The pain of practising as a doctor selling ‘care’ in India

This is not an isolated event. This is an everyday event, illustrated through the example of what I experienced yesterday as a doctor practising in private sector health care of India. I go through this painful experience and still practice as a doctor within a system of care that I disagree with, because only when you are an insider, it is possible to be aware of the situation, speak about it and do what is possible within the system while still calling for it (as well as myself who is an essential part of it) to think if it is capable of transformation into a kinder version, rather than the profit-higher-than-anything version that it is currently. 

A 68 year old man came to the clinic with his wife, son, daughter-in-law and his 10 year old granddaughter. He ran a small grocery shop at Tiruppur, a nearby town. Small grocers are essentially a subsistence business, in which consistent hard work provides just enough money to run the family. Money comes in only as long as an individual is able to run the business. Usually, no reliable saving is possible. 

Abdominal pain for a month led to diagnosis of a malignant mass in the pancreatic head with involvement of a major blood vessel close by. He said he was never ill in all his adulthood, a true blessing in these times. Pain was disabling and gave a constant reminder of the life-threatening cancer that was slowly consuming his body. After a detailed review of records and review of the CT scan images, I told him that he had a locally advanced pancreatic head cancer and that this cannot be surgically removed. At least not upfront, as the first step of treatment. 

He would need to undergo a special method of intervention called endoscopic ultrasound scan guided biopsy, a method to obtain a small amount of tissue from the mass in the pancreas to see what type of cancer it is. Simultaneously, by a procedure called ERCP (Endoscopic Retrograde Cholangio Pancreaticography), a stent needs to be placed in the bile duct that was being obstructed by the pancreatic mass, causing jaundice. Based on the type of cancer, he will need preoperative chemotherapy (neoadjuvant chemotherapy) that may or may not result in reasonable shrinkage of the tumour. If there is response alone, a surgical removal of the pancreatic mass would later be possible. 

Then came the selling part of the care. In fact, it had begun as soon as they stepped inside the hospital where my clinic was. They had to pay a fee of INR 500 (INR five hundred only) for this consultation to happen. That was the cost paid to even see me!

Fear of suffering and death

Now that he knows that he has an aggressive tumour in pancreas in which all treatment is but a way of buying little extra time, rather than any scope for healthy longevity, he was a broken man. He cried in front of me and in front of his entire family. Fear of death and suffering is so real. I tried to console him saying that we will guide him well, keep him as pain-free as possible and help him go through this difficult phase of life. 

Pain of the cost of care

When his family asked about expenses for this care in my private sector practice, I told them that the initial endoscopic procedures, biopsy and stent placement for jaundice could cost around INR 3 lakhs. I could see an unpleasant surprise in their eyes and body language. I advised them not to borrow for care and that the same care is available at Government Mohan Kumaramangalam Medical College Hospital where all such facilities are available. His family showed the usual lower middle class hesitation in considering care in a government system. Fear of apathy in the care process (though not always true) and fear of government sector not matching up to private sector in the procedures themselves were showing up in the conversation that followed. These are the common fears that push our patients to borrow beyond their means to provide private health care for their relatives. 

It is better to be poor -the middle class suffering

The poor are spared. They have no choice but to reach out to government sector health care. The upper middle class are usually insured for private health care and the rich (though really few in number anywhere in India) can buy Indian health care anywhere. 

Private health care and medical tourism- “so-called” pride of India

India’s private health care is being praised as high in quality and very affordable compared to that available in Europe, the UK or the USA. Indian governments, whether the Union government or the state governments, take pride in offering low cost, high quality care for foreign nationals in India’s growing private health sector. Such hospitals and doctors are seen in high esteem by the political class and business class of India. But, for vast majority of Indians, who are either lower middle class or poor, access to such care is lacking. 

Political expediency, not the real solution- Public insurance giving private care

Poorly conceived programs like public-private partnerships and provision of high cost health care in private sector for certain illnesses in private hospitals are advanced by governments which seem to have no awareness of where the root of the problem lies. It looks politically expedient to do such showmanship than provide real long term solutions by strengthening the public sector. All government insurance programs, whether they are PMJAY or CMCHIS of government of Tamil Nadu, put public money mostly into private sector hands and further weaken the public sector health care. 

Talking about cost while children listen

I was looking at the patient’s granddaughter, a child who was 10 years old, wondering what she will think of this conversation as. What does it teach her? That we are able to sell a care process to a suffering man at the weakest moment of his life! What values are we (including me) teaching this young girl about life? We are probably showing her at a tender age that money is more important than anything to go through life. Is this the value we want to pass on to our next generation? Question loomed making me silent and withdrawn after they left my office.