The other day, I learned about a doctor who had paid Rs 1.75 crore to get into a postgraduate surgical program in a private medical college in Kerala.
There has been so much talk on the unethical practices among doctors in India, the deteriorating standards of medical practice, the non-availability of senior doctors after regular hours, the corporate takeover and management of health care systems, and the general mistrust of doctors by patients. As somebody who joined this profession 48 years ago because of the lure of the high integrity, honesty and the honor of being a doctor, I must confess that I too am appalled about the state of affairs of medicine in India today.
Service and servanthood were the beacons of our calling. Working in a non-profit organization, where teamwork, supporting colleagues, looking after each other's patients, teaching, mentoring and encouraging younger talent, and the joy of showing empathy to other human beings less fortunate than us – the poor, needy, sick, miserable patient - were the reasons we joined the medical profession. Because of our ability to help others, we were treated with respect and favor by everyone. Sadly that is no longer the case.
Fifty percent of the medical college seats in most of the private medical colleges in the country, till recently, were being "sold" to the "highest bidder."
Having spent my entire life in the Christian Medical College and Hospital (CMCH) in Vellore, I must admit I lived in an utopian idealistic place, far removed from the present system. And having retired from Vellore, and working in another private institution, I now realize why patients come to Vellore in such huge numbers for treatment. The infrastructure there can be worse than in many corporate hospitals, the services we provide (in terms of the time and difficulty to get an appointment to see a doctor, and the delay in getting investigations and surgery or treatment done) can be very often mediocre, and the waiting interminable. As is so often, the doctors are too busy to spend quality time with the patients. And CMCH is not cheap by any means. Yet, daily, patients queue up there by the thousands.
I have realized it is only because of one single reason. It is because they trust us, because they know we don’t make any extra money for seeing them, or doing surgery on them. Many patients come only for an opinion, and then go elsewhere for their treatment where it is done quicker, or at a more convenient or affordable place, or at a place with better infrastructure and facilities.
They come only because they want an honest opinion
Why has this happened?
It has all boiled down to medicine becoming a business today, and the patient a customer.
It starts with the selection of medical students. Fity percent of the medical college seats in most of the private medical colleges are allotted to the "management." In spite of the NEET exam being introduced this year, private medical colleges have only increased their fees, making admission unattainable in the "management quota" seats for the poor.
Merit is definitely important in being a doctor. Clever, hardworking, diligent, conscientious students are necessary, in order to be trained to become competent doctors. But the NEET exam is not the panacea or universal remedy for all the problems of selection. Personality traits like compassion, integrity, social sensitivity, an all-round personality etc. are also equally important. Selection should be based on all of the above criteria, before students are admitted for the medical course. Therefore, an interview conducted with integrity is invaluable in weeding out people unfit for our noble profession. Just selecting students on their ability to pay will result in very poor quality doctors being let loose on the public.
The next problem is the proliferation of private medical colleges in the name of "need for more doctors." Inadequate infrastructure, fake faculty being shown on the rolls, forged patient names and records, false registers being made to show "ghost" patients, and registers of fallacious surgeries and procedures that were performed in the institution, etc. are blatantly done, to meet the minimum requirements to run the course. And because of lack of patients in the hospital, these colleges resort to bribing corrupt inspectors to get recognition from the Medical Council of India (MCI) for permission to carry on the courses.
This is not something new. In a case against its then president, in November 2001, the Delhi High Court had called the MCI a "den of corruption." A parliamentary committee which was appointed in 2016 to look into it, has described the MCI, as a "club" of influential medical practitioners who act without any fear of governance and regulations, which follows "no medical ethos." In a scathing indictment, the committee said: "Exempting professional association of doctors from the ambit of Ethics Regulations is nothing short of legitimizing doctors’ associations indulging in unethical and corrupt practices by way of receiving gifts in cash or kind under any pretext from the pharmaceutical industry or allied health industry," terming the action of MCI as "ethically impermissible." But the MCI is still going strong.
Doctors graduating from many of these private medical colleges are poorly trained, and have very little skillsets required to be a competent doctor.
The takeover of government hospitals by the private sector, in the name of "India-is-desperately-short-of-doctors," has added insult to injury, denying the poor treatment at these "now private medical colleges." While it is true that India needs more doctors, we could do without these unprincipled, unscrupulous investors who have demeaned our noble profession.
The third problem is the management of these private institutions.
Having invested substantial amounts of money to start these medical colleges, the owners want immediate returns.
Recently the Delhi government had ordered five top private hospitals in the capital to deposit "unwarranted profits" of more than Rs 700 crore which the government felt had been made by these hospitals in admitting "paying" patients, and denying treatment to the poor. Forty-three private hospitals in the capital were given land at concessional rates on the agreement that they would treat the poor for free. Initially, the hospitals had promised to set aside 10 percent of in-patient beds and provide 25 percent of outpatient services free of cost to the poor. Investigations revealed that poor patients were hardly treated in these hospitals, and most poor patients were not welcome, or were referred to a government hospital from these hospitals.
Let's face it. Most private hospitals are in it for the business. These are driven by capitalists - those in the construction business, and big time pharmaceuticals with no interest whatsoever in the poor patient. The patient is only a customer who brings in business. Corporate hospitals give incentives to doctors for surgeries and procedures done (and so a number of unnecessary procedures are performed on the unsuspecting patient), kick backs for referrals from private practitioners, give "percentages" to doctors for investigations ordered, and ask for "second opinions" to get other doctors involved in the same racket.
Unnecessary tests, X-ray’s and scans (the current cost of a post graduate radiology seat in some private medical colleges is about Rs 2 crore); unnecessary, unindicated and harmful insertion of stents for coronary artery disease; duplicating investigations (to be done only at the lab of their choice from where they will get a kickback); and performing unnecessary surgeries and procedures are the state of health care in the nation today. They are interested only in the money. And what does it matter if in the process the poor patient is cheated? The health industry may be doing very well, but the health of the poor in our country is abysmal as a result.
Quality accreditation and managing of health care systems is being pushed through by corporate and business houses, equipment manufacturers and dealers, and by a new breed of health care managers who are obsessed with protocols, procedures, documentation etc., driving up the cost to patients while the poor patient is forgotten in the entire process. Quality is extremely important, but not at the expense of turning away a poor patient.
Finally, we doctors ourselves are the biggest offenders in this business. Doctors have to recover their money that they have paid for admission into these private medical colleges! And so get involved in all the dishonest practices mentioned above. And to get their due promotions, as is necessitated by the Medical Council of India, doctors resort to "fraud" research published in "pay-for-publication, no-questions- asked" journals, which are then added to the body of literature, and quoted in meta analysis worldwide. Sponsored holidays and trips abroad by pharmaceuticals in the name of "educating" the doctor and "updating" his knowledge is another common incentive given to doctors.
And the poor patient is left to deal with uncaring, unconcerned, mercenary doctors, interested only in making a quick buck. It is therefore no surprise that there is so much cynicism among patients, this all-pervading trust deficit between the doctor and his patient, who just doesn’t know if a doctor’s opinion is swayed by his avarice. Predictably, the patient is not sure that the advice he has received from a doctor is in his best interest.
A colleague of mine told me some time ago "If you go to a government office now, and say you are a doctor, they will respect you, get up, offer you a seat, and treat you courteously. But in a few years time, if you go there, and say you are a doctor, they will open their drawer, take out a gun and shoot you! Because in their eyes you are a crook."
I say this with a great deal of sadness. But the humane, compassionate, caring doctor, who worries about patients' welfare, who treats them with a "holistic approach," and who is willing to work extra long hours beyond the call of duty, without expecting remuneration for it, is a relic of the past.
The need of the hour is a sincere, upright, concerned, kind, ethical doctor, whose primary interest is the patient; who is available, affordable, and empathetic; who touches them, holds their hands, examines them, cares for them, and treats them like human beings in desperate need – instead of exploiting them.
A doctor with a heart. And a soul.
"One who loves his fellow men."
Like Abou Ben Adhem, may their tribe increase.
(The author is a former head of the department of cardiothoracic surgery at Christian Medical College and Hospital, Vellore. He is currently the chief administrative officer, and head of the cardiothoracic surgery department at Pushpagiri Heart Institute, Tiruvalla.)