Objective Assessment of Primary Healthcare Leadership

In our primary healthcare leadership fellowship that's been running for 2 years now, we've only used self-assessment by fellows as a measure of impact till now.

While self-assessment is the easiest to perform and also gives a good sense of subjective measures like confidence and readiness, bringing objectivity to the measurement of impact is important for academic rigor.

The subject of measurement here is leadership. How do we objectively measure leadership and/or growth in leadership?

For that, it becomes necessary to define leadership in some way. Fortunately, there's an article that RK keeps showing everyone which details 6 roles of a family physician. 

The roles are

• Care provider
• Consultant
• Capacity builder
• Clinical trainer
• Clinical governance leader
• Champion of community orientated primary care

We can define primary healthcare leadership as excellence in all these roles. It is easier to develop objective measures for some of these at least.

Here are some examples:

Capacity builder - How many practitioners are being or have been mentored/supported by the practitioner?

Clinical trainer - How many workplace trainings have the practitioner conducted in the past 3 months?

Champion of community orientated services - Has the practitioner worked with the community to develop/promote any community based service?

It is important to evaluate these at the baseline, incorporate growth in these dimensions as an expectation during the onboarding process, and re-evaluate these at the end of the fellowship to get an objective metric of leadership growth.

With Great Power Comes Great Accountability

Where should the line between 'doctors should be held accountable for medical malpractice' and 'doctors are humans and they can make mistakes' be? [Source]

There is a world where this dichotomy/binary is not entirely false - medical negligence/malpractice jurisdiction. And the courts in such cases have a very nuanced approach to this question. For example, here is what the consumer court says:

What is medical negligence?
Negligence is simply the failure to exercise due care. It occurs when a doctor fails to perform to the standards of his or her profession. The three ingredients of negligence are as follows: 1. The defendant owes a duty of care to the plaintiff. 2. The defendant has breached this duty of care. 3. The plaintiff has suffered an injury due to this breach.

What is medical malpractice?
A medical malpractice is a claim of negligence committed by a professional health care provider -- such as a doctor, nurse, dentist, technician, hospital or hospital worker -- whose treatment of a patient departs from a standard of care met by those with similar training and experience, resulting in harm to a patient or patients.

Does someone who is not satisfied with the results of their surgery have viable medical negligence claim?
In general, there are no guarantees of medical results, and unexpected or unsuccessful results do not necessarily mean negligence has occurred. To succeed in a medical negligence case, a consumer has to show an injury or damages that resulted from the doctor's deviation from the standard of care applicable to the procedure.

These are intentionally vague about what the "standard of care" is supposed to be. Because it would be very unwise to define that in law. The only people who can reasonably inform a court whether a particular care delivered is standard or sub-standard is a group of experts (a group of doctors practicing that kind of care). That's a double edged sword though.

Because, for one, it puts doctors at an advantage. It is their own kind who will decide and therefore there is a conflict of interest in the design of the system itself. But on the other hand, this system can ensure that every case is judged through a medical practitioner's gaze rather than through an outsider's gaze.

When it comes to practice, there are a few imperfections in the system.

1) Doctors are sometimes the worst allies of other doctors. In many negligence cases, the group of doctors who inform the court on whether the standards of care have been met or not, intentionally raises the standard of care (with the benefit of hindsight). This has disastrous consequences for the doctor involved in litigation.

2) It is difficult to navigate the legal system. The consumer court is the best place for patients to approach in the case of medical negligence issues because the patient is the favored litigant in consumer courts. These courts exist for the consumer and by default take their side. The other fora - medical council and criminal courts - are places where it is very difficult for a patient to win. And that would explain the low number of cases registered in such fora. I couldn't find official statistics in consumer court websites, but a researcher claims that there were 3241 cases registered in consumer courts throughout India in 2018, and 2638 cases in 2019. I would think those numbers are true - yet they are very very low.

But it would be a great mistake to rely on the legal system to improve healthcare. Law should often be the last resort to many complex social issues - because it is very difficult to get the law right in such situations. And case-by-case approach like in medical negligence above puts great stress on the legal system (if there are enough number of cases) which in turn leads to bad outcomes for whoever gets tangled in a case.

For example, there are ethical issues where taking a side is not straightforward. Take the case of Ayurveda prescriptions by modern medicine practitioners. There are doctors who think that whatever satisfies a patient's goals about their health is medicine. But there are doctors who would rather let the patient suffer than give up their ego regarding "evidence". And then there are doctors who think that anything modern medicine throws up is evidence based and prescribe mercilessly.

These are fundamentally hard ethical conundrums. Do you take every doctor who doesn't agree with your way of thinking to the court? That'd be a good way to waste your life.

There are solutions which work out much faster. Outside the courts.

One is activism. Activism is where you constantly make noise and draw attention towards a particular cause. You can be as creative as you want. You can use various tools. But the end goal is that people start caring about your cause. This is political. And there will be lots of political opposition too. In issues where one side is completely non-existent, activism has very big impact in putting that side up as an equal cause. For example, in today's India, patient rights is something that's rarely discussed in healthcare. And activism on that is probably very helpful.

Then there is frank politics. This is the kind where you influence an MP who's kind towards your cause to raise the issue in Parliament or in the public sphere. Basically, politicizing an issue. Inviting the opposition leader to a protest is the sure-shot way to politicize something.

Journalism works too. Journalism is kind of like activism in this case. But the advantage with journalism is that it is perceived more like research than like activism. There is a "truth" value to journalism. A lot of people consume journalism and take it to be "truth" by default. Propaganda in such spaces is very effective on such people.

Research is another option. This gives an academic clothing to your advocacy. It legitimizes every other method by making them more "scientific". Research takes considerable amount of investment, but if you are dedicated to one particular topic, you may as well wear this garb.

There are probably many other things one can do to improve healthcare from outside courts. But these are just examples to show that we need not rely on courts/law for this.

What should these methods of advocacy take up as their cause? I think a focus on accountability is a good thing. And by accountability, I do not mean a system where a scapegoat is found and suspended.

Let me describe accountability with an example. In VMH, we used to do mortality meets. We meet, with all the relevant people present. We take deaths which happened after the last meeting. There is a person who leads the meet who would have identified a few cases where there is something critically wrong with the care delivered. The participants then discuss various concerns related to how that came about. They then find and fix critical issues in the system which contributes to the problem. Trainings on specific topics get scheduled, devices are bought or fixed, staff pattern is changed, physical layout of the hospital is changed, triage system is changed, ... anything and everything that can be changed for a better outcome in the next patient is identified and possibly changed.

Where is the accountability in this? The accountability is in a group of people who think it is the responsible thing to do to conduct a mortality meet. When they are working towards fixing the systemic problems. When they hold themselves responsible and do everything in their power to change things. That's accountability.

Lack of accountability is best demonstrated by the RTI responses of our government regarding COVID management. Wherever the government has said "we do not have the data" they are showing exemplary lack of accountability. That it is okay to say "we do not have the data" means that they assume no accountability of what is going on. That it is okay to blame someone else is the hallmark of lack of accountability. When someone takes accountability, they say "I have done this, this, and this, and I'm waiting for this, this and this." When someone doesn't take accountability they say "But my hands are tied."

Advocacy should be aimed at bringing in accountability in all parts of the healthcare system. Education, governance, administration, healthcare delivery, etc.

Who should do such advocacy? Who should be responsible for healthcare system in India? I have written about it previously.

Sure, change is slow. Some work requires generations. But, we can't not do what we should be doing, right? We should start by holding ourselves accountable, by asking us what we can do and what we are doing. That'll give us greater courage in asking others to be accountable.

Changing The "System"

People of all kinds routinely blame the "system" for many things. They're absolutely right. It is the system that shapes human behavior. In a system where certain behaviors are rewarded, those behaviors are repeated. And vice versa. We are all Pavlov's dogs in that sense.

That's why awards and honors are instituted. To reward the right kind of behavior even if that's not the expected norm. Awards motivate extraordinary people. What motivates ordinary people? The system.

The "system" is the system that encourages and supports ordinary people to do things that they do in their ordinary life.

The system includes written laws, unwritten laws, stereotypes, hierarchies, economic condition, political condition, geographic and physical condition, infrastructure, feelings, mythology, myths, news, fake news, communication, ... literally everything you can think of forms the system.

Who builds the system?

The naivest answer to this and the most convenient answer for "ordinary" people is to blame politicians for building the system. This is especially true for people who consider themselves apolitical. Sadly their politics is that of selfish avoidance of responsibility. It is not always the fault of intention. People who can't stand oppression and feel like there is so much to do that they cannot be responsible for any of it will unconsciously try to talk about why it is not their responsibility. But often it is selfish laziness.

The better answer is that "we" build the system. Who are we? Anyone who can be involved in building the system builds the system. By commission or by omission.

Who can change the system?

Intuitively, the people who built the system can change the system. True. But not all have equal role in building the system. Neither do all have equal say in changing the system. The people who can change the system the easiest are the people with most agency, privilege, and voice.

Who can not change the system?

People who become a slave to the system, who sacrifice their agency, privilege, and voice to the system instead of questioning it. They absolutely cannot change the system.

Why does the system perpetuate?

Because it is easier to continue the system than to change the system. Anyone who wants to change the system has to find ways of sustaining and motivating themselves. Then they have to question the system and work against it. They have to do this at the peril of losing access to their accustomed rewards from the system. They have to stand up against their acquaintances who enjoy the benefits of the system. They have to shake things up. They have to stand out. They have to put themselves at great risk.

The biggest enemies of people who want to change the system are the people who do not want to change the system. The people who benefit from the system usually do not want the system to change, because of inertia, even if they superficially blame the system for everything.

How to change the system?

If you agree with most of what I said above, the answer to this is straightforward.

Prerequisite: Have a lot of privilege. Have the mental space to take on challenging things. Have help, support, guidance. Have plan B, plan C. Privilege is a gift.

(An aside on privilege. A lot of the privileged folks think that they're not privileged. When they hear the word "privilege" they imagine Mukesh Ambani's inheritance with Narendra Modi's popularity and influence. If you can read this blog post, you're already more privileged than a lot of people on this planet. Reading is a privilege. English is a privilege. Internet is a privilege. Time is a privilege. Sure you might be facing oppression in many ways. But that doesn't take your privileges away. Everyone on the planet faces some or the other oppression, and a lot of them face more oppression than you do. It is a lot easier if you count your privileges and use them.)

The first step is to find loopholes in the system to build yourself sustainable income outside the parts you want to change. This might look like joining pre-existing teams doing what you want to do, finding scholarships or grants, monetizing on a rare skill, etc. Creativity is key here. If you do not have any privilege that you can leverage to achieve this step, then you're out of luck. The best thing you can do is continue being part of the system and silently help those who are trying to change the system.

The next step is to find motivation. There is so much to do and so many generations worth of work. Find problems that you can solve. Find problems solving which will give you satisfaction. Find cracks that make it easier to break the system. Define short-term successes. Think and act with purpose.

Then help others who want to do the same. Amplify voices. Volunteer effort. Offer support. Build friendships. Build capacity. Build community.

Things not to do

When thinking idealistically, it can be easy to develop hatred to those who are doing things differently from you. If people are trying to change the system and they are doing it in a way that you do not approve of, engage in respectful debates with open mind. Sometimes they might be doing it right and you are wrong and you can change your ways. Sometimes vice versa. Sometimes both of you can find useful elements to do things differently. Even when there are unsolvable disagreements, it is easier to think about those as fundamentally hard questions with no one right answer. Do not develop hatred for people who do things differently.

Do not become intellectually arrogant. Intellectual humility is when you keep your intellectual outlook about the world detached from your ego. And you're ready to take a hit on the outlook at any moment. And you're willing to change them. Intellectual arrogance is when you refuse to change your outlook from what you formed in early adulthood.

 

Validity of this strategy

This may not be the only way to do things. But this seems like a reasonable way, to me, at the moment.

Don't Let Them Dehumanize You, Doctors!

The society will try to dehumanize you in various ways. And you will feel pressurized to play along too. Don't let them do that to you, as much as possible.

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Every patient comes to you with the expectation of a complete cure. They do not care that you are human. Reset their expectations. Let them know that there are limits to what you can do. Stay human.

Once, I was second call in VMH when a patient was brought dead to the hospital. The doctor on duty wanted to send them home in the same ambulance they came in so that they don't have to be bothered about arranging transport. But the relatives were getting angry that the doctor is not trying to save the life of the patient. I was called in. The patient was "obviously" dead. But it wasn't that obvious to the people who loved the patient. They were expecting an omnipotent doctor to be able to bring the patient back from dead.

People will always come to you with unreasonable expectations - whether they express it or not. Preemptively address those and reset those expectations. Don't let them dehumanize you.

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One patient sees one doctor a day. One doctor sees many more patients a day. Patients do not know this or do not care about this. Each patient thinks that it is reasonable to expect that the doctor prioritizes their care above everyone else's. Omnipresence is not human.

When dealing with multiple patients and feeling overwhelmed, let each of your patient know about your situation and limitation. Before they get a chance to complain that you're not giving them the care they deserve, let them know that you are thinned out and helpless.

There is a limit to how many patients you can care for. The society wants you to treat this limit as adjustable with a bit of overwork. Don't let them dehumanize you.

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You might have been taught that it is unprofessional to express emotions in your duty. But it is very human to have emotions.

There's a trick I use with anger. I don't lash out on people with anger. But I tell patients that I'm angry or that something they've done or are doing is making me angry. There's no easier way to communicate!

I have also used "I am feeling anxious about ...", "I am scared that ...", "It makes me sad too that ...".

Put a label to your feeling and put it across to your patient. Let them know. Let them know that you're human. Don't let them think that you are not.

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You can't know everything. You can't remember everything. Open textbooks in front of your patient. Show them the search terms and the apps you use.

Tell them that you will have to look the answer for that up. Ask them for links to the articles they read to reach at their own internet-guided-diagnosis. I've more than once been linked to cutting edge research that I wasn't even aware of.

Don't let the unreasonable expectation of a charismatic omniscient doctor dehumanize you.

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You need to eat. You need money. Whether your patients are rich or poor doesn't change those facts. But that's not what the patients think. They think of healthcare as a profitable business. They think of healthcare as a necessary service. They expect you to sacrifice profit. They expect you to sacrifice compensation, even.

Show them the reality. Show them how you're saving them money by giving them the right treatment. Show them the expenses you incur in doing so. Tell them how the one hour you just spent with them is already heavily subsidized. (If you don't realize this, just answer this question after a minute of thinking. "How much, would you say, is an hour of your time worth?" And when you answer it, make sure you account for the opportunity cost you incur by not doing other things that you're capable of doing.) Give them a lesson in economics. 

Let them know that it's not omnibenevolence, but it is self-love that is human.

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Don't look at the patient-doctor relationship as a purely biomedical one. It is a deeply political one. And a deeply human one. It need not be one way. It should not be one way. Anything that comes in the way of making it complicated needs to be given considerable time and addressed.

History Taking Through Heart

I was trying out the Daily Rounds app on Android and came across a case description "Unilateral limb swelling in a 51 year old lady. No comorbidities. KFT normal. How to proceed to diagnosis?"

This reminded me about how clueless I was about history taking during medical school. I think if I've learnt anything well by now, it is on how to take a detailed history. And looking at this question made me realize how much that helps me in coming to diagnoses. So here are some super simple tips to take detailed history while building a personal connection - which doesn't require any knowledge of pathology or medicine.

Start with the person

You might have learnt that asking for name is the way to build rapport. But that's a lie. Asking for name is so you can write it in your notes. If you want to build rapport, talk to the person in front of you (and not the patient). I've found that the question "have you had breakfast?" in their language (adjusted for the time of the day) is a super simple way to build rapport. And the reason is that this is what regular people usually ask each other casually when they are on the road.

This lets the patient relax and breathe free. With just one sentence you're telling them that you're a human like them and you respect them like another human. That their sickness is secondary to their human existence.

Move to the patient

Now you let them talk. Unless they're experienced, they will not have arranged in their mind what to tell you. For the first few minutes, let the patient speak without interruption. Let them figure out what their problem is while they're talking to you. Use only head nods, and "hmm" to communicate that you're listening. Make sure you're looking at the patient and don't give off an impression that you're not listening.

If the patient stops after describing just one symptom, just give it back to them as a question. 

"I have headache" Long pause.

"Headache?" with a puzzled, but caring face.

Awkward long pause.

"Yes. The right side of my head feels like it is exploding, since yesterday"

"Hmm. Tell me."

"That's it. I'm unable to get up from bed."

Pause.

"And everything becomes dim and dark to see"

...

Once you let the patient figure out that you're there to listen, they'll tell you everything you need to know without asking.

Get the timeline right

Once you know the presenting complaints, it's time to arrange them in the right order with dates. Ask specifically about when they were completely alright. Get as specific a date as possible about when things started. (The longer people have been having symptoms, the less specific you can get. But still.) Retrace the course of their illness from day 1 of symptom. Find out the order of symptoms. Find out the progression of illness. Find out what they've been doing (I betcha they've gone to another doctor already or tried something). Find out why they decided to come to you. (That needs a point of its own)

Find out why they came to you

There's a reason the patient has come to you. This is not the same as the chief complaints. Some are scared and are coming for reassurance. Some are tired and want relief. Some have been referred by someone else for a specific reason. Confirm the reason why the patient has come to you. This becomes super helpful when you're figuring out the management. As a bonus, it allows you to address the exact concern the patient has.

Let them know you are on their side

This is the turning point in the consultation. You have heard the patient. You have understood their concern. You now win their trust by telling them that you are there to help them. And then you start talking a bit.

Ask your questions

You should have held the questions in your mind till now. The time to start asking them is now. Start with clarification of symptoms. Ask for negative history. Ask about comorbidities. Ask about past history, family history, socioeconomic history, and so on.

Asking negative history

For asking specific negative history, you'll need to know about diseases. But there is a way to avoid that pre-requisite. Go from head to toe. (You'll need some anatomy, physiology knowledge). 

 

Look at the head and ask about all the organs that you see. Bonus point if you touch their head when talking about the head. (But that's not always appropriate. Use your gut sense). Ask how their sight has been, how their hearing, taste, smell has been. Have they had cough, cold, throat ache? Then look underneath the skull. How has their memory, sleep, thoughts, etc been? (There is hair, tongue, teeth, and so many finer details I've skipped for brevity. You will have to be careful not to ask too many questions too. This is just an algorithm to generate questions mindlessly. Filter those questions by applying your mind.)

Then go down to the chest. There are lungs, heart, esophagus, neck + thyroid. Ask questions about things that could go wrong there. Then the upper limbs.

Then the abdomen/pelvis. These have so many organs. Liver, spleen, kidneys, adrenals, pancreas (endocrine, especially), and the alimentary tract per se. And depending on your patient, uterus, ovaries, so on. It is easy to forget the back with spinal cord.

Then there are genitals and lower limbs.

 

Then there are some general things like fever, bodyache which don't really fit into this organ by organ thing but they usually come up somewhere in between.

This is only one way to generate questions. Depending on how much differential diagnoses you have in your mind based on chief complaints, you might be able to come up with questions without using this algorithm.

Other histories

The best way to take history like past history, socioeconomic history, etc is to imagine yourself in the patient's life. What is this person? Where are they coming from? Where are they going? What do they do in their daily life? How's their life like? What's their family? What do they do after getting up from their bed till they go back to bed? Do they take some medicines? Do they go to hospitals? Do they drive a tractor? Do they work in three houses?

This part of the history should ideally go like a conversation that has become really interesting and you "want to know everything about" the other person. But often we don't have a lot of time to spend here. And it is inappropriate to spend a lot of time here. Just get a fair sense of each slice of your patient's life.

What has their relationship with themselves been? Do they treat their body and mind well? Do they consume alcohol or use tobacco? Do they eat well? Do they exercise? Do they work too hard?

 

What has their relationship with their family been. Who is their caretaker? Could someone in the family be giving rise to their sickness? What's the family dynamics?

What has their relationship with the society been. Are they generally happy with life? What do they do in their life?

What has their relationship with the medical system been. Do they have any diagnoses? Do they have any other doctors? How many times have they had significant medical care in the past and why?

Summarize your idea of pressing issues back to the patient

By this time you have gone far away from chief complaints and to bring the attention (the patient's and yours) back to it, you can summarize what you think is the problem the patient is going through to them. And then after you get the patient's confirmation you can proceed to examination.

Advantages and disadvantages of this method

What I've described here, like other ways of history taking, is just a template. This one is focused on getting a whole picture of a patient's life without using a lot of knowledge about diseases. Another advantage is that you can build a lot of empathy. But it is also very time consuming. It often takes 45 minutes to an hour just with the history if done this way.

What Patients Don't Know About Medical Schools

There are people who assume that doctors who get into medical school through reservation end up as bad doctors. They have no clue how medical school works.

I won't go into the reasons why reservation (or affirmative action) exists. That is one of the easiest ways for governments to "do something" towards inequity in the society. This post is about the relationship between medical school and bad doctors.

Defining bad doctor

Let's first define a "bad" doctor. An objective way of measuring that would be - a bad doctor is someone who kills the most number of patients. There's a problem with that though. A doctor with no patients would then not be a bad doctor. And a surgeon who takes on the most difficult cases (with proportionately higher chances of deaths) would also be considered a bad doctor. So, the absolute number of patient deaths is not a very good measure of the badness of a doctor.

Maybe we can then take the subjective measure of "patient satisfaction". The doctor who gets 1-star rating for most consultations is a bad doctor. That is tricky though. The doctor cannot keep only the emotions of the patient in mind. The doctor also has to worry about the medical issues. If a patient prefers that the doctor does not examine their abdomen, a doctor who is dealing with this patient's "pain abdomen" may score poorly on patient satisfaction if the doctor does consider it important to palpate abdomen. Patients might be less satisfied if the doctor doesn't prescribe them a few medicines. 

If "patient satisfaction" is measured in a longer term wherein the formalities of a consultation are forgotten and all that remains is the satisfaction of achieving good health, maybe then it is a good measure.

People in the profession can also score doctors. I could make up a criteria for scoring doctors. I could say the doctor who practices the most rational, ethical, and cost-effective medical care is the best doctor and vice versa.

A hospital can say that the doctor who generates the most revenue for the hospital is the best doctor.

Someone can say that the doctor who works the longest hours is the best doctor.

It is thus clear that who is a good doctor and who is a bad doctor is a difficult thing to have consensus on. Let us nevertheless choose a popular vantage point.

Let us call the doctors who are irrational in their care and leads to poor health outcomes as bad doctors. (I had initially included "insensitive to their patients" in that list, but apparently many of us elites think that the fictional (or not?) "Dr House" is a good doctor. So we will first talk about these "good" doctors and later come to whether there are alternate definitions of good doctors).

Medical school training

What does a medical school train doctors in? Indian medical schools (at least the south Indian universities I know about) confer MBBS degree on someone based purely on theory exams and practical exams with theory given more weight. The whole training for 4.5 years is focused on what those exams need. And how're those exams conducted?

Theory exams are mostly single sentence questions that goes like "Write a brief note on <insert health condition name>". (You can see many question papers in the archives of this blog). There is no "Higher Order Thinking Skills" involved in MBBS theory papers. The only skill tested is that of ability to memorize a lot and write a lot more.

Practical exams are slightly better. In the clinical subjects, there would be patients called "cases" who are examined on the spot by the candidate and afterwards an examiner(s) and the candidate discuss the "case". These practical exams are not scored with an "Objective Structured Clinical Examination" pattern. Therefore, it doesn't matter how you examine your patient or if you examine them at all, all that matters is that you have the right diagnosis and that you can discuss lots of points about that diagnosis with the examiner. In reality, often the diagnosis of the patient is "leaked" to the candidate before the exam and once that is known the patient is just a prop in the act.

In summary, medical school tests you on how well you can remember the textbooks - and that alone.

Does that mean all the training in medical school is towards that? No. There are some islands (in form of an exceptional lecturer, post-graduate or peer) where other skills are focused on. But to a large extent medical school training is towards what is tested.

In reality, medical school training does not help people perform good even in these tests because medical school training is literally paid doctors who have no philosophy on teaching (let alone facilitating learning) passing their time with by wasting the valuable time of learners. If medical school professors were sent to teach 12th standard biology classes, their students would dropout and re-join 11th standard in the computer science stream.

(Of course there are some really good people. And the bar is so low that even someone who talks to their students with kindness are considered good professors in medical school. Anyhow, let's not be bogged down by exceptions)

How are doctors made then?

Doctors become doctors not because of medical schools, but in spite of medical schools. It is mostly their interaction with textbooks, peers, patients, and life in general that makes them doctors. And only because the law restricts this opportunity to the confines of medical schools, it is restricted to medical schools.

The skills involved in patient care - communication, courage, critical thinking, empathy, leadership, etc have nothing to do with medical school training.

The theoretical knowledge involved in patient care are all textbooks based.

Procedural skills are learnt by doing (on real patients) with some supervision and there are no special courses to improve or learn these skills in a setting where it is okay to make mistakes.

Where do doctors really learn their craft then?

MBBS doctors start learning real medicine towards the end of MBBS (on their own). They get really good at it only after MBBS - either by working as a postgraduate student or by working in hospitals.

And these opportunities to learn after MBBS are really diverse and heterogeneous. Some work as residents in certain specialty departments where they learn a lot about those specialties (and a bit about medical care in general). Some do this with a gap of a few years (spent in PG entrance preparation).

From then on they keep getting better at it. Because every new patient they're responsible for teaches them something new.

In essence, the 5 years in MBBS has little to do with how good/bad your doctor is. Medical school is a place where doctors learn about the outline and the syllabus of MBBS. After graduating is where they learn to treat people - and that is what decides how good your doctor turns out to be.

What makes a good doctor?

Privilege plays a role. If one has the privilege to get trained abroad (or in India) in medical schools that are interested in pedagogy, ethics, and rationality, there is a good chance that they learn to become better doctors. Also if one has the privilege to afford to work with lesser known good doctors within India, again there is a good chance that they learn to become better doctors.

Scientific temper and critical thinking plays a role. I'm not really certain how one gains these skills. Life experiences that makes one skeptic may help, perhaps? Or reading about science might help too.

Empathy and emotional intelligence plays a role. Understanding one's patient and their context is critical to be able to understand what they're saying. Often the patient is telling the doctor the diagnosis, but the doctor can't hear because they cannot connect.

If you're under the impression that performance in an entrance test is what makes a good doctor, you've gotten it completely wrong.

Want to Predict COVID? Ask the medical officers or lab managers

From the beginning of this pandemic I've had very accurate predictions of COVID surge, lull, and fall from two kinds of people - PHC medical officers and lab managers.

The PHC medical officers see anywhere upwards of 200 sick people per day and they get to see how many people are coming in with COVID like symptoms and notice patterns before they are even tested.

The lab managers keep a track of test positivity rate (and test rate) and can sense that it is getting overwhelming vs underwhelming.

The only kind of people who haven't particularly been helpful are the people who draw graphs based on numbers from government sources.

Three Stories On Connecting Health Data

 Story 1

There was a small research institute with 20 people. Someone among the staff did an online survey to ask everyone their demographic details (name, age, gender, email address) and their diet.

After four months, another person ran another survey. By then there were 23 people in this institute. This surveyor asked everyone their name, email address, haemoglobin.

 

Now the director of the institute wanted to connect diet to haemoglobin levels. So they took up the older survey and assumed that since email addresses will probably remain the same, they could use that field to "connect" these databases together. But, alas, there was one person who changed her email from @gmail.com to @institute.org

 

But never mind. They knew who it was. So they just fixed this by copy pasting rows in a spreadsheet.

Story 2

A survey was done in 20 villages. There were two teams of 5 data collectors who divided the villages equally. They went to households and collected from the people demographic details, answers to a lot of questions about health, and also the GPS location of the households.

Then, 5 months later, the PI got more funding to do a haemoglobin study for 600 people. The PI decided to divide this fund in such a way that 300 people who come to a nearby hospital would get tested and 300 people from the previous survey (6 villages) would get tested.

 

One of the previous data collection teams was called in. Turns out 5 of those villages were surveyed by the same team in the past. Fresh from the previous survey, they went to these villages and quickly located the households they had previously surveyed. Once they were in, they used the names of the individuals to locate their past record from the surveying app and added haemoglobin values too. But in some households there were no people as they had gone for work.

In the remaining one village, they used the GPS location to find out the households. It was slightly harder, but it was doable because the application with which they collected the data could directly point them to the household location. It worked when the GPS would work. When the GPS wouldn't work, they would look at the names of the people in the households and ask people whether they knew where those houses were. Somehow they made it work.

 

In the hospital, meanwhile, some of those missing people from these villages had come and they were getting haemoglobin tests. But this data was not being collected.

Story 3

The Government of Karnataka decided to do tribal health research. They collected data (demographics, height, weight, BP). Then they assigned to each individual a unique ID number. Something called Namma-ID. They told them that they should keep these Namma-ID numbers safe and that these would give them benefits in healthcare, etc. And someone in the government had the idea that the data they collected should be available for researchers. Any researcher who signs a confidentiality clause would be given all the data (name, father/husband name (still patriarchal in 2021), home address, village name, Namma-ID, etc included). There was one doctor in the area who got themselves access to this data. This doc narrowed down the data to their own village and the set of people with hypertension and saved that in a spreadsheet. 

 

Every time someone came to their clinic, the doctor would ask if they had a Namma-ID and if so the doctor would look at their height, weight, and BP from the GoK data. If they didn't bring their Namma-ID, the doctor would ask their name and try to search. Sometimes the doctor would have to try various spellings to get the right person's record. But somehow the doctor would find the right record and add more details when that particular visit was over.

Then there were times when people who were new to the village came to the doctor's clinic. The doctor would spend minutes searching for this new person's record. The poor villager would be sitting on the patient's chair wondering why the doctor wasn't asking any question about the health issue.

Whose Responsibility is Health?

How do you trigger a never-ending debate on Twitter about health? You have two options. Either talk about a bridge course from Ayurveda into modern medicine. Or talk about compulsory rural service.

Why, though? The superficial reason is that Twitter is a stupid medium where there is not enough space to make a nuanced argument. The deeper reason is that it is not clear whose responsibility "health" is. And that's because there are two ways of defining what "health" is.

There are folks who take health to mean absence of diseases. Even when the community medicine department in medical schools keeps talking about WHO definition of health, many medical graduates focus on "diseases" because the rest of the medical school talks only about diseases. This percolates to the rest of the society and in the overall society there is a clear notion that health is the absence of diseases and that healthcare is access to curative services.

The impact of this definition is most strikingly visible in what people coming out of medical schools tend to do with their lives.

They seek specialties and super specialties (like interventional radiology, dermatology, and cardiology). They do not have a problem in spending one, two, or three years in trying to get post-graduation seats. They seek work in the largest hospitals in the largest cities. They make their life about "diseases" and restrict their role to providers of disease-curative services.

But this definition is not just restricted to doctors.

• Faculties in medical schools continue to teach students that health is about "diseases". (Even in some community medicine departments).
  
• Government of India spends a significant share of health budget on setting up/upgrading hospitals and on reimbursing curative services through elaborate insurance schemes.
• When there is a pandemic, technologists rise up and try to "help" with their mathematical models. But they don't think they have anything to do with health during non-pandemic times.
  
• People think about health only during bouts of illnesses. They pay for healthcare only in the context of curative services. (Or insurance premiums for schemes that apply only to curative services).
• There is no talk about health during election campaigns.

There is a wider, (arguably more "real") definition of health - as a "state of complete physical, mental and social well-being". This is often forgotten. As per this definition, we have country full of unhealthy people. And people who stick to this definition make the case that health has as much to do with the society and its politics as it has to do with hospitals.

They argue that education, opportunity (to make a living), dignity, equality, rights against exploitation, justice, access to technology, and so many other factors go into deciding whether individuals are healthy.

When it comes to doctors (and other medical professionals), they have two ways to spend their lives in this society.

1. Follow the narrow definition of health where all that matters to them is the survival of their "patients" - those who come to the hospitals.
2. Follow the broader definition of health where they are leaders and change makers and politicians and advocates.

Unfortunately, in the never-ending cycle of disease management and education to manage diseases, most of our medical professionals (doctors, nurses, etc) are not trained to take on the broader definition of health as their "job". Which leaves them restricted to following the former kind of life.

The broader definition of health is then left for a very small set of people to work on. They are variously known as "public health professionals", "family physicians", "primary care practitioners", "community health specialists", etc.

The task for this small group of people, on the other hand, is humongous. While delivering curative services require to match demand with enough supply of resources (human and non-human), working on the larger definition of health often needs a whole different approach. For, the problems in (social (?)) determinants of health like gender, class, education, economic condition, and so on often require action beyond individuals and institutions. Some of these work span generations. And there is no linear progress. Sometimes societies regress to worse conditions too.

Now, here is the problem. This bigger task should not be and cannot be done by "medical" professionals alone. It requires collaborative action from communities, lawyers, politicians, engineers, economists, artists, historians, every person imaginable. Because that work is not related to "medicine" alone.

Now, let us look at the controversial topics that we started this post with.

In both bridge courses and compulsory rural service what the governments seem to be trying to do is to increase the number of "qualified" doctors (and hopefully other medical professionals) in rural areas. We can assume that their assumption is that if there are enough trained curative service providers, there will be some respite.

And they are probably not a 100% wrong in making that assumption. If a person with wisdom and training goes to a place that can benefit from that wisdom and training, that place will benefit at least a bit. (Taru Jindal's story is an example).

But there are some important counter-arguments

• The nature of these policies are sometimes objectionable. "Mandatory" rural service is as controversial as mandatory military conscription. Bridge courses may often be seen as unscientific or unfair.
• The training in medical schools (especially when they get more "specialized") need not be tuned to the context and needs of rural communities. Even if medical professionals are trying to deliver only curative services, they can be quite disoriented when they find that they don't have the investigations and interventions they need at arm's length.
  
• To stress on the point of training, there probably is very little of leadership training in medical schools and often in communities where the health system is next to nil leadership is a critical element in being able to set up systems.
• The kind of leadership challenges one faces in rural communities could be different, and the solutions might often require larger systemic changes (refer the broader definition of health).

It is counter-productive to train a generation of medical professionals in delivering curative services in cities and then expect them to perform in a broader, entirely different, and disproportionately more challenging role as health care leaders in rural areas. 

You can send them to well functioning hospitals with all facilities in rural areas and they probably will find their groove. The irony is when you are sending them to rural areas to build such hospitals and/or systems for health without giving them any training in that.

And it is not all medical school training that I'm talking about. It is also the societal training. We as a society are training many professionals (doctors, engineers, included) with a very narrow definition of purpose and meaning ascribed to their profession. If you are a doctor - the meaning of your life is to treat the sick. If you are an engineer - the meaning of your life is to plan and build things. And so on. When have we, as a society, encouraged people to ask larger questions. Like "Why are people falling sick?", "Why does this thing have to be built?", "What is my role in perpetuating the system the way it is?", "How is it possible that there are widespread inequities in the world while there are enough resources for all humans to have a dignified life?", "How are our decisions and actions endangering the survival of this planet?", "What is the relation between care for others and democracy?"

The questions that matter often have solutions that require collective action. And that often includes many kinds of individuals (no matter what their "job" or "background" is) to take action. Sometimes that includes you. Do you consider that as your responsibility? If you do not, then you are part of the problem.

Questions to Ask About Vaccine Data Tracking

In vaccine data tracking debate, please question the assumption that the government needs to track who is taking vaccine.

What are the implications of not tracking who is taking vaccine? What are the risks and benefits? Who gets excluded when IDs are required for vaccine? What is the government trying to prevent by making IDs mandatory? What are the costs of tracking vaccine beneficiaries? What will the tracking be used for?

Only if tracking people is required does discussing the mechanism of such tracking make sense.

Wonder Regimen to End Tuberculosis in India

Have you ever looked at Tuberculosis and thought, "Hmm. I wish there is a way to end this disease"?

Well, wonder no more.

Anurag Bhargava, Madhavi Bhargava & Anika Juneja have come up with a regimen that can achieve your dream.

Another good news is that treatment with this regimen can also be helpful in many other diseases.

Even better, it is a non-invasive regimen.

Want to learn the regimen and start using it in your practice?

Click here [PDF, 1.9MB] to know more. (You might want to skip to the end for the actual prescription, but read the full paper for context).

Dr Anika Juneja, one of the authors of this paper, has won the India HPSR Fellowship this year.