In the protest surrounding suspension of Dr Saibal Jana and Dr Dipankar Sengupta, a debate has emerged around what an MBBS doctor can and cannot do, especially in rural settings. This is a very complex question that requires a complex legal answer.
There are several relevant case laws and even acts like Clinical Establishments Act which talk about some aspects of this debate. But let us look at it from a more fundamental and fresh perspective.
Law is not static. It is subject to continuous change. Law is not blind either. It is acutely aware of context. Therefore, there is no need to frame a universal, absolute, strict law regarding a nuanced question like this.
What are some of the considerations that must be kept in mind when framing a law on this question?
- How to bring equitable healthcare to the people of our country?
- How to protect people from harm?
- What is the situation with respect to human resource availability in rural healthcare?
- How do referral pathways work in our country?
- How does medical education work?
What makes a rural place "rural"? Places are considered rural when they have small population and consequently very few markers of urbanization (like large buildings that accommodate many people in a small area and huge roads that accommodate heavy traffic). Many rural areas won't have a movie theater. Because there are so few people that it would be difficult to run a cinema and make profit. Similarly, the economics of small numbers do not allow a "specialist" doctor to practice only their specialty in rural area. It also makes it difficult for them to invest in equipment that might be required for specialty practice. In many ways, specialist practice is economically impossible in rural areas.
On the other hand, a generalist is able to successfully practice in rural areas. Someone who is willing to see a large number of people with many different health conditions can survive in a rural economy rather comfortably.
Is it possible to have multi-specialty hospitals in rural areas, if the rural economy cannot sustain specialists? Yes! This is possible through team work. There are many rural hospitals which work by association with specialists who might be present only on one day a week or available over phone calls. This unique symbiotic arrangement has organically developed in many rural places in India. The reason is that just because a place is small, the health needs of the people in that place will not be small. (To paraphrase Dr Yogesh Jain). Rural places also require specialized care. The demand is there, but the volume is low.
If you can have one specialist come on one day and manage all the cases that require that specialist's care, the rural hospital can club many patients together on that particular day and make it an economically feasible day for the specialist. If the specialty is something like surgery which requires post-op care and follow-up, rural hospitals can manage with generalists who work with the guidance of specialist in arranging that follow-up care.
What specialists typically tend to do in such arrangements is also empower the rural generalist in being able to handle more complicated cases. This happens in many ways. The availability of specialist guidance increases the confidence of the generalist. Doing things with a specialist transfers necessary skill. And working under these arrangements for a while makes them able to work independently as well.
That is how medicine is. Medicine is not something that you finish learning in a specific number of years in a medical college and then go out and practice forever. Medicine is something that you learn every day. Even the specialists learns on the go. They hone their skills day by day, with every new patient.
Now, let us imagine the same rural area without this delicate arrangement in place. Imagine a doctor who has just finished MBBS has come to practice in a rural area and have started a small clinic or are in a PHC. What are they supposed to do there? Can they treat pneumonia? Can they manage someone with schizophrenia? What about deliveries? Can they conduct a delivery? How about I&D for abscesses? Can they prescribe Morphine for palliative care? Would it be alright for them to stabilize a poly-trauma patient? Someone with an Acute Coronary Syndrome? What happens when a patient comes to them with long history of cough and fever? What about someone with chronic headache? How about someone with loss of balance? Or someone with a distal radius fracture?
In a world focused on specialties and urban model of care, many of these patients would have to be referred to the average specialist in the nearest urban setting. But there is not a lot of insight into how many of these referrals are successful. How many reach the right kind of "specialist"? How many decide to suffer than seek inaccessible care? How many settle with an alternative medicine practitioner who decides to take the risk of handling the condition with the knowledge and confidence they have? How many die lost in the referral pathways? How many die at home?
In a world that's person-centered, we would encourage the MBBS doctor to take all of these factors into consideration and take a calculated risk in cases where that would be in the best interest of the patient. In cases where the patient is otherwise going to not receive any care, it is often in the best interest of the patient that the MBBS doctor, even if they do not have the skill of an average specialist, attempt something risky.
Of course that shouldn't come at a cost to the patient. This has to be a careful decision that's discussed with the patient. A shared decision has to be made between the doctor and the patient as to the risks and the alternative options. But it is these informed risk taking that's going to help that doctor level up.
A progressive outlook at medical education should think about what resources can be made available to this isolated doctor to be safe in the risks that they're taking. What kind of guidance and resources can be made available to them to increase their chances of success and increase their level of competencies.
It is when we are able to create such empowered generalists in rural healthcare that we can start bridging some of the huge gaps in rural healthcare. The law should not become an obstacle in this mission. The law should be progressive enough to encourage these possibilities. The law should be promoting this decentralization of healthcare. The law should be focused on people and their well-being.
The question should not be "What can an MBBS doctor do?". The question should be "What should an MBBS doctor do?"
