In a well functioning market, patients
(the consumers) will know clearly their doctors' professional skills,
qualifications, results, feedback from others, fees etc. They will be
able to compare doctors and choose wisely. Regulators will be working
effectively and keeping a close eye on the profession for various
However, the market is not working well.
Patients do not have any other information about their doctors. The only
thing they pretty much know is how much their doctor is charging.
Results are immaterial as patients have no means to verify them anyway
and lies and exaggerations are commonplace. In a very fee/charge
sensitive environment, General Practitioners are hence constantly
driving each other down on pricing to attract patients. It then reaches
a level where, in a civilised society, it is impossible to live on an
earned wage that forces them to look for income elsewhere. The easiest
source of that income is commission from laboratories and specialists
for referrals. Patients are not aware that this is happening as they
seemingly have a choice in deciding which labs or specialists they go
to. Whatever little do they know is, that every single lab/ specialist
(the vast majority) will send their doctor the commission. In that
sense, it is immaterial where they go.
From the point of view of specialists or
laboratories, no matter how good you are, you need your general
practitioner colleagues in medical profession to confirm that to the
patients as patients have no validated tools to be able to verify
authenticity of any facts. In this situation, you become the biggest
surgeon in town if you give out the biggest cuts to the general
practitioners. If you are not so good or a new surgeon in the area, you
have to work even harder!
Like rest of India, there is a lot of
black money circulating in the system as most payments to doctors and
labs by patients are cash with very few authentic receipts.
So, how can we even begin to solve this? I
have following suggestions to make. Needless to say, it needs help from
all stake holders, if we are to even to begin to see a change.
1. State and Medical Councils should raise
awareness about cut practice and commissions and clearly explain to
their members that it is both unethical and illegal to give and take
commissions. Money should not play any consideration in who they refer
their patients to or who they advise their patients to go to? When money
is involved, patients cannot be sure that their advice is not biased.
They should even make examples of some doctors by cancelling their
privileges to practice. It shouldn't be too difficult to organise some
2. Doctors should start charging their
patients more if they can't survive on their income rather than
supplementing it through unfair means. Government and medical councils
should educate the public that it costs to study medicine and become a
doctor and that it costs to live. This service can't be provided for
free. For free or subsidised healthcare, we should reinforce our state
medical sector. Needless to say, we need to work on increasing the reach
of insurance sector as well.
3. Results of doctors and feedback from
other patients etc should be validated and made available to patients.
In this context, we need mechanisms to ensure doctors engage in
continuing medical education and have systems of auditing their
4. Tax authorities should ask
doctors/labs/hospitals to provide their patients with proper receipts.
They should close in on the black money being generated by hospitals and
labs, which is then dished out to general practitioners through
5. Media should keep a spotlight on these
issues and monitor the situation periodically.
6. Medical colleges and academicians in
these institutions should make these issues a top priority item in
No doctor wants to work unethically. This
is not why we join this noble profession. But doctors also have a life
and a family. They also expect to work and live with dignity. It is up
to the wider society to provide us with a mechanism, which is
sustainable. Currently, we are stuck in a massive waterfall of declining
standards, which is constantly dragging us down. Each individual is
helpless in fighting this force. Together, we can change it. Are we all
ready for it?
[Dr Kamal Mahawar is
Senior Consultant in Bariatric and Metabolic Surgery at Indraprastha
Apollo Hospitals, New Delhi]