An ardent observer, analyst and critic of politics and current happenings. Truly believes in human equality, poor and peasants have first right on resources, and rule of law essential in a democracy.
Here are my reflections and collections. Follow me on Twitter @nharshakumar
Modern medicine has advanced a lot but “death by intensive care” in isolation, with ventilator and life support systems is all the more painful and frightening. No one would like to die that way. While certain amount of pain is inevitable at the time of death, palliative treatment will help minimize pain, avoid the distress caused physically and monetarily.
Death is the one certainty in life. About 10% die due to a sudden death. The remaining will have to go through a bed-bound stage before going finally. Half of them end up in ICU's and one-third with ventilator and other life support systems. These people die miserable death in isolated hygiene rooms with no loved ones on bedside at the time of death.
Every human being yearns for a peaceful death. People who are terminally ill or bed-ridden at least expect a dignified death, but most of them are denied that privilege owing to certain misconceptions. People should be made aware of the real situation.
Palliative care is about giving empathetic treatment to patients and the concept of spending one's final days largely at peace with oneself and then dying with dignity.
It is true that we cannot always fully control the disease and pain of our loved ones, but we can certainly mitigate their level of pain through palliative care options.
About 8.4 million people die in India every year. At least 5 million of them will have significant suffering during the bed-ridden state — pain, breathlessness or a host of other symptoms, not to mention the emotional and social distress that may be associated.
In India, the poor die in agony in neglect, the middle-class die in agony in ignorance, and the rich die in agony on a ventilator. No one gets a dignified and pain-free death.
The poor are rejected by hospitals and told that “there is nothing more we can do, so go home”; the middle class gets futile treatment that breaks the family financially; those having resources are imprisoned in intensive care units and put on meaningless artificial life support measures that often cause intense physical, psychological and financial distress.
This suffering is unnecessary. Palliative care can relieve distress and enables the person to live, and when the time comes to die, with as much comfort and dignity as possible.
In 2015, in a study of 80 countries on Quality of Death Index, India was ranked among the 15 worst countries to die in. The denial of access to pain relief, if it causes severe pain and suffering, constitutes cruel, inhuman or degrading treatment or punishment.
In the absence of palliative care, treatment of incurable diseases becomes inappropriate. The implications on the family are seldom recognised or discussed. In the absence of any form of support, family members have to leave their jobs and the next generation is forced to drop out of school.
Even today, the basic principles of modern pain management are not being taught to medical and nursing students.
Many elderly people and their children want aggressive treatment, advanced tests, and the latest remedies — which may not really enhance the quality of life. Everything that can be done will be done in a major hospital, whether it is necessary or not, at a cost. Patients may fall into an endless loop of irrevocable conditions, extending their suffering.
People should set down on paper their well-considered preferences with regard to the kind of treatment that should be given to him/her in case they become at some point too incapacitated to take a decision and express it. This will make it easier for their children, caregivers and relatives to take a decision on their behalf.
Governments have neglected health care and private sector exploiting and pushing 4 crore people annually below poverty line is a matter of national shame.
A solution at the national level seemed promising when the Ministry of Health of the Government of India created a National Programme for Palliative Care (NPPC) in 2012. However it lacked budget allocations.
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.
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.
