To Dr Suresh Chandra Sharma
Chairperson of the National Medical Commission
Pocket-14, Sector – 8, Dwarka Phase – 1
New Delhi 110077
The National Medical Commission (NMC) act of 2020 sets to reform the medical education sector. The act states that the commission would develop “competency based dynamic curriculum at undergraduate level,” maintain the quality of education, and address the needs of primary and community medicine (Bajpai, 2020). I applaud the work that the council has undertaken and believe it is an ambitious and necessary project for improving the country’s healthcare infrastructure. Hence, I am writing to you to discuss how we can improve the quality of Indian healthcare through the addition of ethnographic techniques to medical school curricula. The change I am proposing would make the to-be doctors skilled at treating their patients by going beyond biology and improving doctor-patient relationships. Today, I am writing both as an outsider and insider in the Indian medical system. I am a student of medical anthropology at University College London, and I have been in the Indian healthcare system all my life, but especially so in the past ten years because of epilepsy. The changes that I am offering are not only well-researched but are coming from a deeply personal space after witnessing clinics and doctors in this past decade. I implore you to read further.
Dr G Swaminath (2007) writes that Indian doctors believe that being proficient and delivering specialised medical services supersedes the doctor-patient relationship. As a child with epilepsy, I was never asked about how I felt about my illness or, for that matter, even my medications. Prescriptions were given in less than a minute. I had not uttered a single word, and my appointment was over. I also know that my experience is not peculiar. Friends, family, and fellow patients I know are all enduring the same thing in their appointments. Today, I cannot over-emphasise the importance of the doctor-patient relationship. Empathic physician-patient communication has a direct impact on patient compliance and clinical outcomes (Neuwirth ZE, 1999). There has been limited research on the role of empathy in clinical care in India. The importance of physician empathy is not yet well-reflected in medicine (ibid.). Doctors can build meaningful relationships with their patients, and clinicians can use ethnography to understand what is at stake for their patients.
Ethnography is the term used in anthropology for its core methodology. It “emphasises engagement with others and with the practices that people undertake in their local worlds” (Kleinman and Benson, 2004). The experience of the individual is important to both the anthropologist and the clinician- as they both investigate how the patient understands and responds to illness. The “Explanatory Models Approach” is an interview technique that tries to understand how the social world impacts and weaves into people’s understanding of illnesses. This approach can be used to perform a “mini-ethnography” which is organised into sex steps. It asks the patient many crucial questions, such as:
1. What do you call this problem?
2. What is the cause?
3. How does it affect your body and mind?
4. What do you fear about the condition and treatment?
These kinds of patient-centred questions help build a more holistic understanding of the patients’ experience beyond a purely medicalised understanding of their health status.
India, as you know, is a culturally diverse country with various religious interpretations of illnesses and alternative systems of healing. These impact what the patients believe and the choices they make to alleviate suffering. Ethan Watters, in his essay “The Americanisation of Mental Illness” (2010) critiques modern-day practitioners by arguing that they have assumed two things. One, scientific discoveries are beyond the influence of culture. Secondly, that this assumption allows practitioners to overlook the cultural biases of their predecessors. Scientific discoveries and medical practice do not occur in a cultural vacuum. How people decide on their medication depends on various factors, what Longhofer et al. (2004) call the “social grid of management.” This system includes interactions between several actors (patients, families, therapists, psychiatrists) that shape the medical journey of the individual. The clinic appointment is not merely biological, but a social and economic process as well.
As a doctor yourself, I am sure you must have heard and read cases like these. Two cases in particular, express how important social and religious beliefs are within a patient’s medical journey. In 2010, a 36-year-old woman with epilepsy died in Kodinar, Rajkot after she was not given food for 22 days and was made to sleep on hot sand under the sun. Her husband’s family believed that she was possessed and needed to perform an exorcism (legaldrift, 2010). In another case, a young Sikh woman who was predisposed to diabetes discussed how her family prioritises cooking over exercising. While she was enthusiastic about exercising to prevent diabetes, she felt she could not do it because of gender norms (Sidhu et al., 2023). The two cases mentioned above show how illnesses are not conceived in a biomedical framework by the patients like medical professionals but often in entirely different terms.
In both cases, the approach of mini-ethnography would help by informing the doctor of illness beliefs of their patients and preventing them from making assumptions about their patients’ lifestyle and treatment choices. This would not only create an empathic doctor-patient relationship but also enable the clinician to address issues such as treatment compliance. Imaginative empathy is a central tenet of ethnography. Therefore, this method is hugely beneficial in comprehending patients’ social, economic, and political lives. We can tailor the mini-ethnography to the social lives of Indian patients. Though this approach has been introduced in American schools and is not universal, translation is possible.
Translation work is necessary and is indeed the need of the hour. India’s initiation to western medicine was strained by colonial rule. The medical curriculum has not significantly changed from colonial times (Anshu and Supe, 2016). Calls have been made to reform the system that makes medical education meaningful (ibid). What this letter is proposing is not to imitate a method that the west has found useful but to make it meaningful for local contexts across Indian healthcare systems. The mini-ethnography, when tailored, could address a myriad of issues. It will help understand the uneasy relationship patients have with western medicine and traditional methods. Hseih et al. (2016) found that medical students, when trained to apply this anthropological approach, recorded information they otherwise would not have asked their patients. One of the students remarked on the efficacy of this method when they realised that one of their patients Ms Lin. was reluctant to western medicine not because of her old age but because of the shock she experienced from her sudden introduction to western medicine. In this study, only 5% of the students were aware of healthcare inequality that such patients deal with when coming to clinics (ibid.)
People in this country often take help from traditional methods, sometimes concurrently with allopathic medicines. Singh and Sharan (2020) write about a sufi-ji who asks them what will happen when the asylums and the psychiatric wards in India get full? It can accommodate a maximum of 30,000 patients. The shrine, on the other hand, receives more patients in a single day. People use traditional medicine for a variety of reasons, ethnography can aid practitioners to understand the rationale behind such decisions. The mini-ethnography can help perform a task similar to translation for clinicians to understand the social lives of their patients. It can start a conversation. The task is not to discourage people from their means of healing; it is not to overlook the conflict people seem to be in with biomedicine, but to attempt to understand the patient’s view.
This addition to the curriculum is not a short-term project, and it would take a long time for this to come into action. Faculties will need to be trained before they get to teaching and students will take time to adjust to this interview method and narrative approach. I am also aware that the country is facing a striking shortage of doctors. The Ayushman Bharat Initiative introduced in 2019 reported that India will need 1.50 lakh mid-level healthcare professionals for primary and preventive healthcare in the next 3-5 years. It will take 7-8 years to increase the supply of doctors (Kumari, 2022). This shortage affects the quality and length of appointments. A study on consulting time published by BMJ Open reported India to be one of the worst on the list, with an average of 2 minutes per appointment (“Indian doctors only,” 2017). The work on improving the quality of healthcare must happen concurrently while we work on the issue of shortage. I would be happy to make a detailed report on how this plan can come to action with the resources we do have. Like NMC’s work, it is ambitious, but I do believe that it is an attainable dream. Please let me know if you’re interested in a discussion, I would be happy to work with you to make healthcare more effective and emphatic for people in India.
Anshu, Supe. A. (2016, October 20). Evolution of medical education in India: The impact of colonialism. Journal of postgraduate medicine. Retrieved March 20, 2023, from https://pubmed.ncbi.nlm.nih.gov/27763484/
Bajpai , V. (2020, June 24). National Medical Commission act : A cure worse than the malady. Economic and Political Weekly. Retrieved March 20, 2023, from https://www.epw.in/journal/2020/9/commentary/national-medical-commission-act.html
Hsieh, J.-G., Hsu, M., & Wang, Y.-W. (2016). An anthropological approach to teach and evaluate cultural competence in medical students – the application of mini-ethnography in medical history taking. Medical Education Online, 21(1). https://doi.org/10.3402/meo.v21.32561
Indian doctors only spend 2 minutes with patients, which is among the worst in the world, reveals study. https://www.outlookindia.com/. (2017, November 9). Retrieved March 20, 2023, from https://www.outlookindia.com/website/story/indian-doctors-only-spend-2-minutes-with-patients-which-is-among-the-worst-in-th/304118
Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 3(10). https://doi.org/10.1371/journal.pmed.0030294
Kumari , S. (2022, July 1). Overcoming the doctor shortage in India: The role of Community Health Providers . SPRF. Retrieved March 20, 2023, from https://sprf.in/overcoming-the-doctor-shortage-in-india-the-role-of-community-health-providers/
Legaldrift. (2010). The temples of demons. Home – Legally India – Career Intelligence for Lawyers, Law Students. Retrieved March 20, 2023, from https://www.legallyindia.com/views/entry/the-temples-of-demons-html
Longhofer, J., J. Floersch, and J.H. Jenkins. (2004). Medication effect interpretation and the social grid of management. Social Work in Mental Health 1, no. 4: 71–89.
Sidhu, T., Lemetyinen, H., & Edge, D. (2020). ‘diabetes doesn’t matter as long as we’re keeping traditions alive’: A qualitative study exploring the knowledge and awareness of type 2 diabetes and related risk factors amongst the young Punjabi Sikh population in the UK. Ethnicity & Health, 27(4), 781–799. https://doi.org/10.1080/13557858.2020.1827141
Swaminath, G. (2007). Doctor-patient communication: Patient perception. Indian Journal of Psychiatry, 49(3), 150–153. https://doi.org/10.4103/0019-5545.37309
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Watters, E. (2010, January 8). The Americanization of mental illness. The New York Times. Retrieved March 20, 2023, from https://www.nytimes.com/2010/01/10/magazine/10psyche-t.html
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