Thread by @scanman

#Thread Family Doctors (Primary Care) Vs Speciality Care in #India
A few weeks ago, in response to a different thread (

https://twitter.com/scanman/status/1122023034611568640?s=20

) there was a comment from @spinesurgeon that we need family physicians. (1/31)

Another comment in that thread by @VaradhKrish referred to the issue of patients going directly to specialists, bypassing primary care doctors. (2/31)

The problem of patients going to specialists directly, rather than to primary care/family doctors first and then being referred by them to specialists is one that requires a more in-depth analysis. (3/31)

I believe this problem is unique to regions that are blessed with advanced medical facilities – states like #TamilNadu, #Kerala, #Maharashtra & some cities like Bengaluru, Mysuru & Hyderabad. I’ll take TN as an example as it’s the state that I know the most about. (4/31)

The decline of neighbourhood family doctors and the origin of the trend of patients directly seeking treatment from specialists can be traced to a series of parallel and interconnected events that began in the 1980s. (5/31)

The '80s saw the first concerted effort by the TN government to increase medical postgraduate seats and give preference to doctors who were in government service for opting for PG specialities. (6/31)

The TN government also embarked on an ambitious programme to expand the government sector medical facilities from the primary health centre to tertiary care (medical college and district) hospital level, increasing the number of specialists posted in these facilities. (7/31)

The '80s were also the beginning of the heydays of private hospitals, polyclinics & clinics in Tier 2, 3 cities and small towns in the state offering multiple specialities. This is directly related to the increased number of postgraduate seats that were available. (8/31)

The '80s and '90s also saw the exponential growth of postgraduate seats in private medical colleges, less in TN than in neighbouring Karnataka, where many of our young MBBS doctors went to pursue PG studies. (9/31)

Parallel to this growth in medical facilities was an increasing awareness about health and healthcare facilities in a rapidly urbanising populace fostered by a growing regional print and electronic media. (10/31)

All these factors contributed in varying degrees to a general perception that a doctor with "just an MBBS degree" is not good enough for taking care of our minor illnesses, routine check-ups and follow-ups. (11/31)

Anyone with the most basic knowledge of healthcare would know that these minor illnesses make up the vast majority of a population's healthcare needs – the bottom of the healthcare pyramid. (12/31)

So we witnessed the demise of the concept of the neighbourhood "family doctor" towards the end of the 20th century. We lost the very basic filter in the system that prevents overburdening secondary and tertiary care centres and the specialists manning them. (13/31)

Our healthcare delivery is now heavily skewed towards specialisation. The vast majority of neighbourhood clinics in #TamilNadu are manned by specialists nowadays. (14/31)

The small number of neighbourhood clinics that are run by MBBS doctors are invariably part-time clinics where the doctors have other full-time jobs either in the government or private sectors. (15/31)

I know of no fresh MBBS doctor in the past decade who has started a neighbourhood clinic. I'm very sure this is the norm and not an exception. This could be the case in many other states as well. (16/31)

Almost all fresh MBBS doctors take time off to prepare for their postgraduate entrance exams. They don't want to waste time working even in hospital settings, leave alone neighbourhood clinics. (17/31)

Private hospitals are struggling to get MBBS duty medical officers. Many hospitals resort to employing foreign medical graduates who haven't yet passed the licensing exam (FMGE Screening Test). Many unscrupulous hospitals employ AYUSH graduates instead of MBBS doctors. (18/31)

Since there's less demand, the market has responded with reduced supply of primary care/family doctors. The central @MoHFW_INDIA & National Board of Examinations tried to promote DNB Family Medicine as a postgraduate speciality, but it's a half-hearted effort at best. (19/31)

So, we have a skewed system where the bottom of the healthcare pyramid is being serviced by specialists.
What's wrong with that?
Aren't people going to get better care from better trained/experienced specialist doctors rather than "just MBBS" doctors? (20/31)

I don't believe, and most experts agree, that the general population is served better by specialists at the primary care level. Actually, the presence of specialists at the bottom of the pyramid inherently increases the cost of healthcare delivery. (21/31)

A couple of simple examples will illustrate this. A person who goes to their family doctor with burning upper abdominal pain will probably just pay a visit's fee and be sent away shortly with a prescription for a course of anti-ulcer medicines. (22/31)

The same person, if they go directly to a specialist, a medical or surgical gastroenterologist, for their stomach ache will definitely have to undergo some blood tests, an endoscopy, probably an ultrasound scan and pay a higher consultation fee. (23/31)

They would in all likelihood walk out of the specialist's clinic with a similar prescription for a course of anti-ulcer medicines. But at a far higher cost, and after having spent more time. (24/31)

Extrapolate the scenario for a person who goes with complaints of headache of a few days duration to their family doctor and to a neurologist or neurosurgeon. Or to any other common minor illness for which a specialist's opinion is sought. (25/31)

It becomes very obvious that the cost of even simple outpatient care increases exponentially when a specialist is involved. (26/31)

Patients being screened initially by primary care family doctors and judiciously referred to specialists will keep healthcare costs under control. But this is a pipe-dream as of now. We are now living in an obscenely skewed healthcare delivery system. (27/31)

The entrenched specialist-rich system will resist any change that involves relinquishing of power/income. Moreover the current and emerging health insurance scenario in the country encourages the existing system. (28/31)

I don’t know of any insurance system in the country that reimburses outpatient primary care. I don’t think there are many that reimburse even speciality OP care. Even the much vaunted Ayushman Bharat PMJAY scheme heavily encourages speciality care in its present form. (29/31)

We, in India, are still producing more MBBS doctors per year than specialists. It's not too late to correct the system. But it will take a total change in the thought process of the government and medical education establishment. (30/31)

I’m a pessimist who doesn’t believe that this is likely to happen in my professional lifetime.
Let's hope the future will be better and brighter in #India for primary care and family doctors. (31/31)

@threadreaderapp unroll

@threadreaderapp As @spinesurgeon rightly pointed out, another important thing that contributed to the loss of family doctors is the 1995 Supreme Court decision in IMA v VP Shantha that brought the medical profession within the ambit of a ‘service’ as defined in the Consumer Protection Act, 1986.

Many "medical negligence" verdicts in consumer protection forums & our courts have reinforced the belief that "just MBBS" doctors are not competent to treat most ailments. Obviously this led to specialists opinions being sought for stuff that can be handled at the primary level.

I believe more than the Consumer Protection Act (CPA) 1986, or the SC verdict of 1995, the current insurance-driven healthcare climate and the Clinical Establishment Acts (CEA) of various states are going to be the final nails in the coffin containing family doctors.

As already mentioned in the thread above, there is almost no insurance coverage for primary care. CEA requirements make the running of anything other than single-room outpatient consultancies costly and cumbersome. It's very difficult for MBBS primary care doctors to comply.