The evolving marketplace and services

In a perfect world, the government would supervise and facilitate. It would create a level playing field. For everyone. The morally perfect human would work hard and help his brethren. This socialist utopia underpinned the dreams of Marx, Engels, and Lenin. But the human reality is more complicated. I, Me, and Myself are more prevalent than one would like to admit. We pine for the perfect world order, but these realities must be factored into any hallowed healthcare plan. The moralist, the educationist, the narcissist, the idealist, the capitalist, and the socialist work side by side to create a semblance of harmony.

History

Healthcare has evolved over the ages. No one is quite sure how it was dispensed in the primitive societies. In the Greco-Roman era, the healer was a saintly figure who spent his time contemplating science and had no worldly desires. The society took care of his necessities which were minimal, for the healer was an ascetic. The pictures of Galen, Hippocrates, and Susruta show a calming face with a beautiful look. Such was the grip of this description that humans stopped thinking that healthcare could be improved. Hippocrates and Galen were gospel. It is said that for 1500 hundred years human medical thinking revolved around the writings, dictums and theories of these two great personalities. More realistically healthcare stopped evolving for 1500 years as it was difficult to question the ‘saint-healer’.

Human Behaviour

But humans survive because they evolve. In thought and in deed. The credit for pushing healthcare forward has to be given to the midwife and the barber surgeon. The senior midwives of localities started questioning dictums by quoting their experiences. They did the ‘unthinkable’ by going against the wisdom of past legends. Surgery was seen as a horrible profession practised by the lowest in the society. The barber surgeon. Amputations, debridements and incision-drainages were carried out by these gentlemen who often carried guns as their surgeries were done in public places with hundreds of people watching. These barber surgeons often carried guns to ward off crowds who would try and lynch them if things went wrong. They often did. Legendary figures like Ambroise Pare belong to this group of healthcare giants. The housewife was driven by kindness and the barber surgeon by commerce. Both pushed healthcare forwards and their contribution is immense. One might see the picture of Hippocrates and Galen in our hallowed teaching institutions. But we will never keep the picture of the portly weatherbeaten housewife and the nameless bloodied barber surgeon in boots except when we want to demonstrate how far we have come from those barbaric times. Our enlightenment is very selective.

The socialist type thought process appeals to all of us. The modern doctor is always judged through this prism. A prism that wants doctors to be benign, intelligent, obedient with no worldly desires. This picture, while extremely desirable, goes against the very grain of human behaviour. Humans indulge in self-aggrandisement, narcissism, commercial pursuits and professional jousting. No amount of counselling and religious teaching has taken this atavistic group of tendencies out of the human being. Good societies have a balancing group of kinder, curious, accommodating and soft-hearted people. No science or process has been able to separate the two groups. And no amount of brilliance ever will. A mix of people makes a good alloy. Administrations have to plan accordingly.

Kashmir and its healthcare 

In the 90s Kashmir had two large institutions which delivered healthcare to the population. The SMHS and its Associated Hospitals and the SKIMS Soura. They followed and have been following two separate protocols. The SMHS allows private practice and the SKIMS does not. The underpinning thought process was that the AIIMS model would be replicated by SKIMS and research and patient care would flourish. A Noble thought process indeed. But one criticism of the process has to be made. Inherent human nature was never factored into this plan. The alloy is difficult to build with one thought process. The SMHS in contrast was a medley of private and governmental pursuits with less emphasis on research. The criticism it attracted was that doctors were not focused on their hospital work and financial gains forced them to curtail their duties.

In the 1990s and 2000s the arguments had merit. Significant merit. SKIMS did produce more research and higher end healthcare. SMHS provided mass healthcare and lagged in delivering research and cutting-edge procedures. The thought of private practice being evil perhaps derives from this era. One factor that has to be mentioned here is that SKIMS had many firsts. The first superspecialists, first super specialist departments, relative autonomy and the first mover advantage. SKIMS like Maruti Suzuki started many services far ahead of other hospitals. The doctors who headed these departments were household names. Legends who led a revolution. Fame, efficiency and a name was enough. Even after retirement these legends are known and respected all over the valley. They retain a significant market value. Years after retirement these greats are still sought out by patients. They have enjoyed the best of both worlds. Academics and finance.

The earthquake

But two things have created an earthquake in healthcare planning and thinking. The economic liberalisation and the changes in the NMC/MCI statutes. The changes have eased training difficulties. Dozens of doctors from the valley are training all over India in specialties and super-specialties. This has negated the first mover advantage of SKIMS considerably. I disagree when people say that SKIMS has lost its glory. It is still the same institute that it was. It appears to have become less important. This is due to the arrival of a multitude of specialists and superspecialists in the valley. These doctors work in the SMHS and district hospitals all over the valley. Other hospitals and institutions have grown spectacularly. The SMHS has equalled SKIMS and maybe even surpassed it in certain areas. Manpower of a very high quality is available. Manpower that wasn’t available in the previous decades.

The False AIIMS equivalence

SKIMS is thought to be the AIIMS of Kashmir. There is a fundamental flaw in this thought process. AIIMS is the nerve centre of Indian healthcare. Autonomous, freely funded with a referral flowing in from the whole of a vast country. Rare disease, patient bulk, protocols, continuous training and a very high quality human resource. This model can only be mimed here but not reproduced. The government has created several institutions all over the country but none can touch AIIMS. The name is a brand. And here lies the secret. The AIIMS doctors label is enduring. He can be an academician in his first phase and enjoy a commercial transition in the second phase of his life. Regular conference presentations, seminars and mindspace occupation means that the corporates want them. This is something that all doctors of that institute know. That the commercial interests can be cashed in anytime. The future is secure. This is something that doctors from SKIMS who have recently retired cannot say. The competitive marketplace in Kashmir has not allowed any space for them to develop a private practice post retirement.

The IPL example

A few decades ago the best players in the cricketing world were prevented from playing cricket for counties. This was meant to protect them from exposure and over work. They were wrapped in wool. Many giants of that generation never played county cricket unless they had to work on a weakness. With the rise of the commercial aspect of cricket and the bonanza of IPL, cricketers do not avoid the IPL. The commercial aspect and the glitz can be condemned, but the significant rise in the skillset of the players of this league cannot be denied. India can make 5 teams who would rank amongst the best in the world. Just imagine a top cricketer who plays for the country only and then goes home for net practice and spends time with his kids. Can anyone quote an example? The modern world thrives on competition. The dilscoop, slinga, reverse sweep and the switch hit have taken root due to the IPL.

The rise of SMHS

The SMHS has risen significantly over the last 20 years. There is no doubt that health planners have provided the infrastructure, employed manpower and equipment. However, one thing that is frequently overlooked is the competitive marketplace which has forced doctors in the SMHS to deliver better services in their private clinics and this has had an effect on improved delivery in the hospital. This can be seen across the board. This is a model that is seen in the JLNM and the district hospitals too. The superspecialist delivers above and beyond the call of duty. That does not mean that commercial interests are the only drivers of this growth. There are people who are service oriented all over the valley, but the private practising doctor has been a significant factor in driving the growth of SMHS and the district hospitals.

How should private practice be viewed in the modern world?

Private practice is an evil when viewed from a utopian prism. However, there is no doubt that ban on private practice has caused a significant drop in standards in Medical Colleges across India. Even PGI Chandigarh is not the force that it once was. Corporate healthcare has definitely pushed the quality of healthcare in India but there are significant concerns in costs, indications and the necessity of interventions. The hybrid model might provide a more sustainable model. Self regulated because of the presence of colleagues and driven by competition. However this can be debated.

What about research?

There is no doubt that SMHS hasn’t kept up with the research produced by SKIMS. However, blaming private practice for this is a little premature. The non-clinical branches across Kashmir do not indulge in private practice, but they do not produce a lot of research. In an attempt to boost research the NMC made it mandatory to produce research papers during interviews and promotions. I do not think a study has been conducted on this particular point, but there has been an exponential rise in the number of predatory journals and predatory conferences extracting money from doctors who do not naturally enjoy research. I would always want the research to be left to the researcher. India produces thousands of theses every year. How many find a way onto globally respected platforms? It is important to facilitate the researcher and fund and review the departments based on the quality of work they produce.

What am I trying to say?      

Whatever your prism, private practice is driving the growth of government hospitals. Call it a necessary evil or a modern financial reality. The barber surgeon is derided in texts, so is the housewife, but their contribution of freeing healthcare from stagnation of the Galen and Hippocratic eras is indisputable.

Private practice cannot be dismissed on the basis of sweeping statements based on relatively dated socialist utopia. There has to be a regular study every five years on the benefits it is delivering and costs it is extracting from employing hospitals based on hard facts. Figures, developments and procedures. Also one has to factor in the self-aggrandisement aspect. A doctor will go the extra mile in the pursuit of market fame. At both the clinic and the hospital. Like it or not.