February 23, 2020
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Hypocratic Practice

That seems to be the case with the Indian health sector. While most doctors toil nobly away, the rotten few erode a basic element: trust.

Hypocratic Practice
Hypocratic Practice
Eighteen-year-old Vikramjeet Rathore of Delhi died after being operated for a boil on his behind. Five months later, his family is still as baffled as bereaved: "How could qualified doctors kill a child doing such a minor surgery? And after they'd messed up, why did they transfer Vikram to a little-known private nursing home in faraway west Delhi where they declared him dead within hours, this when we were just 10 minutes away from big places like the All-India Institute of Medical Sciences and Safdarjung Hospital? How dare they explain away Vikram's death as no more than an allergic reaction to anaesthesia? Why were no tests done before the operation?" The bewildered questions, the tears, simply don't cease in the Rathore household. Just as business hasn't stopped at the unlicensed south Delhi-based Rahat Bhagat Nursing Home where the Rathores lost Vikramjeet on September 16, 2002.

Sure, December saw owner Dr Monica Bhagat presenting herself for the first round of hearings in the case that the Rathores have filed against her in the Delhi Medical Council. But barring such interludes, she seems to be gainfully occupied; Dr Bhagat was "busy in the operation theatre" when Outlook contacted her for her version. She didn't call back.

Doctors attending to Anuja Thakur at the Shivam Nursing Home in Patna's Kankarbagh locality, though, did come calling after her family questioned the necessity of the surgery performed on her last June. Anuja's uterus had been removed—without even informing Anuja or her family, let alone seeking their consent, this just the day after she had delivered her first child at the nursing home. "Shivam's owner, Dr Shanti Rai, his doctor son-in-law and 10 musclemen barged into Anuja's room," alleges father-in-law Rajendra Thakur, also a doctor. "How dare we doubt Dr Rai's wisdom, they shouted, and took to thrashing us, breaking my son's limbs. Plus, they took away our prescriptions. Dr Rai's inexperienced gynaecologist daughter-in-law had goofed up during the delivery, so they decided to remove the evidence, Anuja's uterus." The feud is currently in the court of the city's chief judicial magistrate.

But the defendant doctors, the Rais, are unwavering: "Anuja was suffering post-partum haemorrhage, excessive post-delivery bleeding, so we removed her uterus and saved her life..."

We have always believed, always known our doctors to be saviours. But do we know that every 11th Indian doctor has a malpractice case against him or her? This by the conservative calculations made by health activists. Do we know that health tops the list of India's most corrupt sectors? According to a 2001 Transparency International study, health providers grabbed 28 per cent of the bribes paid in the country, a huge Rs 7,578 crore. And do we know that even doctors, at least those with a finger on the pulse of the problem, have begun complaining of the lack of regulation in medical practice and education in India? Just last week, at a national conference of state medical councils held in Delhi, doctors publicly spoke of lacunae in registration laws that make escape easy for medics who malpractice, of novices from unrecognised institutions finding jobs easily and of doctors pushing drugs against patients' interests for bribes from pharma firms.

Enough evidence, one would think, for us to believe that many among our doctors are making mistakes. Mistakes that we have long, and largely unquestioningly, paid for: sometimes with our physical well-being, our limbs and lives and at most other times, with lots of money. But symptoms are that people want this malady cured. Wronged patients are increasingly taking their grievances against negligent doctors to courts and medical councils across the country. Looks like the Vulnerable Patient wants to be a Vigilant Customer.And has begun asking, with due apologies to the many doctors who work tirelessly at keeping us healthy: can our doctors be trusted?

"It would certainly help if we stopped treating doctors like gods to begin with, scared of asking, cross-questioning them, popping any pill they prescribe.... We shouldn't be anti-doctor but certainly anti-erring doctors and unafraid of reporting them," advises Moloy Ganguly of Calcutta-based People for Better Treatment (PBT). Counsel that many are already acting on: just over a year old, PBT gets hundreds of letters every month, with supporting documents, from people seeking legal help in cases they want to file against their doctors. Which doesn't surprise Dr Samiran Nundy, surgeon at Delhi's Gangaram Hospital and editor of the quarterly Issues in Medical Ethics. "There will be even more medical litigation in the coming times," he observes. "What with people accessing more information through the media, the Internet, in turn expecting more from doctors. And our doctors are being outstripped by advances in medicine." But defensive medicine, he fears, is bound to be the fallout of such litigation, "where, afraid of being caught on the wrong foot, the doctor may send a patient complaining of headache for expensive tests to rule out brain tumour".

At any rate, even now people rarely know why certain tests are performed on them and why some others aren't. A case in point is Delhi's Sonjoy Mitra. For 11 months now, he is tirelessly making rounds of media offices and the consumer court to prove his claim that his 70-year-old father, who died about a month after heart surgery at the capital's Apollo Hospital last March, wasn't tested to verify whether he'd be able to withstand the exhaustion of such a massive operation. "The doctor was in such a hurry to operate, like a child wanting a lollipop. Tests would have shown my father as inoperable," Mitra alleges. "So, the pre-operative report said my father had no history of asthma and when he did not recover after the surgery, the discharge report conveniently said he had bronchial asthma for 20 years." Mitra claims his father finally died after a dose of Restyl SR, a drug prescribed by the same doctor and one which Mitra says is never given to heart patients: "I have seen my father wheezing to death because doctors didn't care enough. I'll make them pay, then donate the money."

But even such closures aren't possible for some. Archana Saha, 42, of Calcutta, still suffers the consequences of a botched-up caesarean section she had seven years ago. She had gone into coma; expensive treatment over months that ruined her family financially saw Archana through, but barely. "She's like a newborn, speechless, she needs a 24-hour nurse, she cries when she's hungry or soiled," says husband Tapan Saha. He has lost once in the consumer court for being unable to produce medical witnesses but continues to be on the lookout for another lawyer.

However, Anwar Khan, a grain-seller in Bhopal, cannot afford a lawyer anymore; he has even sold his house to bear his 10-year-old son Arshad's medical expenses. In December 2001, Arshad was taken to the Jawaharlal Nehru Hospital after he fell from a tree. The injection administered in his waist triggered off a gasping bout and severe rashes. Horrified, Khan took the boy to a private nursing home but gangrene had set in Arshad's legs by then and both had to be amputated at the ankle.

"But medical malpractice is even more nasty than doctors making drastic errors of judgement about which injection, which drug to administer, or accidentally leaving a gauge in a patient's stomach," says Dr C.M. Gulhati, editor of monthly medical journal MIMS India.He draws up a long list of factors that aid and abet the crime of medical malpractice: a doctor's lack of knowledge, lack of continuing education in medicine, absence of a system of re-examining doctors to see if they have kept up with the progress in medicine, unethical practices like taking cuts from each other for cross-referring patients, over-treatment of patients to earn a heftier fee, drug misuse and overuse, acceptance of bribes from pharmaceutical companies to push their products. And importantly, the near-ineffectiveness of our 19 state medical councils and their umbrella organisation, the Medical Council of India (MCI), bodies which have the power to deregister doctors guilty of professional misconduct.

Here's an indication of the MCI's credibility. The Delhi High Court in a 2001 ruling labelled it "a den of corruption". MCI secretary Dr Meenu Sachdev refuses to comment on the tag, for it's a matter "sub judice". But she talks about everyone's desire to have doctors deregistered over trivial matters: "People come in with complaints like the doctor didn't ask me to sit, he wasn't available when I needed him, he overcharged me. You don't haggle with lawyers, do you? So why haggle with doctors? After all, medical professionals aren't sadhus, they need to maintain a lifestyle!" The MCI received 118 complaints against doctors between April 2001 and March 2002. Only four doctors were deregistered and we don't know for how long. Sixty-five complaints were referred to the state medical councils.

Where things aren't very different. Take the Tamil Nadu Medical Council (TNMC). Dysfunctional for almost 20 years, it got Dr C.M.K. Reddy as its head about two months ago. "We have already started receiving about four complaints a week," he says. "But I admit medical councils in most states are largely inactive and exist only on paper." In fact, when Outlook asked a senior doctor in a Chennai government hospital about TNMC, he neither knew of its powers, nor its address.

Mumbai-based Bhagwati Raheja, 64, goes as far as to say doctors prefer being tried in the medical councils over being taken to the courts. He should know. Raheja had a hard time finding a doctor who would give him a medical opinion when he wanted to file a case against three doctors of Nanavati Hospital, where his wife had a surgery he believes killed her less than a month later. When a doctor finally did agree to provide a medical opinion for a fee, he refused to sign it. But the Maharashtra Medical Council (mmc) wouldn't agree on anything less than a signed medical opinion as evidence. "Only those who want to be humiliated should go to our medical councils. You aren't allowed to cross-examine doctors, not allowed lawyers and are expected to argue the case yourself as a layman. You soon realise the interrogators are friends of the accused and, being co-professionals, they would rather protect each other than you," Raheja fumes.

P.C. Singhi, 74, also from Mumbai, did manage to get a favourable verdict from the mmc after a two-year-long inquiry in 1991. Yet, his struggle is far from over. Bombay Hospital's Dr Prafula B. Desai had insisted on operating upon Singhi's wife, a cancer patient, in December 1987, against the advice of all other doctors who'd treated her previously, including one from New York's Sloan Kettering Memorial Hospital. Singhi still shudders at the memory: "One of Desai's juniors had opened her up, found 'very bad conditions' inside, which was reported to Desai as he was stepping out of another operation theatre, upon which Desai ordered my wife to be stitched up without so much as once looking at her." She lived on for another two years to suffer the painful aftermath of the surgery, "screaming, crying in pain, cursing the doctor who'd caused her this misery.She made me promise that I would bring him to justice". Singhi has spent 14 years trying to live up to his pledge. It was only after the mmc found Desai guilty that a criminal case could be filed against him; a case that has since been in various courts, including the Supreme Court, with Desai, alleges Singhi, employing every stalling tactic in the book: "Since I too am a cancer patient, Dr Desai's waiting for me to die."

Anyway, the way it is framed, our law isn't too intimidating. Explains Bharat Jairaj, advocate with Chennai's Citizen Consumer and Civic Action Group, "Cases of negligent driving and medical negligence are both filed and examined under the provisions of the same law in India, Section 304A of the Indian Penal Code. According to this, causing the death of any person by doing any rash or negligent act not amounting to culpable homicide is punishable with up to two years of imprisonment, or with fine, or with both." But such maximum sentencing doesn't happen even in landmark pro-patient rulings like the one made by the Alipore court, Calcutta, in May 2002 in the Anuradha Saha case. Two of the three accused doctors held guilty of "negligent and inappropriate treatment" that caused Anuradha's death got away with sentences of no more than three months' imprisonment and Rs 3,000 fine. The loophole: bail at Rs 5,000 each, which kept them out of jail.

Frustrated with such insufficiencies in redressal mechanisms, patients have begun giving vent to their fury in most undesirable ways. Angry with the numerous medical negligence cases being reported in their state, people in Kerala took to violence. The Dhanalakshmi Hospital in Kannur was burnt down by mobs last May after 38-year-old Muraleedharan died after a piles surgery. Dr Jameela Beevi, gynaecologist at the Eranakulam government hospital, was mobbed for refusing to treat a poor woman for a lower fee; the crowd subjected her to a public trial and then garlanded her with slippers. Understandably, October 1, 2002, saw the Kerala chapter of the Indian Medical Association (IMA) organise the first ever strike by doctors protesting against unacceptable levels of harassment. Says Dr Govind Shenoy of IMA, Kerala, "There's no safety for doctors. People have to believe doctors never make any deliberate mistakes, just human errors."

Logic that Lucknow-based Rita Sharma, 38, won't buy. Her body's bloated, she's developed iodine imbalance and has lost control over her bladder, all after she underwent a surgery she doubts she even needed. She's taken her doctors to the consumer court and recalls how they had given neither her nor her family time to think: a quick ultra-sound, news of a tumour in her uterus and Rita was under the scalpel. "I was sent off to buy 'strings' for the stitches while she was being operated," remembers her husband G.C. Sharma. "The entire thing was such an unorganised and hurried affair." The surgery had cost the Sharmas Rs 15,000.

"Pushing people into operations that seem questionable, grabbing and soliciting business, aggressive public relation drives, over-treating for the sake of sustained payments—these have become an intrinsic part of private health set-ups now," says Amit Sengupta of Delhi Science Forum, "How else can huge investments needed for hi-tech equipment, swank clinics, cuts and commissions to be paid, find returns?" Considering 90 per cent of the ailments for which people visit doctors are self-limiting, "it's in the interest of the health industry to make us believe that modern medicine is a magic bullet and maybe even to keep us sick longer!"

Coded jargon categorises patients into two types in many private medical practices, reveal insiders: "Eco and Thera," Economic or Therapeutic for the uninitiated. So there are some patients who need to be treated, others to be made money on.But Arul Raj, president of the IMA, based in Tuticorin, Tamil Nadu, dismisses such allegations. People feel the pinch when it comes to paying up medical bills, he says, as health expenses are the only ones that aren't budgeted for: "Finances for groceries, even holidays are planned, not for sickness. Having said that, we admit there's a tremendous mismatch between patient expectations and services offered by us." So, the IMA has dedicated this, its platinum jubilee year, to "Doctor-Society Relationship": "To ensure doctors work at being trusted members of society again." Clearly, this will need significant effort.

Soma Wadhwa With Charubala Annuncio in Mumbai, Manjira Majumdar in Calcutta, Amarnath Tewary in Patna, Leela Menon in Kochi, K.S. Shaini in Bhopal and S. Anand in Chennai

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