K. JAVEED NAYEEM writes: After Aamir Khan stirred up a hornet’s nest with his show about the misdeeds of doctors, I seem to have done the same with my article, which some people have seen as a defensive act from a member of the medical fraternity.
I have received many letters from viewers of the show and my readers too who have vented out their gall at the heart-rending sorrow of the victims and my audacity in protecting the image of the doctors supposedly responsible for it.
Apart from the two cases I discussed last week, many have challenged me to disprove him on the other counts where he has revealed many more misdeeds of doctors. I certainly will do so in full measure before I pull the curtain down on this matter, which I do not intend to do in a hurry.
I stepped in just because I felt that in showing what certainly seemed to be the main issue of that episode, Aamir Khan certainly picked on two very wrong cases to prove his point about all that has gone wrong with the practice of medicine in our country.
Yes, medical practice is no longer as sacrosanct as it once was and there is a lot that needs to be set right if it has to serve the needs of suffering humanity.
While someone attempts this, I would like to remind society here that a lot needs to be set right if medical practice has to serve the needs of practising doctors too.
If only Aamir Khan had done a little bit of research to locate some real cases of medical malpractice or negligence and ferreted out the real incriminating evidence behind them, before presenting them before his audience, he would have done some real service to society.
Moreover, instead of just presenting one version of what happened it would have been most appropriate and fair to all concerned if he had simultaneously or immediately after, given a chance for the doctors or the hospital managements to present their defence.
This would have made it more interesting and lent the utmost credibility not only to his show but also to his image and intentions. Of what use is any re-buttal if it has to be done through some other source or on some other platform? Even now, it is not too late for him to arrange this in one of the forthcoming episodes and I hope he does it.
Coming to his accusation that most doctors prescribe only expensive, branded drugs even when much cheaper generic alternatives are easily available, I would like to set the facts right here. It is true that for every branded drug there are at least a hundred cheaper versions readily available in Indian market.
This is thanks to our government’s policy of allowing anyone with a little money to ‘buy’ a drug manufacturing licence and start making a killing. Beyond this shred of paper that ensures complete legal immunity no other infrastructure whatsoever is necessary to set up a drug manufacturing plant in a tin-roofed shed, located in a seedy bylane and ply this lucrative trade.
Most such drugs do not have any drug inside. So, what goes into these tablets, capsules or tonics? They contain either plain chalk powder, sawdust or sweetened and coloured water.
If this seems like an exaggeration, why do we regularly have incidents in our country of spurious and sub-standard drugs and even vaccines killing the people who happen to receive them?
Why do the drugs dispensed by our government hospitals fail to bring down the high fever that bends the bodies of the poor patients who go there, while the same drug prescribed by the very same government doctor but dispensed by the private chemist across the road quickly puts them back on their feet?
One of my former professors at the Mysore Medical College who valued his integrity and honesty more than the instant material wealth it would have brought him, refused a promotion and returned from an administrative posting when he was pestered by spurious drug manufacturers to accept huge bribes and clear their pending applications.
He chose to remain in his almost non-paying teaching job, preferring to sleep on a pillow of a clear conscience rather than on a bed of currency notes. Today, without exception whatsoever, every one in the city respects him as the best example and embodiment of the rare qualities that one seeks in a doctor.
And, for this uprightness, he also happens to be one of my guiding beacons and I turn to him for the right counsel whenever I am faced with a professional problem or a moral dilemma.
The companies that manufacture branded versions of drugs have a reputation and a track record to protect and they will therefore get periodic quality checks done by authorised agencies to uphold the set standards.
In this respect, many reputed Indian companies and multinational manufacturing giants who have invested much money into research and development naturally keep the prices of their products a little high. This is understandably inevitable and we have to accept the fact that quality can come only at a cost.
It has now become a fashion to simply blame multinationals for all our problems.
Yes, multinationals may be exploiting us with their expensive products and in doing so they may even qualify to be called anti-nationals but at least they give us safe and effective drugs. If your doctor insists on your buying a particular brand of medicine, it is often because he or she has established faith in it.
On the other hand, if you end up buying a generic drug whose manufacturer is unknown and whose quality can therefore never be ensured, with what confidence can he or she treat you?
People may accuse doctors of yielding to the enticement and pressure of pharma companies but that is not the whole truth. If only generic drugs are permitted to be sold in the country as some people wish, the profit margins to the sellers, instead of the quality of the drug, will decide what the patients get.
I would prefer to give up practising medicine altogether if I have to do so without any control over what my patients get as medicine.
That is why all my prescriptions carry a line in small print at the bottom that says: “Responsibility for this prescription ceases if drugs are substituted, redispensed or sold without a valid bill.”
Aamir Khan while talking on the show and also before a Parliamentary Standing Committee yesterday about the need to promote generic drugs to keep treatment costs low should have taken a little trouble to ascertain the sources of drugs dispensed at most of the government hospitals across the country today.
As far as I know, we should be surprised if any of these drugs happen to be from any of the top 20 trust-worthy drug-manufacturing companies, which are operating in India. This is thanks to corrupt officials and politicians who rule the roost.
It is an open secret that heavy bribes have to be paid at every stage, to get oneself on the list of drug suppliers to the government healthcare sector and also to get tenders passed from time to time.
Therefore, it is no surprise that as each bureaucratic milestone is painfully crossed, the quantity of the real drug in the formulation naturally keeps decreasing until only the chalk powder, the sawdust and the sugar-water that I talked about, manage to reach the final destination!
Common sense should tell us that good drugs that really work, can only come from good companies that can get the prices that do justice to their quality control and good manufacturing practices.
In our country, all the good intentions of a doctor who insists on any particular brand of the prescribed drug can be derailed by many agencies.
With the already prevalent suspicion in most patients’ minds, just a whisper that the doctor is on the payroll or patronage of a drug company, from one dishonest chemist who wants to sell a brand that pays him more, is enough to convert doubt into conviction.
Patients must understand the fact that the best advertisement for any doctor’s capability is the efficacy of his or her treatment and in this respect, no doctor will endanger his reputation by prescribing a drug of doubtful quality simply to get a cut from any pharma company, as alleged on Aamir Khan’s show.
The great Khan further talked of needless lab tests that doctors order just to get commissions from labs who in turn recover these expenses by issuing reports without actually doing the tests.
While I do agree that most labs these days pay cuts to beat competition and stay in business, I do not think any decent medical lab would issue reports without performing the tests. If this practice exists, it is only at the slimy bottom of medical practice where the most unethical practitioners of the art operate and it is no index of the integrity and honesty of doctors in general.
But when something as ugly as selective female foeticide does exist in our country, and since some medical doctors have been found guilty of it, we cannot completely deny the existence of these ‘unperformed tests’.
Since doctors too have now been brought under the purview of the consumer protection act, litigation has become easy and cost-free for any disgruntled patient. Patients can now file cases against doctors at the drop of a hat over the most frivolous issues and doctors who used to spend their leisure hours unwinding in tennis courts, are now forced to spend much time and money in standing and defending themselves in law courts.
Very often, they have to be at the receiving end of adverse and financially burdensome judgements, as they cannot prove the correctness of their actions on the strength of paper records and reports.
Because courts go only by material evidence while deciding cases, doctors now to indemnify themselves against litigation are forced to order a plethora of lab tests and also go in for higher and higher malpractice insurance. Naturally, unknown to them, it is the patients themselves who end up paying the cost of these tests and the premiums for these insurance policies.
The commissions paid by labs are just a side effect of this sad development and they are actually not the main cause for the unnecessary tests, which now have to be accepted as quite justified, considering the present scenario. The labs have to resort to this unethical practice because they have to stay in business and recover their investments after paying the steep interest on their bank loans.
Today, it is no surprise that more than 75 per cent of the wide array of lab tests that doctors order, is what the consumer protection act has forced on them. The moment this act came into the scene, the sanctity of the relationship between the patient and the doctor that existed over the years died forever.
With just one stroke of the law-making pen, the sacred Vaidya of the age-old Indian shloka: ‘Vaidyo Narayana Hari‘ was unceremoniously tossed out of the hospital window.
Now, like how it happens in a Shakespearean tragedy, the scene has changed completely and the patient is only an aggressive consumer and the doctor only a very defensive service provider.
You may argue here that not all patients are aggressive and vindictive. But how are we to decide who the good ones and bad ones are, beforehand?
In this cat-and-mouse game, Dr Jekyll can become Mr Hyde and vise versa, without warning.
We doctors regularly see not just really aggrieved and wronged patients turning to the courts but also those who did not like the outcome of their treatment. There are records of people having gone to court with false charges simply because hospital bills were not waived off or reduced as requested by them.
I know of many patients who attribute all that befalls them later to the ‘wrong’ treatment that they once received at some hospital.
Similarly, I routinely encounter women who blame the tubectomy operation they underwent decades ago for all the aches, pains, coughs, colds and cancers that they now suffer from.
I have once seen the inside of a consumer court as an expert witness and I did not find it a very comforting or friendly place. While watching the proceedings, I noticed charges being traded left and right by litigants, like paper missiles, without any regard to the wisdom enshrined in any textbook, either medical or legal.
Now I do not intend to revisit the place, especially as a defendant.
What I am going to say here may shock you but even I am guilty of ordering some ‘unnecessary’ lab tests sometimes in my practice. However, these lab tests are only unnecessary from the point of view that if I am fully honest, I really do not need their help to make a diagnosis, which is where all lab tests are meant to help us.
I order these often expensive tests only to keep myself and my practice safe from any medical malpractice litigation. Very often, even where I find the diagnosis staring at me in my face, I never proceed to announce it or treat the condition before I get the verdict straight from the horse’s mouth.
And, here my helpful horse is the friendly neighbourhood diagnostic lab, which is naturally a pretty expensive horse to boot because of all the expensive equipment it bears on its back.
In the event of the need to treat some poor patients, which I do quite often in my practice, I ask the patients’ relatives to simply sign an undertaking that they cannot afford the cost of the recommended tests and are therefore willing to go by my clinical diagnosis.
I then quickly keep this precious document in my bank locker, which I have hired just for this purpose!
For me these uninvestigated cases are the most comforting ones to treat, as they, while making me feel like a real doctor from the good old times, do not impose a strain on my conscience.
Coming to the really pathetic portrayal on Aamir Khan’s show of the plight of women from Andhra Pradesh who seem to have been subjected en masse to needless hysterectomies or removal of the uterus, I am almost certain that this must have been some kind of an insurance racket involving unscrupulous middlemen and it needs to be investigated fully. All those found guilty, including the doctors if any, should receive the most deterrent punishment.
These days whenever patients get themselves some kind of medical insurance, agencies which would have sold them the policy, often prevail upon them to make the best use of the cover before its term expires. They do this to make the insured persons feel that investing on the policy was a worthwhile expenditure because it helped them to get treated for some ailment, real or imaginary.
While most of us would be happy not to have needed our medical insurance cover, many people especially from the lower strata of society, feel cheated if they have to get it renewed year after year without putting its benefits to any use.
I regularly come across many patients who are desperately impatient to put their medical insurance to some use and it is often a difficult task to dissuade them from doing so.
Very recently, a lady came to my clinic with a medical insurance policy for Rs. 1,000, which she had received as a compliment for buying a crate of dish-washing soap. Under its cover, she wanted me to certify that she was under my treatment for which she was willing to share 50 per cent of the amount with me.
When I did not oblige she went away complaining that I was so unhelpful in getting her what was legitimately her due under the policy. She would perhaps have even felt that I stood my ground only because the miserable incentive was not large enough to make me abandon my principles!
Aamir Khan should understand and accept the fact that the medical fraternity he is lampooning on his show is guided and governed by many complex issues that deal with life’s most complex and elusive problems.
Practising medicine is more of an art than a science, where two identical problems often do not respond identically despite identical lines of treatment. When it comes to medicine, he is after all only a layman and medicine certainly is not his cup of tea like how it is mine! I wish his attention now shifts to something he understands better.
For instance, the black money that keeps the projector wheels turning or the close liaison between the film industry and the underworld. But that takes the kind of courage that this kind of Khan perhaps does not have in him.
(K. Javeed Nayeem is a practising physician who writes a weekly column in Star of Mysore, where this piece appeared over two weeks)