Last time we met we were all praises about the bolstering of fruitful general practice. We eulogised a healthcare system that runs with the GP as it’s spine and recognised the role it has to play in maintaining an economically and holistically slick healthcare system. I’ve always indulged in the habit of pertinent quoting at pertinent places and so I do here once again, hoping that it wont mind you. So here is how I find internet commonplaces describe GPs:

Wikipedia: ‘A general practitioner manages types of illness that present in an undifferentiated way at an early stage of development, which may require urgent intervention. The holistic approach of general practice aims to take into consideration the biological, psychological and social factors. They have particular skills in treating people with multiple health issues.’

Then again……….NHS careers: ‘GPs call on an extensive knowledge of medical conditions to be able to assess a problem and decide an appropriate action. They deal with problems that combine physical, psychological and social components. No other speciality offers such a wide remit of treating everything from pregnant women, babies to mental illness and sports medicine. General practice gives the opportunity to prevent illness and not just treat it.’

To create such a multicompetent doctor so apt at his practice, a medical student has to make his way through a medical school that orients him with the medical world. During these years, he takes up a concoction prepared from the general aspects of every single specialty. This concoction has everything that a GP is expected to put into practice. But this concoction, even in it’s most simplified form, is collosal, too crude to be carried into practice straightaway, and incorrigibly evanescent. To gain enough practical approach, such an unconditioned doctor has to go through a period of applied learning. It’s in this period of applied learning that a student develops “knowledge pathways” from the vast ocean of medical school knowledge-pathways through which relevant, specific information can flow into the practical scenario of medical practice. This period of applied learning enables him to carve a practical world out of a theoretical void and finally function independently as a competent doctor. To achieve this end, we have 3 years of family medicine residency in the U.S., 2 years of foundation training+3 years of “run through” GP speciality training in the U.K., 4 years of GP training programme in Spain and 1 year of compulsory rotating internship in India.

Now look at this rather interesting but spirit bashing piece of research I found at The World Bank “shocking facts about primary healthcare in india, and their implications”. I’ll quote only a few really important paragraphs but I recommend you go through the entire piece of research. “Das and his colleagues spent 150 hours training each of 22 Indians to be credible fake patients. These actors were then sent into the consulting rooms of 305 medical providers – some in rural Madhya Pradesh (MP), others in urban Delhi – to allow the study team to assess the quality of care that the providers were delivering”. The medical conditions that were chosen were asthma, unstable angina and dysentery in a fictious child left lone at home. Then again:

“In case you’re a little skeptical (I must admit I was early on in this research), consider these two facts. First, in follow-up visits, no provider in MP voiced any suspicion about fake patients; in Delhi, private providers did spot some fake patients, but spotted less than 1% of them. Second, providers who stuck closest to the checklist were more likely to get the “correct” diagnosis; had the fake patients been unconvincing, the study team would have found the opposite.”

“In just one third of fake patient interactions in both MP and Delhi did the provider ask all the essential questions and do all the essential exams. This didn’t vary much across the three conditions. And in only one third of cases in MP did the provider give a diagnosis. Shockingly, only 12% of the diagnoses the MP providers offered were completely correct; another 41% got a partially correct diagnosis. Providers in Delhi did better, but managed only a 22% fully-correct diagnosis rate. Unsurprisingly, the rate at which providers prescribed the right treatment was highly unspectacular: 30% in MP and 46% in Delhi.

What the study team uncovered next was even more shocking. While unqualified providers in both MP and Delhi asked fewer of the recommended questions and did fewer of the recommended exams, they were no less likely to prescribe the correct treatment. Moreover, while providers in better- equipped facilities in MP asked rather more questions and did rather more tests, they were also no more likely to prescribe the right treatment. Interestingly, private providers were significantly more likely to ask the right questions and do the right exams. However, they were not more likely to prescribe the right treatment; in Delhi, in fact, they were significantly less likely to do so.”

In no way can a single such study be considered sacrosanct, neither are these inconsistencies entirely ascribable to an inefficient medical training- but the role of the same cannot be negated altogether either. Anyone who has a significant touch with Indian MBBS knows that graduate medical training today is not sufficient for the everyday medic to practise medicine independently, contrary to what their licenses claim. A freshly baked MBBS graduate is in desperate need of further years of supervised training to gather enough practical approach for a resolute independent practice. And if you happen to circumvent that, all you are gifted with is an escalated rate of injudicious referral of patients, irrational prescribing, unjustified investigations, lacking competencies and sub ethical practice. And then, our eyes open up to the fact that we need to stop rambling about govt. policies and inattractive salaries, since a good chunk of the problem boils down to our system of medical instruction.

Let’s refrain from delving into things like corruption and vile practices; let’s possess nescient eyes and look at an otherwise unruffled system. Talking of our medical school, it’s not hard to discern that it’s unduly theory dominated. It often goes almost to the extent of manufacturing theoretical doctors( like theoretical physicists). We have issues in our examinations that make them vulnerable to cramming and devious memorisation techniques. The standard of our practical instruction varies unduly across institutions, and is often so much under regulated that it assures little practical impression. And that’s just to cut it short. Combine that with the vastness of MBBS and at the end of medical school, you find the medico in a hall of babel.

After the medical school students go through one year of compulsory rotating internship- the year that is thought to set the foundation stone of GP experience, with 2 months assigned to each major and 1/2 for each minor. A 2 month period in a speciality, it entails, is all that an MBBS graduate needs to imbibe fairly everything pertinent to general practice that branch has to offer. If that doesn’t sound preposterous enough, you need to have a look at what portion of internship actually assures ‘learning and instruction’. For most of the part, an intern either does the vapid, routine and rote work( say sample collection) over and over again( many of them won’t even require primary school degree), or carries out tasks where there’s little backing up thought( say, for example, writing prescriptions mindlessly). In the variable fraction of time left behind, learning is left to student and staff attitude, jammy coincidences and serendipity. There’s a huge Govt.-private hospital dichotomy defying uniformity in internship experiences. It does little to tell about the mains, nooks and corners of general practice. And at the end, there’s no examination that tests GP skills before exit. And all of that, I’ll say, is how you put it in the most gentle language. The reality is that the standard of internship experience varies widely across institutions, and in many of them- there is little order, hardly any standardisation of activity, any definition of role and regulation of work ethic- and all you find is an utter pandemonium that ransacks the internee of everything other than what he needs to function at the bottom of the food chain in a tertiary care setting.

It has often been cited that a good reason for fresh graduates hankering to be specialists is because they want to gain a more complete, well-rounded knowledge of what they practise in. And I can’t but scruple to deny the truth in that statement. I, and I’m sure as hell you too, have known how unsettling it feels to keep moving on with half knowledge. And in a setting where training in general practice involves only a passing overview of different specialties, expecting graduates to show even a modicum of interest in it would be a collosal waste of time.

It appears quite clearly as I ponder, how we’ve made certain assumptions while designing our system of instruction. We’ve inclined towards believing that something elusive will automatically cause a mere overview of specialities imbibed in medical school to metamorphose into a well rounded knowledge of general practice. We’ve been loath at acknowledging that general practice has it’s own implications, that it needs specially directed and standardised instruction, that it needs sufficient time off the tertiary care setting to be trained in primary care, and that it needs a real evaluation system to test GP skills. In a sense, we’ve vouched for a ‘just too general’ GP. And it would take little time for the perspicacious mind to comprehend why general practice has lost it’s lustre and has been plunged into near oblivion over years. It’s pretty obvious that to actuate a strong primary care system would require a cadre of competent and specialised GPs, but how do we exactly see that happening?

It vexes my mind to end this post on such a precarious note but that’s how, I feel, things work out correctly. Next time we catch up we’ll be in my final post in the GP series that’ll talk more stuff and little trifle.

The views expressed in this article are entirely the authors and do not necessarily convey the a position taken by Daily Rounds.

Guest Post by Dr. Soham D Bhaduri. Dr. Bhaduri is a medical graduate and a Philosophy of Mind enthusiast, and blogs at www.freethinkingmedic.blogspot.com

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