Tag Archives: Dr. Nadkarni

Out of bounds for the poor – Dr Sadanand Nadkarni

12 Jul


24 May

I had mentioned in my last article that we have a strong case against consumer protection act being made applicable to the medical profession. This is that strong argument, and I believe it will work if properly put up. But before that, let me tell a past incidence.

Mr. Madhav Gadkari was the editor of Loksatta–a Marathi news-paper. He was very out-spoken -to a fault. Once he wrote an article stating that the High Court Judges are most negligent. One judge sleeps while the advocate is pleading, and wakes up only when he has finished. Another judge gives a favourable judgement when a particular female lawyer pleads because she is very beautiful. Yet another judge is partially deaf and uses hearing aids. But whenever he is bored, the said judge removes his hearing aid and dozes off. Obviously the judges have already made up their minds without hearing the opposite side. An article so brazenly accusing the high court judges was bound to invite “Contempt of Court” proceedings against Mr. Madhav Gadkari and the Loksatta newspaper. The High Court bench demanded an unconditional apology, but both of them refused to apologise. Instead, Mr. Gadkari asserted that he was telling the truth; he can prove his statements with concrete instances against each of the judges and therefore it is not a case of contempt of court but it is a right of the media to inform the public about the actual facts of high court proceedings. He pleaded that he may be allowed to bring his material and his witnesses to prove his point.

Strangely, (or appropriately?) the high court bench refused to give him such an opportunity and gave a verdict against him. The supreme court, on appeal, upheld high court judgement and Mr. Gadkari was punished with a token fine. The judgment, in effect, said that the citizens of the country have strong faith in the judiciary and its impartiality. This faith of the citizens is the strongest pillar on which the entire judicial system is based and accepted by the people. If this faith is eroded, the people coming to the court for justice will start doubting each and every judgement and the whole judicial system will collapse. Even if it is presumed that a few judges are defaulters as mentioned by the article concerned and even if Mr. Gadkari had sufficient proofs to prove, it is extremely unsafe to allow these facts to be brought to light as the whole judicial system will collapse as mentioned earlier. TRUTH CANNOT BE ENOUGH WHEN THE FATE OF THE WHOLE (JUDICIAL) SYSTEM IS AT STAKE.

The same argument can be applied with equal force to the health service provided by qualified doctors. In most ordinary illnesses, it is FAITH THAT HEALS. The prescriptions of the doctor help but they are not the actual healers in most instances. Even in major illnesses, faith contributes a lot in healing and helps substantially more in allowing doctors to take decisions. Therefore, the whole system of clinical practice  will collapse, if the Faith of the people in Doctors is lost. And that is exactly what is happening after the Consumer Protection Act has been made applicable to the Medical Practitioners. The health- care system has collapsed and  therefore TRUTH CANNOT BE ENOUGH  TO PROSECUTE THE DOCTORS WHEN THE FATE OF THE (HEALTH-CARE) SYSTEM IS AT STAKE.

The consumer Protection Act was enacted to protect the consumers who purchased goods or services from being cheated by the shopkeepers. It was then claimed that the act was not applicable to medical services as there was no contract  nor any promise of result. The argument was first rejected by the Kerala High Court; the Honourable judge insisted that it is a contract between the doctor and the patient. But we can insist that it is a contract essentially based ON FAITH. In most illnesses, it is the  faith that heals. If faith is excluded, and it becomes a mere contract, the clinician has to work fool-proof. He cannot take the slightest risk. If a patient comes for chronic headache, he has to advise a C.T. Scan and a fundoscopy before declaring that it is due to psychological reasons -which he knew anyway in the first place only.  A cardiac condition has to be ruled out by E,C.G.,2D Echo, and angiography, for a patient with pricking pain in the chest, before he is relieved by Antacids. Clinical judgement, based on general circumstances and other symptoms could be fallacious. The doctor would not take any risk, even if the patient was poor. “Let him refuse” will be his response.

Thus, the C.P.A. is contributing to the collapse of the health-care system, even if it may not be solely responsible for it. Nor is it  helping the real sufferers. There is no punishment for the doctor. He has to only pay compensation which he now collects from all his patients through higher charges to pay for his indemnity insurance. Actually, C.P.A. can only be compared to the “Blood Money” law in Pakistan wherein a murderer is let free by paying the victim’s family a defined amount of money.

The medical science and its application in clinical practice has progressed a great deal through “trial and error”. What was considered “The Latest in Management” has often been discarded as junk a decade later. Noradrenaline was considered a miracle drug a generation ago but is now considered a very dangerous drug. This progress is achieved through relentless discussions and critical analysis of the treatment protocols/drugs continuously through years.  The critical specialists continuously find faults with the present practice in their clinical meetings in medical colleges and scientific conferences. The C.P.A. has put a virtual full-stop to such free and frank discussions even in the closed-door meetings. The news that “something went wrong, the treatment was faulty” would leak out in no time. There are press reporters amongst the very doctors attending the meeting! So, the meetings avoid being critical and conveniently push the blame on “lack of modern equipment, modern facilities or paucity of technical staff”. Thus instead of any efforts to improve the personal skills or improved understanding of the subject, the whole medical profession is prefering to fall into the hands of the manufacturers of high cost modern equipments. These manufacturers are already aggressive in their marketing, trying to impress that their new product will definitely reduce the errors. Time and again these claims have been proved wrong; but  the manufacturers come-out with a new product. The ultimate sufferer is the Patient who has to bear the additional costs, often without any additional benefits. C.P.A. has contributed a lot to this decaying  process by abolishing all resistance of the conscientious and socially oriented specialist doctors. If the act was made non-applicable to the medical profession, it is distinctly possible that the movement against abuse of high technology and costly treatments would revive as it is the need of the country. Even the rich developed countries like U.S.A. and U.K. are finding it difficult to meet the expenses of the health care and their leaders are desperate to find ways to reduce the costs.

Therefore looking at the disastrous effects on the doctor patient relationship, some alternative method of compensation needs to be evolved. It is also necessary that  grossly defaulting doctors be suitably punished.

The Finance Minister had recently announced a 5% tax on all hospital bills of air conditioned hospitals with more than 25 beds. This would have gone to the coffers of the central government. Instead, the medical profession could agree to a 5% tax to be collected from each and every hospital/nursing home/diagnostic centre but this would form a Reserve Fund for compensating the aggrieved patients. The same medical centre could be allowed to use upto 50% of the amount it has deposited while the remaining 50% could go to the common pool. In this system, there is no discussion or dispute about the guilt or otherwise of the doctor or the hospital. Only those patients in whom the complications or death was mostly unexpected would be compensated. It would also be possible to compensate families where the earning member on whom the family was mostly dependent, gets crippled or dies due to an acute illness-even if there was no accusation about his/her treatment. If CPA was made non-applicable to health-care services, such a scheme would be widely accepted  by  the society and it  will not disrupt the faith of the society in  doctors. This idea was proposed by Dr. R.D. Lele but was not considered seriously by the fraternity.

In addition, the medical fraternity could offer certain noble concessions to the affected family, if and when unexpected complications occur. It can be stipulated that the family will have to bear the additional expenses upto Rs. one lakh or two and half times the original estimate whichever is higher but after that the doctor/s would charge  a nominal fee or nothing  for his visits, and the hospital will also collect minimum [cost]charges for all services, investigations, and medicines etc. Such a step, taken by the association and publicly announced, as Professional Ethics, will go a long way to soften the public opinion.

But it would be unfair not to keep the doctors answerable for their conduct. As shown earlier, the C.P.A. has hardly achieved this objective. It would be better if the Govt. evolves a regulatory authority and the fraternity accepts it. The concerned authority will not question the decisions of doctors but certainly will examine whether the protocols were properly followed or not. The government has already passed “Clinical Establishment Act 2010” and accreditation is already on the cards. All the establishments can now be accredited as 1) Convalescent home 2) Day Care Centre 3) Nursing Home 4) Mini Hospital 5) Hospital and 6) Five Starred Hi-Tech Hospital. [This is just an arbitrary classification to emphasise the categorisation of the establishment that will define vaguely the types of cases the centre can take up, depending on the facilities and the staff therein.] Similarly, display of charges for various services, including the fees of the specialists, was made mandatory by MCI but was not being followed. This rule can be strictly implemented. The medical council is already making it compulsory for the doctors to attend refresher courses before re-registering them. Good clinical and hospital records should be made mandatory which must include good clinical notes, the final diagnosis with staging and the time of the visit of the specialist and his findings and management advice. Committees could be appointed in each district and each metropolitan city to look into the complaints and take appropriate action. The rationale of the specialist’ advice cannot be questioned, as each specialist is an “Expert” even in legal terms. Therefore he is entitled to take his own decisions.

These regulatory mechanisms, if strictly implemented, will regulate the conduct of the doctor and the hospital far better than at present. The interests of the patient will be sufficiently safe guarded. It is in the interest of every one that the C.P.A. should be made non-applicable to the medical profession because it is a contract with faith as its main ingredient and because the whole health care system is collapsing under the weight of C.P.A. If these facts are repeatedly highlighted through the media and the medical conferences and if a P. I. L. is lodged in the high court, I feel confident that the courts will reverse their present decision.

About the Author:

Dr. S.V. Nadkarni

Ex. Dean L.T.M. Med. College,
Sion, Mumbai,
Email: sadanadkarni@gmail.com,
Tel: 09320044525 / 022-24468633,
Website: www.healthandsociety.in
Suraj Eleganza II, Mahim (W)-400016

Allow Doctors to make Mistakes

25 Apr

1. Sangam Yadav, 35, a taxi-driver had severe abdominal pain, he was treated in casualty department but did not get relief and wanted admission. But the lady doctor did not feel he was serious enough to need admission. A scuffle and doctor-bashing. Indeed – patient was not serious.

2. Ramdas Patil, 33, an auto-driver attended V.N. Desai Hospital in Santa-Cruz(E), in early morning hours. He was given an injection but died within 10 minutes. Doctors were blamed for “delay” and for “wrong” injection. Mob-Fury, Hospital property damage, Dharana, doctors’ strike. Finally, diagnosis haemorrhagic pancreatitis – nothing could have been done. The injection was innocuous.

3. End stage renal disease, patient admitted repeatedly-died. Yet Dr. Dahake assaulted and injured in K.E.M. Hospital.

4. A patient delivers in private nursing home, but starts bleeding profusely. The doctor transfers the patient urgently, even accompanies the patient – inspite of transfusions and efforts, patient dies. The relatives go back to the Nursing Home and destroy furniture and equipment. Postpartum haemorrhage is a rare but known dreaded complication of even a normal delivery.

Incidences are galore, but the reaction of the Press and general public is same. ‘Doctors/hospitals are negligent, and sympathy for the mob’. Even if their violent acts are mildly condemned, they were ‘Angry’, ‘Upset’ ‘Agitated’- Never ‘Roudy’ ‘Hooligans’. There is hardly any word supporting the claims of the doctors/hospitals that the violent incidences were totally unjustified. It is left to the Association of the medical professionals to defend themselves. Naturally, ‘Bandh’ and Strikes are becoming part of their professional life.

But is that all? No. The escalating costs of health services and over crowding of the tertiary hospitals are directly related to these strained relationships. Generally, the doctors are highly sensitive about-even scared of – complications or deaths at their hands; these cause disrepute and adversely affect their practice. Therefore, by nature, doctors advise more investigations and more precautions than really necessary-to be on the safer side. But two generations back, they took into account the patient’s economic and social condition and often took upon themselves the burden of deciding not to overburden him with heavy expenses, by avoiding costly modes of investigation and treatment. Now no more! With the dangers of law suits and even more – of assaults and damage to property– Darwin’s law of ‘Preservation of self and preservation of species’ overrides all other considerations.

Doctors ask for every investigation, prescribe the most-modern costliest of medicines and on the patients’ raising slightest doubts, seek self-protection by calling higher specialists, cardiologist for chest-pain, diabetologist for diabetes, and nephrologist for urine trouble. Too many cooks easily spoil your (health care) broth. (Crooks? No. I really meant cooks). Normally, faith heals; but when suspicion and antogornism grow, faith cannot heal. Every symptom has to be proved objectively to be inconsequential. Therefore, your headache is cured by the same aspirin but only after MRI of the brain, and fundoscopy by an ophthalmologist. Your pricking pain in the chest calls for Angio-graphy, after ECG, Stress-test and 2-D Echo, to be declared as due to indigestion and gases.
But this is not all! if you get admitted to a nursing home or a small hospital, you will certainly be treated well as long as your condition is relatively stable or you need a relatively straight forward operation. But, if the patient becomes even a bit serious and/or relatives start asking too many questions, most of the average doctors play safe and advise the patient to go to a major hospital –even when he has enough knowledge and skill to treat the condition – ‘No Assault, No Destruction, No Law–suit, please’, they seem to say. Thus, many I.C.U. patients are transferred to 5-star hospitals. This explains the strange paradoxical phenomenon that there is no bed available in a 40-50 bedded I.C.U. of 5-Star Hospitals despite exorbitant costs while I.C.U.s in small hospitals are virtually vacant.

The situation in public hospitals is even worse. At one time, peripheral hospitals were bristling with activity. Lecturers and post-graduate student residents were posted and fresh young honorary specialists were keen to gain experience. Learning Experience was a great motivational force. No more so now. Now it is drab routine working. With fixed (low) salary or honorarium, money-incentive is zero. Job satisfaction would have been a good motivational force if, indeed, there was any job satisfaction. Are the patients grateful? Instead, there are mostly complaints and grievances and the ‘elected’ ‘rulers’ come shouting and cursing the doctors who are only ‘Paid’ ‘Servants’. Why should they risk assaults and damages at all? It is better to pack off every risky patient, be he a medically risky patient or a socially risky person. Everyone is advised to go to major teaching Hospital-Sion, KEM etc.. The simplest excuse is lack of staff and/or lack of equipment. A clamour for more staff and modern equipment is strongly supported by people, the Press and the Media. This explains another strange phenomenon that teaching hospitals are over-over-crowded while peripheral hospitals work with ‘Susegad’ style upto 2pm or so and then virtually go to sleep. When someone like Ramdas Patil suddenly disturbs this sleepy atmosphere in early morning hours, at V.N. Desai hospital in Santa-Cruz, it is no wonder that things go wrong. The ‘Susegad’ style of working can not suddenly change into Jet’ style, anywhere in the world. Some scape-goats are massacred and everything continues as usual.

Much more attention is required in various other directions. Medical Education has to be re-oriented to become compatible with social needs. System of working must be changed, proper motivation ought to be created for doctors to work – and performance based emoluments has to be one of them. But at the same time, ‘Riots, Assaults and Destructions’ ought to be condemned outright – whether the doctor/hospital is right or wrong. It can not help – It certainly worsens the situation – and people will suffer more. People will have to develope a little more faith in doctors – at least those who talk and explain – and allow them to make errors of judgment; often not even that – the death or the complication could be inevitable, unavoidable. Please allow Doctors to make mistakes – so they will be willing to treat you at reasonable costs and available facilities.

About: Dr. Sadanand Nadkarni
General Surgeon, Former Dean, L.T.Med.College, Sion.

Contact: sadanadkarni@gmail.com, 9320044525

Website: www.healthandsociety.in

Disclaimer: All the contents of this Article is provided “As Is”. That means there is no warranty of any kind. Indianhealthjournal makes no claim that the Article’s information is appropriate in any jurisdiction or that the products described in the Article will be available for purchase in all jurisdiction.

Improving Health-Care in India

22 Sep

Date: 23 September 2010

Author: Dr. Sadanand Vinayak Nadkarni

About: MS. Gen Surgery, Former Dean of Sion Hospital (LTMGH), Ex-Medical Director – Bhatia Hospital, Advisor to Govt. of Goa- 2 years-Organized Trauma Care Service in Goa Medical College, Author – Management of the sick healthcare system

Contact: sadanadkarni@gmail.com , http://www.healthandsociety.in

I wanted the title to be improving Health-care System in India. But I refrained from adding the word ‘System’. When the system does not exist, where is the question of improving it?

Look at the scenario in Health-care. Though Allopathic System is widely accepted and practiced, there are Ayurvedic & Unani Siddha & Homeopath doctors; – “Ayush” as they are called and they practice allopath freely without any fear of action against them. Even, among the allopath the role of each group is not defined, even conventionalty.  There are M.B.B.S. doctors who are supposed to offer Primary Health-Care or assist the specialists in hospitals, and there are specialists. Then there are full-time paid doctors in state and corporate section, while others do private practice and earn their bread and butter and cheese if you like. But family physicians freely prescribe the costliest drugs and ask for costliest of the modern investigations, while specialists treat cough and cold, or abdominal pain due to indigestion or simple menstrual disorders. The full time paid consultants openly enter into the field of private practice – ‘outside the office-hours’ but office hours not being well defined, they practice inside the office hours too. A corrupt officer is more faithful to his bribe-giving master than to the state; similarly, these specialists remain more faithful to their private patients, ignoring their original patients in the govt. or corporate section. All this needs to be corrected, through stern administrative action.

The most important need of the society is primary health-care, but it remains the most neglected service. In fact, primary health-care is better in the public sector than in the private sector. Almost 80% of the M.B.B.S. doctors choose to do post-graduation and become specialist. So, only those who fail to get a seat for specialization become primary health-care providers – they join state service or enter into private practice. And what is the experience, they have gained? Nothing, A specialist is trained for 3 years, a family physician not even for 3 days? The massive shortage of P.H.C. providers leaves the field wide open for non-allopath and 80% of the rural and semi-urban and urban slum population is served by non-allopaths who freely practice allopathy – without any proper training. Thus nearly 100% of the primary health-care services are in the hands of “Quacks”.

What is the result? First inability to diagnose. Not having learnt clinical methods and the simple art of differential diagnosis, they are not confident about their own findings and need support. Secondly, their main source for knowledge is now M.R.’s (Medical Representatives) and agents promoting high-tech CT scan / MRI’s etc. Thus the practice of using costly drugs, costly investigations, starts at the primary level itself. Their only other alternative is to send the patient to specialists who, in turn, strongly advocate surgery or procedures and hospital admissions. Even small, simple diseases cause intense panic and immense expense which, in turn, adds significantly to the modern psycho-somatic illnesses like high-blood-pressure, Heart-disease and diabetes. The viscious cycle continues – but needs to the stopped – at least slowed down.

“Advances” in the medical field are making matters worse. The press and the visual media keep high-lighting ‘miracles of Modern Medical Science.” A 10 day child with heart disease successfully operated – a new cardiac procedure and the patient goes home in 3 days – cancer detected when no tumour was palpable and treated successfully without operation (Julia Roberts)

A crazy demand is created for bringing in “modern medicine”, and thus for high-tech equipments and costly medicines. We boast that the Indian medical system has become very advanced and can compete with the developed countries. The statement is quite true. It is as true as that Narayan Murthy’s  Infosis and Azim Premji’s Wipro are among the top10 companies in the world or that Mukesh Ambani will be the richest man in the world by 2014. It does not disprove the fact that 38% of the Indians are below poverty-line or 60% of Mumbaikars are living in Zopadpattis. The people needing and / or offording the ‘ Miraculous’ treatments are one in a lakh. Most people need primary and secondary care at a reasonable cost, by competent health providers, which they are not getting.

So what can be done to improve health-care in the country?

1)      G.P.’s must get proper training. In a medical college admitting 100 students, at least 10 to 15 posts must be available for a 2 years training  in general practice. They will rotate through all departments like medicine, surgery, paediatrics etc. in the morning shift and work in dispensaries (run by medical college) in the afternoons, under the guidance of experienced physicians.

2)      We must face the fact that Non-allopaths are doing allopathic practice and covering up the shortage or G.P.’s in rural and semi-urban areas. But, a report published today (Sunday Times 19th Sept 2010 P 15) confirms my belief that their services are substandard (almost disastrous). It should be made mandatory that they must get trained in allopathy by working in district – hospitals 18 months to 2 years and obtain a certificate. Otherwise, they should be considered as unqualified quacks and dealt with.

3)      M.B.B.S. doctors or G.P.’s must be banned from using very costly medicines, including anti-biotics as also from advising very costly high-tech investigations and procedures. They must refer such cases to a specialist. The list of such costly drugs (as also drugs introduced in the last 2 years) and also very costly investigations can be easily prepared with the help of F.D.A. and duly notified. Action can be taken against hospitals and diagnostic centers, if they perform such tests and against pharmacies if they sell such drugs, prescribed by non-specialists.

This will greatly curb their abuse and markedly reduce health-care costs.

4)      Middle class people suffer the most. Public hospitals are over crowded and private hospitals are unbearably costly. Medical college hospitals as also other public hospitals should work in 2nd shift (afternoon 4 pm to 10 pm) to serve ‘paying class’ patients with reasonable charges and 25% beds in the wards be reserved for them & full time, specialists should be offered incentive payment – practice within the premises. Private practice outside the premises should be totally banned for all full-time paid doctors.

5)      The society must bring increasing pressure on Nursing Homes to improve their standard and display their charges clearly. Accreditation must become mandatory. This will lead to ‘Group Practice, & the Nursing homes will be able to sustain the expenses needed to maintain the standard of their staff and of their equipments.

There are many other things that need to be done and I have discussed these in my (recently published) book.

Management of the Sick Health-Care System

The price of the book is Rs. 100/- only (postage & cheque clearance changes Rs. 25 interested readers can contact me or the publisher with a cheque of Rs. 100/- & their address (Rs. 25/- extra outside Mumbai Area for postage & cheque clearance.)

%d bloggers like this: