Misplaced Reverence for Super-Specialists Has Led to Lopsided Public Health Priorities in India

Healthcare systems have to grapple with a variety of problems in terms of both diagnosis and treatment. Some of these problems are complex and are unique to countries like India. First, India does not have a formal referral system routed through a general practitioner (GP). The standard practice is for the patient to try one doctor/hospital after another until there is some improvement in the medical condition. Second, there is the problem of patients switching from one therapeutic system to another. When allopathy fails, Ayurveda or homeopathy becomes an alternative. Past experiences and anecdotal reports guide the destiny of the Indian patient more than evidence-based medicine. 

While there can be no gold standard for treatment choices, diagnostic procedures are generally bound by rules and definitions. Because therapeutic choices depend on the final diagnosis, an incorrect diagnosis would invariably result in the failure of treatment.

Undue Preference for Specialists

A very important, but generally overlooked reason for diagnostic dilemmas in India may be attributed to the unjustifiable preference for specialists over GPs. This is a problem rooted in the Indian perception of “prestige-based hierarchies” (Sharma et al 2013).  Patients in urban areas and living in states with better health indicators (for example, Kerala) insist on consulting a specialist for everything. Many such patients, based on their symptoms, choose the specialist themselves (Makkar et al 2003).

"Everyone wants to come to a super-specialist: If they have a headache … consult a neurologist. For chest pain, you consult a cardiologist" (Ruddock 2015). This issue is complicated and goes beyond the problem triad of developing countries: poor healthcare availability, affordability and accessibility. The primary health centres (PHCs) are often shunned by the middle classes and those above; these patients prefer to seek treatment in secondary or tertiary care even for common conditions such as cold, fever, and diarrhoea. The respectable norm, unfortunately, is to consult a specialist in a city.  Many who cannot afford to pay for a specialist’s services would borrow money or pledge their property. Only the poorest depend on government-run PHCs wherein GPs make the referrals. 

Such a self-referral system is problematic because patients often go to the wrong specialist (Makkar et al 2003). To make matters worse, patient prejudices are compounded by the prejudicial bias of a specialist. Hashem et al (2003) demonstrated a positive bias among specialists to attribute diagnosis within their own specialty. In a systematic study, specialists trained in cardiology, haematology, and infectious diseases were presented with four cases, of which three were from the above sub-specialties and the fourth was in gastroenterology (outside their speciality). When asked to give up to six differential diagnoses, each specialist indicated greater bias towards diagnostic conditions within their own individual specialty. The lone case of gastroenterology was the most overlooked, because none of the specialists who participated in the study were trained in gastroenterology. This is in line with what philosopher Wayne Dyer once said, “If you change the way you look at things, the things you look at change.” 

Ironically, the undue preference for specialists is particularly hurtful to the public health profile of India, troubled by an acute shortage of physicians, especially in rural areas (Sharma et al 2013). India’s Central Bureau of Health Intelligence shows that about two-thirds of rural Indians have only one-third of the country's doctors. Eighty-three percent of specialist posts in rural areas are not filled (Ruddock 2015). Specialists gravitate to urban areas and abroad, where there is greater opportunity, money, and comfort, depriving the rural sectors of their fair share of specialists.  

A study by Anna Ruddock (2015) throws light on how adequate emphasis on training GPs could have prevented this. India’s obsession for specialisation starts with the most reputed medical colleges such as the All India Institute of Medical Sciences (AIIMS), Delhi. Consequently, AIIMS, a tertiary care teaching hospital, ends up treating many cases of exacerbations that occur from neglecting primary treatment. Many students interviewed in the aforementioned study said: 

"MBBS is considered nothing here. You are supposed to do post-graduate studies and then after that super-specialisation … super-specialty is everything." (Ruddock 2015) 

The general mood of the medical students is nothing but the reflection of public perception in urban environments like Delhi.

In an effort to reduce regional imbalances in healthcare access, the government of India has pledged to expand the network of elite, tertiary-care institutions by establishing several AIIMS-like hospitals in other states in India. However, these are likely to end up producing more and more specialists for serving the urban elite, thereby draining resources from primary care. 

Indian physicians have also been found to treat patients outside their own specialty. It is not unusual to see GPs treating epilepsy, even when there is a neurologist in the same hospital. There is a feeling that the patient would be lost to a competitor. This happens despite the Indian physician being among the busiest in the world, dealing with hundreds of patients every day. 

Diagnostic Errors

It would be naïve to think that diagnostic errors are a problem unique to India. In 1973, David Rosenhan, a psychology professor at Stanford University along with seven others (three women and four men) got admitted to different psychiatric clinics in the United States by pretending that they were hearing vague voices. Soon after admission, they all said they felt fine and behaved normally. Some of them thought they would soon be caught pretending. However, no such thing happened. The pseudo patients had to agree that they were mentally ill and were expected to comply with antipsychotic treatment. They spent an average of 19 days in the hospital (7 to 52 days) before discharge. Six were “diagnosed” as schizophrenics in remission and one was diagnosed as manic-depressive. Rosenhan published his findings in Science, a respected scientific journal. Outraged by the sensational report, a certain hospital challenged Rosenhan to send more pseudo patients to them. Rosenhan agreed. In the next few weeks, the hospital identified 41 potential pseudo patients out of 193 new admissions. But it turned out that Rosenhan had not sent any pseudo patient to the hospital (Rosenhan 1973).

While the Rosenhan experiment clearly demonstrates a measurable bias in psychiatric diagnosis, what about illnesses with an obvious biochemical or radiological diagnostic marker? In another interesting study, 100 randomly selected autopsies at a German university hospital were cross-checked with case sheets for ascertaining the veracity of the physician’s diagnosis (Kirch and Schafii 1996). About 10% of the autopsies revealed a misdiagnosis that adversely affected prognosis. Authors concluded that new diagnostic techniques such as ultrasound, computerised tomography, etc did not improve the rate of diagnoses. On the other hand, misinterpretation, technical errors and excessive reliance on new procedures sometimes contributed directly to diagnostic errors. Quite by contrast, the patient's medical history and physical examination facilitated the diagnostic process, producing a correct final diagnosis in 60%–70% of cases. This is a clear verdict in favour of promoting the involvement of family medicine and GPs. Even more importantly, such strategies are particularly helpful to the poor patients who cannot afford expensive diagnostic tests. 
 
Four types of cognitive bias frequently encountered in medical diagnosis are anchoring bias, wishful thinking, confirmatory bias, and availability heuristic (Becker’s Hospital Review 2017). Anchoring bias is the propensity to be influenced by one piece of information, usually the first. Wishful thinking bias persuades doctors to believe in what they want to be true. Confirmatory bias increases the tendency to become selectively attentive to whatever is in line with one’s convictions. Availability heuristic is the tendency to rely excessively on what is readily available in one's memories. Interestingly, specialisation in any discipline is likely to predispose doctors to all the above types of bias. 

Conclusions

In summary, the Indian preference for super-specialists adds an important dimension of “inappropriate acceptability” to the much discussed problem triad in developing countries. Deploying resources for training GPs, implementing a referral system and strengthening primary healthcare would be major steps towards achieving equitable access to quality-assured healthcare. This would require public health to become a priority. Unfortunately, public health, after it was subsumed by the mainstream medical curriculum, lost its multidisciplinary orientation and sense of direction. A recent article in the Economic and Political Weekly (Bajpai 2018) reported that even the recent National Health Policy 2017 does not seem to provide the necessary emphasis to preventive and primary health. In this regard, instead of establishing more tertiary healthcare institutions such as AIIMS, the government should explore the possibility of adapting Delhi’s mohalla clinic (community clinic) model in other Indian states (Lahariya 2017).