How changing landscape of healthcare in India has made it worse for both doctors and patients
A 35-year-old young male once went with a sudden onset of excruciating chest pain to the casualty ward of a nearby tertiary care private hospital. His ECG and blood tests suggested a massive MI (myocardial infarction, or heart attack), and a young cardiologist who attended to him explained to the patient and his attendant about the urgent need to be wheeled in to the cath lab (catheterisation laboratory) for an emergency angiography.
The patient's younger brother immediately called his friend, who was doing a paramedical course, for a second opinion. His friend confidently told him that heart attacks do not happen at such a young age. Maybe the hospital was just making a fuss out of a simple gas trouble, and slyly remarked that private hospitals do such things to make money.
"Just get discharged from the hospital and go to Dr X, one of the general practitioners I know, who is very 'ethical' and experienced." All the negative propaganda that he had heard about private hospitals, and the youthful demeanour of the cardiologist made him work according to his friend's advice without much dilemma.
He reached his next destination in one hour, and by the time the experienced GP could examine the patient, he was already in cardiogenic shock. After some desperate measures of resuscitation, he was referred back to the same private hospital. Unfortunately for the young man, by the time he was brought back to the private hospital, it was too late.
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Another incident: The patient, a 66-year-old businessman was admitted with severe headache and unconsciousness of over one hour. He had suffered bleeding in the free spaces of the brain due to the rupture of a weak point in the brain's blood vessels (subarachnoid haemorrhage).
A brain angiography was immediately done and a large aneurysm (an "outpouching" of the brain vessel, the rupture of which had led to his medical condition) was detected. He was advised by the neurosurgeon that the patient's aneurysm needed to be fixed urgently by "coiling", and every moment passing by was like a ticking bomb that could explode any moment.
As the patient had gained full consciousness without any deficits by that time, and his headache had also receded, and the cost of the procedure was "exorbitant", they sought a second opinion from a relative who stayed in the USA. The guy took one week to get back with his opinion, which was again from a general physician in the US, as the consultation fees charged by a neurosurgeon with a private practice in the US was staggering. The opinion, as expected was very diplomatic with legal equipoise, and of no conclusive nature.
Finally, they decided to defer the intervention and wait, as more and more well-wishers pitched in with expert opinions and adverse feedback of that particular hospital. Just as they were planning to take him to another hospital, the aneurysm ruptured and he again suffered a massive brain haemorrhage.
Things took an ugly turn, when relatives turned hostile towards the hospital, and blamed the doctors for negligence and wrong treatment "that killed their hale and hearty father, who was just a while ago talking so nicely to them".
These are true incidents that happened around me, and I can come up with many more such episodes, where the deficit of trust in the hospital and the doctor led to wrong decisions taken by patients, only to their own peril.
Trust deficit, self-medication
Also, finding a connection between a newly diagnosed ailment and some possibly distant treatment given by some doctor for something entirely unrelated, is a ubiquitous, all-pervading phenomenon, and as doctors, we face it all the time. My grandmother was convinced that she had developed diabetes a few months after taking some eye drops for her cataract surgery. One of my uncles told me that he had developed kidney stones because of the medicines he took post his gall bladder surgery. One of my patients, who is a habitual alcoholic with chronic liver disease, thinks that he has developed haemorrhoids just because of the antacids, multivitamins and abstinence advised by his doctor.
As long as such people were fewer in number compared to the ones who appreciated our efforts, we doctors were never perturbed by such innocuous accusations. But, times have changed.
Low opinion of the doctor
In the good olden days, doctors were a revered and respected cohort. I really envy the uncomplicated and hassle-free life they enjoyed. The stethoscope and the prototype brown briefcase - that carried all the elixirs to myriad ailments - were the two quintessential items that were enough for diagnosis and treatment for all.
Most patients positively "responded" to their treatment (they say half of the ailment is gone if the patients accept the treatment with some faith); some had to be referred to government hospitals or small cosy nursing homes.
The charges didn't burn their pockets and their hearts, of course.
Any untoward incident, or death of a patient, was considered divine will, and a doctor was seldom looked upon with suspicion or/and blamed for it. (It doesn't mean that diseases didn't exist and mortalities didn't happen then; it is just that ignorance was bliss for all and faith in god and doctors was supreme.)
An old aphorism from those days - "The doctor is next to God" - is still used for doctors sometimes, but more as a tool to browbeat his supposed lack of morality. With time, like in any other sphere, healthcare and patient management standards advanced in leaps and bounds, with technical innovations, better medicines and diagnostic tools and specialisation at our disposal.
The meek family physician of yore grew out of his small frame and became more flamboyant, specialised, proactive and tech-savvy with multiple options available to offer to the patient, and as a result, the treatment costs also skyrocketed.
Neglecting healthcare sector
Most of the developed countries came to terms with the huge strides in technological development in medicine, and since healthcare was always their top priority, by default they protected their citizens by providing universal health insurance, or declared free healthcare as a state policy. (Though we accept that they had the money, and had to cater to a smaller population who mostly paid taxes.) In addition, they made uniform rules and strict regulations to govern the medical practice. However, even in the developed countries, private hospitals and clinics are opted for only by the most affluent of the population.
Meanwhile, in India, there have been more "pressing issues like religion, caste, creed and petty politics that took precedence over all others. Naturally, healthcare was an orphan that was owned by none but abused by everybody.
Therefore, the burden of providing healthcare shifted to private players in an unorganised manner, and government conveniently abdicated itself from all its responsibility. The government hospitals crumbled by the sheer load of patients and became dark holes of corruption where money was pumped in without any tangible return.
The vacuum created by the gap was quickly filled in by untrained quacks, unscrupulous men who pose as doctors, Ayurveda practitioners, homeopaths and surgeons without any actual degree or proper training, and they flourished because of their cheap means of healthcare delivery. All this was given a blind eye by successive governments that spent a dismal 2 per cent of the GDP or less on health (as against WHO recommendation that state spending on healthcare should be at least 15 per cent).
Overtime, government medical colleges became towers of apathy and neglect, while private medical colleges, mostly owned by businessmen working as fronts for netas and corrupt babus (who park their ill-gotten money in these organisations) mushroomed all over the country. They charge capitation fees running into lakhs and crores, mostly paid by cash by black money hoarders, and now, they dominate the landscape of medical education.
Corporate hospitals as lifestyle service
The corporate hospitals have ushered in a revolution in Indian healthcare, bringing it cutting edge technology and world standard patient care. But the flip side has been the commensurately rising costs of healthcare.
In big metros, by default or design, the small hospitals and nursing home lost their charm for the patients, who opt for big hospitals nowadays.
The demand of patients go much beyond good treatment: they want five-star comforts, impeccable room service, multi-cuisine restaurants. A new class of professionals called "healthcare managers" have now emerged who take care of all the whims of the new-age "customer patient". The old connect between doctor and patient is getting lost overtime.
Abysmally low healthcare insurance
But the health insurance coverage has been dismally low, because health in India is not a priority at all. As per the NSS statistics, around 86 per cent of the rural population and 82 per cent of the urban population were not covered under any scheme of health, and adding to the trouble was most of them go to the private sector for treatment. And many out of them were inadequately covered.
As the saying goes, we Indians have "kam insurance lene ki beemari".
Health expenses and hospital admissions are always an economic emergency that upset the applecart of the finances of an Indian household, and there creeps in the grumbling frustration and emotional outburst against the hospital and the doctors.
And God forbid, if at all the treatment doesn't help the patient or the patient dies in the hospital, then paying bill becomes an ever more painful experience. After all, when money was spent on treatment, the result expected is 100 per cent recovery.
Ironically, such aspirations and expectations of immortality have been raised by the same advanced healthcare and skilled doctors. The problem in government hospitals is entirely different, with delayed and grossly substandard services in most setups, lack of attention by doctors due to the burgeoning crowd of patients in the OPDs and IPDs, leading to ire and anguish towards the system, which is represented at the ground-level by the doctors, who become victims of abuse and violence.
In the backdrop, morals and ethics in all fields of life has taken a beating, be it the bureaucracy and general administration, police, revenue department, corporations, real Estate and builders, the defence forces, the judiciary, the media, or the engineers in government sector, with politicians sitting at the top. Even the docile bankers have proved that they are not incorruptible in the face of an opportunity, just look at some of them during the demonetisation episode.
Doctors are soft targets
The Consumer Protection Act has positioned the patients as consumers, and negligent doctors are slapped with heavy fines and compensations running in lakhs and crores. But curiously, the doctor was never accepted just as a service provider. He is expected to be charitable, dole out concessions, work for free at times and 24X7 sometimes.
Most of us who have taken the Hippocratic Oath, try to abide by it, but exceptions are everywhere, especially when there is gross non-uniformity in the entrance process to the various medical colleges (government and private) and education and training standards.
Furthermore, like any other profession, the chances of human error cannot be completely eliminated, even though the five-and-half years of rigorous training for MBBS, three years of MD/MS (if you specialise) and three years of MCH/DM (if you super-specialise) interspersed by few years of residency and fellowships of various types are meant to reduce it to the minimum.
It is also a fact that earning rich dividends for his specialised niche job and hard work and diligence that a doctor puts in, is also despised by a section of the society, which is very disappointing. Of course, personal greed and lust for material wares in some doctors may distract them from their ethics, like any other professional in any other field in the world, which needs to be identified and reprimanded and punished by law.
But does it mean that rowdies and disgruntled patients and their attendants may be allowed to resort to verbal and physical violence, rampant vandalism, and hurl baseless allegations without any evidence? As per statistics, about 75 per cent of doctors have suffered violence, physical and verbal, at some time in their career. Is it not alarming? Does it auger well for a democracy, where rule of law should hold supreme?
And the simple reason why doctors are soft targets is that there is no strict penal measures on violence against doctors. Interestingly, the most corrupt sections of the society have fortified themselves from any retributive public action by bringing in laws to safeguard themselves; even pointing a finger of accusation or wrongdoing can land you in jail, forget about touching them physically.
A sensitive relation
It is important to realise that the relationship between doctors and patients is a sensitive one, which needs mutual respect, compassion, trust and perseverance. The deepening wedge of mistrust is only going to be counterproductive for society, leading to rising cost of healthcare and deteriorating standards.
Because, the cost of indemnity covers is going to rise like how it is in the West, which will then reflect in the bills and inadvertent investigations will become a norm. More and more doctors will shun their own private practices, close down their nursing homes and would like to work in a protected environment of a big corporate hospital. It is not a good trend, especially for a poor country like ours, one with zero political will, in which universal insurance cover is but a distant dream.
Moreover, the "brain drain" of quality doctors towards safer and better avenues provided by other countries will bolster mediocrity, that has already seeped in the profession because of the disinterest amongst the youth towards this heavily demanding service.
Solution is better regulation
So, "what is the way out", is the million-dollar question.
1) The government needs to sit with all stakeholders and enact sensible laws to regulate healthcare systems, costs and decide reasonable punitive action, instead of just announcing populist measures to unfairly victimise the doctors, and make a public spectacle of them, to impress the gullible masses.2) People should take insurance for their health, as per the contemporary times. Government should float healthcare insurance schemes for all.3) Public-private partnership should be encouraged for building healthcare infrastructure.4) More money should be spent on healthcare, so that dependence on private hospitals is eased.5) Strict penal laws should be introduced for vandals and goons who disrupt private hospitals and abuse the doctors.6) There should be an immediate crackdown on quacks and sham doctors who are a major pubic hazard.7) Patients should know their doctor's qualification (true qualification, because sometime quacks may look more qualified than a real doctor with their specious decorations and awards), and not get attracted by his "customer friendly fees" and the queue that stands outside his chamber. Please learn to value your health, as you do for your other valuable belongings, and don't leave it to the mercy of any novice.8) The media should have a more sensitive approach and do some basic research before highlighting sensational news against doctors, hospitals and healthcare professionals.9) Private hospitals should keep public relations officers who can communicate with the patients frequently, in a more compassionate manner, to allay their anxiety and misconceptions.10) There should be a complete ban on capitation fees in private medical colleges and substandard medical education in many government and private medical colleges should be put under scrutiny.
Spread awareness
It's time for fellow professionals to beat the drums and raise the alarm!
Those who think that at the end of the day, after all the dust and din is settled, patients have no option but to come to doctors giving substandard service anyway, so no point making all the fuss, may be mistaken.The public perception does matter, and the doctor-patient harmony is very important for healing. The present situation is very disparaging. You do, you are doomed, and you don't, you are damned!
It's abslutely important to fix the problem, and it's now or never.