Tag Archives: Drug

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.

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.

Drug Quality, price and risk in India

Drug Quality, price and risk: repost

(c) Dr. Rajas Deshpande​

Sir, What about the responsibility of quality of drugs used for the treatment? These are the only weapons with which we fight a disease. Does it make pharma a share holder of responsibility in case of adverse outcome ? This is another grey zone to elaborate.

Dear Dr.
Thank you for asking this question.

We must demand as doctors that we will only prescribe local medicines / stents/ catheters, needles etc., but then make it compulsory for everyone including the ministers, govt officials, the actors who comment irresponsibly etc. to only use Indian / cheap healthcare products. Let us see how many rich and famous want to use local drugs / stents / caths for themselves or their families!

We have a society so immature that it does not blame the government for allowing production and sale of low quality medicine / not guaranteeing and monitoring quality of each drug locally produced and marketed, and banning the costly drugs, but thinks that the Doctor should take responsibility of their “Multimillion Health” by prescribing cheapest drugs and tests available, produced locally without any knowledge of their quality!

There are set international standards of quality control for manufacturing of Medicines / Drugs. These apply with minor legal (but not scientific) variation to all pharmaceutical companies. Along with the major international players, there are also major/ minor Indian players in this industry. Many major international pharmaceuticals have been legally tried and punished for manipulating drug related information / bribing or compromising upon its quality: billions of dollars worth such punishments have been on record. There are no examples like this in India, which must mean, the entire industry and the government’s arms dealing with it must be absolutely innocent and honest, and all drugs produced in India must be absolutely good!

Secondly, the control over quality is not over with production of the drug. The transport, storage, sales and instructions given to the patient with each single drug also matter.. You know very well how many Indian drugs even have “readable” information printed upon them.. Leave aside the separate printout/ labels about precautions that must accompany every sale.. All this information is left for the Doctor/ Nurse / Pharmacist to tell the patient, forget the waste of time. This reduces the price of the medicine at the cost of the Doctor’s / Nurse’s time, while everyone else in this chain of sale earns their profit..

Then the after-sales feedback and documentation of serious adverse effects / ineffectiveness of each single drug marketed has to be recorded and reviewed / analysed. We all know this system does not exist in our country… there have been no cases about the drug quality at all: in fact the Doctor is automatically presumed responsible for either greed or guilt of prescribing any drug, either way! If you know the horror of real life story called “Rosche Versus Adams”, it will blow your mind to think what must be going on in a country widely infamous for corruption in all fields..

Always in shortage and underpaid, shouldering all nonmedical aspects of healthcare (which are social / govt. responsibility), the Indian doctor does not have the time / money / power / authority to monitor / report / check / complain against any medicines. If he / she does, we know what might happen. There are mighty, powerful, political, medical, corporate, international, kingmaker people who own much of pharma sector, some mafia too. Can we imagine a simple doctor will be able to fight these?

I am not accusing anyone, but these two links are enough embarrassing, and we can understand that money and power can gag almost each and everyone in India from a ministers to media, so these news will be rare.

http://articles.economictimes.indiatimes.com/…/47705608_1_d

http://www.fiercepharma.com/…/indias-quality-lap…/2014-03-18

There are some good and standard pharmaceuticals, who tell the doctors about their quality control, ask for feedback, and also update the certifications, accreditation etc… so we know they are standard. There are those whose brands have been internationally reviewed, those which are in the market for decades, with established safety. There are new ones with no data, where the only trust is about the maker’s reputation. The onus is upon the doctor to choose. I know most doctors would prefer the best for their patients, and some would consider a relative safety if price can be reduced. Honestly, no doctor can assure the quality of a given medicine, he / she has no way to assure that. But if you prefer Indian made smartphones, Indian made clothes / perfumes / cars, etc. etc., you may also rely upon Indian made drugs/ stents / catheters. The difference is then you absolve the doctor about the responsibility of what he thinks is best for the patient. I know some Indian pharma which have excellent quality of drugs, but most also have heard of frauds. Knowing this, a good doctor cannot vouch for the safety of any drug, Indian or International. The patient must make a choice.
There are umpteen examples of ineffective / low quality Tuberculosis and other drugs scandals (sold in some Govt hospitals) some years ago, but there was never any case decided against this. There were / are examples of doctors making and prescribing their own medicines, which they may know the quality of.
The effective percentage of the active ingredient, its purity, its binding with the excipients, its bioavailability after consumption, its effects on the liver / kidney, brain, eyes, heart etc are all also linked to how much and how rapidly it is absorbed and metabolized. The doses we use are all western-standardised, and we Indians have a tendency (even in Medicine) to presume that those biostats will exactly apply to our population, irrespective of genetic / ethnic/ cultural (food) differences.

A drug may kill (either by its action or inaction) if its quality is not accurate, and this “quality” NO doctor knows. Doctors can only go by their own experience about that particular drug and the company that makes it. So if the patient insists upon buying a certain medicine brand produced in a certain country, it is his / her prerogative and responsibility.

We call many things “ Chinese” and usually mean it as a cheaper / “no guarantee” quality.. We cannot blame if some western / other countries felt same about Indian made medicines, even after the racist / competitive aspect is excluded. Pharma industry has good and bad in ALL countries, including India. The only difference is that we know the levels at which corruption works in our country : Every!

It is easy for filmstars who shoot outside India, drive foreign cars, endorse foreign brands, wear foreign clothes and run to foreign countries for every health issue to cry on national TV and urge everyone to use :Generic” / local drugs. It’s not their life, and if something happens there’s always the Indian Doctor to blame!
We must demand as doctors that we will only prescribe local medicines / stents/ catheters, needles etc., but then make it compulsory for everyone including the ministers, govt officials, the actors who comment irresponsibly etc. to only use Indian / cheap healthcare products. Let us see how many rich and famous want to use local drugs / stents / caths for themselves!

© Rajas Deshpande