Indian Journal of Medical Ethics

At the annual conference of the Association of Medical Consultants (AMC) a couple of years ago, I was pleased to hear an office-bearer of the AMC declare that the association condemns the practice of giving or taking referral commissions.

The ground realities are, alas, quite different. Referral commissions, popularly known as 'cuts', are rampant among the medical community almost all over India. If, as is generally believed, more than 90% of medical consultants are in the practice of splitting fees, it is an obvious inference that most AMC members are also involved in this practice.

When I started practising plastic surgery nearly three years ago, senior practitioners, across specialties, advised me to fall in line and start giving 'cuts'. Otherwise, I would not survive, they said. If everyone else gave and I did not, obviously nobody would refer patients to me.

My mind rebelled. Was it not illogical, unethical and even stupid to split fees, I reasoned. Unfortunately, the fear of sitting idle in the clinic pervaded and I began my practice giving 'cuts'.

However, referrals to a superspecialty were few and far between and occasions to give commissions were scarce. Gradually, I secured attachments to a few trust-managed hospitals where work started coming, albeit slowly.

After three or four months, my mind rebelled again. Why was I giving 'cuts'? Was I a trader and the patient's illness a commodity to be shuffled from trader to trader on a commission basis? Was this not a bribe to the general practitioner to send me more work to make money? Was the patient not a living human being, with dignity, values and a right to obtain good medical care without financial considerations being involved?

Patients are referred to consultants only when the disease or illness is beyond the competence of the general practitioner (GP). When the GP can provide the necessary care himself, he does not refer the patient to a consultant. It almost seems a crime to have studied several years more than the GP. When we pay the GP, are we paying a fine for our extra learning and competence?

Healthcare professionals exist only because there is a need for our care and skills. Indeed, a busy practice for doctors in a society speaks poorly for the state of health of that society. As the scriptures say, Sarve santu niramaya- May all be healthy. Patients come to me for their disease and I am not happy to see a long queue of the sick, outside my clinic. I would do all I can to give them succour with sympathy, but I would prefer to prevent their disease.

If that is the essence of our profession, where is the question of offering bribes to get a patient? I am not a trader; money is not the purpose of my life. My patients come to me for relief and I will do them an injustice if I traded them in their hour of need for money.

Look at the practical side of giving 'cuts'. Does the GP who takes 40% of your hard-earned money take equal responsibility for the welfare of the patient? If a patient wins a compensation claim over the consultant for any reason, will the GP bear 40% of the compensation charges? Are we not stupid to take the onus of 100% responsibility of the patient upon us and take only 60% of the charges due? And the GP gets 40% for a mere referral note!

Besides, there is no limit to the incentive money a GP can ask for. The asking rate is as high as 60% in some areas and it is likely to go higher as we stoop lower. I have heard of a consultant who deposits a lakh of rupees in advance every month with each of his 'fielding' GPs. The 'cut' money is deducted from this deposit according to the referrals made. The GP feels bound to send patients and perhaps the consultant feels secure enough to get a good night's sleep. Ah! The maya of money!

Compounding the problem The problem does not stop there. Consultants hold lavish parties for GPs, shower them with gifts and, if hearsay is to be believed, even arrange for call girls for them. Is there no limit to the indignity to which we will subject ourselves?

I know the psyche of several practitioners, even seniors, who have their practice built on the GP-consultant nexus. They seem to be insecure about future 'business'. 'Will that GP send me his patients this month or not? What if he diverts his patients to the new rival consultant who may be offering more incentive? How can I woo away some more GPs from other consultants?'

I know consultants who have built a good practice on their own without this nexus. They are, I believe, so much at peace with themselves, having nobody to tell them what to do. They can charge less as they do not have to pay the 'GP tax', and thus earn the goodwill of their patients. They may take a couple of years more to settle, but are self-made, more secure and happier.

Look at the inherent dangers involved in such a system. Very often patients get referred to a consultant or investigated only for the sake of kickbacks. Whether the patient's disease really merits a referral or an investigation becomes secondary. The patient goes to the consultant who gives the most 'cuts'. The competence or propriety of the particular consultant in treating that particular illness is often not considered.

Are we not making a mockery of our art and science? Such commercialization goes against the grain of our profession, against humanity, against the love for our skills that we ought to have.

Besides, the practice does not bear well for GPs themselves. They are under duress-even after having giving a referral note-as there is no guarantee that the same patient will not go to another GP and take another note from him too. Often consultants find patients coming to them with multiple referral notes. Ultimately, the person who suffers most in this game is the miserable patient. He has to shell out more money, as most consultants will overcharge when there is a GP involved. Medical treatment is already so expensive; the 'cut' system only adds salt to the patient's wounds.

Similarly, why should I accept kickbacks from a laboratory or an X-ray clinic? I can do well without such ill-gotten money. I am overwhelmed by the smile on my patient's face at the end of everything, knowing that I have done my best and not exploited him in his hour of need.

Woe betide the founders and perpetrators of this evil commission business that has commercialized our pristine profession! Newer consultants are being forced to follow suit or face the prospect of being outcast by the GP community at the start of their practice.

While our authorities must make laws prohibiting this practice, it takes more than the law to change people's behaviour. It will take concerted action on the part of ethical-minded practitioners of medicine to effect this change.

It has been nearly three years since I started practice and, by the grace of the Almighty and the blessings of my satisfied patients, I have survived. The going has not been tough but, after all, it is all in the mind, they say.

Those interested in collective action against the giving or taking of referral commissions can contact the author on (022) 2889 1978.

Vasant Clinic, Sarla Sadan, Pushpa Park, Daftary Road, Malad East, Mumbai 400 097, India. e-mail:arunsheth@hotmail.com