Physician, heal thyself

Medical terrorists is not a term generally used to describe doctors. But Dr Debal Sen is convinced that some of his compatriots in white coats - as well as other healthcare workers and medical authorities - are no better. The Calcutta-based cardiologist goes one step further when he expresses regret about having trained scores of doctors and health workers in the city.

"Now I feel that I've created Frankenstein's monsters," says the former chief resident and research scientist at Maimonides Medical Center (a premier cardiology hospital in Brooklyn, New York), who helped set up three cardiology hospitals in Calcutta.

His distress over the erosion of medical ethics will soon become public. Dr Sen, who is now an independent consultant, plans to write a book to "expose the misdeeds of unscrupulous healthcare providers and authorities".

He is not the only one bemoaning the state of medical care in the country. In July, a national network of doctors who believe in "ethical, rational and de-commercialised" healthcare will start functioning. The forum has been spearheaded by a Pune-based non-government group called Sathi (Support for Advocacy and Training to Health Initiatives).

Meanwhile, for all those who have a story to tell, a website called www.medileaks.in is already in place. It was launched in November by Sunil Nandraj, a social scientist who, along with his friend Alam Singh, has been campaigning for long to ensure that states put in place rules that would bring private medical industry under the law.

"Anybody who has a grievance relating to the medical field, be it a patient, a doctor or a whistleblower, can write to us. We will publish their submissions," Nandraj says. "We have already received many submissions and they will appear on the site soon."

For years, complaints about medical practitioners came mainly from the community of patients. Their accounts were varied, but common. Tales were related about doctors who hospitalised patients without need, forced them to undergo expensive and unnecessary diagnostic tests, called in other consultants for no reason at all and padded the bills.

But the tide has turned. Now the complaints come from the doctors themselves. A new book called Voices of Conscience from the Medical Profession, written by Dr Arun Gadre and Dr Abhay Shukla, contains the damning testimonies of 78 doctors. They speak of kickbacks paid to physicians who referred patients for expensive surgical and investigations procedures, of manipulating diagnostic tests to extract more money from patients and the unholy nexus between doctors and pharmaceutical companies.

"Almost all the doctors Dr Gadre interviewed were alarmed by the gross commercialisation that goes on in the private medical sector," Dr Shukla, Sathi co-ordinator, says.

The overwhelming response to the book - published first in Marathi and subsequently in English last month - prompted Sathi to come up with the doctors' network. The forum would, among other things, raise its voice against irrational drug prescribing, kickbacks, misleading advertisements and corruption in medical bodies.

This is not going to be easy, for the corporate medical sector is powerful. "Doctors who practise medicine rationally are under tremendous pressure from market forces and the corporatised healthcare system," says a Calcutta-based gynaecologist, Dr Sanjib Mukhopadhyay, who was among the experts interviewed by Dr Gadre.

It is ironical that the phenomenal growth of private hospitals - which has made it easier for large sections of the people to seek quality treatment - has also spawned an equally massive growth in corruption.

With more and more private hospitals coming up, there is sharper competition, which prompts hospital authorities to apply pressure on doctors to add to their coffers.

"Nearly 80 per cent of people who seek medical care go to the private sector. A significant part of them are either overcharged or subjected to unnecessary diagnostic procedures. The crass commercialisation that has gripped our healthcare sector has made practising medicine less and less of a profession and more and more of a business," Dr Shukla rues.

That doctors in big hospitals have "targets" is well-known. This means that they have to admit a certain number of patients every month, ensure that a fixed number of tests are conducted and that every case is referred to other specialists. "Either you submit to all this nonsense or stand up to tremendous commercial pressure, which many may find difficult to do," says Dr Shukla. "They just fall into the trap."

But now some doctors are standing up and raising their voice. A new and detailed version of Sathi's book is slated to be launched soon. And more and more whistleblowers are expected to bring such malpractices into the open.

"This is just the tip of the iceberg," maintains Dr Punyabrata Gun, a physician at Shramik Krishak Maitri Swasthya Kendra, Howrah, and one of the whistleblowers quoted in the book. "There is no dearth of doctors in Bengal who wish to blow the lid off greed and corruption."

Some of the tales that the doctors relate are the kind you'd expect to find in horror fiction. A Calcutta-based gastroenteric surgeon, who does not wish to be named, says he has come across cases where doctors have charged patients for gall bladder removal surgery, without actually conducting the surgery. He has heard of similar cases from surgeons related to appendectomy, the surgical removal of the appendix.

A Calcutta chest specialist recounts a hair-raising incident in a city hospital. A lymph node tissue for biopsy (to check for signs of infection or disease) was extracted from his patient by a ward boy because there were no doctors or technicians available. "The patient suffered an obstruction in the lymph node and is undergoing treatment in a different hospital."

Malpractices are rife at fertility clinics, too, stresses Dr Sudip Basu, an obstetrician and gynaecologist. A woman's ova can be collected without permission and transferred to an infertile woman seeking medical help.

Even the medicines that doctors subscribe are sometimes suspect, for pharmaceutical companies are known to give "gifts" to doctors to prescribe a particular brand. The gifts can include air tickets and hotel stay for conferences, foreign travel, easy loans or just kickbacks from chemists. This rampant practice forced the central government to announce a ban on pharmaceutical companies offering freebies to doctors after January 1, 2015.

But the question being asked is if such measures will bring about change. Nandraj believes it will, if it leads to states adopting the Clinical Establishment (Registration and Regulation) Act of 2010 (CEA 2010) or similar pieces of legislation. "There is no appropriate legislation to regulate private clinical establishments in most of the states currently," he points out.

The CEA 2010, currently applicable in Arunachal Pradesh, Himachal Pradesh, Jharkhand, Mizoram, Sikkim and all Union Territories, seeks to regulate clinical establishments and prescribe minimum standards for personnel and infrastructure and force private hospitals to display rate charts for common tests and procedures.

"Of late, Bihar, Rajasthan, Uttar Pradesh and Uttarakhand have adopted the act by passing a resolution. But they have not yet framed the rules or notified state or district level authorities," says Nandraj.

He adds that bureaucrats and politicians are often under pressure to turn a blind eye to such laws. In Bihar, for instance, the act was revived only when the high court directed the government to enact and implement the rules, he says.

Independent regulators can also help stem the rot in the system. Dr Basu adds that malpractices in fertility clinics in Britain are not possible because an independent regulator monitors clinics.

The Indian Medical Association (IMA), a body representing 2.5 lakh doctors, is aware of the campaigns that are sweeping across the country. Dr A. Marthanda Pillai, IMA national president, stresses that it is not against standards but fears that the CEA, in its current form, will lead to "a licence and inspector raj" in the country.

"A private medical establishment in India is subjected to as many as 72 different acts. Besides, we already have a National Accreditation Board for Hospitals and Healthcare Providers," Dr Pillai argues.

Dr Sen holds that the current accreditation procedures meant to assess hospitals are just a sham and the evaluators can be "bought" easily. "There are no medical audits to check the records of these hospitals, unlike in the US or UK," he says.

The "medical terrorists", he says, have to fall in line. "But who will guard the guardians of the healthcare system?"

Nandraj too believes that the current accountability mechanisms are not sufficient to ensure quality and prevent negligence. "That apart, can anyone set a limit to the number of laws that can govern you? It is like somebody saying that since so many laws are already applicable to him, he is not going to get a licence under the Motor Vehicles Act or pay tax under the Income Tax Act," Nandraj says.

But the IMA - which has often been accused of corruption itself - stresses that it is also looking at ways to improve the system. Dr Pillai, while admitting that the doctor-patient relationship has deteriorated drastically, says the IMA has constituted cells at national, state and district levels to redress patients' grievances. "Besides, there are newly formed ethics cells too," he says.

Not many doctors are reassured by the IMA's moves, but there is hope that the strength of united dissenting voices will bring about change. And the phrase - the good doctor - will not be erased from the patient's dictionary.