December 6th, 2017


From Nallu (Shiv Shankar Sastry, a gastro-enterlogist)


Medicine must be the only profession where the service provider, (the doctor) must do his best to ensure that his client, (the patient) goes off happy and never comes back to him and remains happy for not having to come back.

My internet service provider keeps promising me great offers and gifts if I can refer new customers to them and get them more business. Getting more business, attracting more people and ensuring that they keep coming back is a fundamental requirement for any business or commercial service. But not medicine. For doctors this is unethical.

Ethics is a strange beast. It is an ancient code of honour, a covenant to build trust and the understanding that the service provider will do everything possible for the good of the client and will not allow profit or greed to get in the way of selfless service. You will note that I am using the words "service provider" instead of doctor, and "client" instead of patient. I do this deliberately, because legally medicine is a service and patients are consumers. Medical treatment in India comes under the consumer protection act. This ruling came about because private medical practice is a "fee for service" entity - that is, the doctor provides a service and is entitled to charge a fee for that service.

The fact that doctors must charge a fee for their service was recognized in the west long ago. George Bernard Shaw actually wrote a play about the dilemmas that doctors face relating to service and fees. But western nations also realized that doctors must be compensated fairly for their service - and this has made a medical career in the west a magnet for young Indian medical graduates.

The story in India is different. Indian attitudes towards doctors are often based on an imaginary ideal - of a person who has dedicated his life to the service of mankind. He (or she) is the epitome of compassion and sacrifice. Pecuniary considerations are not for the doctor. When a patient, fearing for his life goes to a doctor, the last thing on the patient's mind is that the doctor too may need to lead a life. The compassionate saviour mindset is drummed into young children as their parents desire them to become doctors. Television and other media stories regularly feature interviews of children of adverse circumstances, or of a specially gifted child who is asked about the future. "I want to serve society" blurts the child. "I want to be a doctor". Funnily enough no one seems to realise that becoming a teacher is also service to society - but doctors are thought to be "serving society". And of course we all know that social service must be done gratis. Free. Phukat. Or at least the doctor must at every instant of time be conscious of the fact that the patient is almost invariably poor, or, if not poor, has a daughter's wedding coming up, or has already spent a lot of money on other doctors and other treatments and is now coming to this doctor as a desperate last resort because he has finally heard of this doctor's great skill and compassion.

This is all very well but it is simply unrealistic. Ill health is only a problem for people who suffer from it. For the "health care industry" Ill health is supposed to be a profit making business. Like food and clothing, medicines are sure fire sellers - with huge and unceasing demand. Wealthy multinational Insurance companies are reported in the finance pages of newspapers as wanting to enter the "emerging market" of India's health care industry. To them it is a market where their product is sold, and making a loss or being charitable are not part of the business plan. Doctors are a small cog in this huge business. They have to slot themselves into a position where everyone around them is intent on making a profit while they show the empathy and compassion.

If a patient needs an operation, the first person he must ask about the cost and the person he must depend on is the doctor. The doctor has to make a rough estimate of how much the hospital charges will be, how much the tests and medicines will cost and how much his own charges will be along with the fees of other essential doctors whose skills will be needed. The pharmacy is in it for profit and cannot give a concession on medicines. The hospital is a business - it could be a company with public shareholders. It must show a profit. Ultimately it is the doctor who is required to make a sacrifice and adjust his fees to suit the patient's pocket. The doctor is a "third party" who neither sells medicine nor has control over what the hospital charges.

The three primary "health care delivery parties" are the medical shop, the hospital and the the doctor. The medical shop is a business that sells products at a suitably marked up price to make a profit. The hospital is like a hotel where charges depend on the facilities offered. A general ward, more crowded, less privacy is less expensive. A private room with more space, a bedside telephone and a TV attracts a higher charge. If the patient can afford more, he has the choice of paying more and getting more.

Doctors give exactly the same treatment to every patient, whether the patient is in the general ward or the private room. Therefore doctor's charges must remain exactly the same no matter where the patient happens to be. This is an area where doctors have allowed themselves to be trapped by what I think is an unethical policy. Many corporate hospitals allow only lower doctor's charges for patients in general wards and higher doctor's charges for patients in private rooms. This is an anomaly. Should a doctor charge more for the same treatment just because a patient can afford a more expensive private hospital room? Or should a doctor accept a lower charge for his skills if the patient chooses a general ward? It is almost impossible for a doctor to give lower quality treatment to a patient in a general ward but he is forced to accept lower fees for the same skills compared to a patient in a private room. Doctors actually sign contracts to accept these terms and I think it is only a matter of time before some legal eagle points out the anomaly in different charges for the same treatment.

As far as I am concerned, I charge the same fees whether a patient goes to a general ward or a private room and I state my fees up front, telling the patient that he can himself make his treatment less or more expensive by choosing a general ward or private room. I feel that by doing this I am being transparent and not encouraging the dubious practice of different charges for the same service. Hospitals that have built in anomalous charges for the same service will, in the course of time, have to take note.