Sunday, June 17, 2012

Are Doctors Irrelevant?

My grandmother used to say, “Be careful of what you wish for.” She was right. We have come a long way down this current  path of guileless uncertainty. The charm of the “reap and find reward” seems to be over. Now is the time of reconciliation with the thinner concepts that run freely.

Are doctors irrelevant? Many will and do say yes! These voices are rising in decibels. The din is starting to reverberate through the halls of policymakers and even the laity is mind-numbed into echoing, “The King is dead.” They are ready to worship the new one, “Long live the King.”

Cartoon from the Economist

It seems that in caring for patients, the doctors are on the periphery looking in. Everyone else seems to have a better handle on how patients should be treated. Experts are proliferating and ripping the shroud from under which they have been opining. They are now openly writing editorials. “Ah,” they say, “the doctors are recalcitrant in their thinking.” Maybe we are. Maybe we, out of concern for our patients need to think through things to determine the best course for the diseased, the infirm and the unhealthy. “The doctors are greedy,” they clamor. Maybe we are but mostly about the best possible care that can be rendered. “The doctors are rich and fat,” the headlines grapple with our attention. Maybe we are rich, in knowledge and fat with understanding of it. But in finance most are barely able to keep their heads above water.  At most points in our career we have generously donated our time and monies towards someone’s care without demanding any returns. Here, at the threshold of transformational change to medicine, we look to discard the virtues that have brought recovery from illness, comfort from grief and solace from the inconsolable dissonance of disease, to the shimmering mirage of a vacuous future.

Graph from The Economist

The experts are now billowing through their mouths about how foreign countries like India have only 5 doctors for every 10,000 people, whereas there are 24 per 10,000 in the US. Somehow it has now been determined by The Economist that India has a wonderful concept of Healthcare delivery as compared with the United States. They go on to describe how an ophthalmologist has two patients on either side while he turns from one to the other to save time.  “The Aravind Eye Care System offers surgery to about 350,000 patients a year. Operating rooms have at least two beds, so surgeons can swivel from one patient to the next.” What about transmission of infectious disease? Are there pitfalls to this assembly-line like workshop of surgeries? Oh but that is not discussed. The intent is to marginalize the facts and propound the potential. The largest employer for this form of delivery by the name of Dr. Shetty who has thousands of bed hospitals across India has pushed a bill to reduce the medical education to 3 and ½ years in India. That he says will produce more general doctors to handle the mundane form of health care (as if there was any mundane form). “Dr Shetty’s goal is to offer as many surgeries as possible, without compromising on quality. To do that, he ensures that his surgeons do only the most complex procedures; an army of other workers do everything else. The result is surgeries that cost less than $2,000 each, about one-fifteenth as much as a similar procedure in America.” I wonder what "comprising quality" means to him. There are murmurs from the mimes in the US also, where three years of medical education seems to fit the budget. Are they right? IS the current four-year rigor too rigorous and expensive? What are we missing? I look back and think, was there any redundancy in my training? The answer is a resounding, No! The fundamentals of medicine are the most important ingredient in the doctor’s quiver. Absent that and the understanding of disease will falter. It is quite simple, if you don't know what makes it tick, how do you know what could make it stop ~ ticking that is.

The experts claim that the health service provided by the nurses was non-inferior to that of a doctor. Really?  It boggles my mind as to the difference in education and comprehension of the disease complex in a patient with multiple co-morbidities. Will the nurses have it? Will the physician assistants bear the brunt of understanding a cardiac patient with emphysema and poor renal function going into right-heart failure as the atria fibrillate? Will the nurse practitioner differentiate in a cancer patient, between the potential side effects of the monoclonal antibody therapy, hypertension and an impending stroke? Unfortunately the many nuances in medicine, garnered over years of experiential knowledge, are being laid at the altar of expediency and fiscal prudence.

The television and online presence gives us a preview of the "doctors." Anyone wearing a white coat with a stethoscope around their neck; diagnosing plumbing problem, roach infestation, swimming pool service and the best one yet, the "doctor of democracy." So put a white coat and sport a stethoscope and the knowledge of medicine they seem to imply will magically appear through osmosis.

“Be careful for what you wish for.”

In all of this "transformation and disruption" of medical care, there is good that never gets registers on the meter: newer training concepts are on the threshold of enhancing the experience of the medical students in the US and this, potentially, may help make the medical students more adept in handling patient care. At the North Shore Long Island Medical College the training of the new up and coming doctors is being done in the real world scenarios: (Video Link Below)


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