'This is going to hurt'

I knew at an early age that a career in medicine was my calling. As a doctor, I have helped scores of patients. I have also lost a few along the way. Despite being in the field for over three decades, I still hurt when I lose a patient. 

It is easy to memorise the symptoms of cancer in a classroom, but it is extremely difficult to deliver that news to a patient or caregiver. There was a world of difference between theory and real life.

1. Primary healthcare

My initial postings in government hospitals opened my eyes to the harsh realities of life. I was posted to one such Public Health Centre (PHC) in Velliyur, a village not too far from Chennai but with poor commuting facilities. Doctors were expected to stay in the village and work in the PHC. There was no provision for running water at the centre, and we had to get water from a nearby well. Every day, we would have to walk to the well and fetch a bucket of water to keep outside the room for our needs, even to wash our hands between examining patients. This was the situation in the late 1980s. This was not unique to this healthcare centre. Even today, there are PHCs across the country without access to running water. I have also heard of many that remain locked for months, as the doctors on duty would not turn up. These doctors know the right palms to grease— they not only contrive to escape any retribution but also to get postings at better locations.

Well into the 21st century, there are still PHCs which are either completely closed or only partly functional. A few of them serve as cattle sheds and some as shelter from the elements! There is an appalling passivity when it comes to the management of primary healthcare in India.

According to the Rural Health Statistics Report 2021-2022 released by the Health Ministry, there is a shortage of 83.2 per cent of surgeons, 74.2 per cent of obstetricians and gynaecologists, 79.1 per cent of physicians and 81.6 per cent of paediatricians in the healthcare system in the rural areas. The report further stated that only 45.1% of PHCs function on a 24x7 basis. Of the 5,480 functioning Community Health Centres (CHC), only 541 had all four specialists.

2. Medical negligence

In November 2022, a young athlete lost her life in a government hospital in Tamil Nadu due to gross medical negligence. Seventeen-year-old Priya had undergone an arthroscopic ligament repair procedure, during which a tourniquet was applied to minimise bleeding. However, the hospital staff forgot to loosen the tourniquet after the surgery. When the patient screamed in pain, they gave her more analgesics to reduce the pain. They did not realise that the tourniquet had not been released and was thus effectively cutting off the blood supply to her lower limb. The prolonged pressure from the tourniquet caused a lack of blood flow and led to gangrene of the leg. She was then moved to another hospital, where the leg had to be amputated. However, as the treatment continued, she developed sepsis, causing multiple organ failure leading to her untimely death. A young life was snuffed out due to sheer negligence. If you think that it is only the government sector that is apathetic, think again.

My friend and former national table tennis champion Late V Chandrasekhar was admitted to one of the most well-known corporate hospitals in the country, following a recommendation, for arthroscopic surgery for a knee injury. Chandra was then only 25 years old, on his way to even greater heights in the field of table tennis. He went into the hospital expecting that he would, after a short rehabilitation programme, continue playing for the country. But he came out a wreck, physically. He was virtually paralysed for some time. His speech and vision were completely impaired. It later emerged that the oxygen supply to his brain was cut off during the surgery. There was a blame game between the surgeon and the anaesthetist—and though Chandra filed and won a case against the hospital much later, it was of little solace to him. Given his celebrity status, this case made national headlines and raised a lot of public outrage. Yet, even today, thousands of Chandras walk into a hospital hoping for a cure and walk out a mere shadow of their former selves. These cases are hushed up and the staff and hospital involved are rarely penalised.

3. Prohibitive costs

If this is the state of hospitals, pharmaceutical companies are not far behind. In a country like India, medical expenses are usually out-of-pocket transactions, as not everyone is insured. Even with price regulation by the government, the cost of medication is prohibitive, and thousands of people abandon treatment midway. 

Generic drugs cost up to 85% less than branded drugs. A generic drug is a medication created to be the same as an existing approved brand name drug in dosage form, safety, strength, route of administration, quality and performance characteristics. But, there are many concerns related to both generic and branded drugs manufactured in India. Often, it has been found that these drugs contain less than the required amount of Active Pharmaceutical Ingredients (API).

The manufacturing conditions in many plants—characterised by poor levels of quality control, poor process control, and non-adherence to good manufacturing practices (GMPs)—are questionable. Every year, we see instances of how Indian pharma companies were found to have violated GMP norms by fudging data or cutting corners. 

4. Big pharma and lab rats

Big Pharma, a term used to denote the global pharmaceutical industry, affects the way doctors prescribe—or rather push—medications irrespective of the needs of the patient. Pharma companies spend a lot of money on research and, technically, any drug that is developed needs to go through intensive checks and clinical trials before they are launched. The clinical trials are supposed to be well monitored and done with the complete consent of the participant. However, companies are known to conduct dodgy trials in India, where the laws are not as rigid as in Western countries. Often, the participants are akin to hapless lab rats who have been coerced into the trial.

In 2012, the NGO Swasthya Adhikar Manch filed a public interest petition against illegal clinical trials. The Supreme Court came down heavily on the government and expressed shock at what it said was a ‘disturbing’ figure of 3,458 deaths and 14,320 serious side effects documented among volunteers of clinical trials that were conducted in India between 2005 and 2012.

5. Lack of training and knowledge

One area that lacks focus is how much doctors know. This is very important because knowledge and skills are not uniform across any profession and if you end up with a doctor who does not know enough, you could pay with your life. Contrary to popular belief, the biggest and brightest corporate hospitals are no guarantee of finding the best doctors.

A study by the World Bank in 2012 in the states of Madhya Pradesh and Delhi found that quacks actually outperformed qualified doctors. Appalling as it is, this is a sad reflection of the extent of the crisis that we face. While there are pockets of excellence comparable to the best in the world, especially in the metros, the vast majority of the country is left at the mercy of poorly trained (or even untrained) and often money-minded doctors. We need to understand that the doctor we go to may not have the necessary knowledge or skills to provide effective care.

6. Greed, not altruism

As I spent more years in practice, I realised that the driving force behind the industry is not altruism but greed—across all levels of the hierarchy. The authorities turn a blind eye as their pockets are also lined by various players. A study by the Public Health Foundation of India (PHFI) published in the British Medical Journal in 2018 reveals that around 55 million (5.5 crores) Indians are pushed into poverty in a single year due to healthcare costs.

A few factors affecting the Indian health sector are limited access to quality care, lack of affordable hospitals, ill-equipped healthcare professionals, corporate greed leading to unwanted and unnecessary procedures, target-meeting attitudes, medicos playing God, and an almost complete lack of understanding of the outcomes, consequences and management of healthcare, leading to zero accountability.

A call for change

What are we doing about this? We fret and fume, hope that it does not happen to us and heave a sigh of relief if we do manage to escape the medical trap. Most of us still believe that expensive treatments at a premium corporate hospital ensure quality healthcare and that it is only government hospitals that offer subpar treatment. We believe that if our doctor has a friendly bedside manner, they are extremely competent. But nothing can be further from the truth. As a close witness to the many vagaries of the healthcare system, I am appalled by the general apathy and acceptance of its shortcomings. This conversation needs to take centre stage for true reform.

That said, over the decades, I have seen a vast improvement in the quality and reach of healthcare in India. But, at the same time, I am a witness to an increased focus on profitability and an I-don’t-care attitude towards patients. Many healthcare decisions are taken by people who are far removed from the stark realities of the Indian situation. Such is the acceptance of these situations in India that, apart from a few newspaper articles and social media posts, there have been very few calls for sweeping healthcare reforms. The Indian healthcare system, in one word, is horror. The fate of the people who enter the system depends much on God’s grace and luck; it is often based on the doctor and the hospital they go to for care. 

My aim is not to demean the healthcare system in India. To be fair, thousands of sincere, benevolent doctors and healthcare staff put in great effort in rendering service to their patients. They are the warriors who help keep a broken and sinking system afloat, and I salute them. But they are a small minority and their well-meaning efforts are despite the system and not because of it. 

How to choose a doctor

Ask these questions while selecting a doctor, be it a GP or a specialist.
If most of these can be answered with a ‘yes’, then you are most likely in good hands.

1. Does the doctor have a postgraduate degree? While doctors with just an MBBS are qualified and highly capable (especially some of the older doctors), a postgraduate degree does ensure a higher level of knowledge. A specialist must have additional qualifications in their chosen area. 

2. Is the doctor available for a consultation within a reasonable time frame? You need a doctor to be available when you have a problem and not have to wait for a week or more just for an appointment.

3. Is the doctor’s clinic clean and hygienic? Does the nurse or attendant follow the proper processes for a triage?

4. Is the doctor an empathetic listener and communicator? Do they answer all your questions and doubts?

5. Is the doctor okay with getting the prescriptions filled and tests done at a place of your choice and convenience? If the doctor insists on you going to a particular pharmacy or lab, treat that as a red flag.

6. Is the doctor’s first prescription relatively short? Unless you have a particularly serious health issue, for most other cases, a maximum of two or three medicines would suffice.

7. Is the doctor as engaged and responsive during review and subsequent visits? A doctor showing progressively lesser interest during follow-up visits is often a warning sign.

8. Is the doctor available in case there is an emergency? In today’s connected world, some doctors share their numbers or email IDs for emergency purposes. Ensure that you have either of these contact details with you at all times. But remember that these are to be used only if
there is an emergency. For all non-emergency situations send them a text and do not call. Respect their boundaries at all times.

The author has over 25 years of medical experience. He worked as a consultant physician in Chennai and holds an MD in Internal Medicine. He has been a key member of TCS' Healthcare Innovation team and is a well-known television personality. His book 'Sick Business: The Truth Behind Healthcare In India' was published recently by HarperCollins.

Disclaimer: Views are personal and do not necessarily reflect those of DH and its affiliations.