Cut-practice- The role of consumer awareness

Cut-practice is such a thing that the 'victim' or patients have no means to protect themselves from it. Therefore consumer awareness has a very limited role to play in deterring this practice.

Consumer awareness will only make the patient suspicious and add to his/ her stress levels; there is no way to confirm whether the doctor is doing cut-practice or not. Even if I myself am a doctor, there is no way even I can tell that I am being charged for cuts or not. So how will any ordinary non-medical person figure out that and protect himself/ herself?

Hence, it is absolutely essential that doctors only have to cultivate the good sense not to get into this practice and fight against it.

 I feel whistle-blowers have a tremendous role in reducing this problem. Other than doctors, individuals like chartered accountants who give suggestions, professionals who supply software to automatically route the cuts, income tax officers who scrutinise, and such other stake-holders in this system should expose their clients/ write about it. At least stop contributing to it in any way. 

Lancet- Covering the case of cut-practice in medicine

Tackling corruption in Indian medicine
Some doctors and non-governmental organisations are taking up the fi ght against corruption in
Indian medicine, which many observers claim is widespread in the country. Dinsa Sachan reports.
When a cheque landed on the desk of
63-year-old doctor Himmatrao Saluba
Bawaskar, from a diagnostic centre
under the guise of “professional fee”,
Bawaskar not only returned it, but
he also fi led a complaint against the
centre with the Medical Council of
India (MCI), the national watchdog
for medical education and doctors.
His case is currently being heard by the
state medical council of Maharashtra.
Kickbacks have been part of the
Indian medical practice since the
beginning, says Puneet Bedi, a leading
gynaecologist based in New Delhi
who has appeared on Indian television
to speak about medical ethics in the
country. He notes that many hospitals
and clinics routinely issue cheques to
doctors under sanitised names such as
“professional fee” to encourage them
to recommend their services to their
patients.
K K Aggarwal, a Delhi-based physician
on the ethics committee of MCI,
says there’s no method at present to
document the percentage of doctors
taking kickbacks, but he admits that
the practice exists.
Recent trends may have accentuated
the problem. Bedi explains by citing
an example: out of some 17 million
inhabitants of Delhi, barely 1 million
can dream of getting treated at a
private hospital. “So all the hospitals
are vying for patients from that small
percentage of people”, he explains.
“If they’re not going to use kickbacks,
they won’t stay in business.” Bawaskar
adds that hospitals sometimes put
doctors under tremendous pressure
to reach a certain target number
of patients, and offering bribes for
patient referrals becomes the only way
to achieve that target.
Amar Jesani, editor of the Indian
Journal of Medical Ethics (IJME), says,
“It’s the patient who ends up paying
extra money [in medical fees] to cover
for the kickbacks.” Amit Sengupta, of
People’s Health Movement (India),
says people want to practise honestly
but they get sucked into the system.
“The system throws those out who
don’t conform to its rules”, he says.
Experts, including Jesani and
Sengupta, believe that one reason
malpractice flourishes is because of
MCI’s lethargy in cracking down on
wrongdoers. In 1996, a Chennai-based
nephrologist M K Mani wrote to MCI
and reproduced his correspondence
with a diagnostic centre that had
offered him a “professional fee” in
the IJME. The diagnostic centre had
repeatedly sent cheques to the doctor,
and even though Mani continued to
write to the Council, no action was
taken by the organisation.
Jesani adds that state medical councils
are also slow to act on issues. However,
last year, in response to a question in
parliament, the government said that
the MCI had received 1948 complaints
against doctors between 2008–09
and 2010–11. Of these, 718 were
referred to the relevant state medical
council, while the remaining
1230 complaints were dealt with by the
MCI itself. As a result, 32 doctors had
their licenses temporarily suspended
and 14 doctors were given a caution.
Still, Sengupta says, “In its current
form, the organisation is more
like a closed club consisting only
of doctors.” He advocates a more
democratised approach in choosing
its administrators. “There is a need
for more legal experts, administrators,
and civil society people in their
committees”, he argues.
Moreover, MCI has invited public
scrutiny and notoriety in the past
few years. MCI chairman Ketan Desai
was arrested and dismissed from the
organisation in 2010 on charges of
accepting a bribe. However, he was
later found to be not guilty. Following
this case, the government disbanded
the MCI’s governing body and
brought in a board of governors to
look after its aff airs. In a bid to restore
MCI’s functioning to its previous
format, elections will be staged
in early December to select a new
council, consisting of the president,
vice president, and the executive
committee.
S K Sarin, former MCI chairman,
defends MCI. “The MCI rules are quite
robust, but enforcement is a problem.
In my time, we cracked down on
plenty of doctors for misconduct. The
ethics committee used to take legal
action on its own in response to tipoff
s. There were several instances of
doctors making their own foundations
and getting donations from pharma
companies, accepting foreign trips for
themselves and their families. These
were thoroughly investigated and due
“...many hospitals and clinics
routinely issue cheques to
doctors under sanitised names
such as ‘professional fee’ to
encourage them to use their
services.”
Tom Grill/Corbis

CUT-PRACTICE- An organised 'white-collar' economic offense

A few days ago someone objected to my saying that practitioners of cut-practice should be booked under MCOCA. The argument was that you cannot compare this with acts like terrorism or money-laundering that are actually covered under this Act. Besides it could antagonise doctors and make them into adversaries. I absolutely dont buy these arguments. I still hold that cut-practice doctors should be booked under MCOCA only.

The way cut-practice harms unsuspecting patients and undermines the fabric of our country- it is no less than any act of terrorism or treason. Just that our perpetrators are educated, sauve and respected members of the community. Having a much sought-after qualification and practicing a 'Noble' profession cannot redeem the fact that you are robbing someone because you believe you deserve more money. In other words it is just a 'white collar' crime.

Cut-practice cannot be done singly. It always depends on good teamwork. That is why it is an organised crime. The hold of this system is so strong (at least in Mumbai) that some doctors have been completely unable to establish their practice without getting into it (so they claim).

I really have no desire to offend anybody. The truth is that among the practitioners of cut-practice are my closest friends, admired colleagues and such other individuals whom I actually value and respect. Thats besides the point. Cut-practice is a crime against humanity. If my associates feel offended by me and want me to change; I would expect the same from them- Cut practice offends me, so stop it.

Someone may say that if you cannot convince your close ones, then why are you eating our head. My approach is that I dont want to tell anyone about doing or not doing cut-practice. I just want the community to know that cut-practice is harmful for the community and that I dont do cut-practice. And my refusal to do cut-practice did put me at a disadvantage in my work, and I am not okay with that. If it were that more and more people stop doing cut-practice of their own will, it will benefit all doctors and patients. I just want everybody, including the administration to see this point. Booking the doctors under stringent laws will help in this direction.

A life without cuts

'Dr Vani, you are such a bright Psychiatrist. But I am sad to tell you, you are not practical-minded'. 'Just go with the flow- give cuts and concentrate on treating patients' 'Changing the World is not a Doctor's job. Look at it this way- Our job is to treat patients and if you dont give cuts you dont get patients......then whats the use of all this learning and commitment?' Words of wisdom from a senior Family Physician. Spoken with genuine feeling and a desire to see me succeed. But Sir, its not like that. Its about the means as much as the end.
        Initially I did not participate in cut-practice because MCI rules said not to do cut-practice. After 10 yrs in private practice, I agree and genuinely feel that one should not do cut-practice.
         After I finished my MD, I joined Dr Harish Shetty's practice as Part-time Assistant. For 2 months I searched for 'jobs' in the mornings and worked with Dr Shetty in the evenings. Within 2 months, he encouraged me to start a morning OPD and told me it was possible to do so without being in cut-practice. So 3 times a week I would be in my clinic, whereas the other 3 days I roamed in Andheri, Santacruz and Parle East and West introducing myself to every doctor, school principal, business owner, etc.
         My job helped me cover my costs. Some people were referred by Dr Shetty, some by my Family Physician, highly esteemed Dr Pingle. A very significant number were sent by my alma mater, NIMHANS. Very few patients walked-in. But the numbers were pathetic. In my first year, I managed a royal number of about 150 consultations in my private practice! But I was present in my clinic punctually, taking every chance to promote my work. Because of trying this and that, and maternity leave and other female-related challenges, I had about 4 false starts in my practice over the last ten years. Only the last 14 months have seen some stability.
         Over the years its built up to sustainable levels. Now I dont need a job to pay my bills. I can cover my costs and also meet my financial goals. I admit that the latter are modest because hubbie dear is the primary breadwinner. It is also true that I am the housewife in my family and spend much less time working. But my hourly earnings are comparable to my hyperactive full-time colleagues. I dont know what I would do if I had to work full-time, as I really do not have those numbers in my practice. Being a part-timer is really a boon for my self esteem right now. But I am confident I could have worked out something, if I had to work full time and generate that much work- I dont want to worry myself over hypothetical failures.
          As I never gave cuts- I could earn as much by working less. I spend my waiting time studying Psychiatry and keep myself up-to-date. As I never took cuts, I was never under obligation to waste my Sundays and Holidays attending mindless programmes arranged by diagnostic centres and pharma companies. I generally relaxed and recovered my health and spirits.
                I am Queen of my domain. I decide how my time should be spent. I give a receipt for EVERY transaction. I have filed honest IT returns and feel very proud when the income tax amount increases every year. Anyway I dont like taxable income, because it is so difficult to get IT Refunds. So I am not afraid of IT department, and my CA is happy because he has a straightforward job of presenting my accounts.
        I cannot tell you how confident I feel that I am surviving on my own steam and the sense of superiority I get. Right from the beginning I have placed a high value on 'perfection' 'excellence' 'achievement' and even from my school days have always tried to distinguish myself in my studies and work. I am immensely proud of getting my education from all good institutes through path of merit.
         Cut-practice is nothing but corruption. Corruption is for persons who are less in some way. Among doctors, is may be due to poor confidence or if you dont have a proper degree from a good institution. Or even if you have all that, it is possible that you are greedy or simply so weak-willed that you are unable to think for yourself.
           I never thought I was ever among any of the above. Thats why I chose never to be in cut-practice. Over the years the clinical work I have done, the friends I have made and the respect I have earned- have vindicated my stand. It is true that Changing the World is a very difficult thing for a doctor, as we are very busy and dealing with individual problems of our patients. But if you have a strong ethical value-based thought process and the will to survive the challenges and the maturity to suffer for your beliefs- why Should I change for the World? No Sir, I dont want to change the world. But I just dont want to change myself too. Is that okay with you?

A COLUMN IN IMA MAGAZINE- ABT CUT PRACTICE

Several years ago, I did a monthly column in the monthly magazine of IMA Mumbai West "Medical Image". It involved publishing opinions of doctors on different issues and the column was named 'WHITEQUOTES'. 

Once I asked the doctors about Cut practice and following is the article:

IMA-NOVEMBER

IMA-NOV.

WHITEQUOTES

According to the MCI Act of 2002, splitting of fees (cut-practice) is designated as illegal and unethical. One study done in Ahmedabad (Bhat, IIM-A, 2003) found that 40% doctors engaged in this practice. Many doctors are probably not aware of the legal and ethical implications of this practice and regard it as a ‘necessary evil’. So we asked some members to respond to this contentious issue, and following are their responses:

Ideally while giving referrals, the primary consideration should be the expertise of the consultant. However, in cut-practice this is overtaken by monetary considerations. So, merit and skill are compromised. Ultimately patient loses out on good care.

Dr Sudhir Warrier, Orthopaedic surgeon, Dadar

It is widespread practice nowadays. In my opinion established consultants do not need to oblige anyone for referrals, but for fresh consultants it becomes difficult to get any work. The young specialists do not get work, not because they are worse doctors, but because they are raw and not known. So, to get referrals they offer financial incentives. By and large it is not right, but it becomes a question of survival for some.

Dr Ashok Shetty, Family Physician, Marol

I am against cut-practice as it is totally against medical ethics. We (doctors) should all come out in open against it- let the patient decide where to go for treatment. I don’t know about other fields, but in our field where we deal with life and death, this is completely unjustifiable.

Dr Neemish Kamat, Radiologist, Vile Parle West

There are two outlooks to it: Some people regard it as a professional kind of sharing of money, without any other connotation. The second aspect is that it may affect transparency in work, increases cost to patient and creates unnecessary obligations to the consultant. Patients may become suspicious and the Family Physician may lose the patient’s trust, which is not such a pleasant thing.

Dr Priyadarshini Gokhale, Family Physician, Bandra West

It is a current trend, so much so that it is becoming impossible for young doctors to establish practice without this system. So some consultants are forced to accept it, even though it is unethical.  Maybe, some senior consultants with an independent practice should leave this system. This practice has started as all the consultants are competing for attention of the limited number of patients who are capable of paying for their treatment.

Dr Rajiv Tungare, Consultant Physician, Goregaon.                                                                                

-Compiled by Dr Vani Kulhalli