Unfair practice

Growing corruption and malpractices in the medical field raise the question whether measures like regulation and audit of medical practice will have to be initiated to protect the gullible public.

A CT scan in progress. While medical investigations are necessary in many cases, all too often patients end up paying for tests they do not need.

AN 82-year-old patient from a middle-class background was admitted to a private hospital in Pune for an appendicitis procedure. A magnetic resonance imaging (MRI) was conducted, though the patient’s relatives had expressed doubts about the need for such a scan for a case of appendicitis that had been clinically diagnosed. Upon the patient’s discharge from the hospital, he was billed Rs.89,000.

A woman was admitted to a multi-specialty hospital for a knee joint ligament operation. Specialists from every department in the hospital examined her, including a gynaecologist. When she objected, doctors said they wanted to rule out possibilities of other illnesses plaguing her.

Almost everybody who has fallen sick and accessed health care in India in recent times has similar stories to share. Overreach in the medical profession has become rampant, like a gnawing itch one learns to live with. Over the years, patients have been conditioned to believe that doctors who do not give lengthy prescriptions are not qualified enough, says Dr Amar Jesani, Editor of Indian Journal of Medical Ethics .

“Over-prescription is popular now but extra medicine can be harmful. Injections are given at the drop of a hat. But if a medication can be taken orally, then why inject, unless there is an emergency?” he says. Antibiotics and tonics are prescribed indiscriminately, and patients have become habituated to these. There are several nutrients that can be absorbed through food, and yet supplements have become a way of life, he adds.

Dr Sanjeev Chhibber, a senior cancer surgeon in Delhi and the president of the Naya Daur Party, says that doctors sometimes prescribe unnecessary investigations because of the kickbacks they receive from pharmacies, laboratories, equipment sellers and sundry other medical “brokers”.

“There are only a handful of doctors in the capital who have never taken commissions in their lives. There exists a strong nexus between hospitals, both private and public, and pathology laboratories. One of the biggest government hospitals in the capital refers all its investigations to fly-by-night laboratories that have set up shop right outside its gates. These depend on the hospital for business and in return offer generous commissions,” he told Frontline .

While the public sector institutions need to be made accountable, doctors feel that the rot in the private sector goes deeper. Doctors in the private sector are given business targets by the corporate owners of hospitals. If they fail to meet the targets, their association with the hospital may even be jeopardised, says Chhibber. If the doctors are able to generate a certain amount of business, they may be rewarded by a percentage of it. The Kokilaben Dhirubhai Ambani Hospital in Mumbai was recently in the news for this. It was proposing a scheme, “Elite Forum for Doctors”, where doctors would be rewarded with money for referring patients to the hospital. When the Maharashtra Medical Council (MMC) issued a show-cause notice to the hospital, they apologised and withdrew the scheme. That the biggest corporate house in the country apologised to a body that is toothless by its own admission is remarkable. Last year, Dr H.S. Bawaskar, who runs a hospital in Raigad district of Maharashtra, filed a complaint with the MMC with documentary proof of a diagnostic centre sending him a “cut” for referring his patients to it for scanning. There have been instances where gullible people travelling to towns and district centres from villages for treatment have been practically kidnapped from the railway stations or bus terminals by brokers and herded off to hospitals that give them a “commission”.

Agents, brokers and medical representatives have become permanent fixtures in hospitals and doctor’s clinics.

“Go to any hospital, and you will see hordes of medical representatives from pharmaceutical companies hovering around with gifts for the doctors,” says Jesani. Kickbacks are not the only factor that prompts unnecessary prescription, though. Brainwashing by doctors ensures that patients themselves ask for powerful medicines.

“You gave me a 500 mg dose last time which gave me instant relief, please do not give a lower dose,” says Jesani, mimicking a patient.

In order to restore a degree of faith in the doctors, cardiologists at the All India Institute of Medical Sciences (AIIMS) have come together to form the Society for Less Investigative Medicine (SLIM). It attempts to improve the doctor-patient relationship and sensitise people to unnecessary tests and annual check-ups that only add to the costs and do nothing to improve health. Leading the movement is Dr Balram Bhargava, who completed his medical education at King George’s Medical University in Lucknow and was subsequently trained in the United Kingdom. He has been a faculty member at the AIIMS for about 25 years. For the past eight or 10 years, he has been facing outpatients who come with huge files full of investigation reports and ask to be treated. “This is not the way I have learnt medicine. And no disease, with very few exceptions, can be prevented by screening. Diabetes, blood pressure, cholesterol and obesity need to be checked. The physician can help the patient manage these by talking about diet and lifestyle. New knowledge says that one needn’t get everything monitored regularly unless one is 40 years old or there is a strong family history of a certain illness. In fact, investigations give a false sense of assurance to the patient,” he explains.

Government hospitals have also started taking the route of over-investigation, feels Dr Bhargava.

The problem of kickbacks is worse in rural areas. Dr Arun Gadre, who had a private gynaecology practice in the small village of Lasalgaon in Maharashtra’s Nashik district for 20 years, refused to succumb to commercialisation. He lost his practice. Several doctors in the city used to refer patients to him in the first 10 years of his practice. Then, gradually, the referrals started drying up. Bribes had become common in the cities and doctors saw no profit in recommending a doctor from the village. They began referring patients had to hospitals in cities for treatment.

Talking of malpractices in the medical profession, Gadre said: “Barring a few, who left the profession altogether, nobody raised an eyebrow.” People in urban areas can be vigilant and avoid getting trapped in such things, they can ask questions. But in rural areas there is unfortunately a herd mentality, which helps the monopoly of the private sector. There is no second opinion to be had. General physicians have become courier centres who refer patients to private specialists. People have so much belief in family physicians that they don’t know they are being cheated.”

Gadre is about to release a book put together by interviewing close to 70 doctors across the country. The English version of the book, A Testimony of the Rational Private Doctors , is expected to look into the influence of the pharmaceutical sector on professionals in the field and questions about insurance, among other things. “It appears as if the rational and conscientious doctors may well become an extinct species soon. In conclusion I can say that blind belief in privatisation is not a good idea at all. PPP [private-public partnership] has become a buzzword in the sector. Private medical colleges are springing up everywhere. Students pay Rs.2 crore to study radiology, what will they do once they are in the field?”

Will audits help?

This leads us to the question whether independent audit of medical practice, on the lines of that in the United States, will be a good idea for India. Just like audit of the accounts of engineering firms, medical audit can be useful to ensure quality of service in the medical field, says Jesani.

“At present, there are no checks and balances in the system, resulting in all sorts of foul play. Self-regulation has simply not worked. Audits can help determine whether investigations have been appropriately advised or not. It also has financial implications. But in order to have audits, there is a need to have good record systems. The full history should be available. Protocols are required, standard of treatment is required. These are sometimes not available in India.”

In a situation where the Medical Council of India (MCI) is ineffective, self-regulation is simply not enough. Though audits cannot stop malpractice, they can expose it and may be the first step in the right direction.

Another way to remove corruption from the medical fraternity would be to sever the link between pharmaceutical companies and doctors, says Jesani. Re-educating doctors on over-medication can also help. He says doctors take umbrage at even the slightest question raised about ethics in the profession. They prefer to dismiss doubts by saying there are a few rotten apples or a few black sheep, like in any fraternity. But Jesani claims that, unfortunately, it is the other way around—one must search hard to find a few good sheep.

Gadre proposes adherence to the Clinical Establishments Act, 2010, but points to its many flaws, especially its bureaucratic approach. He proposes that the law should be made more participative. “Firstly, there should be a district-level multi-stakeholder body with representation from the IMA [Indian Medical Association], civil society and the government, which will have the power to oversee its implementation and haul up sarkari babus for any failure. Secondly, a retired judge should be a part of it for the legal guidance of patients, who can directly approach it for redress. Thirdly, it should be a separate government implementing unit with a four-pronged agenda of registering, monitoring, regulation and redress. Lastly, standards should be decided locally. If only Delhi decides, it will be hijacked by corporate lobbies. Standards should be practical and feasible for all.”

Market logic

In an increasingly privatised health-care system, it is interesting to note how the world perceives the Indian market. According to 2014 Global life sciences outlook “Resilience and reinvention in a changing marketplace” by Deloitte, strong growth is forecast for India, where pharmaceutical sales are expected to more than double by 2016.

This means more pharmaceutical companies are gearing up for penetration in the country.

Even though the U.S. model of private health care is not viable here, India is following the American system rather than the National Health Service of the U.K., which has been voted better than the U.S. system by many international observers. Bhargava points to an article in the British Medical Journal by Michael McCarthy about a comparative study produced by the Commonwealth Fund 2014.

According to the report, the U.K. was voted the best, followed by Switzerland, Sweden, Australia, the Netherlands and Germany, New Zealand and Norway, France, Canada and, lastly, the U.S. (for the fifth time in a row).

The report concluded that its findings showed “a consistent relationship between how a country performs in terms of equity and how patients rate other dimensions of performance: the lower the performance score for equity, the lower the performance on other measures. This suggests that, when a country fails to meet the needs of the most vulnerable, it also fails to meet the needs of the average citizen.” It is a point that India would do well to take note of.

Among the developing nations, Cuba’s universal and free health-care system is noteworthy and replicating it could fetch good dividends.

In Cuba, every community or neighbourhood has a family doctor who resides in the same area and is the first point of contact for an ill person. When required, the general physician will refer a patient to the specialists. The state-run health system has enabled Cuba to spend less on per person annually and get more done.

The average life expectancy in Cuba is 77.5 years and its infant mortality rate is one of the lowest in the world. This socialist country’s model of health care is worth following.