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Apr-Jun2004-12(2)
CONTROVERSY
Staying
on
Thomas
George
Dr Sanjeev Gupta returned to the UK because he
found the practice of medicine in India professionally unsatisfying, ethically
problematic and financially unrewarding. His experiences will evoke empathy and
perhaps déjà vu among many medical professionals in India. Let us look at each
of these areas.
Professional
satisfaction
Dr Gupta found medical practice in India
unscientific. Generally speaking, there was little evidence-based practice;
specifically there was a misuse of antibiotics and an overuse of investigations.
Although many doctors paid lip service to scientific principles, they did not
practise them. Dr Gupta tried discussions; they did not work. There is no doubt
that his experience mirrors the reality. In India, there are no protocols for
antibiotic usage, investigations or the indications for surgery. Here and there,
some hospitals and individuals do have such protocols, but these are the
exceptions, not the rule. In short, there are no systems. While doctors in
countries that have set up such systems sometimes complain of over-regulation,
it is generally accepted that such systems have ensured better outcomes for
patients.
In the Indian ‘medical bazaar’, the patient has no
guidance system. The media is full of glowing reports of this or that hospital
(mostly private), doing this or that procedure. Most of these procedures are
routinely done abroad and within the competence of a large number of
practitioners in India. The procedures are usually uncommon only because they
are expensive. In the absence of good quality information, the public is led to
believe that the expensive treatment being touted is the ‘best’. There is hardly
any information on the appropriate indications or the problems that can arise.
Unfortunately, people of doubtful integrity often dominate the professional
bodies that should be involved in evolving protocols. Nearly all professional
bodies are used as another medium to advertise the medical glitterati. We, the
medical professionals, should force these bodies to evolve guidelines. The
public, through various self-help groups, should demand the same. This great
change in medical practice in India will not come on its own. Individual doctors
talking to colleagues, as Dr Gupta did, will help, but this is not
enough.
Ethical problems
The problem of practising ethical medicine in India
is closely linked to the lack of professionalism and systems. Many of the
problems that Dr Gupta enumerates, such as taking cuts for referrals, not being
open about the cost of treatment, misleading the patient about the appropriate
treatment, etc., are blatantly wrong. They are possible because of the absence
of a system. Since patients have no method except hearsay, to choose between
different doctors, they are vulnerable to exploitation. Unless we set up a
system of area-wise demarcation for general practitioners, a referral system and
regular audits of practice, such unethical practices are likely to continue. It
is ironic that way back in 1946, Joseph Bhore suggested such a system. Many
governments have paid lip service to it, but vested interests have successfully
sabotaged its implementation.
Financial rewards
Many doctors in India struggle to make ends meet at
the beginning of their careers. Those who have read A J Cronin’s accounts of
medicine in the UK in the early part of the 20th century will find parallels
with the present situation in India. Perhaps financial difficulties push the
young doctor into unethical practices.
Questions
Is it impossible to practise ethical medicine in
India? Are all doctors in India unethical and unprofessional? The answer to both
questions is an emphatic no. There are many thoroughly professional and ethical
doctors. It is difficult but not impossible to practise scientifically sound and
ethically irreproachable medicine in India. However, this usually involves
sacrifices. Most doctors, for whom science and ethics are paramount, sacrifice
professional advancement and financial reward. They are found everywhere: in
low-profile general practices, trust hospitals and the state-run medical system.
However, these niches can be a sort of solution for the individual doctor. They
are certainly not the solution to the systemic problems of medical care in
India.
One last issue remains: Should Dr Gupta have
remained in India? The decision to live and work in a particular place is
complex and highly personal. For those fortunate enough to have a choice in the
matter, it is obvious that they will choose the place where they are
comfortable. Dr Gupta is troubled by his decision to return to the UK. He seems
to consider it a betrayal of his motherland. Here I think he has confused a lot
of issues. He talks of his admiration for freedom fighters Bhagat Singh and
Khudiram Bose and their readiness to die to achieve the independence of India.
He feels that returning to work in India is a present-day equivalent. I feel
that the two situations are in no way similar. Love of any kind, including that
for one’s country, does not exist in a vacuum. The struggle for the freedom of
India was rooted in the personal oppression that all Indians faced in greater or
smaller measure. The struggle for freedom was also a struggle for individual
freedom. It was based on the understanding that no Indian could be a full
citizen of India, let alone of the world, unless the country was free. In this
extreme situation some exceptional people were willing to make exceptional
sacrifices.
Dr Gupta’s situation is different. It is not
obvious that the country has a pressing need for specialists like him. In fact,
in the urban areas, there is already a surplus of specialists. In the remote
parts of India, where they are in short supply, there are probably no facilities
to practise the kind of medicine that Dr Gupta is accustomed to. He returned to
India out of a vague and romantic desire to ‘serve the country’. It is not
surprising that he was easily disappointed when the country did not make this
‘service’ easy! In the absence of any special need for his services he felt
neither wanted nor appreciated. In addition, the financial rewards were meagre.
In such a situation, the life he had left in the UK must have seemed good indeed
and it is not surprising that he returned.
The desire to contribute to one’s native land is
noble. Those who undergo extreme hardship to serve their fellow citizens
definitely deserve praise and appreciation. However, if one does not have the
stomach for this kind of sacrifice, there is no need to feel guilty. It is far
better to serve people gladly in a place of one’s choice than to be constantly
unhappy.
Nowadays, a kind of pseudonationalism
seems to be popular among expatriate Indians. Usually it takes the easy path of
financial support for regressive practices and political parties in India, under
the guise of supporting ‘traditions’, ‘Indian values’ and the like. Few people
have the capacity to forsake a comfortable life in the service of their fellow
citizens. Dr Gupta has provided a graphic description of what a medical
practitioner returning to India is likely to face. Working for change is never
easy.
Thomas George,
114J, Railway Quarters, Rostrevor Garden,
Chennai 600018, India. e-mail:gezarore@hotmail.com