The Sunday Magazine of national daily New Indian Express of April 11 2022 carried an article authored by Anand Neelakantan titled ‘Standardize private Hospital Rates to Stop Exploitation of Patients’ https://www.newindianexpress.com/magazine/voices/2022/apr/10/standardise-private-hospital-ratesto-stop-exploitation-of-patients-2439271.html
The article opens with a painful incident of a gynecologist in Rajasthan driven to suicide after she was charged with ‘murder’ by the police after one of her patients succumbed to Postpartum Hemorrhage (bleeding after delivery).
The article, subsequently, goes on to red-flag numerous ailments that have, over time, driven Indian healthcare system itself to ill-health viz; an irreparably broken-down doctor-patient relationship which functions on mutual trust, doctors’ preference for money over gratitude from patients, India’s healthcare dispensation functioning on one of the lowest doctor: patient ratio of 0.74:1,000, against 1:1,000 recommended by WHO, corporatization of Indian healthcare, which the author describes as ‘the greatest tragedy to have befallen Indians’, which bared it’s monstrous fangs during the pandemic, doctors deteriorating into salesmen struggling to meet revenue targets set by their corporate employers, ‘every possible (medical) test being forced upon hapless patients irrespective of requirement’, challenging an inadequate health insurance in India.
Last but not the least, the author lashes out at hospitals for not displaying rates for services offered, like wayside dhabas display rates on their menu!
As a surgical gastroenterologist working in a private hospital in Kochi in Kerala in southern India, the article interested me. I am compelled to write this article to discuss the one penned by an accomplished author like Neelakantan. In all fairness, issues alluded to in the article, and are accused of plaguing Indian healthcare dispensation holds water. Honesty has it that they are largely agreed upon. Propriety has it that they are improved on.
But to the clinician in me who has practiced medicine in India for over 30 years, the suggestion by the author to display rates of services offered by hospitals like menu boards displayed outside wayside dhabhas sounded outlandish. To me, such an exercise would only expedite healthcare dispensation’s further deterioration into a business undertaking.
The author’s suggestion bared his ignorance on delicate nuances involved in the art of healing.
The science of medicine is shrouded by unpredictability, as it is involves interplay of numerous variables, which are taught to medical students as disease-related, patient-related and treatment-related factors. These factors, in conjunction decide treatment outcome, and eventually treatment costs. The outcome can range from complete cure from disease to deterioration and maybe even death. Among the factors mentioned, clinicians probably can claim control only on ‘treatment-related’ factors. That too only to a limited extent. Pharmacological or surgical interventions are resorted to when clinicians stumble on complications, sometimes unexpectedly, as a patient is being treated. Modern medicine has progressed by leaps and bounds that such interventions often render them exorbitantly costly. Ironically. Even a simple procedure like drainage of an abscess under local anesthesia isn’t without inherent untoward outcomes. Even administering test dose of a drug like Penicillin to prevent reaction toward it itself isn’t free of eliciting a reaction .This fact renders standardization of treatment costs within a ‘menu card’ not only inappropriate, but also impractical.
I do not want to leave the readers grossly uncertain of treatment outcome by saying so, or leave them ‘scared’ of modern medical intervention. But the fact remains that the human body is intricately and uniquely constructed that each patient responds to treatment, which is always well-intended, differently. That is exactly why the pregnant patient in Rajasthan under the care of the gynecologist succumbed to post-partum hemorrhage (PPH), leading to the latter’s suicide.
Majority of pregnancies end on a happy note. But, some of them eventually end tragically. By losing the mother or the baby, or both. PPH contributes to 38 % of maternal deaths in India. Causes of PPH are myriad. Due care is taken to treat this entity by alacritous obstetricians, with intent to save the mother. While most of them succeed in saving the mother, many end in maternal mortality, even if the source of the bleed- the uterus is eventually removed surgically. Here, death is caused by exanguinating hemorrhage resultant of a cascade of pathological bleeding triggered in the human body through a process called Disseminated intravascular coagulation(DIC). Despite best interventions in the best of hands, which mean well.
Not all pregnant women die of PPH. Why do some develop PPH and DIC? It’s here that patient-related factors come to play in treatment outcome. Medicine has made giant strides through primary, secondary and tertiary preventive interventions, resulting in longevity of humankind. The life expectancy in India which was 69.96 years in 2021 increased to 70.19 years in 2022 by 0.33%- a paradox by itself. Longevity entails an aged population with multiple co-mordities like hypertension, diabetes, malignancy, solid organ failure. It is such older patients with multiple co-morbidities that doctors are increasingly required to treat. Surgical specialties are at the receiving end of this paradox. Surgeons these days operate on patients with multiple co-morbidities, resulting in higher incidence of complications, and vagaries in response to interventions undertaken to treat complications.
The pandemic unraveled the influence co-mordibities on outcomes of treatment more than any disease entity. SARS CoV-2, the virus responsible for Covid-19 created mayhem in those with co-morbidities. Those without were left off lightly. As of June 4 2022, while 53.1 crore were infected by the virus worldwide, only 63 lakhs succumbed. How did the others survive? Did treatment modalities that evolved over these three years, or vaccines that emerged save them from the stranglehold of cytokine storm?
As Uncertainty and unpredictability unfortunately govern the science of treatment and healing, it is impossible to predict treatment outcome, provide ‘guarantee’ to treatment that patients and their families often demand from clinicians. In the same vein, it is impossible to print out treatment costs in hospital lobbies like dhabhas exhibit cost of food they serve on menu boards placed beside them.