How healthcare has evolved for doctors — in conversation with Eka Care

In conversation with Eka Care, Dr Bakshi rewinds to the 1960s family doctor and traces how, decade by decade, better diagnostics and rising capital costs pulled authority away from the individual physician and toward the institution. What follows is an edited transcript of his answer.

Let me rewind to the 1960s, and take two or three minutes over the last seventy or eighty years.

In the 1960s the general practitioner was the centre of healthcare. People went to this doctor. He knew everybody in your family. People trusted him.

What began to change through the seventies and eighties is that science and technology advanced. The CT scan arrived in the early seventies, MRI by the eighties. Diagnostic technology improved, surgical technology improved, intensive care improved. On one hand that led to better outcomes. On the other it led to a much larger capital requirement. An MRI machine costs a few million dollars. How is a GP going to afford an MRI machine? Not possible.

In parallel, knowledge expanded, driven partly by those same diagnostic and treatment techniques. When I was a surgical resident my professor was a general surgeon. He could operate on a varicose vein. He could operate on a liver. He could operate on the heart. Fast forward twenty years and pretty much nobody can, because you have to specialise. Knowing enough about the liver alone is now a career: there are liver transplant surgeons who are not the same people as hepatic surgeons, and liver cancer is done by someone else again. That is the level of knowledge you have to master.

So on one side, specialisation. On the other, rising cost. Together they moved power to the hospital and away from the doctor.

In India you then saw the doctor-entrepreneurs. Dr Prathap Reddy setting up Apollo. Dr Naresh Trehan setting up Escorts. Dr Devi Shetty setting up Narayana. A group of clinicians built these hospital chains.

But come to the 2010s and the real power lies with the ability to raise capital. That is why you now see private equity coming into hospitals.

The reason I am saying all this is that the power of the doctor to influence healthcare has shrunk over the last fifty or sixty years. The doctor has become a technical expert rather than the driver of the ecosystem, while the managers, the financiers and the investors have become more important.

And yet, through all of it, the patient still trusts the doctor. Whatever criticism there may be, in the end, if the doctor says do not do this, then no matter what the CEO of the hospital says, no matter what the pharmaceutical company says, no matter what the device company says, the family will trust the doctor.

I have always made the point that the centre of the healthcare universe is the doctor-patient relationship. Everything else radiates out from it. From it arises the pharmaceutical industry, because the doctor decides the prescription. From it arises the laboratory and the diagnostic business, because the doctor says I want this test, I want this MRI. From it arises the need for a hospital, because the doctor says you need an appendix operation, you need to be admitted.

So if we go back to that configuration and build tools that strengthen the doctor-patient relationship, we are far better aligned with how citizens actually see healthcare. I say citizens rather than patients, because not everybody is a patient.

The alternative view is that the doctor is not significant. If you do not like one doctor, move to the next. People have tried that, and I do not think it works. It is not a restaurant, where you dislike the food and go somewhere else. The doctor-patient relationship is close to a lifelong thing. You are literally handing your life over. Please go and fix my heart. Where else would you need more trust than that? I am letting you cut me open and repair my heart, or my brain, or my kidney.

That need for trust is not going to go away. So the technology companies have to learn to build on it, rather than to minimise it or make fun of it.