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.

20 thoughts on “Fixing the healthcare mess; Satyameva Jayate or showmanship?

  1. As someone who is not a doctor and has little idea about the behind-the-scenes pressures – in other words, an average viewer – I can tell you that when I watched the show, I unhesitatingly applauded most of it. Later on, I did reflect that some of it seemed over the top, and the point about more government shops seemed ridiculous even when I heard it first.

    I guess what I am trying to say – as someone already has said, is that Aamir Khan basically is taking issues that many of us feel very strongly about. Let me give you an example. For a severe outbreak of urticaria, I had to go to a very well-known hospital in Bangalore, and before I even sat down, the doc had written me a prescription for steroids. And this, given that I am in the child-bearing age and could very well have been pregnant or trying to conceive – not that I was, but the doc made no attempts to even ask anything about situation, history etc. For this “consultation”, I was charged Rs. 400. This doc is known as a “top notch” doctor in the city.

    Is it any wonder that most average viewers will empathize with a show like this?
    Aparna recently posted..How Safe Is Your Workplace Really?

    1. Aparna, thanks for the comment, yes, from this side of the table, your perspective as a consumer/customer/patient is often lost, and a lot of the outrage after the episode was because of just this.

  2. Hey Anand,

    Nicely written. I haven’t watched this show but have been watching the large amount of buzz that it has generated. A few observations –

    1. Sitting in medicine OPD in Vellore I used to marvel at the amount of malpractice that most patients I saw had experienced. Some of it was just from lack of knowledge, some it was probably for profit. The lack of a watch dog organization that ensures a minimal level of competence among doctors is probably to blame. Not sure how this would be resolved in our country where no organization is free of corruption.

    2. When I first arrived in the US I was surprised by the difference in people’s attitude towards their physicians. Here they are treated like providers of any other service. Which means that you provide the patient with all their options and then they decide. This obviously involves good communication between the two parties involved. I think our training should definitely focus on this aspect. (our training in Vellore definitely does this)

    3. I certainly don’t agree with the part about the opinion that “people who want to make money, should not take up medicine”. If you want the smartest people to become doctors, you better ensure they are well compensated. Otherwise they will enter other fields especially as the chasm between these fields widens. Wouldn’t you want your life to be in the hands of someone you know is smarter or atleast as smart as you. I definitely would. So give them their due, and don’t expect them to be altruistic especially after spending 8-10 years studying/training.

    I really don’t know how things would change without a major overhaul of the entire system and a general reduction in the level of corruption in all levels of bureaucracy and government related to the field. The fact that people are discussing this though is a step in the right direction.

    Pavan.

    PS :Where are you these days and what are you up to?

    1. Paven,
      awesome to have you here, how is life treating you?
      Am in Bangalore, working with a GP chain.

      Thanks for the comments, I wish more people thought like that. I guess that is the purpose of these shows, or at least our take away from these shows, get talking, and eventually, change happens. mysteriously :)

      Anand

  3. Great article Anand. It is good to see someone from a medical profession has a balanced overview of the situation and I would recommend putting this forward to Mr. Amir Khan. It is important that he gets the feedback and responds to it.
    I am not from a medical profession but my brothers are and my dad was a chemist. I, for a fact, know that not all generics do the job. If you let generics take over the market, margins will be further squeezed and hence the quality of the product will suffer. When there is limited infrastructure, this could lead to corrupt practices, and often result in a disaster, so I don’t completely agree with Amir on that point.
    With respect to bringing the health profession into public domain, the problem is two fold: a) An infrastructure needs to be established that allows a platform for victims of poor treatment to voice their concerns before it can be made public. We have all seen the standard of treatment in government hospitals, it is not pleasing to see, that needs to be rectified before establishing a government run medical system, and b) government backed health systems have failed time and again – which, in my opinion is the bigger problem. Living in the UK, where government has the control over medical profession, the whole thing is shambles. We sometimes don’t get appointments for weeks before going and getting treated. Doctors and health advisers are scared to advise patients for medication that is not prescribed by the law (I can see the reason, but it is just absurd that a patient with a tummy ache is kept on paracetamol for 4 days before being diagnosed with appendicitis).
    As you rightly point out, a corporate competition needs to be set up with close government or independent monitoring, which would give quality healthcare and regulation of the profession. Then only, the doctors and health advisers will get the respect and potentially, income, that they rightly deserve.

    1. Ravijot,

      You have said it right, the govt cannot be trusted as yet, not to take over all control, but maybe to bring in accountability.

      I have no Idea how to contact Mr Khan, dont even know if either of us care to learn from the other :)

      Thanks

  4. Good post, Anand. Well, remember that this Aamir is the same guy who is an Ambassador for the UNICEF for Child Nutrition – but he has no qualms about recieving sponsorship from junk food makers like Coca Cola.

    There was nothing new in the accusations. We’ve been hearing of them from ages. The versatality of people like Mr. Aamir lies in their ability to marry pathetic stories with corporate greed and sell them to the bored Indian television viewer. I’m doubtful about the impact . . .
    Jeevan Kuruvilla recently posted..Anatomy of a Post-Partum Eclampsia

    1. Good job, Anand. But I am little taken aback by what Jeevan just said. Amir is not my friend, and I am not his personal manager, so this post is not about defending Amir. But it is about defending the cause, the meagre step that has been initiated by him. It is very well published that he gets paid a lot of money for his endorsements et al, but to label this show as a marketing gimmick to entertain “bored indian audience” is absurd. Almost always in his show, he mentions that this show is not about passing judgements, it is about educating and bringing to life the issues that the country faces. It is for us to take things from it or take nothing from it, but nothing gives us the right to say that he has vested interests in this. Even if he has got a self interest, for what he is doing, for the mere fact that he has bothered to take the time out from making films and going and talking to people, listened to them and broadcast them to the whole nation, should be rewarded.
      He himself does not have a solution because it is as complex as a brain surgeon’s job, but he has given it a medium and brought these issues to fore. Otherwise, these will get labelled with an easy excuse “yeh to system hai, hum kya karein”.

  5. That was a really good article. Well balanced and comprehensive. A few points that came to my head:

    1. I think doctors should have a lot more training in communication skills, as pointed out.

    2. This may be a controversial subject. The present system of examination and selections for medical training after school tests one thing only. Memory power. Aptitude and attitude testing might make a difference(?).

    3. Doctors should understand that fame and adoration do not come automatically in a business driven system of medicine. Have you seen anyone falling at the feet of an engineer who builds a bridge or makes a car?

    4. And this is my greatest and most fundamental question. Why is India such a corrupt country? Maybe I’m going off-topic but sometimes you really have to look at the woods as a whole if you want to cure an individual tree’s disease.

    1. Prithiv,

      as you commented elsewhere, we have no training at all in communication!
      and yes, exams are messed up, but even with this lot, much can be done. after all medicine is not a homogenous structure, there is place for the anti-social as much as there is for the TLC specialist.

      Why are we corrupt? because we can be.

  6. re: aamir’s suggestion that increased privatization of medical colleges and hospitals and profit motive is the problem, i had the thought that isn’t it the government that began the practice of female foeticide? also, that village in andhra pradesh where an inordinate number of women got hysterectomies — is it again the government coming up with some ass-backward tactic to prevent poor women from having too many babies, and doctors merely banking on it? i think regulation is very important, but it’s not like the government is everyone’s trusted servant either.
    leena recently posted..Predicting and Reporting

    1. Leena, am not sure about the connection between female infanticide and the govt or hysterectomy and the govt, could you elaborate or tell me what source you are referring to?

  7. “…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”
    A very nice reflexive thought from your blog – will keep this in mind. :)
    Prashanth recently posted..Aloha Oe: A review

  8. Very nice post. I think it is very important to not black-and-white this matter as much as possible. And let us not pretend that the issues Aamir brought up is somehow related to people’s opinions on “why” he is doing this show or “how” he is financing himself or this show (Reliance etc etc.). Irrespective of all this, I do not (yet) see a single instance when SMJ takes up an issue that is not already gathered public momentum – to that extent, I think it mirrors “popular” dialogue on matters of social concern. It is a bit provocative (emotionally) and evocative.

    On the brouhaha from the medical community, I really liked what Srivatsan says “Criticism is an opportunity, a possible door to transform a process — it has to be nurtured, not snuffed out with hurt defensiveness.”

    1. Prashant, thanks for stopping by!

      You are right, the man has a good nose for what people want to hear, and he exploits it well.

      Srivats often says stuff I agree with A LOT.

      :)

      see you sometime.

  9. I very much enjoyed reading the article. Many of the concerns you raised are already there in the minds of informed non medicos also, though as a doctor you were able to mention many things that we fail to hear/read/come to know.

    It seems that each “industry” is now in overdrive to protect its business interests. The other day many Christians demanded that an atheist who criticized them should be arrested and punished — the very same Christians who cry against oppression. The same can be seen in any profession. Politicians would love to muzzle free expression of ideas.

    Thus a two-pronged handling of the situation is needed.

    1. People need to be taught what freedom of expression involves. (You cannot have freedom for yourself without allowing freedom of criticism to the fellow who dissents).

    2. People within each profession need to create awareness among their peers for the need for introspection as well as tolerance in listening to the critical voice of outsiders.

    Johnson C. Philip
    Dr. Johnson C. Philip recently posted..Indian Coin Forgeries: Free Ebook (3rd Ed)

    1. Dr. Johnson,

      Very true, freedom of expression works both ways, and am really glad that people are talking about it, because thats the only way new knowledge and “conversion” happens.

      Anand

  10. Clearly and lucidly argued. To be fair, I have not watched this episode of SMJ yet, so I’m going purely by your post. The only point that still needs to be made is, despite whatever short-comings, the fact that we’re having this discussion, and that your blog post was written, have to do with the fact that Aamir Khan decided to back this show.

    I would also much prefer it if the show was as factually accurate as possible, but it is certainly fulfilling its primary function: starting discussions on social issues.

    For that, Mr. Khan has my admiration.

    1. Thanks Saket, if you can stand his dramatics, it is an episode worth watching in fast forward.

      You’ve said it best- we are finally talking about it, doctors, I mean. It has made us uncomfortable and asked awkward questions. that is one of the best signs of good media.

      Thanks for stopping by!

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