Doctors are frustrated, patients are angry, hospitals in the west are going broke, insurance companies that are there only to make money are also declaring Chapter eleven by the day. Time to get back to the old, trusted tradition of family doctors?

“The time has come," the Walrus said,
"To talk of many things:
  Of shoes--and ships--and sealing-wax--                                 
 Of cabbages--and kings--
 And why the sea is boiling hot--                     
And whether pigs have wings."  
               -Lewis Carroll 1872.                   
 

“If one does not learn from history, one will have to relive history,” wrote Cicero, the great Roman thinker.  Medicine has been branching into innumerable specialties and sub-specialties (super-specialties in Hinglish). It has reached a point where the whole modern medical world is standing at the threshold of losing its sway over the common man. A recent survey in the US showed that sixty-two per cent of upper middle class Americans could not afford to go to hospitals there as medicine has become prohibitively expensive despite patients having more than one Medicare insurance policy. Many a time the small print in the insurance policy denies them help when the chips are down. Fifty-seven per cent of the British do not want to go to a modern medical facility, if they could help it, despite the free National Health Service there. “Modern medicine” said Prince Philip, the heir to the British throne, recently “is slightly off balance like the Tower of Pisa for all its breath-taking advances.” He could not be more accurate in his assessment. The alternative medicines have been a $70 billion business last year! Most of that is not proven to be useful, though. There seems to be confusion all over.

In the last half a century medicine has gone to the market place riding piggyback on technology and, consequently, market forces act on it in a big way today. Time was when a patient came to the doctor with all faith (faith heals) and felt that doctor is God and would do his/her best for the hapless patient. Not anymore! Today the doctor is a seller of medical technology and the patient a buyer. Consumerism rules the roost, making doctors practise expensive defensive medicine. Doctors are frustrated, patients are angry, hospitals in the west are going broke, insurance companies that are there only to make money are also declaring Chapter eleven by the day. The administrators seem to be groping in the dark with no clear end in sight. Reminds one of the First Law of Thermodynamics which states that “anything that disintegrates eventually disappears.” Thinking people in the medical world will have to do something before it is too late. Doctors should remember that a patient could live without the help of doctors but a doctor cannot live without patients.

When a patient goes directly to a super specialist any symptom that the patient might have looks like the rare presentation of a disease in the specialist’s own field. The hapless patient gets a battery of tests and interventions only to be told at the end that he/ she does not have a disease of that particular organ! By then the patient has lost most of his/ her earnings. Patient did not get any solace and has had no answer to his problems, either. Most of these interventions are not only unnecessary but could be potentially dangerous. The specialist is like the man with the hammer in the hand wanting to use it badly. For such a man everything looks like a nail needing hammering, wrote Mark Twain years ago.

The only solution is to go back to the time tested family physician system with necessary modifications in the training period to make the family physician truly useful to the sick. The emphasis should be to seek second opinion when in doubt. Time was when medicine was practised only in the patient’s homes. Hospitals were not there. The family physician made his diagnosis at the bedside and did what he could with very little technology. Some indications today point to the fact that there has not been any marked improvement in the per capita deaths today compared to the good old days except that the dying could feel that their life has been prolonged today because of the way they are being intervened in the last ten days of their lives. Death has lost its dignity.  Ninety per cent of the medical care budget in the USA goes to keep seriously ill patients alive in the last ten days of their sojourn on this planet.

Even today a double blind prospective study in London did show that eighty per cent of the accurate final diagnosis and one hundred per cent of the future management strategies could be chalked out at the end of carefully listening to the patient! Family medicine, therefore, is very useful and affordable, if practised scientifically. Only in rare cases a specialist might be needed to intervene at the behest of the family physician. Such specialists must be classed as medical technologists and not true doctors. They should have very little to do with diagnosis of illnesses. A specialist should be like a laboratory supplying the investigation data to the family doctor when in doubt. He could also assist the family doctor to manage the illness using his tools only when needed.

Family Physician in the new Avatar:

After graduation one should take postgraduate training for at least three years in this specialty, before being let loose on the gullible public. The entry criteria for being admitted to this PG course should be the following, in addition to the marks obtained in a replicative entry examination preceding the selection:

•        Can he/she smile naturally at some one?

•        Can he/she touch someone comfortably?

•        Does he/she have an insight into another’s suffering?

If the answer to any of the above questions is in the negative he/ she is debarred from this specialty. They could go into some other area where human direct contact is minimal.

The curriculum for this course should be drawn up very carefully keeping the human being as the supreme commander of all else. True humanism, medical humanism included, is simple the primacy of man in every distress situation. The family physician should be a sort of jack of all trades and he should have a good grounding in human psychology. The recent revelation to modern medicine that all ills from common cold to cancer originate in the human mind and regress also with the help of the mind makes it imperative that the new family physician should have a very thorough understanding of the human psyche. Clinical psychology should occupy a large space in the course.

The next stress should be on health promotive activities and behaviours that help keep healthy people well as long as they live. The doctor should have instructions in interpersonal relations, the social realities of the area where he/she proposes to practise later, other alternative systems of medicine being practiced in the area, as also the religious and cultural beliefs of the patients. Intense training in bedside methods of diagnosis and management are to be stressed, technology being given very limited role. Clinical research methodologies should be thoroughly understood by these doctors as most of the milestone studies were done by family doctors practicing bedside medicine and using their curiosity being organized properly with logical scepticism.

Nutrition and exercise physiology must also be taught in detail. Spirituality, not religion, in its true form should be taught. Spirituality is the same in every religion-sharing and caring, its role in healing has to be stressed in this course. Many studies recently have proved that spirituality does help in disease set up. The new science of CHAOS and fractals using non-linear mathematics should be a part of the curriculum although detailed instructions in this area might be beyond the reach of most medical graduates. This latter is very essential as time evolution in a dynamic system like the human body does not depend on reductionist rules. The time evolution follows the holistic laws of uncertainty. A touch of quantum physics could be taught for the doctor to understand the sub-atomic world and thereby understand the role played by human consciousness in illness and healing. Yoga and meditation should be a part of this course.

Elementary knowledge of statistics and research methodologies is a must for the family doctor to be able to critically look at published data as also to design his/her personal studies of problems in their practice.

Conclusions:

Just as fashions change in society and many a time the old fashion becomes the most modern, family medicine, the foundation of the medical consultation, the coming together of two human beings-the patient and the doctor could be the best institution for the sick. This needs to be quickly revived. It is that foundation, which developed into the first “clinic” and later developed into hospitals of modern era. The latter hi-tech five-star hospital care has gone beyond the reach of most people in society. Hence, there is an urgent need to re-invent that sacred doctor-patient relationship which is the basis of the placebo effect, the shot in the arm for the human immune repair mechanism in all disease conditions. The kingpin in the game is the first contact doctor, the family physician. He needs to be re-equipped for his changing role in the present set up, having been born again as a specialist in his own right. He is the true doctor that “cures rarely, comforts mostly, but consoles always.” The earlier it is done the better for mankind. This is not the most celebrated specialty today, though.
 

“No less in war as elsewhere, the most beautiful and most virtuous deeds are not always the most celebrated ones.”

-Plutarch

(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS. He is also Editor-in-Chief of the Journal of the Science of Healing Outcomes, Chairman of the State Health Society's Expert Committee, Govt of Bihar, Patna. He is former Vice Chancellor of Manipal University at Mangalore and former professor for Cardiology of the Middlesex Hospital Medical School, University of London.)