Indian Journal of Medical Ethics

I am a pathologist in private practice since 1975. Being a consultant, I consider myself to be a specialist in pathology and hence I only give advice in the branches of pathology and microbiology. Though my basic degree is MB,BS, and I see at least 20 diabetic patients per day, I have never given them any suggestion about treatment- not even to my relatives. I believe that as a specialist in a particular field-pathology-I should not venture into other medical colleagues' areas.

This is contrary to the position of pathology in the minds of other medical colleagues. Many seem to think that pathology is the easiest subject, and that they have sufficient knowledge to run a pathology laboratory. A three-year course in pathology after MB, BS is probably a waste in their view. They also think that as we employ technicians, they can run laboratories with their help. Their knowledge of pathology is limited to reading advertisements of automated instruments. They forget that the brain of our laboratories is that of a pathologist, while that in their laboratories is that of a technician. Instruments require not only hands, but also medically trained brains to run them. These doctors do not know that automated machines also require calibration, standar-disation, etc. In addition, they think laboratories earn more. This is true only if inaccurate and substandard methods are followed.

Quacks are seen in every field of medical practice, but quackery in pathology is unique because it is created and blessed by the medical practitioners of various specialties. These medical practitioners start pathology laboratories with the help of technicians-some qualified but mostly unqualified. Most of these laboratories are run in different hospitals or consulting rooms and the technicians are projected intentionally as 'pathologists' to the lay public. That is how quacks in pathology are born.

Take the example of Kolhapur. There are about 23 laboratories run or supervised by pathologists with post-graduate qualifications-and over 250 laboratories run by various medical specialists such as physicians, surgeons, etc., with the help of a technician. Obviously, a non-pathologist medical practitioner (NPMP) has no knowledge of pathology tests. Neither NPMPs nor their technicians (rarely a post-BSc with a diploma in medical laboratory technology [DMLT]) know about quality control or quality assurance or standardisation. Thus, the reports given by these NPMPs and their technicians are either based on faulty methods or on the use of sub-standard reagents. The compromise on the quality of reagents and lack of quality control leads to a poor-quality report. Because of the risk of medicolegal problems, most such reports do not carry the name of either the laboratory or the pathologist.

The new regulations of the Medical Council of India (MCI) were published on April 6, 2002, and state that pathology laboratories should be run only by recognised pathologists, and not by any other medical graduates or by technicians. The regulations are clear on the fact that a physician is defined as a doctor with the basic qualification of MB, BS. Hence, technicians should not label themselves as doctors. If physicians are to 'uphold the dignity and honour of their profession', how can they employ non-medical persons for medical service? Regulation 1.1.3 states that only a qualified person can practise medicine. Thus, a technician who has neither any medical qualification nor registration cannot practise modern medicine or its specialty branch of pathology.

Many non-pathologists start a laboratory using the brains and hands of these technicians. The DMLT is 'to provide qualified technicians in government hospitals to work under a specialist pathologist' and not under any non-pathologist medical graduates/postgraduates, who 'think' themselves to be pathologists. There are hundreds of institutions in Maharashtra which give this degree of DMLT where students never come in contact with any patients or authorised medical education institute. Students are often shown the tests, mostly done by primitive methods in a course that lasts from 15 days to 6 months.

Are such institutions authorised to run such a paramedical course? Many physicians tell us that they themselves have taught their technicians how to do the tests. It is worth remembering that their experience of pathology is limited to a few months of study in the second year of their MB, BS course. The argument that the same technicians work in our laboratory is true but does not take into account the basic laboratory set-up, selection of procedures, proper reagents and instruments, and standardisation.

7.10 A registered medical practitioner shall not issue certificates of efficiency in modern medicine to unqualified or non-medical persons. (A physician cannot train a technician, as he himself is not a specialist in pathology and thus cannot have the authority to train in pathology.)

1.2.1 The principal objective of the medical profession is to render service to humanity with full respect for the dignity of profession and man. Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion. Physicians should try continuously to improve medical knowledge and skills and should make available to their patients and colleagues the benefits of their professional attainments. The physician should practise methods of healing founded on scientific basis and should not associate professionally with anyone who violates this principle. The honoured ideals of the medical profession imply that the responsibilities of the physician extend not only to individuals but also to society.

This tells us that physicians should not associate themselves professionally with anyone who violates this principle. They should also give the advantage of improved medical knowledge (in this case the advanced knowledge of the pathologists, and not of their own technician) to the patient. Thus, every sentence of the above paragraph is violated by such appointments.

1.6 Highest quality assurance in patient care: Every physician should aid in safeguarding the profession against admission to it of those who are deficient in moral character or education. A physician shall not employ in connection with his professional practice any attendant who is neither registered nor enlisted under the Medical Acts in force and shall not permit such persons to attend treat or perform operations upon patients wherever professional discretion or skill is required.

Technicians are neither registered nor enlisted under the Medical Acts in force. They are given certificates and 'allowed to practice independently' by some AIIFD or similar institution from New Delhi/Mumbai, who are not at all concerned with the MCI, which is the only governing Central Government-appointed regulatory authority in the field of modern medicine.

6.4.1 A physician shall not give, solicit or receive nor shall he offer to give solicit or receive any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment. A physician shall not directly or indirectly, participate in or be a party to act of division, transference, assignment, subordination, rebating, splitting or refunding of any fee of medical, surgical or other treatment.

Do I need to elaborate? There are only a few doctors who do not fall prey to such practices. Yet our medical councils do nothing about it. This has been illustrated earlier by M K Mani in this Journal (1). Four months ago, a few pathologists in Maharashtra did something similar and are awaiting a response from the Maharashtra Medical Council and MCI.

6.4.2 Provisions of para 6.4.1 shall apply with equal force to the referring, recommending or procuring by a physician or any person, specimen or material for diagnostic purposes or other study/work. Nothing in this section, however, shall prohibit payment of salaries by a qualified physician to other duly qualified person rendering medical care under his supervision.

Thus, physicians cannot 'refer' any patient to a quack in pathology for diagnostic tests. They cannot pay salary to technicians, as they themselves are not 'duly qualified pathologists' and their technicians are not 'duly qualified persons'.

We all know that no action is ever taken by any authority. Thus, one can continue with impunity. Our only hope is that the general public is now becoming aware of these facts. Perhaps this will lead to a change in attitudes and approach.