Medical Menu as per the Government's Guidelines

The Government has passed another one of their intelligent directives for Private Hospitals in the country. “ Private Hospitals will have to display treatment costs “. While all of us in the medical world immediately understood the futility behind such a brainless announcement, the piece below is an email I received in response to the same. It was just too good to pass up so I am borrowing it for my blog. The language has been edited to a certain extent for correctness.

Just imagine you enter one of the leading private hospitals of the city. You would be welcomed by a board. You always are greeted by a board displaying names of the Consultants at the Hospital, but this time it would be a board like this.

TROUBLE HOSPITALITY PVT LTD 

TODAYS MENU 

Appendicectomy   ( Served all week days during routine hours) 

Rs 25,000  Gen ward,     Rs 30,000 Twin Sharing,      Rs 35, 000 for Single Room.     So simple…… wait… wait …. With Vicryl  Rs 400 extra, 

Spinal anesthesia  Rs 2000 (We use all Disposable spinal needles of BD company) General anesthesia 5000 extra;  

Cautery:  Indian cautery  Rs 1000 extra, Allen Rs 2000 extra and Valley Lab Rs 3000 extra. 

Drain: Corrugated Rubber Drain Rs 25 extra; Tube drain Rs 100 and Romovac Rs 250 

Dressing: Indian dressing white color leucoplast Rs 10, Pink Rs 15, Micropore Rs 20  Mepore and Tegaderm would be 25% handling charges above actual. 

Daily round: First Visit Rs 500   Second Visit Rs 300 (that is if I come on my Bike) Rs 400 if I come in my car. 

Few stars at the most unnoticeable corners: Conditions apply OR … under general ward conditions (under Test conditions). Actual bill may not come DOWN to the bill under test conditions 

Lap Appendicectomy: Rs 35,000 Gen ward,  Rs 45,000 Twin Sharing,   Rs 55,000 Single Room, Rs 65,000 Deluxe, Rs 75,000 for the Suite 

Cautery: Bipolar would be Rs 3000 extra, with Harmonic would be Rs 8000 extra. 

Two port appendicectomy would be Rs 5000 extra, Single port would be Rs 10000 extra and Natural orifice would be Rs 15000 extra.  Those who wish to get more details of our today’s speciality NOTES surgery may please contact our staff; on the TOLL NOT FREE number.

In my college days, we studied that there are 69,788 illnesses and pathological conditions precisely  that can afflict the human body. 

So, I can imagine that if such rate list were to be put for display, they would cover almost all the walls of the hospitals available on the inside of the premises ( as the exteriors are reserved for the Morcha calls of various parties, federations, social  disorganizations, shelter for the homeless etc etc). This would be part of the hospitals CSR strategy.

Coming back to all seriousness. There is a case for letting the patients know the cost of what they are getting into and there must be a way to get it done but mindless directives are not going to help. How about getting insurance providers to put a REASONABLE fix on the prices of surgery and then not backing away from settling when the time comes. The insurance companies had tried to fix a rate on common surgeries but they're rates were so ridiculous that it would't even cover the basic charges in most nursing homes.

The only suitable solution and one that would require a mammoth effort from us, the doctors, is that if we devise package rates for our procedures and stick to them irrespective of who comes in for treatment. Declare it to the patient during the consultation phase itself and then don't fear of them going elsewhere for treatment. If they can afford you, they will come back, else let them go and don't crib!

I'd love to hear comments from other Doctors and of course the views of the general public for whom this is being done.

Write your comments below!

Aamir Khan Vs Robin Hood

A rather curious name for this post, wouldn't you think? Let me try and express what I mean.

First of all, let me make it clear that I had no intention of reacting to the television programme, Satyamev Jayate - which translated means "Truth alone prevails". Unfortunately, a slew of facebook posts and email from doctors has made it necessary for me to write this and clear my mind for more important things like my kids!

Aamir Khan, was, is and most likely will continue to be one of the most respected stars of the bollywood industry. He also is very successful and has a following that will ensure the success of his show. The contents of the show, therefore, must have been reviewed by him, much like a manuscript of a film before he signs.

Now, a lot of people, mainly Doctor's are going on about how his research is incomplete, how he hasn't shown the full picture (pun intended), how he was biased against us in that show. But of course! How do you expect the show to gain ratings unless there is some sensationalism in it. He has to bat for the underdogs to garner support from the mass public that watches his show. He, in effect, has to rob the rich to win over the poor.

Before you take off on me being one sided and blind to the facts, let me state here that most of what he said on that show was and is true and will continue to be so. Yes, there is a large pharma doctor nexus, yes there are benefits we get from them, yes there are many doctors that claim and give referral fees, yes most of the big hospitals have started doing so officially as well. 

But.....

No, not all are like that, no, not all doctors prescribe only expensive medicines, no, not all doctors go on all expense paid vacations to foreign lands and no, not all Doctor's accept referral fees, No, the fee DOES NOT CHANGE if the Doctor refers you somewhere (Surprised?) , no, not all doctors are like politicians! (Ok, I just slipped that one in). 

The only reason he is getting so much attention from the Doctors, is that there has to be some measure of guilt there. Otherwise, no one would have bothered reacting. They're scared that what they do would come out in the open. Like a wounded tiger, there are ready to strike, fangs bared! Like the robbed king they want to get rid of this robin hood! Which only serves to make people think what he said is all true and all correct.

Getting to my main point at hand. Should we get the Medical Council of India (MCI) or the Maharashtra Medical Council (MMC) to change the way Doctor's behave with their patients. I have a few suggestions which are so far out, that probably at first no one would agree with them, but I urge you to read them twice in light of the facts.

1.) Change the way we receive the education needed to save lives. 

As of now, this is just a theme to give and pass the exams. At this point of time, 99.99% of freshly graduated MBBS Doctor's would not know how to do CPR, or treat a patient of Malaria in this country without supervision. We learn by experience and we learn during our internship.

2.) Our internship is basically manual labour where we collect blood, write out reports and histories and rarely if ever prescribe medication

3.) On completion, we are so busy trying to study for post graduate examinations, that there is no time for practical hands on treating knowledge to be gained.

4.) The Government wants us to serve in the Rural areas and to stop us from going abroad to pursue higher education and specialisation. Offer better universities with transparent admission without charging crores to gain admission into super specialisation. This is rampant and ignoring this has the problem so far.

5.) Allow all medical practitioners from all countries all over the world to practice where they want. You'd be surprised at how many Doctor's want to return to their home villages and practice there.

6.) Allow generic drug prescriptions. Shocker! I'd probably get shot by the pharma mafia for this. Most developed countries have generic drug prescriptions and for that matter, qualified pharmacists attending chemist shops and pharmacies!

7.) Consider allowing medicine to function as a brand partner. Allow sponsorships in medicine. Keep in mind this has to be combined with generic drug prescriptions or it won't work.

Look at it this way, in today's world Branding is everything. If I offer my patient a choice between generic ciprofloxacin and branded ciprofloxacin, they most likely choose the latter. If the patient is party to the choice, then why can't I endorse a brand of ciprofloxacin. Make it legal. Make it so that the patient makes the choice! It is possible, just not doable. Anyway, most of the chemists, dole out what ever they see fit in spite of prescriptions saying its the same drug. Just because Aamir says Thanda Matlab Coca Cola, does not mean I will drink only coca cola. I know this is a far fetched generalisation but to an extent it is true with the influence he has.

Further, how come the law makers get away with allowing supremely high prices for drugs available in generic form. If the Pharma companies are working to recover their costs on Research and Development which costs them crores, how about Doctors working to recover their costs of studying till they are 30 just so that they can make a living. 

According to a financial planners estimates, the amount a doctor spends on education (and now Continuing Medical Education, CME) can be recovered only by earning for 50 years taking into account discounting for future value of money and inflation. Which means, if I were to invest all the money I'd spend on my education, I wouldn't need to work for 50 years! I chose to do so, because I want to treat patients. Make them healthy. Have that respect that I deserve. 

Most Doctors would treat a large number of patients for free throughout their lives as medical practitioners. I'm not even counting the ones we serve during our internship and college days (they are still getting treatment remember!) How many shows would Aamir do for free if he wasn't making the millions that he does today?

Would he have gone to the borders if he wasn't a successful Actor and was not sponsored by some product.

Almost everyone lives on sponsorship of some sort. I'm not saying it's ok. I'm just saying it's prevalent and therefore the norm.

Consider this, you come to me as a Patient and I reassure you that you need no medications, You promptly thank me for my wisdom, then question why you have to pay me because I didn't prescribe anything, then go off to the next willing Doctor who is only too eager to write a prescription. Who's the good Doctor now?

Lastly, the issue of consent. This is such a worldwide problem, that it shames me to even address it. Written Informed Consent is something that is 99.99% not successfully obtained anywhere in the country. The reason is this. It is impossible in today's world, to accurately describe all the possible complications of any procedure to the patient in the language he understands best. This is for 2 reasons. One, the Doctor cannot list out everything that can go wrong in details to each patient for each condition and second the patient may nod and assume he has understood but he may not have and will turn at the slightest hint of something going wrong. That is why, the courts, work on the assumption of satisfactory medical effort and not exact workings. The other thing with consents, is that they are most difficult to obtain in emergencies, because they are either given without thinking during such emergent times or the people are just not ready / there to sign the forms. In this case, we're damned if we treat and damned if we don't!

It's not easy being a Doctor. Certainly not as easy as being a TV show host. But, no matter how money minded we have become, we still try and do our best for the patient. Yes, we may try to earn as much as we can out of it, but that's what everyone does. Try and make a living. Only, we do it with the intention of healing someone at the end of it. What's your motivation?

Conferences....A money making event.

Have you ever wondered how even though you are a Doctor, you frequently end up with less hard cash in your pocket that your friend who decided to work with an event company? I found the secret! They are making all their money from us!

What with the MMC deciding to impose credit hour diktat on us, we are forced to attend conferences. Knowing this, most medical associations and a few business minded professionals have decided to milk the proverbial cow by holding grand conferences in grander hotels in even grander cities around the world charging us an arm and a leg to attend and earn these points.

Don't get me wrong. I'm not saying we do not have a choice. Of course, there are local CME's and conferences we can attend, but the excuse is just too good to pass up, isn't it. With the result, we have event companies, charging bombs to organise these events, along with tourism, travel, stay and what not. Final Accounts: Minimum registration for one day at an overseas event - A mere $325 only! The full conference $650, and welcome dinner and grand gala dinner (or some fancy title for a buffet) $100 extra. Sure, they will help you get airfare cheaper (saves a couple of thousand Rupees at the most) because somehow they have to get you there. This is nothing more than the same peer pressure we parents complain about for our children. Of course, you must attend that conference. So many famous Doctors will be there, you must go and meet them! Also, put it on your resume that you went to this grand hotel for the conference.

I have been part of an organising committee of a few such conferences and invariably we always get sponsors for the event. Also, most of the organising committee are free (including stay and travel). Counting the sponsorship amount and even the minimum registrations required for the conference to go on, the organisers stand to make a cool profit of at least 100% of the costs at bare minimum. If the conference is a hit, double this easily. Take home for the event company is  usually a percentage (ranges from 10% to a cool 25% for more experiences companies). That's alright for them, but is it right for the Doctor's to be doing this? 

Son, you are going into business. No where close to medical school! 

MMC Registration Renewal....What A Disgrace! Part 2

In continuation with my previous post, the renewal fiasco plays out like this for most people:

1) Attending medical conferences for the sake of credit hours: No heed given to the topic at hand. If Bluetooth technology was made compulsory at these conferences, we could have a round of counter strike on the phones while the lecture was being delivered, or play Texas Hold 'Em Poker with each other. If no one participates, one can at least complete the entire angry birds sequence.

2) Accumulating above certificates: taking great care that there are no spelling mistakes where the name should go. We didn't even bother this much when we went to register for our Aadhar Cards (the western equivalent of Social Security Numbers)

3) Maintain these certificates: This would include locking them up in our filing cabinets, bank lockers, under the mattress, just out of reach of the children and dogs (God forbid you would have to go and explain how your dog ate your certificate!). You get the general idea, more precious than stocks, bonds and gold certificates, these are! Heavens forbid, you fall short by 2 points and have to attend one more irrelevant conference.

4) DD: Demand Draft / Pay order: Of course, the MMC won't accept cash, lest someone think they are corrupt or can be bribed (like that never happens). So, its off to the bank to make a draft. It must be a Nationalised bank, it clearly states on the notice of the MMC. It's just a mere coincidence that there is one at the compound of the building where it is located. The kicker is that the bank would charge you about 72 Rupees to make the draft in cash. So, make it at your bank through your account, some wise people advise. Sure, I did that. It cost me 56 Rupees. Slightly less, enough to save for fuel to go to the office (Of course, this is possible only people like me who travel by bike, what with fuel set to touch 100 per litre soon)

5) Bright Spot: The IMA has been authorised by the MMC to collect applications on its behalf. Only for its members though. Good enough, we all thought. A lot of people benefited. Not me. You see, the MMC failed to mention in it's good news that they always embed something bad which can only be known if you read between the lines. 

From here on, is my personal experience at getting this done.

6) The Problem: With draft and certificates in hand, I went to the IMA office for the renewal. Just as the person in charge was about to start with me (after about a 10 minute wait, while he was on some other planet apparently cause there was no one else there), he drops one on me. The IMA would not accept the draft. Only cash!! Right. What am I supposed to do with the draft then. Cancel it and return it to the bank. Alright, doable right? I called up the bank (I've learned to keep the bank landline number handy, just for cases like these). It's possible to cancel, he says, but I would be charged. It seems the charges for making a draft and cancelling are the same, i.e. 56 Rupees. I stood to lose 112 Rupees for no fault of mine. I know that this is not a big amount but it's now a matter of principle. Since, the MMC office is not too far from the IMA office, I decide to go there. It's about 4 o'clock now.

7) MMC office: I reach there by about 4.30, worried like crazy that they would be all ready to shut shop. Allow me to digress for a bit. The MMC office is a shame to not only the medical profession but any profession anywhere in the world. If I was to go abroad and describe to my fellow medical professionals where my registration was done, I would lie and say online. The office is on the second floor of a chawl type building, with the mandatory pan stains all over the staircase, with no obvious assistance for the disabled to reach there other than being lifted by someone. The interior of the office stinks of sweat, with gross leakage over its walls, spiderwebs hanging about, with no washroom in sight for any of the 20 people who work there. Coming back to my plight. There was a line of about 20 people waiting to get their papers registered. The layout as shown below:

 

8) The Royal Runaround: As soon as I entered there was a line to my left. Assuming this was the place to be, I asked the lady for assistance. I was told to go on inside. Went in and stood at the desk on the right. No one there. Saw the board up ahead marked Registrar. Went in there. An old man, sitting at his desk told me to go to the door on the right for renewals. Good I said, finally an answer. Went there and stood in line. Luckily, I asked someone if their documents had already been verified. They had. Mine had not. I went back outside to the desk to find someone who would do it. No one there. Walked across to the left. Someone told me to wait and the person would come. No one said where though. Waited, it was nearing 5.15 now. I happened to read a notice saying the registration process would remain open till 6.00 pm. The office next to the registrars was the President's office. No one there either. Went back to the leftmost office. I was told the old man who spoke to me first was the registrar and he would verify the documents. He was sitting across the table from the guy who told me this, but did not budge. I asked him politely to please come back to his desk otherwise, the submission table shown on the right would empty out as all were itching to go home.

  9) Indian Standard Time (late to start and early to finish): He gave his watch a glance and had the audacity to tell me, "Time's up!". Somehow, I controlled my annoyance and told him the notice outside his office says it's open till 6.00 and I had half hour left. 2 more Doctor's came up behind me for their verification. That spoiled his plans of leaving early. Anyway, he was back  and went through my documents. I had 3 sets. 2 for my parents and I for myself. Theirs went through without a problem. I had a certificate from a conference that had granted 8 hours for the duration of 4 days, but he signed off on it saying maximum 6 hours.

10) Clueless: Now, this is a certificate given by the association carrying out the CME, but it has to be passed and signed by the MMC. So, clearly they knew they were signing off on 8 hours of CME credits. Now, it seems, the maximum for this conference was 6 hours. If you are not going to give the 8 points of credit, why issue the certificate saying so in the first place. Just one more discrepancy in the MMC. Anyway, this meant that I fell 2 points short for renewal.

 

11) Options: I do have a paper published in an International Journal, for which, according to the MMC circular I should get credit points. I ask the office person there, what the procedure is to get published papers verified and claim the appropriate credit points. I also had an International Conference attendance CME Credit certificate.

The procedure for both of these is to write an application to the Registrar and submit it to the office and they would get back in 15 days with the credit hours result. This was the primary reason for my trying to get the points out of conferences itself. This meant that I would have to go back to the office another day to submit the copies of the paper and European certificate along with the application.

12) It gets worse: I did that this Monday. I was shocked when I reached. Apparently, the notice of extension of the time frame for renewals (it's now extended to May 2012) was not published in most newspapers with the result that everyone thought 28th February would be the last day. The office was like a fish market with at least a 100 Doctors crammed inside like a jar of sardines!

I quickly walked through some toes and submitted my application and left in shame. Now, to wait and see what happens after 15 days. I wonder, sometimes, if this is worth it! Keep reading for part 3.

MMC Registration Renewal....What A Disgrace!

The Maharashtra Medical Council (MMC) has come up with a new law which states that every registered Medical Practitioner must accumulate credit points to the tune of 6 per year (30 in 5 years) for renewal of their registration, thus enabling them to practice legally. These points can come in the way of Continuing Medical Education (CME) Conferences, Publishing National and International Research Papers, Presentations and even Attending Conferences abroad.Since this law came into effect sometime last year, everyone was given a diktat to accumulate 12 points for renewal this year.

Fantastic Idea, some young Doctor's including myself said. It's worth it. We should keep in touch with new material for our patients. Yes, it was a good idea. But with every good idea that India has, we seem to have a bunch of coconuts running the show in the background. CME's are the backbone of a progressive medical society but the lacklustre MMC seems to have just copied the idea from the west for reasons only they know.

The result of having a good idea but poor execution is that suddenly there is a mad scramble from Doctor's to attend conferences. Any conferences that offer credit hours. It does not matter whether the topics are relevant or not. I could go to a dermat conference, gynaec conference, not have a clue on the latest techniques they use but still get my credit points to renew my registration.

 

Similarly, someone completely unrelated to the field of plastic surgery and robotic surgery could earn as much as 4 points for one conference by just attending it and playing on his/her phone all throughout the conference days and walk out a happier Doctor.

My question is, do you want a Doctor to be accredited only on the basis of attendance. Sounds a bit like nursery school to me. Attendance register, tick. Points, tick. Registration Renewed, Tick!

 

What they have to do it work out a solution wherein Doctors from their respective specialities attend those conferences that are relevant to them. Better still, start online CME's. With a 10 point multiple choice question answer session at the end. Not everyone has the time to close their practice and go for a conference for 2 days in a month. Some of us are still building a practice and need to be on call. This would be a boon for us. If the MMC could do this in partnership with someone, maybe a lot more Doctor's and patients could have more faith in them!

My next post will talk about the ordeal one goes through after the above is completed and you have to go to the MMC office to submit your documents for the renewal.