SATYAMEV JAYATE AND HEALTHCARE

In his latest episode of Satyam jayate Aamir Khan raised the issue of healthcare management and related issues.

The first issue was of unwarranted and improper surgery. There was a time when doctors were deemed Gods. Then came the Consumer protection Act and a whole lot of bitterness crept in. The legal system forced doctors to understand ‘acts of omission’ (not doing what needed to be done) and ‘acts of commission’ (doing wrongly what was done).It was emphasized that acts of omission were more easily upheld, and hence more punishable. I believe that is why the swing was towards avoiding being sued for not doing the needed, resulting in a surge of investigations and aggressive management, even surgery. This is not purported as justification, just my cause and effect analysis. Take it or leave it.

Then there was the issue of unwarranted hysterectomies. There can be no justification for this whatsoever, but here is another scenario. Increasingly, would be parents and expectant mothers are desiring their babies birth as per astrological signs and times. A lot of obstetricians are facing pressure to do Caesarian sections a la carte. Some succumb to the pressure, some don’t (I hope).A great peer pressure is “If I don’t do it, someone else will’. No justification this, but nevertheless very real.

Come the issue of the Medical Council and medical colleges.

The quest to become a doctor has not diminished, albeit it has grown manifold. Why is a different issue! With this growing quest has come the proposition and reality of diminishing number of seats in State medical schools. The reasons are all too obvious, but that is not the subject of this manuscript. What resulted was the mushrooming of a host of private medical schools, where seats could be had sans the hard work and merit, through the backdoor may be, all for a price, and there were hordes of parents willing to shell out any amount so that their wards could ‘carry on the tradition’ or ‘follow in the footsteps’. The sums in vogue are 50-60 lakhs for undergraduate courses and a core and a half for postgraduation in specialties like Orthopaedics. Is it illogical to assume that these sums have to be recovered? No one, not even someone who is not a businessman, can perceive making dead investments of such magnitude. Money has to be recovered. Try and conjecture how. That is where it all begins, where Mr. Hyde takes birth. Who is to blame? “I put it to you, and I leave it to you.

Inspections in medical colleges are a regulatory mechanism, but the MCI inspectors are just as much a part of the present Indian polity. As the famous dialogue of Hindi films goes”Har aadmi bikau hai, agar keemat sahi hai”. Every deed and everyman has a price. No surprises you have a plethora of medical colleges with poor and inadequate infrastructure, inadequate facilities, inflated statistics and unjustifiable admissions through management quota and admission test conducted by their own Universities. So it all goes on. Does Dr Talwar, Chairman of the Board of Governors know about it? I think not, but maybe you think otherwise.

ON THE PRESCRIPTION OF GENERIC MEDICINES

If I am a doctor, I have to prescribe medicines. It is my professional right. As a doctor, it is my duty to write what I consider, to the best of my knowledge and my experience, the best medicines for the patient’s ailment. It is my onus and duty, my obligation and responsibility to try and cure the patient with drugs at my command. It is also binding on me that I shall “do no harm”.

There are umpteen number of drug companies manufacturing drugs. Assuming that all multinational companies manufacture high quality drugs, there is still a plethora of similar drugs in the market. Give me one reason why I should prescribe one reputed company’s drug over another, all criterion being equal. Because they send me regular multicolored brochures? Because their representatives regularly call upon me and encroach on my time to remind me of products which I remember anyway? Or because they leave my table loaded with free samples I don’t need, and have a hard time giving them way because my patients don’t need them either? The ‘Mr. Hydes’ among the doctors have a very plausible and acceptable reason. Because that particular company gives him gifts, or may be takes him to conferences to brush up his professional knowledge and skill. You will find any number who will cry foul at this, but look around, search and tell me of one profession where this is not rampant in some form or the other.

There are well nigh close to 20,000 companies, big and small that manufacture drugs. They are all licensed by the Drug Controller of India, as producing ethical and quality drugs as per the Pharmacopeias. The fact is that actual manufacturers of the generic salt of the drugs are very few, 1333 to be precise, as this requires a large facility for manufacturing from the raw material, and a quality control assessment laboratory to boot. The generic drug manufacturers then sell their products to other smaller manufacturers who merely capsule or bottle them, and sell it under their brand name. In other words most of these drug companies with small turnovers are really packaging units marketing drugs bulk produced by others. Then how come they are able to sell their products cheaper than the generic manufacturers themselves? For one, there is the question of overheads, be it advertising, research and development costs etc., etc., for the bulk producers. Second they prefer to keep their margin of profits higher. The smaller units prefer lower profit margins, but high turnovers. The second factor is the milkman phenomenon. Let me explain. The doodhwala rarely, if ever, brings you pure unadulterated milk. (If he does, it is at an exorbitant price compared to the market rate.) To keep his prices low, he adds water to milk. (Sometimes he adds milk to water, if he craves for even bigger profits.) This increases his bulk quantity and also allows him to lower the cost. The more the water, larger is the volume for distribution and much lower the price, but a far greater turnover and hence far greater profits. Translate this scenario to the pharmaceutical companies and you have a pretty good idea of how the marketing goes. These smaller units have no hesitancy in offering ‘cuts’ to the prescribers and when you envisage that for every ‘Dr. Jekyll’ there are more than an equal number of ‘Mr. Hyde ‘you really have a panoramic picture. To rob Mr. Hyde of his ‘legitimate cut’, there comes the hue and cry to force the doctors to prescribe only generic drugs. Fair enough, but when a generic prescription goes out in the market, who dispenses the company brand? The chemist, and remember he is a trader, a businessman. Mr. Hyde may be discreet sometime, but the chemist will ALWAYS give the brand with the maximum profit margin. Trusting him to do otherwise is like trusting Shylock, of Shakespeare’s Merchant of Venice, to dispense with his pound of flesh. So which will it be- Scylla or Charybdis, the devil or the deep sea? You decide Aamir, for this is the way the cookie crumbles.