Why do Indian doctors refuse to work in villages?

This post was originally an answer in Quora for the same question

This is often a derisive topic among the general public, the politicians and the doctors. I also feel that people talk and pontificate without knowing ground realities. People expect altruistic qualities from their other countrymen while they sit and criticize everyone including doctors. So for those willing to understand what the issue is here are a few reasons why doctors are refusing to work in rural areas.

Infrastructure
The government hospitals in big cities like Bangalore, Kolkata, Mumbai, Delhi, Chennai, etc themselves are not the among the best in infrastructure. Even the basic infrastructure already present is poorly maintained. Most days in a month the CT & MRI scanners are not working. This is more like a rule than the exception.  So too the instruments, microscopes, endoscopes, cautery machines and expensive diagnostic equipments suffer from the same fate. If for some reason something stops working, then it wont be fixed till the end of the year or sometimes never at all. This is the story in big cities. So expecting any kind of infrastructure in a rural set up in India is like day dreaming. 
There are hardly any drugs that are supplied to the Primary Health Centers (PHCs). At the most you would get one huge carton of Paracetamol and a 5 cartons of Diclofenac injections (painkiller) and 10 cartons of Sterile water injections (yes water!) and many more cartons of syringes to inject these. These are highly inadequate to run any kind of village health program. When antibiotics are required, even when the patient can afford (rarely) to buy there is not a medical shop for the next 20-30kms (the nearest town). How would a doctor who has put in so many years getting a medical degree feel in this situation when he can't even treat the people around him. When people do not get better how will they trust him/her? 
Some people would say why not refer? I worked in some villages 20kms from Mysore during my rural postings during internship. When we want to refer, the patient doesn't even have money to take a bus to the city. We would sometimes have to pay from our own pocket or even take them ourselves to ensure they go. If a patient with a simple throat infection has to be referred to the city for treatment it shows the dismal state of our rural healthcare. Imagine the plight of that helpless doctor in these circumstances.

Personnel
The recruitment for the PHCs is from the state public service commission (PSC). In Karnataka, one of the more prosperous states in India more than 50% of the slots remain vacant. Why do you think? The corrupt officials running the KPSC always recruit less even when enough applicants are present since keeping the demand high is very good business for them. The going rate of bribe in Karnataka for a PHC doctor's job right now is around 1.5-2 lakhs. The job has a listed salary of Rs. 30,000 - 42,000 pm! Many of the applicants are recruited on an ad-hoc basis streching from 6 months to 2 years and then the whole process starts again. Giving permanent jobs reduces the officials' black revenue.

Now we have one politician who wants to win the next election. Who can he target? Oh the new medical students graduating out of medical colleges!!! Give some speeches of doctors only making money in cities and not serving the poor, put in some fines, threaten their PG seats and the job is done. If not the media does the rest. After a year of this forced labour where the doctor is given no agenda nor help to set up anything in a village,  he's just kicked out in the open. If that student really wants to serve the villages for a few more years he has to put in all the efforts I mentioned in the previous paragraph. Will any sane man do this? I fail to understand who is benefiting from this futile exercise?

Then comes the specialists and superspecialists who are posted in the peripheral community health centers without even basic infrastructure or even a semblance of an OT. You won't get gloves, linen, sterile instruments or even clean bed in these hospitals. My oncologist friend served his 3 year govt bond after his post graduation in a remote village in Tamil Nadu. He spent everyday of those 3 years referring patients to the city, most of whom never reached there. Forget chemotherapy and radiation the medical college he served in did not even have pharmacy to buy drugs. My Orthopaedic (bone) surgeon friend served a year in a community health center doing everything from delivering babies to making house to house visits of every panchayat leader in the villages around. There were no mid-wives even. He hardly fixed a bone the whole year because there was not even material for the cast. He could not even buy it himself because his salary never came and he quit after a year. How is this stupidity helping improve rural health? Is this the best use of the specialist's expertise?

Administration
I have many of my friends working in PHCs. There is a huge hierarchy in the government medical service where too many people in the middle are hardly working. The doctor assigned responsibility of a PHC is not given autonomous control over the running of the same. 50% of his/her time is spent in CYA* in the administration rigmarole set up by their superiors to escape blame for anything wrong that happens. Rest of it is spent in seeing patients, managing lower level staff, putting up with all kinds of nonsense from the villagers, inspecting the whole village for any risks of Dengue, malaria, gastroenteritis etc. and of course getting frustrated at the system. Even the staff under him is not under his control. He cannot even fire the group D staff of the PHC he is supposed to be heading. There is so much administrative burden on this one single man and he's not even trained to do that. He just has to jump into this dirty puddle and learn to swim by himself. All he really wanted to do was help treat people in the rural areas.
*CYA- cover your ass

No scope of progress
There is no clear career trajectory for a doctor working in a rural area. They may get some reservation in the PG entrance exams but if you continue to do primary health care in the villages you don't go up the ladder at no time during your job. You will keep doing the same job at 60 what you were doing at 25. There is no mentor, forget that- not even someone bothered whether you are progressing. How would you feel to be an intern throughout your life?

Security
Forget it. I won't even speak about it. We can't seem to protect the doctors in the cities how will we even think of those poor village doctors?

Pay
I put this in last, lest people would comment how inconsiderate thinking about paying a doctor. I don't have an issue with the salaries posted but I am bothered by how they pay. 
Let me give you an example to explain. Four friends of mine are serving in PHCs in very remote villages where no doctor wants to go. They are working there because it is closer to their home. They haven't received their salaries since 6 months!!! They have a protest about this for one day and the media vultures eat them up. I know people expect doctors to be so altruistic that they should work for free but which job in the world gets done if you don't pay people for 6 months at a stretch? 
You demand why this happens and they say this minister has to release the funds and that official has to sign the papers, so it takes time. 
So how do govt employees like Bus conductors, Bus drivers, bank officials, group D and other govt officials like IAS, IPS, IFS get their salaries on the 25th of every month without this "inevitable delay" ? 
Because if you don't pay these people on time they won't turn up to work next day. Simple as that.

I'm sure there will be people disagreeing with everything that I've said above and then go on to complain about the rampant corruption among doctors, commissions they receive and sub-standard care of someone they knew. There are many people in India who are like an ostrich with it's head in the sand and thinking everything is all right. They expect solutions to fall from the sky. If they can blame it on someone else their job is done. But I would like someone to suggest how anyone would be able to improve the situation in rural areas without putting the onus on unpaid, ill-treated and frustrated doctors. 

Can someone suggest a good enough solution? 

"OMG!!! How can they ask that?"

How should a medical student use his Internship?

I got asked this question on Quora

How do i make best use of internship during MBBS in India?

It got me thinking as to what internship meant to me. I finished my internship nearly 7 years back so maybe now I have better perspective on what it meant back then. I answered and I thought it would be a good idea to share it here as well.

How should you spend your internship?
Most of my seniors said study hard for your entrance exams since its so hard to crack them. I'm sure most interns would study anyway as a default. I wouldn't stress on that aspect.

I would say use your internship to prioritize your career goals.

What do you want to be?
Sometimes this question is asked too late in a medical student's life.

To prioritize your medical career you need to use your internship as career sampling. 

More than knowing what to take as a specialty you should know what not to take.

Few things I think might help you in that

1. Keep an open mind. 
Never get bogged down by other people's opinions about what you should do. What you do is your business not your uncle's or neighbor auntie's.
2. No work is too small.
Take up every role that you come across. Cleaning a colostomy tube is as important as putting in the colostomy tube through surgery.
3. Respect the patient.
Work towards making them better always and try your best not to hurt them.  Always remember that patients are your best teachers so give them as much respect as you would your teachers.
4. Take ownership of your patient. You might be just an intern who follows your unit head's orders but the patient is still yours. Try to create a personal bond between you and your patient. It always helps you and the patient. Both sides get what they want.
5. Medicine is art. 
Work hard in the wards. Your books will only take you so far but the warfield (wards) is where you learn the craft. Never belittle any ward procedures. IV lines, central lines, urinary catheterization ,repair of emergency lacerations..... You never know what you will come across in the wards. These skills you can never acquire or experience later. I did one central line during my internship and that experience was exhilarating. Being an ophthalmologist now I'll never do it again so I'm thankful I did it then. Wards and patients will give you all the inspiration you need to propel you towards a speciality.
6. Make your peace with death and disease.
Until you reach internship you never realize how much death and disease of your patients can affect you. This is because you will have a personal investment on the patient. You will sometimes feel helpless in the face of mortality and morbidity but that is necessary.
7. Find your role models.
It could be anybody you work with and even your own batchmate who has probably figured it out better than yourself. One is never short of people to look up to.
8. Recognize the wrong people. 
You will come across people who are not good at their job, people who insult and look down on their colleagues and juniors, people who are unethical and so on. Identify those people and make note to yourself never to be like them. Do not let a bad doctor ruin a good speciality option for you. I didn't have good teachers for ophthalmology in my medical school but I didn't let it spoil my opinion of ophthalmology.
9. Maintain your sense of wonder
I feel we need to find wonder in what we do and work towards what we want to be. I would advise the same during one's internship. Never lose that wonder.

Life of a 21st century doctor!

The medical science has seen a sea change over the last century.....more than what has been achieved in the previous 5 centuries put together. The change has been for the better for patients as people are getting cured of diseases which previously had no cures.

In this state of change to expect the medical profession not to change is simply naive. I would like to enumerate the good, the bad and the ugly of the medical profession in general and the joys and challenges of doctors in particular. This is in no way a negative or cynical post. It is more of a perspective of how things are and how it is going to be.

Medical Education

Over the years the field has grown leaps and bounds and this being the era of super specialization.....now doctors are moving on to micro specialization. It has become harder for students to keep up to the whole gamut of information which keeps changing every few years so "specialization in minutiae is inevitable" is  the new world order for doctors. I agree with this in principle but the path to specialization especially in India is difficult, unrewarding and involves a lot of factors unrelated to your capability to be a good doctor. First on the list comes low pay right from the time a medical graduate passes out. This pay never reaches the amount appropriate to his/her level of expertize all through their career unless he/she indulges in any wrong practices or his/her family owns a hospital. Second is the high cost of medical education not only monetarily but in the quality of life a medical student has to endure throughout his student life. An equally capable professional in another field is pretty much well set by the time a doctor can come out to practice and by which time the doctor has a mountain of debt and an unforgiving society. There is very little incentive for a student in India to join the medical profession unless their family owns a hospital or have unending disposable income to spend. This puts the profession beyond the reach of the middle class since there are no returns for the incredible amount of mental and financial investment required from a doctor. So is it any surprise with the quality and character of the doctors of the new era. The brightest and smartest don't want to become doctors since it's simply not reasonable for a middle class family to sustain a medical student. This makes way for corruption and only the people with the insane amounts of money can become doctors in the new era. Are these the kind of doctors you want to trust your lives with?

Those fortunate to be bright enough enough to secure a government medical/ residency seats which they can afford are treated so shabbily by the system. They are often put up in slum like living condition in hostels with bug infested rooms, mosquitoes and the works by government colleges. They are often made to work 80-100hrs a week resulting poor nutrition and low morale. A lot of them end up sick and in extreme cases even dead. On top of that, the added danger of flash mobs assaulting the emergency doctors on call. The general feeling is the residents are often disgusted with the system and with their seniors for perpetuating this unfair system. This is how the brightest in the field are treated by the society. Some links below which might give an idea of how big the problem is.

https://in.news.yahoo.com/why-indian-doctors-fear-for-their-lives-043955469.html?fb_action_ids=10202670862286429&fb_action_types=og.recommends&fb_ref=facebook_cb

http://www.dnaindia.com/mumbai/report-who-takes-care-of-doctors-in-bmc-run-hospitals-2029755

The specialist doctor problem

These days everyone wants to be treated by the specialist. To a lay person it might seem like the most correct thing to do and may feel that super specialist is very accomplished hence also the most capable to treat his disease. In practice however it is a huge waste of resources. In most patient surveys around India and the world 80% of the sickness can be treated at the primary healthcare point. The consequences of making the cardiologist treat a common cold is that the patient is wasting a cardiologist's expertise and overpaying his consultation as well. People don't realize the importance of a general practitioner or general physician in their healthcare. This discourages newly minted medical professionals from taking up general practice. It is just not viable for them. What is the government doing about this problem. They are completely ignoring the issue and like they have treated primary education, they are treating primary healthcare with the same disdain. They aren't hiring permanent staff for their rural areas and those hired are paid salaries once in 6 months. They are forcibly making new residents serve in rural areas. This again is a huge waste of valuable resources. Orthopedic surgeons are doubling up as midwives and delivering babies in rural areas since there are no other doctors. How will this change our primary healthcare in anyway? GPs are not
average doctors as people would like to think. They have a different set of skills than a super specialist. While a super specialist is restricted to a very narrow field of medicine the GP is trained to look at the patient as a whole. More amazing diagnoses is made in a GPs chamber than a neurosurgeon's. But in the new era this important medical community is dwindling.

Quality of life of a Doctor

I'm not saying it is the toughest job on earth but a doctors life now is harder than it has ever been. Very few vacations- no money during student life and no time once you are practicing. 
Family suffers. My father is a doctor and all through my childhood I resented the fact that we took so few family vacations and that my father was never there for the most important events in school or others. All the while he was working day and night to make ends meet and ensure that we, his children get the right education, amenities and taken care of. This made sure that I was a reluctant doctor for the most part of medical school. I eventually found my calling and was "reformed" but it was a painful journey nonetheless. 
It is going to get worse for the future generations. There is this underlying myth that doctors make a lot of money during their careers which is really not true. I had a conversation with a friend from the money making tech industries and he had this to say

"Doctors can't contribute enough financially to the nation to command higher salaries. A doctor ONLY saves lives but engineers,financial analysts and CEOs create wealth which they distribute among themselves."

This is how much value saving lives commands. I was angry at what he said at first but later realized this is how the money creating industries think of doctors: overpaid and untrustworthy. Life and death can't be quantified in stocks and bonds and hence that is not enough. It made me sad as to how this came to pass and this perception is precisely what the next generation of doctors will have to work against. 
Governments post newly minted doctors into rural areas on compulsory postings but on temporary jobs. It is cheap labor for the exchequer, vote banks are taken care of and they don't have to bother about a permanent solution for a complex problem like rural health. 

What these people don't realize is that by having this attitude they will ultimately increase healthcare costs and then everybody suffers.

This inability of the society to acknowledge their altruism will be the reason to discourage the next generation of brilliant students from taking up this unforgiving profession. Doctors are no more demigods or authorities in their field. Their medical decisions will be altered by arm twisting untrusting patients, fear of malpractice suits, defensive medicine, target hounding corporate hospitals, a populist government and an inefficient law system. All this stress while their family still suffers from the lack of their time and money.

http://www.kevinmd.com/blog/2014/11/wish-knew-advice-spouses-doctors-residents.html

Doctor and patient relationship

To a doctor who is just starting out I would say this: ' Your decisions will be questioned at every step. You cannot dismiss patients like you are doing a favor to them. You will have to get down to the level of the patient and sometimes lower'. It will be a big let down in a doctor's life that they keep having their motives questioned every day of their professional lives. I think this is for the better as the doctor community has been too arrogant for far too long. They spend so little time with patients giving the excuse of long patient lists and surgeries. I think this is why people are so distrusting of what we do. Doctors of the new era have to respect the "new patient" who is educated, informed and has 1000 questions. There will be unreasonable patients just like other professionals have unreasonable clients. You have to approach it like how other professionals do. 
Any drug that you prescribe you should know all the side effects. Any surgery that you do you should know all possible complications. Ignorance is never an excuse anymore. It is your job to know. Never be dogmatic and steadfast about your decisions or opinions. Learn humility, patients appreciate that. State your professional opinion clearly before educating your patient about his/her disease and give them more than one choice when possible. Let patients take ownership of the decisions that need to be taken. All this takes time and you would be well advised to give it to them in the first instance or you'll be forced to give it in court. This sword of Damocles hanging over your head seems very unfair when all you wanted to do was do your job well. There is no point complaining about it and we have to make peace with our present day realities. If we want to be counted as professionals we have to be accountable. Period.
Also you need to connect to every patient you meet. For you will have several patients but for a patient you are the only doctor at that point of time. Learn more about your patients and make them feel like you are their doctor rather than make them feel they are your patients. There is a world of a difference in that.

http://mattandjennimurray.blogspot.sg/2014/09/in-defense-of-doctors.html?m=1

http://www.buzzfeed.com/lukelewis/16-doctors-on-the-dumbest-patients-they-have-ever-treated?bffb

Doctors and the media
Doctors in India are the vilified lot and not for small reason due to the unrelenting attitude of the media to slam doctors at every given opportunity. Media misuse their privilege to become just the loudest voice in the room. Most of the popular channels give out gross wrong health advice, unhealthy diet fads and advertisements of dubious cures. If that was not enough we have enough doctor slamming shows like Satyamev Jayate. Shows like these invite doctors and patients to discussion forums and post recording heavily edit the discussion in a very biased fashion to suit only their pre determined point of view and to create sensationalism to increase the TRPs of their shows. Doctors are the favorite punching bags since doctors in India have no voice. They don't form vote banks since they are an educated community which can't be swayed by politicians. They don't have a lobby to fight these instances of injustice since doctors in general don't make enough money impact the finance of any political entity. The Indian Medical Association and its state counterparts sometimes have token protests against these wrongs which not surprisingly never gets reported in the media. Doctors in hospital emergency rooms get beaten up every other day almost in all instances for no fault of theirs. This almost barbaric treatment of junior doctors in hospitals across the country are never reported in the media and if reported would highlight "some mistake" on the part of the treating doctors and never anything defending the doctors. This is because in most instances these assaults on doctors are perpetuated or encouraged by media persons. And strangely if there is any instance of a doctor strike  protesting archaic quota system of medical education, low pay or assault of doctors in hospitals, the same  media will come raining down on the doctor community of holding people's life at ransom. What I'm sad to see is that people don't realize that doctors are not anarchists.They would be more happy treating patients rather than be in protest rallies and fight lathi charges. If they are forced to do these things one has to realize how desperate and frustrated they are with the system. Nobody else is fighting for them and doctors have no choice but to protest in what little way they can. It is sometimes heart rending to see doctors who are on hunger strikes still running emergency clinics in these protest areas since they don't want people to suffer.

Doctors and Doctors

Over the years in the medical profession I have seen as a young doctor trying to make a mark that doctors work against doctors. There is too much professional jealousy and Godfather complex in the doctor community. There is a culture of disrespect which is passed on from the senior doctors to the junior ones. A senior doctor would not bat an eyelid before running down his junior colleague or rival in front of the patients. When you can't respect your own profession how can you expect the patient to respect it. Doctors cannot treat their junior colleagues like slaves at their beck and call. If you don't respect your colleagues the feeling will be mutual. So the first step in the new era will be to respect for everyone from medical student to super specialist. While we are at it there should be respect for everyone concerned with your patients....every person in the health delivery system forms a vital cog in the machinery. The future of healthcare is in creating effective teams rather than hierarchy. Nobody would believe me now but things will change in the near future in India to prevent hierarchy from setting into a system. Only when you remove nepotism , favoritism and godfathers from the picture will we gain a meritorious medical community. Mentors are the need of the day. Only if the present stalwarts mentor the next generation of doctors will there be continued value of our art. But if these stalwarts are insistent on running their personal fiefdoms then its a bleak future ahead.

Finally the joys of being a doctor

Being an optimist has helped me still enjoy my profession in a positive way despite the injustices that are being done to doctors in India. Its been a very long road from being a reluctant doctor to an empathetic doctor and this journey has taught me a lot of lessons. 
One of the joys of being a doctor is having the power to change a person's life and livelihood with one accurate diagnosis and appropriate treatment. A doctor may not move nations or even sometimes not even impress the patient he's treating but power to positively impact another person's life is incredible to say the least and I suspect is the reason why doctors still continue to perfect their art and science. Doctors may not make millions of dollars like lawyers, engineers, management consultants and businessmen but the value they give the patient with their work is not measure able with any material affluence.

From Oculoplasty and back

“Just don’t give up trying to do what you really want to do. Where there’s love and inspiration, I don’t think you can go wrong.” —Ella Fitzgerald

Its been an incredibly long time since I've been active on this blog. Partly because I have been busy and mostly because I haven't been inspired to write in a long time. I was in Bhubaneshwar sometime back and it has kind of brought me back to a place where I almost gave up on Oculoplasty as a career. In my earlier blog posts I had professed immense interest in Oculoplasty and haven't really updated what happened afterwards. Its a huge story worth a potboiler at the very least (ha ha I'm kidding). Well I wont bore you with all the details.

But something incredible happened in the end of September 2013. I got an offer letter from National University Hospital, Singapore accepting me for their Orbit and Oculoplasty clinical fellowship program. I had applied to NUH after my residency  just like the many other institutions I had applied to. Somebody there had seen a spark in me and selected me. I was ecstatic and that hunger to get into the fellowship kept me from giving up during the protracted paperwork process to start my fellowship.

I'm now more than 4 months into my fellowship and its been an amazing experience till now and I feel I'm in the best place that I could be. I have finally found a mentor who could really shape my career the way I would want it to go. I'm learning new things everyday and things I never thought I'll be doing.

I'm training in navigational surgery of Orbital fractures,small incision endoscopic browlift, Aesthetic procedures, attending orbital fracture implant courses and a myriad things I hadnt even imagined I would be able to do.  I realize that i'm at the forefront of technology and innovation in my field here in Singapore. The real challenge will be to use the knowledge and training that I have gained here into a place like India where there are always impediments to one's growth. A lot of it is economic and most of the rest of it is politics and nepotism that thrives in my profession in India. I sometimes worry that I'm getting spoiled by all the high tech gadgetry that I see here in Singapore and I fear becoming obsolete in India. Also I'm recently married so to get the kind of solid support from my wife has been comforting but I understand the sacrifices she's making for my career and it sometimes troubles me.

But after a lot of reflection I realize that the basic emotion here is "Joy". Joy in what I am doing despite hectic schedules of this fellowship and finding happiness in an equally important marriage at the same time. This beats every fear that I'll ever have. I figure that if I'm enjoying what I'm doing I'll find a way to make a living out of it.

The Surgeon Conundrum

“From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Sir Robert Hutchison, 20th century physician, British Medical Journal, 1953

I often hear descriptions of famous surgeons as “great”, “amazing””, “brilliant”,etc. and wonder how those adjectives get decided. The corollary used in describing a surgeon is somewhat akin to a performing artist or an athlete. The problem with such an approach is unlike an athlete who can be assessed by statistics or artists who is assessed by cultural expertise of common people, a surgeon does not lend himself to such assessment. A surgeon does not have a publicly available success rate statistic nor do common people have any expert knowledge of surgical procedures to know if a surgeon is great or not.
Is surgery so hard? Yes and No.
YES because one needs to put in years and years of study to even have the opportunity to hold a scalpel and from then on has to practice relentlessly for many more years to actually master the surgeries in his/her specialty. For that relentless pursuit the surgeons usually have to sacrifice the prime years of their lives to this task, having no time of their own, decreased social and personal life and often living under debt or their parents’ financial benevolence for a little less than half their lives. 
NO because its not magic. Most surgical procedures have certain established techniques which if practiced over many years become second nature to the surgeon. So if you know the rules you are set. Of course it goes without saying that you would need a certain level of aptitude and intelligence to learn the complex machinations of the human body,decent memorization ability and a whole load of patience but essentially surgeons are human beings like the rest of us. Only that we surgeons are the lucky ones among humanity who get to wield the scalpel to help humanity as a reward for all those years of hard work.
Skill can vary of course like in any profession, they can be excellent, good, average, poor and miserable. Skill, we surgeons are often told is what separates the great from the rest and yet there are many average skilled surgeons doing incredible service to mankind which many highly skilled surgeons could not.
So does mere skill of a surgeon decide his greatness? Here its a big no. From what I see from the inside of a surgeon’s world, having started my surgical career 3 yrs back, the greatness of a surgeon has to be measured beyond just skill. Like my Professor in college used to say, “ Any fool can operate,even that cobbler on the street or that OT technician, maybe even skilfully but what should separate you from those fools is that you should be able to judge what surgery the patient needs or if he needs surgery at all?” (he had more colourful words to say, this is the watered down version of it, LOL). I recently heard an amazing perspective from a very famous surgeon (he’s a brilliant surgeon by the way) : “ The reason older experienced surgeons do lesser types of  surgical procedures than younger newer surgeons is not because they are any less fearless or capable than the younger ones its because they are tempered with the wisdom of what works and how well. The ability to cut down on trying too many things and to bring more efficiency and longevity to surgery is what experience brings”  These are two different perspectives with a converging opinion on the importance of clinical judgement of a surgeon being paramount!
Doing too much or doing too little? Where do surgeons draw the line?
For that the “art of judgement” is the crucial quality of a surgeon. I sometimes feel we as surgeons are often guilty of “surgical over-aggressiveness” . There are times when doctors operate when in hindsight just waiting would have done the trick. Sometimes when a medical treatment would be far more beneficial than a surgical one. Other instances when after surgery the patient is worse off than before. It’s not to say these doctors have any vested interests to operate. They mostly always want to help the patient and often in their zeal probably do too much. Sometimes its more harder for the doctor than the patient to accept that nothing more can be done. But again in trying to solve the “doing too much” problem, surgeons should not fall into the “doing too less” trap which so often happens in many hospitals these days where patients aren't demanding or in the know. There are several instances when doctors just chooses to delay instead of taking that acceptable risk to operate since they don't want to be responsible for somebody’s poor surgical outcome. Some don't even refer to a specialist who is capable of doing the surgery with lesser risk. In the end such a patient’s surgery is not done at the correct time resulting in handicap or he/she succumbs to the disease. This attitude is worse than the “doing too much” phenomenon. As an example i distinctly remember one little girl of 5yrs who came with multiple metastatic cancer to my hospital when the original small eye tumour which was detected a year earlier was not operated by the doctor assuming it to be benign. A clear case of doing too less and the experience is so heartbreaking for everybody concerned.
There are no definite answers to most surgical decisions because medicine is a field where results cannot be predicted with pinpoint accuracy like a mathematical model. But surgeons have to take these calls everyday and no one else can do it for them.The surgeon’s judgement sometimes lies between life and death of a patient so its not as simple as people believe it is. I am happy to say with full confidence though that for the most part more good than bad gets done in the full balance of things. The ability to do as much as possible to help the patient yet never letting one go overboard is a balance every surgeon should aspire to attain and this balanced judgement is what makes a surgeon truly GREAT.

Healthcare in India: myth busted

The other day i read that India is one of the top destinations for medical tourists.for those not in the loop this refers to foreigners mostly from developed countries like US, Russia, Germany, Singapore, Korea, etc who do not qualify for healthcare insurance in their home countries who come to India for cheap medical care so that they can get similar or better care for less than one tenth of the price in their home country.When i read this article i couldn't help but wonder whether we should really be gloating over treating foreigners for cheap while millions die in our country due to dire need for basic healthcare.We in India apparently follow a socialistic policy in healthcare. Is it really so?
I recently read an article by Dr. Devi Shetty,a famous cardiothoracic surgeon and leading philanthropist in the field of healthcare.He said only 8% of the people needing cardiac surgery actually get operated and in a country like India we have a huge backlog.In his own words this is ridiculous even for a developing country like India.He has bought down costs of heart surgery to less than Rs. 1lakh and he’s desperately trying to get it to less than Rs. 40k.He’s doing a commendable job and needs every bit of adulation and support he can get.But really where is the Government in all this? its conspicuous by its absence!
I work as a resident in the premier Govt. Eye Institute in West Bengal which incidentally is the top govt  eye inst in the whole of eastern India. we have top of the line instruments, microscopes, lasers, machines, diagnostic aids and first class infrastructure.we undertake all kinds of surgeries done in any of the top institutes of the country.This should in effect should help the masses.But unfortunately not everything is free.True cataract surgery covered by the national program for control of blindness in India is free but nothing much else is totally free of cost for the patient.the patient still has to buy consumables for surgery such as silicone oil or perfluro-gas(Retinal Detachment surgery),silicone prosthesis,sutures and many other consumables.A typical RD surgery costs the patient around Rs. 12,000 in our institute(only consumables).In other diseases for proper diagnosis CT scans,MRI,histopathology,expensive blood reports,immunohistochemistry,etc. needs to be done for which the patient has to shell out from his/her own pocket.All this and not to mention other daily expenditures in eye drops,costly antibiotics,pain killers and sometimes hospital fees.Drugs supplied by the govt. form a woefully short list or for the most part ineffective probably due to adulteration and poor quality control.So many expenditures in a Govt Hospital which is a premier institute at that in a supposedly socialised medical healthcare.This much expenditure to a man/woman who probably earns less than Rs. 100 a day.does it sound right? can our conscience make peace with this fact? if this is the state in a premier institute what is the state of peripheral hospitals.I’m not blaming the people who run our hospital for all this.they are doing a great job to the masses with the limited resources at their disposal.the costs that are being borne by the patients is due to the helplessness of these doctors and due to their endeavour to provide world class care to patients with limited expenditure to the society. In this scenario doctors are stressed to provide healthcare and the public blames them for any incident that happens. This is the reason why doctors in govt sectors are getting frustrated with the system. its not them but our healthcare policy that is to blame.It is flawed left right and centre!
I’m speaking in the midst of one hospital and i’m talking of ground realities in one govt hospital as i’m a part of one.But this is the story of nearly every govt hospital in India.it is just that the categories of expenditure changes.Our society will be judged by how we treat the weakest(read poorest) among us.And our country falls terribly short of an ideal.
As i have mentioned previously in my blogs,Indian govt. spends less than 1percent of our GDP on healthcare.Even countries like Bangladesh and Sri Lanka spend 16 and 32 pc respectively.UK spends 7pc and yet provides Universal free healthcare to every citizen and immigrant.In India 80pc of the health care burden is borne by the pvt. sector.We are quick to downgrade the insurance based healthcare of the USA but in India we neither have an Insurance based healthcare of USA nor a Socialised Healthcare like UK,France,Sweden,Denmark,etc. the common retort by the govt is India is a poor country and we do not collect sufficient taxes to sponsor universal healthcare in India.But this is a poor argument because though only 3 pc of the population pays income tax,we all pay tax in every other way.sales tax,wealth tax,property tax,road tax,service tax,luxury tax,custom tax,education cess,advertisement tax,service tax,value added tax,….phew just to name a few!!!! Only birth tax and death tax is left to be enforced.where does all this money go? We have a horrendous education system,pitiable healthcare and a treacherous bureaucracy and yet we have any non-descript politician worth his salt(not necessarily elected) being ridden across the country in a fleet of 10 cars or helicopters or jets! govt officials,bureaucrats and govt aides lead a life of extreme luxury.our politicians and bureaucrats must be among the richest politicians and bureaucrats in the world(and we are a poor country mind you!!!)No other country in the world has more black money in Swiss Banks than India.So who do you think owns all that money? the above people and also some huge businessmen. So do I still hear somebody call India a poor country. We now know who are the beneficiaries of these many taxes.
Solutions are quite often very simple but simple things aren’t done without a political will in this country.The masses don't demand healthcare because they have nothing to eat so why will anybody talk about health? Healthcare needs to be removed as a state subject and be transferred to being a union subject.Doctors and healthcare professionals need to be paid more as professionalism demands money.you can’t attract the best talent in any industry with pitiful pay packets.same should hold true for healthcare.Govt budgetary allocation to healthcare should increase to 5pc of GDP for a start and should eventually increase to at least 8pc.another 10pc to our education system because to sustain a healthcare this massive we need an educated population.All these budgetary allocation should come from defence cuts.We don't need bombs and missiles.we need medicines and medical care.there needs to be a stringent quality control body for healthcare delivery and of course for the quality of drugs and consumables being supplied.In effect we need a complete overhaul of our healthcare and education policy.Do these sound difficult. hell yes!!! because attitudes need to be changed,awareness needs to be increased and most of all corruption should be minimised.All this is easier said than done but it still is simple stuff no?
I sometimes feel really bad when patients suffer because they either can’t afford treatments or we are restrained from giving them the best treatment due to the many impediments i have mentioned above.There is a certain joy in treating patients and you need to have empathy to understand their varied problems.Its a hell of a tough job but there is nothing else in this world which gives the same high as that got by alleviating suffering of people.It is for this incredible satisfaction that most doctors work even in trying conditions,amongst apathetic govts.,and high personal sacrifices(both monetary and social).So if we doctors can treat our patients without worrying about whether the patient can afford the treatment we can at least bring back nobility to our profession.its not only the rich who deserve to get sick and be cured.even the poor have every right to lead a healthy life.So the next time you fall sick and get treated think about the millions who are not as lucky as you and be grateful for the same.Also try in your own way to do something about it.sometimes a simple thing such as a change in attitude will do.

17th April,2011                                  Raghuraj Hegde