What ails the practice of medicine: The Atlas has shrugged

Abstract

Health-care providers are currently facing a huge challenge. At one end they are expending a huge amount of time and energies on health-care delivery including time spent on upgradation of their knowledge and skills (to remain abreast with the field and be able to provide state-of-art patient care), sometimes even at the expense of themselves and their families. On the other hand they are not receiving adequate re-imbursement for their efforts. To compound the problem several “traders” have entered the profession who are well adept in the materialistic approach abandoning the ethics (which currently happens to be the flavor of society in general), giving a bad name to the whole profession and causing severe grief, embarrassment and even dis-illusion to an average physician. The solution to the problem may lie in weeding out these “black sheep” as also realization by the society that the whole profession should not be wrongly labeled, rather a hard toiling and a morally driven practioner should be given his/her due worth

1. Introduction

The whole health-care industry is pivoted on patients' confidence that physicians possess a body of knowledge and skills which will culminate in the relief of their distress. Towards this end they repose not only trust and faith, invest in time and money but also hold their physicians in a certain esteem reserved for a very few individuals. On the other hand, this task of healing implicitly and/or explicitly imposes a moral stake on the physician. In other words medical professions exists because society believes that her health needs are to be met in a certain respect and therefore her willingness to grant a professional power and privilege in exchange for a commitment to serve selflessly.

2. Archeology of medical practice

The word “Profession” is derived from original Latin profiteor, the meaning of which is self-explanatory. Indeed, during the period of Renaissance and early modern era even Medical Profession was crowded with self-trained Barber-Surgeons, apothecaries, midwives, drug peddlers, and charlatans. Over a period of time, however, three changes occurred. First, its practioners took upto science in a big way; focusing on a systematic analysis of patients' symptoms in diagnosis, observation, experimentation and documentation. Second, the practioners of this profession publically made a strong and inseparable moral commitment that though medical practice may be a source of their living; they will strive to the utmost for the benefit of the patient and not be driven by mere desire for material wealth or personal aggrandizement. Finally, moving beyond the scope and confines of the law of the land, they agreed to a process of self-regulation (Hippocratic Oath, and later formation of Medical Councils). This way health field evolved from the Guild of Barbers and Surgeons to a Society of Medical Professionals (Doctors), different from any other profession and clearly distinguished from mere traders. Understandably, this process also led to separation of Medical Practioners from Chemists (who in turn evolved from the apothecaries and formed a ‘lower’ class of doctors; less educated and less skilled) who sold drugs directly to the patients. Ever since (time of this “Social Contract”) the medical profession has attracted the best of the talents; a certain class of intelligent, hardworking, ethically guided and socially oriented individuals who were motivated not by monetary aspects but prestige and security of their profession. These individuals were willing to spend numerous hours every day (even 12–16 h per day) for long periods of time (more than 12 years for cardiologist and even longer for interventional cardiologists) with a desire to train to achieve perfection in their profession (often not only at the expense of money and self but even their family). The only satisfaction being the prestige within the society, ensured merely by being a member of the profession.

However, the arrival of the modern era has led to a dramatic change in the value system of the society so much so that perhaps for the first time in recent history this profession is at cross-roads. Interestingly what its practioners have lost is not the money (for which most of them anyway did not aspire for in the first place) but their esteem within the society: well exemplified by several examples simplest one being inability to get their wards even in decent schools because most didn't have enough money to pay for the kick-backs expected. But even that doesn't hurt as much as the fact that the society for which they were expected to make so many sacrifices became completely insensitive to their interests and started viewing them with suspicion and in many respects started treating them like lay criminals.

The genesis of all this can perhaps be traced to the paradigm shift in the thought process of humankind, the way in which the knowledge was acquired, which occurred somewhere around Baroque era. Essentially it meant shift in the way knowledge was predominantly acquired from searching for similitude or resemblances (integration) to that by comparison (differentiation).¹ In real world it meant beginning of supremacy of science over art. This in turn translated into Hobbesian shift in philosophy from natural law to the will of the sovereign and shift in the societal focus from duty to rights of an individual, from community service to generation of wealth. These formulations were taken up further by contemporary thinkers, like T.H. Green who emphasized that ownership and generation of wealth, rather than being immoral, actually led to ethical development, to the growth of the will and a sense of responsibility.^2,3 Consequently, money became synonymous with power, prestige and even success. In the bargain, the physicians particularly lacking in money power (unlike businessman, management graduates or even IT professionals) lost not only a lot of prestige in society but worse still seemingly lost the high moral ground that they used to enjoy till quite recently. In similar vein the role of sovereign mutated from Protection of the Community to Protection of an individual; protection of his/her wealth. Thus individual rights became the fashion of the day (with not enough focus on responsibilities of an individual). Not surprisingly, the status of a physician in society has been downgraded from “Physician Philosopher” to “Health Care Provider” from “Custodian of Health” to a stakeholder in health issues. When many of us joined the medical profession we chose it for the respect it entailed along with some desire to be useful to the community; money being the least of priority (albeit financial stability to enable to carry out personal and family responsibilities was indeed expected, rather desired). However, over the course of time “Money has become God” and certainly stature within the society is now co-related with material wealth. Sociologically speaking, changes in one system would cause a change in the other. In other words, the workings of any institution (medical) do not have a philosophy independent of that of the society in which it functions. In context of health-care, the changes in society subtly led to change in the practice of medicine which changed from Parent Child Relationship to a mere “Health-Delivery Expert.” Not surprisingly some rotten apples or black sheep in the herd started to move in the direction of personal wealth at all costs and with no qualms about ethics. Further, it is ironic that the people who have tried to regulate the physicians were not the most ethical people but some of the most ethically challenged components of the community, for example actors. It is hard to pick the worst of those moments, but the nadir was possibly reached when Chief Minister of Bihar commented “Physicians who are guilty of negligence towards poor shall have their hands chopped,” reminiscent of some medieval era dictat. As a result of all this, physicians of old school actually feel cheated and it has led to a lot of confusion in their minds as to whether they chose the right profession at all.

3. Why should profession of medicine not come under the ambit of other professions

The next logical question is that if so many evils have crept in the profession why should it not be treated like any other profession? Homo sapiens is the only specie which is aware of its own mortality. This is perhaps the biblical “Adam's Apple” or the “curse of knowledge.” Psychologically, “Ontological Shock” or simply fear of death (whether they accept it or not) dominates the thought process of all humankind and colors all their deeds and interactions (unlike Freud's proposition). Generally, mankind deals with this psychological trauma by not thinking about it, “escaping from it” living in a grand amnesia so to speak. However, when they are diseased or when they face death, all human beings are forced to face this eventuality and medical professionals is in a unique position to exploit this human paranoia. In other words medical professionals see individuals when they are most vulnerable, most amenable to suggestion and it is easy for some unscrupulous individuals to exploit this situation for their own perceived good. Thus the importance of ethics and morality in medical profession and it is very important that only good people come in this profession and not traders out to make money.

4. Evils in practice of modern medicine: paradise lost

The solution to a particular problem does not lie solely in the archeology of the problem. Rather it lies not only in understanding the problem in entirety, analyzing its reasons but affecting a societal change to attempt solve the problem. Embedded in the notion of social change is a quest to accomplish tasks in a way contrary to how they were previously done. Currently, the major ethical issues prevailing in the medical profession are: pay for referrals (fee splitting), overuse of investigations, self-referral, in-appropriate/overuse of medical devices/therapies etc.

5. Issues of referrals/fee splitting (CUT)

5.1. Definition

Among its Definitions of Unprofessional Conduct, the West Hudson Psychiatric Society Virtual Newsletter (1997) defines fee splitting as “Offering or giving (or receiving) a fee for the referral of a patient (fee splitting), or permitting any person other than an employee or associate to share in your fee, who has not provided an appropriate service directly under your supervision”.⁴ Thus it is essentially the payment of a commission to the referrer with the express intention of ensuring that the referring physician directs more referrals to the payee.

5.2. Background

This practice is indeed a norm in several professions (including law). Interestingly, if one reads the Hippocratic Oath carefully, there is no condemnation of this act of fee splitting (as long as the physician charges a reasonable fee and does not increase it for sharing it in order to obtain a larger number of referrals). Theoretically, every physician has the right to determine his/her professional fees on the basis of experience, wisdom and self-perception of the level of skills required for a particular treatment. Fees may thus vary widely from physician to physician. Hence a particular amount cannot be termed ‘unreasonable’ as long as the patient is aware of the sum to be paid before the service is rendered. What the treating physician does with the fee after it is received by him is entirely and solely his concern and the patient or any other person should have no say in it. Hence if a physician decides to give a portion of his fees to another person (medical or nonmedical) it is entirely legal and ethical to do so provided this is done openly and after obtaining a receipt and the cost of this feedback is not factored in his/her fee. Likewise a general practitioner should refer the patient solely on the qualification and skill set of the specialist with no expectation of financial gains out of this referral practice. Practically, however, the referral pattern is based more on the fact that a particular physician is ready to split his fees rather than that he is the best qualified to render a particular treatment. This practice thus represents a conflict of interest which may adversely affect patient care and well-being, they being referred to those physicians (or hospitals) with whom the referring physician has a “fee splitting” or commission payment type of arrangement. In India it is also called as ‘CUT’ (also spoken as Cee-You-Tee) for its reference to a ‘cut’ from the patients bill. Legally, in India explicit promotion of health services via mass media, advertisements and other direct promotions is not permissible. Thus, practically, the only significant way in which the information on pricing and quality of care institutions and medicines reaches the patient is through their primary care physician. Admittedly, there may be many genuine concerns in the mind of referring physicians for choosing/not choosing a particular specialist but on the balance of things, in most parts of the world, the practice is considered unethical and unacceptable; hence fee splitting is often covert.

5.3. How does it work

All physicians qualified to practice modern medicine take the classical Hippocratic Oath before beginning their professional career. The idealistic values learned during the period of training get shaken up when the physician steps out from a world of ‘practice of medicine’ to one of ‘medical practice’. In today's economic climate, costs are increasing, payments are decreasing and although physicians are working harder, they're making less money. Herein comes a newly qualified practitioner who battling this inverse relationship, sees a value of making ‘practical adjustments’ to sustain his/her practice, who encounters open offers of referral of patients if he/she agrees the predetermined and regularized practice of fee-sharing.

5.4. What are the ways of fee splitting?

The process of fee splitting may be overt or covert. It may involve direct cash feedbacks to the referring physicians or other arrangements for profit share or it may involve offering expensive gifts, sponsoring of a conference or payment of travel expenses. Many corporate and even physician owned hospitals make an interesting arrangement: they make the referring physicians visiting consultants so that they can be paid referral fee as consultation fee; sometimes they even “wash up” for the procedure or surgery (at least on paper) when as a matter of fact they are neither trained or qualified for it. Another interesting “arrangement” is to have consultants in super-speciality hospitals visiting out-reach hospitals to smoothen up the referral arrangement.

5.5. What is the legal status?

While the practice of fee splitting may be standard in other professions (law firms), in medical profession it is unethical even illegal (at least in some countries). It constitutes a form of medical corruption. Guidelines of Medical Council of India expressly prohibit the practice of fee splitting. In several countries the punishment for this practice varies from rebuke, monetary fines, license revocation and other disciplinary actions and even imprisonment. UK has been particularly effective in enforcing this statute.

6. Overuse of investigations

6.1. Definition

Overuse of Investigations is when diagnostic, pathological or radiological investigations are performed/advised with a higher volume or cost than is appropriate and employment of these tests are unlikely to improve patient outcomes (or their withdrawal is unlikely to cause any harm). A similar and closely related concept is over diagnosis, which occurs when patients are given a diagnosis of a condition that will cause no symptoms or harm, but can lead to overtreatment and possible harm after treatment.

6.2. Background

In the past, physicians by themselves were able to accomplish the goals of medicine (which involve the prevention of illness, restoration of health, promotion of health and rehabilitation) as they within themselves possessed all the contemporary know-how. However, with the expansion of medical knowledge, particularly the tools of diagnosis, the medical act is no longer produced only by a compassionate physician serving a needing patient, but clinicians have to increasingly work with diagnostic aids for efficient diagnosis, treatment and management of patients. Thus currently, it is no longer possible for physicians to clinically examine a patient and say that she is suffering from such and such an ailment without the use of laboratory investigations: in fact, the medical laboratory leverages 60–70% of all critical decisions. This situation has led to over-dependence on laboratory investigations which is widely prevalent in hospital practice, including academic departments and may account for as much as 30% of healthcare spending in many countries (notably the United States) and can not only lead to inflating patient bills but can actually result in harm to patients (by over-diagnosis).^5,6 Pertaining to cardiology coronary angiography overuse has ranged even >20% which could predispose to un-necessary angioplasties or surgery, both of which have significant morbidity as well as occasional mortality. Another example may be exercise stress test. As a matter of fact 15% of stress tests may be false positive which may lead to needless worry and further testing; often including an invasive angiogram which itself carries a finite morbidity and mortality. With this in background the American College of Cardiology has actually provided a guideline “When initially evaluating patients who are not having cardiac symptoms, don't perform stress cardiac imaging or advanced non-invasive imaging unless there are markers the patient is at high risk.” As also “Don't perform stress cardiac imaging or advanced non-invasive imaging as part of routine follow-ups in patients without symptoms of cardiovascular disease.”

6.3. Reasons for excessive ordering of tests

The reasons for over-utilization of investigations are many and commonly include defensive behavior and fear or uncertainty, lack of experience, the use of protocols and guidelines, “routine” clinical practice, inadequate educational feedback and clinician's unawareness about the cost of examinations.^15–18 Another interesting factor responsible for this is increase in patient awareness and patient education with the easy accessibility of ample knowledge over internet and other open sources of information like press, many patients are convinced of requirement of certain tests and emphasize its need to their physicians and the physicians just pander to their request of “self-referral.”⁷ However more worrying are factors such as inappropriate financially motivated factors, health system factors, industry, and media factors.⁸

One of the foremost reasons for tendency to excessive investigation is the diminution in the quality of clinical skills or clinical judgment. This again could be partly attributed to the mushrooming of medical colleges across the globe with decrease in the standard of education in the same. This deficiency was lamented long back when Connelly and Steele in their classic article emphasized the need of proper medical education for proper utilization of laboratory tests.⁹ It cannot be emphasized enough that there is no substitute for a good clinical examination, however, the trend has become to practice evidence based medicine based on radiological and pathological findings rather than skill based medicine. A case in example is use of echocardiography to make a diagnosis of structural heart disease, which unless is accompanied by a careful clinical examination it can often be misleading, even counter-productive and harmful. One is often reminded of PDA closure in duct dependent lesions where cyanosis was clinically missed or case of acute dissection masquerading as pericardial effusion and tamponade (where a simple examination as pulse was not properly done). Thus, each investigation requested should have a proper aim and objective based on the history and a thorough clinical examination of the patient. Clinical examination should be the basis for any diagnostic investigation and not vice versa. It should be well understood that while these investigations help reach a diagnosis but may not necessarily provide diagnosis all the time.

Yet another component responsible in the over investigation of simple diseases, is the rise individual rights and empowerment of patients which has led to increase in the number of litigations against the clinicians “errors of omission.” Thus medical fraternity in order to safeguard themselves start practicing defensive medicine which in turn compels them to over investigate even simple ailments. Another mounting reason for increase in screenings tests is the increase in medical insurances and broader medical facilities offered to employees and their family members in various public and private sectors “Executive Check Ups.” While conventional wisdom would have suggested that these insurance set-ups would free the insured of all medical worries and lower the overall burden on the economics of a individual and country (by rationalizing the health-care costs), paradoxically, they are contributing to more worries (increasing hypochondriasis) and are actually escalating the burden? When ones medical expenses are covered by third party insurance companies offering more coverage, patients as wells as physicians like to play it safe and this leads to an array of investigations which otherwise could have been avoided. This pattern is more obvious in countries with so called “100% insurance cover,” where the heath related issues and even health indices are no better if not worse than those countries where they are not.¹⁰

However, most disturbing element in the overuse of different investigations is the financial interest of the physicians. There have been few unendorsed surveys that suggest that physicians with financial interest invested in laboratory and imaging investigations tend to order more investigations than their counterparts who have no such incentive.¹¹ While defensive medicine and self-referral are relatively minor or insignificant issues in developing countries, inappropriate financially motivated factors may be the dominant cause in them. As a matter of fact this problem may be widespread in a country like India where there have been a series of reports focusing on medical corruption.^12–15 The situation took a particularly ugly turn when a couple of years back, an Australian physician, David Berger, wrote in the British Medical Journal (BMJ) on his own experiences of corruption while working in a charitable hospital in India.¹⁶ This was followed by a BMJ editorial bringing this issue to world-wide attention. Subsequently, the BMJ gave a clarion call for a campaign against medical corruption in India.¹⁷ Historically, the physicians were ‘allowed’ to do their own diagnostic tests and even compound their prescriptions. However, with the evolution in the field of medicine and recognizing the ‘conflict of interest’ in providing the medicine a clear distinction between physicians and pharmacists was established. As a matter of fact this distinction has been made mandatory in some countries including India. Likewise, morally a clear distinction between clinical and investigative medicine is the order of the day and a clinician should have no stake in investigative medicine to protect the interests of the patients.

7. Overuse/inappropriate use of therapeutic modalities

7.1. Definition

Overtreatment or inappropriate treatment refers to unnecessary medical interventions. These can include treatment of a self-limited condition, or extensive treatment for a condition that requires only limited treatment. When care is overused, patients are put at risk of complications unnecessarily, while health care providers (such as physicians and hospitals) receive revenue from the over-treatment especially in context of fee-for-service (FFS) payment model, a model prevalent in many developed countries like US and even in many corporate hospitals in developing countries. As a matter of fact FFS leading to overutilization may be the most important contributor to the high cost.

7.2. Background

The appropriate use of devices particularly the cardiology devices including stents is currently the hottest debate in medical fraternity, at least in the West. Recently, some illuminative reports suggested that as many as 12 percent of such elective stent cases were “inappropriate” under the ACC's guidelines, according to a 2011 study in the Journal of the American Medical Association, while 38 percent were “uncertain,” leaving only about half that were “appropriate.”¹⁸ Disturbingly, “More than half of the inappropriate cases were in patients who didn't have any symptoms at all.” Apart from a hefty price tag, the stenting procedure carries risks of complications like major bleeding or tears. Further, after leaving the hospital, people need to take clot-busting medications, which also increase the chance of bleeding. Excessive use of stents has been a source of several law-suits and several heart-rending individual stories. Some variously motivated physicians ignore the fact that randomized studies have shown there is no clear evidence of stenting benefiting those with stable coronary disease, but utilize the psychological fact that majority of patients believe undergoing angioplasty improved their long-term survival rates, rather re-enforce the false belief and scare them into un-necessary procedures. This situation may be not infrequent in countries like India as well where it is not uncommon to hear the adage that “this is a widow-maker lesion” or “life is hanging on a thread” thus feeding on patients and their relatives anxieties. The case of stenting is just a “tip of the iceberg,” similar overuse of medical devices and therapeutic interventions is widespread in other fields as well.

8. Physicians disillusioned!

With all these developments an average physician is completely confused and is facing a serious dilemma as to real goals. The transition probably starts right from the beginning of medical studentship. There is an anecdote; a first-year student arrives on the medical-campus with a heart full of empathy to meet patients’ needs. However, by the end of the medical college education she is no longer enthusiastic about her profession or even serving patients but turns inward in order to survive the day-to-day difficulties even out-right abuse; she faces daily as a medical student. In response to a survey, she expresses, “I've become numb. So much of what I do as a student is stuff that I do not fully believe it. And rather than try to change everything that I consider wrong in the hospital or the community at large.” She confesses, “I just try to get through school in the hope that I will move on to bigger and better things when I have more control over my circumstances” The worry is that this story is getting commoner with many medical students. Even older physicians may be no different. In a recent survey conducted by Merritt Hawkins & Associates (a US physician search and consulting firm), over one half (52%) of the physicians 50–65 years old who responded to the 2007 survey indicated that in the last five years they have found the practice of medicine to be less satisfying, whereas an abysmally low (10%) number of practicing physicians found the practice of medicine to be “very satisfying.”¹⁹ There are three competing impulses: On one hand is the need to self-enrichment both monetary and social but on the other hand is requirement for regulation both by society and self and finally, there are seemingly lofty goals like patient welfare, truth etc. These 3 impulses are completely tearing him/her apart, something akin to Kafkian “Country Doctor.” The fact that majority of them still put a great value to the prestige of being a doctor (much more than money) can be well exemplified by the fact that if you look at any email group of a doctor, emails starting with “dr” or “doc” constitute more than 30% whereas statistical probability of this arrangement is only 0.015% and is certainly much more than any other profession, engineer (“en”) for example. It clearly shows how much personal space is occupied by his/her own profession and how much prestige he/she entails to it so that it even becomes a part of their personality. Another interesting aspect of a physician is (and I am sure many non-physician friends and even their non-physician wives will vouch for it) that whenever two or more physicians meet, all they discuss is their patients (their problems and their solutions). Again I doubt any other professional shows the same kind of “commitment” to their profession. As a matter of fact there is a common adage with the physicians that “patients and medicine” is their first wife. The Merritt Hawkins & Associates survey found that for physicians “patient relationships” and “intellectual stimulation” was the greatest sources of professional satisfaction. Sixty-one percent of physicians cited “patient relationships “as the single greatest source of their professional satisfaction, while 21% cited intellectual stimulation as their single greatest source of professional satisfaction, responses that were generally consistent with those of physicians surveyed in 2004 and 2000. In fact financial rewards contributed to less than 10% of satisfaction.”¹⁹

The fact that physicians place a great importance to ethics and morality is brought out by several facts. The foremost is self-regulation. For example MCI found 75 physicians guilty of Medical Negligence/Misconduct during Jan.2011 to 31.01.2013 (2 year period) and took action against them ranging from warning, censure to removal of name from Indian Medical Register for upto 5 years.²⁰ Although, this indictment may seem miniscule but compare with the fact that self regulation is either non-existent or woefully inadequate in many professions. For example (to best of our knowledge) with Bar Council there were no indictments for last many years (last indictment occurred 8 years back). The case of Press Council of India (PCI) is even more interesting. India has the largest number of newspapers in the world. In the year 2011 80,000 newspapers were registered with PCI. However, the strongest decision that the PCI has taken till 2012 was to censure a publication and direct the editor to publish a rejoinder or an apology in connection to the complaint. Councils for other professions are virtually non-existent.

With this background it is really sad that a physician is losing faith in his/her own profession: well exemplified by the fact that currently even majority of physicians are not encouraging their wards to take up this profession, a marked departure from the popular belief that “doctors sons/daughters become doctors.” Further, this phenomenon is not restricted to India even those countries with so called robust health-care system for example UK are troubled with physician shortage so much so that NHS has to meet the requirement of health-care personnel by recruiting from East Europe and Asia. As a matter of fact, in the Merrit Hawkins survey 57% physicians surveyed conveyed that they would not recommend medicine profession to their children or other younger people.¹⁹ In fact, in a recent survey, 9 out of 10 physicians did not recommend anyone to choose medicine as a profession. Further, several surveys have shown that physicians as professionals have the highest risk of suicide among all professionals.²¹

Thus currently there are two major problems afflicting the profession. First, the loss of prestige of the profession (treating it as a mere trade) which leads to the second problem; shift in priority of physician from patient care to money making. The second problem leads bad long-term outlook for the profession by attracting wrong kind of individuals within this profession.

9. What is the solution?

Firstly each and every physician has to understand the historical evolution of medical practice, only then will he/she will be able to put his own practice is perspective. This knowledge should be imparted right from the beginning. In other words medical education will have to be re-structured where in while focus should be placed on gaining medical knowledge and skills other areas should also be included in curriculum which will help students understand how this profession is different from others i.e. putting others (patients) interest first even before self-interest. Once students get enrolled in medical education they get more and more immersed in the field of medicine so much so that they may even lose contact from society and start looking at it as if from a distance. “Fresher–Senior interaction”, the first initiation in this field strengthens their process where the students start identifying more and more with their profession. Thus need of the hour is to also give a broad introduction to all professions so that we can put our own profession in perspective which will not only help understand the world in general put also better understand our self. Another important education is about understanding “Regarding Pain of Others.” All living beings try to avoid pain; animals even avoid looking at pain of other animals of their species. It is only human who can watch other human in pain (sadists even obtain vicarious pleasure in it). On the other hand, understanding the physical and mental pain of other individual helps sensitize the human being towards it so that they can become committed to its amelioration. Thus, these issues (for e.g. those involving terminally ill patients or other social issues) should be discussed up-front even at student level so that they do not lose touch with pain of the humanity.

Regarding the second problem a simple solution is to strengthen the regulatory bodies to promulgate guidelines, appropriateness criteria, accreditation mechanisms, requirements on training, etc and also enhancing the executive power of these bodies so that they can suitably discipline when necessary. However, a better way at an individual level may be to utilize human behavioral approaches. The usage pattern of investigations may well decrease if every physician while prescribing or performing a investigational procedure was to ask himself/herself, would I prescribe this procedure if the patient was my own child? This puts clinical decision-making based on moral considerations, very closely related but exclusive from the category of ethics. Another approach may be to return to the traditional medicine ideology, where care is provided to the individual based on subjective clinical judgment, notwithstanding the contribution of objective investigative tools.

Admittedly the environment has become rather adverse because of infiltrations of traders in our profession; perhaps most people who now control our profession are traders who have come in with a lure of profit. But we as a Medical Professional should be able to resist the day-to-day temptations offered by them and call “Spade a Spade.” Further we should ourselves become whistle-blowers and sieve out our own who have now become “traders rather than professionals,” and make sure that they change their practice to more ethically mandated one. This way there will be no need for some professional from entertainment industry to tutor us among others or the legal system to penalize us.

The society on its own part certainly has a role to play (Medical Profession too operates within the society). Rational re-imbursement for physicians is important: keeping in mind their experience and skills so that he/she don't have to resort to faulty and un-ethical practices. Further, the society at large should understand the broad ethical and moral mandate of an average physician plus enormous sacrifice undertaken to acquire the knowledge and skills and subsequently enormous dedication (without even concern for themselves and their families) with which an average physician operates. Only then it will instill some trust and confidence and permit right kind of individuals to pursue this profession.

If however, these issues are not addressed and urgent solutions not provided many more Chhattisgarh are just waiting to happen.

Trying to keep up with others

And I know this is what bothers

That's me in the corner

That's me in the spotlight

I'm Losing my religion

Oh no I've said too much

But I haven't said enough

Conflicts of interest

The author has none to declare.

Your comments are invited on the above write-up. Two contrary views/opinions will be published in the next issue of the Indian Heart Journal in the section “Other Side of the Moon”. Write to us at editorihj2015@gmail.com.