E-DRUG: Lest my oath become hypocritical
Lest my oath become hypocritical
DR. ALEXANDER MATHEW
Published in The Hindu August 18, 2013
There have been several revelations of the unholy nexus among doctors,
diagnostic laboratories and pharmaceutical companies.
In addition to this nexus, the perverse practice of
basing incentives for doctors on quantity rather than quality encourages
unethical practices. My own experience in Kerala is no exception. I have
practised paediatrics for the last 40 years - first in the United States and
then in Kerala for the last several years.
I worked in a hospital near Kochi for more than 10 years. It had the basic
handle routine outpatient and inpatient care for the relatively poor clientele
in that area. I tried to give good care, careful clinical examination, limited
laboratory investigations, and minimum medicines and admissions at a very
Then a management consultant came to study the hospital finances. He collected
the number of patients, laboratory work, X-rays, medicines and admissions and
put them through his spreadsheet. He concluded that compared to a similar
number of patients in other hospitals, I was under-utilising the laboratory,
X-ray, pharmacy and hospital beds.
The patients were getting better service at a lesser cost; that my business
was wrong and the spread sheet showed it all. I had a discussion with the
director of the hospital. The ethical discourse saw a reversal of roles and the
argument for enhanced earnings trumped any concern for ethics. It did not take
long for me to leave that hospital.
My next experience was at a bigger and renowned hospital in the same city and
was no different. I was shocked to see what was going on - either with the
knowledge and concurrence or utter indifference of the authorities. Trivial
childhood diseases were categorised as serious problems requiring repeated
tests, unnecessary treatment and unwarranted admissions. Children with mild
viral fever and some joint pain were often diagnosed as having acute rheumatic
fever, without any criterion for diagnosis and without doing any test to confirm
it. Children with the usual viral fevers with cough were diagnosed to have
tuberculosis without any evidence and were put through unnecessary and harmful
X-rays and needless treatment for several months and even years. Many children
with an occasional cough were diagnosed to have asthma and put on unnecessary
It was a difficult task to convince parents that these children had no major
and that they need not come regularly to the hospital any more.
More harmful than unnecessary treatment of healthy children was improper
of those who were really sick and needed treatment. The universally accepted
standard of care for children with moderate to severe asthma is the use of
inhaled steroids to prevent asthma. To my surprise, many of them were admitted
to the hospital repeatedly for 'acute asthma' attacks. I started the use of
inhaled steroids in these children and most of them improved with fewer
attacks. Consequently there were infrequent visits and admission.
My days in this hospital too were numbered as the number of patients coming to
outpatient department came down as did admissions to the in-patient ward.
Though the patients were doing better with fewer tests and medicines, the
shrinking and the management was becoming unhappy. And, again, the cause of
enhanced earnings won the day against any concern for ethics. It did not take
long for me to leave that hospital too.
Assessing doctors by the quantity of patients they see rather than by the
quality of care
they provide is a morally hazardous enterprise. It is just another
manifestation of an attitude which thinks only of maximising profits at any
cost - not just in the corporate hospitals but even in the so-called mission
hospitals which proclaim charity as their main motive.
(The writer is a Diplomate American Board of Pediatrics.
Dr Gopal Dabade,
Dharwad 580 002
Dr Gopal Dabade <firstname.lastname@example.org>