Monday, December 2, 2013

India Medical Times: Doctors are victims of costly training and poor healthcare policies.... by Dr Kunal Sarkar

Doctors are victims of costly training and poor healthcare policies
India Medical Times, Sunday, September 1, 2013 

The guardians of the nation’s health find themselves in a state of desperate sickness. The diagnosis has long been known and shared in privacy; not often have we mustered the guts to express the cardinal manifestations of the disease.

The process of the making of a doctor — is it fair and rational? Both the ethics and method need scrutiny. Based on fallacious reports in the 1980s, governments stymied the expansion of state medical colleges. The opportunity to set up medical colleges was thrown open to the private sector. So we had stiff competition for the seats in government institutions and the private seats were acquired by auction, under the covert legitimization of capitation fees. Private enterprise should have supported the medical colleges with the income from the hospitals. Instead, both the hospitals and the colleges were being supported by the oppressive capitation fee system. Mediocre medical colleges were serviced by substandard hospitals, almost without exception. The attention was not on providing quality education and service but on a hurried capitalization of the prohibitive fee structure.
After initial protests the cowboy educators were joined by the high priests of equitable healthcare, which meant a submission to systematic plunder. Multiple escape routes and exceptions to the merit lists were devised. This ushered in an era of unashamed cash and carry education in a society that was aspiring to be fair and inclusive. The cash and carry segment had engulfed more than 60 per cent of the undergraduate and 40 per cent of the postgraduate seats. The proverbial politician can never be far away from the scent of money — no wonder that this sector is firmly in the clutches of political power brokers.
With the price tags of Rs 50 lakh (1 lakh = 100,000)[1] for an undergraduate seat and Rs 1-4 crore (1 crore = 10,000,000) for a postgraduate seat, are we not kidding ourselves with great expectations of ethical uprightness? The pressures to recover the mortgage are enormous. A naïve society will continue to express surprise that a doctor is a commercial creature. Does he have a choice?
The quality of education is yet another matter. Regardless of how many stages of filtration we set up, money will rule. The chances of a college letting a Rs 3 crore[2] seat go vacant for a term are small. There is still no national standard monitoring agency. The state subject of health remains feudal and fragmented. The Medical Council of India’s process of recognition and renewal has been a ‘you scratch my back, I scratch yours’ type of transaction. The standardization of education and amenities remains a distant dream. The focus of medical education has been the number and cost of seats. Quality has not figured in the agenda — not at all.
The recent judgment that annulled common entrance tests probably had its points of legal validity, but it was a severe setback for the cause of standardization and quality enhancement. It is a pity that successive regimes in the ministry and the MCI have had neither the clarity of purpose nor the legal expertise to push it through.
In recent times, there has been a campaign to exponentially increase the number of postgraduate seats. It is emotive to equate the number of specialists to population statistics. Pragmatism demands that some cognizance is taken of the stagnation in the infrastructure and in absorption opportunities. An increase of specialists with a stagnant national bed count makes little sense. It will produce a gross excess of manpower, thereby producing a cattle market of low-paid professionals. The average pay for a newly qualified postgraduate doctor is already quite modest compared to peer group professionals.
It is all too easy to fan the fire through social media at the expense of the prevailing reality. In the last few years, postgraduate seats have already been increased, but as the healthcare infrastructure has remained virtually stagnant, there is more than a hint of oversupply. Over a good part of the last decade, the national bed census has been static at 10 per 10,000 population, vis-à-vis a projected capacity of twice as much. With all the insight and inspiration, this figure refuses to budge for years on end. What are qualified doctors, who have paid an arm and a leg for their education, supposed to do? Serve in rural outbacks without a modicum of civic infrastructure and livelihood? Their life was supposed to be a profession, not an act of penance. And less than 30 per cent of all doctors are in organized employment. Do we dare to add to this clutter of stagnant mediocrity?
Mindless populism has struck the healthcare industry’s viability another deadly blow. The revenue potential of the industry has been seriously capped with the regulation of charges via population insurance and government reimbursement schemes. These meagre tariffs very often render basic procedures unsustainable for hospitals. For the sake of maintaining numbers, some hospitals patronize these schemes at the cost of viability and quality.
Reduced charges for the financially hard-pressed is not a matter of contention. But if these are applied to all and sundry, the result is catastrophic. Private equity is justified in expecting some return for investment. Is it conceivable that the retail or information technology sector will have their earnings truncated? How do we cost-cap a system, 80 per cent of which is based on private equity? This paradox is further aggravated by the pretences to low-cost care. Low-cost care in mass scale has and will remain a pipe dream. Eighty per cent of the business for such providers is based on market prices with less than a fifth having some form of concession. The slogan is appealing but the economics does not add up. It helps create an image but not a sustainable system. Making unsubstantiated claims without an audit or a national database on procedures and outcome has become a pastime.
Until we resort to a nationalized healthcare system, with both the delivery and professional reimbursement being standardized on a national scale, populism at the expense of economic viability is inevitable, and a dangerous path to tread.
With severe pressure on revenues and margins, the first impact is on the hapless doctors. They are made to toil for a pittance. Barring successful private practitioners, they can bid goodbye to any substantial raise in earnings. The pressure on margins is passed on the doctors. This remains the only professional segment that is being attacked by pseudo-socialization and extreme political populism. It is not surprising that the interest of investors has been slow and unsure.
It is a supreme paradox that after spending crores to buy a mediocre medical education, the young professional is likely to be trapped in a stagnant industry of low growth and lower earnings. How does the young doctor then justify the expensive gestation? Cutting corners of practice and presumed ethics will be enforced as an instinct for survival. The tragedy of being trapped between myopic policy-makers, educational entrepreneurs (out there to make a fast buck) and the false prophets of populism is being enacted in all its frenzy. That the bubble will burst is not in question — it is a matter of time.
In a country where an economist prime minister has ushered in an era of stagnation it is not surprising that medical messiahs have added to the problem and not to the solution. Caught in the crossfire of pseudo-socialization and crude commercialization will the doctor become a truly endangered species?
Dr Kunal Sarkar
Senior Vice Chairman
Medica Superspecialty Hospitals, Kolkata
Note: This article first appeared in The Telegraph on August 31, 2013 (with permission).

[1] 100 Rupees (Rs) = MYR 5.17; thus Rs 50 lakh = MYR 260,000
[2] Rs 3 crore = MYR 1.55 million

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