We all had that one family doctor. The one who always had time. The one who was always accessible. The one who had given one the first shots as a baby. The one who knew the medical history of the grandparents, the parents, the sons and daughters, and perhaps the grandchildren if the doctor lived through it all. This family doctor was the one stop shop for all ailments, both physical and mental. This doctor treated everything from arthritis to diabetes to heart disease, as well as common complains like the flu or an upset stomach.
This is the doctor who has now disappeared, is missed by many with yearning and nostalgia, and has been replaced by different ‘specialists’ for every part of the body.
The specialists’ option is both more time consuming as well as more expensive, yet it seems this is curveball advancement in healthcare thrown at patients. With more awareness and emergence of newer classifications of illnesses, it seems avoiding specialists is something impossible.
“Going to an ENT specialist for sore throat and to a cardiologist for high blood pressure may feel like getting the best care, and often it is, but the overall health is then overlooked with each specialist focusing only on their area and not the person as a whole. A well-trained family physician is capable of dealing with 90 per cent of common health problems of the individual and his/her family, and appropriately referring to specialist if needed,” says Dr Saniya Sabzwari, Geriatric Specialist at AKU.
Doctors like Dr Mohsin Ali Mustafa agree that the role of the GP is irreplaceable. “Primary care especially in the context of a patient, that is, the role of a family physician is the backbone of a healthy and functioning community. Lack of quality and mistrust of ‘GP Clinics’ in Pakistan has led to people approaching consultants as their first stop for medical needs,” he says. Dr Mustafa is the co-founder of Clinic5.
Clinic5 was established with the aim of reducing the burden of disease by providing primary care in communities, at a cost that the average Pakistani can afford. “A good family physician can treat most common ailments and even some complicated medical cases because they have a good command over not just your medical ailment but also the social and family context. This dual understanding is often missing with a specialist,” he adds.
Yasmin Elahi, a writer, is one of those patients who are not in favour of this trend of reaching out to specialists before the GP. “Doctors these days consider patients not a person but a combination of systems and organs. At 65 plus, I have some chronic health problems. Visiting a dermatologist, ENT, a pulmonologist and a rheumatologist separately, is both time and money-consuming and I often put the less pressing problem in the back seat,” she says, and points to an important and perilous side-effect of this trend: self-medication and seeking over-the-counter advice from pharmacists instead of doctors, which more and more patients have begun opting for, just to avoid the expenses as well as the long wait involved in getting an appointment with specialists.
A popular career choice these days when it comes to healthcare is being a physician’s assistant (PA), world over. Its popularity is perhaps the outcome of the void being felt by patients due to a sharp recession in the importance and presence of family physicians.
Daniyal Ahmed, a 2nd year student in the US in the PA programme, sheds light on the issue. “The primary care provider (PCP), or general practitioner (GP), is meant to be the first point of contact for a patient. If you are sick, you visit your PCP; if they deem it is beyond their scope of practice, they refer you to a specialist. By eliminating that role, a large gap in patient care has been created — it puts an unreasonable burden on specialists, who are now effectively serving as PCPs in addition to their subspecialty,” he says.
In the US, according to Ahmed, a huge part of the role of PAs is in primary care. “There’s a chronic physician shortage in primary care and family medicine, largely because it doesn’t pay as well as specialties and is a relatively thankless job. PAs and NPs (Nurse Practitioners) are often hired to fill those roles that we don’t have enough physicians for.”
Dr Ambreen Iqbal’s family mostly doesn’t need to see specialists, as she is a family physician who advises them about their basic health problems. “I think family physicians are like gatekeepers who direct one to the right doctor. They have a holistic approach to patient care. Nowadays specialists are not ready to listen to any complaint other than what falls in their own field. Also, family physicians don’t charge a lot whereas with specialists you have to pay an exorbitant amount.”
“In the past, specialists were few and GPS were many. Specialists would come into the picture only when people were referred to them by their GPs; the culture of going on your own to a specialist was simply not there,” says Pervez Muslim, a Chartered Accountant who has observed closely the pros and cons of GPs and specialists as he has been treated by both, in Pakistan as well as abroad. He feels that as more and more doctors started to go abroad for specialisation and began to return to the country to practice, and due to increased awareness, people started to rely more on specialists.
“Affluence in a certain social strata further cultivated the culture of going directly to specialists. Development of better hospitals in the country made it easy for people to go to such hospitals where only specialists practice. Hence, the tide turned,” he says.
Muslim adds that in this day and age, specialisation is the name of the game in every field and profession. “Jacks of all trades are fading with the passage of time. Their use is now restricted to those who cannot afford to pay to specialists. Unfortunately, this has also become a status symbol.”
The sentiments expressed against specialists, then, seem to be a result of two factors: Firstly, treatment from specialists is a pricier option, and often involves a battery of laboratory tests that patients who are used to GPs find hard to grapple with. The second grievance comes in the form of what seems a lack of empathy. The more a specialist is trained to treat a certain genre of illness, the more disconnected he or she seems with the other illnesses.
“I don’t believe it’s necessarily the specialists themselves who lack empathy or understanding of patients; they are meant to deal with very specific health problems,” says Ahmed.
Dr Mustafa feels that the need of the hour is for standardisation of quality at existing GP clinics and an uplift of their infrastructure so that people can trust the care being dispensed at these centres. “This makes both clinical and economic sense.”
While Dr Sabzwari agrees that the specialist mindset has fragmented care of individuals and families, she adds that it is unavoidable. “The need for specialists will always remain for complicated problems, difficult diagnoses and ailments requiring complex management.”
Thus, varied opinions notwithstanding, and much as patients may resist to the idea, it seems specialists are here to stay.