Thursday, May 31, 2012

Indians skewer medicos on TV: "Physicians, Heal Thy Selves"

I am the son of doctor, my brother is a doctor so are many cousins, nephews and nieces. For a long time I had meant to write a blog on the state of medical education in Tamil Nadu but hesitated out of antagonizing some good people unnecessarily. Anyone who reads this further please understand that I know what I am talking about here and I do so with utmost honesty and in the larger public interest.

Aamir Khan is hosting a talk show and a recent episode was on the state of healthcare in India. The episode highlighted callous malpractices that resulted in loss of life, atrocious practices that fleeced patients, gross incompetence etc. The incidents cited have not been disputed till date, most comments were by the general public on live TV. Doctors flew into a rage and now an association demands that Aamir should apologize. Not one of them thought it fit to say "there is lot of anger out there we should do some soul searching" or "I feel sorry that a mother died due to a doctor we need to get better", or "it is outrageous that a doctor would tell a patient that liver transplant is needed when just an ordinary flatulence medicine would do". No. Not an ounce of empathy for the poor souls but buckets of outrage at Aamir. The worst remark was "a realtor gets 200% commission so why not a doctor get a marginal cut on tests" (referring to commissions to doctors from labs for tests ordered). And then doctors wonder why there is public anger and distrust.

This is not an isolated instance of public ire. Some years back Vijay TV in Chennai hosted a similar show and again the doctors came under withering criticism from the public. Across India there is ire towards doctors. I'd like to give a peek into stinking world of medical 'industry'. Like everything in India there are always exceptions, there will be honest to god good doctors but they are, as I said, 'exceptions'. The good is always an 'exception' in India.

So Many Ways to Earn Money

Very few professions afford so many ways to earn dishonest money as it does for a doctor, especially for a surgeon. Padding prescriptions with expensive drugs to earn cuts from drug reps and pharmacy owners. Cuts from laboratories for tests, again, not infrequently padding tests required. Cuts from scan centers, again many times ordering unnecessary scans. Sometimes a doctor might be a partner in all those centers too thus practically milking the unsuspecting patient from all corners. Most doctors do not even know the words "conflict of interest". Doctors in government hospitals take it a step further. 'Admission practice' is a term for a doctor soliciting bribes from patients to schedule surgeries in government hospitals. Government hospital doctors are also known to scoot out of hospitals to attend private practice. Surgeons scare patients into scheduling unnecessary surgeries, cuts from nursing homes for admitting patients. Again doctors do own nursing homes and admit patients only there even if their nursing home is unsuitable for a particular surgery. Even doctor owned nursing homes lack basic amenities like ambulances (let alone equipped ambulance), clean operation theaters. I am a capitalist, I love profits. Profits are what one makes after all necessary expenses are made NOT at the cost of essentials. MBBS doctors practicing is a stupidity possible only in India. It is a pathetic state that many villages are dependent on such doctors. Doctors prescribe medical devices like cardiac stents and hearing aids indiscriminately to milk cuts from device manufacturers.

Nursing homes and especially private hospitals specialize in fleecing patients than medical care. When a patient chooses to stay in a room rather than a general ward the patient pays room rent. Not content with that most hospitals charge the patient in a room higher prices for lab tests than what they charge a general ward patient. Note, this is not redistribution, the general ward patient is NOT subsidized by the richer patient, both pay full price and more. Nursing homes will not admit certain patients unless a substantial amount is deposited. Clean sterile environment etc are unknown commodities even in pricey hospitals at the center of the city.

Cavalier prescription of expensive drugs to boost bottom-lines of in house pharmacies is a common practice. When hundreds of students come out of private colleges paying tens of lakhs almost no one has the ability to empathize with a poor patient. Private university hospitals used to pay the doctors on their rolls a cut in black money. Its the same doctor who is also a professor teaching students. By the time one comes out of a nursing home one is out of pocket by tens of thousands. At the end of all this if the reader does not feel dizzy or like puking you have either resigned yourself to fate and have thick skin or ...I don't know what to say.All of the above is only scratching the surface.

Degrees Sold as 'Package Deal' and Incompetency

In a country like India the one area where is the government can play a legitimate role is in providing education. Speaking from observing Tamil Nadu, it is in that specific area where state governments have failed miserably. The doctor:population ratio is miserably low in India accentuated (or caused) by low number of colleges. In the 80's Tamil Nadu underwent a revolution in privatizing tertiary education in Engineering and Medicine yielding divergent results. Self-Financing, as they are called, engineering colleges sold seats for Rs 40,000 in the 80'-90's. While that was a large sum it was within the reach of many parents whose children, may not have scored good to enter the few government colleges or, as was the case mostly, sidelined by the brutal corrupt quota system. Private Medical colleges on the other hand collected Rs 10 lakhs in the early 90's, now running into Rs 50 lakhs. This prohibitive cost meant that only the stinking rich could afford it. That category of students usually fell, with minimal exception, into children who cared a damn about academics but had rich parents who wanted their children to have an M.B.B.S. Now it has reached a level where a candidate can do a package deal for Rs 1 crore+ for MBBS+Any PG degree. Do I expect a student who paid Rs 1 crore just to sit in MBBS to clear exams honestly before going to PG? No.

A US Medical aspirant goes through a 4 year degree and THEN sits for a grueling 7 hour MCATS exam. Tamil Nadu students shiver in their slippers to sit for an entrance exam and enter MBBS after +2. For instance, in first year MBBS,  students write two separate exams like Anatomy -1 and Anatomy 2 for a single subject. The University declared, to raise standards, that they need to pass each paper individually as against a 'combined pass' as in past years. Scared students recently took out a rally asking that they should be declared "pass" based on "combined" basis. So before you go under the knife of a doctor in TN ask "did you pass both theory papers separately". Tamil Nadu PG exams are even more ridiculous. If a student served in the government after MBBS he/she gets 1 mark per year of service, they were labeled, "service candidates". So if you warmed a seat for 5 years  you get 5 marks, often times most do not even report to duty. Then there is 69% quota. SC/ST candidates are exempt from eligibility criterion of 50% marks. One reason why FC's shy away from MBBS is that the torture of quota does not end. Quota for MBBS, quota for PG, quota for getting a government posting (thereby becoming a service candidate), quota for government hospital after graduation. Heck one would forget walking on ones own leg after being on crutches for long.

Private colleges have mushroomed so much that getting qualified teachers is difficult. Every retired doctor is now wooed to be a professor. That also serves to satisfy MCI (Medical Council of India) requirements for 'experienced' professors. Most doctors, like most other Indian professionals, think that reading and learning ends on the day of graduation. Result is now private colleges have as teachers old retired people who have not touched a reading material barring a vernacular newspaper.

Are all private colleges bad. Of course not. Some private colleges, in order to earn more money, reach for a higher bar. Now, NRI's are a market to be tapped. Rather than spend close to $300,000 for a medical degree in USA many parents send their kids to India. This market pays higher than TN people but they also expect better facilities and slightly better teaching. Some private medical colleges are now tapping into this and is re-inventing itself. Note, that such NRI students would return to USA after MBBS so the PG degree is still catering mostly to local students.

Private colleges (and government colleges too) are notorious for hiring professors for a day to meet MCI requirements on the day of inspection. MCI chairman was recently arrested by CBI for bribery. He had several thousand crores.

UK's much vaunted NHS stipulates that doctors applying for medical teaching centers have to meet higher standards. That is not so in Tamil Nadu for clinical specialties. 'Teaching' is not considered as requiring separate skill set from being a practicing doctor. The logic being 'if you can do it, you can teach it'. Bollocks, to use a British expression. That's how we have doctors examining students across decades without ever having read any book or journal after their graduation.

To Be Fair, Doctor's Grievances

The medical association that asked Aamir to apologize said "doctors are not aliens and are part of the same corrupt society, do not hold them to a higher standard". That is very sadly true too. Lost in a quagmire of corruption where the fruit we eat, the water we drink, the driving license we renew, the school teacher, the electrician, the land registrar, the jeweler are ALL corrupt can we expect one set of professionals alone to be different. However convincing that argument is it is a cop out. No other profession holds in its hand the ultimate question of life and death. I've seen patients prostrate themselves before a doctor, see a parent swell up with gratitude when a doctor saves his child, see a child go home with a cured mother no other profession, especially in India, begets such gratitude. No other profession holds a critical imbalance in knowledge between the provider and the requester. In no other profession is knowledge or its lack can have such immediate impact. 

How can we expect teachers in medical colleges to be like Lewis Thomas while the government enshrines mediocrity with policy and sometimes with lack of policy. 

My biggest anguish is that the medical community instead of trying to do soul searching is throwing brickbats in self-righteous indignation. It is sad, but it is not surprising. That is India.

Wednesday, May 9, 2012

UK Road Trip: York, Betty's Tea Room, York Museum

Taking a break from politics I'll continue my travelogue. From Edinburgh we proceeded to York. "Quaint" is a word that often comes to mind in Europe and especially in the fabled English countryside. York  is no exception and is superseded only by the picturesque Lake District which we visited next. New York and New York City derive their name from York.

Breakfast was unappetizing with fried bread and moist egg scramble. The bread was indeed just fried, deep fried, in oil. Our first stop was York Minster Cathedral.

The cathedral has a history dating back to 7th century. It is the main draw of the city. Our guide pointed to a small alcove and said "here is where Bishop John Sentamu sat down in fast protesting against the war situation in the middle east in 2006". She was referring to Israel's war (or battle) against Hezbollah in Lebanon in 2006. I asked her "was he protesting against Israel". She replied "he was protesting against the war situation". Now my brother got jittery and I let it go telling my brother "I'd bet that the good bishop did not protest against the 'war situation' when Arafat declared the Second Intifada after walking out of the famous Camp David talks". I later googled and was vindicated.

York is the site of a gruesome anti-semitic violence. In 1190 AD nearly 200 Jewish men, women and children took refuge in Clifford Tower. Many committed suicide fearing torture and forced conversions, those alive, including children were killed in most heinous manner. Jews were later expelled from UK in 1290 AD. Sentamu is York's first Afro-American bishop and is rumored to be popular enough to become the next Arch Bishop of Canterbury. The Afro-American community in USA has a fractured relationship with Jews and Israel. Given this backdrop it is interesting to put Sentamu's fast into perspective.

We then got on to an usual ride on a hop-on hop-off. Our first stop was the famous Shambles shopping street. UK is famous for its 'tea-room's and York had the best, the world famous Betty's Tea Room

We actually just stumbled into Betty's. Once inside we knew we were at a really classy place. Cell phones should be switched off. The pastries, the cake, the silver ware and every thing was just how it should be. It was simply out of the world. We loved it so much that we went back for dinner too.

York's history is blood stained going back to the Viking invasion of what the Viking's referred to as 'Jorvik'. The Vikings and their famed (or notorious) long ships invaded York in 867 AD. A "Jorvik Museum" is very instructive and unique. They had discovered archeological remains dating back by 1000 years in York and the museum in a very innovative manner displays those in a city like miniature setting encased by a glass floor on which we can walk and ponder. A unique mono-rail chair car whisked us through a re-creation of Nordic village.

Having visited Amsterdam then UK and seeing the Nordic history one wonders at how world supremacy had risen and fallen. The Dutch, the British, the Nords were all great powers not too long ago. The sun set on the British empire only recently. I was reminded of Will Durant writing in "Story of Civilization" that each civilization must renew itself to stay relevant. America, the last remaining super power is at the cross-roads of history. When I traveled in European cities I've always wondered at the lack of diversity in demographics. Whether it is Paris or Amsterdam or London or York or Zurich or Edinburgh nothing comes close to the vibrant, vigorous diversity of New York City, Washington DC, San Francisco, Los Angeles, Orlando. THAT is the key of America's dynamism and its secret of constant self-renewal.