[op-ed snap] For a personal healing touch

Context

As the Mayo brothers’ initially modest set-up (Mayo Clinic) prolifically expanded into the ‘multispecialty group practice’ in the U.S., concerns that such arrangements would be bereft of the personal touch in patient care were raised.

Organised structures

• This continued through the evolution of more and more organised structures like Health Maintenance Organisations (HMOs).
• They were criticised for turning healthcare into a marketable commodity sold by healthcare providers in supermarket-like institutions.
• U.S. healthcare ended up as one of the most impersonal healthcare systems.

Problematic proposition

• The NITI Aayog’s 15-year plan for Indian healthcare entitled “Health Systems for a New India: Building Blocks — Potential Pathways to Reform”.
• The report makes proposals for health system strengthening — including the elimination of informality, merging of fragmented risk pools, and reduction of out-of-pocket health spending.
• The proposal to consolidate small practices into larger business-like organisations appears problematic on multiple fronts.

Challenges with the proposition

• Nearly 98% of healthcare providers have less than 10 employees. It is identified as a negative trait.
• Apart from cost and competition-related concerns, it could portend a commodification of healthcare from the bottom-up. 
• The report’s bent towards the U.S. HMO model adds to such a foreboding.
• Loyalty and longitudinality form vital pillars of the patient-physician relationship. 
• The edifice of these is built upon mutual trust, warmth, and understanding that accrues over time between a patient and their personal physician. 
• Momentary and haphazardly physician-patient interactions in a system that limits access to one’s ‘physician of choice’ are incapable of fostering such enduring relationships. 

Family physician

• The role of a family physician is instrumental.
• Apart from providing comprehensive care and coordinating referrals, a family physician’s longitudinal relationship with their patient helps in a better understanding of the patient’s needs and expectations.
• It avoids unnecessary clinical hassles and encounters — this reflects in better outcomes and increased patient satisfaction.

Commercialization of care 

• Widespread commercialisation over the past few decades has entailed that the family physician is a dying breed in India today. 
• This has a sizeable role in impairing the doctor-patient relationship, manifested through violence against healthcare providers. 
• In a setting of overcrowded public hospitals, and profiteering healthcare enterprises, mistrust in the healthcare provider and its gruesome implications are not difficult to anticipate.

Advantage of small clinics

• Studies have demonstrated that healthcare received in small clinics scores higher in terms of patient satisfaction than that received in larger institutions.
• This increased satisfaction manifests as better compliance with the treatment regimen and regular follow-ups, culminating in improved clinical outcomes. 
• A meta-analysis of randomised controlled trials has established that patient-clinician relationship has a statistically significant effect on healthcare outcomes.
• Disregard for this aspect in health services design is bound to entail a sizeable cost to the health system.

The need for empathy

• A popular myth often floated is that considerations regarding emotive aspects of healthcare such as empathy and trust are disparate from health policy and system design considerations. 
• In reality, these are entirely amenable to cultivation through careful, evidence-based manipulation of the health system design and its components. 
• It would necessitate installing an inbuilt family physician ‘gatekeeper’ in the health services system who acts as the first port of call for every registered patient. 
• NITI Aayog’s long-term plan provides a good opportunity to envisage such long-called-for reforms, but that would require not the U.S. model but the U.K. model to be kept at the forefront for emulation. 
• A step of sorts is taken in introducing Attitude, Ethics, and Communication (AETCOM) in the revised undergraduate medical curriculum.