The most obvious solution to the challenges Indian surgeons face is to provide universal healthcare coverage
Being a surgeon in India is very different and probably more interesting than being one anywhere else in the world. Not only are there the usual problems that developing countries have to deal with, like poor, undernourished patients with advanced diseases who throng the underfunded public hospitals, but there is now, in stark contrast, a for-profit and thriving expensive private health sector, to which, in spite of its obvious shortcomings, two thirds of patients go to.
Consequently the Indian surgeon, whether in a public or private hospital, has to constantly adjust patient management based not on what the internationally recognized “best” treatment modalities are, but on what is “appropriate” for a particular individual and based on generally inadequate Indian data. Decisions regarding which investigations to do and which treatment to offer have to be made based on how much the person can afford, how far away he/she is from competent medical care, and what local expertise and technical resources are available there. This is usually very different from what is regarded as ideal according to the published “evidence” which originates in Western countries.
In many major public sector hospitals like the All India Institute of Medical Sciences in Delhi, to which patients come from all parts of the country, the number who need surgery is far greater than the number of healthcare personnel, beds, or operating time available. If these patients were put on a waiting list on a first-come-first-served basis they might have to wait for a procedure, even for cancer, for longer than six months. Consequently the surgical resident who is responsible for allocating admissions has to decide on the order of admissions by using a complicated triage process which depends on the complexity of the disease i.e. whether or not the condition can be adequately treated elsewhere, the economic status of the patient, and the distance he or she has travelled to reach the hospital. Thus at one extreme a middle class man who lives in Delhi and has a small groin hernia will be given a long waiting time for an operation (he will probably get it done in the private sector which he can afford—unless of course he has “influence” and jumps the queue). At the other extreme will be a poor farmer from Bihar with, for example, extrahepatic portal venous obstruction, who has travelled all the way to Delhi in the hope that an operation will save his life. It is the latter who needs to be admitted and treated quickly because he has a life threatening disease which can only be cured by a difficult surgical procedure, which is not performed in the hospitals where he lives.
Unfortunately because of the shortcomings of the public sector most Indians now opt for private hospitals, 80% of which are run “for profit” by healthcare corporations [1]. Here although the management may be “world class” the patient will always be wary of whatever is being advised in the way of diagnostic investigations or treatment. He may wonder whether the investigations are being done mainly to make more money for the hospital. He will generally be correct in his suspicions. It is rumoured that private sector managers who pay their star doctors exorbitant salaries will ask them to justify these salaries by the amount of profit that they generate for the hospital every month, usually by over-investigating and over-treating their patients.
This climate of distrust towards doctors by patients means that even the ethical private practitioner is now in a dilemma about whether to only do simple and low cost tests to save the patient unnecessary expenditure, or whether to do more complicated and expensive ones to avoid being sued for failing to make a diagnosis.
The Indian patient is left to choose between an underfunded and inefficient public hospital and a potentially rapacious private medical facility.
What is to be done? The most obvious solution is to try and provide universal healthcare by increasing the present spending of 4.2% of GDP (of which only 1.2% is contributed by the government) to the Western European levels of up to 9%, which is still less than the huge 17% spent in the USA. [3]
It is imperative that this extra funding is used to build more public health facilities and equip them better. They need to be staffed by surgeons who have undergone training which is relevant to our problems. Certain surgeons could thus be taught to do basic procedures like stitching wounds and setting simple fractures, others to perform appendectomies and hernia operations, and the more complicated problems could be sent to tertiary care hospitals. We could also consider teaching the village “quacks” who are ubiquitous, accessible, affordable, and trusted to perform simple surgical procedures similar to the innovative project which has been done in West Bengal for medicine and published recently in “Science.” [4] Finally there must be much better central control of medical practice by having a revamped Medical Council of India which should become more transparent and maintain rigorous standards in undergraduate and postgraduate medical education and ethical practice.
So why, if there are all these problems, is working as a surgeon in India so satisfying? The first and foremost reason is that most patients are still inordinately grateful and treat a doctor as “next to God.” Secondly the problems can all be solved—each patient has to be treated by using innovative strategies which are appropriate to his or her needs. Finally there is little more satisfying than to cure a patient with a complicated medical problem by applying locally the expertise one has gained from training in the world’s best institutions. It gives being a doctor a real meaning.
Samiran Nundy is the dean of Ganga Ram Postgraduate Institute for Medical Education and Research, New Delhi, India.
Competing interests: None declared.
References:
1 Lawrence C Loh , Cesar Ugarte-Gil & Kwame Darko. Private sector contributions and their effect on physician emigration in the developing world. Bulletin of the World Health Organization 2013;91:227-233. doi: 10.2471/BLT.12.110791
2 Nassir Ul Haq Wani, Kanchan Taneja, Nidhi Adlakha. Health System in India: Opportunities and Challenges for Enhancements. IOSR Journal of Business and Management (IOSR-JBM) e-ISSN: 2278-487X, p-ISSN: 2319-7668. Volume 9, Issue 2 (Mar. – Apr. 2013), PP 74-82
3 Das J, Chowdhury A, Hussam R, Banerjee AV. The impact of 8 training informal health care providers in India: a randomised 9 controlled trial. Science 2016;354(6308). pii:aaf7384.