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Apr-Jun2002-10(2)
DISCUSSION
Unholy nexuses in general
medical practice
BC Rao
It is a matter of concern that general medical
practice as it should be is slowly disappearing in our country, especially in
the urban areas. There are many reasons for this. Specialisation has a glamour
and prestige attached to it, as a result of which specialists also make more
money than do general practitioners (GPs). GPs also have (well founded) fears of
professional isolation as they work in the community and specialists from
institutions. There are no clear-cut geographical distinctions between the work
of GPs and specialists; in many areas specialists have taken over work that GPs
should be doing by right. This particularly true of obstetrics, minor surgery,
most of paediatrics, quite a bit of ophthalmology, ENT and psychiatry
There was a time GPs provided all these services,
led fairly fulfilling lives and were respected for their service to the
community. They could also make a reasonable living without resorting to the
dubious practices which have now crept into their arena. It is no consolation to
know that these unhealthy practices exist in specialities as well.
To some extent one can blame the general lowering
of standards of ethics in all spheres of public life. After all, doctors are
products of the same society. However, certain trends have contributed to the
moral and professional degradation of medical practice in general and general
medical practice in particular.
Fee splitting
This appears to be the norm rather than the
exception in the country's major metropolises. No one is willing to talk openly
about this practice, and I suspect the reason is that most are a party to it.
Nevertheless fee splitting exists and, if I may use the word, 'flourishing'.
There are various ways in which it is done. Let us take these one by
one.
Laboratories and hospitals pay referring doctors
(both general practitioners and consultants). The percentage of payment can be
10 per cent to 20 per cent or more of the total charges. This is usually paid in
cash, in which case it is unaccounted, but it is also paid openly by cheques. If
a doctor were to tell these institutions not to pay him but deduct the amount
from the patient's bill, most will not oblige. That is the reason some of my
colleagues put forth for accepting this consideration. I know one of them
ploughs it back into his charity work. This places GPs in a dilemma
(consultants too). If they direct the patient to a diagnostic centre that agrees
to their terms and gives the patient the benefit, it may be inconvenient for the
patient, besides which they may also have to explain their choice. This can be
awkward and patients may not believe them.
Consultants also pay general practitioners a
percentage of their fee. I believe this practice exists but I don't know the
extent of this practice.
Then, pharmaceutical companies pay doctors, in kind
or otherwise. This type of fee splitting is widely prevalent and no doctor is
exempt from this. All of us including myself have attended continuing medical
education programmes supported by pharmaceutical companies. But the practice
extends beyond such sponsorship. Selected doctors are wined and dined and even
taken out of town to attend professional conferences with private pleasures
thrown in. The question is how far we can go in accepting such sponsorships.
Recently we (the Indian Association of General
Practitioners, a 25-year-old body of Bangalore-based GPs) introduced the concept
of 'paying for your learning' in our monthly CME programmes. A separate register
was kept where doctors attending the programme paid an amount of money which was
not fixed. Many people pay, but many don't as we have intentionally kept it
optional for the present. This takes care of some of our expenses we are still
dependent on sponsorship. Ideally there should be no sponsorship and we should
pay for our learning.
I know of no GP who can really afford to stay out
of town in a reasonably good hotel and attend, on an annual basis, the
conferences which are so essential to update oneself. The few conferences that
they attend once in a blue moon are a financial strain. When an offer comes from
a pharmaceutical company to host them and perhaps their families, will you blame
them if they accept? In any case, such offers usually come to the consultants,
not the GP. Then how do we educate ourselves? The only solution is to organise
such programmes locally with local resources as we are doing in Bangalore. They
are still not entirely free of sponsorship, but we are heading slowly in that
direction.
Let us see where this pernicious nexus is taking
us. Doctors who take these kickbacks will always be on the lookout for patients
whom they can send for investigations, interventions or hospital admission.
Their abilities to think, diagnose and treat the patient erode over the years
and they become qualified referral clerks and qualified quacks. Patients end up
paying more, without knowing that some of this money is going back to the
referring doctors. There is a widespread suspicion that the profession is not
playing fair. This will eventually become common knowledge and the vestige of
respect that the profession commands today will go. Doctors who don't split fees
will be bracketed with those who do, and the entire profession will come to
disrepute. Patients will be afraid to come to us, fearing that we will
unnecessarily prescribe tests and perhaps even create illnesses where none
exist. Doctors who accept the hospitality of pharmaceutical companies
and/or equipment manufacturers are beholden to use and prescribe these products.
They may of good quality but the expenditure incurred on hosting the doctors is
built into the cost of the item and the end user, the patient ultimately
pays.
Hospitals and diagnostic centres with crores of
rupees invested will adopt or are adopting aggressive marketing techniques to
entice more and more doctors into this path of easy money. A cardiologist friend
of mine bemoaned that people will treat us as traders not professionals. I am
afraid this is already so. Salespeople employed by diagnostic centres and
hospitals are approaching us with proposals. Recently I informed one such young
woman that what she was proposing was wrong, and also explained why this was so.
Unfortunately I failed to convince her. She felt it was an excellent business
proposition and I was foolish (or naïve?) to refuse it. I put up a query in our
website's forum board (www.iagponline.com) asking doctors whether
it is justifiable for hospitals to give a percentage back to the referring
doctor. It is nearly three weeks and not a single doctor has responded. This
silence speaks volumes.
The major casualty is our self respect as
professionals. These practices bring us down from the high moral ground that
this profession occupies - or occupied. Already, when a doctor prescribes a
procedure or treatment, the patient doubts if it is really needed. There is a
justifiable suspicion that such procedures are suggested to help doctors and
institutions, not patients. What are the remedies? Can fee splitting be made
legal in the sense that the patient knows he is paying an indirect commission to
the referring doctor? Is this going to solve the moral issues of right and
wrong? Pharmaceutical companies can make public their expenditure on individual
doctors and associations of doctors. Will this expose help? I have no easy
answers to these but current trends make me extremely uncomfortable.
Unwanted treatment and investigations
This is another issue that is causing harm to our
image. Medication and investigation are linked to effective patient management.
Unfortunately they are also linked to our income, and strangely, to the psyche
of our patients and doctors.
Let us take the example of a new patient who comes
to me with a cough as the presenting symptom. I find there is normal air entry
into his lungs, no abnormal chest sounds, normal peak flow rate, normal ear,
nose, throat and my logical conclusion should be that the patient has an
allergic cough and it is probably self limiting. I also know of the recent BMJ
article debunking most cough syrups containing antihistamines as next to
useless. So if I am honest, I will explain to the patient that the illness is
likely to be self limiting nature, advise him that no treatment is required at
present, and request him to return if he gets worse, develops fever or his sleep
gets disturbed. Then the treatment will be with inhaled corticosteroids or
antibiotics. If my practice has an element of consultation then I will collect a
fee for this service. The patient then thanks me and will promptly go to another
doctor.
Let us assume that this doctor is well informed. He
will, after examination, dispense some medicine or give one of the many cough
syrup samples he has with him, or prescribe one of these syrups. He is also
likely to give an injection of vitamin B complex. If the patient has the
fortune or misfortune of going to a consultant, he will most likely get a
prescription for a cough syrup and a note to get a chest x-ray and blood
studies. As with dispensing and injections for a GP, so with investigations for
a consultant. In most cases both are unnecessary but the patient is likely to be
more satisfied with that than with what I did. I leave it to the readers to
guess who made more money.
Many of us do this instead of educating patients.
Generations of doctors have kept the whole nation ignorant of basic health
matters. If I want to be uncharitable I would say that in their ignorance lies
our prosperity. A well informed patient will demand treatment after being
informed, and explaining a problem will mean spending lot more time. This will
mean seeing fewer patients and maybe making less money. The ignorant patient who
believes in the magical powers of an injection or the diagnostic accuracy of the
X-ray will only be satisfied if these are done.
Based on these facts a huge industry has sprung up
which manufactures equipment and drugs used mostly for placebo value. Go and see
any diagnostic centre and evaluate 100 consecutive X-rays and I guarantee that
not even 10 per cent of them will be abnormal. I will not be far wrong if I
stretch this to almost all investigations which will include CT scans and TMTs
and may be even angiograms.
Should we the medical community allow the
perpetuation of such unethical practices? Should we continue to take ethical
shelter under the garb of patient satisfaction? Or should we try and
educate patients? Is it impossible to earn a reasonably honest and decent living
without resorting to these methods?
Dr BC Rao, 847, 2nd
Cross, 7th Main, HAL 2nd Stage, Bangalore 560008. Email:badakere@mantraonline.com