Some concerns raised by Ajeesh in his comment to my post on Malingering needs to be taken seriously. Being a non medical person, he has observed how doctors do wrong things to patients. But the situation is much more complex in reality. It has to be analyzed in the context of the way medical care is provided in our society. There are various models for providing health care. One is the U K kind of situation in which the general practitioner acts as the point of primary contact for all ill persons, except in an emergency. The G P is also the gate keeper, who decides which patients need to be referred to specialist services. Another style is followed in the U S A and some other countries, where the G P has no specific role.
In our country there is no such strict criterion or demarcation. It is the sick person who decides which doctor he will consult. Often this choice is based on many factors. Proximity, his judgment about the gravity of the illness, cost, accessibility etc are important. For a problem which he thinks is minor, a local non specialist will be consulted. For a more serious problem, he may see a specialist in the nearby town. For a serious complaint, he may choose to consult a large hospital or medical college hospital.
Studies have shown that only about 20 to 30% of symptoms seen in general practice have an organic basis. The G P is actually trying to rule out serious diseases by examination or tests. This is done with a desire to keep the costs as low as possible. The risk-benefit ratio has to be carefully understood in this decision. Sometimes the G P may miss serious illness. This will ruin his reputation and worsen the patients' outcome. Hence, to be on the safer side, he may over treat or over do investigations. The public is ignorant of the complexities involved in taking such decisions. The doctor is actually doing this on their behalf, but he is penalised for errors of omission. Committing errors of commission is a different matter altogether.
The situation is further complicated by kickbacks some drug companies or labs offer. Competition from other doctors is also a concern for a G P whose livelihood depends on his practice income. Another complicating issue is the presence of alternate systems and hostile media who tend to blame the doctor for any negative outcome.
It is the job of the government to come out with clear guidelines of duties and responsibilities of different categories of doctors. One way out may be to follow the U K system and ensure that patients contact specialists only through G P referrals. But this also can lead to problems in some situations, though it can reduce health care costs. The role of the specialist will be to confirm the suspicion of the referring G P or to rule out the suspected serious illness. If serious illness is detected, the patient is treated by the specialist. But the present system of administration in our country may not be able to bring about such a drastic change in the pattern of service delivery. The process of conversion from one system to another can bring up crisis situations which will result in antagonism of the public and media. I do not think our political leadership in any state or at the Center has the will or vision to think about major changes. The way drug industry is regulated in our country is another source for problems. This also need drastic measures.
I am stopping here. Comments from the readers are welcome.
ഇന്ത്യ
1 week ago
25 comments:
Dear Harish,
The present situation of health care delivery that exists in India is indeed a big topic...
we have public health experts/ medical professionals of different systems of medicine/Voluntary health organisations/politicians/commission reports etc who have differing views/opinion.
The only consensus being,the present situation is pathetic and need drastic changes.!
In our country, By tradition medical care was provided by tradtional practioners at their residence and normads ,using herbal medicines, mantras,yoga...majic cures etc and other "crude" methods.It still exists and the modern medicine is imposed on the our people by ruling Europeans from top.
Today all these different systems coexist in India in varying propotion depending on the soco-economic status/development of the region...we have large number of traditional healers with different science of healing with reasonable public support ,..and now have Governmental and international support..and huge funding.
The situation is very Very Complex.
US model/Bristish Model/French models etc have merits and demirits..! But what is the ground reality?
The meagure budget allocations for Health,disproptionatly low allocation in priority area,regional discriminations,non profeesional managemnt of health care delivery system,ignorance of politicians who leads the departments,unethical practice/absence of honesty among medical professional,ineefective/ greedy mediacal professional organisations ,unchecked growth of Private sector in health care,weak regulations/laws , low standards of national institutes,virtual absence of original research,muscle power of pharmeceutical industry etc make the scene very very complicated..
I prefer the UK system. Lay people have some difficulty identifying the exact problem that is necessary to choose the specialty. I have seen that a lot of people with headache go directly to a Neurologist. The Neurologist may find the problem and redirect the patient to a proper specialty. But the possibilities for wrong diagnosis, missed diagnosis or biased diagnosis are high in this way. There are many causes for a headache and GP is the best person to decide what to do. The same logic can be applied to most of the common symptoms presented by people. Another interesting example (a real life example) is of ‘chronic cold’. If you consult an allergy specialist you will get antihistamines or steroids. It is bacterial sinusitis if you consult an ENT specialist and he will advise you to take antibiotics. The chances for biases are less if you consult a GP first.
In a TV program, the drug controller of Kerala once told that all brands available in Kerala are of equal quality. I do not know if it is true but there is a huge difference of prices of some drugs. 10mg of Atorvastatin range from Rs.1.70 to Rs.9 and the cheap brands are from Macleods, Mankind or Ajanta pharma. Why there is such a big gap between prices of different companies? Should doctors use drug names instead of brand names? The problem of brand substitution becomes irrelevant if all brands are of same quality and doctors should use drug names instead of brand names. I think government should come up with a strict monitoring of drug quality and prices. Later it will be possible for doctors to use drug names rather than brand names and it will keep drug mafia under control. Drug companies will be forced to lower their prices in that case. I know that drug research requires a lot of money but that can be protected with sufficient patent laws. Prescriptions should be easy to read and patients can make sure that they got the right drug. Persons with bad handwriting should use C A P I T A L L E T T E R S.
It will be nice if practitioners (or their associations) of modern medicine come forward and talk about pseudo medical practices. They are the only qualified-authoritative persons to talk about this particular subject. Society will be more interested to listen to doctors rather than to politicians or NGOs in this matter.
Current system of medical practice in India needs serious attention and a discussion should be initiated by people who believe in the active participation of social reforms.
Thank you.
More on Health care Delivery System
(In our country the public space is occupied mainly by political parties and religious groups & The media attention is focussed on the 'unending quarrels' of leaders with wested interests.Serious public discussion/debate on Health rearely happens.
The public is familiar with cunning/greedy leaders who argue convincingly for their political party or religion or caste to which they represent and try to tarnish opposite leaders/views.so a Modern Medine Doctor appearing for his "science" and discribing other branches which enjoy public support as "unscientific" without proper evidence will not be taken very seriously/kindly by the audience....( credibility crisis !)
& Where is the evidence.? ! In our country, serious research is not happening in modern medicine or traditional medicine( there are lot of negative factors operating against original research works in India).
If we confine our discussion to the practice of modern medicine , UK model /US model etc are not a pracical option for our country where three fouth of our population is living in villages and almost all modern medicine doctors are in cities.
The present finacial situation/ policy of our Govts is not in favour of stengthening further the public health system and are gradually decreasing the Budget allocation for health......leaving the space for private secter to occupy....
NHS is fully state sponsored programme and is impractical for a poor country like India .....it is unreasonable for us ,to imagine that the solution of our problem is to imitate/copy one of the successful system of a Rich/developed country.
Hai sir
Read the topic and comments. A very nice discussion is going on.
How we can take the different systems of medicine (modern medicine, ayurveda, homeo etc) together in GP or UK system.
Will strengthening of present system by strengthening of PHCs and the referral systems solve the problem.
What could be the reason for lack of research in our field. Is it due to financial problems or some other thing
Hi friends,
It is true that Government is irresponsible and irrational in its health policies but I hope that there are so many things a doctor can do to improve public health, independent of Government policies and public opinion, as a responsible social being. My knowledge of modern medicine and pharmacology is very poor and limited so you please correct me when I make mistakes.
Religions and politics attract crowds everywhere. There are problems in India but we are not the worst or I think we are above average compared to all others countries in the world. Of course, you are going to annoy a lot of people if you question the validity of alternate medical practices, and media will celebrate it. Anyway we are not supposed to annoy as many people as Hippocrates once did. Nobody was there to support him though he made many bold statements. It is not the responsibility of a modern practitioner to show evidence for the ineffectiveness of the alternate medical practices. The people who hold strange ideas or practices have the responsibility to show the evidence, or at least the rationality or the logic of such practices. The efficacy of modern medicine can be demonstrated repeatedly. It can be tested and proved with current form of scientific models. Most of the effects are explainable though there are some exceptions. But in alternate medicines, the explainable ones are the exceptions! The common Homeopathic belief is that drugs get more potent with dilutions. It is absurd according to our current understanding of science. If we accept the dilutions theory, we have to reject all that we have learned in School or Colleges. Imagine if some one pour a drop of Homeopathic medicine into the sea! You can not wash a bottle or a spoon that contained Homeopathic medicine once, because after each wash the remaining medicine will become more potent. Let’s stop the fun and it is their duty to demonstrate their strange ideas. There is one interesting study published in Lancet showing the inefficacy of Homeopathic medicines. The biggest argument of alternative medicine is the side effects of modern medicine. Dying from improper treatment is the worst side effect a person can ever enjoy. I think Ayurveda is much better than Homeopathy, there is at least a faint hope. But it is dangerous to treat people without basic knowledge of anatomy, pharmacology, pathogenesis, surgery or other required procedures. Theories of Ayurvedic medicine do not worth discussing, it is like fairy tales. They do not have any idea of how their own drugs work. Clinically significant, scientifically testable and repeatable effects are not common in Ayurvedic Medicine, and their risk reward ratio is very bad. People spend a lot of money and precious time with Chiropractioners, Naturopaths, Siddhas or other pseudo practitioners. It is the moral responsibility of the more educated people to initiate awareness among lay people.
Let’s leave the problem of government policies for a moment, there are many things we can do right away, with more direct impact and clarity. The point I want you to note is that the majority of doctors do not consider the cost effectiveness of a drug they prescribe. They use expensive drugs/brands when there are other equally effective or good drugs/brands are available. And there even worse cases. To give an example, Diuretics and ACE Inhibitors are the recommended first line drugs for primary hypertension. The drugs like Hydrochlorothiazide are very cheap and they are equal or better in efficacy and side effects profile compared to all other antihypertensives. New guidelines like JNC7 recommend it. But majority of doctors’ use 5 or 7 times more expensive, not recommended, not approved and new generation drugs without any justification. Doctors are partially responsible for the increasingly expensive health care system in Kerala. Health care is becoming unaffordable to even middle class, the case of poor is better not discussed. There are reports of (may unreliable) private hospitals doing surgery on brain dead patients and collecting large sum of money informing relatives that the surgery may help the survival.
Most of the districts in Kerala have good accessibility to modern medicine. It can start looking in to developed countries and copy its better aspects.
Modern medicine evolved incorporating useful strategies from other alternate practices. But as a stand alone method, I consider Ayurveda, Yunani or Siddha as useless. Homeopathy is not a medical practice at all and does not deserve to discuss with Modern Medicine. It is a delusion shared by many people and it can only give placebo effects.
Comments are welcome.
Thank you.
Hi,
I think Sharija is right, the strengthening of the Primary Health Centre should be the first step. Patient education, screening of problems, reference to concerned specialties and treatment of minor problems should be done in PHCs. It should work as a gateway. Lack of research is not due to financial problems. Government has money for all other kinds of things. I think there is a lack of interest. Here, professionals are not the result of dedication but it is the result of greed. Parents force the students to select either engineering or medicine. We can’t blame everything on politics and stand aside, we are part of it. We can also become decision makers. We strike for salary increase but how many strikes are there for public interest?
Thank you.
Health.......to continue.
Today DPT vaccine is out of stock in majority of the health centres...which we wanted to strengthen!.DPT vaccine protect our kids against very common three major killer diseases of childhood.(Diphtheria,Whooping cough,Tetenus which were very rampent in pre-vaccine era).Because of the recent decrease in vaccine coverage,all these fatal diseases are staging a grant comeback with many deaths..mainly in backward panchayaths/districts of kerala.
In spite of the extra ordinary public protests by various NGOs and media,All the three reputed Public health laboratories manufacturing and supplying vaccines to the whole nation (and exporting to other countries) have been closed under the direction of Central Drug controller ,on flimsy ground.The Union Health Ministry is expecting to procure the vaccines from the VACCINE park , Madras,(which is expected to be commissioned soon ,funded jointly by MNCs and Indian Private vaccine manufacturer) for the Govt.supply !ALL these three prestigious vaccine manufacturing institutions with the record of serving the nation for more than one hundred years have been closed down with ulterior motives..!
Once the govt.completes the withdrawal from the duty of providing social services like health in favour of market force,preventive health measures like vaccination,family planning ,Infectious disease control programmes( TB control,Malaria,AIDs,Leprosy,Filariasis,Sexually transmitted diseases)health education,safe drinking water supply,enviournmental sanitation,public health engineering,nutrition services etc will break down with disasterous consequences on our health....
So health of the nation depends heavily on the Government policy and decisions.A discussion avoiding politics is incomplete...Individual practice and behaviour of a doctor is of course important....but health of the nation depends more on other important variables.....
But of course ,the question remains valid... what is the role of a modern medical practioner ..at individual level...He doesnt have the lexury of wasting time blaming the system/Govt/politician/public/other system/himself...!!
Even after listening a number of neverending discussions he is still confused!
As Dr.Vijayan rightly pointed, Government policies are the most important thing and we can not continue any discussion without it. There are important problems that require urgent Government attention. Some of are
1. Provide affordable health care to all.
2. Stop the private practice of Government doctors
3. Assess the role of Medical Representatives
4. Implementation and strict monitoring of Drug protocol
5. Corruption in Government hospitals
6. Prosecute pseudo medical practitioners under the magical remedies act
7. Control drug prices
8. Availability of life saving drugs
9. Easily accessible primary health care system
10. Basic research and proper guidance
11. Awareness and patient education programmes
We can not blame the unethical practitioners but we need to know that it is the duty or responsibility of the Government to control such activities. Government should come up with some ways to find and control irresponsible use of drugs, use of expensive drugs while other cheap options are available (that is inevitably pushing the treatment costs higher) or the secret deals with drug companies. We can not entirely depend upon the commitment and compassion of a few doctors though we heartily appreciate them. In the history of time, it was some bold individuals who transformed society, beliefs or the nation. It is not possible anymore in this age of globalization. All reforms should come from Governments. What is the role of a medical representative? We are living in an era of information revolution and internet and a doctor need not depend anymore on a medical representative for any drug information. In reality, we all know that those guys do not have any basic idea of pharmacology or pathology. Advertisements and aggressive marketing strategies should be avoided in health care – in my opinion. Here it is also the government should come up with strict monitoring policies.
Government should not withdraw from public health care system. I have already seen the issue of vaccines in a paper from an NGO. Government should appoint more health care professionals, more fund should be allocated for necessary enhancements etc… The present over load on medical colleges or district hospitals can be eliminated with proper screening at PHCs. PHC should be the gateway. Dr.Harish has already pointed in an earlier post that only 20 to 30 % of problems are organic in cause.
It is a pleasure to know that there are good doctors like Dr.Harish exists in Kerala. It is not my problem if I do not feel the same respect to all others.
We can wait for a good government initiative.
Thank you.
Australian Presciber is a free Medial journal By Australian Medical Association.
Recently it published an interesting letter by one of it's reader,a Nephrologist from Perth.
In Australia, Promotional activities and sponsored programmes by pharmaceutical companies are under strict scrutiny both by Medical professional organisations, Court and State Health department.
A recently conducted International conference in Australia had a record more than 3000 delegates and majority of the doctors were from India.
Inspite of the heavy registration , most of the seats in the different conference Halls were vaccant...! On enquiry it was understood that the 'sponsored consultants" from India have already started enjoying the Beauty of Australia without waiting for the inaugration of the Conference(as part of the "International Conference tour...package" of the pharmaceutical companies, which is illegal in Australia).
The question by the Native doctor was that ,isnt it Unethical for the "Foreign doctors" to indulge in a practice that is illegal in the country that they are on visit?
During a friendly talk one of my friend working in Calicut Airport told me about the increasing number Doctors going to Indonesia via Calicut Airport for medical conferences.almost daily. It seem Bangkok host Medical Conferences daily..! Is it a centre for excellence in mediacl Research ? Anyway nowadays our doctors are very much enthusiastic in attending Conferences abroad.. Was he smiling? !
The Nexus is dangrous and Company will re gain each rupee they spend for these Pleasure trips, using the same doctor..!
(prospective patients!!..be careful..! It is actually your money.! You are sponsoring the pleasure trips...)
Now many companies offer costly Flats/Cars etc to "successful consultants".
A doctor ordering A Scan /other investigation/medicine for ' care of a patients ' should be above suspecion.
Only professional organisations can do things to maintain/improve the status of Medical profession.!
(Unfortunatly in our country even the meetings and the fellowship/liqour party to be followed , is sponsored by pharmaceutical companies/laboratories....and many meetings are a feast/challenge for press photographers ..to take photos of flying glasses/chairs) .....
Sorry,.........eventhough this is too much an exageration,it is a fact that our medical profesiion has failed to live upto the expectation of our public.General Derioration of values should not be a justification for the low standard/misbehaviour.!
Thank you..!
(correction....the favourite foreign country for medical tour is Thailand...not Indonesia)
Dear Dr Vijayan and otheres,
The issue of relationship between pharma industry and medical profession is not very simple or straight forward. Both parties stand to gain from this. Taking commission for services is not seen as something unlawful by the commercial sector. Even the so called 'leaders of public' including former(?) revolutionariues and their parties take a cut for offering public work contracts to any company whom they wish to support. Retail dealers of paints, construction materials, ceramic tiles etc are being offered commissions and foreign trips. This is met from the price paid by the consumers. Here also consumers may be being duped by the retailkers in to buying poor quality materiuals. This also has serious consequences including health hazards.
Even though the medical ethics forbids such activities, who is there to regulate? In a country where members of even the medical council take contributions from private institutions, who can bell the cat? The members of these bodies are appointed by political bosses, who may be gaining from the whole processes. As I said in one of my posts, such grave issues should not be left for the individual conscience of a few persons. My point is this. There is no need of separating doctors from the rest of the community. As in any other field of public activity including politics there are very good, fair and bad individual here also. The same is the case with operators in the pharma industry. It is better to have a balanced view in any issue. The fault lies mostly with the governmenst (I am not referring to any present or past geovernemts specifically). It is the whole process of governance that is at fault.
Attacking all the doctors may help a few of us to be favorites of one or two political parties. In the long run such 'committed' doctors can aspire to become Vice chancellors or SOMEBODY. But nothing is solved by such persons. Dr. Vijayan mentions that taking commission by doctors is unlawful in Australia. We should not forget that it is the Governmewnt that made laws to this effect. I don't think there is a country in which doctors willingly stopped taking commission. A few good persons might have done this out of their belief in God or ethical principles. But that is not the way these things should be done. Thank you
Hi friends,
There is corruption everywhere and it affects all of us negatively. But corruption in different areas can not be treated equal. Corruption in judiciary or health care can not be compared to corruption in fashion industry or film industry. The level of tolerance varies from field to field and I think health care has some sort of priority. Corruption in the cricket board does not affect people directly but it is not the same with Medical College or General Hospital. A corrupted doctor will not be treated same with a corrupted fashion designer or a cricketer. Doctors are the most respected and the most responsible individuals on the earth as their actions have more survival value to all species.
There are many doctors who selected this profession out of interest but that are not case with majority of students now.
Thank you
Dear Harish,
I am still hopeful that the unfortunate unethical practice of medical professon in our country will decrease .
But it would be better for our profession (and public) not to wait for the Government /politicians/public to come with harsh rules and punish our honerable members.!.
The fight agaisnt unethical practice of doctors by a member of our profession is not easy.....it will be considered as an act of betrayal for"cheep popularity""political gain" etc..!the history of our small state itself gives amble evidence to show how painful the struggle could be..!....he will be tarnished/crushed by the finacially powerful gang of doctors who always enjoy the leadership of our professional organisation..
Dr B.Ekbal is still the number one enemy of our profession ...!
He is the author of maximum number of medical books for public to popularise science and medicine ...had written many authentic books/regular articles in almost all newspapers /periodicals/channels in our state and spearheaded many mass movements against irrational drugs,had campaigned for essential drugs,national level campaign for Indian Patent act,conducted many health surveys in our state ,national and international research papers,submitted alternate plans to the Government for health action,the mastermind of medical university for the state,plans for many institute in the state..etc...
Still no doctors in our state like him..He is a betrayer!..Actually all "honerable doctors" love to hate him.!
Though he has done many good things , he has done one crime...which is unpardonable,even to his students.!
He has spoken (publically) against unethical practice of doctors..!
But that is enough.!
The IMAGE of the 'doctor' has been broken!
Unfortunatly he believes that the public has the right to know the reality..IT IS THEIR HEALTH..IT IS THEIR RIGHT..
DOctors themselves will not leave their "paradise"..History shows he is correct.!
Thank you.
hi sorry for the delay. Undoubtedly many doctors are corrupt in our state and country. Most of the corrupt practices are , luckily, not harmful to the patient's heath, but only to his pocket. If men can be so reduced to a level where his self-respect can be bought by a trip to Thailand, i can only express my pity for such a person, and a wonder that it is possible for a person to live without self-respect in front of his family and friends, and be accepted as an intelligent and sensitive person. This is not just doctors, other people as well, but as Ajeesh said, doctors, judges, etc cannot just be excused in the name of being part of a corrupt society. Their decisions materially affect the quality of life, or death of a person, unlike a cement or refrigerator seller. It is absolutely necessary to stop private practice of Govt doctors, with reasonable compensation, as a first step. The main resentment in people is caused by the bipolar nature of the Govt doctors, who are depressive at the hospital, and manic or hypomanic when they reach their home practice. People approach private hospitals expecting some expenses and are not really very much bothered unless the doctor is uncommonly greedy.
The Govt spends crores of rupeees on homoeo madical institutions, which idoes not provide any healthcare worth the name, but is a hotbed of corruption regarding buying drugs etc. Why this German pseudoscience should be encoiraged in india is beyond my imagination.atleast ayurveda is an indigenois form, and though crude, has some products like alkaloids etc which can be useful if isolated and processed properly. I think people like Ajeesh can raise such problems in public, because although we may like to, some of our brethren in the fraternity have copromised our credibility to such an extent that we cannot raise the questions ourselves....thank you
Hi friends,
Sashi has made an excellent unbiased observation and I absolutely agree with him. Every job has its own dignity but I think some jobs require extreme forms of responsibilities. A fault from the military intelligence or a radar operator may cause severe risks to many people in a country. A doctor or a judge has a comparatively lesser form of responsibility but this degree of responsibility is always greater than that of a carpenter, novelist, actors or singers. A student must be well aware of his extraordinary responsibilities when he decides to join MBBS. The degree of responsibility varies even with specialties. A pediatrician is more important to our species than a geriatrician. If a person wants to live like other ordinary guys he must resign from his job as a doctor and may start writing stories, composing music or should work as a clerk for his livelihood.
Gandhi was a lawyer by profession and was not afraid of a lawyer fraternity. And of course, he did not wait for a (British) Government initiative. It is absurd to think ourselves independent of Government or politics. We are part of it. A lot of chapters in our school text books are spent to teach about great personalities like Gandhi or Buddha. A doctor is enough to transform this whole system, a lay person can also achieve this but this special case requires technical or professional knowledge.
As a child, my wife hated her school and wished she could leave.
Years later, when she was in her twenties, she disclosed this
unhappy fact to her parents, and her mother was aghast: 'But
darling, why didn't you come to us and tell us?' Lalla's reply is my
text for today: 'But I didn't know I could.'
I didn't know I could.
(Richard Dawkins in God Delusion)
Here it is the same problem, our poor patients do not know that they can question the doctors. They do not know that they have every right to know what the doctor is doing to them. They do not know that doctors are giving them unnecessarily expensive medications. They do not know that 70 to 80 % of symptoms do not require treatment. They do not know that they do not have to swallow costly antibiotics for their common cold or viral fever. They do not know that they are getting non-recommended drugs for their problems. They do not know that doctors are committed to drug mafia rather than to them. They do not know that there is a WHO guideline for not using more than 2 drugs in a single consultation. They do not know that doctors have to inform them about diagnosis, prognosis or available treatment options. They do not know that they can select a cheaper brand instead of the prescribed brand. They do not know that doctors meetings are not to discuss about medical science but to enjoy liquor and luxury of resorts. They do not know that they can…
A small group of organized and sincere doctors is enough to transform the health care system in Kerala. There are doctors with good writing skills (eg. Dr.Harish) can start writing columns in Malayalam Newspaper to reveal the ugliness of the current system. A doctor can talk about it in a TV Channel. Do not worry that you will not be encouraged. They will, of course, sell you, but you will get a chance to contribute something in public interest. And you will be considered a betrayer by the society of real betrayers! I know (from some reliable sources) that Government is looking for good health care practitioners who can talk about these things as it requires professional medical knowledge. Government has to be careful because it is a game around people’s life and they certainly need technical knowledge.
A Malayalam book discussing health care issues in Kerala will be a good idea.
The first and the most important thing is the awareness. A patient must say “I know that I can”
All other things will follow, Government will be forced to implement new health care policies.
Doctors stopped private practice in Alappuzha. You may have seen it in the TV or Newspaper. People are very happy to listen to this news (a doctor’s arrest by a vigilance team) and it is evident on their faces. The happy guys include medical representatives also! Doctors stopped PP because vigilance department did their job. Will they refuse to treat me if I start to talk about unethical practices? Hartal is common in Alleppey if Sales Tax Department enters a shop. I have heard that Ganja smokers are going to announce a hartal because some police team arrested a Ganja seller. I think you have understood the difficulties of a government initiative.
Thank you.
Dr Vijayan thinks that all evils related to the issue of pharma industry can be solved by a few noncorrupt doctors. I am unhappy to say that he is mistaken. He is making a mountain in to a mole hill knowingly or not. This issue has been discussed and debated all over the world in many prestigious journals. Some regulatory measures have been implementd as a result of all this.
It is clear that majority of the original reasearch to find new drugs are conducted by the corporate sector. This is mostly done by non medical researchers. Doctors have to be employed by them for conducting clinical trials. They also need doctors for writing articles and giving talks to fellow doctors. Again they need doctors to sell these products. No governments will be able to conduct original research for discovering new drugs. This is why I said that the issue is very complex. It is further complicated by patent laws and the current W T O regime. A country like India cannot affords to pay the original price to the patent holders to get the new drugs. We had invented a system of recognizing process patent (the patent is only for the specifc manufacturin process and not for the final product). Thus our companies were able to produce any new drug by using a different process without giving huge suums to the original inventor. But with the advent of WTO regime this may not be possible in future.
The issue is not of a few bad doctors taking kickbacks, but of a whole system of production, distribution and retailsale. The governmett of our country cannot get new drugs for our people without paying huge amounts in future. The alternate models devloped in Bangladesh (by Dr Safarulla Chowdhary is not heard of these days. I remember that he came to calicut medical college during our student days. I remember Dr Ekbal had organized this program). This is why I am skeptical of Dr Vijayan's method. I am not an expert in this area. So anything I have written can be corrected by readers. Thank You.
hi.......the first thing what any doctor has to realise is that he is acting against the laws of nature and evolution. He ensures the survival of the unfit, interfere with the laws of natural selection. The only justification for his profession is that he releves the pain/sorrow/grief pf his fellow human beings. If he is not able to do this in any manner, his work is not worth doing. We do not live in a police state, so pure Govt legislation will not work. hundreds of people are executed in China for corruption inspite of stringent laws. The doctors, to function ethically, need a few ordinary requirements. Like they are given in the West and Aus/NZ etc. They get assured reasonable salary, technical facilities, proper rest and recreation without fear of pecuniary loss, free from threat of physical harm as a consequence of any unintended mishap, encouragement and finance for genuine research etc. Just fear of Govt keeping them in check is simplistic. Compare that situstion to India, and anyhody would be a fool to expect Indian doctors to put in the same efforts, without any of the support earlier mentioned. But individuals who have the ability to undertake such activities, like binayak sen in Chattisgarh, should be encouraged. Once again we fall into compartmentalised thinking, an almost theological obsession with the only one right way to achieve ends. There are multiple streams that can flow at the same time to a common river. The contribution of one cannot be belittled compared to the other since each only contribute, not diminish. So individual, public, govt, and public actions are all welcome and are not mutually exclusive. I personally think attachment to political parties may be an individual preference, but the effort to drag Medicine to fit a particular ideology is a detriment to medicine. Politics as it is practised in our country is an adversarial form, while Medicine is universal and inclusive. One can have a view on how public health delivery can be improved, but decisions on drugs, effects, dosages, choices, are best left to experts. The experts may sometimes be compromised, but we don't have to depend on individuals, a general consensus will emerge, especially in today's world of the internet and communication.
Ajeesh, it is always not necessary that drugs be withheld unless any severe illness is detected. People have a right to a quality of life, and if a patient is in discomfort, he has a right to get relief from that discomfort, and not the dubious benefits of a lecture on the silliness of his illness. A person has every right to be relieved of his physical difficulties even if they seem trivial to us. That relief may ease his mind, and as you know, may prevent it from taking a functional overlay, which is a complication of not giving him relief. That's the reason why people walk out of rural clinics with medicines which we deem useless.note that most of these drugs are of short duration, commonly used, and relatively harmless. Of course there are exceptions that i don't approve of, especially when unnecessary costly drugs are pushed through. Common drugs can be used for relief of minor problems, or the patient may brood about the symptoms and develop mobid thoughts about the illness ,and may seek quackery as a remedy which is ultimately more dangerous. This is a practical decision to be made by doctors, without unnecessarily inducing a fear of modern drugs on people when they are not in a position to make logical decisions, that is, when they are sick.....thank you
Dear Sashi and others,
I have some genuine doubts that I hope you will be able to clear with your unbiased observation and analytical skills that I really appreciate.
Are you sure that doctors acting against the laws of evolution?
Latest assumptions in the evolution, or I am in the camp believing that genes or genetic code as a basic unit of evolution. The concept of individual organism/group/species as a basic unit of evolution necessarily leads to a lot of technical difficulties. The typical examples of “worker ants”, “cuckoos in another species nest”, “altruistic behavior of individual organisms” etc… are enough. I do not want to delve deep into it here. The individual organism is a compromise and not a perfect result of evolution. Evolution is blind and it has no foresight.
It is the genes act of survival is what we call “Medicine”. Dogs or cats lick clean their body and it is not against evolution. We repair ourselves using medical science, it is a phenotypic effect of our genes. Natural selection is blind and the very idea of interfering with it invokes the assumption that it has foresight. We are not, and we can’t interfere with it.
A doctor is trying to preserve or assure the survival of human genetic code and in technical terms a doctor is a phenotypic effect of a patient.
Sorry for being having such a mechanical view. But I am in search of unbiased truth, and nothing else satisfies me.
Your observation that ‘pure governance will not work’ is right. So I insist on public awareness.
You talked of “assured reasonable salary, technical facilities, proper rest and recreation without fear of pecuniary loss, free from threat of physical harm as a consequence of any unintended mishap, encouragement and finance for genuine research etc.” but it is applicable to almost all professions. Only a small group in India gets proper salary and other basic requirements. It should be expected from a developing country like India, especially suffering from a huge population, regional issues and poverty.
You can not wait for better requirements, it is our hard work that is going to foster development. We have to compromise, we have to work without proper compensations (as compared to developed countries). And above all, it is not an excuse for corruption or unethical practice.
Dr Binayak Sen, VS Ramachandran, M. S. Swaminathan or people like them are born and started work here, in this country without your so called proper requirements. If you are willing, excuse is an illusion.
“Of course there are exceptions that i don't approve of, especially when unnecessary costly drugs are pushed through.” - Sashi
Is it an exception or a rule of the majority?
I am living in Alappuzha right now, here it is a rule rather than an exception. 2 doctors recently got arrested by vigilance from Alappuzha Medical College. In friendly discussions, not a single person talked in favor of them, including medical representatives, medical shop and lab owners. I know almost all doctors and almost all medical representatives in my district. In the recent 2 or 3 years, situation deteriorated rapidly. But the corruption in other areas did not worse so fast, it has even decreased in some departments.
Why doctors did stop private practice in Alappuzha for a doctor arrested by vigilance? Isn’t it an evidence of organized crime?
You talked of exceptions, you go to any district and collect a lot of prescriptions randomly and look at the diagnosis and prescriptions. I challenge you, and I predict that there will be an excessive use of drugs, especially antibiotics for viral infections, and definitely these drugs belong to expensive – not recommended as a first line treatment class.
If it is simply for the comfort of a patient, a doctor can use less expensive antibiotics like ‘Microdox’ (Doxycycline), and also I think this drug is under utilized now. Fashion, trends and novelty are the rules, and doctors are manipulated by pharmaceutical companies.
Drugs are not going to kill anyone but its financial implications are serious. A consultation of a government private practitioner + laboratory expenses + drug costs come up to Rs.500/-. A clerk in Kerala Government Service get Rs.7000/- per month. He is paying more than 2 days salary for a single consultation. If some doctors are unnecessarily giving expensive medications, some of the patients will unnecessarily induce fear of drugs among lay people!
I am not blindly accusing doctors alone. I am in the opinion that doctors must get better attention from relevant authorities.
Thank you all for bringing up a socially important discussion.
Thank you again.
Dear Harish ,
""Dr Vijayan thinks that all evils related to the issue of pharma industry can be solved by a few noncorrupt doctors"".
No,I am not so innocent to believe that a few noncorrupt doctors can solve issues related to pharma industry!!!.
I had talked about many other serious issues in the field of health . ... It is true that I mentioned Pharma industry and their growing unholy allience with medical profession also....
All over the world it is the doctors/professional organisations who take the responsibilty of informing the Govt./Judiciary and public aganist the commercial interests of pharmaceutical companies when ever it jeopardise the public interest..because nobody can accomplish it in a better way..they are the experts who can protect their society!..
I can quote hundreds of true stories of doctors/organisations who have fought(legaly and on various other platforms) for the interest of public , from all over the world.
All major Medical journals like British Medical journal,Lancet,JAMA,Australian Prescriber etc give top priority for issues related ethics/medicine.Every issue discuss atleast one topic related to ethics..Recently BMJ had devoted one issue exclusevely to discuss the growing influence/changing strategies of pharma on Medical profession....All authoured by reputed consultants !.
Then, Why should doctors of our country alone hesitate to discuss ethics in medical practice? I have no answers.!
Why they keep/treat 'the very few doctors' who venture to discuss ethics in profession as betrayer of the profession? It appears as an emotional response, out of love for the fellow beings ..........but I think ,in the long run the 'denial/protective response' in not going to do good for the profession .
You admit that ,like other professional organisations/political parties ,medical professional organisations also have hidden agenda.!
Medical profession should not have an hidden agenda.!
IT IS COMMON SENSE.
I need not explain it.
it is more harmful to the medical profession than the public to whom it purpot to serve!
The trade union attitude that dominate the leadership of our organisation has influenced the rank to such an extend that they resort to physical fight with the patients on the slightest provocation.!
They dont have a second thought to declare medical bundhs..! They celebrate the success of their Harthals..! And blame Autorikshaw drivers for resorting to lightening strike..!
I believe ,medical profession should seriosly discuss the right/ethics of healthcare providers to threaten the society by denying medical care to the patients who have no second option.
I request you to discuss this issue....
Right of Medical professional organisations to deny medical care to the patients as an organised method of bargaining..!
Thank you..
Hi friends,
Dr.Harish is a good doctor and he also spends his precious time to promote public health. But he blindly assumes that all other doctors are like him. He underestimated the seriousness of the issue. In all other countries, medical organizations are working in the interest of public but here it is supporting crime. Unethical practice of doctors in India is an organized crime as it is evident from the activities of medical associations. They protect criminals and encourage them.
Pharmaceutical pimps have a special love for popular doctors, doctors with a lot of patients. They provide all pleasures to these doctors and manipulate them to promote unnecessarily expensive novel drugs without any justification. Open public trials of expensive novel drugs must be done in developed countries. Poor people of Kerala should not be a target for them.
There is no role for a medical representative in Kerala other than deal settlements. Ethical practitioners should close their doors for them, as they are not supposed to give any valuable drug information. Doctors should not accept money from drug mafia to spend time in luxury resorts or in the beds of child prostitutes of Thailand, in the name of medical science, medical tours or organizational meetings.
Aggressive marketing campaigns, unnecessary strikes and private practice of government doctors should be banned. Health professionals can not be compared to other professionals. Health is the most important thing to a human being. Proven cases of corrupted doctors should be terminated from the medical service and their license should be withdrawn. I have already said that if some one wants to be a little bit of irresponsible like others, they should immediately resign from medical profession and start a new career that is less important to public interest. Medical Hartals also cause serious threat to the life of many innocent people, not only manhandling of doctors. But of course, doctors who sexually abuse patients may be manhandled.
Government doctors have different attitudes towards patients in hospital and PP rooms. I have one experience. Once I went to the Alappuzha Medical College to diagnose my hypertension and the Alleppey’s most recommended physician examined me. He checked my BP, it was 150/100 and immediately prescribed amlodipine 5mg. I was only aged 26 or 27 at that time. He did not do any blood, urine or other necessary examinations to rule out secondary hypertension. Any MBBS doctors know that it is necessary to rule out secondary hypertension in young adults. He gambled with my life out of pure irresponsibility. I went to consult the same physician for a hay fever after two weeks. Lo, he advised blood examinations and gave me a novel antihistamine as a tablet, another antihistamine as in the form of a nasal spray combined with steroids. So a patient in a PP room is more valuable than a patient sitting in a government hospital. Dr.Harish was in Alleppey at that time, I hope he remembers the incident and he advised me to rule out other serious issues. I am really grateful to him.
It is shame to be a part of an organization that strike for a corrupted person. Dr.B.Ikbal well deserves our attention. He has contributed a lot in public interest than any other doctors in Kerala. There may be other great personalities who remain anonymous but a public open protest is the requirement of our time, sufficient to trigger a mass movement. Writing Malayalam books to popularize science is not a silly achievement and it is more worth than giving good treatments to a few. Doctors like Harish, Sashi and Vijayan must come forward and start writing or speaking about unethical problems in Public Health Care system. You can also write anonymously if you have some practical difficulties, or use a pen name. You can also send it to me anonymously and I will publish it in a pseudo name. A double blind social work! We, including me, have become so afraid to talk of injustice in public. It again shows the overwhelming power of our enemies and the organized form of corruption.
Doctors must inform the patients about diagnosis, prognosis and available treatment options. It is their health and they have every right to know. Information should be provided in a simple language enough for the patient. In a poor country like ours, doctors must always resort to cheaper options independent of the patient’s financial situation to avoid unnecessary skyrocketing of treatment costs.
Please share your views.
Thank you.
Hi friends,
Do all organizations have hidden agenda?
Such statements stem from a cognitive bias of generalization. I do not think that all organizations or individuals have hidden agendas.
What was the hidden agenda of Indian freedom movement, Bhoodan Prasthan, Guruvayoor Sathyagraham, Indian National Army, Gandhi, Buddha or Sree Narayana Guru?
What do you think of KSSP, Medha Patkar, Vandana Shiva, Ramachandra Guha etc… ?
It’s like some extremists’ thought of other activists in Kerala as CIA agents!
Postmodern apolitical thinkers blame that all politicians are corrupted.
Indian politics, especially politics in Kerala is far better than politics in other countries. No developed country has such a democratic system like ours. Indian politics is not based on Skin Colour like in America or other European countries.
Kerala is the best state in India to live, at least to me. Our political organizations and NGOs have contributed significantly in this respect.
The statements like “All organizations have hidden agendas”, “Politics is too bad to join and I should stay away from”, “Government should do all things” and “All public protestors doing it for some hidden purpose” will not lead us into anywhere.
It is a fashion these days to blame everything on the government!
Thank you.
Hi friends,
There are incidences of unconscious drug substitution happening in our medical shops. Most of the medical shop staffs are under educated for the job and the writing style of majority of doctors add to the existing difficulty. Medical Shops offer poor salary and working atmosphere, so there is no hope of improvement otherwise government comes up with a strict policy of pharmacists only shops.
There are a lot of unemployed pharmacists in our state. Their education will be fruitful if government comes up with a strict policy.
Stopping private practice of government doctors also provide tremendous job opportunities for unemployed MBBS holders. They can set up small private clinics in rural areas. Now the revenue is only shared to a few people who are established at the mercy of government hospitals.
Thank you.
Where is Dr.Vijayan?
We need to continue the discussion, we have only touched the tip of an Ice berg. I like to discuss socially important problems. There are other serious problems, individual issues may be nothing compared to it.
Here are some:
Laboratory reference ranges and diagnostic criteria are manipulated to include more patients and drug treatment and it is obviously for the benefit of the industry.
Text book writers get huge sum of money to include particular brands/drugs in the books.
Most of the medical studies and drug trials are conducted, supported or promoted by the multinational pharmaceutical companies. Do you think that they are doing this entirely for the sake of the mankind?
Are they interested to develop drugs to cure diseases or disorders?
Or, are they interested to make drugs that give good comfort and used for a life term or long term basis?
What is more profitable to pharmaceutical companies? What do you expect them?
After patent expiry pharmaceutical companies come up with enantiomers like Escitalopram or Esomeprazole. The get new patent and sell it at higher prices. They manipulate doctors to use newer drugs without any apparent benefits in most of the cases. They withdraw or discourage to use older drugs. There may be some exceptions in efficacy and drug tolerance but mostly it is a business trick.
Should we allow this?
There are numerous problems with Private models of drug research and health care. It will only increase time after time. We know how Eli Lilly got approval for Fluoxetine. Drug approval is a matter of power and money. FDA guys who are responsible for screening of drugs are accepting money from pharmaceutical companies, and there is evidence for this. This is not yellow paper journalism.
Pharmaceutical companies hide important information from both health care professionals and public. It is more rampant in psychiatry. They come up with fairy tales like explanations of drug mechanism and action. They do not accept that they do not have any idea of what causes the disorders or how their damn drugs works. Drugs are immensely helpful to patients and we all accept that, but current marketing strategies are unacceptable.
The time is already late to think of Public Model of Drug Research and Health Care.
It may slow down the progress a bit but what is the use of a fast drug development without improving quality of human life. America is a dream destination for doctors and we know what is happening there now. In terms of quality of life, America is far behind many other small countries. I think people of Bhutan have more leisure and happiness than Americans. I will opt for Kerala to live again if you give me two options of America and Kerala. US Dollar is a flawed currency and their model of health care (now blindly copied here) is also not sustainable, they are well aware of it. They are investing their money into emerging markets like India and China, and looking into other countries for better models of health care practices now.
Priority areas must be handled in public sector if you need a sustainable system.
Thank you.
Ajeesh, you are right again. We have only sighted the ice berg's tip. This is an issue to be discussed by doctors, economists, political leaders, public, entrepreneurs and anybody who wants to have a say in it. Doctor bashing done by a section of media and a few doctors cannot solve anything. It is just 'holier than thou' attitude.
There are accusations that newer diagnostic entities are carved out by specialists on the payroll of certain companies to help them marker newer molecules. Similarly older molecules, when they lose the market edge due to competition from newer drugs, are again dressed up and presented for newer indications with new 'evidence'. Compared to what is happening in the pharma sector the worrld over, the issue of a few doctors taking few pens or even going to 'thigh land and Bangcock' is miniscule. But I fully support the view of Dr Vijayan that the medical prfession should show self restraint and willing to enforce disciplne.
Thank you
Hi,
We can only see the tip of the ice berg, remaining areas are hidden. But it doesn’t mean that we should not act, we should continuously hammer the tip that we see.
Cont… in a newer post titled “Unholy Alliacne”
Thank you.
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