If you want to know what it is like to be a Family Physician in India, take a trip to the Golden Temple, Vellore.
My wife and I utilised a recent invitation to attend a Convocation at CMC Vellore to take a much-needed 3-day holiday. On our way back home to Gurgaon, our initial plan was to leave early morning from Vellore and do some sight-seeing in Chennai. At the last minute we changed our minds and decided to stay back in Vellore and go see the Tripadvisor #2 Thing To Do in Vellore, having already covered the #1 Thing (Temple in Vellore Fort) in an earlier trip.
In a similar vein, Family Practice was my last choice as a career. Towards the end of my MBBS I felt very disillusioned with medicine, especially with the way it is practiced in Indian hospitals, in a rigid hierarchical and doctor-centred model with little or no regard to the person of the junior doctor, much less the patient or his/her family. I used the excuse of joining a masters course in the US to postpone the inevitable post-graduate training that all Indian doctors are expected to undergo.
The course in Health Informatics turned out to be great, and I thoroughly enjoyed my time there – did research on CPR, learnt a new language, helped the Indian student community, and travelled extensively, covering 25 out of 50 US states! But the withdrawal symptoms of medicine kept gnawing at me. I asked a lot of doctors in the informatics field, and they were unanimous – you can’t give up medicine, can’t escape doing post-graduate training in a clinical speciality.
Family and other circumstances brought me back to India in the middle of 2008. In another attempt at avoiding clinical training, I went to Mumbai to learn entrepreneurship and joined a start-up there. We were helping NGOs to add health care services in the communities they were working in. We set up a primary care clinic for one such partner, and as luck would have it, the Chief Minister of the state inaugurated the facility 2 months before the expected date of launch! Since we hadn’t hired any doctor for the clinic yet, I grudgingly accepted the role of the Family Physician, and started seeing patients, after almost five years of being out of practice! Thus began my tryst as a primary care physician.
My wife and I were reasonably sure that we would enjoy our time at the Golden Temple. But when we shared our plan with friends, we were met with scepticism. Some said it’s only worth visiting in the evening. Others said it takes too much time. Internet reviewers accused the place of being too commercial. Well, there’s not much else to do in Vellore! We decided to go ahead and give it a try and see for ourselves.
One of the reasons I came back to India was to have tough problems to solve. With reasonable success of the first few primary care clinics I helped set up for construction workers, the idea grew in my mind that the simple remedy for the deplorable state of Indian healthcare was to setup more such clinics where qualified doctors provided quality primary care! Let me start with this simple solution and then I’ll tackle more complex problems!
Not everyone shared my enthusiasm. Lots of questions were thrown my way. Why not continue doing more of what we’re already doing? Why would people come to see a GP when they can directly consult a super-specialist? Where will you find competent doctors? Once doctors become successful why would they continue working with you? Since I did not have any better business idea at that time, I decided to forge ahead and prove the nay-sayers wrong by setting up 100 Family Practice Clinics within 4 years!
We engaged in some customary haggling with an auto driver, and satisfactorily brought down the asking price by Rs 20. The auto sped towards the temple on smooth roads, until, abruptly, it took a right turn onto a rough unpaved street, and the ride suddenly turned bumpy! With nervous sweaty fingers I quickly opened Google Maps to see where we were being abducted to! From what I could see, the direct road from Vellore city to the temple was closed due to a fly-over under construction, and of course the auto driver preferred a bumpy short cut over a longer, smoother road!
The short-cut I took to solve all of India’s healthcare woes turned out to be no less bumpy. I tried and failed at several “marketing tactics”, most notably health checkup camps and inserting pamphlets in newspapers, both of which required waking up very early morning – something I absolutely hated! Huge variations in footfall from day to day and from season to season made it almost impossible to plan for the future, and my statistical modelling skills were laid to waste. When my funder (that is, my father) tightened the purse strings, and said he won’t fund the losses any more, I closed almost half the clinics I had opened till then.
Many primary care organisations had started in various parts of India around the same time as me, and many of them folded up or changed tracks within a couple of years. The most jarring consequence of all this was that I had to start practicing as a Family Physician full-time in one of the clinics, as there was no more money to hire a doctor on salary for that clinic. It felt like life had brought me to do the one thing I never imagined myself doing! Being just a GP?! Was this all that I was destined for?
Once I knew the reason the auto took the bumpy short-cut, and accepted the fate of my back, I started looking around. The auto was passing through a quaint residential area, the kind of neighbourhood where real India lives. Where you can see an old man carrying water in a plastic can for his bath. Where the only place children have for their games is the yard of the local temple, mosque or church. Where a family might build a cosy nest, but might be shy calling friends and relatives over to visit them.
But at the same time, this was the place where real India lives. Where you can find people proudly painting their small abodes in their favourite bright shades of green, blue, purple and orange. Where chicken and cows roam around freely and doors are unlocked, because the community looks after each other. Where banana trees and louki creepers grow in empty plots. And the small shrine survives on the small donations people share out of their small incomes.
Being a full-time Family Physician was tough on me emotionally, primarily because from the first day of starting medical college, the only choices after MBBS were Indian PG or USMLE, as if being just a GP was unworthy of someone graduating from the top medical institute of the country, a waste of talent and training, so to speak! The only positive thought that guided me was that I wanted to give the best possible care to the patient sitting in front of me. “Since I have committed to being a Family Physician, let me try to be the best Family Physician I can be.”
And that opened my eyes to the wonders of Family Practice! For, to collect the best possible history, I had to learn to listen and encourage people to tell their story in their own words. To do the best possible examination, I had to learn how to use body language and simple explanations to put them at their ease. To improve compliance with medicines, I had to learn to negotiate in the patient’s lingo. And to improve compliance with lifestyle changes, I had to empathise with their unique circumstances and brainstorm with them how to achieve their SMART Goals. Interestingly, this worked for the patients too! I’m guessing that they could sense the intent, and were happy to finally find a doctor who was just doing the common sense things thoroughly, in a sincere attempt to help them!
As I picked up the knowledge, the skill, and the craft of being a Family Physician, I felt more and more confident that finally I was doing something of value. I did a Masters course in Family Medicine from CMC Vellore, and then started teaching in the same course, which further cemented my belief in these positive values. More so, I was amazed to see the way the families accepted me, took me into confidence with their deepest secrets, and came back again and again in their times of need. It also dawned on me that they belonged to all strata of the society, from the rickshaw puller to the South East Asia head of a Fortune 500 company, that everyone saw value in having a Family Doctor they could call their own, and that any well-meaning doctor can make a comfortable living as a Family Physician.
But the most unexpected outcome of being a Family Physician was that as I helped others to heal, I found myself healing too. I found my self-doubts and insecurities melting away. I grew closer to God, much more humble and much less judgemental. And I honed the art of riding the waves of uncertainty like an equanimous surfer, falling often, rolling around in turbulence, and showing up every morning for some more!
The auto soon found the main road and sped once again with full uproar, like autos do on clear roads. Golden Temple turned out to be a calm, green place with beautifully designed architecture and sculptures. A significant part of the charm of the place is contributed by their no-mobile-phone policy, which results in a 2-3 hour WhatsApp-selfie detox, and you get time to smell the flowers and do some introspection.
Looking around and thinking about things does throw up some complicated questions. Shri Shakthi Amma, the founder of the place, is considered an incarnation of the Divine Mother, and there are photos of him in peaceful poses and him doing charity work, all over the place. There are many counters selling different things, from prasad, saree offerings, and calendars, to herbal products, wooden handicraft, and lighted models of the temple. There are several points where you can spend money for extra religious credit – light a diya, touch a chakra, donate a rice packet, etc. And if you’re feeling particularly religious, you could donate a few thousand rupees and get special pujas performed! At what point does it stop being a spiritual place and become a commercial enterprise? Is it possible to be both spiritual and commercial? Where do you draw the lines of ethical conduct?
Being a Private Family Practitioner in modern India is no less complicated. Just like a temple, health facilities in India are also expected to run on charity, or at best make marginal profits. Moreover, a clinic runs primarily on the charm and competence of a single doctor, who is elevated almost to the status of a deity. I often joke with my patients. When they say, doctor, we come to your clinic just to see you, and half our troubles go away just seeing your serene face, I tell them, why don’t you keep a photo of mine with you in your purse or wallet! And one of them actually clicked my picture!
The art of running a value-based enterprise means to grapple with some complicated equations, almost daily. I have to ensure that the financial benefit of being revered by the patients never overtakes the fact that I must use this reverence as a tool to build the patients’ own self-reliance in managing their illness. I must introduce more and more innovative services and products in the clinic, to augment the primary care consultation, but can never sell these products or services overtly. I must cross-subsidise the services – have luxury services like home visits for the super-rich, to compensate for the almost-free care provided to the lower-income folks.
Early on, I found one principle which has helped me stay on track, and possibly helped my organisation survive, where many have come and gone. I told myself that if I can proudly tell my patients something that I’m doing, then it’s ethical. I’ve always felt that transparency and trust go together, and travel far! As they help build a strong foundation on which an ecosystem can thrive – one which employs people, supports local enterprises, and elevates the level of quality of services – much like the Golden Temple at Vellore!
On our way back to Vellore city, we could see the fly-over which had resulted in our detour. The portion that we could see seemed fully built and ready to accept traffic. Yet, for some unknown reason, barriers had been placed to prevent vehicles from getting on the fly-over. Having experienced infrastructure development in India in the past, we could imagine the reasons to be as varied as the government having run out of money due to delays, or an unshifted electrical pole with a missing chunk of construction around it, or unavailability of the chief minister to cut the ribbon and inaugurate it!
Family Practice in India has been ready to take off for several years now. There are many programs training doctors in Family Medicine principles and the essential knowledge and skill needed for independent practice. But the path after training seems full of barriers. There are not many opportunities for us to practice as consultants in corporate hospitals or clinics, nor can we expect academic positions in medical colleges. The government does not recognise Family Medicine as a speciality in its PHCs and CHCs. And starting one’s own private practice looks very daunting to young physicians!
There are several systematic reasons why there’s no easy path for FM graduates in India. Low budgetary allocation for healthcare especially primary care by the government is the main reason why there are so little financially viable opportunities in primary care. Plus the government does not seem to be doing enough to eradicate unethical practices by untrained providers, and dispensing of prescription drugs by pharmacists without doctor prescriptions.
The biggest reason, though, is in our minds. During our medical education, which mostly happens in tertiary care hospitals, we get no experience of a Family Practice. If at all GPs are mentioned, they’re derided for missing this diagnosis or mismanaging that illness. The more time we spend in hospitals during and after our MBBS, the more it’s hammered into us that we’re worthless without a specialist degree! We keep gathering diplomas and certificates, and waiting for someone to cut the umbilical cord and tell us, yes, now you’re ready to practice independently!
Even if the fly-over to a successful career in Family Medicine is not ready yet, there are enough side roads to reach where we want to be. Some might be bumpy, some might take a longer time, but then we get to form a close bond with the community during these adventures! And at the end of the road, life comes full circle – we become the kind of doctor we always wanted to be in childhood, the kind of doctor who inspired us to join this profession in the first place – the wise, philosophical, sometimes whimsical, mostly friendly, neighbourhood Family Doctor.