Dr Sanjeev Gupta returned to the UK because he found the practice of medicine in India professionally unsatisfying, ethically problematic and financially unrewarding. His experiences will evoke empathy and perhaps deja vu among many medical professionals in India. Let us look at each of these areas.

Professional satisfaction

Dr Gupta found medical practice in India unscientific. Generally speaking, there was little evidence-based practice; specifically there was a misuse of antibiotics and an overuse of investigations. Although many doctors paid lip service to scientific principles, they did not practise them. Dr Gupta tried discussions; they did not work. There is no doubt that his experience mirrors the reality. In India, there are no protocols for antibiotic usage, investigations or the indications for surgery. Here and there, some hospitals and individuals do have such protocols, but these are the exceptions, not the rule. In short, there are no systems. While doctors in countries that have set up such systems sometimes complain of over-regulation, it is generally accepted that such systems have ensured better outcomes for patients.

In the Indian ‘medical bazaar’, the patient has no guidance system. The media is full of glowing reports of this or that hospital (mostly private), doing this or that procedure. Most of these procedures are routinely done abroad and within the competence of a large number of practitioners in India. The procedures are usually uncommon only because they are expensive. In the absence of good quality information, the public is led to believe that the expensive treatment being touted is the ‘best’. There is hardly any information on the appropriate indications or the problems that can arise. Unfortunately, people of doubtful integrity often dominate the professional bodies that should be involved in evolving protocols. Nearly all professional bodies are used as another medium to advertise the medical glitterati. We, the medical professionals, should force these bodies to evolve guidelines. The public, through various self-help groups, should demand the same. This great change in medical practice in India will not come on its own. Individual doctors talking to colleagues, as Dr Gupta did, will help, but this is not enough.

Ethical problems

The problem of practising ethical medicine in India is closely linked to the lack of professionalism and systems. Many of the problems that Dr Gupta enumerates, such as taking cuts for referrals, not being open about the cost of treatment, misleading the patient about the appropriate treatment, etc., are blatantly wrong. They are possible because of the absence of a system. Since patients have no method except hearsay, to choose between different doctors, they are vulnerable to exploitation. Unless we set up a system of area-wise demarcation for general practitioners, a referral system and regular audits of practice, such unethical practices are likely to continue. It is ironic that way back in 1946, Joseph Bhore suggested such a system. Many governments have paid lip service to it, but vested interests have successfully sabotaged its implementation.

Financial rewards

Many doctors in India struggle to make ends meet at the beginning of their careers. Those who have read A J Cronin’s accounts of medicine in the UK in the early part of the 20th century will find parallels with the present situation in India. Perhaps financial difficulties push the young doctor into unethical practices.

Questions

Is it impossible to practise ethical medicine in India? Are all doctors in India unethical and unprofessional? The answer to both questions is an emphatic no. There are many thoroughly professional and ethical doctors. It is difficult but not impossible to practise scientifically sound and ethically irreproachable medicine in India. However, this usually involves sacrifices. Most doctors, for whom science and ethics are paramount, sacrifice professional advancement and financial reward. They are found everywhere: in low-profile general practices, trust hospitals and the state-run medical system. However, these niches can be a sort of solution for the individual doctor. They are certainly not the solution to the systemic problems of medical care in India.

One last issue remains: Should Dr Gupta have remained in India? The decision to live and work in a particular place is complex and highly personal. For those fortunate enough to have a choice in the matter, it is obvious that they will choose the place where they are comfortable. Dr Gupta is troubled by his decision to return to the UK. He seems to consider it a betrayal of his motherland. Here I think he has confused a lot of issues. He talks of his admiration for freedom fighters Bhagat Singh and Khudiram Bose and their readiness to die to achieve the independence of India. He feels that returning to work in India is a present-day equivalent. I feel that the two situations are in no way similar. Love of any kind, including that for one’s country, does not exist in a vacuum. The struggle for the freedom of India was rooted in the personal oppression that all Indians faced in greater or smaller measure. The struggle for freedom was also a struggle for individual freedom. It was based on the understanding that no Indian could be a full citizen of India, let alone of the world, unless the country was free. In this extreme situation some exceptional people were willing to make exceptional sacrifices.

Dr Gupta’s situation is different. It is not obvious that the country has a pressing need for specialists like him. In fact, in the urban areas, there is already a surplus of specialists. In the remote parts of India, where they are in short supply, there are probably no facilities to practise the kind of medicine that Dr Gupta is accustomed to. He returned to India out of a vague and romantic desire to ‘serve the country’. It is not surprising that he was easily disappointed when the country did not make this ‘service’ easy! In the absence of any special need for his services he felt neither wanted nor appreciated. In addition, the financial rewards were meagre. In such a situation, the life he had left in the UK must have seemed good indeed and it is not surprising that he returned.

The desire to contribute to one’s native land is noble. Those who undergo extreme hardship to serve their fellow citizens definitely deserve praise and appreciation. However, if one does not have the stomach for this kind of sacrifice, there is no need to feel guilty. It is far better to serve people gladly in a place of one’s choice than to be constantly unhappy.

Nowadays, a kind of pseudonationalism seems to be popular among expatriate Indians. Usually it takes the easy path of financial support for regressive practices and political parties in India, under the guise of supporting ‘traditions’, ‘Indian values’ and the like. Few people have the capacity to forsake a comfortable life in the service of their fellow citizens. Dr Gupta has provided a graphic description of what a medical practitioner returning to India is likely to face. Working for change is never easy.