Dissenting Diagnosis: private medical sector's hard truths

Dr Arun Gadre and Dr Abhay Shukla, authors of the book

• Traditionally, doctors have enjoyed great social prestige and the gratitude of their patients, but this has not spread to higher personal or professional standards or to the highest ethical standards.
• Complaints about the state of medical care are increasing in today’ India: whether it’s unnecessary investigations, botched operations or expensive—sometimes even harmful—medication. But while the unease is widespread, few outside the profession understand the extent to which the medical system is being distorted. 
• Dr Arun Gadre and Dr Abhay Shukla have gathered evidence from seventy-eight practising doctors, in both the private and public medical sectors, to expose the ways in which vulnerable patients are exploited by a system that promotes unscrupulous medical practices. At a time when the medical sector is growing rapidly, especially in urban areas, with the proliferation of multi-specialty hospitals and the adoption of ever-more sophisticated technologies, rational and ethical medical care is becoming increasingly rare. 
• Honest doctors feel under siege, professional bodies meant to regulate the medical sector fail to do so, and the influence of the powerful pharmaceutical industry becomes even more pervasive. Drawing on the frank and courageous statements of these seventy-eight doctors dismayed at the state of their profession, Dissenting Diagnosis lays bare the corruption afflicting the medical sector in India and sets out solutions for a healthier future.
• With testimonials from 78 doctors practicing in six states and across 23 fields of medicine (including traditional), the book spares no one. From big "hospital malls" right down to autorickshaw drivers (paid to direct patients to specific clinic), it claims, everyone is on the take.
• According to  WHO about 3.5 crores of Indians are pushed below poverty line each year just on account of expenditure on private medical services since they can not access good quality public health care services. 
• Regulatory bodies that exist today are inward-looking, closed committees, incestuous groups that lack openness and hence fail to check their own members. 
• Doctors who were grounded in the idea of service have felt ground swept away under their feet, their traditions of 'keep the patient foremost' rapidly buried under the ruthless logic of 'keep profits foremost'. There has been decline of transparency in medical sector and over all position of  many doctors and their associations has been complicit silence or active support of the guilty.
• Many private doctors often send patients with complicated illness or terminal diseases to government hospitals or AIIMS as dumping ground. And poor patients who can't afford expenses of private medical care also come to these institutions. That is why doctors from these institutions have significant knowledge. 
• The rot is deepening with the increasing onslaught of big corporate hospitals, growing pressure from the pharmaceutical industry and massively expanding clout of medical equipment agencies.

SOME EXCERPTS

• When a teenager’s family approached me for a second opinion about terminating an unwanted pregnancy, I discovered that the girl was not pregnant to begin with. The family was shown someone else’s blood work to convince them of the need for an abortion, says Pune-based gynaecologist, Dr Arun Gadre.
• There’s a code of honour among doctors and while they may compete, publicly, one doctor will not criticise another. It is extremely hard for the families of patients to fight medical malpractices and get justice because they would simply not find a doctor to come forward and testify in court, as would be required.
• Just as shopping malls have come up to sell groceries and consumer goods, corporate and large multi-specialty private hospitals have come up to sell medical services. Majority of these corporate hospitals are not owned by doctors. Seeing the large profits to be made in private medical sector, non-medical investors are pouring money into these private medical businesses to maximise returns on their investment.
• While there do exist doctors practising ethically, they are far-far less compared to those who have fallen prey to unethical activities for whatever reasons; and the former are constantly being threatened and frightened into making way for the latter.
• A senior pathologist explained to the authors: ‘Even my MBBS friends — who have now become consultants — do not refer patients to me because I don’t give them cuts.’
• Learning from the lives of those among us who still practise rational and ethical medicine, and taking guidance from them, is one great way to start.
• We have sunk to such depths that I have come to the conclusion that things will (now) improve simply because there is no way they can become any worse says a general surgeon.
• The 'packages' offered by multispeciality corporate hospitals, incorporating a range of tests under 'master checkup', not only drains an individual of his hard-earned money but the collected samples go down the 'sink' as well. The sink tests essentially means samples collected from patients are just thrown into the wash basin without testing as doctors prescribe such tests, which by mutual understanding, are "not actually carried out" by the pathologist.
• These corporate hospitals run on a perverted concept. Their only purpose is to satisfy the interests of their shareholders. The more profit the better. They go on prescribing needless investigations and surgeries.
• The initial chapters contain information about things that most educated people have an inkling of: the nexus between pharmaceutical companies and corporate hospitals; the pressure on doctors to prescribe as many costly investigations and tests as possible, to earn a pre-specified revenue for their hospitals; the lack of transparency and the emotional exploitation of patients’ families in situations where every second counts and composed reflection isn’t possible.
• It has become a common practice to bring expensive new medicines to market in place of useful cheaper medicines just to increase profits.
• Many elderly persons who only need proper spectacles have been told to get operated for cataract (which they don’t even have), and they are told the charges are Rs.30,000-40,000. Those who have insurance fall into the trap and go in for the surgery. Those who don’t have insurance, if go for a second honest opinion, they might get saved!
• Some hospitals where they don’t actually admit patients, but merely prepare the paperwork for insurance claim. The hospital, the patient and the TPA share the proceeds.
• A senior super-specialist urologist had to leave a corporate hospital because its young MBBS CEO castigated him for not performing a particular operation for removal of a kidney stone where there was no need for any such procedure.
• A person had to sell his apartment after a major corporate hospital came up with a bill of an astounding Rs 42 lakh for the treatment of his wife. "The actual expenditure cannot possibly even come close to this."
• Medical Council of India (MCI), has turned a blind eye to the systemic assualt on ethics in the medical profession. Whatever actions the MCI ethics committee take in Delhi, the state councils defy.
• With onslaught of technology, doctors lost their clinical sense. They increasingly depend on investigations rather on their experience and skills. Doing full body investigations routinely without any indications.
• When the patient is young, and the disease is reversible - certainly doctor should use ventilator. But what is the point in pushing forward for a short while an old man's death with ICU and ventilator that too while doctor ruin him financially and increase his sufferings?
• Modern medicine is not personalized medicine as it used to be but became an evident based medicine. Most diseases get cured with idiopathic treatment. If not then investigations were ordered on fifth day but in these modern days they are ordered on day one. 
• If prescriptions of generic medicines is made mandatory, cost of medicines would become very low. It is a rare patient who gets away with one or two investigations. Most patients hold a list of unnecessary investigations.
• Among other shocking revelations, the book describes how in the absence of serious ailments, a "pretense" of surgery is performed, a patient is given anesthesia and some stitches are put on the skin, to show that an operation has been done.
• Dr Vijay Ajgaonkar, a senior Mumbai-based diabetologist, says “If you look at the issue objectively, it is not our role to make money by taking advantage of another person’s illness. But this is exactly what is happening. They put terminally ill 70 to 80-year-olds on ventilators, keeping the hospital meter running by unnecessarily using the ICU and ventilator.”
• Doctors do not even record the patient's history properly, said Dr Punyabrata Goon, a General Practitioner in Kolkata. They just write out a list of investigations as they get a commission for doing that, he says. "Almost all the laboratories in our area give 50% commission and almost all the doctors accept these commissions. For many doctors, the money earned through commissions is much more than that earned from fees. In our area, the commission rates are: X-rays 25%, and 33% for MRIs and CT scans," he says.
• Even a normal fever is shown as dengue or in worst case scenario.
• A young doctor's lament, on him being pulled up by the CEO of a corporate hospital for "low conversion rate" of 15% as opposed to 40% fixed by the management is also recorded in the book. Conversion rate means out of the total number of patients seen by the doctor, the percentage which are advised to undergo surgery or procedures.
• That malpractices in healthcare exist will come as no surprise to anyone who has dealt firsthand with the beast.
• A young man says - I remember my dadi’s exasperated cackle when she was being sent home following a stint in Max Saket in late 2014: after five days in the hospital where a doctor would drop by once or twice a day, give a curt instruction and swish out in 30 seconds (having added Rs 900 to our already-sizable bill for each such “consultation”), she was discharged with a diagnosis of piles when, even in her groggy state, she knew it was no such thing; that her gastric problems were an effect of the blood-thinners she had been taking since her angioplasty. How she rolled her eyes and muttered as we put her on the stretcher for the ambulance. Sure enough, after she spent a very uncomfortable month at home, we were back in the hospital explaining her case all over again to a new set of smiling doctors who made the correct diagnosis this time – not so much because of competence, I suspect, but because there were only so many available possibilities.
• The story about a speed-obsessed senior surgeon, for instance, who accidentally cut a major artery during a routine kidney operation, consequently had to remove the entire organ instead of just the stones – and later told the patient’s family that he had executed a heroic last-minute turnaround because the kidney was damaged beforehand. Another story is about a hospital that hid a deceased patient’s body to put pressure on the family since they hadn’t been able to pay the full bill.

Asia’s third-largest economy spends about 1% of its GDP on public health, compared with China’s 3% and the United States’ 8.3%. In European countries, the figure is even higher. Indian states manage their health budgets separately, but the overall direction in which the sector is moving is alarming. In 2015, India was ranked 112 in healthcare globally by WHO, which is tragic for an economy of this size. India has to step up expenditure on public health to at least to 5% and needs to regulate the sector.

It is better to deserve honors and not have them 

than to have them and not deserve them ... Mark Twain

Tagore Telugu Movie (2003) - Hospital Very Funny Scene

During mid 1970's, a colleague of mine visited an ophthalmologist who has sent him to a neurologist at KEM Hospital in Mumbai (then Bombay). He was diagnosed brain tumor and was admitted and emergency surgery was done within hours. He was a bachelor and had neither money nor a companion with him. His uninformed absence was noted in the office. After two weeks he walked into office and explained colleagues what has happened to him that made everyone dumbfounded. Gone are those days, where anyone could undergo brain surgery with zero expenditure and no one to attend him! 

The root causes of all these maladies are greed in all walks of life, capitation fees in private medical colleges and total disregard for ethics and values. Ethical & Moral education must be imparted right from childhood in addition to the western school syllabus. These days most doctors are non-merit & capitation fees paid students and their competence is hardly excellent. 

These days most doctors & hospitals are predators in the guise of saviors. Since we don't have choice, we should take care of ourselves.

Fortis charges over Rs 15 lakh to treat child with dengue

 

• Every person, especially who is doling out lakhs of rupees to hospital, is entitled to know the details for all such payments prior to payment and and justification thereof and whether the treatment is being done in right direction or not.
• Self certification that there is no negligence, no over billing done, all protocols followed etc are unacceptable when parents/children/relatives of the patient are kept in dark about the condition of patient deteriorating and at the end patient dies.
• Isolating the patient in ICU in the name of 'infection control' is another reason for trauma.
• The underlying reason is the greed of the corporate hospitals having invested crores of rupees in the hospital & its facilities and doctors who spend millions for acquiring their medical degree and post graduation degrees etc.
• Teaching, Medical and Justice dispensation are noble professions, and doctors and hospitals must follow ethics under all circumstances. Immorality and corruption in these professions are contemptible. Justification that their degradation is in line with general degradation of society as such, is unacceptable nonsense.
• Corporate hospitals & doctors charging exorbitant amounts resulted in abnormal premiums being paid by all insurers.
• Prima facie, 660 syringes and 2700 gloves indicates the whole bill is cooked up and the patient might have passed some days before. Only a thorough criminal investigation will bring truth to the forefront.

An elite class that is free to operate without limits - whether limits imposed 

by the rule of law or fear of the responses from those harmed by their behavior - 

is an elite class that will plunder, degrade, and cheat at will, and act endlessly 

to fortify its own power ... Glenn Greenwald

In the absence self discipline and adherence to ethical practices, robust consumer protection laws, active consumer awareness and ruthless law enforcement mechanisms, emulating liberalization and promoting private sector and destroying public sector is grossly injurious to semi literate societies like ours. Today, the condition of government hospitals and schools doesn't enthuse anyone to avail its services. Arogyasri, Tuition fee reimbursement etc seemingly does good for common man but in reality it fills coffers of corporate hospitals and fulfill greed of doctors while depriving precious funds for government colleges and hospitals. The realistic solution would be strong govt and non-profit trust hospitals virtually competing with corporate hospitals. Govt must increase its spending from present 1.2% of GDP to at least 5% of GDP on health care and also spending on school education from present 2.5% to over 5% of GDP, of course with transparency and accountability and corruption eliminated. This requires political will and administrative honesty apart from public patronizing. 

A Cyclist - is a disaster for the economy

1. He does not buy the car and does not take a car loan. 
2. Does not buy vehicle insurance. 
3. Does not buy fuel. 
4. Does not use the services of repair shops and car washes. 
5. Does not fear “civic responsibility”. 
6. Does not use paid parking. 
7. Does not become obese. 
8. Yes, and well, dammit ! Healthy people are not needed for the economy. They do not buy drugs. They do not go to private doctors. They do not increase the country's GDP ! Total disaster!!! This is how corporate think 
9. On the contrary, every new McDonald's outlet creates 30 jobs: 10 Dentists, 10 Cardiologists and 10 Weight Loss Experts. 

So, what do you prefer- Cycling or fast food? 

It was amusing. Bikes were very popular before cars. Cars were viewed as a natural progression (it is sure easier going up a hill). This progress drove industrialization, higher productivity, and so forth. Giving up cars and using bikes do indeed threaten the car companies.


The present arbitrary economic system is flawed, which favors wastage & destruction and sees efficiency & lowered unnecessary consumption as a good thing. The numbers like the GDP are calculated with no eye to the long-term future, and the fact is that 'All resources are finite'.

Malpractices by Doctors

Bangalore, 27 September 2011

This is an article by Dr B M Hegde, MD, FRCP, FRCPE, FRCPG, FRCPI, FACC, FAMS  - Padma Bhushan Awardee 2010.

Most of these observations are either completely or partially true. Corruption has many names, and one of civil society isn't innocent either. Professionals and businessmen of various sorts indulge in unscrupulous practices. I recently had a chat with some doctors, surgeons and owners of nursing homes about the tricks of their trade. Here is what they said

1) 40-60% kickbacks for lab tests. When a doctor (whether family doctor / general physician, consultant or surgeon) prescribes tests - pathology, radiology, X-rays, MRIs etc. - the laboratory conducting those tests gives commissions. In South and Central Mumbai -- 40%. In the suburbs north of Bandra -- a whopping 60 per cent! He probably earns a lot more in this way than the consulting fees that you pay.

2) 30-40% for referring to consultants, specialists & surgeons. When your friendly GP refers you to a specialist or surgeon, he gets 30-40%.

3) 30-40% of total hospital charges. If the GP or consultant recommends hospitalization, he will receive kickback from the private nursing home as a percentage of all charges including ICU, bed, nursing care, surgery.

4) Sink tests. Some tests prescribed by doctors are not needed. They are there to inflate bills and commissions. The pathology lab understands what is unnecessary. These are called "sink tests"; blood, urine, stool samples collected will be thrown.

5) Admitting the patient to "keep him under observation". People go to cardiologists feeling unwell and anxious. Most of them aren't really having a heart attack, and cardiologists and family doctors are well aware of this. They admit such safe patients, put them on a saline drip with mild sedation, and send them home after 3-4 days after charging them a fat amount for ICU, bed charges, visiting doctors fees.

6) ICU minus intensive care. Nursing homes all over the suburbs are run by doctor couples or as one-man-shows. In such places, nurses and ward boys are 10th class drop-outs in ill-fitting uniforms and bare feet. These "nurses" sit at the reception counter, give injections and saline drips, perform ECGs, apply dressings and change bandages, and assist in the operation theatre. At night, they even sit outside the Intensive Care Units; there is no resident doctor. In case of a crisis, the doctor -- who usually lives in the same building -- will turn up after 20 minutes, after this nurse calls him. Such ICUs admit safe patients to fill up beds. Genuine patients who require emergency care are sent elsewhere to hospitals having a Resident Medical Officer (RMO) round-the-clock.

7) Unnecessary caesarean surgeries and hysterectomies. Many surgical procedures are done to keep the cash register ringing. Caesarean deliveries and hysterectomy (removal of uterus) are high on the list. While the woman with labour -pains is screaming and panicking, the obstetrician who gently suggests that caesarean is best seems like an angel sent by God! Menopausal women experience bodily changes that make them nervous and gullible. They can be frightened by words like " and "fibroids" that are in almost every normal woman's radiology reports. When a gynaecologist gently suggests womb removal "as a precaution", most women and their husbands agree without a second's thought.

8) Cosmetic surgery advertized through newspapers. Liposuction and plastic surgery are not minor procedures. Some are life-threateningly major. But advertisements make them appear as easy as facials and waxing. The Indian medical council has strict rules against such misrepresentation. But nobody is interested in taking action.

9) Indirect kickbacks from doctors to prestigious hospitals. To be on the panel of a prestigious hospital, there is give-and-take involved. The hospital expects the doctor to refer many patients for hospital admission. If he fails to send a certain number of patients, he is quietly dumped. And so he likes to admit patients even when there is no need.

10) "Emergency surgery" on dead body. If a surgeon hurriedly wheels your patient from the Intensive Care Unit to the operation theater, refuses to let you go inside and see him, and wants your signature on the consent form for "an emergency operation to save his life", it is likely that your patient is already dead. The "emergency operation" is for inflating the bill; if you agree for it, the surgeon will come out 15 minutes later and report that your patient died on the operation table. And then, when you take  delivery of the dead body, you will pay OT charges, anesthesiologist's charges, blah-blah-

Wonder how widespread this is. Or, is it a matter of a few black sheep giving a bad name to the entire fraternity? Doctors are humans too. You can't trust them blindly. Please understand the difference.

Young surgeons and old ones. The young ones who are setting up nursing home etc. have heavy loans to settle. To pay back the loan, they have to perform as many operations as possible. Also, to build a reputation, they have to perform a large number of operations and develop their skills. So, at first, every case seems fit for cutting. But with age, experience and prosperity, many surgeons lose their taste for cutting, and stop recommending operations.

Physicians and surgeons. To a man with a hammer, every problem looks like a nail. Surgeons like to solve medical problems by cutting, just as physicians first seek solutions with drugs. So, if you take your medical problem to a surgeon first, the chances are that you will unnecessarily end up on the operation table. Instead, please go to an ordinary GP first.
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The article missed an usual item. Kickbacks from medical shops which is variable depending upon factors like proximity, volumes etc but the amounts are significant. A medical shop attached to a busy nursing home usually pays up entire electricity bill apart from goodwill amount of few lakhs of rupees and attending to doctor's sundry needs.

The "Tagore" telugu movie of the year 2003, is not a fiction but an exaggeration and dramatization of actual happenings in corporate hospitals.


My View:
You and your family should have a family physician with whom you should develop good relationship. Overtime he will be well conversant with your family health issues. Use his referral contacts in case any specialist requirements. Take his help at every stage including second opinion etc. Being a family friend he would be equally concerned about your well being and what you can afford and what you can't. He may not be a saint at least he knows where he should stop. Approaching specialist directly or corporate hospitals at the first instance, you might end up with unnecessary tests & procedures and exorbitant bills even for a normal ailment.

Health Care - How to Manage

Consider the case of a middle-aged executive from the New York City area who experienced chest pain. He went to a cardiologist, who ordered a full workup, including a CT scan of his chest. The scan found no heart problem, but at the edge of the film the radiologist noticed "something funny" in the neck area. A neck surgeon performed a biopsy and found nothing wrong. The cardiologist then performed an angiogram to look for abnormalities in the blood vessels. Complications from that procedure landed the executive in the hospital for a brief period. By the time it was over, his bills were more than $150,000 and he still had no diagnosis. Eventually the pain disappeared on its own.

Months later, when the executive's chest pain returned, he told his medical history to an internist who asked him what he was doing at the time. "Oh, we started gardening again," the man told him. It turned out that overzealous use of his string trimmer had strained a chest muscle, a condition that required no treatment other than an over-the-counter pain reliever. None of the high-priced specialists had considered muscle strain, a common condition often mistaken for heart pain.

General Physicians are trained to manage the "whole person," who can help keep seriously ill people doing well and out of the hospital. Consider Conservative & Palliative treatments before opting for risky, expensive & painful radical and extraordinary treatments.

• Conservative treatment is aimed at preventing a condition from becoming worse, in the expectation that either natural healing will occur or progress of the disease will be so slow that no drastic treatment will be justified. It is designed to avoid radical measures or operative procedures. 
• Palliative treatment is designed to relieve symptoms, and improve your quality of life. It can be used at any stage of an illness if there are troubling symptoms, such as pain or sickness.
• Radical treatment is vigorous treatment that aims at the complete cure of a disease rather than the mere relief of symptoms. 
• Extraordinary treatment is usually highly invasive and might be considered burdensome to the patient.

Radical medical care can lead to more pain with no gain. Though the idea that more health care is better seems to make sense, none of the above necessarily helps you live better or longer. In fact, too much medical care might shorten your life.

What you can do:

• If you have a choice, consider using a General Physician or Specialist Doctor attached to a hospital who practices conservative care.
• Work with your General Physician, or the specialist in charge of your specific condition, on preventive measures that can help you avoid unneeded hospitalizations.
• When hospital stays are needed, try to ensure that a family member or friend is there whenever possible to monitor the patient's care.
• For tests, ask: Will this test change the way you treat the disease? If not, what is the benefit of doing it? Is this test likely to lead to follow-up tests, biopsies, or other diagnostic procedures? How will this benefit my health?
• For treatments, ask: Is this likely to extend my life, and if so, for how long? How do its side effects and risks compare with the symptoms and risks of my disease itself? What will happen if I do not have the treatment?
• Develop a good, long-term relationship with a your General Physician. When medical problems arise, ask this doctor or your main specialist to coordinate all of your treatment.
• Keep and update your own medical record. Whenever you get care from any other doctor, hospital, laboratory, or clinic, have a record of it sent to your General Physician and to yourself.
• Keep an up-to-date list of all your medications, including prescription drugs, over-the-counter drugs, and dietary supplements. Include brand and generic name, dosage strength (such as 10 mg), and dosing schedule (such as once a day). Note any drugs that have caused bad side effects.
• Don't be pressured into agreeing to invasive life-support treatments, such as feeding tubes, without a thorough discussion of the patient's prognosis, personal preferences (if known), and overall condition.

Health Insurance Policy covers hospitalization expenses* for 24 hrs or more only, with some exclusions during first two years. Make sure to buy family policy for Rs.2 lakhs or more (max. Rs.5 lakhs) and renew in time every year.

Finally, branded medicines are very very expensive in India. Most common medicines are available as Generic Medicines, 20-40% cheaper than branded medicines, and are available in Generic Medical Stores.

* Hospitalization expenses nowadays amounts to a lakh of rupees even for minor procedures in private / corporate hospitals.