Doctor's dilemma

A large percentage of our population depend on private medical practitioners for their primary care needs. This is despite the fact of there being in place a well structured and widely spread network of PHCs [primary health centres] and sub health centres [SHCs]. It is beyond the scope of this article to describe the ills besetting this network of health centres and why people don’t chose to seek help in these centres.

GPs come in different hues and colours. They include practioners of different systems like Ayurveda, Siddha, Unani, Homeopathy, Naturopathy, Electrotherapy, Hydrotherapy, Reiky, several kinds of Yoga and the like. Some of these combine their craft with dispensation of allopathic drugs. If you include chemists who also dispense advice and medicines you would not be very wrong. All these provide some sort of primary care. My paper is confined to the working methods of doctors who practice allopathic system and who have a basic MBBS degree.

In this write up I have tried to analyse why this section of qualified allopathic doctors have failed to deliver comprehensive, affordable quality medical care. As this is linked to unethical practices, it has some relevance to what is being discussed in this conference

It is a basic principle that when a cheaper and effective drug is available, that should be used preferably by the oral route unless there are specific reasons for not doing so. This rule is generally not followed. The reasons are: patient’s belief that injected drug is more powerful than the oral one and also their willingness to pay more. Doctors put in no effort to dispel this belief and in fact exploit this by obliging the patient. Costs of injectables are much higher than oral drugs and the cost of care thus goes up. Many doctors run unnecessary IV drips and the reason is the same. Demand for X-rays, Ultrasounds, CT and MRI studies and many lab tests is far in excess of actual need and again is driven by commercial rather than clinical considerations.

With the advent of private players into the health care scene urban India is witnessing a bloom in institutions providing health care. These laboratories and hospitals are competing for custom of the paying Indian. Doctors are enticed with monetary and other inducements to refer patients. It is common knowledge that this cut practice is wide spread and it adds to the cost of health care. It is also a medically known fact yearly medical examinations [package deals] as screening methods, when indiscriminately applied to all and sundry, are a huge waste of money and another reason for pushing up the cost of care.

Pharma companies and medical men have always been cosy bedfellows. One encourages the other to the detriment of the patient. When one can carry out a decent family practice with about 200 drugs where is the need for 10,000 odd combinations and brands of drugs which are available in the market? Pharma companies and equipment manufacturers sponsor doctors CME [continued medical education]. These meetings can be local, in another town or even abroad. Depending on his use to the company, the doctor’s travel, stay and even entertainment is taken care off. The sponsor naturally expects and in fact gets the returns by the way prescriptions and use of the branded equipment. Those who don’t want to enter into such a relationship often find it hard to organise professional meets or participate in one. That there are still few doctors left who have survived is fact that surprises me.

Are these facts not known to the consumers? Of course they know or are coming to know. This one of the reasons why they no longer hold us with the same degree of respect that they did 30 years ago. Physical assaults and increasing litigation are the direct outcome of this perception that we are exploiters.

Why are we unethical? The answers are many. A combination of prevailing socio economic scenario and the compulsion to keep up with the Joneses at any cost is one reason. Add to this the basic human quality of greed and inability to accept a low profile life in a society which seems to respect only the wealthy is another. Add family and peer pressure, we have a tailor made situation for practicing unethical medicine.

The only silver lining is that society is becoming more informed. Hopefully, the informed citizen of the future will seek out honest doctors if they exist, and will be able to get the profession to mend its ways.

This write up is based on a presentation made at the recently concluded bio ethics conference.