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.

Corporate hospitals killing small hospitals and exploiting patients

No matter how compelling the reasons, governments cannot be guided by emotions of moral outrage and of right and wrong. A democratic society is founded on the basis of the rule of law that must guide government actions. This is so in order to avoid governments misusing their power, resorting to arbitrary action and ensuring fair play and natural justice. This then implies casting a special responsibility on the governments who are charged with the duty of providing good governance to its people. 

• Having declared health as an industry working on the principle of return on investment and making profits over the welfare and well being of the patients, governments have a special duty to lay down laws, rules and regulations to stop providers and hospital establishments from getting away with predatory behavior or malpractice.
• During the past twenty years, following liberalisation policies, the growth of the IT industry and other factors, as well as disposable incomes among certain classes, have increased – though this is not the case across the social spectrum. 
• As one doctor has said, Pune city, which should have fifty Sassoon Hospitals (public hospitals), has only one, although new corporate and multi-speciality hospitals are coming up daily.
• These corpotrate hospitals are bright and glittering. In some ways, they are like shopping malls. Some have even been registered as charity hospitals, but their only objective is profit. Partly because of their state-of-the-art equipment, but also because of a growing lack of choice, as older hospitals run by trusts or individuals close down, people are going to these hospitals. Such hospitals foster the impression that they provide high-quality services, which justifies their high costs of care.
• There is another important aspect of such “hospital-malls”. New technology costs lakhs and crores of rupees. If these machines are now indispensable for diagnosis, hospitals run by individual doctors are less able to compete. If the medical sector is left to the mercy of the market, and if the foundation of the whole business is profit, where will this take us?
• Government health services have been weakened due to government indifference, and that is why there is scope for corporate hospitals to prosper. Due to the entry of corporates, the order of priorities has changed. Now the doctors’ priority is no longer the best interests of the patients, but the profit earned by the shareholders of the company.
• In corporate hospitals, each patient may be seen by multiple specialists. An orthopaedic is called because the hands and feet are aching; a neurologist for numbness in the hands. They come and look at the patient and their charges are added to the bill. Is it useful for multiple specialists to examine a patient? This question is never even asked. Investigations are not based on what the patient’s illness is, and whether there is a need for specific investigations. Given any complaint, they produce a list of investigations that must be done. 
• Totally unnecessary surgeries are being performed in corporate hospitals. During investigations, they may see a small stone in the gall bladder. It is not causing the patient any problems. But they scare the patient into going in for a surgery.
• Public relations officers of many corporate hospitals keep roaming around to visit doctors; they entice doctors to send patients (to their hospitals) by tempting them with cuts. Nearly everybody indulges in this practice. It must be legally banned.
• These corporate hospitals charge bills of Rs 1 lakh and more, while the surgeon gets only Rs 4000 to 5000.
• Some corporate and large hospitals admit bogus patients under the Rajiv Gandhi Health Scheme (a publicly funded health insurance scheme). They give the admitted person money, and plenty to eat and drink. They prepare records showing that an angioplasty or angiography has been done on that person, when actually nothing has been done. How the government comes out with such schemes, without first regulating private hospitals is a mystery? Without regulation, the basic objectives of such schemes are lost, and they become mechanisms for corporate hospitals to loot public funds.
• There is no humanism to be found in corporate hospitals. Small hospitals are being destroyed due to these corporates. In small hospitals, there is at least the possibility that the doctor has not lost his basic sense of humanism. They wait for the patient to make the payment. They give concessions. None of this happens in corporate hospitals. This must stop.
• A corporate ophthalmology hospital maintain everything five-star style, but forget about the patient. When the patient comes, they give him lemonade or tea. They advertise that they have the latest hi-tech optics shop. The patient melts because of the free lemonade, and he buys a pair of spectacles that have an actual value of Rs 200 or so, for Rs 3000–5000! The in-house optician is the main income avenue of corporate hospitals. Sometimes they offer a free check-up. The scheme has a 20-per-cent-off offer, just like in a mall. The whole atmosphere is designed to tempt.
• Corporates can implement government schemes and insurance schemes. For small private hospitals when reimbursements are delayed they don’t have the time to keep making trips back and forth to get payment from the insurance company.
• Corporate hospitals vie for tie-ups with large public sector companies. These public enterprises give exorbitant reimbursement to their employees. The big corporates draw in cases from all over the state. But junior trainee doctors operate on those cases! Further, often the quality of these corporate hospitals is not as good as they claim in their advertisements. When they do a cataract operation, they even charge a high amount of money for an expensive lens, but implant an average-quality lens.
• If a patient goes with my referral note, he gets 30 to 40 per cent off on an MRI (because I do not take any commission). One patient forgot to take my note. He was charged the full amount, and a cut went to some third party - says a practising paediatrician.
• Nowadays people want glamour and marketing. They have become used to the mall culture. The concept of ‘master check- up’ (packages of large number of tests, of which many may be unnecessary) has gotten into their heads. Now doctors who practise ethically and scientifically are looked upon with contempt, because they obviously can’t afford this glitter. But people often don’t know what they are getting into by going to corporate hospitals.

The current obsession to privatise health, as if it is a commercial enterprise like Air India or a ITDC hotel, is not founded on the belief that patients will gain access to good quality of health care. Instead it smacks more of an admission of governments’ inability to govern and enforce laws in order to ensure that in the name of quality, private hospitals do not play havoc with the vulnerable patients. If truly committed to patients well being, then it is incumbent on the government to come up with stringent laws that will not provide any scope to private players to be negligent, callous or exploitative.

Read the source article

Truth about how some doctors exploit their patients

Fighting the rot in India's private healthcare feat. 

Dr Arun Gadre & Dr. Abhay Shukla

The corporate hospitals provide employment to almost 90% of graduate doctors, 95% of PG doctors .These corporate hospitals have numbed people’s sensitivities. These hospitals are like malls. Our society does not need them. Instead, all tertiary health care should be provided by the government. And corporate hospitals must also be compelled to provide mandatory treatment of emergency cases, whether paid or otherwise. This would enable people go to any of the nearest hospitals for emergency treatment, even if they don't have money or coverage.

Medicines and Stents, A loot in India.

Medicnes:
During 1970's I remember buying C Vitamin tablets CELIN by Glaxo were Re. 1 each. After some years IDPL launched SUCKCEE C Vitamin tablets for under Rs.0.10 each. Such was the loot by MNC's in the name of patent and so called exploded R&D expenses recovery. Doctor's always prescribed CELIN never SUCKCEE because of perks offered by Glaxo through their dealers and medical representatives.

Before 1970, there was no patent protection in India. So production of generic medicine got a boost and it increased so much that India started being called the “pharmacy of the world”. But after 2004-05, with the advent of patent protection, the situation has changed rapidly.

But people have a Right to Life. Generic medicines should be produced in abundance by keeping peoples’ interest in mind. At the same time, the quality and standards of generic drugs must be maintained. It is the duty of the government to regulate the quality control mechanism of generic drugs so that its credibility never gets questioned. Adulteration in medicine is a serious offence and it must be dealt through a stringent mechanism.

It is all because of multinational companies’ influence. They give a cut and perks to doctors. Doctors are given the licence to practise by the government of India. Can’t we issue them the licence on the condition that they will prescribe generic medicines to the extent possible? They will prescribe MNCs’ drugs only when no options are there among generics. As per MCI rules, doctors should prescribe cheaper drugs whenever possible. Violation of this rule should be made cognizable offence punishable including heavy penalties and cancellation of practice licence.

Prescription format should be standardized with columns of brand and generic name both written in adjacent columns and giving complete details of the doctor.

In a country like India, a lifesaving drug of Rs 9,000 is sold at over Rs 2 lakhs.

R&D must be taken care of. The burden of R&D expenses need not necessarily borne by the immediate drug users alone. It should be borne by the society as a whole. The government should refinance it. R&D should be there for the welfare of humankind and it must not be a licence to extort people. Even though companies have the right to charge high price until the patent expires, such higher prices should be justified and such higher price should be with a cap so that the drug is affordable by all. Any kind of manipulation of patent should be prevented and penalized.The government must cap sales and profit margins and provide good medicines at fair price.

Public sector drug companies like IDPL should be revived and rejuvenated to produce more and more generic drugs for benefit of common man.

A poor worker in my agriculture farm was all set to buy medicines worth Rs.750 from a medical shop in a small town. I happened to be around and asked the medical shop owner, to charge only cost to cost basis as a favor to me. Then the bill came down to Rs.200. Imagine the extent of loot. Mind boggling 300%. Half of the loot (150%) will go to the prescribing doctor since all these drugs are lesser known local brands.

Stents:
In 2010, out of estimated 3,500 stent implants carried out every month in Andhra Pradesh, at least 30% were unnecessary as per experts. While China accounts for nearly 30% of the global value, India claims around 25% of the stents market.

Some doctors while explaining the extent of corruption said, if a patient does not require a stent, he is being implanted with one, while a patient needing one implant is instead implanted with two. At least 20-25 varieties of stents are available in India, including imported ones and the cost ranges from bare metal variety costing Rs 15,000 to the advanced bio-absorbable stents costing Rs 3 lakh.

In 2010, the CBI that probed the cardiac stent scam in the state found that a hospital was billing for a high quality stent, but actually implanting a low quality one during surgery. The CBI probe allegedly involved several corporate hospitals and staff of CGHS in Hyderabad.