Tag Archives: doctor’s fees

Can Anyone Solve The Mystery of Atmaram’s Courtroom Death?

Can Anyone Solve The Mystery of Atmaram’s Courtroom Death?

©️Dr. Rajas Deshpande

A hungry poor man named Atmaram went to a big hotel, had a nice big meal, and told he had no money to pay. He was beaten up and handed over to the police. He was released after a warning and a slap.

Next day he filled up petrol in his bike, and said he couldn’t pay. He was again beaten up, handed over to the police. Then he went to the medical shop, bought medicines and mineral water, ate the medicine, drank water from the bottle, and again said he couldn’t pay. He was now jailed for a week.

Next week his house was damaged by heavy rains, so he went and requested to be allowed to sleep in the house of the chief minister. He was arrested again, thrashed up.

As angry Atmaram shouted at the police, he was beaten up by them, another crime was added to his offences. In the court, Atmaram insulted the lawyers and judges and accused them of accepting bribes and charging too much. The judge punished him extra for his behaviour. Atmaram was angry and threw his shoe at the judge. His punishment was extended.

“You must respect the authority “ the court said.

“But I am poor, I need free food and petrol and medicines. I need sympathy too” Atmaram argued.

“You should have begged and applied for favours and eaten in places that provide charity meals. Petrol, however essential, has the same price for everyone. You can sleep on the footpath, and above all, you are not allowed rudeness and violence because you are poor and needy” The court said.©️Dr. Rajas Deshpande

When released from the jail, Atmaram drank a lot of desi alcohol, had an accident and fractured many bones. He went to the best private hospital, got operated and refused to pay his bills that crossed one lac rupees. When the hospital insisted, the operating doctors were beaten up by Atmaran’s relatives, the hospital was vandalised, the police arrested the doctor who saved Atmaram’s life, the government closed down the hospital, while the media and the society kept villainising the entire medical profession.

The headlines next day reported the sympathy expressed uniformly by wag addicted tongues: some said the entire profession was tainted, some blamed the greed of the doctors, even some doctors desperate for attention shed crocodile tears about the ethics in this profession. ©️Dr. Rajas Deshpande

In the courtroom, during the trial, Atmaram sat facing the doctor, still heavily bandaged.

The hon’ble judge, kind but surrounded by security, told the doctor accused of negligence and malpractice in the court: “You as a doctor carry more responsibility for ethical behaviour upon your shoulders. You should never turn away the poor”.

The doctor, defending himself, asked “but Milord, doesn’t our constitution insist on equality? Why do you yourself or ministers get security but not the doctor? Why isn’t everyone supposed to stick to ethics in every profession including politics, police and judiciary? Why are others exempt? How do you explain beating up of doctors while also saying that the society treated them like gods?”.

There were no answers. The kind court asked if the doctor had to say anything else in his own defence.

The doctor said

“Yes Milord, but the real answers will hurt:

Jealousy against medical professionals across society and many other professions is a reality. Why else will anyone who couldn’t qualify to become a doctor try and teach the qualified doctors what they should do?”©️Dr. Rajas Deshpande

“A culture of exploitation of non-votebank groups

and a complete failure of government healthcare with no one accepting responsibility is well known to everyone, but even judges have no courage to suo motu question this and correct it, even when they see the poor dying”. ©️Dr. Rajas Deshpande

“In a country with never ending poverty, how much free can a healthcare facility provide? For how long? This is already forcing closure of hospitals and exodus of good doctors out of the country.”©️Dr. Rajas Deshpande

“Milord, can you assure that every doctor will get his/ her fees as per his service to every patient, and if the patient can’t pay, that much charge will be exempted from the income tax of that doctor? How else do you except a doctor to meet his needs and dreams? Just because there are millions of poor patients, is the doctor’s life and hard work taken for granted? If there has to be financial sacrifice, why not have everyone contribute to it by creating a national health tax fund for treatment of poor patients? Why healthcare is subsidised only at the cost of a doctor?”

Just at this point, Atmaram, who sat in front of the judge, collapsed unconscious, almost blue black.

The shocked judge requested the doctor to examine him.

“He is no more” said the doctor.

“What could have happened ?” asked the kind but sweating judge.

The doctor told the court about three possible reasons. Two of them were scientific and medical: a sudden cardiac event or a large blood clot in the lungs common after fractures and trauma.

The third non-medical, unscientific cause made the Judge seriously ponder.©️Dr. Rajas Deshpande

“Will this court be now closed down, Milord? Will your efficiency be questioned, will you allow the relatives to attack you and understand their sad situation at the cost of your murder?”

“I understand what you mean” said the kind judge.

Needless to say, the doctor was released without a blame.

Can anyone please solve the mystery of the third non medical, unscientific possible cause of Atmaram’s death?

(C) Dr. Rajas Deshpande

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The “Cheap Competition” among Doctors: a Hidden Cancer.

The “Cheap Competition” among Doctors: a Hidden Cancer.
©Dr. Rajas Deshpande
Neurologist, Pune.

A majority of medical students in India are actually from poor or middle class background. Most students come in this profession for service to the suffering and also for social respect. Every doctor passing out in India does not pay crores of rupees for education. This is a system created and maintained by all governments for their strongmen as a source of huge earnings. Many of these “paying” students also work hard and earn their degree. However some few look at the amount spent as an investment and try to earn it back by unfair means. This is NOT the fault of the majority of good doctors (both non-paying and paying) who work hard to acquire their skills and help the society. © Dr. Rajas Deshpande

As the society expects “cheapest” advice even for most complicated health issues, some newcomers, those who are under qualified, those who do not have a good number, and some who don’t have the confidence keep their “Consultation fees” quite low, and rely upon alternate income: through tests, procedures and surgeries, through percentage in hospital bills. Thus, though the ‘entry ticket’ is low, the ‘hidden charges’ compensate for the doctor’s (genuine) hard work and skill.
However, not all ‘low fees’ doctors are bad, but keep their rates low to be able to compete, no one wants to criticise those who have low fees for ulterior motives. This competition to keep the consultation fees low to attract patients has generated most evils in the medical practice. Unfortunately, this is unlikely to change soon, as most people prefer this.© Dr. Rajas Deshpande

The low “Consultation fees“ model works best for even good, skilled and experienced surgeons and branches with procedures (plasty/ scopy etc.), where the patient usually does not question the charges for the procedures or surgery, just because every patient prefers best skilled doctor. There is also a recent trend to offer even “procedures and surgeries” at a competitive low cost by some hospitals, who employ the inexperienced or inadequately qualified/ trained doctors, beginners, lowest skilled nurses, technicians and other staff and instrumentation, catheters, joints, other prostheses. The whole show will be put up for “short term goals”, risking patient’s life and compromising many aspects of good care. In many “cheap packages”, the long term outcomes may be at risk.

Those who run hospitals have many profit sources: right from the tea sold inside the hospital campus to the room charges, pathology and radiology, nursing, drugs and everything used, they earn profits under multiple headings. This is also why they can afford to keep their consultation fees extremely low. However, most doctors employed at such hospitals are not paid anything besides their own low consultation fees, while they remain the face of the “total-bill” for all patients. This system encourages rich doctors who invest in alternative sources of income than the consultation fees alone. © Dr. Rajas Deshpande

Physicians / specialists must rely only upon their OPD consultation and IPD visits. If a proper examination is to be done in each case, and all questions of every patient are to be addressed, one cannot see more than 20-25 patients in a day. Thus if he / she keeps low fees, it becomes difficult to sustain in any Indian city. So they must see as many patients as they can, only addressing the immediate medical issue, and unable to answer many queries of the patient and relatives. If a good doctor decides to spend more time with each patient, and gives up relying upon the “hidden income”, he must charge a much higher consultation fees to just sustain in a good city.

The social anger against doctors mostly comes from increased expenditures on health and unrealistic expectations. Although there are greedy doctors, a majority are just doing their best to make a good name by offering the best service at a low price. Quality healthcare will always come with a higher price-tag, a good doctor will have a higher fees, and that if one wants the “backdoor / cut / referral practice “ to end, one must be prepared to pay higher fees.

In a country where loud and sweet talk, deception and lies are preferred by majority over genuine service, honesty and truth, it is difficult to change the basic attitudes: on both sides..

There indeed are some honourable doctors and hospitals who know the value of their own service, and offer the best to their patient. But even they are usually considered “Greedy” by the very patients whose miseries they end. There are senior / skilled doctors who charge from three to ten thousand or more per consultation, and most of our powerful and ministers go to these doctors too. Although this consultation fees appears high, the accuracy of the opinion and advice often save the patients lacs of rupees. If a surgeon advises a surgery, he/ she can earn many thousands, but if the same surgeon with his skills and experience treats the patient conservatively, avoids surgery and gets good results, the patient is unwilling to pay even half the price of that surgery for the same result. What would anyone do in such a case? The concept that “A Right Opinion by the Right Specialist” saves the patient huge amounts of money and discomfort is yet to dawn upon the Indian society.

The market of cheap has always survived, but in the long run, cheap options always come with a greater final price tag upon health: often your life.

It is my sincere appeal to all my fellow practitioners from the newer generations to please change this structure. See a moderate number of patients per day, charge according to your skill, experience and time, do not undercharge or bargain, then alone this system of backdoor incomes will gradually change. Of course you must consider concessions for the really poor, and accommodate those who cannot pay by keeping a separate time/ OPD for them.

© Dr. Rajas Deshpande
Neurologist, Pune.

PS:
Many city-based imbeciles without any doctor in their family will immediately say that all doctors should go to villages. Those who suggest that, please make your own children (if you have) doctors (if they have the caliber) and send them to villages. Why doesn’t the government make it compulsory for every mla and mp who draws lifelong financial benefits from the country’s exchequer, to send their kids to medical schools and serve in rural India compulsorily? Why is it not compulsory for the elected members to take all treatment in their own electorate? Every law is bent every which way possible to accommodate the healthcare requirements of all the rich and powerful, whether it is kidney transplant or joint replacement, but when extending healthcare to the poor and unaffording, the same people from various ruling parties conveniently point fingers at the medical professionals!

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The Overdose of Medical Advice

The Overdose of Medical Advice
© Dr. Rajas Deshpande
“If the doctors want to go to a five star hotel, they must pay for it” said someone recently in a headline.
Well yes, like any hardworking honest professional, even a doctor may want to go to a five star hotel occasionally, and have a good time, especially given the sadness that surrounds his / her profession. There is nothing that prevents me as a doctor from wanting to go to a five star hotel once in a while, and I do not feel guilty about wanting to live a good life. Earlier, I was happy to attend some great lectures by the world’s best doctors brought to India by the pharma industry (because the government never can), now I will just pay for myself.
Whether a five star meal comes from the profit of pharma industry or the hard work of doctor’s fees, there will be objections for sure. The problem is not the five star meal, the problem is elsewhere. So the different ministries can officially host super luxurious parties on different religious / non religious occasions to woo voters via the taxpayer’s money (and the media will describe the Biryanis and Gulab Jamuns in paragraphs), but the doctor must never eat a free luxury meal!
Many non medical professions, industries, financiers, film industry people, bankers and builders host dinners / other events at five star hotels, and many government officers / ministers attend them. Do they all pay for themselves? Just because a minister attends a five star dinner, he cannot be presumed to be doing a hidden favour to some industry, likewise, a doctor attending an academic event cannot be presumed to be doing a favour to any pharma. © Dr. Rajas Deshpande
It is doubtless that some doctors may have misused this facility and overspent. But the huge advantage: giants in the different medical fields from the developed world coming and educating the doctors in India will be greatly sacrificed by such limitations.
Given the social envy and jealousy against the doctors now rampant, it is probably an inevitable but unfair step by some organisations recently to ban pharma sponsorship of certain medical events at five star hotels. It is also a good initiative to reduce drug prices. But then, can the same organisations and even the federal bodies show the same guts and ban following malpractices too:
Open sale of undergraduate and postgraduate medical seats all over India, that creates funds worth trillions, benefitting even some in the highest offices of the country? Where does this money come from, and where does it finally go? Are we innocent enough to presume that the patient is not ultimately paying for this? © Dr. Rajas Deshpande
Under the medical consumer protection act, is not the government required to make all the facilities of healthcare available at all government hospitals in our country at subsidised rates? It is argued that taxpayers are paying for the education of medical students who enter medical colleges by merit, which is wrong, because the taxpayers are actually paying for good health facilities at the said hospitals. But most of the hospitals / medical centres run by the government are understaffed and run far below acceptable conditions. How many government health set ups have been evaluated for accreditation by standard bodies, and what are the results?
The insurance companies and corporate hospitals have held the private doctors prisoners of their atrocious conditions, and even the paying patients are being provided a substandard service, thanks to a total absence of any willingness to question any of this on the part of administration.
The demand and supply of “Cheap everything” in medical profession has now gone to such a dangerous extent, that substandard staff, incompletely qualified professionals, low rate medical instrumentation and quality of service, and above all, ineffective / low quality medicines have become a horrific reality already, even at some corporate hospitals dominated and dictated by the insurance sector.
They are giving people what they want: Glittering Cheap Healthcare. It is so surprising that the patients are happy with only this one quality of service and drugs: cheapness. The day that our society will understand that like anything else, good healthcare will cost more and will obviously involve more profit-making, our health scenario will improve. © Dr. Rajas Deshpande
The IMA, while trying to play safe and readily making rules like banning sponsorship, should take a firm stand to fight against the one sided war waged upon the medical profession by some.
Written in a state of perfect peace, not frustration.
Because I am not sold out to the desire to be liked by everyone, especially those against doctors.
© Dr. Rajas Deshpande

The Morphine That Killed a Hospital

© Dr. Rajas Deshpande

“He fell down while checking the patient”, said the panicked Dr. Mrs. Sane about her husband, “and became unconscious”.

Dr. Sane tried to maintain his calm. A sick doctor has the curse of knowing the worst of everything, and has a perpetual feeling of sitting upon a ticking time-bomb. It was a sad feeling to see this middle aged brilliant general practitioner fighting tears.

“Sir, the OPD numbers have shot up because of these epidemics, especially dengue. I see over a hundred patients every day. The Inpatient beds are full. There are daily problems: medical, administrative and medico-legal.. those I am used to. But now there are too many politico-social and press-related issues that worry me”.

Dr. Deshmukh, a senior practitioner and a common friend, accompanied Dr. Sane. He cautiously poked him “You must tell the doctor what happened the day before”.
“Oh that’s a part of our profession” Dr. Sane replied.
I insisted that he must tell me.

Reluctantly, he disclosed: “Some goons came in with a municipal councillor and threatened to waive off the bills of a dengue patient. He was in the ICU for five days, quite bad, but went home walking. Till the time he improved, they kept on threatening us to break the hospital and thrash us if something went wrong. Upon discharge, they didn’t pay a single rupee. There’s nowhere to complain, as the hospital requires many municipal permissions”. © Dr. Rajas Deshpande

Dr. Mrs Sane lost her cool. She started sobbing. “No one blames those who dump garbage, keep their surroundings unclean. No one is blamed when epidemics spread and thousands die. No one is held responsible for failures of almost all preventive services and lack of basic facilities at government’s healthcare institutes. But the already overworked general practitioners must bear the brunt of everyone’s anger: the public and press are always free to bash the last face they see: the doctor who is actually helping every patient,.. Dr. Sane has not had a proper lunch, not spent a full day with kids in months.. That hospital has become our curse“ She broke down.

It was so logical! The offices responsible cannot even be reached. The court does not see any of these system failures that cause millions of deaths all across India, happily ordering lakhs and crores and imprisonments for doctors, for trivial mistakes.
Whom to blame? Oh yes, the doctor who has studied to treat the sick!

Anyway, in a country fond of muscular heroes and billionaire godmen, who expects a brainy analysis? © Dr. Rajas Deshpande

“I had a dream of making best health facilities available for my area. I have taken a big loan. We treat poor patients free anyway. Many rich are sent by local politicians, leaders, administrators with instructions to attend immediately and free too. Paying patients are mostly suspicious because of all the negative things publicised by press about all doctors., they also expect immediate and positive outcomes. I have not slept for many a nights. “

I examined him.He had obvious features of being fatigued mentally and physically.. A syncopal attack, where the BP drops down suddenly and makes the patient unconscious, was likely. I advised him tests and told him to take rest for there days.

“Not possible, sir! Even now the OPD is waiting” he replied. An angry Dr. Mrs Sane requested me to intervene.

“Your duty to the society does not free you from the duty towards your own health and family” I requested him. But Dr. Sane agreed only when Dr. Deshmukh offered to send over a junior doctor to his hospital to take care of the OPD.

“How have you been, Sir?” I asked Dr. Deshmukh. He is one of the most respected and busiest general practitioners in town, with a big hospital. © Dr. Rajas Deshpande

Dr. Deshmukh smiled.
“I had an angioplasty three months ago. The only risk factor was high BP and stress. There is no use fighting or explaining our situation to the society, government or press. I have closed down my hospital. I only see OPD patients now. Anyway many patients thought that I worked day and night for earning more money. Let them go to the corporate or government hospitals.”

The death of his hospital was not a surprising news, many small private hospitals and nursing homes are either closing down or converting into profit-making franchises. Many doctors are suffering high BP, cardiac and neurological problems and even dying due to excessive stress.

The meaning of this nightmare will soon unfold upon our society.
Till then, this is a heartfelt appeal to all the over-stressed doctors to rethink about their priorities, rearrange life and make sure stress does not kill.

For the morphine of “medical social service” is only good in small doses, it kills when overdone!
© Dr. Rajas Deshpande

“Get Out, Doctor! You Are Finished!”

“Get Out, Doctor! You Are Finished!”© Dr. Rajas Deshpande
“Doctor, it’s this way or highway. We have many from your specialty in the waiting list. Do you accept to go by our policies or do you want to resign? Mind well, if you disagree, we will see to it that your name is blacklisted in every hospital in this city”.
As Dr. Sumeet stood there thinking, one of the administrative doctors, always a first class bottom licker, commented “These days doctors are like W*****, throw money at them and you get them to do anything you want”.
One junior doctor, still hot blooded, walked away. Dr. Sumeet asked that medical superintendent to mind his language. There was no reply. The bosses had really enjoyed the comparison, and while eating their pistachios at the hands of their secretaries, laughed aloud.
Dr. Sumeet felt devastated in that super luxury office, among the administrative officers and his own senior doctors from that hospital. He had returned from Germany a year ago, and joined this corporate hospital that was recruiting specialists. They had also offered him a decent salary, and accepted his condition that no patient will be sent back from his OPD for lack of money. © Dr. Rajas Deshpande
However, he had had to face a lot of jealousy and hatred from his senior doctors as he was looked upon as a competition. This is extremely common in India, and however stifled, a major truth. But no one ever stood against the bosses of corporate hospitals, so they had to accept his appointment.
The same corporate also owned other industries, namely Gold, Cement, Cloth, Petroleum etc. They were a “closed” community, all in the administration belonged to a particular caste. This hospital was another of their ‘profit oriented investment’, and did really well as most of the public can easily be fooled by the words “Free, Concession, Accreditation, World Class etc”. Medical illiterates (read general public) are really taken for a ride by healthcare advertisements of corporate hospitals.
Few months after Dr. Sumeet joined the hospital, the CEO changed, and another “extremely loyal invertebrate profitmaker insider” came in as the new CEO. From prehistoric period, he was considered as the best pet of that corporate family. The new CEO started by applying all the labour and profit criteria of cement industry to this hospital. If anyone argued, his famous dialogue was “If Sirjee (the owner of the corporate) wants, he will make the sun rise from the west. You are not aware that his reach is beyond the highest in India”. Anyone who uttered a word against any policy was isolated, humiliated and finally thrown off. Various allegations and ‘proofs’were easily furnished by a dedicated ‘execution panel’.
The new CEO changed the conditions that were accepted when Dr. Sumeet had joined. He was now given a target that his patients have to increase by 25 percent every six months, so should his tests, surgical referrals, etc. Free cases were cancelled. Many doctors spoke in private about this, but no one wanted to lose their job, as it is very difficult to get attachments in multispecialty hospitals. © Dr. Rajas Deshpande
As Dr. Sumeet had argued, he was given this ultimatum. He appealed to the senior doctors in that room, most of them looked away. Some told him they had always warned him not to be ‘over-smart’.
“I will reply in three days” said Dr. Sumeet and left the room.
He had nowhere to go. He had shifted his family to this new city and his children were already adjusted in their school. He had chosen this city after long deliberation, and had recently bought a flat with a loan, so he needed a stable income. His parents were teachers, he did not have the kind of money required to make his own hospital. All his friends had one answer: “Adjust “. He decided to plead once more to the management, to allow him to provide free consultation to really poor patients, and to continue a contract not based upon income generation. © Dr. Rajas Deshpande
Next morning, as he entered the hospital, one of the servants (being from the inner caste, his title was ‘General Manager’) came to see him with a huge grin upon his face. “The CEO sahab has asked you to empty your belongings by afternoon. This office is given to another doctor”.

He went to the CEO, who refused to see him.

The same medical superintendent came out.

“Doc we do not require your services any more. Get out, You are finished” he said.

“Why?” asked Dr. Sumeet. “I want an explanation”.

“We have many reasons. You do not fall in line with our policies. You are insubordinate. Also, some staff say you are having an affair with another doctor in the hospital. We also had a complaint about you yesterday from a patient”. © Dr. Rajas Deshpande
The complaint was obviously custom-made, and there was no way to argue about the affair allegation. Medical staff working together in an extremely orthodox country has to face those allegations very commonly. How such allegations disqualified him as a doctor was beyond him.
There was no argument now. He was escorted by security team out of the hospital, in full view of many specialist doctors (his friends), patients (treated by him), and others, but no one had a word to say. After he came out of the campus, one doctor friend accompanied him home silently.
He wrote to many senior doctors. There were no replies. He wrote to the medical councils. There was no reply. One senior member of the medical council told him in confidence: “ All the Medical Council rules are only for doctors. Medical councils in India have zero control over private hospitals, especially corporate hospitals”. IMA and other doctor’s bodies are clueless and directionless about the open exploitation, humiliation and destruction of doctor’s careers, especially new-coming specialists. In a country devoid of specialists, it is paradoxical that so many specialists are continually fired / thrown off / made to leave corporate hospitals which take advantage of the competition among doctors. Sadly, the doctor community, with too many self-proclaimed geniuses, has failed to unite and protect itself from this corporate onslaught. It is pathetic to see some greedy doctors competing to see each other down. © Dr. Rajas Deshpande
His practice was super-specialised and required a multispecialty set up with inpatients. There are very few government set ups in India like those. The rules, conditions in most govt. hospitals are idiotic, age-old, and the payments are laughably low. Also, the govt institutes are mostly headed by you know whos.There are indeed some charity super-specialty set ups, but most are religion / cult / faith based.
Dr. Sumeet decided to work it out his way. The corporate hospital which fired him made sure that his name was defamed in every possible way, they left a many pronged negative feedback everywhere. © Dr. Rajas Deshpande. There is no remuneration for the career murders of the intellectuals in every field in India, caused by two-faced systems run by invisible hands.
Gradually, he picked up, losing years of his career. He found out a hospital that respected his wishes to treat the poor free, and did not insist on numbers.
The complete ignorant and irresponsible stance of senior doctors when someone wrongs the junior doctors, the complete lack of any control over the policies of corporate hospitals by any medical council or governments, and the impotent stance by many a doctor’s organisations has spread the healthcare-toxic corporate medical culture all over India.
Doctors should at least make directories and online lists (maybe anonymous to begin with) of hospitals which force doctors to accept malpractices, or do not respect terms of agreement and sack doctors without any mistake. These should also be reported to the medical councils. Any hospital sacking any doctor should have to send an explanation to the Govt., medical council and IMA for the reason of dismissal, and the doctor should also be able to explain his / her side of the story. Hospitals which “use and throw” doctors as per wish, without reason or logical explanation must be brought to the book. © Dr. Rajas Deshpande
Most corporates have excellent backup and protection from the government, and all they will do is to shift the blame on the doctors’ fees, hiding from the patient, media and society the umpteen other profiting headings that the patient thinks are benefit to the doctors. This is a tough war.
Another joke is that while the educational qualification and training of any doctor is strictly scrutinised by medical councils and media, the qualifications of those who own hospitals, run them are completely neglected. No wonder illiterate politicians, “Business Class” corporate houses and CEOs bully doctors into practicing policies which are often against the best practice principles of healthcare.
Very few non-medical CEOs actually have a good knowledge of medical ethics and principles, agree to logical arguments.© Dr. Rajas Deshpande
The media and society who advise umpteen things and expect a lot from the doctors never stand up for a good doctor. Everyone who has met one bad doctor cries all his / her life about all doctors. As if there were no bad apples in their field! The ‘hyper idealistic’ population expects that the entire healthcare comes under the heading of ‘charity practices’., unwilling to spend upon their own health. If malpractices and backdoor incomes are to go, the public should realise that the actual fees will increase.
Governments will always make populist, ultra-short term policies in healthcare, without involving the brainy specialists in practice. If the Medical Council or IMA do not take a firm stand, any doctor who takes a stand against existing corporates / medical malpractices will be orphaned by his / her own community, often boycott, and categorically defamed: until their career is destroyed or they leave the country.
Many Dr. Sumeets are actually suffering this right now in India, with no respite.
Doctors must also realise that this war will never be won fighting alone. If the subsequent generations are to get better quality healthcare, we should start by identifying the problems first.
An easier, nay, wiser option for every super-specialist is to leave India.

© Dr. Rajas Deshpande
PS: The “Chamcha Doctors” who line up with the corporates to compromise in healthcare principles must do some soul searching. Earning profits is not a crime, compromising medical principles is. A real “Doctor” will never do so.
Dedicated to the thousands of young medical specialists who are right now suffering this hell.

RD

Negligence cases deserving severe punishment.

Negligence cases deserving severe punishment.
© Dr. Rajas Deshpande

A police sub inspector in civil dress, his wife and three kids aged 8, 5 and 1 were brought to casualty. All profusely bleeding. My job as an intern was to secure IV line and stop bleeding. As the CMO questioned the PSI, we all realised as suspected from the stink that the police officer was drunk. He had run into a braking truck from behind. One kid and the wife died the same night. He created a ruckus in his drunk state, threatening to kill everyone in the casualty. “If my wife dies, I will see to it that your life is ruined” he threatened to the CMO. The CMO kept on doing his duty, stressed and hurt. We were all real scared next few days. Everyone sympathises with such a loss. No one will aid or enjoy anyone’s death in a hospital.
Then why this curse of blames?

“This happened due to that doctor’s wrong treatment” : common words now heard in many clinics daily. Who causes maximum deaths due to negligence? Can only a doctor cause medical negligence? No.

These medical negligence cases must be punished too, with bad press, crores of rupees in fines, and public humiliation. You be the judge who is guilty:

Teenager son of an MLA. Played with wild snakes as a hobby, proudly encouraged by this MLA. Bitten by a cobra, landed in icu critical. A patient on ventilator was ‘shifted out early’ to accomodate the MLAs son.

Doctor advised a blood thinning medicine to prevent clots after diagnosing clotting disorder,. Patient went with her husband to a quack, took unknown herbal medicine and stopped blood thinner. Developed strokes, now in a vegetative state.

Patient advised to quit alcohol,,as it caused fits. Counselled with family and friends. In a week had alcohol with same friends, had fits, died in casualty.

Diabetic, told to control diet, continued to binge-eat sweets, lovingly cooked by wifey. Landed in coma due to very high blood sugars.

Pet dog, unimmunised, bit many on the same day, the dog died in three days. One diabetic patient bit by this dog died of sepsis / infection (not rabies). Immense horror among the ten-odd families of bitten members till date after a year.

Kid aged 14, parents allowed him to ride two wheeler on road without licence, killed on spot colliding with a truck. Toddler unwatched on the road died, run over by a truck.

60 year old Mother has giddiness for three days, son and daughter in law not free till fourth day to take her to hospital. Dies in casualty due to stroke.

Patient advised not to fast as it may increase chances of having fits. Fasted and landed in ICU with status epilepticus (a series of continuous fits).

Traffic police at a crowded junction busy with his “routine” away from his spot. Head on collision, two dead.

Unfortunately, in almost all above cases, the treating doctors were beaten up, casualty staff and hospitals vandalised, doctors sued, bad press judged an entire profession almost like a criminal, for not saving the victim.
© Dr. Rajas Deshpande

Often the relatives refuse to take patients to higher centers, expecting “big, advanced treatments and impractical outcomes” from low-cost, small nursing homes not equipped with specialty facilities, then end up vandalising or blaming such set-ups upon inevitable disappointment. Missed medicine, overdose, unobserved children, helpless neglected elderly parents, smoking, alcohol, traffic accidents all cause millions of deaths. So do delayed admissions, some herbals and “unknown” medicines, hunger, poverty, stress at home and workplace.

But it is the “death in hospital” that alone matters, and by default the blame is pinned upon the doctor!

Some actors can kill, rape, go naked, smoke, drink, race, gamble, pee in public, set records for drunken misdemeanours on and off screen, knowing that most illiterate and immature populations imitate them blindly. But they will tell the nation how the medical profession (for which they themselves did not opt in spite of excellent merit in school or in some cases even college) should behave and treat patients!

The few honourable judges who have now realised the “blackmail potential” of medical negligence cases, have fortunately started referring these cases to panels of medical experts before concluding and fixing charges. The only maturity issue that remains is about local goons and politicos with flitting loyalties looking for publicity at the cost of the harmless and intellectual population of doctors. These goons turn the helpless frustration, panic reaction towards tragedy and poverty of our society into anger against doctors and hospitals. As long as there are sane people in the responsible media, there is good hope.

Doctors must start recording without bitterness, any hostile tendencies, lies, deviation from duties towards the patient, advised and declined tests and treatment, neglect and avoidance patterns to provide adequate care for the patient by the relatives. Also the exact circumstances of onset of the problems (patient was drunk / drugged / under medication effect / fasting / missed medicine) etc. and relevant past that may have contributed to the event. This will minimise the allegations and misrepresentation of facts.
© Dr. Rajas Deshpande

Ofcourse the doctors must also discharge their duty with the highest standards of practice possible in their set-up. They must communicate well and explain the condition atleast once to the concerned relatives. They must behave courteously, sympathetically and try to understand and forgive the panic states of relatives within the sphere of civilised behaviour. We all love our patients. But like in every other relationship, we fail to say it aloud and make it clear with our behaviour, thanks to heavily stressful and inadequate lives we lead. Let us make an effort on our side to take one more step in the direction of kindness and understanding, in a hope of saving this profession from defamation at the hands of middlemen.

Let us make a greater effort to tell the society that it is only a doctor who will never intend harm. The only reliable rescue from the clutches of death, even a doctor fails sometimes. The effort has to be recognised if not always rewarded, but never suspected.

Negligence, you see, is easy to pin only upon the doctor.
All others are forgiven any number of deaths in all other types of negligence.
© Dr. Rajas Deshpande

Please share without editing and with credits.

Lifehacks for the Doctor

Lifehacks for the Doctor
With interview of a renowned Cardiologist.
© Dr. Rajas Deshpande

Lifehack:
a strategy or technique adopted in order to manage one’s time and daily activities in a more efficient way.

Are you talented, hardworking, hurried, bitter, artificial, irritable, insecure, obsessive, egoistic, money-minded, dissatisfied and longing for a better life? Yes? Then you must be a successful Doctor!

While medical practice is of paramount and sacred importance, the duties as a spouse and parent are absolute too, there is no replacement for you there (Well, in most cases!). If your “Kick” of being completely swept away by the needs of your practice and competition drowns your own personality and the requirements of your family, you may be a overindulging doctor who is a terrible parent or spouse. Only your family will carry you in their arms few years from now, no one else. Rethink how you treat them today.
Are you really earning “For Them” or for your own super-ego, for overcoming the ever widening valley which converts every luxury into a necessity you must have? The justified feeling that “If I have learnt so much and am so talented, work so hard, I must earn real good”. Has money / affluence become your self-assessment criteria? If so, you may be no different than an attention seeking, beautiful, very very attractive but dumb individual. You trade health, family and life for money.

Calm agility of mind and body are hallmarks of a doctor, and too many tasks, irritability, bitterness, insecurity and lack of satisfaction are making this impossible.

Let us identify how we can reduce stress and improve the quality of life. The only life we have.
1. Separate work and family cellphones. Switch off the work phone outside work hours, except on emergency day. Provide all your patients with casualty / emergency contacts, and only your assistant should be able to reach you on your personal number.
2. Hire and train assistants when feasible, they may assist you with secondary/ nonclinical tasks, paperwork etc.
3. Take a big picture look at your day / time correlation, you will be surprised:
Work (8-10 hours),
Commuting (1 hour),
Sleep (7 hours),
Kids (1 hour) till they are 18.
Spouse (dedicated 1 hour: you married for togetherness all life, right?),
Communication / emails / Internet (1 hour), and
‘Self’ time (1 hour)
Total = 20-22 hours.

You will still have 2-4 hours left for cooking / housekeeping / etc. (to be done by both if both are working). If we expect the society to be modern, we must also give up the traditional “wife at home however educated or smart” and “husband rules” attitude. Family is equal responsibilities to be shared with mutual agreement.

If only one partner is working, it is easier to arrange schedules. If both are working, one may prefer non-clinical / paraclinical duties till kids can take care of themselves. Singles are anyways happier till a certain age!

It is extremely essential to disconnect from the work to be completely with your kids / spouse. Strictly avoid talking about workplace at home, especially do not take your stress to bed.
Switching off cellphone at night is a big step in the evolution of a Doctor’s peace of mind.

You can practice far better with a calm and healthy mind. Hence the necessity of good sleep and self time.

4: Find an activity that makes you feel calm and happy. Don’t need to explain this to anyone, don’t need to feel guilty, this is therapeutic. This must be done alone for an hour everyday , with all communications switched off. Some suggestions:
Music: Listening, Composing, Singing, Learning
Writing, Reading, Painting
Gardening, Watering plants (magically calming effect).
Swimming, Cycling, Dancing, Gymming, Yoga
Long walks / drives if good, uncrowded roads nearby.

One of my senior colleagues Dr. Jagdish Hiremath (Director of the Ruby Hall CathLab) is one of the busiest and renowned Cardiologists in the town, and never skips a smile when a colleague crosses him. Always appears at peace with himself and others. I asked him how he manages such a stressful life of a successful interventional cardiologist. As we talked, I realised his answers are worth what every doctor must think about:

Dr. JSH: “I prefer to be in the present 100%, whether with patient or otherwise. I concentrate upon the task in front of me and blank out all else, so I can do justice to that task. When I am with a patient or in cathlab, my cellphones are diverted to my assistants or receptionist, and I am not disturbed. This helps me, and the patient also feels happy about it. My assistants filter out unnecessary calls and pass on the genuine ones to me as a message, I call and talk to them on my way home”.

Me: “Newcomers, especially superspecialists, face the dilemma: that cut-practice or referral practice is the only way they can start, as no one offers any salary till you have a good patient-base. It is almost impossible for the beginners to start in a decent place without submitting to the existing pay structures”.

Dr. JSH: “Yes that is a shortcoming in our system. But then, the concepts of ethics, morals are quite twisted in medicine today. We must never compromise in doing the best for the patient. But then, others should not decide or dictate how the medical charging systems work: neither insurance people, nor media, community or anyone else. Because they never understand / acknowledge the importance of talent and skill”.

Yes, I thought: who else will allow other professions/ government, society or insurance companies to decide the value of their services? Will they allow others to dictate how they use / share their charges? It is only the doctors who have allowed this, and it is high time everyone else shuts up about this and doctors redefine the charging structures.

Me: “Sir, medical education has become “Earning PG” oriented. MBBS doctors do not get good teachers, and are not clinically well groomed. They are smarter and have better net-knowledge, but not good clinicians. They have become “MCQ Doctors”.

Dr. JSH: “I have always said that MBBS should be ‘the making of a doctor’, and not only stepping stone for PG. We need better institutes, better teaching. A doctor must grow as a human being lifelong, and it must start at this level. Even the PGs are exploited too much. Their teachers should understand that they are no more traditional ‘students’ in college, they are grown up married doctors with families, and must be treated like employees rather than servants”.

Feeling a sense of having learnt something invaluable, I thanked him and left.

There’s this “Becoming a Man (or Woman)” of every Doctor: when they start treating independently and confidently. Then comes the phase of an “All Out” effort to increase practice: extreme self neglect and hardwork, running from one hospital to another. Then one day they wake up to the reality.

All the stories of Morals and Ethics taught and expected of a Doctor are like the things that parents tell their kids not to do, while doing these themselves.

The Indian Doctor’s Enlightenment (approximate latency 5-7 years in practice) comes packed in bitterness and depression towards the very society he / she serves. They realise that the society has lost trust and respect towards us, even the recognition of the extreme education and hardwork doctors have to perpetually live in. An educated patient expects global standard healthcare at Indian rates. The uneducated look upon the doctor as a bandit.

So if you have become the typical successful doctor “Hurried, bitter, artificial, irritable, insecure, obsessive, egoistic, money-minded, dissatisfied and longing for a better life”, it is time for a reboot. No medical bodies stand by or defend doctors. So we must learn and try to sort out this mess ourselves.

For life is change, and wisdom lies in the wish for a better life.
It is high time Doctors learn to take care of themselves.
Wishing all Doctors best of health and a beautiful, rewarding life of success and satisfaction.

© Dr. Rajas Deshpande
(This is Part II of “Delusions, Doc?)

Special Thanks
Dr. Jagdish Hiremath,
Director Cathlab Ruby Hall Clinic

“Why can’t the doctor be more compassionate, spend more time with patients?”

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“Why can’t the doctor be more compassionate, spend more time with patients?”

© Dr. Rajas Deshpande

Ms. Bonnie Wilson asks:
“When are doctors (not all) going to grow some compassion or least show some and listen to what we actually have to say and maybe spend just a few more minutes to get to know the patient a little bit???? Then maybe more patients would appreciate their doctor more. I’ve been fighting a disease for 16 years now and a lot of doctors don’t even spend five minutes with you. Only speaking from many years of experience as a patient”.

Dear Ms Wilson, thanks for asking this question, it helps me introspect.

Simple answer:
Give the doc a patient who pays as per time and skill required for the consult, and they will spend an entire day with that patient. Give the doc a patient who writes down “Doctor, I have complete faith and trust in you, do your best to treat me, I promise not to sue you or blame you if in the course of my treatment something goes wrong. I respect your intention, and know that you are a human being capable of mistakes, I will be compassionate to you too.”, and they will cross all barriers to help / satisfy that patient every which way medically feasible.
Also add “I will endlessly wait in the doctor’s waiting room till the earlier patient smiles and leaves”.

Not possible? There you are!
In the 15 years of medical training, we hear innumerable sermons about being compassionate and “Listening to and Understanding” the patient. We have always learnt and taught in medicine to “Listen” carefully, so most doctors attempt this in practice, not all keep it up. Some learn the knack to “extract” the correct info to work faster.

Now imagine the Doctor’s side.

How long is “Little longer”?
75% patients really don’t have the sense of time when they talk about their illness. Instead of being to the point and realizing that this is a “professional consultation”, they go on to recite unnecessary over description / umpteen repetitions of the same complaints, even after the doctor jots them down, with confused details of their own symptoms, changing them often. Some tell their own interpretations about each of the symptoms, and complete detailed conversations that they had with their family / other doctors about those symptoms. Many ask the doctor to repeat long explanations, then some relatives ask it again. Many revise prescription medicines at least three-four times, in spite of writing down correct instructions. Many keep blaming the doctors and crying in our cabin for “incurable” disease diagnoses, thinking that the doctor is hiding good treatment for want of more money! We sympathize and explain, but cannot go on all day, especially if other patients are waiting anxiously for their turn.

Many patients fumble, forget, come disorganized (this is super-exaggerated in India, where there is no unified health record system, and patients carry messed up bundles of test reports / case sheets from many different specialists). Most (even literates) come without even the list of currently ongoing medicines, then call their family from doc’s cabin to enquire about these, and then the huge discussion about spellings, content etc. consumes double the scheduled time of consult, while other patients wait and complain. There is total lack of awareness of one’s own health responsibilities, even those who spend hours chatting in the waiting room don’t organise their thoughts or make notes for the consult, wasting time with the doc in “recalling” things!

In the western world too, there are many patients who go on describing the “unnecessary detail”, some talk too much, some talk slow, take a long time to recall and answer, and mostly come “unprepared” for the consult, without noting down questions they want to ask, and symptoms / medicines they want to discuss. Then the innocent “recalling” in the doctor’s cabin is quite irritating for the overworked doctors.

The third and the most difficult category of patients: the “over-prepared” patients / relatives, who have hyper-googled every symptom, every medicine and then come with a huge (and mostly irrelevant) list of questions about their minor symptoms. Stupidest of the claims on the internet are then discussed unnecessarily, and the frightened patient / relative really test the patience of the doctor. They are seldom satisfied with anything or anyone.

At what price?
Enter medical insurance. Enter the “Charitable Labelling” of healthcare in India, where iPhone will cost the same as in USA and UK, but the superspecialist doctor trained in USA/UK/Canada/ Australia etc. (with his own life, merit and money) must charge as per the basic general practitioner and local socio-political expectations. So the doctor has no freedom to charge the consult as per time required.

Result: more time translates into less income, worldwide.

Reaction of the society: So what if you earn less? You are a doctor. You are a spiritual saint who just earns in goodwill and respect, converts that by magic into money and then we charge you everything including taxes in cash! We all can dream luxury and good life, you can’t!

My question: What’s in it for the doctor in spending more (extra) time with the patient?

It is a pleasure for the good doctor to spend more time, explain in detail and compassionately listen to each patient, but then he/ she returns home to piles of unpaid bills and an unhappy family. Most Indian specialists don’t even afford their own home by the age of 40! Most western doctors are frustrated by the dictat of insurance companies that for a decent earning, they must see higher number of patients. No insurance company pays a good doctor better.

As for Compassion issue:
I have some really innocent questions to ask patients / society:

1. When any doctor was prosecuted for medical negligence in some case, how many times has any patient openly said “This doctor was very good to me”? Many doctors prosecuted must have saved hundreds of lives. Who stood by them when their careers were ruined by single mistakes? How many patients whose life they saved offered to help with the compensations the punished docs had to pay?

2. How many times did society / luminaries / media show compassion to the needs / plights of medical profession? Underpayment and Overwork, Victimisation and Insecurity are universal in this profession. Who showed any compassion ?

3. Can you be compassionate to someone who is being a “Customer” with the right and threat to sue you for an amount that will ruin your life, reputation, career and family? Can you be compassionate to someone who suspects every motive of yours, cross checks everything you say, argues with you, threatens you, does not have faith in you and will forget you the day their health problem is over, only to return when they need you again?

4. Can you be compassionate to someone who records your words of reassurance and uses them against you as a legal proof of “misguiding”? Can you talk nicely to someone who treats you arrogantly, mannerlessly and looks down upon you as a “Money maker” rather than a respectably educated hardworking Doctor?

Indian Docs carry the whole burden of the country’s mismanaged healthcare system upon their shoulders. Millions of poor, unaffording patients are RIGHT NOW being treated by thousands of doctors FREE. Most patients get better than not.
But
When the uneducated filmstars rubbish the whole profession to prove themselves tall, some movie claims that doctors treat dead bodies to earn more money, no one speaks a word against it. Why?
When senior doctors who spent lifetime serving the poor are wrongly suspended by politicians without any enquiry, not a peep from the society.
Why?
When doctors are killed, attacked upon, and abused, media justifies / glorifies such events.
Why?
Some of the senior doctors cannot stop talking ideal, even at the cost of their children’s lives. “Spend more time with the patient, be more compassionate” they say. I agree.
But we never hear from them when a doctor is killed. They are never seen defending those doctors who faced 12 crores worth compensation punishments, when laws like PCPNDT send young and old doctors directly to jail for documentation errors. It is very fashionable and hip to be a hypocrite and speak what people like. To understand any issue, there is a simple formality: think of both sides. Who thinks about the Doctor’s side of the story?

There is a worldwide notion: that doctors are guilty of earning more money by wrong means like hurrying. For those who think this, I have one question: Which Doctor in the world has more money than the price of YOUR life? If they save you, they are blamed for high charges. If they don’t save you, they are sued for unbelievably stupid compensations. This is the paradox: that lost lives have become costlier, saved lives don’t matter anymore.

There of course are a few greedy doctors, who need to improve. These are few and a shame.

The real tragedy of our faithless lives is this: Nobody ever thinks that a doctor may really be working faster and harder to help more patients rather than to earn more money!! He/ She may be struggling with his / her loans, sacrificing his/her own health and family time, fighting frustration, but still listening day-in and day-out to crying, complaining people merely out of the wish to relieve their agonies.

What price is the time you are away from your family? What price is years of sleepless nights? What price is the mental trauma of seeing dead bodies every day? What compassion did any doctor get for these, from media, judiciary, society, anyone?

© Dr. Rajas Deshpande

PS: Less time does not mean wrong diagnosis or approach. Mostly it means “Cut off talk to bare minimum interaction necessary for this consult”.

@ Bonnie Wilson, thanks for the opportunity you created for me to answer this concern. While this is not a personal reply, I agree with you that more time and compassion will go a long good way, but then both sides need to introspect and change.
RD

Painful Injection

Injection
© Dr. Rajas Deshpande

“Anyone Treat Anything” and the “Add-On complaints”.

“Doc I have come to you for this severe headache since last five months”.
Examined, investigated, prescription given.
5 days later:
“Doc there is no relief. This back pain is killing me”.
“What about the headache you had?”
“Oh that went away the next day, but this backache has been there for years now. I forgot to tell you last time. I also want you to review and advise about my Sugar and BP medicines”.
……………..
Specialty practice in India is considered to be just like family practice. The concept of “problem-based” consultation is yet to arrive. Once seen by a specialist, all the subsequent health issues are thought to be automatically the responsibility of that doctor, and he / she is supposed to solve them at a “Follow-Up” charge for years. The concept of “New health issue, New consult” is yet to dawn.

Unfair to compare, but this is like visiting a hotel once to eat an unlimited Rice Plate, and then keeping on visiting repeatedly later to reap the “unlimited” benefit from the bill paid on the first day.

There are two sides. Some specialists also encourage this “treating everything” once the patient comes to them, and often transgress their field of expertise to keep on treating everything till the time something goes wrong, when alone a cross-reference is made. Once someone starts practice in some specialty, they should ideally only stick to that branch, unless it is an emergency.

Even at the cost of patient “misunderstanding and blaming”, some specialists follow this correct practice of referring to another specialist where indicated.

“You only give the treatment, doc for everything.. we have faith in you” is very rewarding and beautiful to hear, but at the same time a doctor who thinks he/she can should think twice.

The second issue is that of “Going on adding” the complaints even after the doctor has finished examination and has already issued a prescription.

The whole process is logical, and disciplined: recording the complaints and other medical details, then performing a physical examination, reviewing old test reports and advising new, writing a prescription, and explaining the condition and management to the patient. There are limitations in the time spent for one patient, and a single significant complaint added later after the prescription is written can change the diagnostic possibilities (“I just remembered, I had episodes of unconsciousness / tuberculosis / head injury in the past”). It then becomes imperative that the doctor rewrites the case history, and changes tests advised and even treatment sometimes.

There are simple solutions, but these become difficult in India.
1. The doc must spend extra time with every patient to give them sufficient time to remember. This is feasible only when the charges are time based, as some patients are not done talking even after 30 minutes. The experienced docs then learn the skills and tricks to save time and to “steer” the patient.
2. Patient can fill up / record forms while in the waiting room, where almost all important questions are already mentioned, so one cannot miss. This is difficult in two ways: most of our population is illiterate, and even the literates do not fill up these forms properly. Also, most of the working class come “flying” in a hurry to “get over with this quickly and fly to another meeting/ chore”, so they keep busy with their cellphones in the waiting area (sometimes even in the doctor’s chamber). Secondly, such mention of “all earlier health issues” also invites unwanted exaggeration of otherwise minor complaints especially in the depressed / suppressed / anxious and overenthusiastic patients, often diverting from the main health issue.
3. Doctor’s assistants / junior doctors “filtering” the information for each case: this may be the best option, but again the specialist must take responsibility for their mistakes. Also, one must remember that patients often do not take the “assistant doctors” seriously and may omit crucial information while talking to them. Also, a patient who pays for a specialist’s service deserves interview and examination by that specialist, not only a quick overview of an assistant’s opinion.
4. Patient must make and retain a notebook / digital diary common to all his / her medical issues, consults, details of all prior treatment and tests and carry it for every consult, minor or major. While the doctors / hospitals are supposed to keep their own records, they are blind to what happens outside their medical jurisdiction, so it becomes almost useless. A unified national healthcare software is at least 10 years away.

The IMA / MCI must devise large scale patient education programmes that will help curb the misunderstandings, hate, violence which society harbors towards medical professionals. Encouraging correct referrals, specifying doctor’s fees based upon the equation of “Time + Skill + Experience + Complications in a case” at different levels from family practitioners to super specialists may also help. A basic model of “Primary General Practitioner” who attends simple health issues with referral to a specialist based upon patient’s choice / proximity / GP’s honest opinion and suggesting at least two specialist names will help control this “Anyone Treat Anything” practice so rampant today.

There always will be allegations of “cut practice” whenever there is referral, as average human nature finds pleasure in blaming others especially successful and presuming everyone else a sinner while imagining oneself a moral-ethical icon.

To imagine that everyone in the medical profession is a sinner and guilty, and everyone in the society is innocent is a sign of immaturity of intellect. This is our working diagnosis right now.
© Dr. Rajas Deshpande