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 facilities to 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 reasonable cost.
Then a management consultant came to study the hospital finances. He collected data on 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 model 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 the story 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 drugs.
It was a difficult task to convince parents that these children had no major illnesses and that they need not come regularly to the hospital any more.
More harmful than unnecessary treatment of healthy children was improper management 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 the outpatient department came down as did admissions to the in-patient ward.
Though the patients were doing better with fewer tests and medicines, the revenues were 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. Email: firstname.lastname@example.org)