With the decline in the stock of the profession due to kickbacks in diagnostics and surgeries, medical associations and state medical councils have risen from slumber and started active campaigning to curb the malpractices. Taking strong cognizance of unethical incentives, interpretation charges, cuts and commissions’ given out by some to middlemen, the Telangana State Medical Council has recently issued its first notice to a diagnostic center at Kalkaji Colony in Warangal. Radiologists and labs in Tamil Nadu, Andhra, Rajasthan and several other states have decided to do away the malpractices that make investigations expensive and unaffordable. Other state medical councils, IMA bodies and other professional associations are likely to follow suit. This step alone will bring down the costs of healthcare by 30-50%. This will help to redeem the image of the medical profession in a big way. Will every doctor/healthcare worker join in this noble march?
Conflict of interest
Patients all over the country fear that doctors have a selfish motive in ordering investigations or surgeries and that the same may be un-necessary and not in the best interest of the diagnosis or treatment. Many a time the tests may not be done at all and ‘normal’ reports are sent as filler. The scale of this practice is probably embodied in a remark made by a professor of cardiology in the Indian Journal of Medical Ethics: “Pernicious as it is, cut practice has come to stay.” The general perception that it is a widespread problem, is causing maximum damage to the credibility of the profession. Almost every single medical practitioner I know confirms that it is a rampant phenomenon, declaring of course in the same breath that they are the only ones around to not indulge in it! Even charitable and public hospitals are not spared. Last couple of decades has seen a near complete erosion of faith in his profession. This is probably best exemplified in the way patients routinely seek multiple opinions to determine the correct course of action. The comments like “ It is impossible to survive without giving commissions, but you can refuse to take it”, or a reluctant “It is the industry norm these days” is no excuse to indulge in bribery of any kind. It seems to have become standard practice, part of community culture you could say. Like with everything else, once a critical number of people are involved, the others have no choice. You might be unwilling but it’s the majority that will decide the rules of the game that you will have to follow sooner or later. Recent demonetization has given a ray of hope to the incentive givers.
It is estimated that some 39 million families are pushed into poverty every year in India, simply as a result of mounting health care expenses incurred. Commissions to doctors account for a significant proportion of that cost and the trust deficit further escalates costs thanks to second and third opinions sought by patients. Cost to society as a whole is much higher if we consider the time wasted in taking these different opinions and making sense of it all. Shouldn’t patients just be able to go a doctor, pay a reasonable fee and trust the advice they get?
Life is harder when you have just qualified and have a family to feed. No matter how good you are, you need your general practitioner colleagues to back up your credentials in front of the patients. 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 harder.
Some private hospitals set targets for their consultants where continued practicing privileges depend on achievement of a certain turnover. What do you think these doctors then have to do to meet these targets? Won’t they be more likely to request unnecessary diagnostic tests or offer higher cuts to general practitioners? If we respect wealth, irrespective of how it is obtained, and give it a social status, why wouldn’t everyone seek it by hook or by crook? Wealth brings you respect and the tag of being “successful” in society. One lacking wealth, no matter how deserving, is labeled a “failure”.
Commissions and cut practice happen elsewhere in the world too, but it is the scale of this practice in India that is worrisome. Whereas in other countries, it seems to be confined to a few doctors, here it appears to have become part of the system — a system that individual doctors are powerless against. Currently, our approach seems somewhat inconsistent. On one hand, we are encouraging massive corporatization of health, but on the other, we complain when hospitals behave like corporate. Some doctors feel that bringing medicine under the fold of the Consumer Protection Act has further constricted the character of their relationship with patients. We can either go down the vicious cycle of cuts, increasing health care costs and reducing the number of people who can afford it; or get rid of cuts, make health care affordable for more people, and improve our own prospects in return in an ethical manner. Currently, our actions are defeating our own objectives. Even if one presumed for a moment that they weren’t earning a lot, might that be because India is a developing country and doctors can’t expect a quality of life and compensation much better than the rest of the population?
As a society, we must understand that if we expect doctors to work honestly and ethically, we have to reward them adequately in financial terms.