losing jobs

During the big Recession in 2008 I saw a lot of young patients who had lost jobs or were ‘on the bench’. They had families to support and EMIs to pay on their homes and cars. They would come in to talk, share and perhaps find a little clarity. There wasn’t much I could actually do to reduce their distress apart from listen and try to help them find some hope, or prescribe medicines if anxiety/depression were unbearable, and sleep elusive. I was glad when the stream of pink-slipped people finally dried up over the next couple of years.

A few years later there was a surge in patients who had been told to ‘re-skill’ if they didn’t want to be laid off. Most of them were in the forties. Specialists, including me, are in a sort of a competency trap because we have lost all our other skills, save the ones we use every day. For instance, I’m not sure how well I could suture up a laceration or do a lumbar puncture, both of which I did very well earlier. If I were given this ultimatum to re-skill I would be totally lost.

I hear there are bootcamps to ‘upskill’ engineers, i.e. transform them from mechanical engineers to coders, so I suppose it works for some. Maybe it is possible to teach an old dog new tricks sometimes, especially if there’s a looming risk of job loss or being passed over for promotion.

I was shocked that people could be thrown out of jobs the way old animals are put out to pasture! Until I met these patients, I took it for granted that people learnt on the job all the time, gaining experience and new skills, keeping abreast of new developments through discussions with colleagues, reading journals and attending conferences, and occasionally attending a workshop on a specific topic. That’s mainly how we still brush up our skills. Of course, we now learn of new developments in our field as soon as they are published online, unlike in years past when we had to wait to read journals in a library, or subscribe.

Disruption, which used to mean an annoying interruption until recently, is now something wonderful to be applauded. On the positive side, disruption creates new markets and brings in more revenue. Does it mean that if you aren’t disruptive, you are stagnant and not very useful to your company, so you get laid off?

As AI replaces people at jobs, developers tell us it will create more jobs. But they will be different jobs, and they won’t be for the people who lost their jobs, isn’t it? The new jobs will go to people who can program and operate robots, right? Jobs gained > jobs lost is true only if it doesn’t matter that the people who lost their jobs either slid below the poverty line or committed suicide after poisoning their little kids when life became impossible. You can’t substitute one set of people for another claiming that the net number of jobs has increased, can you?

I do understand that AI has its uses. For example, ophthalmologists can diagnose diabetic retinopathy earlier than they have been doing until now, thanks to AI. If it is detected at an earlier stage, there’s a better chance of preventing visual impairment in people with longstanding diabetes. Here the AI is assisting the doctor, not replacing him. I’m not against AI. It is good tech, I agree.

But young people without the educational qualifications for sophisticated jobs like these also need to work and earn a living. The picture above is of an itinerant scissors-grinder. He visits my street once every two-three months. I’m surprised this occupation still exists! And below is a picture of a man selling cotton candy in traffic jams. Every time there is a recession in the world the lives of these people – informal sector – are affected but they don’t get stimulus packages from the government. How do they manage?

I watched the South Korean movie ‘Parasite’ recently. The dynamics between the Park family and the Kim family can happen on a much larger scale if joblessness – and the widening income inequality between the rich and poor – continues to worsen. It’s not that these feelings don’t exist in people now, perhaps they haven’t reached the surface and erupted yet. At the end of the movie one does wonder who are the parasites, the Parks or the Kims, or is it a bizarre symbiosis.

Jeff Bezos was in India a few days ago. Hundreds of traders and owners of small businesses gathered to confront him and protest Amazon’s pricing and selling practices. They shouted slogans and held placards saying ‘Bezos go back’. Will Bezos ever understand how precarious the lives of thousands of small traders and retailers are, struggling as they are to support their families and, in many cases, old parents and others as well? I guess not. Nor is it his problem to solve.

Last week I bought a paper cutter. I had a choice: order on Amazon and have it delivered at my doorstep for Rs.670, or walk to the store ten minutes away and buy it for Rs.750. I walked to the store. There were two young men running the business together. When I casually mentioned that it was available on Amazon for Rs.670 their faces fell and one of them said, “We can’t afford to do that. Amazon is undercutting us”. I felt sorry for them. I wish they could run their business the old-fashioned way. But things change. Like the classic case of the Kodak film company going bankrupt once digital photography came into existence, I suppose the old has to give way to the new.

So, now, what happens to all these unfortunate people deprived of a source of income? I don’t suppose there is a generic answer to this question. Maybe each individual has to use his ingenuity and talent to create an agreeable world for himself. He has to pick himself up by the bootstraps and start afresh after each blow dealt by new developments. That’s what actually happens as far as I can see. People are unbelievably resilient and hopeful, especially when they have children, a careworn wife and old parents to care for. Unfortunately, there is no economist, government or godfather, only planning and hard work – and luck – that take people where they want to be.

 

 

the guttering candle of trust

What is the difference between a doctor-patient relationship and a service provider-consumer one in the practice of Medicine?

I started working at a time when the latter didn’t exist in my profession. That was in the eighties. Good patient care was the only thing that counted, and making a diagnosis on the basis of history and clinical examination alone was a matter of pride. Ordering a hundred irrelevant lab investigations would have been considered a waste of patients’ money then. The attitude of patients, doctors and nursing staff towards each other was one of mutual trust and respect. Defensive medicine was unheard of. This is all true, not distorted by nostalgia.

Cut to today, and the question I started this post with.

When a patient meets me for a consultation for the first time it is with faith that I will understand and resolve his psychiatric problem. My conscience responds to the trust in his eyes and I feel an eagerness to help. A rapport is easily established. He tells his story. I write it all down, clarifying and processing as he speaks, finish the examination, and formulate a diagnosis. I answer questions about his symptoms and treatment, and give a prescription if necessary. I give him a rough timeline regarding prognosis, no guarantees. He accepts that. By then he is visibly relaxed, more hopeful. Supportive psychotherapy, a part of psychiatric treatment, is carried out in an atmosphere of trust and mutual respect, the patient’s for me as a professional, and mine for him as a human being. I spend the last few minutes of the session outlining the schedule for that.

When a customer/consumer/client meets me for a consultation for the first time he looks at me doubtfully, or with a forced smile, or even with frank mistrust. Then he sits down gingerly, pulls out his cell phone and shows me what he has downloaded from the internet, and tells me his diagnosis. Or he might hand me a sheaf of heavily highlighted print-outs. He’s done his research. Fair enough. “Anything else?” I say. “Can I call you by first name?” he asks. I know that this question is just a way of letting me know that he’s been sent to America a couple of times on work by the firm he works for (and this hint is supposed to convey something more about his place in the world), because this sort of familiarity is not the norm here, and being Indian, he very well knows it. He’s obviously approaching the consultation like a meeting between two people with equal knowledge, warily, as if a deal is being struck between a buyer and seller in which there is a risk of his being cheated.

The warmth and concern that I feel towards a patient just don’t well up in me when I’m faced with a consumer. And the mistrust in his eyes doesn’t engage my conscience at all. There is no rapport, only a job to be done. So I take the history and do a mental state examination in a neutral, clinical manner. Diagnosis made, questions answered, prescription given, effects of medicines explained. Check, check, check, check. Duty as service provider faithfully completed. Unless a positive change occurs during the session – which can happen for various reasons – it can’t be a very satisfying experience for either of us. And supportive psychotherapy is not possible because that requires empathy, something that is not generated in a buyer-and-seller type of transaction.

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When I was a postgraduate student one of the prescribed textbooks was the Oxford textbook of Psychiatry, a regular-sized medical text book. In the newer edition, New Oxford textbook of Psychiatry that runs into two huge volumes, there is a chapter titled The psychiatrist as manager that wasn’t in the old one.

Regarding Managed care* the authors say:

• Managed care is the use of business managerial principles, strategies and techniques in health care.
• Essentially, it is a reform of health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry or governmental bodies ruled by the same principles.

This is the difference between then and now, patient and consumer, doctor and service provider, as I see it.

Regarding Quality management** the authors say: Excellence relies on a few fundamental concepts:

• Results Orientation: Excellence is achieving results that delight all the organization’s stakeholders.
• Customer Focus: Excellence is creating sustainable customer value.

Who are the organization’s stakeholders? Who are the customers? Hospital owners and patients respectively, I suppose. So patients bring sustainable customer value to give delightful results to the hospital owners? Unless I’m taking this jargon too literally, something doesn’t seem right with this paradigm in terms of caring for sick people.

Using the word customer (= a person who buys goods or services from a shop or business) in place of patient (= one who is suffering) seems to trivialize his suffering, although taken literally, the patient is buying a service. It’s as if compassion, empathy, the patient’s dignity, and ordinary niceties no longer have a place in this highly commercialized world of healthcare, where sick people are mere commodities to profit from.

(received as a forward)

Why has this happened? Is it plain greed? Is it part of the rampant corruption in our country? Or is it genuinely related to inflation? Is it because doctors run hospitals not in their capacity as medical people, but as businessmen? Or because people who own and run hospitals are not doctors at all? Could it be the numbing, desensitizing, faith-eroding effect of the large amounts of violence and injustice we all are exposed to in the form of news, television serials, computer games and movies? All of the above?

To get back to the point, people tend to give up on institutions that let them down too often. Adding to patients’ crisis of faith is public perception of hospitals as being more focused on profits than on healing, because incidents of patients being greatly overcharged for medical devices like coronary stents and knee implants, and consumables like syringes and needles are frequently being reported in the press today. Information about deleterious effects of prescription medicines, although often incomplete and misleading, is available on the net and people are more reluctant to take them. From what I hear from my own relatives and friends, people now have considerably lower expectations of doctors and hospitals, and some are openly cynical.

The trust between a doctor and patient — ­that was almost a given in the eighties — is now a guttering flame that I have to fan to life with almost every new case. While the blinkered juggernaut of allopathic healthcare barrels down its chosen route, patients are skipping out of its way by switching to alternative medicine for everything except the most acute medical problems. As a doctor I think they are throwing the baby out with the bathwater, but it’s going to be hard to convince them that many of us do abide by medical ethics. It is probably too late to win back their trust when it has reached a point where the government has had to step in with regulations to cap prices of drugs, medical devices, diagnostic services and treatment procedures, making newspaper headlines every day.

Of course, once we are totally replaced by Artificial Intelligence and robots, none of this will matter. Nobody can halt the inexorable advance of research in AI and people working in that field believe they are on to a good thing. Like driverless cars. Doctorless patients. Currently, computers can only analyze structured data, but it’s just a question of time before they are programmed to handle unstructured data generated by doctors’ observations and conclusions in individual cases. Sophia and her ilk can do the job. Doctors can be phased out. Going by the optimism and excitement in AI, I presume they will take care of sick people so perfectly that res ipsa loquitur will become redundant and the OED will call iatrogenesis an obsolete word!

Branches of study like Biomedical Engineering already exist in engineering colleges in India, and inter-professional programs are already part of medical curricula in many medical colleges in the US. So this change from the traditional practice of Medicine is bound to occur. This is the future, but thankfully not my future, so it has the feel of something viewed on a screen or imagined while reading a book. Anyway, I hope all this makes health care more accessible to the poor, that’s all.

* New Oxford textbook of Psychiatry, Vol 1, 2^nd ed, page 45

** New Oxford textbook of Psychiatry, Vol 1, 2^nd ed, page 43