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The medical profession in India is in crisis and society no
longer holds the medical profession in the high esteem it
used to in the past. Most honest doctors would agree that
ethical standards in the profession are deteriorating, and
this seems to be a downward spiral. When, where and why does
the rot start – and what can we do about it ?
Most people still believe that when youngsters join medical
college in order to become doctors, they usually do it because
they have idealistic goals and want to serve and help others.
Of course, it doesn’t hurt that doctors have a good
income, but that’s like icing on the cake . You would
expect that by the time they become doctors, after going through
five & half years of medical college and three years of
residency , they will have thoroughly imbibed these ideals
and goals from their seniors so that they can serve society
as caring and selfless doctors. However, in real life, the
situation seems to be completely the opposite, and idealistic
students seem to become hardened and cynical by the time they
graduate.
We have learnt - rather painfully and rather sorrowfully -
that we’ve already lost the battle before they even
join medical college . By the time they are in the eighth
standard, they seem to have only one priority in life - to
get as close to 100% marks as possible, by any means, fair
or foul. This is why school classes seem to have been replaced
by coaching classes . This means that by the time this child
has finished his XIIth Std and is about to join medical college,
a mind set has already been established. Most students are
fiercely competitive – and seem to feel that the end
justifies the means. In medical college , things get worse
- the eventual goal , of course , is to get as close to the
top as possible in the final MBBS exams because all subsequent
registrations and post graduate seats depend on that . Medical
students are no longer really looking at medicine as a profession
which is meant to serve humanity – that has now become
incidental. In olden days , students needed to have a have
a vocational aptitude before they considered going in for
medicine. Today, of course, this is not considered at all.
Not by the parent, certainly not the child himself because
the child is relatively immature, not the teacher in school,
and certainly not the people who select who is going to enter
medical college. In the past, factors like whether you were
interested in human beings and how you behaved with others
was an important criterion in selecting medical students.
It still is, in medical colleges in UK and USA today, where
students are interviewed before the final selection. With
our system, we select any Tom , Dick and Harry whose only
criterion is that he has
obtained more than 99 marks. The second major problem which
has set in is the advent of the private medical colleges .
Here, you end up paying through your nose for that seat. So,
you have already made a big capital investment – and
the family than expects a return on that investment ! The
other factor which worsens the situation in medical colleges
is a rapidly reducing numbers of role models , because most
medical college professors today are “full-timers”
who treat teaching as just a job they are paid to do. What
is also happening is that there are now a large number of
youngsters who earn huge incomes very fast – everyone
wants to become rich quick ! Medical college students are
no exceptions - they also want what their friends have - a
flat, a car, posh consulting rooms . All these factors combine
together, so that the chief goal of a medical student now
is to become successful in practise, rather than provide good
care to patients.
Many patients today feel that medicine has become a business,
and that doctors are just out to make money, by indulging
in unethical practices such as unnecessary surgery; ordering
expensive lab tests; and asking for excessive consultations
amongst one another. They sense that doctors have become corrupt,
and that unethical practices flourish. Doctors justify this
by saying that all of society has become corrupt today, and
it’s not fair to judge them by different standards –
the same benchmarks should apply to all professions. If we
are willing to accept corrupt politicians, then why should
we single out corrupt doctors ? A lot of junior doctors also
justify their unethical practises by saying – my seniors
are doing it as well – why shouldn’t I ? Many
doctors feel that they are overworked and underpaid; and that
society owes them money because they work so hard, so patients
should not grudge them their fees.
Just like there are lots of corrupt doctors, fortunately there
are also umpteen examples in the medical profession today
of individuals who have done well for themselves and have
risen to the top without being unethical. Names which come
to mind include: Dr Noshir Wadia, Dr Dastur , Dr Udwadia,
and Dr Chaubal. None of these people have stooped to any kind
of malpractise, they are absolutely straight – and they
are at the top of the profession . They are doing reasonably
well – and have an unmatched reputation to boot, and
are excellent role models we can try to emulate. Of course,
if you set your aspirations at an unrealistic level –
if you want the latest model Mercedes , a bungalow, and a
holiday abroad every 3 months, then you will have to indulge
in underhand practises. However, if you have rational goals
- I want shelter, food, education for my children and care
for my family , these can be acquired by any doctor who is
honest and straight forward .
When most doctors start practice , they don’t start
it with the intention of being crooked. However, when they
hang out their shingle, they find that the reality is that
patients will not come to them unless they grease the palm
of the local GPs. That’s what everyone else is doing,
so you better do it as well – the competition is intense
! And when they start, they do it for financial reasons .
Most justify this by saying, I need to do it now to survive
- but after four or five years, when I am well settled, I’ll
stop. The sad reality, of course is, that once you start,
you cannot stop – it’s a downward slippery. There
are two or three methods by which juniors could be helped
to stay straight. The first would be for his senior to down
load work to him. In the past, senior consultants would act
as mentors to their post graduate students and say - come
, set up your clinic in this locality. I get lots of patient
coming from your area and I will direct them to you. Dr Sanzgiri,
Dr R N Cooper, Dr Joshi are some famous names who come to
mind, and many of their students are now leading doctors.
The second method would be to encourage junior doctors to
start practise in the right town. Unfortunately, every one
wants to settle down in Bombay, Hyderabad, Bangalore, Delhi
– and this is neither sensible or practical. If the
same individual was to relocate in a relatively small place
, he would not encounter these teething problems. The interesting
thing is that in no time at all, they have a roaring practise,
with their own bungalows and cars – because there is
no competition – and they are the only act in town !
More importantly, they also have immense social prestige,
and they often leave their contemporaries in larger towns
far behind. The final method is perhaps the best – we
need to develop some means of identifying honest and upright
doctors who are competent and skilled, and then publicise
these names, so that they are available to all patients. Retired
senior doctors who have an unblemished reputation could offer
this service. They would sit down very transparently, very
openly and evaluate other doctors . You could then publish
this list of reputed and ethical doctors – and this
list would help patients to identify honest doctors of proven
competence. You may not be able to evaluate the crookedness
of a doctor, but identifying honest doctors will be a first
step in the right direction ! The list need not be comprehensive
in the beginning, but once it becomes an established practise,
doctors will start clamouring to be evaluated, so that they
can get on to the list ! This is not likely to be a very popular
suggestion, because doctors are usually egoistic individuals
who do not like being judged by others – but if we do
not establish a mechanism of doing so, good doctors will start
getting tarred with the same brush, and all doctors will suffer
as a consequence,
While most doctors are aware of unethical practises and corruption
in the medical profession, most prefer keeping quiet about
this . Society generally perceives that doctors engage in
a conspiracy of silence and secrecy – and most doctors
refuse to stick their necks out by identifying "bad"
doctors. This is a major reason why patients have not been
able to lodge complaints against doctors in the Consumer Courts.
The Consumer Court requires two doctors to verify that the
case has merit, before accepting a complaint against a doctor.
In reality, since doctors refuse to opine against another
doctor, most of these complaints never see the light of day.
While most doctors are worried about the skeletons in their
own cupboards, if any doctor wants to improve the system,
he needs to have the guts to stick his neck out. He may get
ostracized by his colleagues in the process, but there is
really no other option if we need to set our own house in
order. Unfortunately, most doctors are completely apathetic
and couldn’t care less, and this is
indicative of the malaise affecting our whole society at large.
This is why we get what we deserve , including our politicians.
Unfortunately, the entire medical system has become morally
bankrupt . Large corporate hospitals too indulge in malpractise
by pressuring their staff doctors to admit a minimum number
of patients, as well as to generate a certain amount of revenue.
It is a sad reality that these hospitals are profit-making
bodies, and their primary concern is going to be their bottom-line.
However, they cannot function without doctors on their staff,
and doctors could get together to resist these pressure tactics.
Unfortunately, doctors are often so embroiled in petty politics,
that they cannot band together to look after their own interests.
The pharmaceutical industry is also guilty of shoddy ethical
behavior. They aggressively push their products, and entice
doctors to prescribe the latest and most expensive "me-too"
pill – irrespective of whether or not it is in the patient’s
best interests . This is true of the medical equipment industry
as well, which wants doctors to buy the latest and newest
( and most expensive) scanner. This means that doctors then
get pressurised into scanning large numbers of patients daily,
whether or not their patients need these scans, in order to
make their investment cost-effective. These companies are
commercial organisations – and their goal is to maximise
their profits , by any means. If doctors are willing to be
bribed, it just shows how morally bankrupt they are. In fact,
a major responsibility of a good doctor is to act as a gatekeeper
of medical resources, so that he uses them wisely and efficiently
for his patients. Unfortunately, this misuse of medical resources
is a worldwide phenomenon – as documented by the many
Medicaid scams in USA. The Indian system is even sicker than
others – and the real tragedy is that the sufferers
are the poor defenceless masses, who cannot fight back.
Being ethical in your daily medical practice is straightforward
if you remember the three basic principles of medical ethics:
autonomy; beneficence; and non-maleficence. Being ethical
simply means respecting your patient’s ability to make
his own decisions for themselves; making sure that what you
do helps your patients; and does not harm them. Finally, it
all boils down to the golden rule – treat your patients
the way you would like to be treated yourself !
Our education teaches us what is right and what is wrong -
and even if the rest of the world does what is wrong we should
choose to ignore that and concentrate on what is right and
do it. You have to use your own conscience as a guide. Remember
that we are all human beings first and last – and that
the best doctor is one who follows his heart and takes an
active interest in helping other human beings . Society gradually
does recognize doctors who are good and ethical. It does take
a long time to build up a good and honourable reputation but
then this lasts for a lifetime . And the best thing is you
also get a good night’s sleep !
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