13 August 2014

Resurrect the General Practitioner!

If you have a persistent headache you might rub some medicinal oil on your head or take a Paracetamol tablet.  If you have aches and pains, there’s peyava, there’s koththamalli with some venivelgeta or Siddhalepa.  Even a cat medicates itself, chewing on kuppameniya when feeling out of sorts.  A little boy trips and bruises his knee and his friends will administer first aid for example in the form of grating a kurumbettiya on a rough surface and packing the pulp on the wound.  It is when the ‘bad feeling’ persists that people think of a vedamahattaya or physician in general, although in these dengue-scare days worried parents rush their fever-ridden children to hospital (after making them take a blood test of course). 

Now there’s nothing wrong in self-diagnosis when it comes to slight temperature, a bout of sneezing or body-aches after a hard day’s work.  Nothing wrong in self-administering some goda vedakam such as coriander, samahan, jeevani or Siddhalepa.  The danger lies when non-specialists either diagnose or prescribe or do both in the case of serious illnesses.  In a world where even the best medical practitioners (like those in other professions) err, it would be downright silly for a layman to believe he can do as good a job as a physician.  Sadly, that’s what a lot of people do.

There was a time when patients knew that doctors knew better.  They were not presumptuous.  They did not self-diagnose. They waited their turn and when they were called they described ailment to the best of their ability, answered questions, let the doctor conduct his or her own rudimentary tests, conclude and prescribe a course of treatment.  If the doctor felt that a condition was serious to warrant examination by a person who specializes in the particular area the patient would be referred to a relevant specialist.  That was what a GP or General Practitioner did.

Today, however, except in areas so remote that the first ‘port of call’ was the local physician, patients have taken over some of the critical functions of the GP.  They decide first that they are so seriously ill that they need to see a specialist.  In other words they presume that they, more than anyone else including a GP have a better idea about what’s wrong with them or which part of the body needs specialist attention.  So they ask around.  They do their own referrals. 

It is of course good business for ‘clinics’, consultancy centers and private hospitals, but all things considered it is an unnecessary cost produced by arrogance and ignorance on the part of patients (or their loved ones).   

What is forgotten or rather what patients have ‘learned’ to forget is the role of the GP.  The GP provides person-centered, continuing, comprehensive and coordinated whole-person healthcare to individuals and families in particular communities.  It is in recognition of all this that GPs are called ‘family doctors’. 

The GP is an integral and central component of an effective healthcare system in a country.  The GP is cognizant of a patient’s needs, values and desired health outcomes and these are central to evaluations carried out.  Long term relationships with patients are critical to understanding and trust.  A continuing doctor-patient relationship has a positive impact on wellbeing and resilience.  Take that out, or rather replace it with what is essentially and ridiculously a self-assessment element, and you deny yourself all the benefits freely available (in Sri Lanka as of now) that make for better health. 

Most importantly, a GP is endowed with high level diagnostic and therapeutic skills.  Deny yourself that and you pay for it (with considerable interest) when health falls apart.  All you have to remember is that a GP will yield a referral if and only if it is necessary for specialized treatment.  A specialist, in turn, will treat a GP’s referral with the sobriety it deserves.  Sure, he or she will treat you if consulted but might very well prescribe exactly what the GP would have (counting out of course the compulsion to over-prescribe the unnecessary for monetary rewards from the pharmaceutical industry). 

Today, in Sri Lanka, there is no regulation over referrals.  The GP has been effectively axed from the process and exists more as default option than as integral component of an effective healthcare system.  Those responsible ought to seriously consider re-installing the General Practitioner in his/her true role as far as patients are concerned: first stop this side of medical emergencies.