Vanishing Primary Healthcare: The General Practitioner Is An Endangered Species In India
Along with the ubiquitous sparrow, our general practitioners of family medicine (GPs) have seemingly disappeared from our cities. With approximately 9.9 lakh doctors that registered with the Medical Council of India (MCI) (June 2016) being concentrated in India’s cities, the common complaint about under-served rural versus gluts in urban areas masks this emerging problem. Where are our young GPs hiding? Family doctors have been the main stay of the primary care – preventive and curative. When primary care shifts to the hospital and specialists it is noted that, although costs go up, patients tend to access medical services less frequently, with less accuracy, and only for more serious illness.
The personalized preventive evidence-based screening at the family doctor is also replaced by standard one size fits all health-check packages. Additionally patient compliance in chronic disease treatment is directly related to easy access to primary care GPs (NHS, UK). So what happened to the doctors who provided this important service? According to data from the MCI, nearly 42,000 MBBS doctors get added to the Indian pool of doctors every year. Of these, up to 10,000 migrate abroad for fellowships or higher studies. Another 20,000 take up postgraduate courses in India, and close to 2000 MBBS graduates quit the medical field and venture into allied or unrelated fields. Eventually, a measly 8000–10,000 take up general medical practice as a profession. Experiences with setting up corporate chains of clinics and outreach centers have shown us the bottlenecks are the in supply of trained doctors (also nurses, support technicians, paramedics).
Let me enumerate three of the commonest cited obstacles to setting up practice from the doctors we hired:
Inadequate training. The current MBBS syllabus does not cover enough to produce reasonably confident doctors who can work independently. The National Board of Examinations along with others has started PG courses for family health – they are much of the same stuff.
Inadequate support. Being a GP can feel like the loneliest job on earth. There is very little peer-to-peer support, almost zero chances to discuss cases, and reduced opportunity to continue learning new or alternative methods. Limited exposure to marketing, business and management tools, legal counsel, technology, HR hamstrings GPs’ aiming to run a successful practice/business.
Inadequate career planning. The family doctor is often like the factory job-worker, that is, you work, you earn. Career and personal growth is unclear. Group practice (old style polyclinics) with built-in insurance and buffers is increasingly rare.
Fledging chains of corporate clinics, homecare, diagnostic services in primary care have had patchy success – the ones that succeed build on a good base of doctors and services; those that do not, fail. This is the advice I give to all doctors who want to know the potential future in opting out of medicine and pursuing an MBA or a degree in hospital management. The obstacles are not unsurmountable – there is hope for entrepreneurs in medicine. I advise – lean in, do not opt out.
The exodus from GP practice was partly due to the change in the nature of medicine 40 years ago, when it moved to more invasive and intensive therapeutic areas that were impossible to deliver in outpatient clinics. 15 years ago, it moved again – this time toward minimally invasive protocol-driven care, closer to home. We can make this change work for entrepreneur doctors. It is time we helped our young doctors leap over obstacles, take control of primary medical delivery and earn an ethical, well-compensated, rewarding livelihood.
