Monthly Archives: July 2017

Doctor’s Fees: A Taboo Topic

Doctor’s Fees: A Taboo Topic
© Dr. Rajas Deshpande
 
A famous industrialist from Pune recently visited my OPD. My Boss called me on phone and told me to waive off the fees, as he was a close friend of my Boss. The industrialist was not only well behaved, but well-read too. He had a complicated problem, had seen Neurologists etc. in India and UK. He asked many questions, and I was happy to have been able to reply to most. The consultation lasted over 45 minutes. He went out, and was told by the receptionist that his fees was waived off. He knocked my door, came back in, and placed three thousand rupees on my table. My usual fees is half that.
“Doc, I don’t believe in taking advantage. You gave me all the time I needed, and I have paid far more to the foreign doctors for a fraction of that time” he said.
 
Just a few days prior, a European patient from Mumbai had visited with her Indian in-laws, and after a detailed consultation, when they went out and paid the usual fees of 1500 INR, she messaged me: that this was far lower for the service they received. © Dr. Rajas Deshpande
 
Two days ago, on Saturday night at 9 PM, one lady rushed in without appointment, an engineer now working in Pune. Quite lavish in her get up and paraphernalia, she told me she had recently delivered a baby in the USA and then returned to India. After we finished the consultation that lasted over 30 minutes, and included many questions and explanations about her “minor” neurological problem, about justification of diagnosis, every medicine, about lactation, and about her prior medical consultations, I was happy that I had answered all her questions, and was able to treat her without any tests. Then she said: “And yes, doc, your fees is too high. Most doctors in my area charge less than that. I want concession”.
 
Earlier it was quite embarrassing for me to discuss money with patients. I felt it was below my dignity to have to talk about money, and humiliating to have to explain my fees. When I decided what I charged, it was after a prolonged thought process, and awareness of Indian healthcare scenario and socioeconomic conditions. While being available for genuinely poor patients, I did not want to resort to any backdoor incomes, and also wanted to give every patient the best of my skill acquired over 15 years of education, and enough time. There are clean doctors, far more senior than me, in my branch, who know this well and charge a lot more as consultation fees than I do (some over 5000 INR for a single consult), for they know their own worth. But there also are few who for their own reasons continue to charge far lesser, some with a noble intention (usually at the fag end of their career), some with alternative plans. It is a personal preference of the doctor, especially specialist. A correct diagnosis and honest /right advise is becoming rare and rare, what with the quality of medical education and an admixture of streams, which aim at the fast, cheap, objective and basic rather than specialized, subjective and accurate. © Dr. Rajas Deshpande
 
In absence of any comparable example, (medical service is not comparable to any other, but to quote an example that most should understand), I have to mention this: when one buys land, home, good food or technology, one pays differently at different places, for different brands. No one argues about the rates of foreign cellphones or jewelry, even about cinema tickets, but the most important service of all: health, is considered a bargainable, perpetually low cost charity. Basic and emergency healthcare doesn’t mean attached super-technology, five star rooms and washrooms and air conditioning, best qualified staff and ancillary services. © Dr. Rajas Deshpande
 
Used to this question very frequently, I told this lady that my fees was the same as that of most super-specialists in larger cities, that it was based upon qualification, experience, skill and time spent. She wouldn’t listen, and refused to pay. I told her she could avail of the free OPD meant for poor patients if she had a BPL card or if she was a farmer. “I can afford, I am not poor. But I want concession, because some doctors in my area charge only XXX”she said. © Dr. Rajas Deshpande
 
A senior doctor had advised me during the beginning of my practice: “Concentrate on the affordability of the middle class. Manage your time with the patient according to their affordability, people are rarely willing to pay the doctor. If your consultation fees is high, you will turn off many patients, because even the rich opt for the cheapest possible healthcare, including the doctor”. © Dr. Rajas Deshpande
 
Of course I did not want to discriminate. But over a period of time I realized that most of the forced free categories keep on repeatedly visiting various specialists / hospitals (a free category patient visits over three consultants for every medical issue) because it is free/ low cost, this is a frustrating scenario. Even the affording class visits many specialists for the same problem because the doctor’s fees is too ‘affordable’.
 
A doctor must always be kind and compassionate, but in India, he / she also needs to be practical to avoid being exploited. Compare to the availability of a free food service at your home for the poor. Check out for yourself how many misuse it, and how often. © Dr. Rajas Deshpande
 
Various pathies and specialties have a different fees structure, and people must be educated that all doctors cannot charge the same. A surgeon or physician with more skill, experience, expertise and good outcomes is definitely entitled to charge more than his peers. After all, what is a few thousand rupees when one’s health is concerned? When filing suits against doctors who commit mistakes, people claim in crores, a fact that must be accounted for when the doctor charges his / her fees.
 
“Your fees has increased” said a patient, who has paid the same fees for last 8 years. When I asked him to name any commodity whose price hasn’t increased in last eight years, he said “But you are a doctor”. © Dr. Rajas Deshpande
 
Among all the inflations happening everywhere, it is only the doctor’s fees that mostly remains unchanged for years. There are excellent charity institutes with great healthcare services , also many government hospitals, but most people want a “Premium / Priority” healthcare service at their lowest rates, refusing to stand in a queue at such hospitals. © Dr. Rajas Deshpande
 
The cut throat competition among hospitals to match society’s low cost healthcare expectations has resulted in a nightmare: most of the permanent staff being hired is low-salary, low qualification overworked, and exploited, many of the consumables used are of a questionable quality. This reflects worst in most critical care units and some surgical units. Very few will understand the true depth of this horrible tragedy.
 
While all cut-practice and other malpractices must end, while every doctor must compassionately aim at resolving the health problem that the patient trusts him / her with, and satisfy the patient as much as possible, it is also necessary that people understand that good healthcare will come at a higher cost. No doctor should refuse emergency /basic treatment to a patient who really cannot afford. Other than this, “Cheaper Doctors are the kindest and the best” is a devastating superstition we must eradicate.
 
© Dr. Rajas Deshpande
 
Please share unedited.

An Ideal Patient

 

An Ideal Patient
© Dr. Rajas Deshpande

unnamed (2)

“My health is my domain, you are a member on my health team. You have a part to play, and I have a responsibility to imbibe your advice with complete trust, along with that of the other specialists I see. There are so many things in my life that are beyond your control: what I eat, what I do, how much I work or sleep or exercise, how I react, my mentation, and even my spirituality. All these affect my health, and I must assume the responsibility for that. My illness if not your fault.
Rajas, we meet like the tips of two pyramids, with few specific issues to resolve. We cannot know the entire pyramid, and it is unnecessary too. I have strong faith about why we should have met even as a doctor and a patient, I believe destiny has a purpose. The meeting between a doctor and a patient, not only you and me, can be so much beyond only a professional medical consultation: just so long as we have enough trust and shoulder our respective responsibilities well”.

These are the precious words of Ms. Prema Camp.

Once she came to my OPD, and asked me why I looked stressed. I told her my mom was critically ill, admitted at the same hospital. Mom was conscious then, but was quite shocked due to her recent worsening, As a son, I had limitations in counseling mom. Ms. Camp took my permission, went to the room where mom was admitted, and chatted with her a few hours, relaxing her with gentle anecdotes.

My patient and now a friend from last 5 years, Ms. Prema Camp shuttles between USA and India frequently. She maintains a meticulous record of all her health related documents, follows all advice to the last dot, enquires about every doubt that crops up, reads extensively still only asks relevant questions, and manages her side of the responsibility perfectly: researching and finding out the right type of food for herself, following strict and disciplined schedules of diet and exercise, and avoiding all unnecessary medicines. She has a phenomenal memory, but she has never used it to relate any bad experiences from her past, in spite of having many. If at all there’s something negative about her past, she mentions only the good that invariably came out of it. Age does not affect her at all, and she independently manages everything without any assistance (although she has highly placed daughters in the USA who care for her). Her blogs have an enviable readership too!

Every time she comes over, I learn something precious, especially about the effect of mind upon health and life. She brings me books and films related to health, hoping that it will help other patients too.
I do not know if it is entirely due to her growing up with the freedom of thought in USA, the spiritual pursuits which brought her to India, or both, but I find something quite rare in her: the ability to pursue a thought or an idea fearlessly to its conclusion, and to then honestly accept that conclusion. Irrespective of whether the world has yet grown up to it or not. Irrespective also of personal likes and dislikes.

Although I always stick to the professional etiquettes with a poker face, there are patients who crossover to this side of me and become friends. Then the barter system of payment via goodwill and information exchange works best, money becomes so redundant! Needless to say, she has never once misused the facility to call or message in spite of having my personal cell.

When I apologized for being late today, she smiled and said “Oh I enjoyed every bit of waiting here, I could get some time to read”.
I wish I keep learning these things from her!

© Dr. Rajas Deshpande

The Angry Husband Pandemic

The Angry Husband Pandemic

© Dr. Rajas Deshpande

“She can’t tell properly. I will tell” said the husband when I asked the patient what were her complaints. Right from the name, it was him who had answered all the questions for her.

“Does she have a speech problem?” I asked him.

“No” he replied, then the wife started telling her complaints.

The list was typical of stress related complaints: chronic aches and pains, sleep problems, lack of interest, tiredness, giddiness: a picture also frighteningly common among the youth today.

“What do you think is the main reason for your stress?” I asked, after I found that her examination was normal. The husband offered to wait outside, and she said yes.

Once he was out, the lady regained her composure, took in a deep breath, and folded her hands. “Doc, please don’t tell all this to him. I am terrified. My husband is a very angry person, and reacts very aggressively to small mistakes or whatever is against his wish. He was not this angry earlier, but he is under a lot of work pressure himself, so whenever he comes home, I think I have to accept this anger because he has no other place to vent his feelings. Even when he calls, he snaps at the smallest of things, scolds and insults me. On weekends he wants to be left alone and if at all I try to interact he has outbursts of anger. Earlier I thought that this was the beginning phase of his career, so I tolerated. But now my whole life revolves around this fear of his reactions. He treats other women very formally and mannerfully, but treats me like dirt”. © Dr. Rajas Deshpande

She wasn’t alone. The phenomenon of wife being intimidated by anger of her husband is one of the most common relationship statuses in India. Even when 70 or 80 year old couples visit, the wife usually requests the doctor to advise her life partner of over 50 years to control his anger. Superiority and validity of anger of a man over a woman is so commonly accepted in India, that if some husband treats his wife equal, questions are raised as to his being “man-enough”. Paradox: I know of a wife who told her husband in their terminal fight before divorce: “May be you didn’t know how to handle a woman. Maybe you should have slapped and kicked me and treated me like my father treated my mom. They never had fights, because he knew how to shut her up”.

The implications of applying the Global western culture to an orthodox society are many, and mostly disastrous where human relationships are concerned. While some women proudly boast about the anger and domination of their husbands, and how ‘secure’ they feel about this ‘manliness’ that controls them, only a few realise how far away from true gender equality we all are. Growing up with “Princesses and Damsels in Distress” being rescued by “Knights In Shining Armours”, we have probably conditioned our minds too much to notice whether the Knight treated the Princess well in the “Happily Ever After”.

Let us not even talk about the “he-works-and-earns-so-naturally-tired-and-angry” type, or the “Highly-praises-his-wife-in-public-but-treats-her-like-dirt-at-home” type. The blind acceptance of what earlier generations considered normalcy and words in lieu of actions are both crimes we are all equally guilty of. © Dr. Rajas Deshpande

Implications of this angry husband? A woman who spends her life never growing up being herself, stays a slave to his whimsical outbursts of love playing a hide-and seek with humiliation and anger. Some do this while working and raising children, while some others do it sacrificing the high education and training they have taken, in the name of making a family.

Making a family also means happiness and freedom of thought, speech and action for a woman, responsibility sharing and respect towards the feelings of each other, but this is yet to dawn in many societies, where the bread winner automatically becomes the master and the remaining family members his slave. © Dr. Rajas Deshpande

To be just, one must also mention that there indeed are women counterparts of this phenomenon, where the anger outbursts of a woman hold the entire family for an emotional ransom, where the husband and kids never can feel ‘at home’ in the one where she dwells. But fortunately this is rare.

There also are rare pleasures of meeting some brilliant couples who have mannerful and respectful attitude towards each other (not a show). They hold hands, stay together, and laugh genuinely, whether in public or at home. Those are the definitions of love. An occasional tiff may be unavoidable, but there’s rarely anything that cannot be resolved when the two in a relationship know the correct balance between words and silence. © Dr. Rajas Deshpande

Sometimes some diplomatic men boast with too many chests about their success and achievements, while mentioning in their speeches how their wife was their strength and how she is an ‘equal partner’ in their success, how they could succeed because ‘she looked after the family and kids’, just looking at the wife’s face tells volumes about the reality. My stupid mind is sometimes tempted to ask “Did she choose that or was her duty taken for granted?”.

As I counselled the couple, I realised that so many times we cannot fight deep rooted socio-cultural notions of gender inequality. In the age of rabid egos where there are more break ups than patch ups, where we know more words than feelings, where winning verbal argument is considered a superior ability to healing actions, it is becoming perpetually difficult to imagine that marital relationships will evolve any further unless immediate steps are taken to educate children right from school about the correct interpretation of gender equality and the incorrectness of what is being accepted as normalcy: “Anger Outbursts” under the pretext of being stressed or busy.

For anger or the presumption that it is justified against one’s life partner as a ‘soul venting’ mechanism are both unhealthy for everyone involved: a disease that has now become a pandemic.

© Dr. Rajas Deshpande

Please share unedited if you believe in true gender equality.

The Medical Secret Service: Unknown Angels

The Medical Secret Service: Unknown Angels
© Dr. Rajas Deshpande

“Hullo, Vishwa? Please consider this an emergency. One of my rural patients is here, she is on XXX brand of tablets, she has finished the dose, needs more immediately for another three months. She cannot get them. She has to return by an evening bus. Can you do something?” I was in a hurry, between patients.
“Yes, Sir, I will arrange within a few hours” Vishwa said, and indeed, within two hours, the nearest medical shop called, saying that the medicine was available for the patient at a discount.
That evening I called to thank Vishwa, only to be shocked.
“Sir, you were in a hurry today morning so I didn’t tell, I had a heart attack last night, and an angioplasty was done. I am ok now.” said the 30 year old to me.
Like the thousands of his community, the Medical Representatives, he is immensely contributing to the healthcare industry, unrecognized and unacknowledged. © Dr. Rajas Deshpande

“”What is your job? Just passing on bribes to the doctors? My cousin said to me, Sir, and I did not reply. You should not argue with the one who has poison in his heart. People look down upon us, but they will never understand what we do” said a 60 year old man who had spent life as a medical representative, now a national manager. “We have no choice of judgment, our job is to be the link between the doctor and the company, and to make sure our medicine is available” he said.

Millions of busy doctors, overloaded with their work, have no clue how many pharma companies exist, what medicines they make, what medicines are newly launched, what is the brand name or price etc. It is not practically possible to read the whole new drug launch book every month. This community of medical representatives alone is the link between the pharma companies and the doctors, updating us about various new drug launches in India, their availability etc. They also arrange for academic events so necessary for the doctors and medical students. © Dr. Rajas Deshpande

“Some Doctors are very good and treat us respectfully” said Janvi, who has spent over 20 years in this profession, “but some expect favours from the companies, in the form of tours, dinners and other things. Sometimes, I have had an occasional trespassing of moral lines by some doctor, but that was rare. One needs to be able to take care of one’s dignity and self -respect. Especially Indian women face a lot of difficulty and gender bias when making a career, at all levels.” she said.
“The pressure for women in this industry is immense, and like any careerist woman, I faced a lot of presumptive hate too. If a woman, and especially good looking, is successful, our society already has made its judgment as to the reasons of her success. Most Indian men do not tolerate the idea of a woman succeeding ahead of them. Of course, one must clearly set priorities as to whether one wants to make a career or family, and if both, where the compromises will be, because both are full time jobs at least for any woman. Most doctors have treated me well though, and most doctors also want to do good for their patients”. © Dr. Rajas Deshpande

In my 20 years of career as a doctor, I have never come across a Medical Representative who turned down my request to help a patient: lacs of rupees worth of medicines I have asked them to arrange free for my patients, and they have arranged without a question. Thousands of poor patients receive free / discounted costly medicines, injectables, even stents etc., thanks to the generous efforts of this community and their companies. Thousands of medical camps are arranged all over India, where patients get free check ups from doctors and free medicines by pharmas, arranged by the Medical Representatives, but there is seldom any recognition of this service.

Unlike in most other professions, this community helps out its members without bringing in the competition, and in a recent event, when a regional manager suffered a critical head injury, MRs from different companies collected funds to pay for his bills.

Very few people notice how cruelly difficult the life of a medical representative is. They have to meet a certain number of doctors every day. They often stand for uncertain hours and have days longer than 18 hours, as some doctors finish their OPDs long after midnight. Family life is screwed. They are also responsible for making available the stocks of their brand medicine at different medical shops, and have to bargain with everyone: the stockist, distributor, hospitals, and sometimes the medical shops for making their brand available. The final sale figures are their assessment at every month-end. To achieve targets is essential in pharma industry as in any business, to survive. It is the Medical representatives community that faces the brunt on both sides: company pressure and the medical profession.
Unfortunately, our hate-bespectacled society cannot see anything beyond its suspicions: that all companies offer bribes and all doctors take them, that all doctors deliberately prescribe costlier medicine to earn cuts, and that the whole medical service is driven by money. This is somewhat like a suspicious husband who has a very beautiful and loyal wife, but cannot be happy with her because of his own paranoia. © Dr. Rajas Deshpande

I know many doctors who do not ask for any personal favours from the pharma, do not accept gifts, and pass on all the benefits to their patients. But I do not know any mention of gratefulness for such doctors anywhere. Without the medical representatives playing their part well, the medical profession will be quite helpless.

This article is to salute the thousands of medical representatives who work hard day and night, live an extremely compromised life, and still contribute to the service by medical profession, making life easy for millions of patients.
© Dr. Rajas Deshpande

If a medical representative has helped you / your patient, please share this article.

A Statue For Good Health Please

A Statue For Good Health Please
 
© Dr. Rajas Deshpande
 
The 7 year old child with a swollen face and a bandage upon his skull tried to smile through his hazy awareness. He wasn’t feeling good, and his face said so amply. His father who accompanied him sat cross legged, angry and upset, and said “I don’t want him to take lifelong medicine. Suggest something else”.
 
His son was a known case of seizures / epilepsy, and was advised by each one of the three neurologists he had already seen, to continue the anti epileptic medicine. The adamant father not only did not start those medicines, but kept on searching for opinions that suited his convenience and understanding, and treating the kid with unproven herbal therapies and fanatic diets. The poor helpless child, otherwise healthy, had had over three fits in last one week, this time the boy had fallen off stairs during a fit, and sustained a head injury. The father refused to see his own faults, a very common tendency.
 
“The doctor who bandaged him also gave him some injection. Because of its side effects he is so sleepy” the father added, “He told me to admit the child but I don’t think it is necessary. I want your second opinion ”.
 
There are rare days when I let my patience be gagged by my duty, some people really do not get simple, humble and mannerful language.
 
“Sir, you are making a criminal mistake. You are not a health expert, and have no authority to withhold treatment of your dependant, especially a child. It was your mistake to stop the antiepileptic medicine. The child must be seen by a pediatric epilepsy specialist immediately. He is sleepy because of the fit and the head injury. He needs in-hospital care and urgent restarting of epilepsy medicines” I started to notice I was raising my voice. Realising that the child’s well being was more important than correcting his father’s mistake, I toned down and explained to the father that there was no choice, and more fits could risk the kid’s life.
 
“Can you give hundred percent guarantee that your medicine will cure him?” asked the cunning father.
 
“No doctor in the world can give any guarantees, and should not too. It is my duty to tell you what is necessary for the health and life of the patient”. I so much wished I had the authority to have the father arrested, and so helpless a situation it was, that there was no agency in India to report this to.
 
“It is a huge task for us to take father to hospital, you know” said a millionaire recently to me, because him and his four brothers who lived in the palatial mansion built by the same father did not find enough time to accompany him to the doctor.
 
Thousands of children suffer and even die because their adamant parents refuse to treat them in time, or even refuse to continue the advised treatment. The same fate is meted out to many dependent elderly. The romance of poverty and politics makes it easy to shift all the blame on the govt. / private practitioners who see the patient last, when it is too late.
 
The IMA, which just correctly advised doctors not to drink alcohol or go to parties, should also draft a proposal of “Criminal Child and Elderly Health Abuse” and pursue it with the PMO. All children and elderly must be taken to the doctor immediately when sick, and following the doctor’s advice must be made a legal binding upon them. Then alone this health crime will stop.
 
The same quasi-intelligent people who advise doctors to “Keep calm and communicate properly with the drunken, aggressive relatives of terminally brought patients” should also use the same halfwit to advise the community to treat their dependents in time.
 
This is my sincere, heartfelt request to our kind Prime Minister / Health minister: save our children and elderly who need proper medical care, but are denied the same in time. We need this more than any gardens and decorations, more than statues and memorials, more than any other development. May all the treatment of all the kids below the age of 15 be free all over India, may every kid and elderly be insured for health.
 
In the service of my beloved motherland.
 
Jai Hind!
 
Narendra Modi PMO (India)
 
© Dr. Rajas Deshpande
 
PS: Modified story to mask identity.
Please share without editing.
Thank you.