Monthly Archives: June 2012

Long Form Indian writing Digest 003

The phenomenal Mary Kom—five-times world champion and mother of two is profiled in Intelligent Life

India’s Gold hope in the upcoming Olympics is interviewed by Rahul Bhattacharya

But next to Mary, these other girls were ponderous. Their feet were sluggish, their positioning not so clever. She could fight with her guard down, testing her reflexes by offering them her bare chin as a target, and counter-attacking in angles unfamiliar to boxers who take the orthodox stance.

All around the gym the girls furtively watched her. They covet her low-gravity wound-up springiness, her pure petite explosiveness. They would love to lunge so wide and fast, and never need to wrestle or go to the ropes. Aggression is her hallmark, and it makes her exhilarating to watch.

“Yeh leh Mary,” Mr Bhaskar Bhatt goads her, “take this. And this.” This too is the play of boxing.

“He tries to make me angry,” she says later, “but I have to be cool.” Her grimace is hidden by her white gumshield. You can feel her burn; it’s been 80 minutes now.

Whatever Has Happened to Civil Society?

Neera Chandhoke, who teaches political science at the University of Delhi, and is director of the Developing Countries Research Centre, University of Delhi, takes a detailed look at the rise and fall of Civil society in India. She traces its history, political challenges, failures and success.

One of the most creative of Marxist theorists, Antonio Gramsci (1891-1937), had warned us that liberal democratic states possess formidable capacities to harness civil society to their projects of domination. Civil society, according to Gramsci, is the space, where the state and the dominant classes produce and reproduce projects of hegemony. And this is exactly what has happened in India. The rush of political theory that acclaimed civil society in the aftermath of the Velvet Revolutions of 1989 eagerly claimed that it is only the third sphere that can take on the state and the market. The participants in the debate had forgotten Gramsci. And they paid a heavy price for this, because liberal democratic states – and India is one of the most sophisticated of this genre of states – quickly moved to neutralise civil society by laying down the boundaries of what is politically permissible and what is not.

 

Fixing the healthcare mess; Satyameva Jayate or showmanship?

Dear fellow Doctor; from your Facebook posts, emails to me and tweets, it is obvious to me that the Satyamev Jayate episode on corruption in healthcare worried you deeply. some of you were happy that such an exposé happened, but most of you were worried that there was over-dramatization and untruth in the presentation, and that this would lead to doctors loosing respect in the sights of their patients. As it is, India is known for its violence towards healthcare personnel, it is only fair that you feel that people would use this show as an excuse to attack more doctors.

I too, felt that many of the things Mr. Amir Khan said were unbelievable, some of them were clearly exaggerations and one-sided and I wondered about the truth behind the cases he presented.

But before we jump into another analysis of how Amir Khan got his medicine wrong, let’s look at a few other things.

Here is a list of some of the recent healthcare related scams and exposes that happened independent of Mr. Khan
  1. Senior Professors of prestigious institutions caught following orders from Pharma companies about drug safety reports to the DCGCI.
  2. AMRI, Kolkata hospital fire – revealed bad infrastructure, collusion of top doctors in hushing up things, lack of training and preparation in dealing with emergencies.
  3. Female infanticide – Millions of female babies are being aborted. A phenomenon Involving parents, Radiologists, Gynecologists.
  4. IMA protesting against nurses strike even as they support doctor’s strikes. This, in-spite of the horrendous working conditions and pay of nurses.
  5. MCI’s dissolution – It was so corrupt, that even a corrupt government had to agree.
  6. Surrogate mother industry - poor women being exploited, paid, but not as much as promised, not following international norms in number of pregnancies.
  7. Harvesting of ova- recent report shows how this is probably harming young girls without their knowledge.
  8. NRHM scam for which 22 doctors were suspended – INR6000 Crores is thought to have been stolen.
  9. Hysterectomy epidemic. – Need I explain?
  10. Illegal clinical trials and deaths from them.
  11. Reports of patients being affected from drug trials and not being compensated.
  12. The AYUSH report – No standardization, AYUSH doctors prescribing non AYUSH medication.

There are more, of course.

Let’s now look at the main points raised by Amir Khan in his program; not specific cases, because he is not a doctor and is not qualified to make judgment calls on treatments given to patients. Let us just look at the basic complaints patients had.

  • There is lack of communication between doctors and patients. They don’t feel like they are part of the decision-making process about their own disease.
  • There is a lot of bad handling of deaths, accidental deaths etc. News not being shared, defensiveness, etc.
  • Actions of many or some doctors is leading to a wide-spread distrust or doctors, more so because if you go to 2-3 doctors for the same problem, they often suggest different treatments
  • Issues with improper consent taking and explaining of need for surgeries and other procedures.
  • Lack of information about what a hospital is licensed to do, what training doctors have, and the fear that people without sufficient training are treating them.
  • Referral fees, cuts and other forms of bribes paid to doctors affecting medical judgment.
  • Money being a major deciding factor in issuing medical college licenses and other kinds of licensees.
  • Bad policing by medical bodies leading to un-checked unethical and bad medical practices.
  • Too much power held by private players who don’t care about medicine, just profit.
  • For the government, healthcare spending seems to be low priority.
  • Poor get differential treatment.

Is any of this fabricated or unreal?

They are real; you and I know this.

We are poor communicators, busy as hell, running between wards and OPD or from one clinic to other, often we just cannot find the time to sit down and explain things to each patient. There is also the problem that what we think is communication might not be what the patient wants, and our training does not really help or prepare us to communicate better.

All of you have heard stories, of patients being admitted into the ICU for what turned out to be gastritis, and probably seen patients who have had two cholecystectomies and appendixes removed from both sides of the body. This happens, a lot, and it is a frustration we all share.

How can we reconcile with the fact that an unknown, but very large part of healthcare practice in India has a less than ideal or even acceptable level of quality and that the system is designed not for the patient, but for the professional?

While we mull on that, here are some things he got wrong, in brief.

  1. Using branded expensive drugs and not cheap generics – Not all drugs have generics, not all generics are tested, and in many instances there is significant difference in quality. There is also the patient’s expectation to use standard medicines. Much as I hate them, I can trust the quality of medicine made by a large pharma company, how do I trust a generic?
  2. Healthcare as a business is not necessarily evil, and the solutions that were put forward, including making everything government run is simply out of touch with reality. Your neighborhood green grocer is a businessman; this does not mean he will sell you poisoned vegetables if it gives him better profits. Businesses can be run ethically, and markets have great power of self-regulation.
  3. Doctors have a right to livelihood. Just because we are doctors, to expect sacrificial living is ridiculous. If indeed, as Amir Khan suggests, we are the smartest of the lot, then we deserve proportionate incomes.
  4. Doctors control only a part of the healthcare system; costs of drugs are for most parts out of our control, as are institutional costs. Blaming doctors for high cost of drugs comes from not understanding the basics.
  5. Doctors have an exalted position, but this kind of a mess could not have been created without collusion and involvement of regulators, businesses, government, other members of the medical team, and the market. Blaming just us is myopic.
  6. “Most doctors in India need to get their licenses revoked” is an unforgivably careless and unsubstantiated claim. While I don’t want an apology from him, Mr. Khan should know that it only displays his ignorance.
  7. “Will not see a doctor in India” What about Devi Shetty? Again, a very careless thing to say, but hey, it’s his choice. There are people who don’t want to vaccinate their kids, some people even say this on TV, but that is their choice, their life.

Back to the show.

Most of the reactions against the show hinged on one of the cases discussed in which there was ambiguity about the process. In this clamor to prove that Amir Khan got his medicine wrong, we forgot and ignored the other stuff, the stuff that I listed above.

Dr. R Srivatsan, Senior Fellow at Anveshi Research Centre for Women’s Studies wrote this in an email when this episode came out:

I think when a critique is mounted against you, it is important to look close and hard at yourself and the community you belong to. Where there is smoke, there is bound to be a fire you don’t want!  Most often people don’t have the time to bother to criticize you — except when you cause a great deal of pain.  Criticism is an opportunity, a possible door to transform a process — it has to be nurtured, not snuffed out with hurt defensiveness.

Could we benefit from such a show? Can we use this time to weed out or at least distance ourselves from those whose practices all of us find distasteful?

Doctors are at a particular advantage here; it doesn’t matter how famous Amir khan is, it doesn’t matter how widely his message reaches, people still need doctors. Maybe we can use this as an opportunity to make things better.

Let’s agree to this:

  1. People who were on the show are real people; I think it is safe to assume that they were speaking their truth. Even if one of them was not, there were others who were. They don’t need to speak untruth because there is no lack of bad diagnoses being handed out. We need to live with the fact that there are unscrupulous doctors, and we all know people who fit the bill.  Protesting this fact is only helping them.
  2. Amir Khan is an actor.  He runs a reality TV show. He is not a scientist, has no background in public administration, and the show is not a journal nor a scientific exposition. There will be things wrong with the show. He will get facts wrong. Have you met people who spend their Sunday morning reading out the Journal of Industrial Biochemistry to their families? Didn’t think so. Facts are often boring, Mr. Khan will try to make them attractive and sometimes, the real face will get buried under the make-up.
  3. No silly excuses. Some of you made what is possibly the silliest of excuses, ever. “Everybody is doing it, why target Doctors?” SILLY. I’m going to let you figure out why.

We work long hours, the pay isn’t amazing, the system is corrupt, without cutbacks and the pharma parties, life would be tough. We want that to change, we want to practice great medicine and have a life.  We want pays that are proportionate to our effort and attainment, we would like to be respected and acknowledged for the good work we do.

How is cursing Amir Khan helping us achieve any of that? What will help? I think we know some of the answers, not all of them. What are they? Lets talk.

Introducing What’s Up Doc? A column at eSocialSciences.org

I am giddy with glee to announce that I will be writing a monthly column about the practice of medicine and related issues at eSocialSciences, a “region-focused repository and a new and yet evolving publication space for easy and quick dissemination of scholarly work that can be a space for discourse among researchers, policy makers and the civil society.”

This month’s column is about communication and medicine. Medicine is all about good communication, they say, yet, very little is said or taught in most medical schools about how to be good at it. Do read and comment.

“Be nice to patients”: Communication and Practice of Medicine.

Medical school began with a series of “introduction to medicine” lectures. One of them was on communication, taught by the same professor who introduced us to medical ethics.

 

In the medical ethics class, through a case-discussion, she impressed upon us the need for being non-judgmental when dealing with patients. She did a fantastic job, considering she had just one 45 minute lecture. Her lecture on communications, though, is a blur. In my defense it was 11 years ago and I remember her parting words very well. When we told her after the lecture that there was just one session on communication and this clearly needed more sessions she said “I’ve been telling them, but who listens to psychiatrists?”

 

Doctors and other healthcare professionals, I would love to hear more from you about this, and related topics. Do comment.