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 third world problems 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, three quarters of the patients go first.
Consequently, the Indian surgeon, whether in a public or private hospital, has to constantly adjust patient management based not on what are internationally-recognized ‘best’ treatment modalities 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 on how much the person can afford, how far away he 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” in Western countries. For instance, there is a disease known as extrahepatic portal venous obstruction which is very rare in the West but not uncommon in India. Patients with this condition have massive and sometimes fatal blood vomiting but their liver function is normal. For these patients, it may be ‘appropriate’ to make the diagnosis by simply feeling the abdomen for an enlarged spleen, confirm it by a low cost ultrasound examination, and follow this by a one-time complex operation called a lienorenal shunt, which will cure 95% of the patients. This contrasts with the patients with blood vomiting in Western countries who are subjected to extensive investigations like CT scans followed by treatment with drugs or repeated endoscopic ligation of their enlarged oesophageal veins. In these countries, blood vomiting is usually a consequence of alcohol abuse which damages the liver and these patients do not benefit from surgical procedures. This is an example of why we must work out solutions to our very different problems in India and not follow blindly what we read in Western textbooks and journals.
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 resources available. If these patients were put on a waiting list on a first-come-first-served basis they may 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 admission by using a complicated and possibly more rational triage process depending on the complexity of the disease, 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 later date for operation (he will probably get it done in the private sector which he can probably afford – unless of course he has ‘influence’ and jumps the queue). At the other extreme may be a poor farmer from Bihar with 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 is more ‘deserving’ and has to be admitted and treated quickly because he has a life-threatening disease which can only be cured by a procedure 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. Although the management may be ‘world class’, the patient will always be wary of the diagnostic investigations or treatment advised and wonder whether these are being done mainly to make more money for the hospital.
With the current distrust of doctors by patients, even the ethical private practitioner is now in a dilemma to conduct simple and low cost tests to save the patient unnecessary expenditure or conduct more complicated and expensive ones to avoid being sued for failing to make a diagnosis.
The hapless Indian patient at present is left to choose between an underfunded and inefficient public hospital and a rapacious private medical facility.
What is to be done? The most obvious solution is to try and provide universal health care by increasing the present spending of 4.2% of the GDP (of which only 1.2% is contributed by the government) to the Western European levels of up to 9% which is less than the huge 17% spent in the United States.
With this extra amount it is imperative to build more and equip better public health facilities manned by surgeons who have undergone training relevant to our problems. Certain surgeons could thus be taught to do basic procedures like stitching wounds and setting simple fractures, others to perform appendicectomies and hernia operations, and the more complicated problems could be sent to tertiary care hospitals. New medical schools are needed but they should not be run as profit making businesses, as they are at present. If government financing is not available, they could be not-for-profit institutions run by trusts.
Finally there must be better central control of the medical practice by having a revamped Medical Council of India that is more transparent and honest 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 the patients are inordinately grateful and treat doctors as ‘next to God’. Secondly the problems are very interesting with easily-available solutions; each patient has to be treated, not necessarily according to what is written in Western textbooks, but by using innovative strategies appropriate to his or her needs. Finally there is little more satisfaction than curing someone 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.
Featured image credit: All India Institute of Medical Sciences, Bhubaneswar Sijua, Patrapada, Bhubaneswar, Odisha 751019 by Krupasindhu Muduli. CC BY-SA 3.0 via Wikimedia Commons.
Dear sirs Dr. Nundy and Dr. Gouma,
Congratulations on this wonderful write up.
I was a DNB resident in the Department of Surgical Gastroenterology and Liver Transplantation at Sir Ganga Ram Hospital from 2010-13. The Department was headed by Dr. Nundy. I I worked as a fellow and adhoc faculty at GI and HPB oncology at Tata Memorial Hospital, Mumbai and am presently a fellow in colorectal service. I must say I am truly blessed to have worked at these two premier centres. We need more of such exemplery academic departments and hospitals. The Motto should be affordable service, premier education and research which finds answers to our problems.
Very well written thoughts. India definitely needs to improve upon healthcare coverage to its population and it has to take private healthcare players along. And private players have to find ways to optimize surgical costs to make it accessible to all.
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