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| Sunday, 2 October 2005 |
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Features |  |
| News Business Features Editorial
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Medical treatment or business venture? by Consumer Watch It was in the late 1970s early 1980s that one first encountered the rather disturbing reality that in the United States, the practice of medicine, a once noble service that was even considered a vocation, had evolved in that country, into a "Business", with its professional goals being diverted from those of service to those of sales promotion and bottom line profit. One never seriously thought that these business approaches to a profession held in high regard and respect for centuries in Sri Lanka, which has its own historic traditions of indigenous medicine, would permeate this society as well, and seriously damage the way medicine is practised here. But they have. A medical practitioner's legal right to have a 'Private Practice' in addition to services provided as part of regular employment is what is deemed to have corrupted the practice of medicine in Sri Lanka. The lure of additional income to doctors receiving salaries that hardly meet the rising costs of living no doubt have been hard to resist. In the United States, it now costs a student as much as $250,000 or more for tuition alone (i.e., over Rs. 2.5 million) to obtain an M.D. (Doctor of Medicine), which is obtainable only as a postgraduate degree, and this only AFTER obtaining a Bachelors Degree, which costs perhaps a further $60,000 to $200,000. In Sri Lanka, on the other hand, qualified students are admitted direct to the Faculties of Medicine, and they obtain their MBBS (Bachelor of Medicine, Bachelor of Surgery) after nearly 5 years of study. The M.D. can be sat for only after an internship has been completed. All of the tuition during the several years of study for the MBBS is paid for by the Government of Sri Lanka (i.e., by the taxpayers). Bedside manner Thus, in the United States, the infiltration of business practices into Medicine came about with these continually spiralling costs of medical education, and the student loans that had seen doctors through their medical education, having to be repaid. The greater the number of patients a doctor could accommodate meant the greater the accumulated fees thereby, and the faster the enormous loans could be paid off. So medical practice evolved into one in which less and less time was spent on examining the patient, with less and less time also spent on giving the psychological therapy that went with doctor patient interaction such as when obtaining important information on patient history through conversation with the patient. Ascertaining patient history etc. came instead to be obtained through form-filling. The old adage of a "bedside manner" being one of the hallmarks of a popular doctor and part of the psychotherapeutic aspect of healing became more and more obsolete. Along with all this came the influence of large pharmaceutical companies that promised material benefits such as commissions, educational scholarships for children, fully paid for seminars, vacations, cruises etc. etc. to doctors as incentives for the sale of the drugs they manufactured. Medicine had indeed become a 'Business.' Doctors in fact began taking Business degrees such as MBAs in order to properly 'manage' their practices. Public Relations aspects such as courteous service for maintaining a clientele, as well as pleasant waiting-room environments, were all seen as part and parcel of running a good business, and became recognised add-ons, standard in medical clinics in the West. Doctors were required by their Practice Rules to see at least 5-6 patients per hour (i.e. not more than 10 min per patient) in order for the business to be successful. Greed factor Some of these transformations of Medicine from profession to business have now taken place in Sri Lanka as well, although the economic pressures that drove the American experience do not exist here. Sadly, we seem to be adopting even more fast-paced doctor/patient interactions here, and these seem to be driven more by the "greed factor," than by the "need factor." While no one grudges the doctors their efforts to make additional income, the problem for the consumer is that the balance between the regular service and the private practice has become weighted too much in favour of the latter, and that in general today, the patient feels woefully exploited. Just the other day, a friend was deploring the fact that after having channelled an appointment with a consultant medical practitioner, he had been scheduled for 6.45 p.m., but waited from 6.30 p.m. for the doctor who finally arrived at 9 p.m., and saw patients only until 10 p.m. During that one hour the doctor saw as many as 55 patients, at the end of which he rushed off saying he had to be at another hospital and could not see any other patients that day. We have been told that 2 1/2 hr. is in fact a short wait in comparison to what most patients have to undergo. A patient told us that he had waited for over four hours to see a consultant neurologist. He was finally taken in at about 11 p.m., and the doctor was so tired he was nodding off. To add insult to injury, while this patient was being examined, the next patient was brought into the doctor's office by the nurse and made to sit at the back of the room; a gentle hint that the examination should be terminated fast? Several aspects for consumer complaint arise from these incidents: 1. No doctor can be expected to make a proper diagnosis if the time spent on a patient is only a little over one minute. With the turnaround time being so short, can a doctor actually make a good examination diagnosis and prescription? 2. The patient who has had to wait for hours awaiting his/her turn to be called in, will invariably be irritable and even angry, and record a blood pressure higher than normal. Is this anxiety factor taken into account? 3. If a doctor who has invariably worked a whole day at some hospital clinic, does private practice late into the evening hours, it is natural that he/she would be tired and exhausted. Can one expect a proper examination, diagnosis and prescription in these situations? Shortage of doctors? With these long waiting lines to see a doctor, and the long hours that doctors work in order to see all the patients who wish to consult them, it seems natural to ask the questions: Is there a shortage of qualified doctors in Sri Lanka? Or, is there an excess of illness in Sri Lanka? Or, do people in their anxiety to seek the best treatment, tend to see consultant physicians for the most trivial ailment? This last factor is likely to contribute much to the situation in Sri Lanka where the population has become accustomed to free medical services and over the years an increased health-related awareness and the linked anxieties that go with it, has reached a point where it is now common practice to seek medical attention for common ailments that could have been treated with home remedies. There is a hyped up urgency to get the 'best' doctor to see a patient at the earliest symptom of anything that could vary, for example, from influenza to viral encephalitis. Gone are the days when one was asked to 'take two aspirins and call the doctor in the morning,' or one would resort to a local peyava and rest and proper nutrition as first line of therapy. Now that new technology such as immunological methods of diagnosis are available, even those illnesses which needed a few days to evolve symptomatically into overtly recognisable disease can be diagnosed early, of course at very high cost, and intervention through stabilisation methods, usually involving hospitalisation, can be applied. That middle path of patience and a reasonable wait before seeking medical intervention has been abandoned. All this lends towards the high costs and the thriving of medicine as a business. Not to speak of the overuse of antibiotics and other strong medications, often resulting in side effects including the generalised depression of the patient's immune system, and increased likelihood of further infections in the long term. The cycle goes round and round. Status symbol Also, the health system in Sri Lanka does not require that a patient be 'referred' to the consultant by a general medical practitioner or family doctor at the primary-care level. Anyone can seek an appointment with a consultant. Granted that this may be acceptable if the patient has tons of money to spend, but if it is a societal status symbol and a misunderstood aspect of medical care that one goes direct to a consultant rather than through the intermediary of a primary-care physician, it needs to be addressed, for the sakes of both patients and doctors. In most 'developed' countries, a consultant will generally see a patient only on being 'referred' by the family doctor or general practitioner. This screens out patients seeking appointments with consultants for minor ailments. Furthermore, the patient comes to the consultant with a properly recorded medical history that makes it possible for the consultant to evaluate the patient without undue wastage of precious time. Laissez faire attitude Sri Lanka's medical education and health care system are superior, but community organisation to fit the health care system is lacking. There is a laissez-faire attitude mixed with the sense that although the health care system is government managed, those who use the government's system must have the independence to go to any practitioner they choose. This is acceptable and works well if the community is small, but becomes erratic and unmanageable when large populations are involved. Like so many aspects of Sri Lankan life, the lack of system and organisation, especially in large urban populations, culminates in a sense of anarchy. If every family in an areas is registered with a primary care physician (either government or private) for that particular area, the system would filter patients better and in a more organised way, so that both patients and doctors would find greater satisfaction in their interactions. In the UK on whose system, the National Health Service, we have modeled ours, patients are now required to have a primary care physician through whom only, access to all the other facilities of the Health Care system is provided. On a lighter note, just the other day, we happened to visit a free medical clinic in Colombo city run by the Health Dept., in order to have a Blood Pressure check and was very impressed to find that it was extremely clean and well organised, with a helpful and pleasant lady doctor in charge. Added to this there were no queues. A neighbour later told that queues sometimes spilled over into the street, but at the time we stepped in, we were the only patients. We wondered whether the patients who should have attended this clinic were instead at some private medical clinic, waiting for hours to see a channelled consultant! Our congratulations go to the Health Dept. for this clinic at the Vajira Road/Duplication Road intersection, which we consumers hope is typical of other such free clinics in the country. Sri Lanka's health care system is indeed a boon to its people, but we the people must understand at what cost this nation provides that care, and not abuse it by overuse or underuse. The system in Sri Lanka is something for us to be proud of, and deficiencies in the system that we too easily complain about should be looked on in that perspective while we look for, suggest, and make improvements. In the United States, which has a health insurance-based system, an earlier tendency to abuse the system by both doctors and patients alike as everything got paid for, was rectified by a redefined system of increased premiums coupled with trimmed services and closer check on the services rendered. However, this has worked negatively due to unethical practices by the insurance companies, and has reached a point where patients are now not insuring themselves anymore. On a more philosophical note, the 'Middle Path' is what seems so difficult to maintain and what is so elusive. However much we refine a system, unless ethical behaviour is recognised as an essential ingredient of a society's ethos, and practised by the humans who comprise it, system failure seems inevitable. Sri Lankans are blessed to live in a country that offers so many free essential services, but these have to be appreciated and 'managed' within a moral framework. The National Consumer Watch of Sri Lanka can be reached at 143, Vajira
Road, Colombo 5. |
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