NON SEBI SED OMNIBUS –Latin words in a British Era institute, built by, for, and run by Indians. This was my introduction to Medical School. The words are indeed the guiding life philosophy of not just doctors created by my college, but doctors everywhere; it means – not for self, but all, and encompasses the Hippocratic oath and empathy of the profession into one simple sentence. While working in such a noble profession, dedicated to the service of humanity, transgressing national, religious, and ethnocultural divides, doctors have made medicine a respected field worldwide. But after all the reverence and the caring and the selflessness, we are reminded it is a profession, an occupation, a job. At the end of the day, the doctor must earn to provide for themself and their loved ones. So what exactly is the fine line between medicine being the noble service field or dropping to the publicly perceived obscenity of medical practice, that is business?
Medicine has undergone a drastic change in the past few decades, from knowing almost nothing to knowing close to everything. In practical terms, this means we have shifted from one drug for all ailments (penicillin for literally every infection) to a specific drug for even the rarest of rare conditions. The average physician’s mind is loaded with more facts, figures, and numbers than most people in human history, and they must rely on themselves to effectively recall this during patient care. Now, doesn’t that deserve appropriate remuneration? That is the question of ailing medicos today: should the healer live amidst and like the people they treat, or should they be compensated for all their time, effort, and skills that set them apart from the rest?
Dr Sanjay Shah, former President, IMA, has attributed the shift in attitude towards medicine to commercialization of the field, owing to large lacunae present in the government healthcare model. When private players take over an industry dedicated to selfless service, it is bound to have the profit motive to secure its interest and long-term survival. This is reflected in its ever-increasing influence in affecting the policy and practices of the medical community.
“When physicians have banded together to form corporate entities or hospitals, they have eventually found themselves out of their depth. None of us learns anything about managing a business in medical school. Enter the management consultant, accompanied by his band of trusted executives with large salaries and a new vocabulary. They have sometimes provided good advice, but unlike the physicians, they put profits first and patients next.” – Dr Prameet Singh, Psychiatrist, NY, USA.
A sizable few doctors believe physicians must embrace the business component of medicine. This is not to say they hope to reap enormous profits from providing patient care but simply adopt business practices and acumen to help improve operational efficacy and enable the hospital to work to its maximal capacity. This type of thinking and application of business science is quite useful in the resource-constrained setting of India’s government hospitals, which work while providing massive patient subsidies for treatment and diagnostic procedures.
As mentioned earlier, it is now possible to treat even the rarest conditions that ail the body; and that is a miracle of modern technology. The people who made those technologies possible and accessible for medical service do deserve credit. Often, these drugs and therapies have huge costs of research and development, something that gets passed onto the end consumer. With sky-high costs, it might seem a bit Darwinian (‘survival of the fittest’) – the rich may live, but the poor have no hope. However, to some extent, companies can justify their costs by claiming they need to secure their break-even point, that such drugs won’t sell a lot, and they need to keep prices high to ensure company viability.
A nurse in the USA, where privatized healthcare is more than commonplace, recalls from her experience of 50+ years and tells the story of how the pharmaceutical industry has created the delusion of living a consequence-free life since the drugs to treat any problem have already been made. Simply put, they have eliminated the felt need to stay healthy, and she believes that this thought process might have trickled down into medical practice – being heavily influenced by pharma reps and advertisements – to the point where a medical practitioner might feel “there is no money in keeping people healthy”.
Even reading about the first-hand account of a patient of Age-Related Macular Degeneration(ARMD) shows us how the modern medicine industry has more likely than not fallen from grace and is viewed by the public as a money-making machine. The author laments how medicine secretly wishes for good health because even in old age, it stands to make a profit from ‘life-saving’ medication.
A study conducted to check for differences in patient satisfaction in for-profit, and not-for-profit setups found enrollees in nonprofit plans were more likely to be very satisfied with their overall care than those in for-profit plans. Among those in for-profit plans, sick enrollees were more likely than healthy enrollees to report unmet need or delayed care and organizational or administrative barriers to care; they also reported higher out-of-pocket spending during the previous year. While the study hails from the USA, which is famous for inequitable healthcare, a similar worrying trend is developing in India as well.
From the research standpoint, the close association of Big Pharma (The global revenue of these companies was more than $1 Trillion) with drug safety and efficacy testing and sponsorship of clinical trials presents a clear conflict of interest, and the impact can be seen, when only articles supportive of the therapy measure – be it a drug or a device – get the research funding. Many authors have called out this behaviour of pharmaceutical companies since whatever is published influences the practice of millions of doctors all over the world, and exerting this undue influence further cements the possibility that the doctor will prescribe a pricey medication over the generic one because all studies are full of praise for this new drug formulation. The MCI had also conducted a probe into prescriptions of 300 doctors when it found them preferring a more expensive alternative instead of the generic and much more affordable option.
Irrespective of the fact of whether this problem of profiteering affects the whole or part of the medical community, we must be aware of how it looks to the onlooker or the passerby; because although the community at large may have patient interests at mind, it is the snide remark or cheeky comment on the malpractice of a few misguided medical professionals that can malign the image of the entire group.
As one doctor has very quaintly coaxed us to introspect into the situation, no matter whether we consider medicine a business or a service, we must wonder “what business are doctors in?” Is it about treating patients to help them recover from whatever ails them, no matter the cost to society at large? Or is it about providing a patient with a limb prosthesis even though they cannot afford to pay for it? What about keeping the public healthy first, so they do not get sick, and saving all that money and technology? Are we not supposed to provide parking bays for our patients so they will not be driving around in circles while we literally drive into our offices?”
And it is not simply a lecture in ethics – we must embrace the fact that we now live in a Post-truth era, where emotions and stories matter more than patient statistics and the number of digits in our bottom line. A doctor stands as an embodiment of the morality of the society; when medicine comes to mean profiting from suffering, from the public viewpoint, it is equivalent to violating the sacrosanct bond of doctor-patient. We must take a step back and recalculate; viewing medicine as a business is not healthy from a doctor’s angle. While we aren’t best equipped to handle the management of large hospitals, we are very well aware of how and what to communicate with the patient to ensure their comfort and allay their apprehension. Thinking of each patient as a mere statistic for the hospital ledger would be detrimental in the long run. As a community, we need to band together to maintain our image and strengthen our bonds with the public. We must work to put the image of the profit-seeking physician to rest, once and for all.
