| Group Captain (Dr) Sanjeev Sood |
This year, a popular TV talk show ‘Satyamev Jayate’ hosted by actor Aamir Khan cast some serious aspersions against medical profession on the issue of ethics in its fourth episode; and female foeticide in the first episode. The show had participation of some industry leaders, aggrieved patients and the selected audience who highlighted some critical issues that hit at the very core values, further eroding public faith in medical profession.
The show stirred a hornet’s nest and evoked intense reactions from the medical community. The controversy generated by the show and its aftershock is still being felt in the medical circles and public. The response varied from demand for an outright apology from the actor from bodies like Indian Medical Association (IMA) and Medscape to more sober voices of need for some serious soul searching and having a strong self regulatory mechanism. Another programme, telecast on NDTV on June 10, 2012, ‘We the People-Brain Drain-Bond-ed to India’, dwelt on issues like brain drain of healthcare professionals. Given this backdrop, there is a need to take a reality check on these sensitive issues related to healthcare and also offer possible solutions.
MCI: The sentinel of medical ethics
When patient comes to a doctor, he is in no position to judge the quality of care due to inherent complexity of healthcare and his lack of requisite information. There exists a tremendous information asymmetry between the provider and patient. Further, the entity providing the advice is also providing the services, leading to a possibility of provider-induced demand for services.
The code of ethics, as laid down under The Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002, serves as an institutional response to safeguard the interest of patients and to enforce a social obligation on providera to live up to a set of values and standards voluntarily adopted by the fraternity.
Medical Council of India (MCI) is the regulatory body for upholding this code and ensuring its enforcement. But unfortunately, this august body itself is mired in controversies and is in an ad hoc state of affairs; and to say the least, in the absence of any effective implementation, is also perceived to be a toothless and spineless body.
There is a need to reinstate autonomy and restore democracy in the current structure of MCI so as to represent national consensus and improve quality of medical education.
Privatisation of medical education
The Government faces a formidable task of overcoming the shortage of skilled workforce by opening up more medical colleges to meet WHO norms of medical personnel for our ever increasing population. The Government is getting seized of this matter and has initiated a slew of measures like relaxing land requirement norms. Seeing the enormity of this task, it is not possible without the participation of corporate entities and private sector. There is nothing flawed in this policy, since higher education is privatised and unsubsidised in most countries.
Deprived students too can study at these institutes by availing soft education loans. But unfortunately, education loans are more expensive than car loans in our country.
However, what is lacking in this policy is the enforcement of good education standards, which is the responsibility of MCI. Charging capitation fees is legally banned. Yet seats for certain lucrative specialities are sold for huge sums of money. Such money machines produce ‘EMI doctors’, whose sole aim is to recover this investment. Obviously, such colleges and corrupt practices cannot flourish without the nexus of MCI and politicians, who actually own these colleges.
To ensure quality of education and prevent mushrooming of fake colleges, MCI can certainly conduct surprise visits and blind inspections (where neither the college nor the inspector knows where he is going to inspect) to these institutes. It doesn’t take a Sherlock Holmes to make out if the physicians and admitted patients are fake and the arrangements are makeshift. If the MCI chooses to turn a blind eye to such practices and still recognise these money machines, it is unfair to blame medical professionals for these maladies.
Female foeticide: A horrendous crime
Female foeticide is essentially a socio-cultural problem for which our Government has a taken a stringent legislative approach through PCPNDT Act 2003. This is one abominable crime where few black sheep in the profession have brought disrepute to the entire community. The adverse sex ratio is higher in affluent sections of the society since they have access to ultrasonography. Though the law blames the doctors and ultrasound machines for this situation, the sex ratio was adverse even before the advent of this technology, till late 80s.
This Act comes down heavily on the medical profession for not only any violations but also for any procedural lapses. On the flip side, with raids being done and machines sealed, operators to be registered and this entire legal maze to be navigated, this Act has become the nemesis for any well meaning physician. In fact, it has dampened the effective utilisation of this diagnostic procedure in diverse clinical settings.
Whatever may be the odds; the medical profession must come clean on this issue and do everything possible to stop this evil practice. Some initiatives, like Doctors Against Sex Selection (DASS) have set an award for anyone who helps in nabbing doctors violating this Act, need to be scaled up.
Government could have been more ingenuous by offering free education and other incentives to a girl child, using technology like ‘Silent Observer’ embedded in to ultasound machines and operationalising state-wide pregnancy tracking systems like eMamta, to remedy the problem which is essentially socio-cultural.
Cuts and commissions: It hurts!
Another malady afflicting the medical profession is rampant practice of soliciting cuts and commissions on referral to other physicians, diagnostic labs or chemists. In such cases, the advice offered to the patient is not always unbiased and in the best interest of the patient. Cut practice is a menace that leads to escalation of healthcare cost, overuse of investigations and overmedication. Such a malpractice can only be sustained if members of the fraternity tolerate and support it. Since a physician is a service provider and not a businessman/ trader, soliciting commission is unethical. Therefore, medical fraternity itself is to be blamed for this malpractice and cannot pass the buck to politicians or State.
Generic vs branded drugs: It is all about efficacy
It is alleged that doctors prefer to prescribe branded drugs, newer vaccines and imported devices to receive up to 30 per cent commission from pharma companies, rather than prescribing cheaper generic medicine or indigenous devices, such as Raju-Kalam stent, contrary to WHO recommendations.
But this is a partial truth and is as blatant as saying that software companies selling antivirus programme are themselves infecting computers with virus. The prices of the drugs are regulated by the DPCO, NPPA, and DCGI under MoC&F. The State run ‘Jan Aushadhi stores’, meant to provide generic medicine have been non starters in last three years and have most of drugs out of stock. Further, in critical conditions, doctors prefer to prescribe reliable drugs with proven efficacy to achieve better clinical outcomes irrespective of the price tag. MNCs have also outsourced manufacturing generic drugs under doubtful quality control. With high percentage of counterfeit drugs being sold in the market, there is no guarantee that generic drugs have the desired bioequivalence.
Further, in spite of all the brouhaha by pharma companies, their promotional activities may not translate into higher bottom lines; that may just remain a marketing exercise. So, if they sponsor a CME or gift a pen; such an innocuous promotional activity should not raise suspicion, as long as it’s within limits.
Misuse of certain procedures
The fact that the clinical decisions are not always based on evidence under most situations is not a revelation. There is a wide inconsistency in performance of procedures like caesarean sections, tonsillectomies, joint replacements, coronary angiographies and CABG; and underuse of other proven therapies. Such procedures certainly need to be subjected to clinical audit to curb their overuse. What is more glaring is the misuse of procedures like hysterectomies when unwarranted. Such cases of mass hysterectomies, as reported in Kowdipally village in Medak, AP and earlier in Ajmer, Rajasthan are appalling. The SMCs should suo moto investigate such cases and take action against those found guilty. In view of the need to practice evidence-based medicine, there is a need to develop standard treatment guidelines and clinical protocols, such as, mandatory pap smear and ultrasound before contemplating hysterectomy.
Getting doctors to rural areas
The state has initiated a slew of coercive measures to post doctors in rural areas, like proposal to increase the duration of MBBS, linking with PG seats, obligatory rural postings, banning immigration to the US and more recently imposing heavy penalty on students who do not comply with this diktat. But these irrational measures have not met with success, since the Government has failed to visualise the big picture and reality of free market economy. Before taking such drastic measures, there is a need to provide adequate infrastructure in villages and resources in PHCs for providing better care and living conditions. A person who becomes a doctor does so to lead a better quality and standard of living which each citizen is entitled to. And why selectively target doctors alone and not other cadres who have an equal role to play in rural development.
To overcome this problem, Government can upgrade district hospitals in resource poor areas to medical institutes, so that the native students who graduate from there are inclined to settle there. Such a measure shall go a long way in overcoming the shortage of doctors in rural areas.
The fair view: treat us like human beings
While putting doctors in the dock may fetch good TRPs, one must adhere to journalistic norms and present complete facts before drawing conclusions. One must not belittle the sacrifices made and hardships faced in the course of becoming a doctor, besides poor working conditions and 24*7*365 emergencies, the need for specialisation and competition to keep oneself updated, COPRA hanging like sword of Damocles; the occupational hazards of acquiring infection and the brunt of mob violence. Becoming a doctor demands great struggle during prime years of one’s youth for not so commensurate rewards in the end. Exasperated, doctors say, ‘don’t treat us like a God, just treat us like a human being’. The fact that the number of students taking the medical exam has declined recently bears testimony to this harsh reality.
Coming back to Satyamev Jayate, while all may not be well with medical profession, but such a doctored talk show with a one sided version, putting words into a guest’s mouth to get selective opinion and audience with exaggerated expressions only plays to the gallery. Besides factual inaccuracies, the show took unnecessary potshots and was scornful in its overall tone and tenor towards the profession.
The show gave an impression that an honest and good doctor cannot survive in India, which is fundamentally incorrect. Rather he is likely to be more successful and sought after by his patients in comparison to his dishonest colleagues. If a few doctors leave Indian shores because of the corrupt system, what about the scores of doctors who return back to be successful medical entrepreneurs and thousands who choose to stay back and serve in India? If the Indian healthcare system is so sick, how come it has emerged as the preferred destination for medical tourism and more importantly, relieves sufferings and pain of thousands of patients every day with unparallel commitment?
However, what has hurt the medical community most is that the show did not unequivocally highlight at any stage that inspite of some wrong doers in the profession, the majority are still ethical and conscientious and such a percentage is higher than that in any other cadre or profession. A sermon so harsh without offering a solution does no justice to a complex issue like medical ethics, especially after pocketing a whooping sum by the host for just creating awareness!
In the meanwhile in another show, the actor has refused to apologise to the IMA and said he is ready to face any legal action. He expressed his highest regard for the profession and added that if the medical profession has been defamed by anybody, it is by those who are indulging in unethical practices.
Identifying the root cause
Irrespective of this dose of pontification, apology or no apology; the fact remains that healthcare needs healing; the medical profession needs serious introspection and develop a strong self regulatory mechanism. The entire fraternity must come clean on certain maladies ailing the profession as a whole.
Part of the problem is that the Government and society still continues to see healthcare through the prism of socialism caught in the time warp of the 60s. The prejudice that doctors are under oath and receive subsidised education and should be ever willing to serve humanity is so passé and unpragmatic. Doctors are obliged to serve by choice, not by compulsion.
In the recent past, cost of all inputs into healthcare, like land, equipment, medical education and staff salaries have gone very high; electricity and water tariffs have to be paid at commercial tariffs by most healthcare equipment manufacturers, yet the system expects healthcare to be inexpensive. For a society worshipping Lord Mammon so deeply, isn’t it too virtuous to expect physicians to abide by 2400 years old Hippocrates oath, which is no more than an anachronistic document?
The healthcare sector is most regulated and medical ethics encompass many issues and values. However, while MCI may lay down guidelines and define ethics, such principles are not always easy to uphold. For example, informed consent is far from being informed in most situations, since the content of all forms is standardised and each patient is unique and interprets it differently. Trainees regularly see patients in most institutes which is not always in the best interest of patient and hence unethical. These ethical transgressions are universal and not unique to India. Some of the legal statutes are like a minefield and tricky to navigate.
Today, doctors are caught in a moral dilemma of taking purely an ethical approach or charting a commercial path in their careers. In a rush to chase top and bottom lines, some easily forget that there is a patient in between who deserves an ethical care.
The way forward
The Government on its part needs to play a pivotal role by taking certain policy decisions and allocating sufficient budget for healthcare. It needs to strengthen public healthcare system, check rampant corruption in cases like NRHM scam, curb the sale of counterfeit drugs and promote health microinsurance so as to provide enabling environment and achieve universal healthcare.
A large part of unethical practices are attributable to quacks, the neighbourhood chemist, pharma companies, entities like hospitals and even IMA, who are a strong force in the healthcare ecosystem and are beyond the purview of MCI Act. Therefore any solution to the problem has to be found in the entire ecosystem of healthcare, not just allopathic doctors.
The MCI and IMA have failed miserably to curb rampant quackery, improve quality of medical education, and effectively enforce medical ethics. Certainly, professional bodies like MCI and IMA need to get their act together, rather than being at loggerheads; and work effectively towards restoring public faith into the system. Another solution is to educate and empower patients as an equal partner and important stakeholder towards delivery of patient centric care.
Conclusion
Though the talk show might have ruffled some feathers, the collective conscious of the community is always there to enlighten and inspire the medical profession in such turbulent times. it is time we rededicated ourselves to professional ethics and earn more bouquets than brickbats from the society. Otherwise, the nation’s dream to achieve healthy India may remain elusive forever.
The author is a NABH empanelled assessor and prolific writer on healthcare matters. He can be contacted at doc_ssood@yahoo.com