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Monday, January 05, 2009

What are the pros and cons of seeing a specialist vs. a general practitioner for day-to-day illnesses of children?

The title looks forbidding, does it not? It must be first made clear that what I am about to write is most applicable for the kind of practice in India. You see, and this is for readers from places other than India, we have a two tiered private practice system in India, which is in addition to the practice that is available from municipal and government hospitals, which is collectively referred to as the "public" system. 

Going back to the private practice, we have general practitioners, or family doctors, who have the basic practice of seeing all ages of patients from a newborn baby to a nonagenerian (that is someone who is over 90); he/she not only sees the patient, he/she may refer the patient to a specialist or to a lab or a diagnostic centre, and finally, if no referrals are done, he/she may, in the patient's best interest, even dispense a medicinal mixture of syrups and tablets. This is charged quite nominally.

On the second tier, of course, are the various specialists, and they include, not just the basic specialists like pediatricians, but also super-specialists like cardiac surgeons, neuro-surgeons and the like. These doctors, some of whom have their own hospitals or nursing homes to manage in-patients, are those who have studied further and specialised in a particular area. They are generally known to see the patients and write down medicines which have to be purchased from the pharmacy. Their practice is more in the nature of a consultation, and hence, their charges are also higher.

The question that many parents do NOT ask is: should I go to the G.P. and get the medicines or should I seek an appointment with a specialist? Now, this post is not meant to denigrade G.P.s or shower enconiums on specialists, since I have known G.P.s who are really good at diagnosing and treating illnesses on a day-to-day basis; conversely, I have seen specialists who are bad ... bad enough to jeopardise the life of their own patients because of errors of omission or commission. 

Generally, however, the benefits of going to a specialist increase as the age of the pediatric patient comes down ... in the youngest of the young, it is always better to visit a specialist. This is not only because G.P.s have less knowledge about how to manage the baby-patient, but also because babies cannot speak, and the index of suspicion of a major illness has to be very high so that no problem is missed out. Action must also be that much more prompt; for example, a child of 10 years with a mild cough can be managed by the G.P., but the same complaint in a small 1-month old baby may be associated with a potentially bigger problem like a pneumonia and may need even hospitalisation. 

In addition to this age-related difference, there are a few more advantages of going to a specialist: as the medicines are prescribed, there is no secrecy of the prescribed medicines, and this allows the patient to cross check the treatment with any other doctor of his own choice (something like a second opinion, but without the formality of a request sent by the first doctor - a thing that is very normal in India). Also, the complete course of therapy is written down, so that the patient does not have to go to the doctor every day. Whereas, with the G.P., only 1-2 days' treatment is usually dispensed,  and often, as there is some relief, the patient is then NOT taken back to the doctor.

This is not to say that G.P.s are not at all advantageous! They are! Sometimes, they are the only doctors available, for example, late in the evenings when the consultants have already left. At times, they are better able to understand the dynamics of a disease as they know the entire family, they have visited the patients' homes, and so on. This helps them to easily decipher environmental or epidemiological clues to a possible infectious illness. Also, they probably have known 2-3 previous generations of the child and know which illnesses prevail in a particular family, what kind of thinking (howsoever much abstruse or crazy it might be) prevails among the senior members of a family and so on. Finally, as they have seen the treatments of many different specialists in their years of practice, they are often able to pinpoint the better specialists from among the many who are practising in that area.

Does this make the decision making easier or more difficult? I don't know, but it is for you, dear reader, to understand what I am saying.

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