in most of government hospital in Delhi the pay scale for Sister grade -II is 9300-34800 with grade pay 4600 ..... Most state government pay junior doctors and nurses less then this.....
Doctors reply to Aamir Khan [Satyamev Jayate]
- Thread starter Agent_47
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SUbsidy.. thats available to every one. Even i would have got for my engineering had I studied in my state for engineering even though my father was an NRI. Not illegally but through legal channels. My parents dont earn any thing much from properties in India so definitely income certificate would have been available. Luckily I din opt those.
All courses in government colleges are subsidized as per their statistics. A medical student has to churn out over 1 lakh even in medical colleges across Karnataka (as far as I know). If they have subsidy then they are utilized also. junior doctors..
IIM's IIT's sainik school etc etc all are subsidised. Why no one is forcing them? And who knows probably we would have been able to eradicate poverty all over India and may be world if we had got IIM guys managing our country.
Good for you to start your studies and self medication but don't blame on increasing cost.. I hope 10 to 15 years back you were getting the same salary as today and your lifestyle and requirements were same. My salary covers the increasing cost.. hope yours does soon.
harpoon
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I didn't said anything against subsidy. My question is simple..Is Rs 34,000 too low a salary to start your career in medical field??
ironman1
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hey guys ! it is a very worthwhile thread on this forum. nice discussion .
many questions were raised,
the first thing people said that
"since this is a noble profession doctor's should not go after money."
my experience is that all professions are only good when they are incentive based; that is you do the quality work and you get the incentive in form of respect/monetary benefit. for doctor's , for a long time , respect was there and it was phenomenal. i being a doctor know this , but society changed, now there is only one thing that is constantly respected in society "money". in last 10-15 yrs society has stopped respecting those who deserve it, and it affected doctors too. a single case of public humiliation of your hard working colleague who could not save his patient inspite of putting all effort in it , etches something in your soul , and you change realizing that your daydream of "respect" are way into past. but as there are few good patients( they are respectful and are respected back) they keep that charitable , human part of you alive and kicking. so if you need good doctors you need to change the societal response to them. just in case , my father is an ideal doctor, never did private practice; did the government job with a fervor on low pay ( never falling for corruption). 5 yrs back the government did not pay his salary for 3 yrs ( babau demanded only 10000) , but my father being honest did not give him a penny (he said you being a doctor earn a lot, this should be no effort to you), 3 yrs we fought the case in court ,spending some 35000 plus and the court ordered the salary to be paid ( that too without interest ) of last 3 yrs, and nobody was punished.( and please don't give it to me that since you were affected that does not matter and your duty to humanity and else, because it does, and humanity comprise of these people as well)
well that was a bit off topic but should be understandable why people in general( or doctors) go after money.
also somebody said " lots of diagnostic test just to earn money from a specific lab"
first- specific lab- trust me on this - all labs have different quality control, some have good reporting ( good personnel) and some bad. and you don't need "bad". it wastes patient's money and risk his life.
second- number of tests- tests of different disease have increased considerably. somebody gave an example of abdominal pain and how doctor ripped him. here is differential diagnosis of harrison's medicine
i tried but can't post links : in short a "big list with lots of life threatening conditions including heavy words as cancer and stuff
sure there is more to life than saving money. it is always better to to safe than sorry. but if you do not want to spend much always tell your doctor that. standard protocol is he will advise you for necessity of tests and will mention that you are unwilling for further evaluation in your prescription. but my advice is never put money over your health.
one more example would be that previously( even 6 yrs back) when a young (below 25) came with a chest pain , we never preferred to make first diagnosis as a heart attack but now we are getting more and more of such cases daily.
many questions were raised,
the first thing people said that
"since this is a noble profession doctor's should not go after money."
my experience is that all professions are only good when they are incentive based; that is you do the quality work and you get the incentive in form of respect/monetary benefit. for doctor's , for a long time , respect was there and it was phenomenal. i being a doctor know this , but society changed, now there is only one thing that is constantly respected in society "money". in last 10-15 yrs society has stopped respecting those who deserve it, and it affected doctors too. a single case of public humiliation of your hard working colleague who could not save his patient inspite of putting all effort in it , etches something in your soul , and you change realizing that your daydream of "respect" are way into past. but as there are few good patients( they are respectful and are respected back) they keep that charitable , human part of you alive and kicking. so if you need good doctors you need to change the societal response to them. just in case , my father is an ideal doctor, never did private practice; did the government job with a fervor on low pay ( never falling for corruption). 5 yrs back the government did not pay his salary for 3 yrs ( babau demanded only 10000) , but my father being honest did not give him a penny (he said you being a doctor earn a lot, this should be no effort to you), 3 yrs we fought the case in court ,spending some 35000 plus and the court ordered the salary to be paid ( that too without interest ) of last 3 yrs, and nobody was punished.( and please don't give it to me that since you were affected that does not matter and your duty to humanity and else, because it does, and humanity comprise of these people as well)
well that was a bit off topic but should be understandable why people in general( or doctors) go after money.
also somebody said " lots of diagnostic test just to earn money from a specific lab"
first- specific lab- trust me on this - all labs have different quality control, some have good reporting ( good personnel) and some bad. and you don't need "bad". it wastes patient's money and risk his life.
second- number of tests- tests of different disease have increased considerably. somebody gave an example of abdominal pain and how doctor ripped him. here is differential diagnosis of harrison's medicine
i tried but can't post links : in short a "big list with lots of life threatening conditions including heavy words as cancer and stuff
sure there is more to life than saving money. it is always better to to safe than sorry. but if you do not want to spend much always tell your doctor that. standard protocol is he will advise you for necessity of tests and will mention that you are unwilling for further evaluation in your prescription. but my advice is never put money over your health.
one more example would be that previously( even 6 yrs back) when a young (below 25) came with a chest pain , we never preferred to make first diagnosis as a heart attack but now we are getting more and more of such cases daily.
Satyamev jayathe: Doctors vs Aamir - who is correct?
Truth is bitter but unfortunately it is true. Most of the issues shown in the Aamirs show were correct starting from manufacture of a doctor to the conduct of a doctor. Some doctors who indulge in these activities got offended unnecessarily and want to observe a black day on 25th of this month which is unwarranted because it will give unnecessary advertisement to this truth more than what the episode of Satyameva jayathe did.
My only complaint is the excessive dramatization of the stories (bordering on sensationalism) he presented in the initial part of the show. The way the stories were presented was in a very bad taste. The first patient obviously had Diabetic foot and had his toe amputated. It is true that amputation would not have been necessary had the patient taken his diabetic medicines properly. The second had a corporate itch and went there for a small problem where evidence based medicine was taken to great levels (all sorts of possible tests in that condition were done at a premium and the patient knew the costs before entering that hospital). Many times, these corporate patients want instant relief and ask for every possible test and when the diagnosis becomes apparent, they blame the hospital for the costs.
The third one was lined up for a cadaveric renal transplant obviously because nobody in the family didn't want to donate kidney to her. Unfortunately, the patient died because of a mishap (Disseminated Intravasular Coagulation) which can happen some times in these complicated surgeries. But, one should realize that the doctor didnt kill her intentionally- whether the death was due to a botched Pancreatic transplant or any other reason, only the operating team would know. Nobody, not even the relatives of the patient could understand the mental agony the Nephrologist and surgeon would have gone through the whole episode. The way Mr. Aamir and the patients husband were talking through the episode indicating that the whole surgery was not indicated (Their foolish remark that a patients with kidney failure can stay on dialysis forever without ever needing a transplant) shows that they were hell bent on blaming the surgical team. The last one- one of the spectators indicating that her relative was asked to undergo liver transplant was the most unbelievable. No doctor, even in his insanest state of his mind would think that the patient or his relatives are a bunch of morons to utter a sentence like this without proper indication. All these stories indicate that the first part of the episode was scripted to show all the doctors in a bad light and presented strictly a unilateral view point.
Investigation cuts
At the same time, it is true that many doctors take cuts. Many Doctors partly live on the MRIs they write for many patients and some of the top Doctors are provided high end vehicles by the diagnostic centers as an incentive for this reason. Many CT scans are also unwarranted. Many labs give cuts to the doctors who refer to them- 10-30% depending on the competition. This system is so much entrenched in the diagnostic facilities that even if the patient goes on his own, they are charged the same amount as the referred patient and the referral fee is clandestinely pocketed by the manager or technician of the diagnostic lab.
This "excessive investigations" fiasco is not solely because of the doctors. One has to realize that most of these investigations are forced by the patients because every patient wants instant diagnosis and instant cure nowadays. A patient with ordinary viral fever doesnt believe the diagnosis till he gets all possible diagnostic tests before the fever comes down on its own on the 4th or 5th day. Either the patient or mostly the patients relatives pester the doctor so much that even if a proper doctor is sure about his diagnosis, he ultimately gives in and writes those investigations.
The most disgraceful one is cuts from doctor to doctor. Many doctors expect to be paid if any patient they refer undergo any medical or surgical procedure in the target centre. Most of the busy and successful doctors of the present era built their empires like this and the doctors who felt ethical enough to eschew this practice remained obscure. In the erstwhile era, ANM workers and RMPs, used to accompany the patient and collect their commissions for bringing the patient. Doctors hosting dinners to RMPs was a well known secret of success. Now, Doctors also degraded to that level and expect money in return for referring the patient.
Most doctors are now capitalizing on these cuts and treating this as a secondary consultation fee rather than unethical income. But there are also many good apples in the system. Some doctors explicitly write and tell the diagnostic centre to charge the patient lesser amount. Some doctors dont take the referral fee to pass on the benefit (when the necessity arises) to a poor patient whose investigations would be done free of charge.
I have seen many young doctors who were against the cuts, ultimately subdued by the current system. Who doesnt want free money? When the next person is taking money without getting punished, why cant I? attitude creeps slowly in to the new doctor. Only when the Government comes up with a law prohibiting these practices, this practice will stop. All the doctors who believe that they are in the comfort zone pocketing this money would think twice when it becomes unsafe to accept money. When the doctors stop this practice, the price of these investigations will come down and become affordable to most patients.
Brands and generic medicines
What is the worth of a generic actor? somebody asked me. Hardly thousands of rupees. But, why Aamir khan is taking crores of money? Its the Brand stupid he replied. It is true. Even when the generic and branded are available side by side, if branded is available at an affordable price- we normally buy it. We want nice packaging and nice names on the cover. When we have money, we go to malls and when we dont have it, we go to the shop near our house. Everything we consume is available at a cheap price- from the soaps to shoes. When something is available at a cheaper price, we are suspicious of it when we have money. This is normal human attitude.
Let me be serious... I am not against generic medicines. My viewpoint is that both branded and generic medicines should be made available and it is the patient who should decide regarding them. The way to enforce this is by forcing all the doctors to write both the brand and drug name in capital letters, if possible by law. Many times, one cannot decipher the code language in which the prescription is written, leave alone finding the drugs name in CIMS. Poor patients and people who believe in generic medicines can take those medicines and the other set can take branded items. Even in countries where they are available side by side, the penetration level of Generics is less than 15%. The following picture best illustrates the present viewpoint of generic drugs among western people.
In fact, if you put the question "what are generic medicines"- not all doctors have a definite answer for that and most of the patients equate them with counterfeit medicines. Even doctors, when they purchase medicines for their own use prefer branded medicines to generic drugs because they don't believe them. Even after 14 years of medical practice, I had only a faint glimpse of generic drugs. When I asked my colleagues and some patients, I found out that most of them believe in branded medicines because they are produced properly (only when the brand name is put on the cover, the manufacturers properly produce the drug) whereas the generic drugs are not produced according to guidelines. But it is not correct.
Let me take a small detour and explain about generic medicines - Generic drugs are chemically identical to brand name drugs in every way: dose, safety, strength, how the drug is meant to be taken, quality, intended use, and bioavailability. Only the price is different, and the fact that they are sold under their chemical name (Courtesy - Generics, fast facts on Internet). Generic drugs are less expensive than brand name drugs because generic manufacturers dont bear the investment costs of new drug development. New drugs are developed under patent protection. The patent protects a companys investment in research, development, and marketing by giving the company the sole right to sell the drug while the patent is in effect. As patents near expiration, manufacturers apply to the Drug Authority to sell generic versions. Generics manufacturers havent paid for developing a drug, so they can sell their product at reduced prices. Generic competition usually results in lower prices on the brand-name version as well. By the way, brand name manufacturers make about half of generic drugs. Generic drugs are subject to the same standards as all drugs and must be manufactured in factories that also meet regulations. (But in India, the problem is with quality control procedures because these are under the control of government officials and nobody has belief in them at present). Generic penetration varies widely from country to country; in Europe, for example, generics account for almost 18% of the German pharmaceutical market but only 11% of the pharma market in France. The European average share is 15%; this compares with 10% of the U.S. pharmaceutical market, but only 6% of the market in Japan. This data shows the power of branded pharmaceuticals even in countries where people are educated.
The way we, the doctors, are bombarded by the Pharma companies with gifts and tours, we hardly take note of the generic medicines. Pharma companies work on the human weakness and play it very well. The way we feel obliged to write a particular drug for at least for a few days after receiving a small pen which we can buy outside for 20 Rs. and forced to promote a brand after receiving a free tour speaks volumes of the ingenuity of the drug companies marketing strategies. Drug companies work on this simple human weakness that everyone has - People may reject money but accept gifts and the obligation level to the sponsor is still the same. Leave alone Generic- even in branded, there is a lot of difference in price. To decipher why somebody writes higher priced brand doesnt require rocket science.
If everybody buys generic medicines, one thing will happen for sure- Most of the Doctors will stop receiving gifts and would have to pay from their pockets for attending conferences and their Foreign tours. Without the branded medicines sponsoring the events, most of the unnecessary conferences will not take place. But, this will definitely decrease the medical bills of the patients and increase the credibility of doctors. But, the ultimate question is where are the generic pharmacies? because even when I wanted to get them for my personal use, I could not find the outlets nearby.
Medical seats
In India, there is still clamor and glamour for medicine not solely because it is a noble occupation but because it is a lucrative trade. There are many MCI certified dying medical colleges which function without faculty or patients but keep on attracting students who are not concerned about education but only bothered about getting the degree. This is because of the reason that in India, the degree gives anyone the right to do anything on the patient, irrespective of how they get the degree. The absence of any licentiate exam to practice medicine and the absence of any entrance exam for getting postgraduate degree in these new colleges is allowing even mediocre students bold enough to enter medical field to reap its monetary benefits.
Most of the newly mushrooming colleges assure their students medical degrees - either graduate (MBBS) or post graduate (MS/MD) because their very survival depends on doling out these degrees. It is an open secret in India that with money, ($90000- $100000 for MBBS, $125000- $275000 for post graduation and super specialty) one can surely become a post graduate, if not a super specialist because there are no independent qualifying exams in between. The exams these colleges organize on their own are a sham just to hoodwink the public. If anybody wants to follow an authentic route and join DNB course, they have to surmount two obstacles- The ridiculously hard DNB Exam (Tougher than MD/MS) and the recalcitrant MCI treating them as second class citizens.
There was always huge uproar in India regarding affirmative action in selecting students for medical courses citing the gold standard of Merit, but when money determines the entry in to these private colleges, all the elite and media so far remained silent. When a few fake pilots were found recently, there was pandemonium in the country. The only difference between them and these doctors is a fake pilot kills many people at a single time and gets killed in the process but a thousand fake doctors kill one person at a time but not killed in the process and act as slow poison in the society". Another problem is when somebody pays huge amounts as investment for the degree, even if he/she is good intentioned and intelligent, they subconsciously resort to unethical practices raising the health care costs of the society.
The problem is very much evident in many colleges in South India. Many colleges do not attract even 250 outpatients a day and inpatients are woefully inadequate for any sort of clinical teaching. The enthusiasm and dedication of a few good students is neutralized by the lack of patients who are slowly demotivated and released in to the society as apathetic and incompetent people who dont put value on medical ethics and values because they were brought up in the colleges following the same corrupt values and practices. In many colleges, a post graduate in surgery does not even perform an appendix or hernia surgery during his training. Most of them learn by experimenting on the patients after getting their degree. In the whole of Chattisgarh and Jharkhand, whose combined area is one and half times that of Tamilnadu and combined population is almost equal to Tamilnadu, we have only 6 medical colleges out of which one is derecognized- whereas there are 18 government colleges and 22 private colleges in Tamilnadu. No wonder, there is gross disparity in health indicators between these states.
Just a small revision in these statistics- In the last 2 years , especially this year, all the private colleges are showing the scare of Common entrance test and increased the fee by 50% (CET cess). The cost of average MBBS seat has gone up from 30 to 50 lakh rupees (in some top private colleges the seat is sold at 70 lakh rupees). MD Radiology seat is being sold for 1.5 crores and MS orthopaedics for 1 crore. "Are you joking Mr.Azad and Mr.Sibal? Are you serious about CET? ". If you are not serious about this, this new pricing is here to stay.
Health schemes
The Aamirs show which tried to portray Mr. Devi shetty as a messiah exhibited his ignorance about this type of health insurance schemes. All these health schemes take money away from primary care to tertiary care and benefit only private hospitals and in turn completely destroy the government healthcare. Diseases also have their status- When a small kid dies of diarrhea which can be easily prevented with a small amount of money, nobody is bothered. Heart diseases and cancers are treated as royal diseases and everyone want money to be spent on them. In our country, many people die of easily preventable infectious causes than heart diseases and cancers. But the problem is - private hospitals don't make money from preventive care, instead, they can make money only from curing high end diseases by doing costly procedures.
The Yashaswini scheme is not free of loopholes as promised by Mr. Shetty. But it is his ingenuity in manipulating the health system to his advantage, that mandates accolades. What he did was- organized apparently free OPDs which worked clandestinely as workshops for accumulating cases (the moral hazard in these cases was never evaluated), got inpatients for his empty wards and OT's, given full work to his diagnostics for which the patient pays, marketed his schemes as low cost surgeries where in fact the patient pays for the expensive ancillary equipment and stents.
His whole scheme depended on two factors - one that the middle class people won't crib for the recurring small expenses and happily pay for them in return for a bigger single expense and the other most important thing is, it is foolish to extend this scheme to really poor people. The scheme was started 2 years after the establishment of his Narayana Hrudayalaya with 500 beds, 10 operating theaters and two cath labs. His hospitals occupancy rate was below 30%. Then only he tapped the power of the cooperatives because all the farmers enrolled in the cooperatives would have some amount of land and they belong to lower middle class or above, perfect targets. Their surgeries were done at a low cost but for diagnostic tests and expensive ancillary surgical equipment they were charged (Out of the targeted 8.2 million people only 3 million are enrolled so far). The people working in the same agricultural fields (land laborers) are not covered in this scheme because he knew that they cannot pay for the diagnostic tests and the expensive OT equipment. 94% of the money so far spent under the scheme went to private hospitals. Narayana Hrudayalaya alone claimed 32% of the claimed amount for 15% of the total cases in 2008-09. If we multiply 3 million members (initially the number was 1.6 million) with 90 rupees (premium per year), it comes to around 18 crore rupees and for the last 8 years the total collected premium was a maximum of 144 crore rupees. With that amount, no insurance scheme can run. In fact, in the first 5 years, total collected amount as premium was 87,30,20,853 rupees whereas the amout paid to the network hospitals was 280 crore rupees - (source- Harvard Case Study, Karnataka Yashaswini Health Insurance Scheme). So, who exactly is paying the deficit?
But he showed one important fact - if the same repetitive surgeries are done at a single center, the expense of the surgery would be low and this has to be followed in the government sponsored insurance schemes, where instead of giving everyone the chance to do the surgery, identify some centers and select one among them which can provide the selected procedure for a reasonable cost and competence.
Status of a Doctor
When very few doctors were available in the society as in the past, the doctor was treated like a demigod and was put on a pedestal. Everyone wanted to associate themselves with a doctor and wanted to be his/her friend. If anybody survived, it was because of the doctor and if anybody died it was because of fate. May be it is still true in areas where very few doctors are available. But in urban areas where the market is flooded with doctors, every action of a doctor is scrutinized and the doctor is forced to practice defensively. The current longevity promised by the progresses in Medicine (Diagnostics and therapeutics) are truly putting heavy burden on the doctor forcing him to practice defensive medicine paving the way to use all the possible investigations in that particular clinical condition. Doctors are found guilty not because some investigation is done but because something is missed because of the non-performance of a certain test.
Everyone who is complaining regarding the costs of medical care should understand one simple thing- Every advance in medicine is costly and the present longevity offered by advances in medicine does not come cheaply. To construct and maintain a hospital according to whims and fancies of individual patients and cheap medical care do not run hand in hand. Even a small lapse from cleaning, medical and nursing team invites a sarcastic comment "we did not come here for a government type of care" from many patients. In fact, most of the advanced surgeries are cheaper in India by a huge margin. If people compare the price of most of the surgeries to the rates 15 years ago, they can easily decipher that the rates did not change much and if inflation is taken in to account, most of the surgeries in fact became much cheaper. Average doctor's income has decreased and most of the other professions' income drastically increased. Most of the costs incurred by the patient are the infrastructure costs i.e. Room rents, ICU charges, OT maintenance charges and Instrument charges.
Nobody has a family doctor anymore to act as one of the family heads and catalyst for decreasing the costs of medical care. Everyone runs to a specialist with a tunnel vision straightaway and later blame the system for the costs. The way people change their doctors, the same way they change their clothes speaks about the casual attitude of most of the people. The way doctors are beaten and killed, although they are isolated events, tells us about the degrading status of the doctors in the society. General public also should stop pretending that the whole muck is the handiwork of Doctors and they have no stake in it. Many patients think twice before paying the consultation fee and ask the doctor whether he needs to pay when he comes for a second visit but dont blink an eye before getting costly investigations and asking for costly drugs. When a patient survives, they praise medicine as a noble occupation and if the same doctor makes a small mistake they burn his reputation at stakes. I believe that corruption starts from both ends. If people are rational, we dont get politicians like the ones we are having now. In the same way, unethical doctors are flourishing and the ones who still cling to clinical acumen and ethics are having a difficult time practicing medicine.
Human body is not a fixed circuit like a machine. We are still miles away from deciphering the human body and human code. Although we found out the genetic code, it's on and off switches and it's interaction with the environment is not fully known. For many diseases, there is no single ideal approach. Even evidence based medicine talks about statistics but not what is required for an individual patient. Ultimately the burden of choosing the treatment falls on the patient and the doctor acts only as a facilitator. If one chooses a poor works man, the outcome will definitely be poor. The outcome of a patient - Doctor interaction depends on multiple factors- ABC2 i.e. Availability of a Doctor, Behaviour, Competence and ultimately Cost. These factors do not occupy fixed proportions but influence every interaction between a doctor and patient. Most often, competence and ethical behaviour of the doctor take backseat to accommodate the other factors when a patient decides to visit a doctor. Just because a doctor is charging higher consultation fee doesn't make him a bad doctor, if he is not taking cuts and prescribing proper treatment. It is the responsibility of the patient to do a background check on the doctor nowadays because of the wide gap between the standards of colleges producing doctors. Many times patients think that it is below their dignity to ask about the costs of a procedure or hospital stay. It is the duty of the patient to ask about the costs involved and decide whether it fits in to his budget. No patient should flaunt his medical insurance before deciding the mode of treatment lest he be easy prey for costly procedures and moral hazard because nowadays there is a very thin line between medical and surgical managements. In the big doctor's jungle, there are virtuous cows as well as a few tigers and a patient would not become a prey if he does a proper check.
There was a statement about Mr. Manmohan Singh few days back in The Hindu Editorial Guilty on many accounts but not corrupt which applies absolutely to the current medical profession. Medicine is already treated like a business by many people since the supreme court judgement. But most of us didn't treat it like business. Otherwise, the situation would have been much more worse. Millions of Doctor - Patient interactions happen in our country every single day. Out of them, even at this very moment, some may go wrong either because of the doctor or patient's illness. Some of them are definitely because of the doctors, but one should observe the fact that they are very few, not even 0.01%. The public should note the fact there are much more good people than bad men in our profession.
We agree that we are all not good men. We reflect the current society because we are drawn from it. When the society goes bad, the doctors also go bad. But, don't forget one thing- Doctors in comparison to other professions are the last people to go immoral because of the ethics inherent in their profession and if it is happening, it shows the society's direction. But one thing is sure - We, Doctors, still draw inspiration from an occasional patient living against all odds because of our efforts and an occasional patient saying "Thank you very much, Doctor". Sometimes, these simple words remind us of our noble profession and arrest our moral slide. Most of us lost our youth studying those immense books and many diseased patients. Most of us became indifferent after seeing death from close quarters but never lost our empathy and humanity. Most of us lost our family lives and pampered our kids because of the limited time we have for them because of our profession. Most of us feel more happy when a patient becomes alright from a complication than when our own children are cured from illnesses. Most of us stretched our limits when patients put complete faith in us. Most of us even when we are sick attend to the patients with a single thought - "what would happen to the patients if I am not there". We dont embody higher spiritual goals and sacrifice lest we be sages and live in Himalayas but most of the time what drives us is the noble cause because after some time, money won't drive us.
The sad thing is we lost half of our credibility when money entered the system- money for degree scheme (which is started by politicians) which corrupted the production of Doctors (Even in Medicine, 50% used to belong to the bottom half of the class and as money entered the system blatantly, the number will rise to 90% in a short time) and the other half because of the kickbacks we received from the Diagnostics and Pharmaceutical industry which corrupted the Conduct of the established Doctors.
Ultimately, I would like to pose some simple questions to Mr.Aamir. Will you go to a corporate hospital or a reputed ethical doctor when you get sick? Will you refuse all those costly tests or take opinion regarding those tests from somebody else? Will you use generic medicines? Are you using generic drugs at your home? When a film is being made, do you pay all the hotel bills and personal bills? Do you receive gifts when you are offered or say no to them? Are you acting in art or meaningful movies (what art is really meant for just like a true doctor is truly meant for treating a patient irrespective of money) instead of commercial movies charging crores of rupees? One should follow what he/she is preaching. But I would like to thank you for pointing out our mistakes and generating a debate even though your other fingers are not clean. The issue in front of us is whether to run this medical business as law says it, ethically or not. Getting apologies from Mr. Aamir won't absolve ourselves from the guilt. But if we accept our faults and act upon it, we may be able to revive our glorious past. We have to impose some self imposed restrictions on us and IMA should instead of fighting with Aamir, should devise a plan to come clean out of this ugly episode. Then only we can give integrity to the statement Satyameva Jayathe and "Dharmo Rakshitha Rakshithaha".
Truth is bitter but unfortunately it is true. Most of the issues shown in the Aamirs show were correct starting from manufacture of a doctor to the conduct of a doctor. Some doctors who indulge in these activities got offended unnecessarily and want to observe a black day on 25th of this month which is unwarranted because it will give unnecessary advertisement to this truth more than what the episode of Satyameva jayathe did.
My only complaint is the excessive dramatization of the stories (bordering on sensationalism) he presented in the initial part of the show. The way the stories were presented was in a very bad taste. The first patient obviously had Diabetic foot and had his toe amputated. It is true that amputation would not have been necessary had the patient taken his diabetic medicines properly. The second had a corporate itch and went there for a small problem where evidence based medicine was taken to great levels (all sorts of possible tests in that condition were done at a premium and the patient knew the costs before entering that hospital). Many times, these corporate patients want instant relief and ask for every possible test and when the diagnosis becomes apparent, they blame the hospital for the costs.
The third one was lined up for a cadaveric renal transplant obviously because nobody in the family didn't want to donate kidney to her. Unfortunately, the patient died because of a mishap (Disseminated Intravasular Coagulation) which can happen some times in these complicated surgeries. But, one should realize that the doctor didnt kill her intentionally- whether the death was due to a botched Pancreatic transplant or any other reason, only the operating team would know. Nobody, not even the relatives of the patient could understand the mental agony the Nephrologist and surgeon would have gone through the whole episode. The way Mr. Aamir and the patients husband were talking through the episode indicating that the whole surgery was not indicated (Their foolish remark that a patients with kidney failure can stay on dialysis forever without ever needing a transplant) shows that they were hell bent on blaming the surgical team. The last one- one of the spectators indicating that her relative was asked to undergo liver transplant was the most unbelievable. No doctor, even in his insanest state of his mind would think that the patient or his relatives are a bunch of morons to utter a sentence like this without proper indication. All these stories indicate that the first part of the episode was scripted to show all the doctors in a bad light and presented strictly a unilateral view point.
Investigation cuts
At the same time, it is true that many doctors take cuts. Many Doctors partly live on the MRIs they write for many patients and some of the top Doctors are provided high end vehicles by the diagnostic centers as an incentive for this reason. Many CT scans are also unwarranted. Many labs give cuts to the doctors who refer to them- 10-30% depending on the competition. This system is so much entrenched in the diagnostic facilities that even if the patient goes on his own, they are charged the same amount as the referred patient and the referral fee is clandestinely pocketed by the manager or technician of the diagnostic lab.
This "excessive investigations" fiasco is not solely because of the doctors. One has to realize that most of these investigations are forced by the patients because every patient wants instant diagnosis and instant cure nowadays. A patient with ordinary viral fever doesnt believe the diagnosis till he gets all possible diagnostic tests before the fever comes down on its own on the 4th or 5th day. Either the patient or mostly the patients relatives pester the doctor so much that even if a proper doctor is sure about his diagnosis, he ultimately gives in and writes those investigations.
The most disgraceful one is cuts from doctor to doctor. Many doctors expect to be paid if any patient they refer undergo any medical or surgical procedure in the target centre. Most of the busy and successful doctors of the present era built their empires like this and the doctors who felt ethical enough to eschew this practice remained obscure. In the erstwhile era, ANM workers and RMPs, used to accompany the patient and collect their commissions for bringing the patient. Doctors hosting dinners to RMPs was a well known secret of success. Now, Doctors also degraded to that level and expect money in return for referring the patient.
Most doctors are now capitalizing on these cuts and treating this as a secondary consultation fee rather than unethical income. But there are also many good apples in the system. Some doctors explicitly write and tell the diagnostic centre to charge the patient lesser amount. Some doctors dont take the referral fee to pass on the benefit (when the necessity arises) to a poor patient whose investigations would be done free of charge.
I have seen many young doctors who were against the cuts, ultimately subdued by the current system. Who doesnt want free money? When the next person is taking money without getting punished, why cant I? attitude creeps slowly in to the new doctor. Only when the Government comes up with a law prohibiting these practices, this practice will stop. All the doctors who believe that they are in the comfort zone pocketing this money would think twice when it becomes unsafe to accept money. When the doctors stop this practice, the price of these investigations will come down and become affordable to most patients.
Brands and generic medicines
What is the worth of a generic actor? somebody asked me. Hardly thousands of rupees. But, why Aamir khan is taking crores of money? Its the Brand stupid he replied. It is true. Even when the generic and branded are available side by side, if branded is available at an affordable price- we normally buy it. We want nice packaging and nice names on the cover. When we have money, we go to malls and when we dont have it, we go to the shop near our house. Everything we consume is available at a cheap price- from the soaps to shoes. When something is available at a cheaper price, we are suspicious of it when we have money. This is normal human attitude.
Let me be serious... I am not against generic medicines. My viewpoint is that both branded and generic medicines should be made available and it is the patient who should decide regarding them. The way to enforce this is by forcing all the doctors to write both the brand and drug name in capital letters, if possible by law. Many times, one cannot decipher the code language in which the prescription is written, leave alone finding the drugs name in CIMS. Poor patients and people who believe in generic medicines can take those medicines and the other set can take branded items. Even in countries where they are available side by side, the penetration level of Generics is less than 15%. The following picture best illustrates the present viewpoint of generic drugs among western people.
In fact, if you put the question "what are generic medicines"- not all doctors have a definite answer for that and most of the patients equate them with counterfeit medicines. Even doctors, when they purchase medicines for their own use prefer branded medicines to generic drugs because they don't believe them. Even after 14 years of medical practice, I had only a faint glimpse of generic drugs. When I asked my colleagues and some patients, I found out that most of them believe in branded medicines because they are produced properly (only when the brand name is put on the cover, the manufacturers properly produce the drug) whereas the generic drugs are not produced according to guidelines. But it is not correct.
Let me take a small detour and explain about generic medicines - Generic drugs are chemically identical to brand name drugs in every way: dose, safety, strength, how the drug is meant to be taken, quality, intended use, and bioavailability. Only the price is different, and the fact that they are sold under their chemical name (Courtesy - Generics, fast facts on Internet). Generic drugs are less expensive than brand name drugs because generic manufacturers dont bear the investment costs of new drug development. New drugs are developed under patent protection. The patent protects a companys investment in research, development, and marketing by giving the company the sole right to sell the drug while the patent is in effect. As patents near expiration, manufacturers apply to the Drug Authority to sell generic versions. Generics manufacturers havent paid for developing a drug, so they can sell their product at reduced prices. Generic competition usually results in lower prices on the brand-name version as well. By the way, brand name manufacturers make about half of generic drugs. Generic drugs are subject to the same standards as all drugs and must be manufactured in factories that also meet regulations. (But in India, the problem is with quality control procedures because these are under the control of government officials and nobody has belief in them at present). Generic penetration varies widely from country to country; in Europe, for example, generics account for almost 18% of the German pharmaceutical market but only 11% of the pharma market in France. The European average share is 15%; this compares with 10% of the U.S. pharmaceutical market, but only 6% of the market in Japan. This data shows the power of branded pharmaceuticals even in countries where people are educated.
The way we, the doctors, are bombarded by the Pharma companies with gifts and tours, we hardly take note of the generic medicines. Pharma companies work on the human weakness and play it very well. The way we feel obliged to write a particular drug for at least for a few days after receiving a small pen which we can buy outside for 20 Rs. and forced to promote a brand after receiving a free tour speaks volumes of the ingenuity of the drug companies marketing strategies. Drug companies work on this simple human weakness that everyone has - People may reject money but accept gifts and the obligation level to the sponsor is still the same. Leave alone Generic- even in branded, there is a lot of difference in price. To decipher why somebody writes higher priced brand doesnt require rocket science.
If everybody buys generic medicines, one thing will happen for sure- Most of the Doctors will stop receiving gifts and would have to pay from their pockets for attending conferences and their Foreign tours. Without the branded medicines sponsoring the events, most of the unnecessary conferences will not take place. But, this will definitely decrease the medical bills of the patients and increase the credibility of doctors. But, the ultimate question is where are the generic pharmacies? because even when I wanted to get them for my personal use, I could not find the outlets nearby.
Medical seats
In India, there is still clamor and glamour for medicine not solely because it is a noble occupation but because it is a lucrative trade. There are many MCI certified dying medical colleges which function without faculty or patients but keep on attracting students who are not concerned about education but only bothered about getting the degree. This is because of the reason that in India, the degree gives anyone the right to do anything on the patient, irrespective of how they get the degree. The absence of any licentiate exam to practice medicine and the absence of any entrance exam for getting postgraduate degree in these new colleges is allowing even mediocre students bold enough to enter medical field to reap its monetary benefits.
Most of the newly mushrooming colleges assure their students medical degrees - either graduate (MBBS) or post graduate (MS/MD) because their very survival depends on doling out these degrees. It is an open secret in India that with money, ($90000- $100000 for MBBS, $125000- $275000 for post graduation and super specialty) one can surely become a post graduate, if not a super specialist because there are no independent qualifying exams in between. The exams these colleges organize on their own are a sham just to hoodwink the public. If anybody wants to follow an authentic route and join DNB course, they have to surmount two obstacles- The ridiculously hard DNB Exam (Tougher than MD/MS) and the recalcitrant MCI treating them as second class citizens.
There was always huge uproar in India regarding affirmative action in selecting students for medical courses citing the gold standard of Merit, but when money determines the entry in to these private colleges, all the elite and media so far remained silent. When a few fake pilots were found recently, there was pandemonium in the country. The only difference between them and these doctors is a fake pilot kills many people at a single time and gets killed in the process but a thousand fake doctors kill one person at a time but not killed in the process and act as slow poison in the society". Another problem is when somebody pays huge amounts as investment for the degree, even if he/she is good intentioned and intelligent, they subconsciously resort to unethical practices raising the health care costs of the society.
The problem is very much evident in many colleges in South India. Many colleges do not attract even 250 outpatients a day and inpatients are woefully inadequate for any sort of clinical teaching. The enthusiasm and dedication of a few good students is neutralized by the lack of patients who are slowly demotivated and released in to the society as apathetic and incompetent people who dont put value on medical ethics and values because they were brought up in the colleges following the same corrupt values and practices. In many colleges, a post graduate in surgery does not even perform an appendix or hernia surgery during his training. Most of them learn by experimenting on the patients after getting their degree. In the whole of Chattisgarh and Jharkhand, whose combined area is one and half times that of Tamilnadu and combined population is almost equal to Tamilnadu, we have only 6 medical colleges out of which one is derecognized- whereas there are 18 government colleges and 22 private colleges in Tamilnadu. No wonder, there is gross disparity in health indicators between these states.
Just a small revision in these statistics- In the last 2 years , especially this year, all the private colleges are showing the scare of Common entrance test and increased the fee by 50% (CET cess). The cost of average MBBS seat has gone up from 30 to 50 lakh rupees (in some top private colleges the seat is sold at 70 lakh rupees). MD Radiology seat is being sold for 1.5 crores and MS orthopaedics for 1 crore. "Are you joking Mr.Azad and Mr.Sibal? Are you serious about CET? ". If you are not serious about this, this new pricing is here to stay.
Health schemes
The Aamirs show which tried to portray Mr. Devi shetty as a messiah exhibited his ignorance about this type of health insurance schemes. All these health schemes take money away from primary care to tertiary care and benefit only private hospitals and in turn completely destroy the government healthcare. Diseases also have their status- When a small kid dies of diarrhea which can be easily prevented with a small amount of money, nobody is bothered. Heart diseases and cancers are treated as royal diseases and everyone want money to be spent on them. In our country, many people die of easily preventable infectious causes than heart diseases and cancers. But the problem is - private hospitals don't make money from preventive care, instead, they can make money only from curing high end diseases by doing costly procedures.
The Yashaswini scheme is not free of loopholes as promised by Mr. Shetty. But it is his ingenuity in manipulating the health system to his advantage, that mandates accolades. What he did was- organized apparently free OPDs which worked clandestinely as workshops for accumulating cases (the moral hazard in these cases was never evaluated), got inpatients for his empty wards and OT's, given full work to his diagnostics for which the patient pays, marketed his schemes as low cost surgeries where in fact the patient pays for the expensive ancillary equipment and stents.
His whole scheme depended on two factors - one that the middle class people won't crib for the recurring small expenses and happily pay for them in return for a bigger single expense and the other most important thing is, it is foolish to extend this scheme to really poor people. The scheme was started 2 years after the establishment of his Narayana Hrudayalaya with 500 beds, 10 operating theaters and two cath labs. His hospitals occupancy rate was below 30%. Then only he tapped the power of the cooperatives because all the farmers enrolled in the cooperatives would have some amount of land and they belong to lower middle class or above, perfect targets. Their surgeries were done at a low cost but for diagnostic tests and expensive ancillary surgical equipment they were charged (Out of the targeted 8.2 million people only 3 million are enrolled so far). The people working in the same agricultural fields (land laborers) are not covered in this scheme because he knew that they cannot pay for the diagnostic tests and the expensive OT equipment. 94% of the money so far spent under the scheme went to private hospitals. Narayana Hrudayalaya alone claimed 32% of the claimed amount for 15% of the total cases in 2008-09. If we multiply 3 million members (initially the number was 1.6 million) with 90 rupees (premium per year), it comes to around 18 crore rupees and for the last 8 years the total collected premium was a maximum of 144 crore rupees. With that amount, no insurance scheme can run. In fact, in the first 5 years, total collected amount as premium was 87,30,20,853 rupees whereas the amout paid to the network hospitals was 280 crore rupees - (source- Harvard Case Study, Karnataka Yashaswini Health Insurance Scheme). So, who exactly is paying the deficit?
But he showed one important fact - if the same repetitive surgeries are done at a single center, the expense of the surgery would be low and this has to be followed in the government sponsored insurance schemes, where instead of giving everyone the chance to do the surgery, identify some centers and select one among them which can provide the selected procedure for a reasonable cost and competence.
Status of a Doctor
When very few doctors were available in the society as in the past, the doctor was treated like a demigod and was put on a pedestal. Everyone wanted to associate themselves with a doctor and wanted to be his/her friend. If anybody survived, it was because of the doctor and if anybody died it was because of fate. May be it is still true in areas where very few doctors are available. But in urban areas where the market is flooded with doctors, every action of a doctor is scrutinized and the doctor is forced to practice defensively. The current longevity promised by the progresses in Medicine (Diagnostics and therapeutics) are truly putting heavy burden on the doctor forcing him to practice defensive medicine paving the way to use all the possible investigations in that particular clinical condition. Doctors are found guilty not because some investigation is done but because something is missed because of the non-performance of a certain test.
Everyone who is complaining regarding the costs of medical care should understand one simple thing- Every advance in medicine is costly and the present longevity offered by advances in medicine does not come cheaply. To construct and maintain a hospital according to whims and fancies of individual patients and cheap medical care do not run hand in hand. Even a small lapse from cleaning, medical and nursing team invites a sarcastic comment "we did not come here for a government type of care" from many patients. In fact, most of the advanced surgeries are cheaper in India by a huge margin. If people compare the price of most of the surgeries to the rates 15 years ago, they can easily decipher that the rates did not change much and if inflation is taken in to account, most of the surgeries in fact became much cheaper. Average doctor's income has decreased and most of the other professions' income drastically increased. Most of the costs incurred by the patient are the infrastructure costs i.e. Room rents, ICU charges, OT maintenance charges and Instrument charges.
Nobody has a family doctor anymore to act as one of the family heads and catalyst for decreasing the costs of medical care. Everyone runs to a specialist with a tunnel vision straightaway and later blame the system for the costs. The way people change their doctors, the same way they change their clothes speaks about the casual attitude of most of the people. The way doctors are beaten and killed, although they are isolated events, tells us about the degrading status of the doctors in the society. General public also should stop pretending that the whole muck is the handiwork of Doctors and they have no stake in it. Many patients think twice before paying the consultation fee and ask the doctor whether he needs to pay when he comes for a second visit but dont blink an eye before getting costly investigations and asking for costly drugs. When a patient survives, they praise medicine as a noble occupation and if the same doctor makes a small mistake they burn his reputation at stakes. I believe that corruption starts from both ends. If people are rational, we dont get politicians like the ones we are having now. In the same way, unethical doctors are flourishing and the ones who still cling to clinical acumen and ethics are having a difficult time practicing medicine.
Human body is not a fixed circuit like a machine. We are still miles away from deciphering the human body and human code. Although we found out the genetic code, it's on and off switches and it's interaction with the environment is not fully known. For many diseases, there is no single ideal approach. Even evidence based medicine talks about statistics but not what is required for an individual patient. Ultimately the burden of choosing the treatment falls on the patient and the doctor acts only as a facilitator. If one chooses a poor works man, the outcome will definitely be poor. The outcome of a patient - Doctor interaction depends on multiple factors- ABC2 i.e. Availability of a Doctor, Behaviour, Competence and ultimately Cost. These factors do not occupy fixed proportions but influence every interaction between a doctor and patient. Most often, competence and ethical behaviour of the doctor take backseat to accommodate the other factors when a patient decides to visit a doctor. Just because a doctor is charging higher consultation fee doesn't make him a bad doctor, if he is not taking cuts and prescribing proper treatment. It is the responsibility of the patient to do a background check on the doctor nowadays because of the wide gap between the standards of colleges producing doctors. Many times patients think that it is below their dignity to ask about the costs of a procedure or hospital stay. It is the duty of the patient to ask about the costs involved and decide whether it fits in to his budget. No patient should flaunt his medical insurance before deciding the mode of treatment lest he be easy prey for costly procedures and moral hazard because nowadays there is a very thin line between medical and surgical managements. In the big doctor's jungle, there are virtuous cows as well as a few tigers and a patient would not become a prey if he does a proper check.
There was a statement about Mr. Manmohan Singh few days back in The Hindu Editorial Guilty on many accounts but not corrupt which applies absolutely to the current medical profession. Medicine is already treated like a business by many people since the supreme court judgement. But most of us didn't treat it like business. Otherwise, the situation would have been much more worse. Millions of Doctor - Patient interactions happen in our country every single day. Out of them, even at this very moment, some may go wrong either because of the doctor or patient's illness. Some of them are definitely because of the doctors, but one should observe the fact that they are very few, not even 0.01%. The public should note the fact there are much more good people than bad men in our profession.
We agree that we are all not good men. We reflect the current society because we are drawn from it. When the society goes bad, the doctors also go bad. But, don't forget one thing- Doctors in comparison to other professions are the last people to go immoral because of the ethics inherent in their profession and if it is happening, it shows the society's direction. But one thing is sure - We, Doctors, still draw inspiration from an occasional patient living against all odds because of our efforts and an occasional patient saying "Thank you very much, Doctor". Sometimes, these simple words remind us of our noble profession and arrest our moral slide. Most of us lost our youth studying those immense books and many diseased patients. Most of us became indifferent after seeing death from close quarters but never lost our empathy and humanity. Most of us lost our family lives and pampered our kids because of the limited time we have for them because of our profession. Most of us feel more happy when a patient becomes alright from a complication than when our own children are cured from illnesses. Most of us stretched our limits when patients put complete faith in us. Most of us even when we are sick attend to the patients with a single thought - "what would happen to the patients if I am not there". We dont embody higher spiritual goals and sacrifice lest we be sages and live in Himalayas but most of the time what drives us is the noble cause because after some time, money won't drive us.
The sad thing is we lost half of our credibility when money entered the system- money for degree scheme (which is started by politicians) which corrupted the production of Doctors (Even in Medicine, 50% used to belong to the bottom half of the class and as money entered the system blatantly, the number will rise to 90% in a short time) and the other half because of the kickbacks we received from the Diagnostics and Pharmaceutical industry which corrupted the Conduct of the established Doctors.
Ultimately, I would like to pose some simple questions to Mr.Aamir. Will you go to a corporate hospital or a reputed ethical doctor when you get sick? Will you refuse all those costly tests or take opinion regarding those tests from somebody else? Will you use generic medicines? Are you using generic drugs at your home? When a film is being made, do you pay all the hotel bills and personal bills? Do you receive gifts when you are offered or say no to them? Are you acting in art or meaningful movies (what art is really meant for just like a true doctor is truly meant for treating a patient irrespective of money) instead of commercial movies charging crores of rupees? One should follow what he/she is preaching. But I would like to thank you for pointing out our mistakes and generating a debate even though your other fingers are not clean. The issue in front of us is whether to run this medical business as law says it, ethically or not. Getting apologies from Mr. Aamir won't absolve ourselves from the guilt. But if we accept our faults and act upon it, we may be able to revive our glorious past. We have to impose some self imposed restrictions on us and IMA should instead of fighting with Aamir, should devise a plan to come clean out of this ugly episode. Then only we can give integrity to the statement Satyameva Jayathe and "Dharmo Rakshitha Rakshithaha".
Satyamev jayathe: Doctors vs Aamir - who is correct?
Truth is bitter but unfortunately it is true. Most of the issues shown in the Aamir’s show were correct starting from manufacture of a doctor to the conduct of a doctor. Some doctors who indulge in these activities got offended unnecessarily and want to observe a black day on 25th of this month which is unwarranted because it will give unnecessary advertisement to this truth more than what the episode of Satyameva jayathe did.
My only complaint is the excessive dramatization of the stories (bordering on sensationalism) he presented in the initial part of the show. The way the stories were presented was in a very bad taste. The first patient obviously had Diabetic foot and had his toe amputated. It is true that amputation would not have been necessary had the patient taken his diabetic medicines properly. The second had a corporate itch and went there for a small problem where evidence based medicine was taken to great levels (all sorts of possible tests in that condition were done at a premium and the patient knew the costs before entering that hospital). Many times, these corporate patients want instant relief and ask for every possible test and when the diagnosis becomes apparent, they blame the hospital for the costs.
The third one was lined up for a cadaveric renal transplant obviously because nobody in the family didn't want to donate kidney to her. Unfortunately, the patient died because of a mishap (Disseminated Intravasular Coagulation) which can happen some times in these complicated surgeries. But, one should realize that the doctor didn’t kill her intentionally- whether the death was due to a botched Pancreatic transplant or any other reason, only the operating team would know. Nobody, not even the relatives of the patient could understand the mental agony the Nephrologist and surgeon would have gone through the whole episode. The way Mr. Aamir and the patient’s husband were talking through the episode indicating that the whole surgery was not indicated (Their foolish remark that a patients with kidney failure can stay on dialysis forever without ever needing a transplant) shows that they were hell bent on blaming the surgical team. The last one- one of the spectators indicating that her relative was asked to undergo liver transplant was the most unbelievable. No doctor, even in his insanest state of his mind would think that the patient or his relatives are a bunch of morons to utter a sentence like this without proper indication. All these stories indicate that the first part of the episode was scripted to show all the doctors in a bad light and presented strictly a unilateral view point.
Investigation cuts
At the same time, it is true that many doctors take cuts. Many Doctors partly live on the MRIs they write for many patients and some of the top Doctors are provided high end vehicles by the diagnostic centers as an incentive for this reason. Many CT scans are also unwarranted. Many labs give cuts to the doctors who refer to them- 10-30% depending on the competition. This system is so much entrenched in the diagnostic facilities that even if the patient goes on his own, they are charged the same amount as the referred patient and the referral fee is clandestinely pocketed by the manager or technician of the diagnostic lab.
This "excessive investigations" fiasco is not solely because of the doctors. One has to realize that most of these investigations are forced by the patients because every patient wants instant diagnosis and instant cure nowadays. A patient with ordinary viral fever doesn’t believe the diagnosis till he gets all possible diagnostic tests before the fever comes down on its own on the 4th or 5th day. Either the patient or mostly the patient’s relatives pester the doctor so much that even if a proper doctor is sure about his diagnosis, he ultimately gives in and writes those investigations.
The most disgraceful one is cuts from doctor to doctor. Many doctors expect to be paid if any patient they refer undergo any medical or surgical procedure in the target centre. Most of the busy and successful doctors of the present era built their empires like this and the doctors who felt ethical enough to eschew this practice remained obscure. In the erstwhile era, ANM workers and RMP’s, used to accompany the patient and collect their commissions for bringing the patient. Doctors hosting dinners to RMP’s was a well known secret of success. Now, Doctors also degraded to that level and expect money in return for referring the patient.
Most doctors are now capitalizing on these cuts and treating this as a secondary consultation fee rather than unethical income. But there are also many good apples in the system. Some doctors explicitly write and tell the diagnostic centre to charge the patient lesser amount. Some doctors don’t take the referral fee to pass on the benefit (when the necessity arises) to a poor patient whose investigations would be done free of charge.
I have seen many young doctors who were against the cuts, ultimately subdued by the current system. Who doesn’t want free money? “When the next person is taking money without getting punished, why can’t I?” attitude creeps slowly in to the new doctor. Only when the Government comes up with a law prohibiting these practices, this practice will stop. All the doctors who believe that they are in the comfort zone pocketing this money would think twice when it becomes unsafe to accept money. When the doctors stop this practice, the price of these investigations will come down and become affordable to most patients.
Brands and generic medicines
“What is the worth of a generic actor?” somebody asked me. “Hardly thousands of rupees. But, why Aamir khan is taking crores of money? It’s the Brand stupid” he replied. It is true. Even when the generic and branded are available side by side, if branded is available at an affordable price- we normally buy it. We want nice packaging and nice names on the cover. When we have money, we go to malls and when we don’t have it, we go to the shop near our house. Everything we consume is available at a cheap price- from the soaps to shoes. When something is available at a cheaper price, we are suspicious of it when we have money. This is normal human attitude.
Let me be serious... I am not against generic medicines. My viewpoint is that both branded and generic medicines should be made available and it is the patient who should decide regarding them. The way to enforce this is by forcing all the doctors to write both the brand and drug name in capital letters, if possible by law. Many times, one cannot decipher the code language in which the prescription is written, leave alone finding the drug’s name in CIMS. Poor patients and people who believe in generic medicines can take those medicines and the other set can take branded items. Even in countries where they are available side by side, the penetration level of Generics is less than 15%. The following picture best illustrates the present viewpoint of generic drugs among western people.
In fact, if you put the question "what are generic medicines"- not all doctors have a definite answer for that and most of the patients equate them with counterfeit medicines. Even doctors, when they purchase medicines for their own use prefer branded medicines to generic drugs because they don't believe them. Even after 14 years of medical practice, I had only a faint glimpse of generic drugs. When I asked my colleagues and some patients, I found out that most of them believe in branded medicines because they are produced properly (only when the brand name is put on the cover, the manufacturers properly produce the drug) whereas the generic drugs are not produced according to guidelines. But it is not correct.
Let me take a small detour and explain about generic medicines - Generic drugs are chemically identical to brand name drugs in every way: dose, safety, strength, how the drug is meant to be taken, quality, intended use, and bioavailability. Only the price is different, and the fact that they are sold under their chemical name (Courtesy - Generics, fast facts on Internet). Generic drugs are less expensive than brand name drugs because generic manufacturers don’t bear the investment costs of new drug development. New drugs are developed under patent protection. The patent protects a company’s investment in research, development, and marketing by giving the company the sole right to sell the drug while the patent is in effect. As patents near expiration, manufacturers apply to the Drug Authority to sell generic versions. Generics manufacturers haven’t paid for developing a drug, so they can sell their product at reduced prices. Generic competition usually results in lower prices on the brand-name version as well. By the way, brand name manufacturers make about half of generic drugs. Generic drugs are subject to the same standards as all drugs and must be manufactured in factories that also meet regulations. (But in India, the problem is with quality control procedures because these are under the control of government officials and nobody has belief in them at present). Generic penetration varies widely from country to country; in Europe, for example, generics account for almost 18% of the German pharmaceutical market but only 11% of the pharma market in France. The European average share is 15%; this compares with 10% of the U.S. pharmaceutical market, but only 6% of the market in Japan. This data shows the power of branded pharmaceuticals even in countries where people are educated.
The way we, the doctors, are bombarded by the Pharma companies with gifts and tours, we hardly take note of the generic medicines. Pharma companies work on the human weakness and play it very well. The way we feel obliged to write a particular drug for at least for a few days after receiving a small pen which we can buy outside for 20 Rs. and forced to promote a brand after receiving a free tour speaks volumes of the ingenuity of the drug companies’ marketing strategies. Drug companies work on this simple human weakness that everyone has - People may reject money but accept gifts and the obligation level to the sponsor is still the same. Leave alone Generic- even in branded, there is a lot of difference in price. To decipher why somebody writes higher priced brand doesn’t require rocket science.
If everybody buys generic medicines, one thing will happen for sure- Most of the Doctors will stop receiving gifts and would have to pay from their pockets for attending conferences and their Foreign tours. Without the branded medicines sponsoring the events, most of the unnecessary conferences will not take place. But, this will definitely decrease the medical bills of the patients and increase the credibility of doctors. But, the ultimate question is “where are the generic pharmacies?” because even when I wanted to get them for my personal use, I could not find the outlets nearby.
Medical seats
In India, there is still clamor and glamour for medicine not solely because it is a noble occupation but because it is a lucrative trade. There are many MCI certified dying medical colleges which function without faculty or patients but keep on attracting students who are not concerned about education but only bothered about getting the degree. This is because of the reason that in India, the degree gives anyone the right to do anything on the patient, irrespective of how they get the degree. The absence of any licentiate exam to practice medicine and the absence of any entrance exam for getting postgraduate degree in these new colleges is allowing even mediocre students bold enough to enter medical field to reap its monetary benefits.
Most of the newly mushrooming colleges assure their students medical degrees - either graduate (MBBS) or post graduate (MS/MD) because their very survival depends on doling out these degrees. It is an open secret in India that with money, ($90000- $100000 for MBBS, $125000- $275000 for post graduation and super specialty) one can surely become a post graduate, if not a super specialist because there are no independent qualifying exams in between. The exams these colleges organize on their own are a sham just to hoodwink the public. If anybody wants to follow an authentic route and join DNB course, they have to surmount two obstacles- The ridiculously hard DNB Exam (Tougher than MD/MS) and the recalcitrant MCI treating them as second class citizens.
There was always huge uproar in India regarding affirmative action in selecting students for medical courses citing the gold standard of Merit, but when money determines the entry in to these private colleges, all the elite and media so far remained silent. When a few fake pilots were found recently, there was pandemonium in the country. The only difference between them and these doctors is – “a fake pilot kills many people at a single time and gets killed in the process but a thousand fake doctors kill one person at a time but not killed in the process and act as slow poison in the society". Another problem is when somebody pays huge amounts as investment for the degree, even if he/she is good intentioned and intelligent, they subconsciously resort to unethical practices raising the health care costs of the society.
The problem is very much evident in many colleges in South India. Many colleges do not attract even 250 outpatients a day and inpatients are woefully inadequate for any sort of clinical teaching. The enthusiasm and dedication of a few good students is neutralized by the lack of patients who are slowly demotivated and released in to the society as apathetic and incompetent people who don’t put value on medical ethics and values because they were brought up in the colleges following the same corrupt values and practices. In many colleges, a post graduate in surgery does not even perform an appendix or hernia surgery during his training. Most of them learn by experimenting on the patients after getting their degree. In the whole of Chattisgarh and Jharkhand, whose combined area is one and half times that of Tamilnadu and combined population is almost equal to Tamilnadu, we have only 6 medical colleges out of which one is derecognized- whereas there are 18 government colleges and 22 private colleges in Tamilnadu. No wonder, there is gross disparity in health indicators between these states.
Just a small revision in these statistics- In the last 2 years , especially this year, all the private colleges are showing the scare of Common entrance test and increased the fee by 50% (CET cess). The cost of average MBBS seat has gone up from 30 to 50 lakh rupees (in some top private colleges the seat is sold at 70 lakh rupees). MD Radiology seat is being sold for 1.5 crores and MS orthopaedics for 1 crore. "Are you joking Mr.Azad and Mr.Sibal? Are you serious about CET? ". If you are not serious about this, this new pricing is here to stay.
Health schemes
The Aamir’s show which tried to portray Mr. Devi shetty as a messiah exhibited his ignorance about this type of health insurance schemes. All these health schemes take money away from primary care to tertiary care and benefit only private hospitals and in turn completely destroy the government healthcare. Diseases also have their status- When a small kid dies of diarrhea which can be easily prevented with a small amount of money, nobody is bothered. Heart diseases and cancers are treated as royal diseases and everyone want money to be spent on them. In our country, many people die of easily preventable infectious causes than heart diseases and cancers. But the problem is - private hospitals don't make money from preventive care, instead, they can make money only from curing high end diseases by doing costly procedures.
The Yashaswini scheme is not free of loopholes as promised by Mr. Shetty. But it is his ingenuity in manipulating the health system to his advantage, that mandates accolades. What he did was- organized apparently free OPDs which worked clandestinely as workshops for accumulating cases (the moral hazard in these cases was never evaluated), got inpatients for his empty wards and OT's, given full work to his diagnostics for which the patient pays, marketed his schemes as low cost surgeries where in fact the patient pays for the expensive ancillary equipment and stents.
His whole scheme depended on two factors - one that the middle class people won't crib for the recurring small expenses and happily pay for them in return for a bigger single expense and the other most important thing is, it is foolish to extend this scheme to really poor people. The scheme was started 2 years after the establishment of his Narayana Hrudayalaya with 500 beds, 10 operating theaters and two cath labs. His hospital’s occupancy rate was below 30%. Then only he tapped the power of the cooperatives because all the farmers enrolled in the cooperatives would have some amount of land and they belong to lower middle class or above, perfect targets. Their surgeries were done at a low cost but for diagnostic tests and expensive ancillary surgical equipment they were charged (Out of the targeted 8.2 million people only 3 million are enrolled so far). The people working in the same agricultural fields (land laborers) are not covered in this scheme because he knew that they cannot pay for the diagnostic tests and the expensive OT equipment. 94% of the money so far spent under the scheme went to private hospitals. Narayana Hrudayalaya alone claimed 32% of the claimed amount for 15% of the total cases in 2008-09. If we multiply 3 million members (initially the number was 1.6 million) with 90 rupees (premium per year), it comes to around 18 crore rupees and for the last 8 years the total collected premium was a maximum of 144 crore rupees. With that amount, no insurance scheme can run. In fact, in the first 5 years, total collected amount as premium was 87,30,20,853 rupees whereas the amout paid to the network hospitals was 280 crore rupees - (source- Harvard Case Study, Karnataka Yashaswini Health Insurance Scheme). So, who exactly is paying the deficit?
But he showed one important fact - if the same repetitive surgeries are done at a single center, the expense of the surgery would be low and this has to be followed in the government sponsored insurance schemes, where instead of giving everyone the chance to do the surgery, identify some centers and select one among them which can provide the selected procedure for a reasonable cost and competence.
Status of a Doctor
When very few doctors were available in the society as in the past, the doctor was treated like a demigod and was put on a pedestal. Everyone wanted to associate themselves with a doctor and wanted to be his/her friend. If anybody survived, it was because of the doctor and if anybody died it was because of fate. May be it is still true in areas where very few doctors are available. But in urban areas where the market is flooded with doctors, every action of a doctor is scrutinized and the doctor is forced to practice defensively. The current longevity promised by the progresses in Medicine (Diagnostics and therapeutics) are truly putting heavy burden on the doctor forcing him to practice defensive medicine paving the way to use all the possible investigations in that particular clinical condition. Doctors are found guilty not because some investigation is done but because something is missed because of the non-performance of a certain test.
Everyone who is complaining regarding the costs of medical care should understand one simple thing- Every advance in medicine is costly and the present longevity offered by advances in medicine does not come cheaply. To construct and maintain a hospital according to whims and fancies of individual patients and cheap medical care do not run hand in hand. Even a small lapse from cleaning, medical and nursing team invites a sarcastic comment "we did not come here for a government type of care" from many patients. In fact, most of the advanced surgeries are cheaper in India by a huge margin. If people compare the price of most of the surgeries to the rates 15 years ago, they can easily decipher that the rates did not change much and if inflation is taken in to account, most of the surgeries in fact became much cheaper. Average doctor's income has decreased and most of the other professions' income drastically increased. Most of the costs incurred by the patient are the infrastructure costs i.e. Room rents, ICU charges, OT maintenance charges and Instrument charges.
Nobody has a family doctor anymore to act as one of the family heads and catalyst for decreasing the costs of medical care. Everyone runs to a specialist with a tunnel vision straightaway and later blame the system for the costs. The way people change their doctors, the same way they change their clothes speaks about the casual attitude of most of the people. The way doctors are beaten and killed, although they are isolated events, tells us about the degrading status of the doctors in the society. General public also should stop pretending that the whole muck is the handiwork of Doctors and they have no stake in it. Many patients think twice before paying the consultation fee and ask the doctor whether he needs to pay when he comes for a second visit but don’t blink an eye before getting costly investigations and asking for costly drugs. When a patient survives, they praise medicine as a noble occupation and if the same doctor makes a small mistake they burn his reputation at stakes. I believe that corruption starts from both ends. If people are rational, we don’t get politicians like the ones we are having now. In the same way, unethical doctors are flourishing and the ones who still cling to clinical acumen and ethics are having a difficult time practicing medicine.
Human body is not a fixed circuit like a machine. We are still miles away from deciphering the human body and human code. Although we found out the genetic code, it's on and off switches and it's interaction with the environment is not fully known. For many diseases, there is no single ideal approach. Even evidence based medicine talks about statistics but not what is required for an individual patient. Ultimately the burden of choosing the treatment falls on the patient and the doctor acts only as a facilitator. If one chooses a poor works man, the outcome will definitely be poor. The outcome of a patient - Doctor interaction depends on multiple factors- ABC2 i.e. Availability of a Doctor, Behaviour, Competence and ultimately Cost. These factors do not occupy fixed proportions but influence every interaction between a doctor and patient. Most often, competence and ethical behaviour of the doctor take backseat to accommodate the other factors when a patient decides to visit a doctor. Just because a doctor is charging higher consultation fee doesn't make him a bad doctor, if he is not taking cuts and prescribing proper treatment. It is the responsibility of the patient to do a background check on the doctor nowadays because of the wide gap between the standards of colleges producing doctors. Many times patients think that it is below their dignity to ask about the costs of a procedure or hospital stay. It is the duty of the patient to ask about the costs involved and decide whether it fits in to his budget. No patient should flaunt his medical insurance before deciding the mode of treatment lest he be easy prey for costly procedures and moral hazard because nowadays there is a very thin line between medical and surgical managements. In the big doctor's jungle, there are virtuous cows as well as a few tigers and a patient would not become a prey if he does a proper check.
There was a statement about Mr. Manmohan Singh few days back in The Hindu Editorial “Guilty on many accounts but not corrupt” which applies absolutely to the current medical profession. Medicine is already treated like a business by many people since the supreme court judgement. But most of us didn't treat it like business. Otherwise, the situation would have been much more worse. Millions of Doctor - Patient interactions happen in our country every single day. Out of them, even at this very moment, some may go wrong either because of the doctor or patient's illness. Some of them are definitely because of the doctors, but one should observe the fact that they are very few, not even 0.01%. The public should note the fact there are much more good people than bad men in our profession.
We agree that we are all not good men. We reflect the current society because we are drawn from it. When the society goes bad, the doctors also go bad. But, don't forget one thing- Doctors in comparison to other professions are the last people to go immoral because of the ethics inherent in their profession and if it is happening, it shows the society's direction. But one thing is sure - We, Doctors, still draw inspiration from an occasional patient living against all odds because of our efforts and an occasional patient saying "Thank you very much, Doctor". Sometimes, these simple words remind us of our noble profession and arrest our moral slide. Most of us lost our youth studying those immense books and many diseased patients. Most of us became indifferent after seeing death from close quarters but never lost our empathy and humanity. Most of us lost our family lives and pampered our kids because of the limited time we have for them because of our profession. Most of us feel more happy when a patient becomes alright from a complication than when our own children are cured from illnesses. Most of us stretched our limits when patients put complete faith in us. Most of us even when we are sick attend to the patients with a single thought - "what would happen to the patients if I am not there". We don’t embody higher spiritual goals and sacrifice lest we be sages and live in Himalayas but most of the time what drives us is the noble cause because after some time, money won't drive us.
The sad thing is we lost half of our credibility when money entered the system- money for degree scheme (which is started by politicians) which corrupted the production of Doctors (Even in Medicine, 50% used to belong to the bottom half of the class and as money entered the system blatantly, the number will rise to 90% in a short time) and the other half because of the kickbacks we received from the Diagnostics and Pharmaceutical industry which corrupted the Conduct of the established Doctors.
Ultimately, I would like to pose some simple questions to Mr.Aamir. “Will you go to a corporate hospital or a reputed ethical doctor when you get sick? Will you refuse all those costly tests or take opinion regarding those tests from somebody else? Will you use generic medicines? Are you using generic drugs at your home?” When a film is being made, do you pay all the hotel bills and personal bills? Do you receive gifts when you are offered or say no to them? Are you acting in art or meaningful movies (what art is really meant for just like a true doctor is truly meant for treating a patient irrespective of money) instead of commercial movies charging crores of rupees? One should follow what he/she is preaching. But I would like to thank you for pointing out our mistakes and generating a debate even though your other fingers are not clean. The issue in front of us is whether to run this medical business as law says it, ethically or not. Getting apologies from Mr. Aamir won't absolve ourselves from the guilt. But if we accept our faults and act upon it, we may be able to revive our glorious past. We have to impose some self imposed restrictions on us and IMA should instead of fighting with Aamir, should devise a plan to come clean out of this ugly episode. Then only we can give integrity to the statement “Satyameva Jayathe” and "Dharmo Rakshitha Rakshithaha".
Truth is bitter but unfortunately it is true. Most of the issues shown in the Aamir’s show were correct starting from manufacture of a doctor to the conduct of a doctor. Some doctors who indulge in these activities got offended unnecessarily and want to observe a black day on 25th of this month which is unwarranted because it will give unnecessary advertisement to this truth more than what the episode of Satyameva jayathe did.
My only complaint is the excessive dramatization of the stories (bordering on sensationalism) he presented in the initial part of the show. The way the stories were presented was in a very bad taste. The first patient obviously had Diabetic foot and had his toe amputated. It is true that amputation would not have been necessary had the patient taken his diabetic medicines properly. The second had a corporate itch and went there for a small problem where evidence based medicine was taken to great levels (all sorts of possible tests in that condition were done at a premium and the patient knew the costs before entering that hospital). Many times, these corporate patients want instant relief and ask for every possible test and when the diagnosis becomes apparent, they blame the hospital for the costs.
The third one was lined up for a cadaveric renal transplant obviously because nobody in the family didn't want to donate kidney to her. Unfortunately, the patient died because of a mishap (Disseminated Intravasular Coagulation) which can happen some times in these complicated surgeries. But, one should realize that the doctor didn’t kill her intentionally- whether the death was due to a botched Pancreatic transplant or any other reason, only the operating team would know. Nobody, not even the relatives of the patient could understand the mental agony the Nephrologist and surgeon would have gone through the whole episode. The way Mr. Aamir and the patient’s husband were talking through the episode indicating that the whole surgery was not indicated (Their foolish remark that a patients with kidney failure can stay on dialysis forever without ever needing a transplant) shows that they were hell bent on blaming the surgical team. The last one- one of the spectators indicating that her relative was asked to undergo liver transplant was the most unbelievable. No doctor, even in his insanest state of his mind would think that the patient or his relatives are a bunch of morons to utter a sentence like this without proper indication. All these stories indicate that the first part of the episode was scripted to show all the doctors in a bad light and presented strictly a unilateral view point.
Investigation cuts
At the same time, it is true that many doctors take cuts. Many Doctors partly live on the MRIs they write for many patients and some of the top Doctors are provided high end vehicles by the diagnostic centers as an incentive for this reason. Many CT scans are also unwarranted. Many labs give cuts to the doctors who refer to them- 10-30% depending on the competition. This system is so much entrenched in the diagnostic facilities that even if the patient goes on his own, they are charged the same amount as the referred patient and the referral fee is clandestinely pocketed by the manager or technician of the diagnostic lab.
This "excessive investigations" fiasco is not solely because of the doctors. One has to realize that most of these investigations are forced by the patients because every patient wants instant diagnosis and instant cure nowadays. A patient with ordinary viral fever doesn’t believe the diagnosis till he gets all possible diagnostic tests before the fever comes down on its own on the 4th or 5th day. Either the patient or mostly the patient’s relatives pester the doctor so much that even if a proper doctor is sure about his diagnosis, he ultimately gives in and writes those investigations.
The most disgraceful one is cuts from doctor to doctor. Many doctors expect to be paid if any patient they refer undergo any medical or surgical procedure in the target centre. Most of the busy and successful doctors of the present era built their empires like this and the doctors who felt ethical enough to eschew this practice remained obscure. In the erstwhile era, ANM workers and RMP’s, used to accompany the patient and collect their commissions for bringing the patient. Doctors hosting dinners to RMP’s was a well known secret of success. Now, Doctors also degraded to that level and expect money in return for referring the patient.
Most doctors are now capitalizing on these cuts and treating this as a secondary consultation fee rather than unethical income. But there are also many good apples in the system. Some doctors explicitly write and tell the diagnostic centre to charge the patient lesser amount. Some doctors don’t take the referral fee to pass on the benefit (when the necessity arises) to a poor patient whose investigations would be done free of charge.
I have seen many young doctors who were against the cuts, ultimately subdued by the current system. Who doesn’t want free money? “When the next person is taking money without getting punished, why can’t I?” attitude creeps slowly in to the new doctor. Only when the Government comes up with a law prohibiting these practices, this practice will stop. All the doctors who believe that they are in the comfort zone pocketing this money would think twice when it becomes unsafe to accept money. When the doctors stop this practice, the price of these investigations will come down and become affordable to most patients.
Brands and generic medicines
“What is the worth of a generic actor?” somebody asked me. “Hardly thousands of rupees. But, why Aamir khan is taking crores of money? It’s the Brand stupid” he replied. It is true. Even when the generic and branded are available side by side, if branded is available at an affordable price- we normally buy it. We want nice packaging and nice names on the cover. When we have money, we go to malls and when we don’t have it, we go to the shop near our house. Everything we consume is available at a cheap price- from the soaps to shoes. When something is available at a cheaper price, we are suspicious of it when we have money. This is normal human attitude.
Let me be serious... I am not against generic medicines. My viewpoint is that both branded and generic medicines should be made available and it is the patient who should decide regarding them. The way to enforce this is by forcing all the doctors to write both the brand and drug name in capital letters, if possible by law. Many times, one cannot decipher the code language in which the prescription is written, leave alone finding the drug’s name in CIMS. Poor patients and people who believe in generic medicines can take those medicines and the other set can take branded items. Even in countries where they are available side by side, the penetration level of Generics is less than 15%. The following picture best illustrates the present viewpoint of generic drugs among western people.
In fact, if you put the question "what are generic medicines"- not all doctors have a definite answer for that and most of the patients equate them with counterfeit medicines. Even doctors, when they purchase medicines for their own use prefer branded medicines to generic drugs because they don't believe them. Even after 14 years of medical practice, I had only a faint glimpse of generic drugs. When I asked my colleagues and some patients, I found out that most of them believe in branded medicines because they are produced properly (only when the brand name is put on the cover, the manufacturers properly produce the drug) whereas the generic drugs are not produced according to guidelines. But it is not correct.
Let me take a small detour and explain about generic medicines - Generic drugs are chemically identical to brand name drugs in every way: dose, safety, strength, how the drug is meant to be taken, quality, intended use, and bioavailability. Only the price is different, and the fact that they are sold under their chemical name (Courtesy - Generics, fast facts on Internet). Generic drugs are less expensive than brand name drugs because generic manufacturers don’t bear the investment costs of new drug development. New drugs are developed under patent protection. The patent protects a company’s investment in research, development, and marketing by giving the company the sole right to sell the drug while the patent is in effect. As patents near expiration, manufacturers apply to the Drug Authority to sell generic versions. Generics manufacturers haven’t paid for developing a drug, so they can sell their product at reduced prices. Generic competition usually results in lower prices on the brand-name version as well. By the way, brand name manufacturers make about half of generic drugs. Generic drugs are subject to the same standards as all drugs and must be manufactured in factories that also meet regulations. (But in India, the problem is with quality control procedures because these are under the control of government officials and nobody has belief in them at present). Generic penetration varies widely from country to country; in Europe, for example, generics account for almost 18% of the German pharmaceutical market but only 11% of the pharma market in France. The European average share is 15%; this compares with 10% of the U.S. pharmaceutical market, but only 6% of the market in Japan. This data shows the power of branded pharmaceuticals even in countries where people are educated.
The way we, the doctors, are bombarded by the Pharma companies with gifts and tours, we hardly take note of the generic medicines. Pharma companies work on the human weakness and play it very well. The way we feel obliged to write a particular drug for at least for a few days after receiving a small pen which we can buy outside for 20 Rs. and forced to promote a brand after receiving a free tour speaks volumes of the ingenuity of the drug companies’ marketing strategies. Drug companies work on this simple human weakness that everyone has - People may reject money but accept gifts and the obligation level to the sponsor is still the same. Leave alone Generic- even in branded, there is a lot of difference in price. To decipher why somebody writes higher priced brand doesn’t require rocket science.
If everybody buys generic medicines, one thing will happen for sure- Most of the Doctors will stop receiving gifts and would have to pay from their pockets for attending conferences and their Foreign tours. Without the branded medicines sponsoring the events, most of the unnecessary conferences will not take place. But, this will definitely decrease the medical bills of the patients and increase the credibility of doctors. But, the ultimate question is “where are the generic pharmacies?” because even when I wanted to get them for my personal use, I could not find the outlets nearby.
Medical seats
In India, there is still clamor and glamour for medicine not solely because it is a noble occupation but because it is a lucrative trade. There are many MCI certified dying medical colleges which function without faculty or patients but keep on attracting students who are not concerned about education but only bothered about getting the degree. This is because of the reason that in India, the degree gives anyone the right to do anything on the patient, irrespective of how they get the degree. The absence of any licentiate exam to practice medicine and the absence of any entrance exam for getting postgraduate degree in these new colleges is allowing even mediocre students bold enough to enter medical field to reap its monetary benefits.
Most of the newly mushrooming colleges assure their students medical degrees - either graduate (MBBS) or post graduate (MS/MD) because their very survival depends on doling out these degrees. It is an open secret in India that with money, ($90000- $100000 for MBBS, $125000- $275000 for post graduation and super specialty) one can surely become a post graduate, if not a super specialist because there are no independent qualifying exams in between. The exams these colleges organize on their own are a sham just to hoodwink the public. If anybody wants to follow an authentic route and join DNB course, they have to surmount two obstacles- The ridiculously hard DNB Exam (Tougher than MD/MS) and the recalcitrant MCI treating them as second class citizens.
There was always huge uproar in India regarding affirmative action in selecting students for medical courses citing the gold standard of Merit, but when money determines the entry in to these private colleges, all the elite and media so far remained silent. When a few fake pilots were found recently, there was pandemonium in the country. The only difference between them and these doctors is – “a fake pilot kills many people at a single time and gets killed in the process but a thousand fake doctors kill one person at a time but not killed in the process and act as slow poison in the society". Another problem is when somebody pays huge amounts as investment for the degree, even if he/she is good intentioned and intelligent, they subconsciously resort to unethical practices raising the health care costs of the society.
The problem is very much evident in many colleges in South India. Many colleges do not attract even 250 outpatients a day and inpatients are woefully inadequate for any sort of clinical teaching. The enthusiasm and dedication of a few good students is neutralized by the lack of patients who are slowly demotivated and released in to the society as apathetic and incompetent people who don’t put value on medical ethics and values because they were brought up in the colleges following the same corrupt values and practices. In many colleges, a post graduate in surgery does not even perform an appendix or hernia surgery during his training. Most of them learn by experimenting on the patients after getting their degree. In the whole of Chattisgarh and Jharkhand, whose combined area is one and half times that of Tamilnadu and combined population is almost equal to Tamilnadu, we have only 6 medical colleges out of which one is derecognized- whereas there are 18 government colleges and 22 private colleges in Tamilnadu. No wonder, there is gross disparity in health indicators between these states.
Just a small revision in these statistics- In the last 2 years , especially this year, all the private colleges are showing the scare of Common entrance test and increased the fee by 50% (CET cess). The cost of average MBBS seat has gone up from 30 to 50 lakh rupees (in some top private colleges the seat is sold at 70 lakh rupees). MD Radiology seat is being sold for 1.5 crores and MS orthopaedics for 1 crore. "Are you joking Mr.Azad and Mr.Sibal? Are you serious about CET? ". If you are not serious about this, this new pricing is here to stay.
Health schemes
The Aamir’s show which tried to portray Mr. Devi shetty as a messiah exhibited his ignorance about this type of health insurance schemes. All these health schemes take money away from primary care to tertiary care and benefit only private hospitals and in turn completely destroy the government healthcare. Diseases also have their status- When a small kid dies of diarrhea which can be easily prevented with a small amount of money, nobody is bothered. Heart diseases and cancers are treated as royal diseases and everyone want money to be spent on them. In our country, many people die of easily preventable infectious causes than heart diseases and cancers. But the problem is - private hospitals don't make money from preventive care, instead, they can make money only from curing high end diseases by doing costly procedures.
The Yashaswini scheme is not free of loopholes as promised by Mr. Shetty. But it is his ingenuity in manipulating the health system to his advantage, that mandates accolades. What he did was- organized apparently free OPDs which worked clandestinely as workshops for accumulating cases (the moral hazard in these cases was never evaluated), got inpatients for his empty wards and OT's, given full work to his diagnostics for which the patient pays, marketed his schemes as low cost surgeries where in fact the patient pays for the expensive ancillary equipment and stents.
His whole scheme depended on two factors - one that the middle class people won't crib for the recurring small expenses and happily pay for them in return for a bigger single expense and the other most important thing is, it is foolish to extend this scheme to really poor people. The scheme was started 2 years after the establishment of his Narayana Hrudayalaya with 500 beds, 10 operating theaters and two cath labs. His hospital’s occupancy rate was below 30%. Then only he tapped the power of the cooperatives because all the farmers enrolled in the cooperatives would have some amount of land and they belong to lower middle class or above, perfect targets. Their surgeries were done at a low cost but for diagnostic tests and expensive ancillary surgical equipment they were charged (Out of the targeted 8.2 million people only 3 million are enrolled so far). The people working in the same agricultural fields (land laborers) are not covered in this scheme because he knew that they cannot pay for the diagnostic tests and the expensive OT equipment. 94% of the money so far spent under the scheme went to private hospitals. Narayana Hrudayalaya alone claimed 32% of the claimed amount for 15% of the total cases in 2008-09. If we multiply 3 million members (initially the number was 1.6 million) with 90 rupees (premium per year), it comes to around 18 crore rupees and for the last 8 years the total collected premium was a maximum of 144 crore rupees. With that amount, no insurance scheme can run. In fact, in the first 5 years, total collected amount as premium was 87,30,20,853 rupees whereas the amout paid to the network hospitals was 280 crore rupees - (source- Harvard Case Study, Karnataka Yashaswini Health Insurance Scheme). So, who exactly is paying the deficit?
But he showed one important fact - if the same repetitive surgeries are done at a single center, the expense of the surgery would be low and this has to be followed in the government sponsored insurance schemes, where instead of giving everyone the chance to do the surgery, identify some centers and select one among them which can provide the selected procedure for a reasonable cost and competence.
Status of a Doctor
When very few doctors were available in the society as in the past, the doctor was treated like a demigod and was put on a pedestal. Everyone wanted to associate themselves with a doctor and wanted to be his/her friend. If anybody survived, it was because of the doctor and if anybody died it was because of fate. May be it is still true in areas where very few doctors are available. But in urban areas where the market is flooded with doctors, every action of a doctor is scrutinized and the doctor is forced to practice defensively. The current longevity promised by the progresses in Medicine (Diagnostics and therapeutics) are truly putting heavy burden on the doctor forcing him to practice defensive medicine paving the way to use all the possible investigations in that particular clinical condition. Doctors are found guilty not because some investigation is done but because something is missed because of the non-performance of a certain test.
Everyone who is complaining regarding the costs of medical care should understand one simple thing- Every advance in medicine is costly and the present longevity offered by advances in medicine does not come cheaply. To construct and maintain a hospital according to whims and fancies of individual patients and cheap medical care do not run hand in hand. Even a small lapse from cleaning, medical and nursing team invites a sarcastic comment "we did not come here for a government type of care" from many patients. In fact, most of the advanced surgeries are cheaper in India by a huge margin. If people compare the price of most of the surgeries to the rates 15 years ago, they can easily decipher that the rates did not change much and if inflation is taken in to account, most of the surgeries in fact became much cheaper. Average doctor's income has decreased and most of the other professions' income drastically increased. Most of the costs incurred by the patient are the infrastructure costs i.e. Room rents, ICU charges, OT maintenance charges and Instrument charges.
Nobody has a family doctor anymore to act as one of the family heads and catalyst for decreasing the costs of medical care. Everyone runs to a specialist with a tunnel vision straightaway and later blame the system for the costs. The way people change their doctors, the same way they change their clothes speaks about the casual attitude of most of the people. The way doctors are beaten and killed, although they are isolated events, tells us about the degrading status of the doctors in the society. General public also should stop pretending that the whole muck is the handiwork of Doctors and they have no stake in it. Many patients think twice before paying the consultation fee and ask the doctor whether he needs to pay when he comes for a second visit but don’t blink an eye before getting costly investigations and asking for costly drugs. When a patient survives, they praise medicine as a noble occupation and if the same doctor makes a small mistake they burn his reputation at stakes. I believe that corruption starts from both ends. If people are rational, we don’t get politicians like the ones we are having now. In the same way, unethical doctors are flourishing and the ones who still cling to clinical acumen and ethics are having a difficult time practicing medicine.
Human body is not a fixed circuit like a machine. We are still miles away from deciphering the human body and human code. Although we found out the genetic code, it's on and off switches and it's interaction with the environment is not fully known. For many diseases, there is no single ideal approach. Even evidence based medicine talks about statistics but not what is required for an individual patient. Ultimately the burden of choosing the treatment falls on the patient and the doctor acts only as a facilitator. If one chooses a poor works man, the outcome will definitely be poor. The outcome of a patient - Doctor interaction depends on multiple factors- ABC2 i.e. Availability of a Doctor, Behaviour, Competence and ultimately Cost. These factors do not occupy fixed proportions but influence every interaction between a doctor and patient. Most often, competence and ethical behaviour of the doctor take backseat to accommodate the other factors when a patient decides to visit a doctor. Just because a doctor is charging higher consultation fee doesn't make him a bad doctor, if he is not taking cuts and prescribing proper treatment. It is the responsibility of the patient to do a background check on the doctor nowadays because of the wide gap between the standards of colleges producing doctors. Many times patients think that it is below their dignity to ask about the costs of a procedure or hospital stay. It is the duty of the patient to ask about the costs involved and decide whether it fits in to his budget. No patient should flaunt his medical insurance before deciding the mode of treatment lest he be easy prey for costly procedures and moral hazard because nowadays there is a very thin line between medical and surgical managements. In the big doctor's jungle, there are virtuous cows as well as a few tigers and a patient would not become a prey if he does a proper check.
There was a statement about Mr. Manmohan Singh few days back in The Hindu Editorial “Guilty on many accounts but not corrupt” which applies absolutely to the current medical profession. Medicine is already treated like a business by many people since the supreme court judgement. But most of us didn't treat it like business. Otherwise, the situation would have been much more worse. Millions of Doctor - Patient interactions happen in our country every single day. Out of them, even at this very moment, some may go wrong either because of the doctor or patient's illness. Some of them are definitely because of the doctors, but one should observe the fact that they are very few, not even 0.01%. The public should note the fact there are much more good people than bad men in our profession.
We agree that we are all not good men. We reflect the current society because we are drawn from it. When the society goes bad, the doctors also go bad. But, don't forget one thing- Doctors in comparison to other professions are the last people to go immoral because of the ethics inherent in their profession and if it is happening, it shows the society's direction. But one thing is sure - We, Doctors, still draw inspiration from an occasional patient living against all odds because of our efforts and an occasional patient saying "Thank you very much, Doctor". Sometimes, these simple words remind us of our noble profession and arrest our moral slide. Most of us lost our youth studying those immense books and many diseased patients. Most of us became indifferent after seeing death from close quarters but never lost our empathy and humanity. Most of us lost our family lives and pampered our kids because of the limited time we have for them because of our profession. Most of us feel more happy when a patient becomes alright from a complication than when our own children are cured from illnesses. Most of us stretched our limits when patients put complete faith in us. Most of us even when we are sick attend to the patients with a single thought - "what would happen to the patients if I am not there". We don’t embody higher spiritual goals and sacrifice lest we be sages and live in Himalayas but most of the time what drives us is the noble cause because after some time, money won't drive us.
The sad thing is we lost half of our credibility when money entered the system- money for degree scheme (which is started by politicians) which corrupted the production of Doctors (Even in Medicine, 50% used to belong to the bottom half of the class and as money entered the system blatantly, the number will rise to 90% in a short time) and the other half because of the kickbacks we received from the Diagnostics and Pharmaceutical industry which corrupted the Conduct of the established Doctors.
Ultimately, I would like to pose some simple questions to Mr.Aamir. “Will you go to a corporate hospital or a reputed ethical doctor when you get sick? Will you refuse all those costly tests or take opinion regarding those tests from somebody else? Will you use generic medicines? Are you using generic drugs at your home?” When a film is being made, do you pay all the hotel bills and personal bills? Do you receive gifts when you are offered or say no to them? Are you acting in art or meaningful movies (what art is really meant for just like a true doctor is truly meant for treating a patient irrespective of money) instead of commercial movies charging crores of rupees? One should follow what he/she is preaching. But I would like to thank you for pointing out our mistakes and generating a debate even though your other fingers are not clean. The issue in front of us is whether to run this medical business as law says it, ethically or not. Getting apologies from Mr. Aamir won't absolve ourselves from the guilt. But if we accept our faults and act upon it, we may be able to revive our glorious past. We have to impose some self imposed restrictions on us and IMA should instead of fighting with Aamir, should devise a plan to come clean out of this ugly episode. Then only we can give integrity to the statement “Satyameva Jayathe” and "Dharmo Rakshitha Rakshithaha".
ironman1
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nice article, few things i could agree upon, most i could not !
INVESTIGATION CUTS- yes, they exist , i agree. but how much is a question ! i work in delhi. and if these things were so common, i would not have paid 1200 for my routine blood profile from a good path lab. i could have got the same tests done in govt labs free of costs, but i know the quality, and it's my own blood. a lot of time a patient ask me "which lab". i never tell them the name and let them make their own choices "and yes , due to defensiveness" . but i know it harms patient as i know exactly which lab does better so and so test. but if i explain it "trust me, they'll think i need money" , so even though it is bad, i think patient perception matters more that he does not demonize you.
GENERIC MEDICINE- it was the govt which did away with generics. i remember generic drugs that were as effective . but now we see a counterfeit sort of drug eg CALCIUM for 10 rs a tab in govt procurement (which from a better company you could get in market for 1/-) . almost 50 % of medicine in INDIA are counterfeit. a doctor comes to know about them when they have no effect on patients , and another brand does. so trust me whenever a doctor is writing you a prescription, he takes into account these factors. also now companies follow MCI directive. they don't give you cars( infact they don't give you anything of monetary value above 1000/- ) and for this company's finances are checked by GOI.
here it says hospitals don't take care of diarrhea because it does not pay well. that is most ridiculous, you don't let your patient die of diarrhea, how will you explain pt's relatives that their pt died of such a minor disease . what rubbish !
i believe cashless facilities are way to go. they provide good support and at low cost in good hospitals, at the same time keeping private hospitals extreme billing on them in check .
INVESTIGATION CUTS- yes, they exist , i agree. but how much is a question ! i work in delhi. and if these things were so common, i would not have paid 1200 for my routine blood profile from a good path lab. i could have got the same tests done in govt labs free of costs, but i know the quality, and it's my own blood. a lot of time a patient ask me "which lab". i never tell them the name and let them make their own choices "and yes , due to defensiveness" . but i know it harms patient as i know exactly which lab does better so and so test. but if i explain it "trust me, they'll think i need money" , so even though it is bad, i think patient perception matters more that he does not demonize you.
GENERIC MEDICINE- it was the govt which did away with generics. i remember generic drugs that were as effective . but now we see a counterfeit sort of drug eg CALCIUM for 10 rs a tab in govt procurement (which from a better company you could get in market for 1/-) . almost 50 % of medicine in INDIA are counterfeit. a doctor comes to know about them when they have no effect on patients , and another brand does. so trust me whenever a doctor is writing you a prescription, he takes into account these factors. also now companies follow MCI directive. they don't give you cars( infact they don't give you anything of monetary value above 1000/- ) and for this company's finances are checked by GOI.
here it says hospitals don't take care of diarrhea because it does not pay well. that is most ridiculous, you don't let your patient die of diarrhea, how will you explain pt's relatives that their pt died of such a minor disease . what rubbish !
i believe cashless facilities are way to go. they provide good support and at low cost in good hospitals, at the same time keeping private hospitals extreme billing on them in check .
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