Tuesday, April 1, 2014
Can you practice medicine ethically in India? This is a million dollar question facing every Indian doctor. This is also relevant to thousands of medical students who will become doctors of tomorrow and hundreds of thousands of Indian doctors working abroad, who want to return home but are put off by the character of Indian medical practice.
The problem in Indian medical profession is unique. The vast majority of Indian doctors are working in the private sector or as freelancers. In such a set-up, you are constantly fighting with your colleagues for work in a “market”. Markets are good, but only if properly controlled, and with some oversight from the regulators. The problem of this market is that there are little controls and the regulators (Medical Council of India and State Medical Councils) have largely proved to be ineffective.
In a well functioning market, patients (the consumers) will know clearly their doctors’ professional skills, qualifications, results, feedback from others, fees etc. They will be able to compare doctors and choose wisely. Regulators will be working effectively and keeping a close eye on the profession for various medical malpractices.
However, the market is not working well. Patients do not have any other information about their doctors. The only thing they pretty much know is how much their doctor is charging. Results are immaterial as patients have no means to verify them anyway and lies and exaggerations are commonplace. In a very fee/charge sensitive environment, General Practitioners (GPs) are hence constantly driving each other down on pricing to attract patients. It then reaches a level where, in a civilised society, it is impossible to live on an earned wage that forces them to look for income elsewhere. The easiest source of that income is commission from laboratories and specialists for referrals. Patients are not aware that this is happening as they seemingly have a choice in deciding which labs or specialists they go to. Whatever little do they know is, that every single lab/specialist (the vast majority) will send their doctor the commission. In that sense, it is immaterial where they go.
From the point of view of specialists or laboratories, no matter how good you are, you need your general practitioner colleagues in medical profession to confirm that to the patients, as patients have no validated tools to be able to verify authenticity of any facts. In this situation, you become the biggest surgeon in town if you give out the biggest cuts to the general practitioners. If you are not so good or a new surgeon in the area, you have to work even harder!
Like the rest of India, there is a lot of black money circulating in the system, as most of the payments to doctors and labs by patients are cash with very few authentic receipts.
So, how can we even begin to solve this? I have following suggestions to make. Needless to say, it needs help from all stakeholders, if we are to even to begin to see a change.
1. Medical Council of India and State Medical Councils should raise awareness about the cut practice and commissions and clearly explain to their members that it is both unethical and illegal to give and take commissions. Money should not play any consideration in whom they refer their patients to or who they advise their patients to go to? When money is involved, patients cannot be sure that their (doctors’) advice is not biased. They (Medical Councils) should even make examples of some doctors by cancelling their privileges to practice. It shouldn’t be too difficult to organise some sting operations!
2. Doctors should start charging their patients more if they can’t survive on their income rather than supplementing it through unfair means. Government and medical councils should educate the public that it costs to study medicine and become a doctor and that it costs to live. This service can’t be provided for free. For free or subsidised healthcare, we should reinforce our state medical sector. Needless to say, we need to work on increasing the reach of insurance sector as well.
3. Results of doctors and feedback from other patients etc should be validated and made available to patients. In this context, we need mechanisms to ensure doctors engage in continuing medical education (CME) and have systems of auditing their practice.
4. Tax authorities should ask doctors/labs/hospitals to provide their patients with proper receipts. They should close in on the black money being generated by hospitals and labs, which is then dished out to general practitioners through “marketing” channels.
5. Media should keep a spotlight on these issues and monitor the situation periodically.
6. Medical colleges and academicians in these institutions should make these issues a top priority item in medical curriculum.
No doctor wants to work unethically. This is not why we join this noble profession. But doctors also have a life and a family. They also expect to work and live with dignity. It is up to the wider society to provide us with a mechanism, which is sustainable. Currently, we are stuck in a massive waterfall of declining standards, which is constantly dragging us down. Each individual is helpless in fighting this force. Together, we can change it. Are we all ready for it?
Dr Kamal Mahawar
Senior Consultant in Bariatric and Metabolic Surgery
Indraprastha Apollo Hospitals, New Delhi