As one who entered medical school in the BC era (Before Computers = Before Christ) I have, during the last four decades, witnessed health care evolve. The doctor is now known as a Health Care provider (HCP) and the patient a consumer. Practice used to be a single, face-to-face, very pleasant interaction with a human being, who came full of trust, totally confident that he or she would be totally cured. My teachers taught me to listen to a patient (“he is telling you the diagnosis — listen carefully”) and get more information from his near and dear, who accompany him.
Like a detective appearing on a crime scene, we would painstakingly reconstruct the scene of the crime (the concept of preventing a crime, was still in its infancy). We would look for clues everywhere. Sherlock Holmes and Watson would have been enthralled. After narrowing the suspects to two or three we would physically examine the patient. Then followed an intellectual workout. We had to explain every symptom, every physical finding with the patient's primary reason for seeking medical assistance.
The learned professor would draw diagrams, explaining the raison d'être, invoking anatomy and physiology. As sophisticated imaging was non-existent, the fascinated students had no way of disproving the boss. Management was more than treating the disease. We took into account all remotely influencing factors including socio-economic, educational and domiciliary status.
Choosing the actual treatment was mostly a unilateral decision. To the patient, the physician seated on a lofty pedestal, was an incarnation of Dhanvanthri and Sushrutha! How could he/she ever be wrong? Access to information was the prerogative of the doctor. To “cure sometimes, treat often but comfort always” was the motto.
Today's sceptic would argue, that in the BC era, there had been nothing more to offer, than empathising with a patient. In today's era of personalised medicine, where antibiotics could be customised to suit your genome, where stem cell therapy and surgery of the unborn are options, who wants only a commiserating doctor! The bottom line is technical excellence. Quality of care has to be measured with reproducible objective indices! Encomiums and accolades are for those, who do the most technically challenging, sophisticated procedures, in large numbers. Today, decisions regarding stenting or bypass depends on feasibility, not necessarily, necessity. Laboratory values are often the main parameters used to gauge outcome. Systems, processes, audit, accreditations, RoI (for the naïve doctors of yesteryear RoI is Return on Investment— a concept which then, would have aroused a sense of anathema), review meetings, multiple specialist opinions, familiarity with TPA and nuances of insurance and billing were unheard of. Today, to ensure uniformity and standardisation one has to follow protocols, algorithms and flow charts. Every clinical problem has to be reduced to a series of “what/if.” Such dispassionate, objective mathematical approach is thought to be necessary for high quality disease management.
The 1,800-bed government general hospital of the sixties had one omnipresent Dean. Today a quarternary care institution a third in size, has an MD, a CEO, a COO, a CIO, a CTO, a CKO, a CLO, a CFO, a CSO (Strategy not Security!). One globally renowned diagnostic centre has a Chief Dreamer. CHO (Happiness Officer) is on the anvil. Perhaps such a six sigma approach has made a significant difference in health care outcomes. Today, we have globally renowned medical centres of excellence, which no longer follow high standards, they set them. We no longer should talk about achieving world class. The world should talk of achieving India class. But, somewhere along this journey, have we forgotten that people can die with a brain tumour not of a brain tumour , that we should treat the owner of the disease, not the disease per se , that TLC still should mean Tender Loving Care not Telemedicine Linked Care, that every deviation from the norm ( do we really know what is truly abnormal ) does not need to be corrected, that MRI or PETCT it is still a shadow and it is a human being ,we need to build a rapport with, and that the whole is greater than the sum of its parts. I am excited to see, at first hand how the science fiction of today is becoming the SoP (for my contemporaries, this means Standard Operating Procedure another jargon!) of tomorrow, but deep in my heart is a craving and lingering to go back to the Holmes era. After all, our grey matter is still the most sophisticated computer and arriving at a customised individualised management strategy, taking a truly holistic view, was so much more appealing.
(A Chennai-based neurosurgeon, Dr. Ganapathy is a former secretary and past president of the Neurological Society of India and a former Secretary-General of the Asian Australasian Society of Neurological Surgery. He is also the immediate past president of the Telemedicine Society of India and is president of the Indian Society of Stereotactic and Functional Neurosurgery and an adjunct professor at IIT Madras, Anna University and the Dr. MGR Tamil Nadu Medical University. His email ID is drkganapathy@gmail.com)
