Much has been said and written about entrenched corruption and institutionalised unethical practices in medicine, involving prescription for unnecessary tests and medicines, or recommendations for unnecessary hospitalisation or surgery, either for commissions or to meet targets imposed on doctors by private hospitals.
Apart from such obvious manifestations of corruption, however, is the slow and insidious damage that such corruption has seeded into the field of medicine in general, by thwarting committed professionals who had internalised the Hippocratic Oath in letter and spirit and sought to carry it out in practice. Well known author and gynaecologist, Dr Arun Gadre, is one such.
At a recent panel discussion held in Bangalore to highlight medical malpractices in the private health sector and the burden that it creates, Dr Gadre recounted his experience working as a gynaecologist in a village of Maharashtra, and the unrest he experienced as his idealism collided against the sordid realities in the healthcare business, eventually leading him to give up medical practice.
Choosing a medical career
Inspired by social worker Baba Amte, Dr Gadre, along with his wife, bid farewell to the comforts of city life in 1988 and moved to Lasalgaon, a village in Maharashtra with the noble intention of offering his services as a gynaecologist to the rural poor. Were he not there to conduct Caesareans, the pregnant women of the village would have to travel 70 kilometres to find a gynaecologist surgeon in Nasik.
While his earnings were nowhere close to what it could have been in the city, it was the satisfaction of doing justice to the medical profession, which he held in such high esteem, that took him into the drought-struck regions of rural Maharashtra.
“The medical field is such that students who venture into it cannot help being taken over by the nobility of this profession,” Dr Gadre said in the Panel on Health Rights. “Very rarely can a doctor think only about money while treating his patients.”
“The first ten years in this village constituted the most wonderful experience of my life,” he said with a bitter-sweet nostalgia. Working under ill-equipped conditions, Dr Gadre conducted many successful Caesareans here.
“There was no blood bank, no paediatrician, no hi-tech equipment,” he recollects, “In case of an emergency, it would take over eight hours for a bottle of blood to reach here from Nasik. Yet, I could successfully operate even on patients with an uterus rupture, because they had faith in me.”
Virus of commercialisation
But as the “virus of commercialisation” began spreading like a wild-fire, this essential faith in the doctor began to be eroded. Gadre recalls with regret, “Doctors, who were till then happy to send their patients to me for surgeries, began insisting that their patients go to Nasik, because I did not give them any commission for referring patients to me.”
Recollecting a tragic incident in particular, he spoke about one of his patients who was thus victimised. “She had given five stillbirths. She was a very poor woman and could not afford a surgeon’s fee. I had told her I would accept any amount that she was willing to offer as fees, but that a Caesarean was a must under the conditions. She could have delivered normally, but it was highly probable that the baby would die.”
The expecting woman and her mother were convinced, and had given their consent for surgery. But the doctor she had consulted instigated her relatives to take the patient to a hospital in Nasik, and they had been convinced that it was the only way to save the baby. These relatives descended on Dr Gadre’s clinic and carried her away from his operation theatre to an unqualified practitioner.
“I can never forget the sight of those two women, who came back crying to me the next day, saying they had lost the baby,” he said. It was at this point that Dr Gadre began having his first few doubts about the point behind continuing his practice.
There had been only two cases of post-operative death in his 20 years of practice until then. “In both instances, the patient’s family had only thanked me saying, ‘You tried your best doctor, what more could you do?’”, Dr Gadre said.
But the times were rapidly changing. Instances of unruly mobs attacking surgeons and hospitals if patients died during surgery were being reported with increasing frequency.
“The commercial doctors around me were angry with me as I never gave them any commission. They often tried to instigate mobs against me,” Dr Gadre notes. But it was not only the doctors, but also politicians and patients themselves who had given in to this culture of commercial profiteering.
A mafia grew up around this nexus, waiting to prey upon surgeons who got a complicated case where the probability of death during surgery was high. This was their chance to attack and extort money from him. This trend had spread in urban and rural areas alike, and conscientious, rational doctors were the worst affected.
“I was afraid,” he recollects. “There was no placard on my forehead, proclaiming that I am an ethical doctor. Anything could go wrong in the operation theatre and the consequences could be dire. My wife started getting tremors out of fear.”
It was at this time that he was advised by a friend, who was also a doctor, to stop worrying about the mob. “Just throw a few lakhs on the crying husband’s face and everything will be fine,” his friend told him.
On being told that he did not have the money to buy peace since he never charged his patients high fees, the same doctor told a dismayed Gadre, “Come on, start charging them then. You must increase your turnover!”
This was not why Arun Gadre had entered the medical profession. Things worsened and his nightmare came true when the third patient died in his hospital. As he was conducting a post-mortem after her death, the dead patient’s mother, who was a nurse in the same hospital, stood beside him assuring him that he need not conduct a post-mortem, for it was she who had delivered the patient to him and knew well that the doctor was not to blame.
But by then, a huge mob had already descended on his hospital, demanding compensation. “I refused to give in. Fortunately 70 percent of the people in the mob had been my patient at some point of time or the other in the past and I was spared,” he said.
This incident was a turning point in his life. “I realised that time was up. I could not maintain my morality and ethics in this field if I had to survive. And I quit medical practice that day.”
Voices of Conscience
After quitting medical practice, Dr Gadre joined SATHI (Support for Advocacy and Training to Health Initiatives) as an Associate Coordinator to fight for the health rights of patients and to bring in accountability in both public and private healthcare.
As he decided to compile a report on medical malpractices, he was advised by the activists he was associated with to document complaints from patients. But he had something else in mind. When he expressed his wish to document testimonies of doctors who were frustrated by the corruption that has penetrated deep into the healthcare system in this country, people eyed him incredulously. Which doctor would want to confess to the degeneration of ethics in the profession?
In 2014, Dr Gadre, along with Dr Abhay Shukla of SATHI, interviewed 78 doctors from various cities including Delhi, Mumbai, Pune, Bangalore, Chennai, Calcutta and Nasik, as well as a number of small towns and put together a definitive report on the widely prevalent medical malpractices in private hospitals today. This was compiled in a book titled “Voices of Conscience from the Medical Profession”.
Recollecting his interview with Dr Gautham Mistry, a cardiologist in Chandigarh, Dr Gadre says he was surprised but appreciative of Dr Mistry’s willingness to give an hour-long interview with such brutal honesty. In the interview, Dr Mistry recounted his seven years of experience in private medical practice, admitting candidly that he had succumbed to pressures from the hospital’s management and resorted to unethical practices to meet the targets imposed on him.
Finally, Dr Mistry quit his job at the hospital and is now engaged in consultation only. “I am really frustrated. My knowledge and skills in angioplasty and in monitoring patients in the ICU are being wasted. I might get a 100 patients a day, but I am only giving consultation service. Nonetheless, I will adjust with this reality, rather than go back to unethical medical practice,” Gadre remembers Mistry telling him.
Another super-specialist Dr Gadre has interviewed for the book mentioned about a young doctor in his department who had been summoned by the CEO and warned that he will be shown the gate if his conversion rates, which were 10-15 percent, did not increase to meet the target of 40 percent. In other words, the young doctor, in order to keep his job, had to convince at least 4 out of every 10 patients who visited him for consultation to get admitted in the hospital.
"This young doctor will certainly surrender one day," the interviewee told Dr Gadre. "To survive professionally, he will start conducting or recommending additional procedures that are not required by medical logic. What choice does he have?"
The only choice that he possibly could have under the circumstances is to quit practice in the hospital, a choice that Dr Gadre had been forced to make himself. But where does that leave us? In a healthcare system dominated by unethical doctors or one without any?