Healthcare - The Unholy Practice of the Holy!

Rod of Asclepius

It appears that the recent "Neeyaa Naanaana" episode that aired on 08/17/2014 Vijay TV about "greediness in healthcare field" has created a bunch of fury amidst Tamilnadu medical professionals. Running health care amidst all your competitors is a tricky thing nowadays. In the days of Sushruta and Charaka, it was all probably free. Patients paid voluntarily whatever they wanted to pay to the healers. There was no concept of money and they just paid the doctors in kind. You may get tomatoes from one patient's garden and perhaps snake gourd from the next patient. But now "money" rules in all of our lives! Healthcare is no exception.

In this context I remember the recount of my Kilpauk Medical College classmate's real life experience. A labor-and-delivery case that got botched up, and the lives of the mom and the kiddo could have been lost because of the ego of the administrative heads. But luckily my friend, the physician, was a conscious enough to save those two lives.

Let me tell you that case. It involves two healthcare facilities in Kozhikode district in Kerala that are set in two different small towns separated by 10 kilometers. Let us just simply call these facilities as facility A and facility B.

There was a private practitioner in that town A who established a practice in the early eighties. As more and more cash flowed in from his thriving practice, he went on to open his own pharmacy in a "Benami" name, then expanded on to open his own admitting "facility A". It was his own sole ownership.

In town B, there was a church but no medical practitioner. Like many of the churches in India, this organization masqueraded under the holy name, and underneath all its activities, there was a subtle mission - a desire to see more and more people embrace Christianity. The church ventured out into opening a healthcare (facility B) as there was clear demand for it in that town.

The new facility B had a problem taking off and establishing its roots in the community. The doctors there kept quitting their jobs and the patients could not have any guarantee that they would see the same doctor each successive follow-up visits. It was a 24 hour RMO job for Re 5000 per month salary and none of the local Kerala doctors would take that job. Hence the people continued to be going to the other town and sought health care over there in facility A.

The missionary organization placed an advertisement in "The Hindu" Chennai edition to hire new doctors. Doctors who moved from far-off place like Chennai to Kerala to take such 24 hour RMO jobs offered better hopes to those Kerala employers. They were likely to stay in the same employment longer than Kerala doctors. That strategy frequently worked for them in hiring doctors from other states like Tamilnadu.

This chap, my Kilpauk Medical College classmate went to work for that Catholic Missionary hospital in facility B. His medical qualification was just MBBS and he was capable of doing basic medical care, but not capable of handling any heavy-duty medical case. That facility had only one other doctor, a Obstetrician, also from Chennai. Her job was to build OB-GYN practice for that facility A. Both these doctors took the job in Kerala to work, make some money and at the same time to be studying and preparing for their higher studies in USA/UK.

And slowly facility B started getting some patients coming to them routinely indicating that the patients now trusted this new facility and its two Tamil doctors. The fee was just Re 5 or 10 per visit in 1994 set by the sisters/nuns. The missionary that was running the facility got very happy. And they also got their first prenatal case following with the OB-GYN doctor which meant that they were going to deliver the first child in that little hospital! Once they prove to the community that the facility was capable of delivering children, then hopefully people would quit going to competing private practitioner in the other town. They probably had a plan to then hire a surgeon as well after proving their ability in delivering babies. Then they could venture out into doing "appendectomies" as well. These are the business aspects of medicine - about how to progress from one to another to make it more lucrative.

The OB-GYN doctor took her well-entitled time-off - one weekend off to Chennai to spend time with her family. That weekend became a fateful weekend. Because the first prenatal care patient developed labor pain and showed up at the facility. The sisters/nuns were so embarrassed that their promise to the community had failed because the OB-GYN doctor was not available when needed. That pregnant lady in labour was about to go to Facility A in frustration. But that would be such bad public relationship event for the growth of this facility. So, the sisters/nuns looked up to my friend to deliver the baby successfully.

My friend had delivered several dozen babies during his house-surgeoncy training, but they were all supervised by a post-graduate obstetrician. He had never done this alone. But he agreed to that proposition of conducting the first delivery in that hospital without any help. However he did tell the sisters that he was no expert in this.  In any case he did successfully deliver the baby without complications. Everyone cheered in the delivery room! But the problem was that they couldn't control the post-partum hemorrhage. The mom's blood pressure started dropping. My friend who was just barely out of the medical school was all alone in that small town being solely responsible for the safety of the mom and child. He gave her fluids, but didn't have any blood to give the bleeder. He made the decision to summon the ambulance and transfer the patient to the facility A where access to blood transfusion and expert doctors were all possible.

You would expect the sisters, the ladies walking the holy trail would be the most holy in this situation because of their commitment to nunhood and righteousness. But what the sisters said was the most shocking thing in this case. They just acted like a typical healthcare facility administrator, like a business person, and didn't want the patient to be transferred to their own competitor. They did everything possible arguing with my friend in the delivery room in trying to avoid the transfer because they said "there was nothing more embarrassing than accepting defeat to the competition". That did waste some precious bunch of time. Finally my friend succeeded in transferring the patient. And the patient got her life back after several units of blood transfusion at facility A.

Caduceus

Oh boy, how much has health care changed over period of time! Not just health care, but every thing in life! Money rules everywhere now! You probably thought that I blamed the sisters for the above problem. But you know what my friend did after that event? He negotiated Re 1000 increase per month in his salary from the next month because he was instrumental in the first successful delivery there and also saving the life of the mom by transferring her out in a timely manner.

Everything is money, money, money now! Just few hundred years ago "insuring something" was almost an unknown concept and now we have insurance for everything.

Look how the imagery that represents healthcare has changed over time. The first image in this blog above - that indicates the rod of the Asclepius, the greek mythological deity associated with healing. When healers provided service out of pure goodwill, because of their passion in their profession and an eagerness to help, without charging tooth and nail, then you can think of the above figure. The second image mentioned above is the Caduceus. This figure is frequently confused with imagery representing healthcare activities. When you think of medical profession done for purpose of business, then you probably should think of Caduceus. It indicates a trade, just a freaking healthcare business.

And now, I found this image off of the internet - a modern Caduceus tattooed on a man's back! Look at the tattoo below, it shows good and evil on the opposite sides.

Modern Caduceus - depicting good and evil on opposite sides

We will have to talk about one more profession in this context. The Hindu priests! Thousand years ago, the way the priests behaved was very different than what we see now. They were not supposed to expect fees for their services. If the customer gave them something out of their own will - probably a tumbler of rice grains, some banana fruit, perhaps coconut etc, then they could take it to their home because it was a voluntary offer by the customer. It was considered obscene to set a fee and ask a customer that amount for priestly services. But look at the modern priests nowadays! I remember the priest that came to my house while we had my father's dead body laying in the hall. He came like "Alaipayuthey" movie hero "Madhavan" in his bike with sun goggles on, iphone in his pocket, ear buds in his ears. They had offered a "package deal" for Re. 9600 to perform the 1st day ceremonies. That involves going to the electric crematorium in Besant Nagar and chanting all the mantras so that my father would travel safely to the heavens. Priestly duty offered as a package deal! That priest was pretty business-like, came, did his job, kicked his bike start, and went back to the next death home!

Some professions may be holy in nature, but once the elbow gets extended to collect the monies and riches as fees, then the holiness is gone right here.  Doctors can't offer arguments that they answer pages at night to save lives of other people. Nowadays software consultants go to work and stay in their offices for 14 or 16 hours easy, extending well into night or early morning before they can even come back home. And so does a factory worker in Ambattur doing night duty work! What about that? Can they claim it to be holy? Think about it! If your job description involves answering pages at night, just do it! After all it is done for a fee and not free! I know of many doctors in USA who bill at a minimum of 15 minute time increments to answer their hospice and home health calls and bill it to those companies!

And I read one doctor saying that he cleaned other people's anuses and that he needed to be respected for doing a sordid thing like that. What kind of argument is that? Then what about the chennai corporation latrine cleaner who cleans human excreta all day long in his work? Is he performing a holy profession?

The term "holy" can only be used when you offer some service without expecting anything in return. Selfless, so to speak. But we live in a world where money rules the world and its people. Since the doctor sees the healthcare transaction as a way to make money, he doesn't think about it as "holy". If the outcome of a healthcare transaction was poor (such as death of a patient), then the patients don't hesitate to make that misfortune as fortunate as possible by suing the doctor. That tells you that the patients don't see the healthcare transaction as "holy" either.

Doctors, just grow up! Your patient is ready to go to thermonuclear war against you in the court of law if you did a bad job of what you promised to them initially. Learn to do what you do for your patients well, communicate that nicely to them, your patients, and try to be honest about what you do! Just admit that you are not doing anything for free to your patients. Quit pretending to be Dalai Lama! There is a business aspect to practicing medicine and start admitting to it! Where is the holiness in this? There is no confusion. The world has pronounced the verdict long ago - perhaps in the second part of the last century.

Healthcare is looked as a business and nothing else. Just grow up and come to terms with this realization.