Is defining cardiologists important to curb cardiovascular disease epidemics?

Dear Sir,

Other Side of the Moon – Sundeep Mishra, ‘Who is a cardiologist: Usurpers spawn?’ Indian Heart Journal. 2015; 167: 509–511, has most appropriately and rightly stressed the critical need to define who can be called a cardiologist and who can be accorded the privilege to treat and even perform interventional procedures. But I do not agree with Dr. Sundeep that cardiology is a superspecialty of internal medicine and is a complex field that deals with preventing, diagnosing, and management of cardiovascular diseases. I feel it is a simple subspecialty of internal medicine with only complexity relating to cardiac interventions and I have not seen any cardiologist working for primary prevention of cardiovascular diseases, which is mostly neglected, or the secondary or tertiary preventive aspect, which is mostly taken care by their subordinate staff whether senior residents or DM/DNB students; and in India, a qualified cardiologist concentrates solely and only on cardiac interventions and then after care.

Role of a cardiologist in curbing epidemic of CVDs

Dr. Sundeep has stressed that cardiologist numbers are still woefully inadequate to address the cardiovascular epidemic faced by the country, but I am sure that cardiovascular epidemic will not be curbed even if India is able to train adequate cardiologists, because for curbing any noncommunicable disease epidemic, it is the primary prevention that is the only way and primary prevention needs efficient, effective, and universal primary healthcare system, which most of the cardiologists will ever practice. With growing sophistication of technology, the superspecialists have become increasingly dependent on technology/instruments to make a diagnosis. This has, unfortunately, led to clinical and preventive medicine taking a back seat. Definitely many physicians, even non-doctors posing as cardiologists, have lead to dilution in the quality of cardiac care also raising several serious issues like conning an unsuspecting patient, playing with his/her trust, and clinical mismanagement of the patient with possible serious adverse outcome, including mortality making this issue not only one of ethics but also of law and criminality as well. But this issue can be very well addressed if the Medical Council of India, the State Medical Councils, and the law enforcing agencies enforce the ethical guidelines and punish those who designate themselves other that the designations they are permitted to write by law. So I feel more important is effective and efficient enforcement of ethical guidelines to curb the unqualified or unethical practice rather than taking away the right to practice internal medicine, which definitely include preventive and noninvasive cardiology from the general physicians.

State of primary healthcare and medical education in India

In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, and a decrease in hospitalization and use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health. Primary care serves as the cornerstone for building a strong healthcare system that ensures positive health outcomes and health equity.3, 4 It has been estimated that 75–85% of people in a general population require only primary care services in a given year; 10–12% require referrals to short-term secondary care services; 5–10% use tertiary care specialists. Primary care availability may also be more strongly correlated with health outcomes in areas with greater levels of income inequality, suggesting that expanding primary care availability in these areas may have a substantial impact on population health. Dr. Sundeep has rightly quoted a recent study published in British Medical Journal discussing the state of medical education in India that has raised serious concerns about the quality of care delivered by private and public providers of primary healthcare services in rural and urban India.7, 8 I feel, since glorification of privatization and corporatization, India has witnessed a phenomenal growth in numbers of private medical colleges as compared to government medical colleges. Unregulated rapid growth of private medical colleges, poorly implemented regulations relating to admissions, and inadequate faculty strength, infrastructure, laboratories, or hospitals as per MCI norms and still getting permissions under the influence of money or politicians’ patronage has adversely impacted quality of doctors. Perhaps the worst kind of gross unethical practice happens during inspections of new private medical colleges when busloads of patients are mobilized to fill up empty wards; carloads of doctors are paraded before the inspectors and even instruments are hired or shifted between colleges.

One revolutionary measure of National Eligibility-cum-Entrance Test (NEET) initiated by the government, which would have gone a long way to rationalize medical college admissions and almost eliminated capitation fee, was declared unconstitutional by a Supreme Court Bench of Chief Justice Altamas Kabir and Justices Anil R. Dave and Vikramajit Sen in a majority 2–1 verdict in 2013. Commercialization of education has affected poor brilliant students and has converted students to become materialistic, self-centered, and without values of sacrifice, service, and commitment to the country; a loss that may be difficult to overcome. Medical education today has become a market investment and most doctors go to corporate to get handsome returns. That is why there in inequitable distribution of medical professional concentrated in urban areas neglecting rural areas.

Way forward

I must compliment Dr. Sundeep to raise this rather important ethical and law issue of defining ‘Who is a Cardiologist?’ and ensure that no one else should pose as a cardiologist. But for curbing the epidemic of cardiovascular diseases or noncommunicable diseases, we need more robust, effective, universal primary healthcare rather that increase in number of cardiologists, which I feel will definitely be useful for secondary and tertiary cardiac care. What India needs today is radical revolutionary health reforms concentrating on public, especially rural healthcare rather than promoting private healthcare, including medical education; only then, India will be able to produce quality healthcare professionals ready to serve in rural areas and in turn slow down the speed of noncommunicable disease epidemic. Unless there is a paradigm shift in the understanding of health and its implications and the political will to provide health services to all, there cannot be any substantial improvement in the current pathetic status of public and preventive healthcare. India is an example of private success and public failure. India needs to reform its institutions, including the regulatory intuitions like medical councils.

Conflicts of interest

The authors have none to declare.