Yesterday there was news of Union Health Minister Dr Harshvardhan contemplating action to break the nexus between doctors and diagnostic laboratories. सिर्फ़ News asked some medical practitioners for their perspective of the matter. We got some anecdotes from a doctor and detailed opinions from two other.
Dr Rakesh Parikh, who practices in Jaipur nowadays after some bitter experience in Mumbai where he had wanted to begin his career, said, “Dr TP Medhekar, professor at KEM hospital, Mumbai, used to tell us while teaching that we should be able to reach the diagnosis on history; then examine the patient to confirm the diagnosis. Investigations should be only to protect ourselves from medico-legal cases, he said.”
Another teacher of Dr Parikh, Dr Nalini Shah from the same medical college taught his class that, while ordering any investigation, they should be sure that they are going to make some changes in the treatment of the patient based on the reports.
After completing his specialization, Dr Parikh started practising in Mulund West, Mumbai. After 2-3 days of his starting an outdoor department in a polyclinic, a gentleman came to see him. He told Dr Parikh that, to be able to start getting patients, he must meet all the general practitioners in that area. “I went to meet around 30 such general practitioners, many of whom were not even MBBS. All of them were interested to know where I would admit the patients, to which I had no answer. I later got to know about the chain,” Dr Parikh said.
In Mumbai, most families do have a family physician (GP) of their own, many a time not qualified. If a patient has chest pain, he would usually call his GP, and the GP would get the patient admitted in some hospital under the care of some specialist of his choice. While the specialist would get his charges from the hospital, the GP would get around 40% of total bill of the patient as commission from the hospital.
“After trying for 3-4 months to bypass this chain, I had to shift to a smaller city to start my practice,” Dr Parikh said.
He continued, “The practice countrywide is, most busy doctors, who advice their patients to get investigations done at a certain laboratory, would get a share from the laboratory. A lot of doctors might well be over-investigating patients for having a better share from laboratory.”
But there is a flip side to the story. First, there are some patients who want to get investigated for no reason. “I factually have to disappoint a few of my patients when they start advising me about the investigations that I should prescribe to them! I do lose a few patients because I fail to convince them that the investigations are not needed at that stage,” Dr Parikh said.
“Second, medical practice is no more a service,” he said, adding, “It’s a business that must fall under consumer protection law. There are a number of cases where the doctor is dragged to a court of law for no fault of his once the doctor-patient relationship goes sour.”
“Third,” Dr Parikh continues, “Doctors are the most underpaid professionals in the country. On an average, a doctor starts earning at about 35 years of age. And the mindset of most of people in Tier II cities is that they would not be very happy paying him even Rs 100 for a consultation.”
“Consider the example of a physician doing well in his career in a city like Jaipur. If he manages to get 10-12 patients a day, he would get Rs 30-35,000 per month, out of which he has to manage the rent of the office space, electricity and telephone bills and the salary of the receptionist, if any. Mind you, that’s only after he has spent 35 years of his life and has managed to have a regular inflow of 10-12 patients. What would he do?” posed Dr Parikh.
“This is the scenario in general. Some of the cases may not apply to me,” Dr Parikh concludes.
Dr Arashdeep Singh is a recent medical science graduate. He said, “The nexus between doctors and private laboratories is much talked about after a recent sting operation conducted by a television news channel.”
Dr Singh does not think Dr Harsh Vardhan’s comment needs to be taken seriously. “Being a surgeon, he was not an outsider to this practice and he never took any stand during his whole political career to stop this practice,” he feels.
“This practice of giving commissions (to pathological test centres) is not only limited to laboratories and tests but is also prevalent in transferring patients from one hospital to another or referring a patient to a certain hospital or physician,” he said.
For example, “one may get between 10-20% of a patient’s final bill amount for referring him to a corporate hospital. The Medical Council of India is already aware of this practice. Many hospitals have separate marketing departments to handle this,” Dr Singh informed.
“From a doctor’s perspective,” Dr Singh said, “It is very difficult to stop this practice at the individual level. Yes, one can tell these private labs to divert their ‘cut’ (undue commission) and offer it as a discount to the patient, but again, this is not a practical approach. In terms of transferring patients, this is not even possible.”
As more and more corporate giants are entering into the hospital business, the stiffening of competition will only make this practice flourish; there is no way this can be stopped unless government regulates the prices of various services that come under medical care, Dr Singh opined.
Medical practitioners are a small player in this whole system of incentives and commissions, Dr Singh said. “Things are beyond their control. All they can do is provide discount to a few patients on request. If a doctor relieves the patient financially a bit, another would fleece him. Even nurses and ambulance drivers are part of the medical mafia.”
“The medical profession is no longer a sacred one. It has become another business and has to be treated like one. Then these issues related to ethics won’t come into the picture,” Dr Singh concluded like Dr Parikh.
Beyond the above, Dr MC Gupta, former professor and dean, and founder member of the Medicos Legal Action Group, said, “Dr Vardhan has lashed out several times in the recent days against bribery in the $74 billion healthcare sector, signalling that the new government will make tackling the corruption that blighted the outgoing administration a priority.”
Dr Gupta is not amused by the fact that the medical profession has got commercialised. “Commercialisation is there in all spheres of life. Name it and it is there,” he said, adding, “Judges, police officers, IAS officers, ministers, etc — all take bribes for giving bail, not arresting a person, sanctioning projects, funds and defence purchase etc. Politicians are allowed to open medical, dental, nursing and paramedical colleges purely for making money through capitation fee…”
“In such a scenario,” Dr Gupta said, “MBBS doctors, frequently with their years-long super-specialisation, find themselves acutely short changed, with everybody making lakhs and crores illegally, but they being tied down with rules prescribing how much fees they can charge, how much space their clinic or hospital should operate in… how many employees and what equipment they should have, etc. No wonder that these doctors try to find ways and means to augment modest incomes by some small tricks.” He said the situation becomes all the more difficult for these doctors owing to the high market price of land in commercial areas where they are supposed to practice.
Doctors feel very strongly that there are too many laws that constrict their legal and professionally correct practice, while their competitors — AYUSH practitioners, for example — practise unchecked in spite of their illegal, commercialised practice in the nature of quackery, Dr Gupta feels. “What is more, the same government that pins MBBS doctors to their rule book actively promotes AYUSH quackery,” he said.
Then the doctor brings in reservations to the discourse, which has indeed led to activism by medical practitioners for decades. “Further demoralisation has occurred amongst medical professionals due to the unreasonable (though constitutionally permitted) system of reservations for SC/ST/OBC categories as regards admission to medical courses,” Dr Gupta said, adding that the quota first applies at the stage of appointment in government service and then in promotions as well. “There is no such strict reservation system in the judicial field as regards appointment of judges. Why should the medical profession be regarded as intellectually less demanding, without need for ensuring merit, than the legal profession?” Dr Gupta asked.
“The tendency to stoop to taking ‘cuts’, while certainly undesirable and illegal, has to be viewed in the wider perspective of the overall feeling of despondence and frustration among young doctors. There are instances where doctors get less salary than nurses. In some states, ad hoc appointed medical officers are paid the meagre salary of just Rs 10,000 per month,” Dr Gupta said, projecting corruption as a compulsion.
Dr Gupta believes that agitations for the rights and against injustice to the profession must be carried out by the Indian Medical Association (IMA)! “Such steps need to be taken by the 2 lakh strong IMA with about 1,700 branches,” he said.
“Till today, the IMA has not carried out any well planned scientific survey to find the problems faced by medical students, residents and those in regular service,” Dr Gupta said, adding that their views regarding how to improve the state of health in the country has also not come out officially. “Such a survey should form the basis for the IMA to make strong demands from the government, backed by legal challenge wherever necessary. In the absence of any support from their parent association, the IMA, young doctors just remain bewildered and almost feel like orphans,” Dr Gupta said.
“Commercialisation, as defined above, can never be defended in the medical profession. But, if the government and the politicians expect doctors to work within the four corners of ethics, they must be freed from forced commercialisation in the form of, first, treating medical service like any other commercial service such as private transporters and telephone and internet service providers. Adequate safeguards / provisions must be made in the Consumer Protection Act in this respect,” Dr Gupta said.
“Second,” he concluded that ‘forced commercialisation’ happens also in the form of “treating medical practitioners as commercial enterprises and allowing them to open up their practice only in municipally defined commercial areas, charging commercial rates for water, electricity and telephone services etc, treating hospitals as industry (even though an amendment bill exempting hospitals from the ambit of industry was passed by the parliament but never notified) etc.”