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.

20 comments:

Mathan said...

2. About Aamir Khan's lop sided programme "...Aamir Khan is hosting a talk show and
a recent episode was on the state of healthcare in India. ..
The incidents cited have not been disputed till date.."
Reply : My simple question is "Is it not the duty of the media to present both sides
of the story ? " The incidents cited should have been verified before going on air and
the Docs involved should have been contacted for their side of the story too isnt it ?
The programme and its host never even Declared on Air that these
"Docs were contacted and they didnt respond " .
Yesterday Dr.Sreedhara came out with a reply to the allegations in this issue
here it is http://www.printfriendly.com/print/v2?url=http%3A%2F%2Fpastebin.com%2Fjm0XNmNM

Mathan said...

3.//Not one of them thought it fit to say "there is lot of anger out there
we should do some soul searching" //
Reply - Well if u think so u are wrong ..did u see the other part of the same programme
in which many doctors were shown doing good work too.The fact the MCIs Chairman came on
air and said " we are working towards finding solutions to the problems..."

Mathan said...

4. "MBBS doctors practicing is a stupidity possible only in India"
Reply - Its the single most outrageous comment i have ever read ,EVER.
You may have been fortunate enough to be born in a family filled highly
specialised doctors.That does not give you the right to ridicule the doctors with out
specialisations.I need not explain more to make sure u understand because i know
"Fools rush in" and i can sympathise.

Mathan said...

5.All your comments about the "Business of Medical Education" as in the context of Admission to
Private Medical colleges are correct . But I do not agree with your argument about falling standards
in Medical education as such . Just because they study in a Private Medical college should not be viewed as
less competent ones.

Mathan said...

6.//Most doctors, like most other Indian professionals, think that reading and
learning ends on the day of graduation.//
This is another Gem ?!! There was a generation of doctors who spent their entire
careers without reading any journals & periodicals.But now you cant see a doctor
who doesnt update himself in his field.BTW do you have any idea about how much does
Yearly subscription for Say "Lancet" or "BMJ" or "NEJM" ?

Mathan said...

7.//NRIs..Rather than spend close to $300,000 for a medical degree in USA many parents send their kids to India.//
Ooops!! so u accept Medical Education in India is cheaper , is it ?
And these NRIs complete their MBBS (u said they are incompetent) in india and go back to US to
become Competent Doctors is it ?! #Asshattery at its best !!

and //Note, that such NRI students would return to USA after MBBS
so the PG degree is still catering mostly to local students.//
what is this ? you are confused ?

Mathan said...

8. //Private colleges (and government colleges too) are notorious for hiring professors for a
day to meet MCI requirements on the day of inspection.//
Yes this happens and measures such as biometric systems are now in place to check that too .

Mathan said...

9. //MCI chairman was recently arrested by CBI for bribery. He had several thousand crores.//
Thats the news too old for this audience , No one in Medical community liked his ways anyway.
Infact we celebrated the whole day !! surprised ?!!

Mathan said...

10.//UK's much vaunted NHS stipulates that doctors applying for medical
teaching centers have to meet higher standards.//
Yes the standards expected in UK are different to what is expected in India.
Since many of my friends,colleagues and seniors now in UK are meeting those standards
i presume our doctors are no less competent in this issue.

Mathan said...

11.//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.//
well said ! The lack of policy vision in the field of Medical eduaction has hurt us long enough.
But MCI was too busy running a licence shop that they forgot the other job such as curriculum framing.
If we want to discuss about Reforms in curriculum we can have a full panel dicussion on that too !

Mathan said...

12. Lets come to the most imporatant part of it !!
// 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.//
Reply - I am not attempting to sweap any thing under the carpet here ,
I am not aware of any such cuts given by "drug reps" and pharmacies to doctors.
Dr.C.M.Ghulati who spoke on SMJ quoted that nearly 30% of expenditure of
pharma companies are spent in marketing.And yes pharma reps do give me
some penstands,paper weights and "DOCTOR IN/OUT" board outside my clinic.
Pretty expensive stuff right !
But yes nowadays a few doctors have started to stock drugs & dispense it themselves
(as allowed legally), in an attempt to increase their earnings.
As far as Scan centres and Labs are concerned , no cuts are paid from Hospital-run scans and labs.
Scan centre and labs in cities do resort to cuts to attract more volumes ,
because thats their business model.
If you say we are resorting to more and more investigations now , thats because there more
investigations available now at our doorsteps than say ten years ago.
When my mother had head injury 11 years ago we coulnt do a CT scan in my town , where as now we have
3 CT scan centres in town (including one run by the yours truly).
Moreover many doctors and hopitals now practice "Evidence - based medicine" which demands
these investigations as required by various international certification agencies like JCI.

Mathan said...

13.//For instance, in first year MBBS, students write two separate exams
like Anatomy -1 and Anatomy 2 for a single subject.//
What makes u think that writing it in a single paper will make better doctors ?
The idea is to make sure that the student covers all bases .
And separating the subject into parts has its own advantage, makes learning easier.

Mathan said...

14.//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.//

Simple reply : TOTALLY FALSE.all students Service and Non service are entitled to have that
extra marks according to your post MBBS experience.

Mathan said...

5.// One reason why FC's shy away from MBBS//
"I STRONGLY CONDEMN YOUR USAGE OF "FC" ITS "OC" OPEN CATEGORY ,
NO CASTE IS FORWARD AND NO CASTE IS BACKWARD"

// 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.//
Oh Boy ! there is no point crying over the rules if you end up in the losing side .
Did u wake UP from a coma or something ?
Engineering college admissions / all govt postings are also governed by same rules, alright.

Mathan said...

16.// Heck one would forget walking on ones own leg after being on crutches for long. //
again an unwarranted statement with Mischievous intent .

Mathan said...

17.// Nursing homes and especially private hospitals specialize in fleecing patients than medical care.//
I can say for sure that u have not visited a healthcare facility anywhere outside chennai.

Mathan said...

With this i would like to say categorically that "No one from the Medical community is happy
about the way it goes right now ! No one is happy with status quo !" We are a responsible community
with a written code and ethics to hold on to ! Things should and will improve ,but pointing fingers is not the remedy .
You say you are capitalist, why dont you come back and build a model hospital .
Its easier to write a blog,rip apart a doctors hard earned reputation in just 5mins of "On-Air" time .
But to build an instituition we need to move brick by brick .
Ya we may be far away from western standards, but we will turn around driven by people who you
accuse now of being incompetent.
And , you are just a spectator , because you have choosen to be so !

Athenaeum said...

@Mathan: Here are my comments to your outrage
. BTW a cousin of mine is a radiologist too.

2. Aamir Khan programme did not instigate me to write. I had been meaning to write this blog for a long time the outrage hurled at Aamir was the last straw, not Aamir per se.

3. //none of them// -- I was referring to docs who took umbrage at AAmir in FB, twitter etc (like you :-) ) not that anybody on the program did not show concern. Anyway as i said my blog is NOT about the program primarily.

4./MBBS docs practicing// I stand by it. Go check how a doctor can start practicing in USA. There are excellent MBBS students of course but they are exceptions and that should not be the basis.

5./Just because they study in a Private Medical college/ -- Here you partly agree. One of my cousins studied in such a college and scored 99 percentile in USMLE. She is an NRI student. She was groomed by her doc mother and attended courses in USA in biology during school days. I've clearly explained how the high cost of MBBS seats in private colleges precludes talented students who may not find a seat in Govt College due to reservation etc.

I studied in a self financing Engg college. THe price of Rs 50,000 (I did not pay, I was merit quota) was reachable enough for many students,like those who studied in CBSE (and therefore cannot score 100/100 like state board students). THIS is not the case in private med colleges

In related manner to your comment 7. I had said some private colleges try to attract higher paying NRI students from USA/UK and THEREFORE now have better teachers, better infrastructure etc. BUT those students, educated in US/UK schools, come for MBBS only and leave for US/UK for PG. So PG courses still languish since only local population studies that.

Athenaeum said...

Mathan: continuing for your other comments:

8)// hiring profs for a day// -- This happened as recently as 2007-08 etc.
10)I do not mean that EVERYONE who studies in India is incompetent. I am Indian too :-). Its not about THEIR competency. That, including government colleges (especially them), colleges think a doc because he/she is a doc can teach. No, Teaching is different. Thats why UK's NHS has a different criteria for doctors applying for teaching institutions.

11)//MCI was too busy running a licence shop that they forgot the other job such as curriculum framing.// --- Glad you agree that the governing body of Medicine for India was running a license shop.
12) A doc from Jaslok has pretty much agreed on the cuts etc see http://www.rediff.com/movies/report/doctor-heal-thyself-satyamev-jayate/20120606.htm

13) //What makes u think that writing it in a single paper will make better doctors ?// -- NO that is NOT what I said. Yes having 2 papers to examine students deeper is GREAT. THen they should also pass separately not 'combined'. That is pathetic.

14) In the 80's only those served in Govt service after MBBA got 1 mark for each year and those candidates were referred as "Service candidates". I check TN govt web site itself for current regulation thats what they say. Only when you serve in a PHC/some govt entity after MBBS can you be called "service candidate" not otherwise -- I think-- If everyone gets a mark irrespective of where they 'serve' THAT is ATROCIOUS too. It only makes it worse.

15-16) On reservation: It is pathetic that so many 3rd and 4th generation children (of not so poor or rich or many times children of docs themselves) get quota. That too not just at entrance but PG, then job too. So my comment on 'standing on their legs' is NOT mischievous. The intention is pretty explicit and blunt. NO apologies. Yes it applies to all other divisions too. That an SC/ST student need not even get 50% eligibility marks for applying to PG (and similarly at MBBS) is pathetic.

17) I've visited more nursing homes than you can imagine since I was 6 years old.

Suresh Rajagopal said...

It is a well articulated piece of writing. While there could be a couple of points for debate, the overall intention with which the article has been written is commendable. I do not want to comment about Madan's comments as you have responded to most of them. What Aamir Khan exposed is only the tip of the iceberg. The problem is much deeper and shameful. In my view ethical practitioners together must eliminate the weeds in their community of Medical Profession. Recent incidents at Bulandhshahar and Balia will make every decent doctor put his head down in shame. But the CMS Shishir Kumar, Hony.SG IMA D.R.Rai, UP chapter Sharad Agrawal came on the TV and none of them had the fundamental decency to apologize for the events. And yesterday in Bulandhshara hospital a patient was dying and the so called doctor community on strike singing and dancing on the road was obnoxious to watch.