Before birth and even after death, the medical profession remains indispensible to human beings. Pregnancy to death certificate, society needs doctors. Routine health check- up or Illness, both require medical attention. Vaccination of new born to all age group needs helping hands of doctors. Poor and rich cannot escape from the services of the medical profession. No other profession covers such a wide spectrum of services to human life and all strata of the society.
Let us see the evolution of the medical profession. How the profession and services of Yesterday, Today and Tomorrow has influenced YOU and US.
In the last 65 years, medical knowledge and advances have increased by leaps and bounds. Medical profession originally had five specialities – GRASP – Gynaecology, Radiology, Anaesthesia, Surgery and Physicians. With the research and advances, other branches were developed like Paediatrician, Orthopaedic, ENT, Ophthalmology. Advances never came to a halt. System or organ specialisation started. Heart (Cardiology), Kidney (Nephrology), Brain, Alimentary system (Gastrology), etc. Once the branch develops to an extent, surgical advances in these branches also kept up the pace, so we have a Cardiac surgeon, Genito-Urinary surgeon, Neuro surgeon, Gastro and Colon surgeon and so on. Research is mounting at 20 ft. of written volumes per day from the experience, exchange of views, mistakes, complications of the disease, experiments on animals and trial on human beings. All this knowledge has resulted into new branches raising their heads. Doctors have now started specialising in diseases like Diabetes, Thyroid, Aids, Sexually Transmitted Diseases (STD), Infectious diseases, TB, Leprosy, Allergy, Immunology, etc. After system, organ and disease, symptom speciality raised its head. Vertigo, Asthma, Deafness, Obesity, baldness, and unthinkable speciality 50-65 years before like Hair & Scalp, Nail, Veins, Cosmetology and cosmetic surgery, etc. Humans by nature are ambitious, greedy and always looking for new ways to earn. Advances have spread in all the specialities and corresponding Paediatric and infant counterparts of the speciality not only came into existence but are recognised and university degrees are created. Sub-branches in paediatrics have developed into recognised speciality. To name a few, we have paediatric cardiology and surgery, Paediatric neurology and surgery, Paediatric ENT, Ophthalmology, etc. Ooph. Today, we have Red Blood Cell and White Blood Cell specialists. From GRASP during pre and immediate post independence period, fist has opened. The profession has developed into 300 specialities. BUT…What has happened with all these advances? It is not the system or organ that was snatched, but the living human being got divided and dissected.
Knowledge of each specialist and super specialist became restricted to his own field. As a practicing ENT specialist, my knowledge of dermatology and opthalmology shrunk to an extent that I am afraid of diagnosing a simple ailment of another speciality. So is the plight of all other specialists. We have become Kupmanduk (Frog in the well – person with limited vision).
Every family needs a doctor for routine health chores viz: Routine medicine, taking the appointment of a consultant, accompanying him to the specialist, following the patient’s health, home visits, etc. During pre-independence and till about two decades ago, this routine service provider was called Family Doctor, who not only knew the patient but his entire family, even the healthier ones, knew the family’s health, financial status and even social history. He was not only a doctor but a friend, philosopher and guide. But the advances have gradually taken the toll on this relation. Now, this poor fellow has to cope up with 300 specialities. Let all these advances go at the speed of a Formula 1 Race, a General Practitioner still deals with 300 specialities. His knowledge goes on shrinking and now the time has come that he has become a referral ‘clerk’. He does not like to take risk. It has reduced the family doctor to ‘General Practitioner’ dealing with routine chorus and often labelled as unlikable word – referring practitioner. Specialist can be a Kupmanduk, but he cannot. He cannot specialise into upper half and lower half or right side or left side of the body. Recent government directive that every doctor must attend CME (Continuous Medical Education) programme to get 12 credit hours in a year to renew the practicing licence. Well! the idea is good, but the outcome is wanting.
At the end of 5 ½ years when he receives the degree, he realises that what he has learned is the hospital based medicine, which is of no use to him in general practice. He has seen the patients in the hospital that he is not going to treat, seen the gadgets which he is never going to operate and attended the operation which he is never going to perform. He has never seen patients with early symptoms, approach during home visits, tackling the emergency and psychology of patients. How will he get that? Experimenting on patients? No wonder, for all professionals, the word coined is ‘Practicing’.
Proliferation of medical speciality has spread its tentacles to the supporting industry viz, instruments, gadgets, medicines, etc. Supporting services like nursing, social workers, physiotherapy, etc. cannot lag behind. So? The specialisation has started in these services. Large metropolitan cities which cater not only to the city crowd but also from town and even from abroad has to keep pace with these advances. 75 bed hospital 60 years ago, has been reduced to small nursing home with basic facilities. I know that Rs. 100 crore was big budget for a ‘large’ hospital 50 years ago. Today, a multi-speciality big hospital would cost at least Rs. 1,000 crore. This is TODAY.
Today, any philanthropist desiring to do charitable service perhaps first thinks of starting a charitable clinic which would cater to patients at nominal charges, giving only 50 % of those charges to the attending consultants. Junior consultants also try their hand at such charitable institutions till they develop their own practice. Management of such clinics or hospitals exploit, dictate, bring undue pressure on the working of the doctors for their noble mission. Bigger the institution, greater is the exploitation of doctors and patients. Doctors are keen to mention on their business cards that they are ‘Honorary’ at such hospital with five star set-up and succumb to the dictats of the management. In such institutions,certain amount of revenue should be brought in the coffers. A blind eye is turned to the various complaints forwarded by fleeced patients. If a doctor cannot bring the desired amount in the kitty, overnight he is dismissed. There is no labour law applicable. There is no union. Higher the professional set up, lower is the chance of unity. If one is thrown out, another is already in the wings to replace him. It is the survival of the fittest.
I would like to give only one classic example – a well known heart surgeon openly tells the patients that he will charge a few lakh of rupees in cash over and above the charges fixed for the bypass surgery by the hospital. Either you get your heart repaired or go elsewhere. Hospital is well aware of this menace, but turns a blind eye and becomes deaf because he fills up their ‘Heart’. In fact, these hospitals do market survey to find out which doctors can fill their coffers. Today, specialists in large hospitals feel they do the work but hospitals are earning more out of his work. A doctor gets only 15 % of the total bill of the patients.
Amount invested in constructing and developing a hospital, purchasing new gadgets, discarding old ones due to advances need to be compensated by consultants of the institution (don’t ask how). Name of the philanthropist and the institution is perpetuated in golden letters in the history. Government audit on health care is patchy. Audit cannot afford to displease multi-millionaire philanthropist. They may need that hospital.
Specialists like to remain in the rat race. They go abroad to keep pace with advances but when they come back they have to convince the hos-pital management to implement what they have learned. A group of experts have to convince a group of businessmen. Only consideration for these businessmen for ‘importing’ advances is, it will it generate revenue; benefit to patients is irrelevant. Here the salesmanship and art of communication of the specialists will help to convince the management. One who sells becomes ‘Eminent’. One who cannot remains frustrated. For every specialist of a big hospital, there are at least ten who do not have the modern infrastructure. Year after year, this ratio is increasing.
Our Netas go abroad for surgery or call foreign experts. They go abroad for some undisclosed illness. Our Indian specialist experts then become stand by, onlooker, accompanying like luggage. They come back home, boast and cater to the common man. They write on their letter-heads jumble of alphabets indicating degrees and also do not forget to check proof which mentions honorary to the President, governor, Padma award, etc. Patients fall in trap of such cargo doctors. Some rich people go to such eminent doctors so they can boast in their high society group.
The road of frustration is unending. Milestones appear at regular intervals. Cutthroat competition and politics in hospitals make specialists regret taking up the medical profession. Well decorated consulting room, stationeries will attract five star patients and not knowledge and skill. He knows that money brings money. He knows that Reserve Bank’s coloured paper will bring status to him. Status brings more money. Those who left the glamour of big cities and left for smaller cities and towns not only prospered but also made a niche in the society and became known in the entire city.
Each specialist acquires knowledge and then tries to establish his sub-speciality. He will arrange lectures, seminars and conferences till he is recognised. From where is he going to get money? It is said that never consult a doctor when he is going abroad, buying a new car, renovating his clinic, purchasing flat or his progeny is getting married. He needs money and is searching for the source. We usually go by the services available in bigger cities but Government statistics are an eye opener. There is short fall of 76% doctors, 88% of specialists, 53 % of nurses and 80% of medical technicians on all India basis.
The menace of exploitation commences after one becomes a doctor. Capitation fees for admission to medical college, post graduate seat, hospital attachment runs into lakhs and at times exceeds a crore. A doctor is bound to recover this ‘ investment’ – sooner the better. Malpractice is a cheap word for recovering the investments – split practice, unnecessary investigations, prolonged hospitalisation, gifts from pharma companies, etc. One need not be brainy to search avenues of recovery. This investment was not there Yesterday. Examiners of medical examinations are bestowed with roll number of quite a few candidates of influential origin to show leniency and pass.
For an average doctor without ready ‘Gaddi’ life begins at 40 for a life span of 65 years. Yesterday, we had the option of selecting medicine, engineering and commerce. Today, generation is reluctant to take up medical profession. Many other professions are offering lucrative career and scope for creativity. Today’s generation does not wish to toil for half their life. They don’t crave for prefix ‘Dr.’ before their name. Non- medico girls do not prefer medico husbands. They want fixed hours of work for husband – evening free to spend time together with spouse, eat timely dinner, have family life with children, no night calls and boring doctors’ party. They don’t want a daily wage earner.
Choice of students will shift from medicine to other technical courses, MBA, computer engineering, jobs are available once they get the degree. Their earnings start during their young age. Medical profession is likely to become a hereditary profession. Paradoxically, India’s population is steadily increasing. Poverty and illnesses are also keeping pace with that. Geriatric population is rising as average life span has increased and so also has age related disorders. Stress has invaded all age groups. Need of doctors can never reduce. Every doctor will have a slice of the pie.
New large hospitals will be set up not by any philanthropists but by corporates. Money resources will be channelised into money spinning specialities like cardialogy, neurology, and orthopaedics which are capable of feeding pathology, radiology, anaesthesiology, hospital beds, and operation theatres. Other specialities are likely to get step motherly treatment. GRASP will be replaced. Button-hole surgery will replace exploratory surgery. Robotic surgery will partially replace human skill.
Consulting charges are steadily rising. At present juniors charge around Rs. 500 whereas seniors and super-specialists are satisfied with Rs. 1000 to Rs. 2500 in metropolitan cities like Mumbai.
Hospitalisation is expensive. Even Municipal Corporation and Government hospitals are beyond the means of people of lower income strata to whom these are supposed to be catering to. Angiography and then Angioplasty costs Rs. 47,000 over and above each stent costs Rs. 15,000. By-pass surgery costs Rs.1,05,000. No service is free. The future will become prohibitive even for middle class. Poor and middle class will be compelled to go to either substandard municipal or government hospitals. High cost of in-house medical services in hospitals will downgrade the preference of upper middle class in selection of hospital and type of room. Five star hospitals will be restricted to people from glamour world, corporate, netas or in dial emergency.
Cost of setting up a hospital will sky rocket. Medical insurance with maximum coverage will be a MUST for every individual. As such cashless hospitalisation is accepted by few hospitals. Experience is that insurance companies do not compensate even the legitimate treatment and hospital bill. Medico-legal cases of negligence of the doctors are on the rise in metropolitan cities. Doctors will not be considered as God.
There is silver lining for Chartered Accountants when medical specialities proliferate. Today with mountain of taxation and amendments coming before the budget, during the budget and any time between the budgets not only as per the need but also politically decided. Speciality has also creeped in CA’s profession. Income Tax, Wealth Tax, Sales Tax, VAT, Excise, Import duty, Export duty, Professional Tax, Service Tax, etc. With the volumes of laws and amendments, doctors are unable to keep track of all this. They turn their head towards CA who in tandem with doctors will take care of their financial health.
Medical profession is too personalised. Faith unlike love does not develop at first sight. Doctor is a daily wage earner. The day he does not work, his income is zero unlike a CA. CA’s staff continues to work on the assigned load. He continues to earn even in his absence and the daily wage earner doctors will continue to feed him. We prosper so you will also prosper.
