technology will provide answers to every clinical problem; that its widespread and indiscriminate use will do away with the need for clinical judgment. The sole reliance on technology has also resulted in a devaluation of clinical skills and the failure of the younger generation of doctors to understand its role in medical diagnosis and management.

Technology in certain situations is crucial for diagnosis and management; in others, it can complicate matters. Many diagnostic tests and screening strategies are not absolute and when applied in low prevalence situations, produce false positive results leading to further testing or unnecessary medication. For example, the electroencephalogram (EEG) is only an adjunct in the diagnosis of epilepsy, a condition that should be diagnosed based on history and clinical examination in the vast majority of patients. The EEG’s moderate diagnostic sensitivity and specificity for the condition means that it may record “abnormalities” in normal people when employed indiscriminately and be negative in those with genuine seizures. The inappropriate use of technology will mean costs in terms of not just finances but also psychological stress. The focus on technology to the exclusion of clinical assessment as practised, for example, in the United States, has resulted in an expensive and grossly iniquitous health care system.

Generalist versus specialist approaches: Over the years, the general trend has been to seek specialist advice even for minor illnesses. Such help comes at a price. The absence of a generalist who can act as a gatekeeper means that even simple problems are seen in tertiary care centres and viewed through a specialist’s lens. The specialist, with his or her perspective of excluding the rarest of rare conditions in the field, usually ends up over-investigating even the most innocuous of symptoms. In addition, the specialists’ compartmentalised view of the body often does not allow them to see the big picture and tie up multisystem problems. The lack of confidence in the basic doctor and the absence of family medicine as a speciality compound the problem.

Profit before service: The fall of communism, the rise of capitalistic thought and economic liberalisation have had a major impact on medicine and health care in India. The 1990s saw a reduction in the emphasis on public expenditure with an increase in private and out-of-pocket expenses for health care. The poor functioning of government health facilities resulted in private hospitals and medical practitioners flourishing. Medical tourism has become a profitable industry. Performance incentives in the private sector essentially imply a commission for ordering tests or prescribing branded medication and medical devices. Contracts and commissions replacing salaries also mean that there is no limit to the incomes of physicians, laboratories and hospitals concerned. The complete absence of regulation and audit in these matters often results in unethical practices. Profit before service has become acceptable. Business models and wealth are the new standards to judge the success of doctors.

Hospital and pharmaceutical industries have increased their influence on the practice of medicine. The lack of enforcement of clinical guidelines and standards and the direct conflicts of financial interests often result in unnecessary diagnostic tests and medication and increased costs.

The system of capitation fees for admission to private colleges has increased the investment in medical education. The money transactions often said to be necessary for obtaining the regulatory permissions to start and run courses are transferred by medical colleges to students and doctors. The need to recoup the investment makes those who set up such facilities and those who pass out of them look at their institutions and careers through a business lens. Many such practices, unethical and some even illegal, appear to be the norm.

The many changes have had a cumulative effect, have resulted in increased costs and reduced access to health care for the majority of the population. The iniquitous distribution of health services means the most vulnerable and marginalised, who probably are in the greatest need of health services, are unable to access them. The cost of seeking health care is known to be the single important reason for indebtedness in the country. Yet, the changed culture within society and the medical profession refuses to acknowledge the need for equity.

The way forward

The special social status accorded to physicians necessarily mandates a social commitment to serve the people, especially the underprivileged and the marginalised. Such social obligation is necessary from not only individuals but also institutions, professional medical societies, regulatory authorities and governments. There is need for social audits and for greater social recognition for those who live, work and serve in disadvantaged areas.

Selection to medical schools should also evaluate social consciousness, a record of such service and a commitment to serve vulnerable sections. In selections for higher medical education, greater weightage should be accorded to those who serve in areas of need. The commercialisation of medical education and health care needs to be checked, unethical procedures should be curbed and illegal practices rooted out.

In the changing social climate, it may be necessary to reiterate the need for social commitment from physicians. There is need to reemphasise community responsibility, to highlight service and to provide equitable access to health care for all. Surely, the special social status accorded to physicians should be acknowledged by a social commitment to the health care needs of all people, not only those who can pay. However, it is unrealistic to expect changes in the prevailing medical culture without concomitant alterations in society. The challenge is to transform the prevailing cultures within medicine and in society.

(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore)