All doctors qualified to practice modern medicine take the classical Hippocratic Oath before beginning their professional career. The idealistic values learned during the period of training get shaken up when the doctor steps out from a world of ‘practice of medicine’ to one of ‘medical practice’. Here he sees ‘practical’ adjustments that he is required to make in his clinical and therapeutic decisions and encounters open offers of referral of patients for a predetermined and regularised practice of fee-sharing (‘cut practice’). Since the schedule of charges for professional services is totally individualistic, the illegal and unaccounted fees to be given to the referring doctor usually get added on to the specialist’s fees and are paid unknowingly by the patient.
How ethical is this practice? The subject is debated by doctors in social and academic get-togethers but a status quo has persisted with some doctors for and some against it.
Cut practice occurs in many forms. I list some of them:
If one reads the Hippocratic Oath carefully, there is no condemnation of the act of sharing one’s fees with another doctor involved in the care of a particular patient. It is only by implication that the Oath stipulates that a doctor shall charge a reasonable fee and will not increase it for sharing it in order to obtain a larger number of referrals.
Every doctor determines his/her professional fees on the basis of experience, wisdom and self-perception of the level of skills required for a particular treatment. Fees thus vary widely from doctor to doctor. Hence a particular amount cannot be termed ‘unreasonable’ as long as the patient is aware of the sum to be paid before the service is rendered. What the treating doctor does with the fee after it is received by him is entirely and solely his concern and the patient or any other person has no say in it. Hence if a doctor decides to give a portion of his fees to another person (medical or nonmedical) it is entirely legal and ethical to do so provided this is done openly and after obtaining a receipt.
However such disbursements occur only in theory. In actual practice the referral pattern is based more on the fact that a particular doctor is ready to split his fees rather than that he is the best qualified to render a particular treatment. Several malpractices accompany such referrals. The limitations and scope of a particular procedure are not fully explained in advance. Patients are admitted to a hospital or nursing home in spite of the fact that the place is not adequately equipped to impart a standard of medical care available at another place in the area. Patients are referred to manifestly substandard laboratories. Reports from such laboratories are tnanipulated to suit the requirements of the referring physician.
Various specialised procedures – such as endoscopy, angiography, angioplasty – form lucrative sources of income and are therefore frequently advised even when the stated indications are not scientifically valid. (At times it is difficult for a doctor to say that the procedure advised by another was not required because on most such issues, opinions published in the medical literature support both points of view. There is truly no substitute for one’s own competence and conscience acting as an internal judge and counsel.)
Pernicious as it is, cut practice has come to stay. The medical profession itself has nurtured it. Indiscriminate proliferation of medical colleges with open and shameless support of those in power is adding hundreds of inadequately trained medical graduates every year to the pool of practicing doctors. A large majority of these are concentrated in urban areas with attendant intense competition and battle for survival which favour cut practice.
In the absence of a clear, logical, bold and community oriented health care policy on the part of the government and a lobby of strong, honest, clear thinkers representing the medical profession in the corridors of power, the present situation is unlikely to change in the near future.