Letter from Mumbai

Much Ado About a Move to Condemn ‘Cut Practice’

While debates on medical ethics in other countries focus on topics such as the quality of life in patients with advanced and widespread cancer, the morality of risks in research and making clinical decisions in patients with prolonged unconsciousness, we are still stuck on the rights and wrongs of paying kickbacks or cuts or commissions to doctors and others sending patients to us. It appears that few are aware that all medical councils and other statutory bodies intended to ensure good medical practices have condemned such bribery ages ago.

Irked by these unethical practices, Dr Ramakant Panda, heart surgeon and head of the Asian Heart Institute in Mumbai put up a public hoarding in June 2017, announcing that in this institution patients will be assured ‘Honest opinion. No commission to doctors’.

One would have expected whole-hearted support for this move from every member of the medical profession. Certainly, the national association of doctors—The Indian Medical Association (IMA)—with its oft-proclaimed high standards of medical ethics should have welcomed this public-spirited stand of the hospital.

Not only did IMA not support the hospital but it went on to lodge a complaint with the Advertising Standards Council of India, stating that the advertisement was in poor taste and offensive to the medical profession!

The hospital stuck to its stand. After all, it had not made any comment on practices by other institutions, groups or individuals. Unstated was the feeling that perhaps guilty consciences had been pricked within officials and members of the IMA. Instead of being stimulated into taking steps to eradicate this illegal and unethical practice, however, these worthies decided to insist that the hospital take down the ‘offensive’ hoarding.

The hospital continued to display it.

What did the state government do to resolve this controversy? What do most Indian governments do in such cases? Instead of studying the pros and cons and issuing a ruling—which would appear a simple matter in this case and involve condemning the practice of paying kickbacks and outlawing it—the Maharashtra Government formed a panel to deliberate on and, if necessary, draft a bill ‘to curtail cut practice’.

On its part, the Asian Heart Institute initiated a debate on this practice.

The government has, since, released a draft bill entitled Prevention of Cut Practices in Healthcare Services Act 2017. It proposes penal punishment for 5 years or a fine of ₹50 000 if a doctor, hospital, clinic, nursing home or any medical professional is found involved in getting commissions by referring patients.

The opinion of the president of the Medical Council of India (MCI), Dr Jayshree Mehta on the issue makes interesting reading. The Indian Express reported her statement: ‘Professionalism and ethics must be there to curb this practice. It should be observed, we are active on this issue. Whatever malpractices we are seeing today must be stopped. We are trying to educate doctors in every state.' Dr Mehta said a Central law may prove to be an effective deterrent to the practice. She did not elaborate on the activities undertaken by the MCI in this regard. As with the IMA, the MCI has not felt the need to take any tangible step to curb this malpractice thus far.

Objections have been raised against the draft bill. These include the possible misuse of the proposed law against honest doctors and difficulties in tracking kickbacks. Some also pay tribute to the ingenuity of doctors in obtaining their cuts by other means to the continued detriment of the patients.

The fact that countries such as Great Britain, the USA, Canada and France have successfully passed and implemented such laws decades ago appears to have made no impression on the naysayers.

As yet, the draft of this law has not yet made its way into a legislative debate.

While on the Subject of the Indian Medical Association (Ima)

In a newsletter to members of the IMA, its president, Dr K.K. Aggarwal posted the following message. I reproduce, unaltered, unedited parts of it relevant to statements in the previous section.

‘Straight from the heart: Bechara Mein

‘Why always I am being blamed?

‘I represent the collective consciousness of over ten lac doctors of modern medicine. There was a time when I was considered GOD but today I am being looked upon with suspicion for every act of mine?

‘Why am I looked upon with suspicion when I ask a patient to get MRI done from a specific center having 3 TESLA machine or a CT scan done from a specific center having facilities for minimal radiation.

' Why the patient, PSU or mediclaim are not ready to pay me for my services for accompanying a patient for a CT/ PET scan or MRI and for briefing the radiologist.

‘I agree that payment by or to a physician solely for the referral of a patient is fee splitting and is unethical. But if I am part of decision making for and during the procedure and am legally liable I am entitled for my fee.

‘Any diagnostic center charges for infrastructure + operator charge s+interpretation charge s + machine charge s. Why my transparent investment in the infrastructure be not allowed when I get only my share from the infra structure portion of the cost.

‘Often charges for CT scans are different. Depending on the type of machine, location of the machine and the amount of radiation the machine is emitting. Similarly, the charges of MRI can be different depending on weather it is 1 TESLA, 2 TESLA, 3 TESLA or open MRI or pacemaker friendly MRI. Is it not my professional decision where to send the patient?

‘Why cannot I charge for coordination when I arrange for transport, admission, hospitalization and discharge?'

Predatory Medical Journals

There has been an explosion of medical journals that proclaim that they permit open access to their contents. This would have been welcomed had such journals continued to maintain the high editorial standards of existing indexed journals and judged papers submitted for publication on the basis of originality and ethical research of high quality.

Those journals that charge fees to authors without providing the editorial, supervisory and publishing services that characterize reputed, long-standing journals are classified as predatory. The term predatory was applied to such j ournals on the basis of the fact that susceptible, young researchers and scientists are lured into paying substantial sums for publication of their papers in journals that do not meet scholarly standards.

Members of their editorial boards do not feature outstanding scientists. They do not reveal lists of reviewers and, indeed, may send no papers out for independent peer review. The interval between submission of the paper and its publication is often so short that suspicion of whether any review was done is justified. The quality of science published in such journals is poor. Few such papers are ever referred to by scientists of merit. At times nonsensical papers and even those sent in as hoaxes are published in predatory journals.

The publishers of such journals depend on the need for young clinicians and scientists to publish a large number of papers in a short period, without putting in the requisite hard work. This need has arisen because of the insistence of most selection committees and grant-giving agencies on a certain number of publications. The general perception in our young scientists is that the longer the list, the greater the chances of success. This provokes them to seek rapid publication and amass numbers.

When such journals are published in European or American cities, they hold an almost irresistible attraction for young Indian authors as papers published in them can be classed under ‘Publications in foreign journals’.

While teachers and research guides can do much to curb the rush that has enabled the mushrooming of these journals, institutions and agencies granting funds can also help.

Here is what the National Institute of Mental Health and Neurological Sciences (NIMHANS) in Bengaluru is considering actively.

1. It will stop requiring applicants for posts and grants to submit bibliographies that often run into several pages.
2. Instead, it will request each applicant to submit a list of five publications considered by the candidate to be the best from the total output and relevant to the post or grant under consideration.
3. The scientific judgement on the candidate's research expertise will be made on the basis of the study of these five papers.
4. Such a limitation will also enable each member of the selection or grant-giving committee to study these five papers in detail.

An Unusual Publication By A Retired Wing Commander

Wing Commander Dharam Pal Sabharwal was leading a happy, active life after retirement. He enj oy ed his talks to young, aspiring engineers and did his best to inspire them. He travelled all over the country for this purpose, returning to his happy home each time. He basked in the love and attention of his beloved wife and enjoyed his chats with his sons and their families.

Mrs Sabharwal embodied all the virtues expected in a wife and mother. Fond of her husband and children, loved by her colleagues and students at the school where she taught, ‘Aunty’ to everyone in the air force stations in which they had lived (in part because of the delicious dishes and cakes she made with affection for every child's birthday party), she was a bundle of energy.

Life could not have been better.

The first signs of impending problems came to the Wing Commander in the form of forgetfulness atypical of his wife. She asked him to taste a dish she was making. Surprised, he queried this request as her cooking had always been unfailingly appetizing. ‘I am not sure about whether or not I have put salt into this soup,' she responded. As her husband teased her, she merely said, in a matter-of-fact tone that she was thinking of something else and did not want to put a double dose of salt. This isolated incident would have occasioned no reaction were it not for progressive deterioration in her memory that followed—about visitors, where everyday items had been placed and the day of the week.

Alarm bells starting ringing in their home when she could not find her way to it when returning from outings. She remained unaware that anything was wrong even after her husband suggested a visit to the doctor. Imagine the plight of her husband when the gentle, well-mannered lady went on to show irritation, restlessness and even aggression towards those she loved.

As time passed by, it was obvious that a medical check was due but she would have none of it, explaining away her difficulties as being consequences of absent-mindedness or stress.

As her inability to cope with the needs of her daily routine worsened, she did undergo tests. Alzheimer's disease was eventually diagnosed.

Subsequent events have been well described by the Wing Commander in his book Handling Alzheimer's with courage.

We are brought face to face with the sheer exhaustion of the caregiver. The husband, bereft of peace of mind, doing everything he could think of while searching for better, more effective means of helping her, could have turned into a wreck himself.

We are fortunate that the author is a thinker and a scientist. He pondered, meditated and analysed all the time. Being an engineer, he devised and invented means and techniques and he experimented. When approach ‘A’ did not work or was counterproductive, he retraced his steps and adopted approach ‘B’. By trial and error, he discarded what did not work and used what helped his beloved patient.

Troublesome conflicts arose between the dictates of the mind— rational and logical—and those of the heart, based on emotion and affection. These too are dealt with in detail.

As weeks gave way to months, he honed his philosophy, revised his beliefs and developed a technique for restoring his own peace of mind even as he looked after her more effectively.

While each chapter, in itself, is informative, the final paragraphs in italics are a distillate of lessons learnt.

Families that are forced to deal with the disease in their midst and the intimate caregivers will find inspiration in the manner in which Mr Sabharwal developed the skills required to attend to his wife's increasing need for care and the courage to assist her right up to her death. He describes everyday problems and their solutions as well as he does major changes such as moving house to be able to obtain the help of his son and family.

Finally, a Sentiment to Ponder...

A doctor who can help a poor man and will not do so without afee, has less sense of humanity than a poor ruffian who robs a rich man to supply his necessities. It is something monstrous to consider a man of liberal education tearing the bowels of a poor family by taking for a visit—as fee— what would keep them for a week.

—Richard Steel (1672-1729)