Social advocacy and awareness can save you from avoidable interventions
While knowledge about failings of some hospitals may help you to avoid traps, having faith in the advice of your family doctor or second opinion from medical institutes like PGI is essential. Dr Kameshwar Prasad, professor and head of neurology at AIIMS, suggests medical audit. “Lab tests and imaging, procedures such as angioplasty, knee replacement and caesarean section must be audited. The government should appoint monitoring committees for random checks of patient data to identify instances where needless tests or procedures have been prescribed,” Dr Prasad said. Formation of SLIM (society for less investigative medicine) by cardiologists at AIIMS is also a pointer to right thinking of some good doctors to make healthcare more affordable. A recent report in Times of India from Chennai is an eye opener: More than two lakh cataract surgeries in a year, a two-fold jump in caesarean section, a sharp spiral in hysterectomies, too many joint replacements and so on. Some doctors are increasingly becoming scalpel-happy, may be due to extraneous reasons.
- As per TOI report a senior orthopedic surgeon in a corporate hospital explained: “We have a quota to meet every month. Many of us see patients as a potential candidate on our operating table. Only two out of five, however, agree. Many go for a second opinion – and don’t return.” The surgeon is among the 78 medical practitioners who provided testimony to Pune-based NGO SATHI (Support for Advocacy and Training to Health Initiatives) that compiled a report on unethical practices and corruption in healthcare. “A doctor said he was pulled up by the hospital administration for having only a 10% ‘conversion rate’ – referring to the number of patients who were advised to undergo surgery,” said NGO. For a Rs2 lakh surgery, the doctor, probably gets Rs25,000, while the rest goes to the hospital, it said. Despite this, “more people are drawn to the glamour attached to corporate hospitals,” said a cardio-thoracic surgeon at a multi-specialty hospital. He said doctors in his hospital are paid according to the number of procedures they undertake. Dr George Thomas, former editor of the Indian Journal of Medical Ethics, said the country has few guidelines to check the practice and there are no protocols set by independent bodies. A patient narrated how his shoulder pain got better with exercise although a cardiac surgery was prescribed, while another spoke of how physiotherapy cured his back pain for which a surgery was recommended. However, not all elective procedures are unnecessary. Doctors say, in some cases, the patients’ themselves ask for a surgery like in the case of many cesarean sections.
- Here is a sting operation! A patient was brought in emergency room. Doctors asked relatives of patients to deposit money before they begin with any treatment. After preliminary examination of the patient, doctors put the patient on ventilator and life support system and started calculating, explaining and charging cost to the relatives. Later on One relative made it clear to the doctor that their conversation has been recorded and they already had taken patient to another hospital before they came to them and previous hospital had already declared the patient as dead and issued death certificate. Later on relatives threatened to file lawsuit against the hospital and doctors for initiating unnecessary treatments. Finally the Hospital paid some cash to the relatives to avoid any breakout of this news.
- Let us be clear of any wrong impression/interpretation of the above- doctors are not more greedy, may be even less, but remain a part of the whole society viz. (i) IT companies sell the systems/services and features to client which they don’t need (ii) A car mechanic tell you, you need to replace some parts to avoid any car failure or to have longer car life (iii) Financial advisers or product sellers promising guaranteed returns (iv) Cell phone companies charging you for KB/MB usage of internet when you cannot verify how much exactly was you internet usage.. (v) Banks tell you to deposit your money with them when they can’t guarantee they will return it when you need it. (vi) Government printing money with RBI governor’s promise but value of currency is continuously deteriorating. (vii) B-Schools which tell you that they will teach you management (in return of hefty fees) when most of the management is common sense and the part of management which is not common sense like accounting standards, business laws can be learned from youtube/internet (viii) Patients feign ailments and press for false bills to siphon out money from the employer/insurance company. (ix) Cheating by travel and tour operators is rampant (x) corruption in Government departments has become universally organized viz. revenue, police, income tax, judiciary, education and what not! However that is no justification or satisfaction for unethical processes in medical field.
- Some unethical practices need to be checked!Kokilaben Dhirubai Ambani Hospital (KDAH) in Mumbai acknowledged, in a letter to the Maharashtra Medical Council, that it offered “incentives to doctors” to refer patients to the hospital. The complaint before MMC stated that the hospital had been sending out forms to various doctors to enroll in a forum promising a reward of Rs 1 lakh for 40 admissions per annum, Rs 1.5 lakh for 50 admissions and Rs 2.5 lakh for 75 admissions.
Earlier an Australian doctor, Dr David Berger, wrote in British medical journal, “I saw one patient in India with no apparent structural heart disease and uncomplicated essential hypertension who had been followed up by a city cardiologist with an echocardiogram every three months, a totally unnecessary investigation.” In response to the above Dr. Nandy of Sir Gangaram hospital wrote: “In many of our five-star corporate hospitals, where the main motive seems to be profit, there is an institutionalized system of so called ‘facilitation charges’ or fees for ‘diagnostic help’ given to physicians who refer patients regularly and for expensive procedures like organ transplants which may reach Rs 1-2 lakh”. Dr MK Mani, chief nephrologist in Apollo Hospital Chennai, told TOI that the practice of doctors getting kickbacks from any expensive operation or diagnostic procedure was pervasive.
Dr Sanjay Nagral, from Jaslok Hospital in Mumbai and a member of the editorial board of Indian Journal of Medical Ethics, believes that the widespread practice of cuts is linked to the way the private sector, which has grown to dominate healthcare in India, is vying for the market. In the case of nationalized healthcare, as in the UK, private doctors are paid a full time salary so that there is no incentive for them to recommend unnecessary procedures or investigations. In India private doctors are taxed right and left and given step-motherly treatment at every step, which shapes their approach towards their clients. Deterrence to stop unethical practices has to come from within the profession,” said Dr Nagral.
- Clinical establishment act can be counterproductive
Clinical Establishments Act, a Central law prescribes maximum cost of medical procedures and services standardized, besides round the clock emergency services at each clinic. The law, passed by Parliament in 2010 and notified two years later, provides for registration of all health facilities, clinics and pathology labs, even if it is run by a single doctor. It also stipulates the minimum requirements for facilities and manpower. As health is a state subject, it was up to individual state governments to enact the Clinical Establishments (Registration and Regulation) Act. Arunachal Pradesh, Himachal Pradesh, Mizoram and Sikkim have so far opted to implement the law. It’s also in force in all Union territories.
The Act permits health authorities to conduct inspections and penalize or cancel licences of hospitals that are found to be fleecing patients, either by prescribing needless tests and procedures, or overcharging. The cost of tests such as MRI also varies from one centre to the other. While the need for self regulation is real, the draconian laws can put healthcare in back gear, as it may lead to closure of simple neighborhood friendly consultation centers. This will also entail unemployment and hardship to large number of senior doctors, who are sitting in their own homes and look to beat the blues of ageing while rendering valuable advice on part time basis to their friends, relatives, many others-which is often free.
Similarly application of COPRA (Consumer protection act) to medical consultation/services has not improved healthcare. In fact it has stopped most of the doctors from doing their best or led them to practice defensive medicine. The desire to shun unethical practices has to come from within the profession!