Public Private Health Divide

THE GREAT PUBLIC PRIVATE HEALTHCARE DIVIDE-------a doctor speaks 

      

      I joined the medical profession in 1992 technically speaking, as I was a  medical student before that. There is a vast difference in the way I think, the way I behave and the way I treat from then and now.I used to look for role models then and in my own way I used to always find them.The calm surgery house surgeon who taught me for hours how to put intravenous cannulas,the surgery senior resident who taught me how to remain awake after a 24 hours duty and still have the enthusiasm to teach the steps of appendicectomy to an intern he would never meet after a week,the medical senior resident who grilled us for hours during morning rounds just to empower us with more knowledge. There was always so much to learn and so much to imbibe that not a moment was spent in procrastination.The medical education in the preclinical days however was quite ruthless according to me. Hours of cramming fat dissection books ,15 people working on the same cadaver,tough practical exams after every two months when the demonstrator would get some animal like pleasure in announcing your pitiable low scores.The behaviour of the professors and teachers made one feel that failing in one of these exams was akin to damaging your career for ever. In the first six months of my starting the medical journey,there wasn’t a single night when I didn’t cry myself to sleep thinking that I wouldn’t be able to go to college the next day. The students who had their siblings as seniors generally fared well.They already knew what was expected and accordingly crammed up the inticracies of arteries, mucles and veins in advance.Every thing that we gobbled up whether it was biochemistry,physiology,pharmacology,microbiology and so on was far removed from the reality that we would be facing in the subsequent years.But looking back I think that every single day of those long years of hardships toughened us up for the long corrugated journey of the medical world.

It was during internship that I got a taste of professional life that we would be facing in future.The plight of poor patients moved me and I realised how poor people suffer in disease physically and socially. Women coming in with a 2 gm%  haemoglobin with inversion uterus,women brought in a charpoy with rupture uterus ,women with intestine hanging out of uterus dumped in front of us and relatives untraceable for hours after that. I could see the obstetric residents working for hours and still not being able to do enough.  During my postgraduation years that I came face to face with human suffering and physical pain. There was no room for exhaustion. During the 12 hour continous duty we would see sometimes the whole spectrum of obstetric mishaps starting from intractable postpartum haemorrhage to secondary abdominal pregnancy.We could save some and we couldnt save some but each patient taught me to be a better clinician and a more humanitarian doctor.When I moved to the private sector due to lack of government jobs in the city the scenario drastically changed. The medical practice in government hospitals is so different from care giving in private hospitals that as a doctor I took very long to adjust to it.In the former you had these scores of patients in the labour room  where you are taking a quick history ,doing quick obstetric examinations and the whole focus is on making a fast diagnosis and expediate the treatment so that there is a speedy turn over of patients. Beds were always in demand and the quicker you were in managing the patient the more competent you were considered by your seniors.  I slowly and steadily improved my clinical and surgical skills. By the time I became a senior resident I became quite settled in the art  and science of Obstetrics. We were often so enthralled in the variety and complication and the challenge of certain neglected cases that we were quite unaware of the social and humanitarian aspects of these  patients. You could say work was worship for us and for the 36 continous  hours that we were on duty virtually nothing crossed our minds except how efficiently we could clinically manage our patients. We were also under pressure of proving ourselves academically to our teachers so that we could be better clinicians. If we could diagnose a case of silent rupture of uterus or a very rare case of secondary abdominal pregnancy we got a pat on the back and we felt proud about saving a precious mother”s life . It really did not matter to our seniors how much we talked to a sick patient or how much time we spent in counselling the relatives. The fact is that we really did not have so much time because  we had to move on to the next patient who required our help. At the end of each month we had an audit in which the focus was how much better and quicker we could have clinically managed a patient leading to lesser morbidity. The scenario drastically changed when we moved onto the private sector. It took a long time for me to understand and accept that 60% of the gynaecology patients belonging to the upper socioeconomic class who reported to the OPD (outpatient department) did not really need any significant expert medical help but only routine check ups and a lot of assurance and counselling. Now how good a doctor you are was solely decided by the patient and her attendants and their perception on the other hand was quite often solely depended on your bedside manners and how well you talked to them.  Clinical skill and clinical outcome was important but secondary. It was a lot about how patient you are in answering sometimes the same questions over  and over again during a consultation. In this context I must also add that the success of the practitioner is mostly depended on the referrals she gets either from other doctors or from her old patients. In the process many bright but novice less manipulative private practitioners have failed to even make a beginning in this terribly competitive world of private practice. As a society we are constantly losing out on the services of some very well trained young enthusiastic doctors . In a  country with an appalling doctor patient ratio of 1:1700 it should ideally never be the doctor”s responsibility to procure patients. The private sector is profit driven. Academic medicine which provides the medical profession the wellspring to thrive, study, carry out research, evaluate, treat, learn and improve is often ignored.Academic medicine and Research also contributes to the overall progress in medicine and brings down health care costs .  I know that one day in the far distant future things will change and more public private partnerships  will create a balance between the overworked exhausted doctor in the public sector and the underutilised dedicated young doctor in the private sector.I am also optimistic because I know some young hospital directors who are aware of this paradox and want to change the situation to improve the overall quality of health care at all levels