Do doctors not want to be doctors, anymore?

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Dr. Parthasarathy was a household name in Bangalore. A graduate of medicine from the pre-Independence days; he was what was then called an LMP – an early 20th CE version of the MBBS, expanded as a Licensed Medical Practitioner. He was a big man a little more than six feet tall; portly, had a ruddy complexion, dressed in tweeds and suspenders and always wore a tie. Oh, and a beret. Bangalore was an English cantonment town; its culture, lifestyle and entertainment was very Western (cosmopolitan they called it) and this sort of attire was quite commonplace for the time.

His office was on a tree lined but busy commercial avenue named for the trees whose sky framing canopy exists to this very day – the beautiful Sampige mara, or the Eastern Magnolia (Magnolia champaca). It was a tiny place with dark wood paneling the walls; a feature which, despite making everything feel boxed in, had an incongruous but comforting Harley Street ambience. There were wood partition screens with big blocks of carved wood for legs that divided the place into small cubby hole practice rooms. Some had eye-level ground glass panels with cut-glass green inserts and with inbuilt in-out slats. A totally unnecessary addition considering that once he settled into his chair (he had no formal desk), his shoes would always poke out from underneath the partition. It was a wonder he managed to squeeze his frame into the small cubicle that had just enough space for making a quick half turn. I was small then and, to my miniature eyes, his office seemed like the inside of wooden chest. I can only imagine what the adults felt. Apart from this room, there was an examination room and in the back a compounder’s room with a small procedure table mounted against the wall. The entry had a waiting area with narrow benches along the wall that seated a quarter of the bum and on which you had to necessarily sit erect because if you stretched your legs you’d lock ankles with your equally ill and not a little irate neighbor. Shelves on the wall had an assortment of dusty magazines and comics that were never touched. Even if kids asked to look; scowling adults would ignore them.

The partitions between these rooms were themselves relics of another era. The interiors were so dark that even during the daytime; a naked bulb or two would always be on. Their dim incandescence filtered through the gritty ground glass panels like fog, with a mysterious effect of clairvoyance. The partitions didn’t ride all the way up to the ceiling and so, every conversation behind them was well heard by all. No one made eye contact with the patient emerging from his very public, but separated, meeting with the doctor. All screams and groans were equally communal. Our anxiety and their noise rose in harmonious concord. Children invariably started crying and harassed parents would run out into the welcome distractions of the street. Across from a side door there was a tiny alleyway that led to a pharmacy – ‘Famous Drug House’. And on the other side was a bakery that had wonderful smelling bread. We never got to taste it, since the only reason we were there was if one of us was ill and any attempt to opportune the elders for ‘bakery’ goods at such a time would be rebuffed. We were left to indulge our longing stares and smell the air. The clinic’s interiors and the bakery aroma gave fever induced deliriums a welcome respite. There was no reception, no pesky counters, no fussy data recorders and no fancy gadgets. Just a big jolly doctor with a big heart and what looked like a giant stethoscope. There were also some painful glass syringes in the back with the compounder but that’s a side story.

Sitting in his office it felt like 1840; you could almost hear the horse carriages rattling over cobblestoned paths and the horses harrumphing outside. That he could create this ambience in a busy thoroughfare in the heart of a bustling neighborhood is testament to the man himself. I often wondered if it was our overactive imagination fed on English children’s books that made us think so; but, no. I am quite certain that most others’ reminiscences would be along these lines. Maybe it was another figment of my imagination but, every person who emerged from that cubicle would have a look of lighthearted relief. The good doctor would’ve dissipated their anxiety and all that was left was the minor matter of the physical ailment for which he’d have armed them with bolstering words of courage, a prescript for some medicine and a recommendation to sample the bread with very hot milk and a generous sprinkling of sugar. After which, he would boom over the partition – ‘next’ – and we would make way for the next sufferer in line, impatiently waiting our turn for his magic.

He practiced there, in that same place, for sixty five years. Maybe, more. Every day he would open shop at the same time. On time, every time until his very last day. Retire home for a siesta and return with renewed vigor in the evening. For a staggering number of years, well into the nineties; he unfailingly followed this same routine. William James would’ve been proud. Do I hear you say, fees? I remember a board outside that said two Rupees per consult. There was a box by the side of the door in which the fees were to be dropped. Many would plead inability to pay that and he would never protest. I remember him locking up one late evening when my father and I hurried to catch him; and I remember too, the jolly gusto with which he unlocked the big padlock and took us in. He silenced our fervent apologies by ordering hot almond milk from the bakery; noticing clearly that I was without the mindful escort of my mother. A liberty he would never have accorded himself in her presence. A secret delight, he knew I could only sample this way.

This was the doctor figure of our growing years. The one we modeled our ambitions around.  The one we wanted to be when we grew up. The one we tried to emulate. And yet, here we are today with a measure of the heart perhaps but with not a spot of the persona; that even the most generous would fail in making a favorable comparison.

So, what changed and why? Of course the practice method itself is vastly different. Complex technologies have come to dominate our science. Today, a doctor wouldn’t be able to stay financially viable with a practice like that. The business of medicine and health has become so huge; it has come to occupy a permanent fixture in our lives. No more do people go to see the doctor for the occasional times when they are ill. It is now commonplace routine to go when well in order to be told that all is well. This change has been talked and discussed ad nauseumwith so many different points of view. What is less talked about; is how the humans, in medicine and running it, have changed.

A doctor was seen as a member, a necessary and vital part, of a community. Neither the community nor the doctor saw themselves as separate entities, distinct from each other. Medicine was a social profession. As such, most doctors were sociable and social beings. They ‘liked’ interacting with the community. They thrived on it; they actively sought it. A good portion of their knowledge was also empirical. It came equally from listening, observing, communicating; none of which was possible without spending time with people. Less time was spent maintaining records; more in conversation with the patient. By doing so, they consigned to memory their patients’ stories which, for them, was the best record of all. For doctors like Dr Parthasarathy, it was about the people. He and his tribe saw themselves first as pillars of the community and as healers only after.

Today’s doctors are vastly different. Though the patient load is frequently blamed for the change; it was more the explosive invasion of technology that fueled it. The much talked of thoughtful lateral shift, that incorporated the old ways into the new, did not happen. Almost overnight, these grand viziers of health were cast overboard and the new, technology and drug driven medicine, moved into its place. The change happened right under our noses; but sadly, the regulatory bodies did not have the muscle or the will to stem the tide and give it direction. As each machine made more exquisite diagnosis and after books became tomes of data, doctors had little choice but to submit to the constraints of time bound learning of both text and technology. Slowly they receded into the great buildings with sharp white lights and chemical odors of sanitation, behind reception desks and complicated registration procedures, behind payments and reimbursements and behind monitors and data screens. The simple human interaction of eye contact, a smile, a warm handshake, a comforting word or two, a shared experience, – qualities that are so ordinary they ought not to be an expectation – these same qualities slowly ceded space to the mechanized takeover of electronic systems and the creation of a health industry. Where medicine was once about community and its people; it now became a single minded pursuit in the excellence of the self. More degrees, more accreditations, more gizmos, more procedures, more papers and more zonal dress codes. A series of layers, each taking the doctor farther away from his primary interest – the community and the patient. Patients thus morphed into bodies, into data, diseases, symptoms, signs and a diagnosis. The tortured anxiety of a patient’s eyes became unrecognizable to the tortured anxiety of the doctor’s pressure to stay in the game. For both, the interaction has become a discontented trek to nowhere.

We could retrace our steps in time to some extent by empowering Primary Care Physicians and Family Medicine Specialists. It would require easing of the controls over these fields and making them competitive by increasing reimbursement to these practitioners. By making Primary Care a profession of choice we give ourselves a second chance at rebuilding health delivery to a standard of care that only a synergy of both the art and science of medicine can bring. However, policy change is so slow in comparison with the speed of technological advancement that by the time this decision is implemented, it will probably take a form very different from the one that is currently envisaged.

The flipside of all this is that it might only be a couple of generations that feel this angst. Doctors and medicine have only changed in lockstep with a rapidly evolving societal dynamic. A new generation is turning the corner; those brought up on technology, whose daily life is ruled by it and who therefore don’t expect much different from their doctors. To this group; the contradiction of doctors morphing into hi-tech health industry technicians might not matter as much. At that point in the future; will we still want empathy and the personal touch from our doctors, or will we settle for technical prowess and peer ratings. With doctors on track to becoming service providers, and in the absence of investment in primary care, the gaps of the heart will probably be plugged by resources like social networks and patient communities. The last especially holds great promise as a bridge between a physician’s sterile prescription and the actual life tools for sustaining cure and for balancing illness with a quality of life.

Maybe, by then, a doctor will cease to embody our nostalgia for empathetic care. Perhaps, a name change will come about and we will call ourselves something more in keeping with the time. And roses will no longer be roses and their smells no longer as sweet.


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