Tag Archives: Hypocrisy

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 Human Humbug Virus (HHV)

The Human Humbug Virus (HHV)
© Dr. Rajas Deshpande

It’s a boon that the animals did not learn human languages and are not allowed to have facebook accounts. Otherwise Tigers would have complained about how cruel Lions are, and Rabbits would have intensely criticised Elephants for eating too much.

There is a huge number of “Advisors to the Doctors, Hospitals and Medical Professionals” from various non-medical streams, whose basic qualification in this field is the ability to carry on meaningless humbug that suits the social unrest against Doctors as a class.

Let me clarify few things at the outset: I love and respect my patients and colleagues, but not blindly, and most of the doctors I know also always keep their patient’s good above everything else. Most of my patients also reciprocate positively and many patients like / love / treat their doctor like a family member.

It is some “Good-for-nothing-else” social crusaders that create the rift between patients and doctors, and also prejudice the ‘lesser thinkers’ into believing that the very person treating them is their enemy out to dupe them. These are the victims of “Human Humbug Virus”. This epidemic is spreading fast, and also seems to have affected some doctors who advise their colleagues from other specialties how to practice, without having any experience of practicing that specialty.

A friend recently asked: “What should the average (saamanya) and needy (garaju/ zarooratmand) patient do on holidays if the doctors switch of their mobiles?”. I am surprised.

Are doctors not among the average and needy, given that most Indian docs belong to the middle class? Which other government offices remain open for the average and needy on holidays? If a doctor who has finished his work at 2 AM needs a ride home, who will be ready to provide it? If a doctor is beaten up by drunk relatives, who among the society has spoken against it?

There is this myth being spread: that the doctors beaten up were rude, did not communicate well, did not explain, did not reach in time etc. To tell my own experience in last 20 years, most doctors do their best to explain things to the relatives, especially in a critical case. If the relatives are uneducated, drunk, panicked etc., the doctor cannot wait until they learn and understand. There are lady doctors beaten up in emergencies too: how does our society and the Humbugs explain it?
Then again, anyone right from the prime minister to the supreme court judge can get angry on duty if they don’t like someone or something, so why can’t a doctor get angry at the mannerless, shouting, drunk and violent? How much time and energy is a doctor on emergency duty supposed to waste upon such relatives? Where every second matters, why should other patient’s lives be risked because of relatives who refuse to understand simple logic? Do all these people understand the complicated problems and risks in medicine?

Why presume that it is the doctor’s responsibility to attend all health problems of the poor and the needy on all days? Why don’t these humbugs ask the government about the scanty / absent facilities at all its hospitals meant to serve the poor and needy? So the answer to the question “What should the average and needy patients do on a holiday?” is that “Please go to the government / charity hospital nearest to you, and if you are unhappy about its service, ask the government about it. The doctors who have finished their compulsory govt. services and left govt. jobs are no longer liable to be available 24 /7 for everyone. The only understandable exception is emergencies, in which case too, a doctor at home cannot do much, so one should seek an ambulance and go to the nearest hospital. Most hospitals provide emergency services as duty, and will be happy to help the “emergency” part of it. But is that all? No. On holidays, the emergency facilities are misused as mentioned in the earlier article.

To those who advise the medical professionals on behalf of the “needy and poor”, let it be known that there are hundreds of needy and poor patients in all govt. hospitals RIGHT NOW who need help other than medical care. They need food, medicines not provided by govt., emotional support, transport to and from the hospital, home care and attendance by someone etc., including their toilet. How many of the humbugs who preach sermons to the doctors actually go and help these “poor and needy” patients at home or hospital for their non-medical issues?
© Dr. Rajas Deshpande

Recently an 82 years old orphan was admitted under my care in a critical condition, for 8 days. He needed some medicines from outside the hospital. I requested the young male relatives of some other stable patients in that ward if they can please get the medicines from a shop just outside the hospital (clarifying that I would of course pay for them): they flatly refused! Our security guards at the hospital actually attended to the needs of this patient till his discharge. This is the awareness, readiness and participation of our society in patient care: it just dumps ALL medical & non medical issues of everyone to be attended by the doctors 24/7, nobody cares now about other patients.

If you are really interested in helping poor and needy patients, please go to the nearest hospital and you will find at least few patients who need your help. Stop firing your pompous rifles of hypocrisy from upon the doctor’s shoulders. There are orphanages refusing kids, having no foodstuff / education facilities for those residing in them, there are old-age homes where patients cannot walk because there is no one to support them, there are beggars at each traffic signal openly abusing infants and children by giving them sedatives, keeping their wounds open to create sympathy, carrying them without covering their heads in open burning heat of the summers, there are poor disabled as well as manic, violent beggars on all streets… what has any film star, any politician, any government done for them? Go help those needy and poor, my dear HHV victims, before pointing fingers at the doctors.

Unconscious trauma victims and unknown dead bodies are commonly brought into most casualties. Most doctors go far beyond their duty to make the alive survive and dead reach their relatives. Who among the “Humbug advisors” has helped there ever? Only the doctors know how many sons and daughters write forms “Not to continue medical care / ventilation” for their parents who still have some chance of survival, and how many take home an unconscious / critical patient home from hospital, under different excuses.

I have many patients and mature non-medical friends I adore, and we share a very good bond. They will understand the plight of this situation readily. For the remaining, I clarify: It is every doctor’s duty to help a patient in emergency, but the society must stop abusing and advising the very profession which is striving to serve its interests. A few corrupt doctors is not the whole truth.

It is easy to presume and talk ideals. After 30 years of practice some doctors do get their desired home and peace in life, and then they expect that the newer generations should never expect to do better than they themselves did. ‘In our times”, “All our life” etc. are spoken as if the newer generation is begging / dreaming to be you. They are not. Let the new doctors please do better than to earn a big home or a small hospital in retirement. Let them take India to new heights in medical research, in discoveries, finding cures, winning Nobel prizes, and making world-class medical set-ups in India, for all its citizens rich and poor, and let the government pay for those set ups and the treatments too!
Simultaneously let the new gen docs also live a good life. Let them make better families. Let their wives and children not be punished for their choice of a noble profession.

Our prime minister said to the IAS class conference just yesterday: “Why tense? Quality time with family is a must!”. Why doesn’t this apply to the doctors too?

Coming back to the humbug virus affecting even some doctors, it’s high time we realise that every specialty has its own requirements, problems, methods which have evolved over decades. So a cardiologist cannot advise a gynaecologist how to practice, nor can a pediatrician advise an orthopedic surgeon what to do in a trauma case. (And yes, all of these should also not tell neurologists / psychiatrists to see patients faster and charge lower!!). We must have separate boards of practice control / discipline for different specialties. These boards must decide the practice standards for their specialty and fees too. Blanket rules may apply for the common purpose, but diversity is necessary to evolve our system into a better one than what we have today.

The first measure is to identify and treat the victims of this Human Humbug Virus. Next time someone advises the doctors about their duties and helping the poor and needy, especially on weekends and holidays, please request them for their contacts to upload on public platforms so doctors can start sending the poor and needy patient’s non-medical issues to them. Let the channels crying foul about the medical issues donate all the revenue generated during such news and the ads therein for the care of poor patients in govt. hospitals.

Otherwise the HHV will destroy whatever good has survived in this noble profession.

© Dr. Rajas Deshpande

Issued in good faith.
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The Good Doctor Myth

The Good Doctor Myth:
This article may hurt some feelings. I apologize in advance, but this is how I truly feel. Basically for students and patients.

“Just looking at the doctor took away half my pain / illness”
“The doctor always makes me laugh and reassures.. A very nice human being, very compassionate”
“I am very close to the doctor.. he/ she calls me his younger brother / sister etc.”
“He / She is so busy, but still saw me and advised”

It is quite common to hear these sentences in a hospital. It is expected from a doctor that he / she must dress well, speak well, be nice, mannerful and compassionate, and ease out the patient’s worries.

This I agree is essential, but is this all? Would any smiling / laughing pleasant, well dressed and well behaved doctor who takes away your worries by well – chosen words (and a pat on the back) be enough to handle your life?

Think again.

For making a health decision, what all qualities must the qualified doctor have?

1. Exactness of current knowledge and literature about that particular illness.
2. Experience in handling that particular illness and its complications, without
involving ego (Many would just decline counter-opinion just because it came
from a rival / junior etc.)
3. Analytical abilities based upon a combination of the above two.
4. Concentration: possible only when you are not very busy or supermultitasking.
5. A complete knowledge of the patient’s health profile: Detailed history, medical
conditions, ongoing treatments (allopathic and other), ongoing diet, allergies,
other specialists treating the patient, addictions etc.
6. Surgical skills in that particular specialty.
7. A readiness to explain the true nature of illness, its complications, all
treatment options etc., a respect for patient’s choices (not persuading the
patient to make a choice by telling only the worst possibility) , readiness to
accept mistakes and explain the patient about them.

We are in the age of superspecialisation. This means the basic doctor (MBBS) goes through specialisation (MD /MS = 3years) in a specialty, then through Superspecialisation (DM /MCh = 3years), then through fellowships (2-3 years) as a postdoctoral superspecialist. (There are many other true and fake degrees, which again is a debatable topic).

As one climbs higher in a specialty, he /she becomes less and less expert in other fields as they need more concentration upon one subject for many years. One is supposed to refer the patient to another / superior specialist in case of a condition that is not one’s own specialty or beyond experience.

However, many doctors who appear very pleasant to the patient because of the qualities mentioned above, take advantage of the patient’s faith in them, and keep on treating the patient either themselves or through specialists of their choice / liking / etc. (This is what the patients know as ”rackets” in our profession).

This results in:

False reassurance of safety / lifespan in treatable / untreatable medical conditions.
Delay in treatment / incorrect / overtreatment (Stroke / Cancer / Parkinsonism)
Wrong drug / dose choices (most common example: epilepsy).
Complications due to drug interactions / disease worsening/ combinations of these two.
Falsely attributing complications to some pre-existing disease.
Incomplete evaluation / screening before surgery that results in surgical / postsurgical complications.
Accidents due to non-treatment of conditions that may make the patient unconscious.

The “Good Doctor” is the one who, besides being polite, nice, compassionate and understanding, spends time for interacting / talking to the patient, examining him / her in detail, explaining the diagnostic possibilities and need for investigations advised, risks involved, and realistically addressing the patient’s fears in a kind manner. The good doctor will also answer all questions that the patient has about this consult / diagnosis, and offer all possible options of treatment. He / she will also freely mention the dilemmas in diagnosis (instead of “impressing the patient” by pretending to understand and answer everything) and also the problems he/she could not solve, and suggest references to other colleagues / specialists for a second opinion.

A good surgeon will talk to the patient after surgery, mention his / her associates / assistants who helped during the surgery, and explain good and bad outcomes boldly, thus gaining patient’s confidence in truth.

Gone are the days of a smiling / laughing “I-know-it-all-don’t-you-care” pseudoreassuring doctor who would definitely uplift a patient’s mood, but certainly cause harm by mis/delayed diagnosis. Also gone are the days when patients should accept a “quick” consult in a hurry by a very busy doctor continuously attending phone, handling a hundred things simultaneously etc… A decision for treatment, and especially surgical intervention must always come from a calm and concentrated mind.

The patient must also know that if a doctor is to spend more time with you, he/ she will have to see less patients, so the consulting fees may increase as per time / skill. Patients should concentrate upon what is being told, avoiding repetition of the same questions. Google based interview of the specialist should be avoided. One must have complete faith in the qualities, abilities of his / her doctor, unless proven otherwise.

The purpose of this article is to highlight that only external appearances and behaviours do not make a good doctor, as is the general perception especially among the frightened, depressed and illiterate patients.

Wishing best health to all.

Rajas Deshpande