Some simple steps that can help provide 
affordable, quality health care anywhere in India
By Dr Kavery Nambisan

Healing bond: Dr Anupam Sibal with a patient at Indraprastha Apollo Hospitals, Delhi. Among the essential qualities of a doctor is the ability to empathise / Photo: Arvind Jain

Medical care in our country is like a patchwork quilt: a few small segments sewn with lovely silk while the rest are frayed and falling apart. Millions of Indians are deprived of basic medical facilities because they are too expensive. Well-to-do Indians have the right to be healthy. The rest simply suffer or die. We like to boast about the richness of our culture and about the billionaires who figure prominently in the news but when it comes to human development, we are paupers.
The imbalance in health care, the dreadful state of most government hospitals and the exorbitant fees charged by private doctors are common knowledge. How shall we redress these?

Like several of my colleagues, I have spent most of my surgical career working in rural areas, in south and north India. In many such places, being the only qualified surgeon, I had to handle all types of cases. Rural folk are hard-pressed for money and cannot spend too much on any illness. My experience and that of my colleagues shows that quality medical care that is affordable can be given anywhere in India (or any other country) by following a few essential steps.

As medical students we spend five and a half years learning the art and science of medicine. But we are not sensitised to the unique nature of a profession that has to deal with pain and suffering all the time. Mere moral lectures will not do. One way to sensitise young minds is by introducing humanities into the medical curriculum as is being done in many countries. It will help produce more rounded personalities, better equipped to take on the high-pressure job of a doctor while retaining human values.

For a young doctor, there are riches to be had from working with an experienced senior, especially in a hospital where the resources are not plentiful. He will learn to adapt and innovate, use his clinical judgment and will not be easily tempted to do too many investigative procedures like blood tests, X-rays and scans. He will be an all-round doctor rather than one with narrow experience. We certainly need specialists and super-specialists for the treatment of certain problems but for the majority of ailments, an efficient MBBS doctor is all you need. He can learn multiple skills by working with a senior who is willing to pass on his experience and knowledge.

A surgeon working in a small town or village should be able to do a hernia repair, mend a broken forearm, manage prostate trouble or do a caesarean section. He should be able to handle common medical problems like chest infections, skin allergies, diabetes, angina and high blood pressure. A multi-skilled doctor can handle 85-90 per cent of all patients walking in or wheeled into the hospital.
Doctors must have the ability to empathise. This quality can be developed by any doctor who is able to put herself in the patient’s place. She is then more likely to come up with the right mode of treatment.

A part of this process is telling the patient why he fell ill, explaining the disease and teaching ways of preventing future problems. This is an essential part of a doctor’s job but is totally neglected for two reasons: patients never ask questions like “What caused this illness?”, “What exactly is diabetes/blood pressure/eczema?” or “How do I protect myself in future?” Most of us prefer to fall sick and then be cured after suffering the pain and agony. This is silly, because learning how to prevent future problems is far better for health. Instead we are grateful when the doctor gives a few minutes of her precious time to prescribe medicines.

We doctors like to think that we have too much to do and little time to talk to patients. By readjusting our priorities and the way we work, it can be done. The rewards are tremendous, for both patient and doctor.
Small, well-run hospitals are much more efficient than large ones. It may make good business sense to have 1,000- and 2,000-bed mega-centres with hundreds of doctors and thousands of paramedics, and the main objective of making a profit. This usually results in diminished quality of care. The ideal in-patient capacity for a rural or a small-town hospital is 60 beds. In a city, it could go up to 100 or, because of multiple speciality departments, 200. In such hospitals, the doctors, nurses and other staff get to know each other. They meet and talk every day, not just as medical professionals but also as ordinary human beings. This makes it easier for them to work as a team and it boosts their morale. They are less stressed and more caring. For the patient, a well-managed small hospital with efficient doctors and staff is a real boon.

A good hospital will say ‘no’ to unnecessary gadgets. A hospital should have only those machines which are in regular use, with the exception of certain life-saving emergency equipment which are essential. Before any new purchase is made, its usefulness and running expenditure must be carefully looked into. Some hospitals buy equipment the way a fashion-crazy youngster blindly follows the latest style, without stopping to consider if it will suit her. The running expenses for rarely used equipment will be very high, and patients will be made to go through needless investigations in order to recover the money.
Most illnesses require fairly simple treatment and very little in the form of investigations and tests. An efficient doctor and nurse can do far more than any gadget. In many peripheral hospitals, seriously ill patients (like those who have suffered a heart attack or undergone major surgery) are being cared for perfectly well by giving intensive nursing care without the use of a multitude of gadgets. When more sophisticated methods are absolutely essential, such patients can be referred to a higher, multi-speciality centre. This will be psychologically better for the patient, and the medical bills will be a fraction of what one would pay in a fully-equipped ICU.

Choices such as these—of keeping the treatment simple and effective at all times—have to be made by those who run small hospitals. Any patient who cannot be treated without sophisticated gadgetry and/or by super-specialists should be referred to the appropriate centre at the earliest. In the vast majority of cases, this is not necessary.
For a doctor (or nurse or any hospital staff), there is no greater joy than that of seeing a patient cured and happy before going home. If more doctors can come together with this purpose in mind, we can do much more for the health of our nation than by blindly applying our knowledge. The knowledge is very important. But without genuine caring, it is at best cosmetic. And from experience, I know that a good living can be honestly made without chasing money.

Can doctors fulfil the real needs of patients? We need to make the right choices. The rest is simple.

Nambisan is a surgeon and novelist. Her most recent novel, The Story That Must Not Be Told, is shortlisted for the DSC South Asian Literary Prize.

source: http://www.week.manoramaonline.com / Cover Story / THE WEEK / Saturday, November 19th, 2011