Optimizing Medicine Residency Training Programs

Visit the link below to download the full version of this book:

https://medipdf.com/product/optimizing-medicine-residency-training-programs/

Click Download Now

 

Appendix............................................................................................................................................. 234

Related References............................................................................................................................. 245

Compilation of References................................................................................................................ 281

About the Author............................................................................................................................... 298

Index.................................................................................................................................................... 299
 vii

Foreword

Like all children who nurse a dream, mine was to become a doctor when I grew up.
That stately yet warm figure, whom we used to term our ‘family doctor’, with his white starched shirt
and twinkling eyes, shining with wisdom and compassion, and a healing touch- aided by little colorful
pills and potions in glass bottles- that could soothe away any aches and pains and banish the fevers.
Of course, visits to the biology laboratory and the dissections it entailed in higher grades in school,
and the smells that had to be endured, put paid to all my childhood dreams. That and the voluminous
tomes with long unpronounceable words that had to be studied in order to get that haloed tag of ‘Dr’.
Doctors had now become for me a symbol of hope, of care and cure, and of moneybags!
In all our collective minds, sometimes unacknowledged, doctors do come to occupy the position of
a demigod. Most of us revere their attention and wait painstakingly for a ‘darshan’, oops, appointment,
sometimes for a couple of hours, even when we have taken a prior timing and are going to pay hand-
somely for it!
I have seen patients waiting patiently (pun intended) in snaking queues, when they have been ill and
could ill afford to sit, and needed to rest, just in the hope that a ten minute interaction with the doc would
alleviate their suffering.
Though I now looked on my childhood longing of becoming a doctor with a distant disbelief, I car-
ried within me a lingering image of awe, credibility and trust that I had always reposed in the medical
fraternity. And I did what people who carry a subconsciously tenacious wish do. I married it!
I married a doctor, investing the person with a larger than life image: an image that all of us, at one
point of time or the other, in lesser or more degree, especially in our darkest hours, hold on to as a single
source of light- an image of an objective scientist, a compassionate soul, a miraculous healer and a good
listener imbued with an affable manner and an all knowing heart!
Having observed and interacted with doctors over the years, both from a distance and at close quar-
ters, on a personal level as well as a patient, I am constantly amazed by their ability to work round the
clock, keeping erratic hours and irregular meal times, being on call seven days a week, and yet being
able to keep a balanced, calm mind amidst the crisis of several genuine as well as hypochondriac cases.
On the other hand I have witnessed the all too human side of them.
Gone are the days of personal attention, when your doctor not only knew your medical history but
also your personal one. With the corporate culture now infiltrating even the medical profession, patients
have become a number and name, and surgeries are performed on the body rather than the person.
The humane side of the profession has given way to a sterile, objective, clinical evaluation of symp-
toms. The disease or illness is looked upon in isolation, separating the parts from the whole. We now
have super specialists who study a part of the body part. As a result any patient who is hospitalized is
attended to by a retinue of specialists and super specialists, all giving their individual diagnosis, which
often may even be at variance with each other.

 Foreword

Patients too have a wide choice. Doctor shopping is not uncommon, with an individual visiting 3
to 4 doctors to get an ‘opinion’ before deciding which doc is best suited for the treatment. The doctor
of course has a long list of ‘tests and procedures’ to be carried out, and reports to be submitted before
announcing his or her diagnosis.
As with all professions, the medical fraternity too has slid into consumerism and competition. Of
open ended diagnosis and long drawn treatments, which seem to line several pockets, including those
of fast mushrooming diagnostic centers and laboratories.
To be fair, advances in medical sciences have in some case necessitated these. Because of a prolifera-
tion of medical knowledge and the easy media access to this, many people have half baked theories and
opinions. To cut through this clutter and confusion, reports in black and white and doctors with a cold
clinical no nonsense attitude are often the call of the day. And of course, increased stress has released
several hypochondriacs amongst us, and doctors need to be able to separate the genuine from the placebos!
In the midst of this melee, there are doctors who really heal. With their presence and wisdom that
goes beyond what is mentioned in medical literature, who are old worldly in their approach yet who have
kept up with advances in medicine worldwide, who have a pulse placed firmly on the patients state of
mind as well as who cure holistically. They are the ones who still retain the nobility of the profession and
continue to inspire our respect and gratitude. They are the ones who we lay people call the angels of god.
So it is fitting and timely that Jayita Poduval has come out with her book- ‘Optimizing Medicine
Residency Training Programs’. It presents both the human as well as the clinical side of the medical
profession. It addresses both the concerns of the patient as well as the doctor. And in doing so helps
both sides to come to a better and deeper understanding of cure, concern and care. It bridges the divide
that has widened over the years and attempts to cross it with experience, knowledge and instinctive
sensitivity. It gives us an inner view of the rigorous life and training of health care professionals and the
demands placed on them, nearly 24/7. Most importantly, it offers perspective in an unbiased- yet warm,
objective, perceptive, rational and humane- manner on the medical profession, its practitioners and its
recipients. It’s a book with a good bedside manner!

Sharmila Bhosale
Life Positive Junior, India

Sharmila Bhosale is a features writer with leading publications, editor of a children’s magazine and a copywriter. She has a
degree in psychology and pursues music and photography. She is also an intrepid traveler and spiritual seeker, though the two,
quite often, can come to mean almost the same thing.

viii
 ix

Preface

Thinking about the nature of medical practice in current times brings to mind my own days of medical
training- both graduate and thereafter residency. There was no prescribed subject of medical ethics as
such in the entire undergraduate curriculum, neither was there a charter or rulebook for resident doc-
tors as exists in many leading institutions and countries nowadays. We were all fiercely competitive,
enterprising and highly motivated students and most of us had taken up this line of study for one of the
following three reasons- first, we were toppers in school and had excelled in the life sciences, namely
biology and to some extent chemistry. Second, we had a family background in medicine to inspire us
and support our drive and motivation or a vacancy to fill in since there was no doctor in the family,
and we were expected to fetch much needed laurels to our clan in this regard. Third, and probably the
chief propeller for our talents, skills and enthusiasm was the fact that the majority of us were seeking a
passport for better opportunities for study and work in the West, namely the United Kingdom and the
United States of America!
This was indeed the dream of many a young Indian science graduate back then, and here also the
reasons were well founded. Medical services in India were mostly in the government sector or indepen-
dent private practice. The first one assured one of a ‘permanent job’ and the second one the prospect of
unlimited wealth- both at extreme ends of a spectrum. The government job would pay very poorly and
also render one liable to be sent to remote or rural areas, or both- away from family and a social circle.
A private practice was usually permissible as the pay was paltry, but then all such doctors were not keen
to practice as well as work at a job- there were those who really were interested in having a life of their
own though the returns would be somewhat poor. Those who did both would leave at home an unhappy
wife and children unfamiliar with and deprived of the love and affection of their father. Only the women
physicians perhaps were able to keep a job and be happy as they would have their husbands to fend
for them. In private practice, one started low, with just a stethoscope and a writing table. By and by, in
variable amounts of time taken to do so, one would progress to a well equipped consulting room, then
a small outdoor clinic with an attached dispensary, and in due course of time, to a large nursing home
or a small stand alone hospital. Patients came, some got better, some lingered on with their ailment till
it was time to take leave of the world, and a few died in the early days of treatment. In all this time, the
doctor’s name and fame continued to grow till one day he himself died of a ripe old age………..
Does this sound like a fairy tale?
Indeed it does, but such was the reality just a few decades ago. If we speak to some of the people
of that generation too, there is hardly a mention of a ‘bad’ doctor or ‘evil’ doctor or a doctor who was
simply out to make money, even though a good number of them did die rich and leave a huge legacy for
generations to come. And we would never hear of a doctor being sent to jail!


 Preface

Were the doctors back then too good, or their patients too gullible?
The answer to this question might unlock the overwhelming riddle of what is better known as the
health care industry in these times. The riddle that keeps humanity suffering in spite of the so called
advances in the science of health, the riddle of the care we all desire but are instead denied, and the
greatest riddle- the one that has made an industry out of a once ‘noble’ calling.
Let us try to answer it nevertheless. Did we have better doctors to treat us in the early part of the last
century? We had the family doctor of course and sometimes we had to go to the hospital for a surgery
or childbirth. Most of the time we got better, but sometimes we became worse and some even died. But
then everyone would have to die some day, is it not, so we finished the last rites of the deceased and went
on with our lives. How often was it that we blamed the doctor for not trying to do better than what he
already had done? Indeed, we all went home and were at peace in the firm belief that all that could have
been done had really been done. Therefore, how modern medicine is actually perceived by the health
consumer today could be an enlightening experience for a medical professional. I knew I had stirred a
hornet’s nest when I posed the question to some of my friends outside the professional sphere and I had
to provide the answers as satisfactorily as I could. It did of course open up a Pandora’s Box of ideas and
information for me, something new that I was discovering on an almost daily basis.

Hippocrates- father of medicine- is believed to have remarked- “the life so short, the craft so long to
learn.”

Indeed, one lifetime is not enough to know everything about the complex and multi- dimensional
subject of medicine. In Hippocrates’ time, moreover, longevity was limited and medicine was less of a
science and more like arcane witchcraft. Few people could achieve mastery over the subject, let alone
practice it. A “good” doctor was someone with years and years of experience, and therefore, wisdom.
Even today, when one is so much better informed about health, one prefers to seek treatment from a much
experienced “senior” doctor- with white hair, white coat and plenty of wise words- probably keeping in
line with the fact that “each patient carries his own doctor inside him”, as observed by American author
Norman Cousins in “Anatomy of an Illness”. It would be fairly easy to read all books on medicine within
a short span of time, but virtually impossible to acquire the “healing touch” in as much. This fact also
explains why medicine is such a multilayered subject and doctors so misunderstood. Leo Tolstoy was
perhaps not wrong when he commented in “War and Peace” that “though the doctors treated him, let
his blood, and gave him medications to drink, he nevertheless recovered.”
Of course, any doctor would bristle with indignation at such a statement, but the truth remains that
medicine, and doctors, would always be viewed with suspicion. And right from a young age, this culture
of antagonism is widely prevalent, as the celebrated author of children’s books- J.K. Rowling, in “Harry
Potter and the order of the Phoenix” exclaims- “Doctors? Those Muggle nutters that cut people up?” Is
it because, as American writer Jodi Picoult feels, “doctors put a wall up between themselves and their
patients; nurses broke it down.”? After all, medicine is really about experience- both of the doctor in
terms of skill and wisdom, and of the patient in the context of satisfaction and wellness. The process
of gaining skill and wisdom is for the most part by way of multiple, sometimes repetitive, experiences
over a prolonged period of time.
“Every man is the sum total of his reactions to experience. As your experiences differ and multiply,
you become a different man, and hence your perspective changes. This goes on and on. Every reaction is
a learning process; every significant experience alters your perspective.” Hunter S. Thompson, American

x
Preface

journalist and writer, perhaps describes what might be the essence of a doctor’s training- learning by
experience.
In medicine experiential learning occurs through regular or periodic contact with patients in a real life
scenario, thus imparting practical knowledge and acquisition of basic skills- both soft skills and proce-
dural skills. Since patients are expected to visit hospitals and health care centers for their needs, doctors
in training must be present at these places in order to glean knowledge and experience. Most hospitals
provide services round the clock so the most ideal place for such training is a hospital, as compared to
other health care centers like community or day clinics, nursing homes and hospices, though a part of
the training may also be carried out in these centers.
In order to provide services round the clock, health care personnel including trainee doctors must be
available at all times or “residing at the hospital”. Trainee doctors are mandatorily resident doctors so
that they can become familiar with each and every aspect of health care delivery. Hospital services are
composed of diagnostic and therapeutic services and are broadly known as the para clinical and clinical
services respectively. Thus resident doctors are those pursuing a specialization course in any of these
clinical or para clinical specialties after their graduate medical qualification. The subjects that are typi-
cally considered the broad clinical specialties are General Surgery, General Medicine, Obstetrics and
Gynecology, Pediatrics, Orthopedics, Psychiatry, Dermatology, Ophthalmology, Otorhinolaryngology,
Family Medicine, Community Medicine, Pathology, Radiology, Medical Microbiology and Clinical
Pharmacology and to some extent Forensic Medicine. In many countries and institutions, even the
subjects that constitute the basic sciences in medicine, namely Anatomy, Physiology and Biochemistry,
have clinical applications that may be provided as hospital services for patients, for example genetic
studies and counseling, sleep studies and biochemical tests. Thus students seeking to specialize in these
areas also contribute to the population of resident doctors. The important and common link through all
these services is the presence and availability of training and teaching staff which make up the qualified
faculty in the respective departments.
Life as a resident leaves a permanent imprint on the individual, not just by virtue of obtaining a
professional qualification, but also in the way his or her character and personality are molded. As the
emerging doctor enters the workforce his or her caliber and competence are judged by the training he or
she has received in all aspects of medical practice. Ineffective training delays or hampers the capacity to
be a productive member of the community. The fact that the practice of medicine is constantly in flux, in
addition to being complex, may further be affected by the quality of new doctors joining the workforce.
To optimize medical and health care practice, therefore, resident medical training must also be optimized.
As much as standards are set, policies made and regulations followed in the vast arena of health care
services and education, one must also take into account how doctors themselves feel about their role
in society, particularly doctors that have newly qualified and joined the health care delivery workforce.
Even though their training may have been of good or high standard, it is perfectly possible for them to
experience difficulty, cynicism and frustration as they finally put their education to use; for the doctors
whose training could have been better, the problems are much worse. Part of the conundrum is perhaps
the mismatch between the expectations from being a doctor and the ground reality in which doctors
have to function.
There are plenty of reasons for this mismatch and this book tries to look at all these, something not
attempted before in medical literature. Here is a profession that is ostensibly “noble” by virtue of its
capacity to make real and dramatic changes in the lives of people, as well as lucrative given the rich
dividends reaped in terms of both income and satisfaction, never mind the tremendous amount of time

xi
 Preface

and resources invested into it in the first place. When the investment exceeds, or seems to exceed, the
returns thereof, the balance tends to tilt away from the attractiveness of medicine as a career. After the
relatively long course of undergraduate medical school another saga of struggle begins for the quest of
specialization with the intense period of residency. Quick returns in terms of monetary and emotional
satisfaction are not always present. Graduate doctors, resident doctors and even practicing doctors dis-
cover soon enough the separation of their dreams from the realities of medical practice. Given the fast
paced and technology driven life of the present era, the gradual erosion of moral and family values, and
the disintegration of society into the haves and have not’s, and one has the perfect recipe for everything
going wrong with the medical profession.
Can this be optimized by exploring the system of medical residency where the doctor actually learns
to come into his or her own? Can incorrect perceptions and misconceptions be corrected, can renewed
vigor and motivation be ignited, can the highest standards of professionalism be inculcated among resi-
dent doctors so that their aspirations are preserved, any disillusionment nipped in the bud and they are
able to give their heart and soul to a career that needs both of these in healthy doses? There are doctors
whom patients wished they really liked and trusted, or doctors who would have been better off doing
something else instead, and also one doctor too many, floating around aimlessly in the labyrinth of today’s
health care industry. Their “lack of professionalism” could be a consequence of a greater social malady
rather than a personal trait. This book is a relook at the systems that are responsible for producing doc-
tors and even though it is like highly complex machinery it can be understood clearly as the sum of its
many simple components. Residency is one of the biggest components and has a pivotal role to play in
the smooth functioning of the health care machinery.
Therefore, the aims and objectives of this book are principally to look at medicine in the larger
context of society and to redefine the role of resident doctors in the health care system. It also seeks
to bring medicine to the common man, and it is hoped that the language in which it is written strikes
a chord with the lay person. It is also written in a fluid prose style and not in a technically precise and
point- wise manner to make for easy reading. For health care to become more relevant to everyone in
the modern era doctors and patients cannot be compartmentalized into separate worlds but must be
amalgamated into the same universe. The evolution of medicine is constantly in the direction of patient
centered medicine from a previous paternalistic model, and patients must be actively involved in their
own well being. Since the ultimate aim, of course, would be “healing”, perhaps a better way to model it
would be “patient oriented medicine”. Each chapter in this book begins with its own aim clearly stated.
Chapter One, Medicine Residency Training, provides a brief treatise of the systems by which modern
medical care is provided to patients in different countries around the world, the role of the government
and private sector, and the pros and cons of insurance.
Chapter Two is all about the fascinating history of medicine. This section gives an account of the
earliest moments which led to the birth of medicine to the epoch of modern health care practice, and
touches upon the various methods and systems in which disease and illness are treated around the world.
Chapter Three then describes the development of the medical residency curriculum in detail and
its importance in both medical service and education. It discusses the somewhat tricky, and sometimes
highly sensitive, issue of the methods of selection and elimination by which students gain entry into the
medical profession and their continuance into residency and specialization. The setting in which the
system of residency can be implemented effectively and a continuum of care provided to patients is also
discussed in this chapter, along with current methods of assessment of the performance of residents,
which is a hotly debated topic in many countries, with some ideas being highly controversial.

xii
Preface

Chapter Four on ‘Ethics and Professionalism’ is the part which is largely familiar to but generally
underdeveloped by residents and resident program directors everywhere, that is, the various activities,
duties and responsibilities of residents throughout their training period.
Chapter Five is for residents specializing in a surgical discipline as they have an added obligation
towards skills training. Also, irrespective of the specialty pursued, the role of research cannot be ignored
and how residents should go about it is elaborated in Chapter Six. Research is a dreaded word among
residents already saddled with work and this chapter would hopefully be helpful for them.
A doctor’s life is one of lifelong learning, and Chapter Seven elucidates the various options for con-
tinuing professional development among medical doctors, directed self learning and avenues for higher
training.
The role of management skills and leadership is not lost upon the doctor in the current health care
scenario, and Chapter Eight delves deep into this subject with a discussion of the various leadership
skills that a doctor must possess and practice.
Being a mother and homemaker over and above being a medical professional, I am a firm believer
in the necessity of a healthy mind in a healthy body- a balance in life and happiness derived from it.
Just like the stewardess in the aircraft who utters a note of caution with the words “please ensure that
you wear your oxygen mask properly before helping others” I cannot help but be convinced that only a
happy doctor can make for a happy patient. Chapter Nine talks about personal issues and how to strike
a balance between work and leisure.
Medicine is seeing sweeping changes across communities and nations. The book ends with a refresh-
ing change. One is particularly fascinated by the amount of writing that doctors have produced, and the
different ways in which both practicing doctors and medical residents touch lives and make a positive
impact upon society in their avatar as writers and story tellers.
Moreover, residency is the watershed event in a doctor’s life and in my case it left me with mixed
feelings about my choice of medicine as a career. This book is by no means an autobiography, that is, my
story alone, because I see many of my colleagues and peers in a similar situation as mine, prompting me
to wonder where we are going wrong and seeking a solution to fix it. I have seen many doctors change
their career path halfway across their journey, but some even earlier when they were just undergraduate
students. The idea was to take up the project of asking all the relevant questions and putting into the ap-
propriate context answers that have come from myriad sources as well as my personal views. No doubt
there are many more opinions out there but I write this book with the hope that it will enable me as well
as others to give all that we have to this most demanding of careers.
May be it is not a change of career but a change in the way we look at it that is the need of the hour-
an innovation of thought, honest introspection, and the grit and determination to follow our instinct. It is
time we- our families and our societies- took a long, hard look at our motivations for taking up medicine
as a career. The structure of the medical curriculum and the residency system remaining largely and
essentially unchanged, the future health of the medical profession depends on the quality of emerging
doctors who would perhaps not only be judged in terms of their professional caliber but by also their
abiding interest and commitment to the profession.

xiii
xiv

Acknowledgment

The author wishes to convey her heartfelt gratitude to the following:

Milind V Kirtane- guide and mentor- for instilling values and virtues, and that pearl of medical wisdom
“The patient comes to you with faith- never let him down”.

Bijayendra Singh and Narayanan Parameswaran- for agreeing to be interviewed and adding an interna-
tional flavor to this venture.

Sharmila Bhosale- friend and accomplished writer- to prepare the Foreword of this book and give it the
much needed ‘common man’s’ perspective that was required.

Patients, resident doctors, colleagues and superiors at the Pondicherry Institute of Medical Sciences- for
the opportunity and purpose to take up this enterprise.

And finally IGI Global Publishers and the reviewers- for valuable guidance and encouragement.



 Section 1
Health and the Doctor
 1

Chapter 1
Medicine Residency Training

ABSTRACT
The purpose of this chapter is to explore how issues with medicine and health care are pervasive all over
the globe- to a lesser or greater extent. The twin contexts of the quality of and access to health care and
medical services are entangled in the deeper complexities of the way the health care machinery works.
Problems with governance, political instability and unrest, environmental factors and legal dilemmas
add to the already chaotic nature of health care establishments, where patients and doctors find them-
selves surrounded and directed by technology most of the time. The doctor- patient relationship suffers
due to multiple factors ranging from a ‘lack of satisfaction’ from the medical consultation to issues of
affordability and funding.

KEY POINTS

• to determine whether the existing health care system and its services are optimum for the popula-
tions it caters to
• to examine the various components of the health care system and the role played by each component
• to detect deficiencies in the health care system or services and to which component it is related
• to determine if any reforms are required and how to bring them about in a systematic manner
• to study the different mechanisms of providing health and medical services to the population
• to understand the role of society and government towards health and its infrastructure
• to appreciate how private sector health care leads to extreme marginalization in society
• to understand the benefits of insurance
• to seek an optimum system of good quality care and access to health for all sections of society
• to establish clear and feasible options for both the provision of medical services as well as the
education and training of medical professionals

DOI: 10.4018/978-1-4666-9527-6.ch001

Copyright © 2016, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.
 
Medicine Residency Training

INTRODUCTION

Health is life. It has gone from being one of the prerequisites of meaningful living to being the primary
pre- occupation of all. The strength of a nation is a clear reflection of the health of its communities- these
communities naturally would be made up of healthy men, women and children.
While the affluent population is always looking out to improve their health quotient, the ones that
are not so affluent struggle to stay alive and in fairly good health. In modern times, money and status
are not enough to ensure good nutrition and thereby good health. On the one hand, lifestyle diseases
affect the rich and the poor in a similar manner. Thus everyone generally attempts not to fall sick and
succumb to the threat of lifestyle disorders. On the other hand, the poor and the marginalized carry an
added burden to survive common but largely avoidable health problems. Most of these problems could
be attributed to poor nutrition and sanitation.
But doctors, in much of the world, are either deified or demonised, depending on place, time, circum-
stance and culture. They hold the key to life so to speak, often compromise with their life, and sometimes
even put their own life at stake. There is the magical touch and the miracle cure. There are also the deeply
buried secrets that sometimes consume doctors and compel them to take their own life. These are the
skeletons in the cupboard that topple out with a medical scandal or shocking news. And then there are
the incredibly brave and heroic acts which go down in history as medical milestones. All of these speak
of the immense aura and attraction of medicine as a career and calling for many a starry eyed youth.
The sector dealing with medical education and residency training is no less fascinating. Not much,
in fact no composite or systematic writing has been published about the exact method by which doctors
are produced, in what way their training takes place, what their trials and tribulations may be, and how
these can be minimized and their training optimized. This book is not only an intellectual undertaking but
also expects to meet the important aspect of understanding, and thereby trying to improve, the system of
medical training. This book therefore takes a global perspective of the medical profession and is relevant
to medical educators and practitioners, and also consumers of health related services everywhere. Cer-
tain peculiarities of individual countries and regions have been discussed briefly throughout this book.

The Health Care Industry

Is medicine an arcane science, a subtle art, a noble profession or a lucrative business?

It is, of course, each one of these and also the sum.
Medicine as a profession has some unique qualities that are not associated with other professions.
First of all it is a science, probably the highest of its kind and with numerous dimensions. The specific
subjects one needs to master are unparalleled in the careers related to science, and are increasing by the
day thanks to massive and tectonic shifts in the nature of the medical and health care profession. Being
a science, it has numerous technical areas that need to be examined in depth and require long years of
study to achieve mastery. Again, being a science, it is precise in its scope and meaning and can be ap-
preciated as a substantive entity. It is a science that defines the artistry of creation and the beauty of the
human being (Leopold, 2014).
Thus medicine has as much to do with art as with science. It studies the structure of the human body
in order to heal its soul. Medical treatment does not just cure disease- it makes a patient better, and
therein is found the secret of the success of medicine to touch and transform lives. Doctors are accorded
much respect and status in society for their ability to heal. It is important to understand the true mean-

2

Medicine Residency Training

ing of this word, especially in modern times. In spite of the amazing technological advances that have
revolutionized medicine and continue to do so, the doctor’s “healing touch” is pivotal to the welfare of
the patient. Acquiring the healing touch and applying it in everyday practice is a most exquisite art, and
sadly something that not all doctors and medical professionals are gifted with (Govette, 2013).
Finally, medicine is not only a ‘noble profession’ but also a shrewd business- a successful doctor is
also a very wealthy one, invariably- and public perception of the “success” of a doctor is, more often
than not, weighed against the monetary assets and not by the technical caliber of the doctor. Medicine
is therefore pursued by most youngsters as an avenue for a “successful” career- one that brings ample
material satisfaction in addition to more mundane comforts. Medicine and health related industries add
immensely to the national economy and have significant socio- economic implications- a nation’s health
is a nation’s wealth (Goold & Lipkin, 1999) (Ridd, Shaw, Lewis, & Salisbury, 2009).
It is therefore extremely complex and intricately intertwined with socio- economic structure. Health
begins with the soundness of mind and body, is then dependent on environmental influences, and ends
with the collapse of physiological processes. It is plain to see that health is a multi- dimensional concept,
and the social determinants of health have long been established. They are, among others, food, shelter,
clothing, and now, more than ever- access to health care. Linked to all these major factors are the social
and political security of nations, economic and educational development, and cultural and religious issues.
Thus ‘health is wealth’ as is heard countless times and small wonder, because human development,
progress and prosperity cannot occur without the basic requirement of a ‘healthy mind in a healthy body’.
These common truisms exemplify two important facts. First, a human being can only function optimally
if both the body and mind are in sound condition. A sound mind means that there is psychological bal-
ance and spiritual fulfilment and not only the absence of an organic disease. Second, the wealth of a
nation- material, social and cultural- depends upon the collective health and well-being of its citizens.
How then is this national interest nurtured and safeguarded? The most desirable option would obvi-
ously be a public sector model of health care in which the state or the government is solely and wholly
responsible for the well-being of its subjects. This would give the impression that a monarchical set up is
the best possible machinery for the health of a community or society. However, history has demonstrated
clearly that this ideal does not hold true and some groups are always excluded from the welfare that is
available and accessible to the rest of the community. Also, the general health needs of the community
would necessarily have to be funded by the monarchy by the direct or indirect taxes imposed on the
community from time to time, and this process would eventually prove to be untenable. Some monar-
chical or dynastic structures might imply a religious or communal allegiance and loyalty in return for
providing health care and medical needs for free. In dictatorships and autocratic setups health care and
essential medical services are available only to a handful and all others are excluded. This obviously
results in a highly skewed health structure and overall poor health for the nation as a whole. Republics
that do not fully follow a democratic policy also do not calculate health into their national agenda. Even
though hospitals and medical educational institutions might exist, the services would not be offered free
of cost or borne by the state. Citizens are thus encouraged- actually compelled- to save for a rainy day,
and therefore the health care industry has limited opportunities for growth.
Almost all democratic governments agree that health is a national priority, but only a few have man-
aged to successfully implement health as a national agenda. Cuba leads by example, and even though a
‘developing’ country, it has recognized and acted upon the need for free basic universal health coverage
for all its citizens. At the level of primary care, it has set a model of sorts, and has also to a large extent
established effective secondary and tertiary levels of care. The public health care system has therefore
been strengthened and the dependence on private health care minimized.