How to build the doctor-patient accord and get closer to 'health for all'

This article was originally published in The Economic Times.

The past few decades have seen a transformation in India's medical profession and within the last four years, the country finally reached the World Health Organization-recommended doctor-to-population ratio of 1:10,000.

Whether the South Asian republic indeed passed that golden finishing line has still stirred debate regarding the data's validity and concerns over the distribution of doctors in urban vs. rural settings, adequacy of training, and the state of infrastructure in public health facilities. However, the inflection point that will truly define the ambition of "Health for All," is the doctor-patient relationship.

The unique relationship between doctors and patients has been interpreted and extensively described by philosophers, sociologists and literary experts for several centuries. The crux of this relationship rests on the patient's trust and the doctor's integrity to uphold ethical standards resulting in a reliable, effective and durable connection.

This relationship was more paternalistic for several centuries, meaning the doctor utilized their skills and chose the interventions while the patient silently complied with the physician's decision. Increasingly, this physician-driven asymmetric model has been challenged in the last few decades by a more autonomous patient-centric relationship with greater patient control, reduced physician dominance and more mutual participation.

This approach, where "the physician tries to enter the patient's world, to see the illness through the patient's eyes," has become the predominant model in clinical practice today.

The doctor-patient relationship has taken a significant beating, though, due to rapidly changing social, cultural, economic and political factors and is contributed almost equally by both parties. India is now witnessing the rapid deterioration of this relationship with population explosion leading to scarcity of doctors and increasing privatization resulting in burgeoning healthcare costs. A study suggested that nearly 75% of medical personnel in India have faced some workplace violence, wherein 70% of cases involve the patient's relatives.

The doctor-patient relationship could be addressed through patient-specific approaches to managing expectations or through systematic changes to bring in a cultural shift.

There are a unique set of cultural, socio-political and economic factors in India that may influence the doctor-patient relationship uniquely. This relationship can be strengthened by valuing the patient as a person and managing the power imbalance, commitment and physician's competence and character.

Patients' trust could be built over time by spending more time listening to the patient and being transparent with them regarding the disease and the proposed care plan. Acknowledging patient challenges and limitations may also help while showing empathy and compassion. Trust can additionally be built by stating unavoidable conflicts of interest upfront and regular physician re-training or re-skilling to remain competent, among other things. More importantly, systemic changes will bring about a paradigm cultural change.

The key element of this approach is reducing the doctor's workload through improved healthcare workforce, infrastructure and access, goals that are easier stated than executed. Current public health spending of 1.5% of GDP has constrained the public sector's capacity and quality of healthcare services. As a result, most of the population is dependent on private healthcare, creating a significant economic burden for a great majority.

The scarcity of doctors and poor infrastructure in rural heartlands remain a major impediment to universal access to healthcare for nearly 70% of the population. The Indian government's near tripling of rural investments to boost the rural economy and infrastructure are steps in the right direction to attract a good workforce and private investments, including public-private partnerships. However, these must continue to grow rapidly to see a significant change in the next decade.

Transparent and effective regulation to improve the quality standards of medical education is probably more important than mere enhancement in the number of medical colleges. The budding doctors also need to learn and inculcate the qualities of empathy and compassion right from the training days.

The doctors also must encourage regulation to ensure re-skilling/re-training periodically to maintain the full range of capabilities, especially in rapidly evolving fields of medicine.

All these actions need a strong intent and a robust plan for execution from governments and policymakers. Policies must also ensure the safety of doctors and deter the patients and their families from violence or harassing doctors when their expectations are not met. These policies must allow doctors to think and take challenging decisions with a clear, un-conflicted and unbiased mind.

From the patient perspective, any fair grievance needs to be heard under consumer protection laws. These laws should be amended in line with current advancements to remain non-partisan and balanced.

Lastly, public education regarding prevention and disease could reduce patient non-compliance with treatments and, to an extent, doctors' non-compliance to standard treatment procedures, for example. Governmental and non-governmental agencies can also leverage technology to play a crucial role in disseminating accurate information to the public.

Such efforts could profoundly improve the doctor-patient relationship and overall delivery of health so that "health for all" becomes a near reality.