Unprecedented advancements in the art and science of medical practice have resulted in many challenges in the practice of medical profession. Medical ethics insist that the doctors’ main obligation is to keep the patients’ interest above everything else. But now, due to the technological dynamism in the medical field and with the entry of profit-motivated private investors in health care, the practice of modern medicine is becoming more and more impersonal and market forces tend to influence decision making by doctors.
Health is a manpower-intensive sector. Health care does not rely on high-tech equipment or facilities alone. Health services’ provision is mainly reliant on human beings, the professional manpower who deliver the services. In health manpower, doctors occupy the most prominent place since they lead the medical teams in hospitals.
While cautioning today’s doctors of not falling into the trap of ill-gotten money, former president of India Dr A P J Abdul Kalam says doctors are the noblest professionals and they stand only next to God when it comes to removing human suffering. For him, generosity, ethics, tolerance and pure concentration on the patient are important virtues medical professionals should possess.
But in India medical practice is plagued by a sizable number of physicians who care more about their own income than their patients’ outcome. Most doctors have private practice in a competitive market with lot of market imperfections. Existing controls and regulations are ineffective in this market. General practitioners rely on the commissions from laboratories and specialists for referrals. There is lot of black money circulating in the system, as most payments to doctors and labs by patients are unaccounted for. The freebies given by pharmaceutical companies and labs force doctors to prescribe unwanted, expensive medicines and investigations. Some doctors themselves testify that laboratories provide them half the cost of the diagnostic tests like a CT scan or MRI. The unholy nexus between medical stores and doctors keep the business and practice roaring.
According to a study by the Planning Commission’s High Level Expert Group, the pharmaceutical industry spent more than 25% of its annual turnover on sales promotion alone as compared to a paltry 7% on research and development in 2008-09. Doctors, pharmaceutical companies and drug inspectors are all partners in a crime endangering the safety of patients. Poor, uneducated, innocent people are robbed.
While doctors are expected to practise medicine, the more “enterprising” among them have become top-level businessmen and entrepreneurs, forgetting their primary responsibility. There are instances of excellent surgeons and cardiologists turning into entrepreneurs running hospital chains. To them business is money and their medical practice doesn’t fetch quick riches. Post-globalisation, this has become a paradigm shift in most professions including academics. Some of them even venture into non-medical areas of businesses like real estate. This is in addition to the large-scale moonlighting seen in the medical profession. Moonlighting in medical profession is a phenomenon by which doctors engaged in the formal sector employment also work in the informal sector resulting in generation of black money.
In most medical college hospitals and leading corporate hospitals, doctors are more interested in taking up clinical trials and projects sponsored by big multinational pharmaceutical companies. In fact, a specialist doctor should spend more time with his patients than with the projects of such companies.
Many doctors fail to understand that they have to treat the whole person, not simply parts or their individual illnesses. Patients with multiple diagnoses require integrated treatment; a holistic approach by an interdisciplinary clinical team. Patients are not inanimate objects.
Many doctors leave the country for greener pastures. The brain drain that results from highly qualified specialists seeking employment abroad is but natural. Resources will move to places where they are rewarded best for their services. In addition to higher earnings, job security, opportunities for education, training and promotion, workplace safety, family welfare and country safety, etc. are factors leading to the emigration of doctors. The financial loss due to the emigration of a doctor can be considered as equal to the cost of educating the doctor. But the remittances of doctors need not always exceed the initial investment in their human capital.
Indian medical students rely heavily on Western textbooks while the West has moved away from textbooks and started relying mostly on original peer-reviewed research papers in reputable journals. Indian doctors apply Western knowledge in a patient population with very different ethnic background and environmental influences. There is minimal evidence-based literature about any disease or treatments from India. Doctors should engage in continuing medical education and stay connected to the fast-changing field of medical science. Even now, in many small towns and villages in India, “medical practice” is a fertile area for quacks. Totally untrained and unlicensed health care providers sometimes end up seeing 40-50 patients a day. They thrive on the trust built over long association with the local population. When regulations are ineffective the competition from genuine physicians in terms of quality, standard and integrated care will drive out quacks.
In India affordable health care reaches the middle class and upper middle class, but not the vast majority of the poor. When India launches reforms in health sector like the Universal Health Care, doctors and their medical practice assume great significance. Best practices in advanced countries like ensuring safer surgery, reducing hospital acquired infections, and minimising readmissions, etc. should be passed on to every new entrant to the profession. The medical fraternity should strive to deliver the highest quality of care and improved clinical outcome in a cost-effective manner.
The Medical Council of India (MCI), the statutory body with the mandate of “registering doctors to practise in India, in order to protect and promote the health and safety of the public by ensuring proper standards in the practice of medicine” is the main authority to ensure fair practices. And for the MCI, it is time to weed out physicians whose practice deviates substantially from good clinical practice.
The writer is professor of economics at Christ University, Bangalore, and can be reached at pmat2012@yahoo.com