Review of Satyamev Jayate: “Does Healthcare Need Healing?”

This is a detailed review of 4^th episode of popular show Satyamev Jayate where Aamir Khan is the host. The theme of this episode was “Every Life is Precious - Does Healthcare Need Healing?”

http://www.satyamevjayate.in/issue04/

http://www.youtube.com/watch?v=1Lg0kUtS8ic

Table of Contents

Background

What I Liked in the Show

Improvement Areas, Mistakes in the Show

Reasons for angry remarks from doctor community

Conclusion

Background

Earlier I did not get a chance to watch the episode completely. And I got carried away by reactions of people in websites, various articles published online etc. and thought the show was done irresponsibly. Though I didn’t express such feelings in any of the public forums, I don’t feel nice to have felt that way in the first place. Here I am today and I stand corrected.

After watching the show end to end, I do not have any disrespect towards Aamir Khan or the show organizers, instead I found the show to be quite good. I did find some improvement areas also which probably caused some of the controversy.

What I Liked in the Show

Here is what I noticed in the show that changed my notion.

-          People who oppose did not get the scope right: First and foremost thing is the scope of the show, which I think many people failed to realize properly (especially those who opposed the show).

Aamir Khan wholeheartedly agreed that doctors are humans too and mistakes can happen (and are acceptable), he never wanted to question such things and hence kept that debate aside. His objective was mainly to focus on deliberate wrong doings by healthcare professionals driven by pure greed. He even kept aside negligence, and the focus area was intentional fraud only.

In other words, the scope of the show is as follows:

o   Unintentional Mistakes

o   Negligence

o   Deliberate Fraud

Negligence can be a very touchy subject and hence I appreciate that he kept it aside.

In short, I strongly feel that there is absolutely no reason why good doctors should feel bad about this show.

-          Who said doctors should not make money?: This is a classical question – is it okay to make big money through noble profession who treat suffering people?

Aamir never said doctors should not make big money; in fact he showcased how Dr. Devi Prasad Shetty and his colleagues make good money along with providing great service. All he said was “If you are able to get a medical seat, I am sure you are quite smart; if your primary intention is to make money then why don’t you try another profession because you might be smart enough to make money in those fields as well”. I don’t see anything wrong in that argument/request.

Is there anyone who says that it is perfectly okay if someone entering medical field considers money as the highest priority? And if someone really feels so, I suggest that they raise their viewpoints and try to change MCI’s code of ethics.

Also, if a doctor openly and officially charges higher fees for a legitimate and quality treatment, I am sure Aamir or anyone won’t raise fingers at such a doctor. Deciding charge for his/her services is a doctor’s right. But a doctor should not cheat patient for money – that’s the main message here.

-          Deliberate fraud cannot be justified: In many cases doctors may be working under tough conditions – in such cases “unintentional mistakes” can happen, sometimes frustration may lead to negligence also (about which I am sure genuine doctors will repent later). But fraud? NO argument can justify deliberate fraud against patients.

-          Pharmacies, Labs: It is well known fact that non-doctor wings of healthcare profession cannot exist independently on their own i.e. pharmacies, labs etc. If doctors are not corrupt, it is not easy for them to be largely corrupt on their own. So, in most of the cases (there may be exceptional cases) any frauds in such places can be traced back to corrupt doctors or doctors who don’t have will/courage to voice against them.

I found the example highlighted where Dr. Anil Picchad, a lab owner, showed tremendous courage to overcome the corrupt system highly appreciable (although he did it only after getting inspired from some personal tragedy). I hope this acts as an inspirational example for many people.

-          Drugs: How many common people are aware of the term Drug Mafia? The show threw some light on this. If a large quantity of ‘generic drugs’ are being exported, then is it not an indication that they are quite good? Let us not mix up fake drug issue and blame generic drugs for failed cases. The proposed idea of government opening generic drug stores everywhere definitely seems to be a good idea, and this was later acknowledged by Dr. Rai from IMA also in one of the TV debates.

Now, I hear some doctors alleging that generic drugs are not really as effective as branded drugs. With all due respect, I request such doctors to provide more examples, scientific data for such claims. Even if they want to speak from their experience, I would love to read more on that.

As a non medical person, from my perspective, when successful doctors like Dr. Deviprasad Shetty and important person like Dr.Rai from IMA endorse generic drugs, I believe burden of proof lies on the people who oppose.

Note: Dr.Deviprasad Sheetty and Dr. Rai endorsed generic drugs in a different debate, not in this show.

-          Role of MCI: I found the statistics provided mind boggling i.e. not a single doctor is stripped off his/her license in last 4 years. I also found the episode of retired army person joining and retiring without being able to improve the system; I found it extremely concerning.

BTW, what did MCI achieve in last few years? Did it achieve anything at all? At least the chief of MCI didn’t bother to highlight any of MCI’s achievements. So, viewer is completely justified in assuming that MCI had completely lost track until recently and now struggling to bounce back.

I found Aamir’s efforts to extract certain concrete answers and promises from MCI chief commendable.

-          Medical Colleges: Forget about number of colleges for a moment; let us assume that government did not take initiatives to meet the demand and hence private entered the arena and filled this gap. Maybe their contributions have to be appreciated in this regard. But let us look at following questions:

o   Is it not an open fact that there is huge amount of donation (cash payment) for management seats? Is it not a fact that person with money but less merit can get a seat through such means?

o   Is it not a fact that people who spend big money on education will also try to make big money and in turn influence/corrupt many others around?

o   Is it not a well known fact that most private medical colleges are built using black money and owned by influential people?

o   Is it not a fact that many staff are temporarily brought in and showcased for the accreditation purposes?

I am glad that all these were told openly in the show. I am also glad to see a suggestion that more government medical colleges should come up.

Note: Many people get medical seats through reservations also even though they don’t have high merit or passion. Personally I am against such an idea, will take it up separately sometime.

-          Case of mass hysterectomy: Even in so called developed western world now this is a controversial subject. In the example highlighted, we can see a clear example of fraud. And Aamir insisted MCI chief to take a look into that specific case and take some action – I appreciated this perseverance.

-          Case of appendicitis: This case looks genuine and sends out an alarm. Appendix is considered as an ‘unnecessary’ body part and removing it won’t affect any body function. Hence, it probably becomes easier for a fraudulent doctor to simply advise appendicitis when there is no real need.

-          Case of Liver Transplantation vs. Gastroenteritis: This case looks genuine because victim was equipped with sufficient information. This is a scary example because two doctors together played the trick on victim. Victims were lucky to escape without any physical harm or loss.

Improvement Areas, Mistakes in the Show

Again I would like to repeat, I found the intent and spirit of the show good, hence I don’t see any reason to oppose it. However, I could find several improvement areas and perhaps even some mistakes in the show.

Degree of fraud: Just because we talk about ultimate ethics that no fraud can be justified, I don’t agree that all frauds are of same degree or some cannot be easily categorized as fraud itself. For ex: Commission/cuts cannot be equated to suggesting a totally unnecessary surgery. Aamir should have really highlighted this practical aspect though at one place he does say that ‘people who violate rules most’ should be first dealt with.

Considering all practices that are formally classified as frauds, by and large we can identify 4 categories:

Category 1: Here patient is not directly affected; this is a very mild form of fraud (technically) and in many cases we can see convincing justifications.

-          Taking commission/cuts or gifts from drug companies and prescribing their drugs only if they are effective and not overly expensive

-          Taking commission/cuts or gifts from pharmacies, labs etc. and prescribing their services only if they are effective and not overly expensive

-          Taking commission/cuts from other doctors and referring to them only if they are good and not overly expensive

-          Little bit inflating the bills for insurance companies (this is fraud against insurance companies)

Category 2: Here patient’s health is not affected but pocket is; sometimes this might result in inconvenience too. However, in practice most doctors do try to spare poor people (Some do feel that poor people should go to government hospitals/doctors if they can’t pay – a debatable topic, isn’t it?)

-          Prescribing costly drugs instead of cheaper and equally effective alternatives

-          Charging poor people extra when their treatment should be covered by some government scheme (In this case, sometimes patients voluntarily ask for better facilities and pay extra too)

-          Prescribing unnecessary diagnostic tests that are not really harmful to the patients

-          Hospitalizing patients early or discharging late without a strong need

Category 3: Here not only patient ends up paying more money, patient’s health and body is also compromised to some extent.

-          Subjecting patients to unnecessary diagnostic tests that may have small/big risks associated with it. For ex: multiple X-Rays

-          Prescribing costly and also inferior drugs

-          Prescribing unnecessary drugs or injections

Category 4: This is the worst case where patient not only has to cough up huge money but also go through lot of physical suffering, and perhaps face disability/death also.

-          Prescribing/Performing procedure/surgery instead of first trying well known treatments through drugs

-          Prescribing/Performing totally unnecessary procedure/surgery

So, when Aamir told MCI chief that numerous doctors would lose their license as per his research team, I am sure most of such doctors belong to category 1, and some will belong to category 2, even smaller number in category 3 and very few in category 4. But Aamir failed to make this distinction.

I wholeheartedly support taking strict actions against category 4 frauds. Frauds in other categories are best dealt with in milder fashion and systematically eradicated through long term planning and policy changes instead of targeting individual doctors.

-          Case of Mrs. Seema Rai’s death: I consider inclusion of this example as a “Media Negligence”. I am sorry for the loss of the family involved, but who is right and who is wrong – we cannot pass judgment here; arguments from both parties look very convincing for a common man.

Instead, the research team could have easily picked up a case where the case is settled and in favor of the patient. Now, many people’s concentration is simply on this case and not on the macro level picture. Unfortunately, this has hurt the original intent of the show.

-          Case of finger amputation: I am sorry to say, but this doesn’t look very convincing to me. If it was a case of fraud, would any doctor himself/herself tell the patient that the first operation was not necessary? Again, I believe it was a poor choice of case that the team picked up. Or it should have been presented better.

Or maybe its another doctor who made such a remark that original surgery was unnecessary. Such thing happens due to jealousy also and need not be an example of fraud. The case should have been investigated more seriously before presenting on TV.

-          State of affairs in government hospitals: Aamir should have highlighted the fraud happening in government institutions also. It is a well known fact that in many such places doctors take fees illegally or ask patients to come for private consultation later, free drugs are sold for money, budget allocated for various purposes are eaten up etc. (and the commission goes all the way up). Some RTI magic would have got his team some interesting data over there.

-          Fake drugs: I am ignorant about exact extent of this issue and related statistics, but I keep hearing that issue of fake drugs is also growing. Maybe the show could have covered something about this, along with the issue of generic drugs.

-          Interview with drug controller: It would have been great if someone from drug controlling authority also had attended the show and interviewed by Aamir. Lets remember that recently one more controversy had come up where some high profile doctors had endorsed some drugs without proper clinical trials.

-          Interview with private medical college owners: Aamir could have invited one of the private medical/dental college owners and asked some unsettling questions or could have showcased their efforts if they are not into fraudulent practices.

When government hasn’t setup a medical college to meet the demands, is it unethical if private parties try to setup a commercially viable education business? Which is better of the evils? Costly doctor or no doctor scenario?

If I am not wrong, recently in Karnataka private schools were strictly prohibited from taking donations – it would be interesting to see reasons behind it and how implementation is happening. Personally, I don’t find it wrong if a private school offers better facilities and charges higher. However, exactly when and where it creates social divides and long term problems is an interesting issue.

-          Commission/Cuts is not a simple issue: I am sure that the commission/cut culture is not a rampant practice. However, the show gives an impression that most doctors make huge money through such practices. I don’t agree with it.

Even if the practice does exist in some places, the percentages highlighted in the show are quite impractical for small towns and rural areas. In any case, this topic needs in depth analysis from practical angle:

o   Lets say in one area the commission/cut culture exists. Lets say one of the doctors decides not to take cut/commission from a private lab owner. Does it mean that lab will simply transfer the benefits to patients?

§  When other doctors continue to demand cut/commissions, the lab cannot decrease charge of a particular test only when it is  prescribed by one particular doctor. Such a thing is impractical.

§  Even if all the doctors agree not to take cut/commission, the lab owner still need not reduce the charge when his/her charges are comparable to many other towns/cities around

o   Lets say most doctors in a town are not taking cut/commission from pharmacies or labs. A new doctor comes and he demands commission from a lab. Why would lab oblige easily? If doctor tempts the lab through ‘basin tests’ proposal as explained in the show, doctor’s proposal might sound tempting. Otherwise, it wouldn’t be possible for lab to give commission to doctor.

o   Lets say most doctors in a particular town make Rs.100/- for a particular treatment; lets say that the money is a fair charge. But lets say that Rs.50/- comes through consultation charge and rest comes through commission from labs. Now, lets say a new doctor Dr.D comes to the town and he/she wishes to be honest. But Dr.D also wishes to make Rs.100/- for that treatment (remember? I said it is fair money) but doesn’t want to accept any commission from the lab. Dr. D will have to charge Rs.100/- to the patient and lab might not reduce their charges just for this one doctor. Eventually patient coughs up more money – can Dr.D sleep with clear conscience even though he/she did nothing wrong?

o   Overall, what I am saying is that the commission/cuts practice is not as bad it seems like, as long as practices don’t heavily belong to category 2 & 3. And most doctors feel that category 1 is not really a fraud – if Dr.Deviprasad Shetty was able to work out some economics, these doctors also have, I don’t see a big deal in that. Also, people who belong to category 2 & 3 conveniently put themselves in category 1 and it is very hard to prove it. Banning this is like banning alcohol, quite impractical. If deserving (meritorious and passionate) candidates get medical seats at cheaper price, then this problem will automatically get reduced.

-          Budget for healthcare: Just talking about increase of 1.4% to 6% of budget is not sufficient. Along with percentage wise comparison, absolute comparison is also important. Many drugs and equipment are from MNCs and cost pretty much same in western world and here, if I am not wrong. Hence, speaking absolute numbers and dividing by population is very important. Then we would get more clarity on what money India has and what level of service we can really expect.

Reasons for angry remarks from doctor community

Based on my observation, some doctors and associations got annoyed and angry about the show because of following main reasons:

-          True intent of the show was not understood by them properly

-          They felt some of the examples shown were not picked up correctly and that brought down value of the show

-          They felt annoyed with no differentiation between various degrees of fraud, when it is pretty much debatable whether some of the things should be or should not be termed as fraud under various challenging circumstances

-          They felt various problems they themselves face are not showcased

Regarding highlighting several challenges faced by doctors and hospitals themselves: There are numerous challenges with respect to quality and price of various products/services from others, attitude of patients and staff, issues due corrupt systems around etc. For more details you can refer to another article that I wrote recently: Challenges faced by Private Hospitals in Kerala

However, such difficult situations can only justify the following:

-          Unintentional mistakes

-          Lesser quality of services

-          Increased charges

-          And (unofficially) maybe perhaps negligence in some rare cases due to frustration/overwork

But the scope of this show was limited to fraud, and it is unreasonable to expect a detailed coverage of all the issues doctors and hospitals face, because none of these challenges should justify fraud anyway. I hope this makes sense.

Conclusion

Please don’t do the same mistake what I did – if you haven’t watched the entire episode end to end, I request you to kindly go through it and then comment.

Overall I found that Aamir showed utmost respect to the good doctors throughout the show; he treated the medical students also nicely and ensured that they left with lot of motivation. Even in his concluding remarks, Aamir clearly highlighted that there are numerous doctors who are practicing with very good intent and with patient welfare as highest priority, and he saluted such doctors.  However, some of the aspects of the show could have been better thought through, including the examples chosen.

On the other hand, I feel sad that some doctors and their associations chose to oppose the show and Aamir instead of gracefully approaching with more constructive thoughts to improve the situation. I certainly feel sad that IMA opposed the show and demanded apology.

Your comments/feedback/criticism are always welcome.

Disclaimer: Though I am not a healthcare providing professional myself, I am associated with and working in a private healthcare providing institute in Kasaragod, Kerala in many ways. The views expressed here are purely mine and do not reflect views of any other individual or firm.