Remedy, Short term and Long
But all this can change. And it better change. How? The steps will have to be short-term and long-term. But both will have to be taken now, if reputations
have to be protected, and medicine has not to become unduly protectionist or combative, both of which would go against its essential thrust and purpose - the principle of beneficence.
A. Short Term Measures
Let us look at some of the short-term measures that have to be put into place with some alacrity before the situation becomes irreparable:
1. Reduce Pharma spending on junkets and trinkets.
32 Ajai R. Singh and Shakuntala A. Singh
2. Increase search for real trend setters in drug research rather than hype over the ‘me too’s’.
3. Avoid manipulation of drug trials so the real champion could be separated from the ‘also rans’, and then go for the publicity blitz, if at all.
4. Avoid getting pliant researchers into drug trials, for they were a deadly component of the production of ‘me too’s’, and the movement towards manipulation of drug
5. Avoid manipulating Journal Editors to publish positive findings of their drug trials and launches. For the final arbiter was the patient, and if he did not get well,
or if he suffered side effects, both the pharma concerned and the pliant researcher and journal would have the muck hurled in their faces. And suffer reduced credibility, which would only hurt
their fortune in the long run.
6. For Indian Pharma, to conduct their own clinical drug trial of the latest blockbuster so projected in the West, and find out whether it was really worth the hype. For they
may be betting their millions on a lame horse. Secondly, they must use the services of researchers whose credentials are above board. Apart from ethical reasons, it was also simply because they would
then know the truth. And could then decide whether they could pump in their millions to hype it up. And rake in the profits that would inevitably ensue.
B. Long Term Measures
The long-term measures are related to the way biomedical advance is to be charted. It is intimately related to the way we look at ourselves today, and wanted to be considered by posterity tomorrow. Which may not be as charitable as we may wish it to be, if we did not make some fundamental and foundational moves today. For that we must take a close look at the prevalent scene.
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There are two parallel developments in medicine today. Both seem to be at loggerheads, and both vie for our attention. The first, which is manifestedly more recent, (but which, we suspect, has been present in the field for a long time), would want us to think of medicine as a corporate enterprise. The other, which is hallowed by tradition, passed on from generation to generation, and considered the essence of good medical practice (but which, we suspect, more mouthed than practiced), considers it a patient welfare centered profession.
Let us here consider the essential thrust of their respective positions.
1. Medicine as a Corporate Enterprise
This approach would insist that if medicine has to continue its forward movement as it is, it has to become a corporate enterprise. In other words, it must be run as an industry.
Profit should be its
watchword. Patients should be clients who are offered services as different packages. And research advanced according to what earned more profits, not necessarily guided
by what served patient interests on a large scale. In other words, medicine turns into business. And, as all socially conscious business enterprises do, it could apportion part of its funds from profits accrued for
socially relevant causes. This could include welfare of socially and economically disadvantaged sections, and those disease entities which were rampant but whose treatment does not rake in the dollars. Like it
was done in all socially conscious businesses, which apportioned a percentage of their profits for socially relevant causes. But none of this at the cost of their primary motive, which was business to make handsome profits.
In this model, ethical practices are to be followed, but those of a business, not of a profession. The basic difference between the two being that for the former it is profits
with patient welfare, and for the latter it is patient welfare with profits. For some the difference may be
34 Ajai R. Singh and Shakuntala A. Singh
difficult to spot. But it will be immediately clear when we say that for a doctor, medical practice means getting the patient well with charging a fee, not charging a fee with getting
the patient well. In other words, it is a matter of what gets precedence, and what will not be forsaken in case of conflict. A sound corporately run medical practice would ensure there was minimal conflict between profits
and patient welfare. In other words, it would indulge in only such profit as resulted from, and in, patient welfare, and carefully eschew all others. But, it would run it as an efficient corporate enterprise.
There are many advantages in this approach. Infrastructure, paramedical staff and treating doctors’ qualifications and practices would be spruced up and become more evidence
based. Patients would
get the most recent medical care delivered efficiently and competently. The patronizing and condescending attitude of physicians, their fossilized and archaic knowledge and
practices, will be eased out. Hospitals would become cheerful looking, sparkling places, like wellrun business premises are. Not the dim dingy looking spaces, with patronizing, ill mannered but golden-hearted docs that still are the norm at most places all over the globe.
There are four main hitches here. One is the massive cost escalation, which is inevitable. The cost escalation could be managed by competition, and increased earning capacity of the consumer. Plus the attitudinal change that better facilities
came at a price. And medical facilities also were like any such facility you paid for. You could not get five star facilities at one star prices. And profit was not a dirty word in medicine. In fact it was desirable, but according to certain sound business practices which maintained ethical parameters of a good business. And whoever said business could not be run on ethical principles? And whoever agreed that profits must involve fleecing someone, or duping a hapless customer? Those days were past, mainly because the consumer was well aware of his rights, and vigilant and emphatic about
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exercising them. And legislation and activism were his comrades in arms.
Second hitch is neglect of disease conditions that afflicted the socially disadvantaged, whose treatment could not rake in the dollars. In such spheres, government and philanthropic organizations, with partial subsidy from medical business with social responsibility, could manage to do justice. Or medical business would pay a ‘Social Welfare Tax,’ which could go to finance such needy activities.
Third hitch is how to curb the questionable business practices of the less scrupulous, which would have a field day when the fig leaf of being a profession was removed. Here market forces would play their role. As would practice guidelines by professional bodies and guilds. As well as peer review and pressure. As also legislation. And of course vigilant patient welfare bodies and activists, and the
ever-hanging Damocles’ sword of litigation. All in all, numerous checks and balances would be in place to see to it that profit maximization was not at the expense of patient welfare. In fact it was based
on, and maximized, it.
Fourth hitch is how to tackle forces of the marketplace, which compel questionable activities on to a business concern. Medicine would be no less immune to it. Overhead
upgradation, competition/unhealthy practices from fellow corporates in the field, cost over runs, over investigation and lengthier indoor stay, costlier treatments and investigations
– all these add on to medical costs. And while some of these factors are inevitable, making medicine a corporate enterprise may legitimize so many others. The way out is again the same forces of the marketplace,
which will help keep medical costs under check because of competitive pricing, enlightened consumer activism, and necessary judicial support to tackle the erring.
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There will be some black sheep in this enterprise. But appropriate procedures would take care their influence is at a minimum. In any case there are black sheep in the medical
profession even today. And there is no evidence to prove that calling medicine a profession rather than a business has reduced its prevalence. In fact it may have given it a license to continue under wraps.
Greater accountability, more transparency, and heightened efficiency are what the sick consumer could then ask for, and get. Ancillary businesses, like those of medical
construction, medical insurance, and paramedical manpower would get a boost, which would generate more employment and increase earning capacities to pay for better and more costly medical care.
All in all, a great way to lend direction to this important development in medicine, which can easily lose its way to the unscrupulous if not guided at this juncture. Or lose momentum by actions of self-proclaimed guardians
of morality, if its positive energies are not harnessed.
2. Medicine as a Patient Welfare Centered Profession
Let us look at the contention of the second approach now.
If medicine has to remain a patient welfare centered profession, dedicated mainly to amelioration of suffering of humanity, and profits/positions/ prestige are only to be attractive perks not the main thing, then something real drastic will have to be set into motion right away. The medical man, and the academic researcher, will have to reign in his avarice. The pharmaceuticals will have to cut down on the pampering of the medics. The profit margins will have to be wholesome but not awesome. Genuine research will have to be forwarded, not spurious questionable activities that are on the
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upswing at the moment. Patient welfare will have to become paramount, regardless of profits. Diseases that afflict major populations will have to remain thrust areas regardless of the quantum of profits generated. And research itself, on the whole, will have to be guided by what is the need of the populace, rather than what is the fancy thing at present. Or what potentially raked in the dollars for the sponsor or the corporately run hospital.
The hallowed profession of medicine traces its lineage to the greats who sacrificed their lives working for disease amelioration. Medicine is a sacred and noble profession, and the suffering of a patient is its greatest challenge, regardless of what and how much it earned for the doctor concerned. No doubt he expects a reasonable life, with its comforts. But he does not vie with, or envy, the businessman who could throw his money around. He has no need for such
funds. Yes, he did need funds to support him, and his research. And he did need the funding agencies to make sufficient money to survive and sponsor medicine’s onward march. But he is not to be a party to
avarice and greed in the name of medicine, in himself or others. He is especially averse to cost escalations of drugs because of pampering of the medical man. He wants stringent procedures in place so that the compromised
researcher, or industry
major, could not manipulate results and take patients, and medicine itself for a ride, or lead it up the wrong alley.
He wants a clear distinction between the business of medicine, which industry follows, and the profession of medicine, which the medical practitioner/researcher should.
He wants regulatory
mechanisms to be set in place for industry, and wants that on a war footing. He also wants no interference in his work from industry, which wants to involve him in questionable
activities. He knows that the
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compulsions of academia/practice and industry are essentially different. He wants each to respect the others’ domain, and not infringe. But he finds industry trying to influence,
and modify, medicine to suit its ends. And finds pliant medical men ready to play game. And he finds that an alarming state of affairs.
He would not want money and grants to play as great a role as it does in medical practice and research today. The stilted growth of medical research towards what benefited
the sponsors, while the whole mass of research and practices, which cries out for attention, remains conveniently neglected, is alarming. It has to be remedied on a war footing.
The number of lawsuits against industry indicate the patient was now awake and would not be taken for a ride. While this is heartening, the fallout of this could be a spoke
in the momentum of medical advance, which he bemoanes. Moreover, malpractice suits against his colleagues maybe a manner to pull up the black sheep. But its increase is intimately related to how questionable business
practices have entered medicine, and ruled the hearts, and minds, of the man whose primary work is to heal.
Hence, he would want the essential patient welfare thrust never to be lost. The medical man ever to remain dedicated to it. The medical ancillary industry, pharma sponsors included,
to play second fiddle,
and earn their millions as a result of, not while dictating, the way medical science had to progress. The patient is the boss, his welfare is the mantra, and the doctor and
other paraphernalia are the means to ensure it. In this profits are needed to forward the onward march of the boss’ welfare, but it could never be at the cost of his welfare. This should be, and would always remain, the guiding force.
Doctors would have to rein in their avarice, which makes them play into the hands of industry. So would researchers. Industry would have to rein in its questionable methods to rake in profits. Patients would have to rein in their methods of intimidating both
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by flimsy lawsuits to claim huge compensations, which may get the money in and embarrass industry/ medical men, but would ultimately result in cost escalation of medical services and defensive medical practice, both detrimental to his welfare.
In other words, a massive movement to set priorities right by all the players concerned. And medicine once again to assume the role it was originally envisaged to play. To dedicate itself to disease amelioration; to dedicate itself wholly and solely to patient welfare. And to nothing else. And staunchly resist any moves from any quarter, howsoever mighty and howsoever tempting, to waylay
it from this path.
In other words, it is a choice between the expedient and the ideal. The choice is rather difficult. But it is better made now before circumstances force it on us when we
are least prepared.
However, the problem is that the two approaches, both strongly convincing in their own way, leave us at a loss. Which to follow, which reject? And on what grounds?
The first one gives paramount importance to profits, but through the process of patient welfare. It appears attractive, and a worthy resolution of the problem. The second
emphasizes patient welfare while not denying the value of commerce. It concentrates on medicine as it has been traditionally practiced.
Is it time to give up on the traditional and move on?
We think it is time to give up on neither, but to resolve issues with an eclectic approach based on a healthy resolution of these two. And move on.
40 Ajai R. Singh and Shakuntala A. Singh