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Oct-Dec2002-10(4)
INSPIRING LIVES
"We need to invest in our
teaching hospitals"
R A
Bhalerao
When we were students, we had role models who came
from the Independence struggle. They were morally, mentally and physically
oriented to doing their best for the country. In the '60s, these individuals,
like Dr Phadke, Dr Baliga, Dr P K Sen, put in tremendous time and energy in
teaching. They spent more than four to five hours every day in KEM hospital,
even as Honoraries. I remember Dr. Baliga coming to take a class for us, after
postponing a case in his private clinic. Such was their commitment.
However, even in those days, it was not uncommon
for surgeons to operate in KEM and collect fees in their private clinics. The
amount collected, however, was paltry. There was subtle priority granted to such
patients. It was the era of 'Note cases'. The patients who had a note for the
named physician would get priority. However, each subsequent dean realised that
this was not a fair practice and the note cases got priority only on the
concerned physician's admission day. This is an example of the inequities in
practice even then.
While I do agree that ethics in the medical
profession have deteriorated over the years, I must say that it is just a
reflection of ethics in society. It would be unfair to say that only doctors are
unethical. In today's world the definition of corruption will have to be
modified. A fair amount of tipping for essential services has become
institutionalised and people are more matter-of-fact about it.
I also feel there was less competition among
consultants in those days. The pressure to earn money was not as high as it is
today. I think, as in politics, the introduction of capitation fee colleges has
increased the investment made by a doctor and his parent. There is pressure to
recover that investment, either through a quick, high-income practice or at the
time of marriage. It is inevitable, then, that medicine is seen as a trade. This
is where unethical practices like fee-splitting come in. The greedy want to earn
far beyond their ability to even spend it. This has very little to do with
medicine and its practice, but the peculiar desire to compete. It is a pressure
typically seen in trade and business.
The last straw on the camel's back is the current
practice of 'starving' teaching public hospitals. This is because of pressure
from private health care vendors who stand to gain if less money is spent on
public hospitals. When we entered the teaching profession, teaching hospitals
like KEM were the top hospitals. Anything complicated would be done first in the
teaching hospitals, then it entered the private sector. With the entry of
corporate and non-profit hospitals, coupled with the poor funding of public
hospitals, public hospitals now cater only to the poor. The current scenario
does not attract the best medical talent. In our time, the teaching job was the
best job anyone could hope for. Though my monthly salary was only Rs 400 then, I
was looked up to, as a teacher. Most of us did not mind waiting till middle age
to earn a reasonable salary and lead a comfortable life. Today's post-1975
generation, are the 'here and now' generation. They are not living on ideals,
they want to earn while they are young. This social phenomenon is prevalent
among other professions like engineering and business administration, where they
are under pressure to earn.
This leads us to two basic tensions between society
and doctors. Society accepts that a doctor can earn money but cannot accept that
a doctor should earn money at the cost of everything else. This is because a
doctor has educated himself at society's expense. When a doctor asks, "Why
should I do charity when architects and accountants are not expected to do so?"
he forgets that the resources he has consumed from society, in both human and
monetary terms, are far more than any other profession. This social awareness
has been lost somewhere down the line, more so with capitation fee colleges
where they feel they have paid for their education and there are no obligations.
Another tension is related to the phenomenon of
doctor shopping. During our time, there was faith in the doctor and his
integrity. Today, patients suspect their doctors, and every case demands a
second opinion. Patients shop for doctors, looking for 'competitive quotes'.
Doctors are resigned to this phenomenon and give advice without commitment to
their patients, because they know the patient may not come back. There is no
doctor-patient relationship. Today's patient is just a client who pays. The
doctor is no longer an advisor giving out holistic advice. Today's doctor does
not feel responsible for the health of society. He feels that is the
responsibility of politicians, administrators, the country in general. He is
just there for health care delivery. This is a basic conflict.
Due to my personality, very rarely has anyone
offered me a bribe. Any offers of donation would be directed to the departmental
development fund, the poor box or to the Dean. My seniors did not take any
money, but by the time I became a professor, it was well known that certain
lecturers were 'free-lancing' in the evenings. The attitude was that if we got
caught we would resign immediately. This was related to poor academic
stimulation coupled with low salaries. A financial disadvantage is tolerated
when compensated for by a professionally satisfying atmosphere.
A model example is the Christian Medical College,
Vellore. You may receive less cash in hand, but all your other needs are taken
care of. The lack of competition locally and the existence of strong religious
tenets add to the dedication of the doctors there.
I do not think that the moral fibre of doctors
today is corroded to a great extent as compared to our time. There are many fine
role models even today. The stories about doctors refusing to operate because
they have not been paid are exaggerated. The vast majority of doctors today are
practising ethically. The black sheep are just a handful who, because they are
in the limelight and openly promote unethical practice, are bringing the entire
fraternity down.
I would like to tell young entrants to medicine
that unfair and unethical practice is no lasting solution. It may give quick
returns initially, but soon, such people start losing sleep and join the club of
doctors with stress disorders, which are on the rise. The only marketing that
works in the long run is that of word of mouth. Such doctors may have to wait a
little longer, but they will get returns for their patience. In my case, the
best referrals come from the patients themselves, not from general practitioners
and peers.
Patients want an honest doctor. They may be
dishonest themselves, but where their own body is concerned they want honesty.
There is a clear dividing line between a good living and greed. During my time
medical professionals were the richest of the community. Not any more. Medicine
is no longer in the running for the best paying profession. There are no more
doctor millionaires. Today, the richest people are entrepreneurs and other
professionals. Parents pushing their children into medicine need to consider
their wards' mental make-up and their ability to sustain physical hardship. They
must also keep in mind that the respectability of the profession is slipping.
Privatisation of health care is not a satisfactory
model for India. On the pretext of lack of funds for sewage disposal, good water
supply, primary care and immunisation, the government is inviting the private
sector to participate in curative health. Medical education must remain
government aided. The private sector has to be regulated by the government so
that exploitation is minimised. Also, charitable institutions need to be
transparent in their functioning.
On the other hand, the government needs a
'corporate style of accountability and management'. Instead of closing down
public hospitals, there is a need for better managed public hospitals. The false
sense of socialism needs to be abandoned. Those who can afford it must pay for
the facilities, with a clause that they may be used for teaching. This money can
be pumped back to pay teachers better, and to buy better equipment. This model
will work. Free health care for everyone is a bad idea.
As told to Nobhojit Roy
Dr R A Bhalerao,Director, Medical Planning and Projects, and Consultant Surgeon, Hinduja Hospital, Mahim, Mumbai.