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The New Doctor and Patient Relationship in India: The Changing Dynamics of Healthcare System in India

Director Cardiology, Fortis Escorts Hospital
Oct 21, 2017 12:23 PM 6 min read
Editorial

Voltaire famously said in the 18th century, “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.”

 

Philosophical wit aside, a Doctor’s perception within mainstream psyche in general excludes such cynicism. Their interaction with a human being at his most vulnerable forges a relationship which is generally based on trust and often borders on reverence. Perhaps it is this very moral perception that has contributed to recent headwinds hitting this profession.

 

It is becoming increasingly commonplace in India for families of deceased patients to physically assault Doctors, over the latter’s audacity to ask for payment or for alleged negligence during treatment. Concerned about their safety, Doctors have been organising mass strikes nationwide from Maharashtra to very recently in Andhra Pradesh.

 

More than 40% of Indian Doctors stress out for fear of violence as per a survey of the Indian Medical Association (IMA). Around 25% are wary of being sued and almost 14% dread criminal prosecution. Never since Independence has confidence in medical practitioners fallen so much. What has gone wrong? Is it a question of greed, lethargy, or forgotten ethics? Or is it a case of unreasonable expectations in a changed paradigm?

 

We’ve come a long way since pre-Independence India when Doctors functioned like family elders i.e. with free advice, few medicines, and inexpensive procedures. High-end healthcare was available to few. The arrival of government dispensaries and hospitals with associated medical colleges was the first step towards delivering better professional care. With the economy opening in the ‘90s and a limited headcount in the public sector – private clinics, nursing homes and corporate hospitals mushroomed. The government slowly retrenched from the responsibility of providing quality healthcare and the private sector jumped in to plug this gap. At the start of the new millennia, almost 70% of healthcare investment came from the private sector.

 

Citizens should expect affordable healthcare as a right. But this expectation should naturally apply only to government facilities. The fact of the matter remains that aside from taking Primary and a marginal share of Secondary healthcare, the state has so far struggled to provide good quality Tertiary care where advanced medical investigation and treatment is required. There are only 1 or 2 public Tertiary care hospitals per state in India.

 

In fact, some states like Punjab have no government hospital with even a functioning Cardiac Cath Lab. Thus, the responsibility for Tertiary care rests mainly on private players. This has led to a paradox in citizens’ perception. People go to Indian government hospitals and are unhappy that the services, though affordable, are of a poor quality. They then approach private hospitals due to lack of options and find the treatment in comparison too expensive. The blame unreasonably falls on the medical community. Patients’ families grumble that either Doctors are negligent or greedy and exploitative. This outcry is worse if the concerned patient passes away after a long and expensive treatment, typically translating into the uproar of Doctors are inhumane as they put dead bodies on ventilators.

 

The final nail in the coffin has been including Doctors and hospital industry under the ambit of the Consumer Protection Act, 1986, slapping stiff penalties in proven cases of negligence. The said Act adds a burden of liability on medical practitioners, forcing them to take a painfully conservative approach towards treatment. Clinical medicine as a result has become “defensive”, implying multiple investigations, unnecessary tests, and consequently – unaffordable care. An ironic situation has arisen where both parties are spending ever more money, the only difference being that patients do it due to ignorance and Doctors do it out of concerns for their protection.

 

The result has been public dissatisfaction and a fracture of the Doctor and patient relationship! And it hardly helps the patient. US data on medical malpractice and associated compensation shows that laws which add disproportionate liabilities on the medical community do not improve the quality of healthcare, as most victims of genuine medical negligence do not sue (c.98%), and most people who file lawsuits end up losing. American Doctors end up spending huge amounts on indemnity insurance, with premiums ranging from $30,000 to $300,000 per year for Surgeons alone. Litigation has hence proven to be a uniformly unsatisfactory solution: it is expensive, lengthy and painful for all parties. It brings out the worst within the “adversaries”- patients’ relatives and Doctors both offer biased versions of the story…and the truth is lost somewhere in between. Whatever be the outcome, all parties go through pain and bitterness and are scarred for life.

 

An important consideration for private healthcare is that it is after all a business enterprise. It does not receive any rebates/financial relief from the government and hence should not be expected to grant any commercial relief in return. Land, construction, equipment, all major capital expenses, are purchased at commercial rates, with appropriate taxes paid at each step. Electricity is paid for at higher than commercial rates (Hotlines) as Cardiac Cath labs, operation theatres and ICUs require a reliable uninterrupted supply. Corporate taxes levied on promoters and income tax liabilities for Doctors all come at slab rates, with no subsidies or exceptions from the government. One must ask where is the discount, the subsidy or incentive for a private hospital or a Doctor to offer a lower price? It is unreasonable to expect top quality care with modern, state-of-the-art equipment, well trained staff, hygiene, and modern amenities at charitable rates. Isn’t there an inherent contradiction here?

 

No doubt the price of private healthcare has escalated over past two decades. But even the best private hospitals in India still offer treatments at around 1/5th – 1/20th the price as compared to the West, even for complex procedures with a high quality of execution. Furthermore, major procedures have not risen in price over the last 10 years. This has not been achieved by government intervention but through iterative business alignments driven by the pressure of competition.

 

I would never tell a patient that he/she cannot afford me: this would violate my basic premise as a Doctor. But what about drugs, consumables, joints, stents, other implants, most of which are imported? How do I provide those to everyone? Furthermore, major commercial calls in hospitals are taken by senior management, so why are Doctors, who represent just the face of a hospital, under attack? Do patients and their families realise that consultation fees in India are one of the lowest in the World and nowhere close to that of a lawyer or an accountant?

 

[Listen in from 43:25 onward to understand some systemic issues afflicting Indian healthcare which has led to recent episodes of violence against Doctors.]

 

Doctors become independent consultants after years of study and training. There are always a few ready to be more “compliant” to gentle corporate and industry pressures and get sucked into the system. What is true of society must be true of doctors as well; they must be just as corrupt as the average person, no more, but no less. PMT is a Pre-Medical Test after all, not a Pre-Morality Test. As a result, there is no doubt that corruption through kickbacks exists: in patient referrals, in drug and implant use, even in recovering bills. There is no defence for this, except that not all Doctors are involved, and similar systems are prevalent in almost all professions. Still, two wrongs don't make a right.

 

The problems underlying the industry are many, but solutions must be found by and amongst us.

 

Violence is unacceptable; there should be zero tolerance and strong legal action and enforcement should follow. But, these structural problems cannot be ignored and should get their due consideration. Doctors should communicate better with patients and their attendants, giving them ample opportunities to discuss their concerns. Social workers should be deployed to build a solid feedback mechanism. Hospital administration should employ adequate staff and residents in addition to consultants, especially in Emergency to minimise cases of negligence.

 

Private hospitals should have a corpus dedicated for economically challenged patients who run the risk of defaulting on dues during an expensive or prolonged treatment. If even a portion of the outstanding bills can be adjusted through such a fund, it will go a long way in defusing tensions. Hospitals should be ready to undergo audits of services provided by independent bodies. The outcomes of each hospital and individual consultants should be made available to promote transparency. The government must subsidise high-quality private healthcare to make it more affordable either through tax incentives or soft financing.

 

Antagonizing healthcare providers each day is not going to serve anyone. Good doctors are losing interest, and becoming detached due to the continued onslaught of media and public frenzy.

 

Atul Gawande, the noted Indian-American surgeon, writes “No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.” Society should ask for no more; we, as doctors, should strive for no less.