A campaign against kickbacks
Giving kickbacks for referring patients for investigations has become a widespread disease. The practice took an epidemic turn with the setting up numerous CT and MRI scan centres. Doctors are canvassed to “extend the indications” for such investigations. In plain English this means doing the investigation when a less expensive one would do as well, or when it is not necessary. The result is that the patient ends up paying more for the investigation and also undergoes unnecessary investigations.
Recently, a non-governmental organisation in a suburb of Chennai published a list of centres in the area which were giving kickbacks. This galvanised the local office-bearers of the Indian Medical Association to call upon all doctors not to indulge in the practice. How effective this call will be is anybody’s guess. The concentration of doctors in urban areas has led to a situation where private practice no longer means an assured income and some doctors resort to all sorts of methods to earn money.
Sadly, even well-established doctors with large incomes are not immune. In fact, some of them own investigation centres which perpetuate the practice. The argument that they would not be able to survive otherwise is belied by the fact that there are numerous centres which do not give such kickbacks and yet are doing very well.
After a gap of about two years, the Madras Medical College harvested multiple organs from a brain-dead accident victim with his wife’s consent. One kidney was used in the hospital itself, another was given to a private hospital. The corneas were used in the Government Ophthalmic hospital. The liver could not be used and there were no takers for the heart. This illustrates that it is possible to get a cadaver transplant programme going if more effort is made. It is not uncommon to read obituaries with the note “eyes donated”. It does not seem such a long step from spreading the message of cornea donation to that of donation of other organs. A corporate hospital which has a very committed nephrologist has managed to do quite a few. The government hospitals which receive a large number of potential donors have not done as well. One important cause is the reluctance of neurologists to certify brain death. They are not inclined to put in the effort for an endeavour which does not directly benefit “their” department!
A recent report in the The Hindu spoke about the widespread graft at the level of the hospital attenders and ayahs in the Government Hospital for Women and Children. It is an open secret that this sort of fleecing of the poor (the only ones who use these hospitals) is rampant in all government hospitals. When asked, the doctor-administrators invariably plead helplessness saying that these staff (known as “class four employees”) have powerful political contacts and cannot be disciplined. However, the Superintendent of the hospital for chest diseases at Tambaram has shown what a lot of difference can be made by personal integrity , hard work and willingness to lead from above. This hospital is a model of discipline, cleanliness and patient care. A large number of patients with the Acquired Immunodeficiency Syndrome are managed here as this is one hospital which does not turn them away.
A report about the overflowing sewage in the Institute of Child Health emphasises the very poor sanitary conditions in most government hospitals. This is part of the general decline in these institutions which were once centres of excellence. With the growth of the corporate sector, politicians and powerful bureaucrats now no longer use government hospitals. Their interest in these institutions is now very little. A newspaper report will provoke some patchwork, but no long- term solutions or plans. Many of these hospitals now seem in terminal decline, yet they are full of the poor who have nowhere else to go. A few dedicated doctors and paramedical staff soldier on, but in general the morale is very low. Most doctors see government service only as a source of stable income till their private practice brings in enough money.
No longer is it a mark of distinction to be on the staff of a teaching hospital. The majority of medical students no longer consider a post in a teaching hospital a desirable career option. Many of those who opt for government service do so in order to get a seat in a post-graduate course since a large number of these seats are reserved for those in government service. The situation is especially bad in the super-speciality departments, where the practices lag far behind current standards of care due to lack of material and staff with the necessary skills. Patients with conditions that are eminently treatable languish for months in the wards.
No one wants to tell them that though the disease is treatable, the facilities are not available. In a situation right out of Orwell, no one is supposed to turn any patient away, everything is supposed to be available in the teaching hospitals, so no one can tell the patient that it is not. Well-meaning doctors who have written prescriptions for material or medicines to be bought outside because they are not available in the hospital have been taken to task. Meanwhile, the poor patients just wait and wait in the hope, mostly futile, that something will be done for them.