Deaths due to Low Quality Medicine- Pharma Industry Needs Strict Regulation


It is  time to treat Pharmaceutical malaise.

    Take example for cough syrup related  66 deaths at Gambia or  Injection Propofol related deaths at PGI Chandigarh. If deep investigations are not done, poor quality medicines will continue to be marketed and doctors would be held responsible for the adverse reactions and deaths. Strict regulations for quality of pharmaceutical agents is need of the hour.

    Usually every problem related to health is called medical malaise, but that is a misnomer.  In fact health care comprises tens of different industries.  Complex interplay of various industries  like pharmaceutical, consumable industry and other businesses associated with  health care  remain invisible to patients. Various important components for example pharma industry, suppliers, biomedical, equipment, consumables remain largely unregulated. Collective malaise of all these is conveniently projected as medical problems  as blame is conveniently passed on to doctors, as they are only visible component of mammoth health business.  Rest all remain invisible, earn money and  doctors are blamed for the poor outcome of the patient, as doctor is the only universal link that is visible with patient. By an average application of wisdom, it is easier to blame doctors for everything that goes wrong with patient.

      Cough syrup related deaths at Gambia or  Injection Propofol related deaths at PGI Chandigarh – two examples are only a tip of the iceberg.  In routine, if patient gets fake or low quality medicines and does not get well, gets side effects, doctor will face harassment. Whereas people involved and industry will be sitting pretty and  make money.

Therefore strict administration and quality check  is required   to correct Pharma malaise. It may be a complex issue because of complexity involved in implementation and execution of policies. But recognition and beginning to think of the problem is also an important step.

Red alert over deaths after Propofol injection- PGI CHANDIGARH

WHO warns over deaths of 66 children in The Gambia (Indian Pharmaceutical Cough syrup).

WHO warns over deaths of 66 children in The Gambia (Indian Pharmaceutical Cough syrup)

The WHO has issued an alert over four cough and cold syrups made by Maiden Pharmaceuticals in India, warning they could be linked to the deaths of 66 children in The Gambia

The World Health Organization (WHO) on Wednesday issued a warning over four cough and cold syrups made by an Indian company, saying that they could be linked to the deaths of 66 children in The Gambia. The WHO said that the cough and cold syrups, made by Maiden Pharmaceuticals in Haryana, could be the reason for serious kidney injuries. “Please do not use them,” the WHO said in its advisory.

The four cough and cold syrups that have been linked to the deaths of 66 children in The Gambia are Promethazine Oral Solution, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup. In a release, the WHO has said that the Indian company has not yet provided guarantees on the safety and quality of these products.

“Laboratory analysis of samples of each of the four products confirms that they contain unacceptable amounts of diethylene glycol and ethylene glycol as contaminants,” the WHO said in a medical product alert. The WHO also warned that while the products had so far been found in The Gambia, they could have been distributed to other countries.

According to the WHO, diethylene glycol and ethylene glycol are toxic to humans when consumed and can prove fatal. Toxic effects can include abdominal pain, vomiting, diarrhoea, inability to pass urine, headache, altered mental state, and acute kidney injury which may lead to death, the WHO said.

New Delhi-based Maiden Pharmaceuticals declined to comment on the matter.

The World Health Organization also said that it was conducting further investigation with the company and regulatory authorities in India regarding the cough syrup linked to deaths of 66 children.

Last month, Gambia’s government said that it has also been investigating the deaths. The government statement came as a spike in cases of acute kidney injury among children under the age of five was detected in late July.

“While the contaminated products have so far only been detected in the Gambia they may have been distributed to other countries,” WHO Director General Tedros Adhanom Ghebreyesus said at a press conference on Wednesday.

The WHO Director General added that WHO recommends all countries detect and remove these products from circulation to prevent further harm to patients.

Meanwhile, the DSCO has already taken up an urgent investigation into the matter with the regulatory authorities in Haryana.

Red alert  over  deaths after Propofol injection- PGI  CHANDIGARH

CHANDIGARH: Five patients had died after they were sedated before surgeries on a single day last week at PGI, prompting doctors to sound a red alert to Central Drugs Standard Control Organisation (CDSCO)on Propofol injection – an anesthetic given before any major surgery. In this case, the drug was taken from the chemist shop in the hospital emergency. “Following a complaint from PGI doctors, we came with a CDSCO team to collect samples. The samples have been sent to Central Drugs Laboratory, Kolkata,” said Sunil Chaudhary, senior drug control officer, UT. He said, “The suspected batch of drugs has been stopped for supply till reports are received.” Sources said test analysis will take around two-three weeks and final report will be submitted by the CDSCO team. The five patients had to undergo orthopaedic and neurosurgeries. On deliberating the cause of deaths, doctors found Propofol injection as the common thread.

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CCI investigates India’s largest hospital chains’ Practices


The potential penalty by India’s fair trade regulator could be steep. The CCI  (The Competition Commission of India)  investigation is the first such action against exorbitant prices of medicines and services fixed by hospitals, which have operated free of regulation so far.

A four-year investigation by India’s fair-trade regulator has concluded that some of India’s largest hospital chains abused their dominance through exorbitant pricing of medical services and products in contravention of competition laws.

The Competition Commission of India (CCI) will soon meet to weigh in on the responses by Apollo Hospitals, Max Healthcare, Fortis Healthcare, Sir Ganga Ram Hospital, Batra Hospital & Medical Research and St. Stephen’s Hospital. It will then decide whether to impose penalties, said people familiar with the matter.

The CCI can impose a penalty of up to 10 percent of the average turnover for the past three preceding financial years of an enterprise that has violated competition laws. The penalties could be steep. Apollo Hospitals posted an average turnover of Rs 12,206 crore and Fortis Rs 4,834 crore in the past three financial years.

The CCI’s director-general found that 12 super-speciality hospitals of these chains that operate in the National Capital Region abused their positions of dominance by charging “unfair and excessive prices” for renting rooms, medicines, medical tests, medical devices, and consumables, according to a copy of the summary report that Moneycontrol reviewed.

Some hospital room rents exceeded those charged by 3-star and 4-star hotels, according to the findings by the DG, who examines anti-competitive practices.

Significance of the investigation

The CCI investigation is the first such action against exorbitant prices of medicines and services fixed by hospitals, which have operated unencumbered by regulation so far. The watchdog’s action could potentially rein in the prices of medicines and healthcare equipment, or at the very least, bring transparency in the way hospitals sell these items, according to competition lawyers.

Of the 12 hospitals that faced CCI scrutiny, six belonged to Max  and two to Fortis.

The CCI and the hospital chains had no comment for this article.

Overcharging without checks

Exorbitant pricing is a common thread running through the CCI investigation report. The hospitals were found to charge more for certain medical tests as well as for X-rays, MRI and ultrasound scans than rates offered by other diagnostic centres. For consumables such as syringes and surgical blades, hospitals charged rates that were higher than those of other consumable makers, according to the CCI report.

The only exception was medicines, which hospitals sold at the maximum retail price, although they earned significant profits by procuring them at lower prices.

The CCI selected the hospitals for investigation on the basis of the number of doctors, paramedics, beds, and turnover for the period 2015-2018. The investigation found that these hospitals do not allow the use of purchase of consumables, medical devices, medicines and medical test results from outside, adding that patients use the service of in-house pharmacy and laboratories for ease of convenience.

Investigative reports pertaining to each of the hospital chains were submitted by the DG to the CCI on December 24, 2021. The CCI forwarded a copy of these reports to the hospitals on July 12, 2022, and sought their responses, according to the people, who did not want to be identified.

The CCI has been examining the pharmaceutical sector in India for years, scrutinising the pricing of medicines by healthcare companies. On April 19, 2020, it cautioned businesses, including healthcare companies, against taking advantage of Covid-19 to contravene competition laws.

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Most Unethical Medical Study Ever- Tuskegee Study for Syphilis


One of the ugliest and unethical human studies in the history, Tuskegee Study raised a host of ethical issues such as informed consent, racism, paternalism, unfair subject selection in research, maleficence, truth telling and justice, among others.   It is really unbelievable to understand the heinous nature of the Tuskegee study.

    The Public Health Service started the study in 1932 in collaboration with Tuskegee University (then the Tuskegee Institute), a historically Black college in Alabama. In the study, investigators enrolled a total of 600 impoverished African-American sharecroppers from Macon County, Alabama.

Tuskegee syphilis study

     Tuskegee syphilis study

The goal was to “observe the natural history of untreated syphilis” in black populations. But the subjects were unaware of this and were simply told they were receiving treatment for bad blood. Actually, they received no treatment at all. Even after penicillin was discovered as a safe and reliable cure for syphilis, the majority of men did not receive it.

In 1932, the USPHS, working with the Tuskegee Institute, began a study to record the natural history of syphilis. It was originally called the “Tuskegee Study of Untreated Syphilis in the Negro Male” (now referred to as the “USPHS Syphilis Study at Tuskegee”).

The study initially involved 600 Black men – 399 with syphilis, 201 who did not have the disease. Participants’ informed consent was not collected. Researchers told the men they were being treated for “bad blood,” a local term used to describe several ailments, including syphilis, anemia, and fatigue. In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance.

By 1943, penicillin was the treatment of choice for syphilis and becoming widely available, but the participants in the study were not offered treatment.

The purpose of the study was to observe the effects of the disease when untreated, though by the end of the study medical advancements meant it was entirely treatable. The men were not informed of the nature of the experiment, and more than 100 died as a result.

None of the infected men were treated with penicillin despite the fact that, by 1947, the antibiotic was widely available and had become the standard treatment for syphilis.

    .

Of these men, 399 had latent syphilis, with a control group of 201 men who were not infected. As an incentive for participation in the study, the men were promised free medical care. While the men were provided with both medical and mental care that they otherwise would not have received,  they were deceived by the PHS, who never informed them of their syphilis diagnosis and provided disguised placebos, ineffective methods, and diagnostic procedures as treatment for “bad blood”.

The men were initially told that the experiment was only going to last six months, but it was extended to 40 years.  After funding for treatment was lost, the study was continued without informing the men that they would never be treated.

The study continued, under numerous Public Health Service supervisors, until 1972, when a leak to the press resulted in its termination on November 16 of that year.  By then, 28 patients had died directly from syphilis, 100 died from complications related to syphilis, 40 of the patients’ wives were infected with syphilis, and 19 children were born with congenital syphilis.

The 40-year Tuskegee Study was a major violation of ethical standards, and has been cited as “arguably the most infamous biomedical research study in U.S. history.”  Its revelation has also been an important cause of distrust in medical science and the US government amongst African Americans.

Later in 1973, a class-action lawsuit was filed on behalf of the study participants and their families, resulting in a $10 million, out-of-court settlement in 1974.

On May 16, 1997, President Bill Clinton issued a formal Presidential Apology for the study.

On May 16, 1997, President Bill Clinton formally apologized on behalf of the United States to victims of the study, calling it shameful and racist. “What was done cannot be undone, but we can end the silence,” he said. “We can stop turning our heads away. We can look at you in the eye, and finally say, on behalf of the American people, what the United States government did was shameful and I am sorry.”

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Time to Regulate Health Administrators & Pharmaceuticals like Doctors #CBI- arrests-Joint-Drugs-Controller


  CBI has arrested Joint Drugs Controller for allegedly taking a ₹4 lakh bribe to clear injections made by  Biocon Biologics .The CBI has arrested Joint Drugs Controller S Eswara Reddy for allegedly receiving a Rs 4 lakh bribe from a conduit to waive the Phase 3 clinical trial of the ‘Insulin Aspart’ injection, an under development Biocon Biologics product to manage Type 1 and Type 2 diabetes, officials said on Tuesday.

        The incident may be just a tip of the iceberg, to indicate collusion between administrators and various industries. It is the time to regulate all important components of health industry including health administrators as doctors are regulated – to achieve real cost effective health care.

          In last few decades, as doctor-patient relationship has been getting more complex and medical industry has controlled the financial interaction, the medical costs have become expensive. Hence the health insurance industry is gradually becoming indispensable. As doctors are at the front and remain the visible component, they are blamed for the expensive medical treatments.  The tremendous rise in health care expenses is usually borne by the government, taxpayer, insurance or patient himself.  Therefore there has been an increasing dependence on investors in health care, along the lines of an industry to ensure its financial viability. 25 factors- why health care is expensive

      Complex interplay of various industries  like pharmaceutical, consumable industry and other businesses associated with  health care  remain invisible to patients. Various important components for example pharma industry, suppliers, biomedical, equipment, consumables remain unregulated.  There is large number of administrators involved in such processes.  Although doctors are strictly regulated and kind of over-regulated but such administrators and financial controllers who play important part in medicine, cost, sale and purchase, remain largely unregulated. Because of such undeserved criticism, doctors have actually been alienated from financial aspect but still they are often perceived as culprits for cost escalation.

CBI has arrested Joint Drugs Controller for allegedly taking a ₹4 lakh bribe to clear injections

       The CBI has arrested Joint Drugs Controller S Eswara Reddy for allegedly receiving a ₹4 lakh bribe to waive the phase three clinical trial of the Insulin Aspart injection, a product of Biocon Biologics under development to manage Type 1 and Type 2 diabetes, officials said on Tuesday.

CBI has arrested Joint Drugs Controller for allegedly taking a ₹4 lakh bribe to clear injections made by  Biocon Biologics

Biocon Biologics is a subsidiary of the  Biocon. The company has denied allegations.The agency has also arrested  director at Synergy Network India Private Limited, who was allegedly giving Reddy a bribe, they said.

After completing the necessary paperwork, the CBI has arrested Reddy and Dua, nabbed during a trap operation on Monday while the alleged bribe exchange was going on, the officials said.

The CBI has also booked Associate Vice President and Head-National Regulatory Affairs (NRA), Biocon Biologics Limited, Bangalore, L Praveen Kumar, as well as Director, Bioinnovat Research Services Private Limited, Delhi, Guljit Sethi in the case under IPC sections of criminal conspiracy and corruption. 

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NMC’s Opaque Policy on Medical College Infrastructure of Disastrous Consequences


        Quality of medical education is a deciding factor for the kind of doctors and hence the character of the treatment that patients are going to get.  Transparency about the infrastructure and faculty of medical college are important and the deciding factors about the credibility of the institute. But the new opaqueness (by National Medical council- NMC) in the system displaying the critical details about medical colleges can have deleterious effects on medical education. The medical students are blind about the claims made by a medical college during inspection for recognition and permission to admit students, which may be not true. There have been many instances and several complaints of ghost faculty in private colleges and mass transfer of faculty during inspection from one government medical college to another.  Not only medical students pay millions to have a seat in private medical colleges, they invest their prime life time in studying medicine. Such opaqueness has a potential to ruin their careers. Medical students will have to work harder to get true information and more careful, about the institute they are getting into.  

NMC’s college infra reports not public, MCI notes taken down too

NMC’s college infra reports not public, MCI notes taken down too

      The National Medical Commission (NMC) does not post college infrastructure assessment reports on its website and has also removed all previous assessment reports posted by the erstwhile Medical Council of India (MCI). So, students or members of the public cannot know what claims were made by a medical college during inspection for recognition and permission to admit students. Why are these assessment reports important? The reports reveal the date of inspection, the names and designation of the inspectors, usually experienced medical faculty from government medical colleges, along with their comments and findings. They reveal what kind of infrastructure existed or was claimed, including inpatient and outpatient load, number of beds and facilities in the teaching hospital and in the college. They reveal the number of faculty shown as employed by the college department-wise. With about 50 new medical colleges opening in 2021, a record for a single year, and especially unusual since it was the peak pandemic year, there were several complaints of ghost faculty in private colleges and mass transfer of faculty during inspection from one government medical college to another. “Not uploading assessment reports shields such substandard colleges with inadequate faculty and infrastructure. They just want to claim more colleges have been opened and that more MBBS seats have been created. It is a numbers game, quality be damned. In the case of private colleges, getting approval without adequate infrastructure or faculty is a windfall as they charge exorbitant fees from students. Usually, approval is given for 100-150 seats. Even at Rs 15 lakh per annum as tuition fees, the college gets to collect Rs 15 crore to Rs 22.5 crore from the first batch,” said a retired professor of a government medical college. “The MCI, which was labelled corrupt and non-functional, used to post the reports of assessments of infrastructure and faculty done according to minimum standard requirements each year,” said Dr Mohammed Khader Meeran, an RTI activist. In response to Dr Meeran’s RTI application seeking college assessment reports of academic years 2020-21 and 2021-22, the NMC said that “the information sought is very voluminous and scattered in various files” and that “it would disproportionately divert the resource of MARB (Medical Assessment & Rating Board) of NMC”.

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Dr Manjula Case NHS-UK: Semantics-Regulator’s own Fitness to Practice Doubtful? #GMC-UK


Regulation of the medical profession has become a tool to oppress doctors.

  Dr Manjula Arora case (NHS-UK) unmasks the everyday struggle of the doctors in present era. Being undervalued and demonized, forced to work as sub-servant to administrators and regulators are considered new normal and has become an accepted form of harassment.  Fatigue and burnout are thought to be routine side effects of being a doctor or nurse.   The unhindered over-regulation has left no stone unturned in spreading hatred and creating an environment of mistrust against the medical profession.  Single stray or a trivial incident   is projected    as an example to portray poor image of medical profession as generalization and as a token of the ‘excellent’ work done by administrators and regulators.   Doctors have become soft targets because of their nature of work as they deal with life and death.   Any trivial issues such as semantics used by Dr Manjula Arora (in this case) were blown out of proportion  and   GMC finds this  as an  opportunity  to send a strict message to the whole profession.  Such incidence  show that regulators and administrators  can use the nature of doctors’ work to be  used against medical profession to make saviours as an  easy prey for  punishments   on the pretext of  dishonesty, negligence or semantics being used  as  legal weapons by law-enforcers, even in case of a perceived bias. In the process of such ‘tokenism’ administrators prove their relevance to the system.

       Regulation of the medical profession has become a tool to oppress doctors. Driving the narrative of doctors as “perfect” beings causes more harm to the doctor-patient relationship than not. Constantly seeking to attain perfection is the very approach that leads to burn out, and more mistakes- causing patient harm.

Dr Manjula Arora’s case

Dr Manjula Arora’s case

Dr Arora has been a doctor since 1988 and is of good character. She asked her employer for a laptop. For context, most employees would reasonably expect their employer to provide work-related IT equipment. She was told that none were available, but her interest would be noted for the next roll-out. Many people would interpret this positive response to mean that they would get a laptop in due course. Clearly if her employer did not intend for her to have a laptop, they could simply have said so. Dr Arora spoke to her IT department about getting a laptop and said she had been ‘promised’ one.

And that’s it. That is the entire extent of her ‘misconduct’.

One could regard her statement as a minor exaggeration, or loose terminology, or careless language or verbal shorthand over a trivial subject.  But no one  should consider it to amount to ‘dishonesty’ unless interpret it in biased manner.

The tribunal took a different view. They concluded that ordinary, decent people would consider her use of the single word ‘promised’ as dishonest.  The tribunal further decided that this so-called dishonesty amounted to misconduct.

They also considered that the misconduct was serious.

They decided her fitness to practice was impaired, and that it was necessary to suspend her to send a message to the profession.The regulator has a difficult task. Good regulation protects patients. Poor regulation harms patients, because doctors will run away from a toxic regulatory environment.

Manjula Arora case: the GMC stumbles again? -BMJ

      The case of Manjula Arora, a GP in Manchester, who has been suspended for a month for supposed “dishonesty” about a laptop, was picked up by a few colleagues, and social media did its work of ensuring the pick-up rate increased exponentially.  One always worries about the latest “MedTwitter” controversy. But this one has come on back of seething annoyance among many doctors about our regulator—the General Medical Council (GMC)—and its perceived bias, with cases such as those of Hadiza Bawa-Garba and Omer Karim still fresh in our memories.

Couple this with the recent Medical Workforce Race Equality Standard (MWRES) data confirming a clear association of increased referrals and convictions on the basis of racial background—or indeed country of origin as regards training—and this case lit the touch paper.

If one considers the publicly available details of the whole trial, you have to scratch your head and wonder how it got to this stage?   Would this happen if the name of the individual was, for example, Michael Andrews?  

The relevance of this case stood on two things—any harm to the patient population, which, to me, should be the primary aim of the GMC, and then dishonesty and disrepute brought upon the medical community.

This ruling makes it clear that there is no risk of harm to the public: “The Tribunal considered that no issues in relation to patient safety had been identified in this case. Dr Arora is a competent clinician, and there is no necessity to protect the public.” That should have ended the issue. But the complications started when interpretation about honesty came into the picture.

“The Tribunal attached significant weight to the fact that Dr Arora’s misconduct was a single incident in relation to the use of a single word, with no evidence of any other similar episodes of dishonesty before or after the event.” If you go into the details of the case, it becomes even more murky, as it’s the interpretation of a word—subjective at best— against the background of someone for whom English is not their first language. But it was deemed enough to warrant a month’s suspension according to the tribunal: “this period would send an appropriate message to the medical profession and to the wider public that Dr Arora’s misconduct, albeit relating to a single fleeting moment of dishonesty and not a planned deception.”

This raises a multitude of questions. Firstly, there is the principle that one fleeting moment of dishonesty could result in suspension. If that’s the standard, then the profession is indeed in trouble, with the GMC now making subjective judgements and being an arbiter of what is deemed to be honest or not. Where does the line get drawn? Discussions about patients or conversations about whether Santa exists or not?

Secondly, and more importantly, there is the suspicion of bias in how that law is being applied. Daniel Sokol has written a recent column which discusses the notion of doctors as the “saintly being”; the epitome of perfection at all times. Yet, within all of us exist the same prejudices and flaws as for the rest of the population. Sokol suggests that doctors have to be “scrupulously honest—in and out of work—unless the situation obviously allows for ethical dishonesty.” Yet he makes no mention of the fact that the GMC seems to apply that principle unevenly across the board. I accept that it can be difficult to see the “problem” others are complaining about, but I can assure you there are very few international medical graduates who have read about Arora’s case and not thought “I know why this has happened.”

There is professionalism, but there is humanity too, and I would propose that driving the narrative of doctors as “perfect” beings causes more harm to the doctor-patient relationship than not. What is honesty? Saying to patients that they need to wait for another 16 hours to get a bed, or holding the hand of the elderly frail lady, comforting her and saying “I am sure something will come up shortly”? It brings back the concept that being a doctor is a vocation. Constantly seeking to attain perfection is the very approach that leads to burn out, and more mistakes—causing patient harm.

Finally, if the role of the GMC is to protect the public from “single moments of untruth,” as this destroys the view among the public that doctors are saints (although I am pretty sure the public don’t see doctors like that in modern life), then there needs to be a discussion of that concept, of the overreach into personal lives, and of where the line is drawn as regards the GMC’s intrusion and inordinate application of that principle. I would suggest the role of the regulator should be for the rare circumstances when there is an interest in behaviour not being repeated or where it cannot be dealt with effectively by an employer.

I work with the GMC closely these days, and I find it immensely frustrating to see such cases as they undermine some significant hard work that is being done by individuals who are determined to change the narrative that the GMC is biased. I would encourage all concerned to look into this case, review it, learn from it, and offer support to Arora. There is a lot of work in hand to repair the damage from the Bawa Garba case, and this case could reinforce those sentiments, which we must avoid.

The intention may once have been for doctors to be Superman, but modern times and the foibles of individuals only permit a Batman. It’s worth remembering neither of them work to harm the public.

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     25 factors- why health care is expensive

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 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

Expensive Medical College  seat- Is it worth it?

Fish Bile ‘Treatment’ Lands Woman in Hospital- Folly of Fringe Theories in medicine


    It has become a common practice to advertise health products or therapies that claim to be panacea for all ailments enhance immunity, to increase power and health by creating an impression on minds on various platforms. Instead of producing scientific evidence, such products and therapies are sold under disguise of natural therapies or alternate medicines. Needless to say, the objective evidence or global neutral trial for the claimed efficacy or about real side effects is always missing.

    Companies have created huge fortunes based on circulation of such pedagogic narratives and social knowledge. But in real sense, these are actually chemical and have biological actions and reactions. Chemical derived from natural sources can have side effects and contain impurities.  Global neutral trials to validate effects and side effects remain an urgent need of the hour for all health products.

   Suffering for the common public is immense. Doctors’  sincere warning had no effect rather they were called as medicine mafia.   Unfortunately  false beliefs  like local religious figures can cure cancer and kidney diseases  cause they could communicate with invisible spirits  and gain knowledge. Unsurprisingly the cranks  have been  wrong and innocent patients suffer.   Doctors objecting to  elevation of  crank theories were painted as  western medicine agents,  or nattering nabobs of negativity.

 Here is an example of the folly of following fringe  theories.

Fish bile ‘treatment’ lands woman in hospital

Fish bile ‘treatment’ lands woman in hospital

 A 52-year-old homemaker from Dum Dum had to undergo a few rounds of dialysis and was put under intense critical care for a renal failure, triggered by ‘fish bile poisoning’. The patient had ingested raw fish bile for four consecutive days as a treatment to cure her diabetes prior to being rushed to Manipal Hospitals Kolkata with acute abdominal pain. Doctors at the Salt Lake hospital found the patient had low blood pressure and was in a state of shock. Initial reports showed a significant derangement of liver and kidney functions. It led doctors to treat common causes of liver and kidney injuries or drug induced organ damage. When further tests didn’t match with these diagnoses, the team started looking for a possible cause. The patient then revealed she had ingested bile of Rohu fish for four days to control her diabetes. “Consuming fish bile causes acute kidney and liver injury with the need to go for long term dialysis. This patient had to be put under dialysis within 72 hours of admission,” said internal medicine and critical care consultant. She was discharged from hospital after a month.

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     25 factors- why health care is expensive

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 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

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Online Health Service Aggregators- New Commission Agents in Medical Business: Increase Cost


 

India features a mixed-market health system where chronically low investment in public health systems has led to the proliferation of private care providers.  In last few years, a bevy of apps and service aggregators have starting operating brazenly in the country, pushing aggressively for tests and surgeries and delivering drugs, often advertised by Superstars and Celebrities. Patient often zigzags between health providers with unclear referral pathways, and ends up receiving questionable quality of care that may typically neither be safe nor affordable.   

       Online health aggregators are nothing more than sophisticated commission agents. The medical business model thrives on advertisement and commission. Government rules prevent doctors from advertising or soliciting for surgeries, but these companies live on advertising. Any doctor or hospital can get advertised through these companies. In lieu of some money, anyone can be declared as the best and hence misguidance to the patients cannot be ruled out. The flow of patients to a health care facility can be enhanced by financing the advertisements and not by actual quality work and results in increasing medical business manifold.  They do not contribute to much needed medical infrastructure and merely redirect patients to existing facilities. They may at the best be able to  become facilitators of the process that attract patients by advertisements and  result in skyrocketing cost to patients. Any of the Hospitals and doctors can be projected as the best, who tie up with these online aggregators in lieu of some money. Therefore the misguidance as well as increased costs is the two main drawbacks of such a lucrative arrangement of this new medical business.  They charge hospitals and doctors for advertisements ( sending more patients) and patients for channelizing them. In the resulting Zig-Zag path, patients are treated more on the basis of advertisements that are many times aired by our ‘Filmy Superstars’.

The health service aggregators have no skin in the game. Neither do they invest in hospitals nor do they have the responsibility of running a hospital, but they want the money which a patient will spend on their health in a hospital. They have conveniently created online apps and are ranked top on search websites. This whole process is against the values and ethics, which healthcare delivery is supposed to be.

Unregulated operations by unscrupulous online health service aggregators pose grave risk to public health.

   

Unregulated operations by unscrupulous online health service aggregators pose grave risk to public health.

  The damage caused by the unchecked presence of health service aggregators online is snowballing into a major healthcare crisis which the Union and state governments can ill afford to ignore. Instead of becoming a part of the solution, they have added to the problem by pushing aggressively for tests, surgeries and healthcare services without any medical requirement or prescription.

  There are plenty of  such apps which advertise about doctor consultations, quick surgeries and direct-to-consumer laboratory tests.

       This is where the trouble begins.

In one  case, the  healthcare aggregator suggested surgery for constipation. The mention of surgery scared the patient, who then approached a hospital where they advised him to improve his diet.

For a kidney stone issue, a healthcare aggregator suggested a laser surgery  to a patient without consulting a urologist. The laser surgery was done and the stones got stuck in his pelvi-uretery junction of the kidney-uretery track. He  became aware of it two weeks later when he had severe pain in his flank, because of which he walked in to a hospital after the app refused to acknowledge his concerns.

In all of these cases, the apps charged almost double the existing rates for surgeries. For a piles operation, in a general ward, a hospital charges between Rs 50,000-70,000, inclusive of medicines in a patient without co-morbidities. The apps charged between 1.25 lakh to 1.5 lakh, while the national public health insurance scheme Ayushman Bharat rates for such surgeries begin at Rs 10,000.

Ads are being run by online health service aggregators in newspapers and all  kind of  media.

For removal of kidney stones, hospitals charge Rs 50,000, while the apps charge upwards of Rs 1 lakh, while on the government’s Ayushman Bharat scheme, it is Rs 33,000.

Circumcision is priced at Rs 60,000 by the healthcare aggregators, when hospitals charge Rs 10,000 for a surgery such as this and it is Rs 3,000 for those availing it using Ayushman Bharat.

Their modus operandi? The healthcare aggregators have tie-ups with certain departments in certain hospitals, where after the app does the diagnosis, a doctor on their payroll is sent to the hospital to perform the surgery. After the surgery, the doctor walks away without any care and the patient is left at the hospital until he gains consciousness. At which point, if there is any immediate post-operative care, the nurse concerned does it based on the instructions of the doctor who left. Then the patient checks out.

    A fee is paid by these healthcare aggregators to these hospitals for use of the premises for the surgery. In most cases, they approach smaller hospitals where either the top administration turns a blind eye towards these activities.    Sometimes, the  doctor who performed the surgery may not be  on their rolls, but that from a healthcare aggregator.

 “The health service aggregators  have no skin in the game. Neither do they invest in hospitals nor do they have the responsibility of running a hospital, but they want the money which a patient will spend on their health in a hospital. They have conveniently created online apps and are ranked top on search websites. This whole process is against what healthcare delivery is supposed to be,” said Dr Jagadish Hiremath, CEO of ACE Suhas Hospital in Bengaluru.

Government rules prevent hospitals from advertising or soliciting for surgeries, pointed out Hiremath, but these companies live on advertising.

Such health care aggregators are feeding off hospitals and they need to be regulated. “If you remove the advertisements, these companies don’t exist. They have no physical presence except for a few labs or clinics,” he added.

“The problem is getting compounded by these discounts and offers for unnecessary medically and unwarranted testing in the name of wellness/immunity packages. It is a price war to offer maximum number of tests at lowest prices which is totally meaningless,” highlighted Malini Aisola, co-convenor of All India Drug Action Network (AIDAN)

These online health service aggregators have added to issue of illegal pathology laboratories mushrooming all over, pointed out Dr Jagadish Keskar of the Maharashtra Association of Pathologists and Microbiologists

  Almost all of them have roped in big names as brand ambassadors – actor Hrithik Roshan, Amitabh Bachchan, singer Guru Randhawa, Rahul Dravid, actor Sonu Sood, actor Rajat Kapoor,  Neha Dhupia, Yuvraj Singh and Randeep Hooda to talk about specific health issues and MS Dhoni.

   “They have all these famous names as brand ambassadors as if they will perform the surgeries or look at your blood in a lab. This confuses the public, who are already bombarded with too much information,” quipped Hiremath.

     Consumer Drug Advocacy group All India Drug Action Network (AIDAN) argued that the direct-to-consumer advertising has to stop completely. “It is too dangerous in healthcare. Aggregators are inducing demand when people are at their most vulnerable due to the pandemic. They are pushing promotions and offers on tests and surgeries and healthcare services without medical assessment or prescription,” said Aisola.

There is a danger particularly with surgeries, contended Aisola, because this could lead to bypassing medical opinions and identifying alternative treatments. When doctors, hospitals and labs associate themselves with the aggregators, there are ethical issues too, she pointed out.

The practice of doctors associating themselves with these healthcare aggregators have alarmed several doctors’ associations. Association of Minimal Access Surgeons of India (AMASI) wrote to its members stating that any member who has made such a contract with healthcare aggregators should disengage immediately failing which a member found to be in contract thereafter may be liable for disciplinary action by regulatory authorities.

They warned that any litigation arising from such practices will not be defended by the association during legal process by way of expert opinion or otherwise.

“It jeopardizes adequate clinical judgment by a trained person regarding need for surgery and decision as to the type of surgery that would be optimum for the particular patient. The apps are made for the sole purpose of making money,” said the AMASI notification.

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Medical Consumer Protection Act: A Loss making deal for patients too?


       With the evolving medical science and health care getting intertwined with business, braided changes in medical regulation and law are not an unexpected development. New models of medical regulation, business and law in health care have emerged and progressed in last few decades.  Despite a wish to govern and regulate medical profession strictly, the laws and regulations still have to go a long way to provide real justice to everyone.   No one really knows how to regulate this difficult area,  which encompasses life and death, deals with extremes of poverty and riches, mortality and morbidity, pain and  relief , sadness and happiness, smiles and sorrow and other uncountable emotions, all intertwined with financial aspects.But the wish of administrators to govern medical profession strictly with punishments is not new.  Hammurabi (5000 years back) at the start of civilization believed that doctors needed to be punished in case there was a poor outcome. Strangely it was at a time, when no one understood the complexity of human body and the limitations of medical science; even basic anatomy and physiology of body was not discovered.  

      Considering the limitations of medical science along with uncertainties and complexities of human body, regulation of medical profession and system of punishments still remains somewhat unfair to doctors, even after 5000 years.  It is still based on principles of revenge and retributions rather than developing a robust system by learning from mistakes. By application of an average wisdom, doctors can be easily blamed for poor outcomes, as they are always and universal a common visible link between treatment and poor outcome. 

           One of the examples of easy punishments for doctors is Medical consumer protection act that was implemented in 1995 for medical services. Patients were defined as consumers and hence doctors were converted to service providers in lieu of some money.  Consequently the changed definitions altered the doctor-patient relationship in an irreversible way.   

    The reality is that neither doctors, nor patients are ready for such a legal relationship. More-over   the system is not robust enough for such a change.   To work with weak infrastructure, non-uniform medical education, poor numbers of support staff, inept health system along with legal complexities has pushed doctors into a shell and predisposed them to harassment. 

          Rather than   developing a system to promote   good doctor-patient relationship, Medical Consumer Protection Act has created a situation of ‘us versus them syndrome’. It caused erosion of doctor-patient relationship and escalated cost of care.   Propagation of stray and occasional incidents about negligence case in court or their outcomes are given disproportionate wide publicity in media. The patients are unable to understand the correct application of such stray incidents to themselves. Such cases may be frivolous,  just one in million or a rarity, but people always try to imagine themselves being in the hospital chaos due to the   scenario projected.  It gives a negative projection about medical services and enhances patients’ fear to seek treatment at right time.

    There is a growing mutual mistrust; doctors too have started looking at every patient as a potential litigant. Especially while dealing with very sick ones, practice of defensive medicine is a natural consequence. This may manifest as excessive investigations, more use of drugs, antibiotics and even reluctance or refusal to treat very sick patients. 

    With the mandate to practise evidence based medicine, doctors need to document everything and to offer everything possible, leading to skyrocketing medical costs.  To save themselves, doctors have to do mammoth paper work, leading to consumption of time that was meant for real deliberations for the benefit of patients.

           Consequently insurance companies, medical industry and lawyers have become indispensable and have positioned themselves in between doctor and patients. Besides creating a rift between doctor and patient, they charge heavily from both sides; from patients (medical insurance, lawyer fee) and doctors (indemnity insurance, lawyer’s fee) alike. The vicious cycle of rising costs, need for insurance, medicolegal suits, and high lawyer fee (for patients and doctors) goes on unabated. All these contribute significantly to overall inflated cost of health care.

       Not uncommonly doctors are used as scape goats to have a concession on the patient’s treatment from administrators.  

       Medical consumer protection act has increased the anxiety and insecurity among   medical professionals.   Doctors can be dragged to courts for trivial reasons, for example the sense of revenge, simply for non-satisfaction, to extract money or simply for avoiding paying for services.  In an era where family members, brothers and sisters fight for money, it will be naïve to think that idea of making money from doctors does not exist. These money-making ideas are further stoked by the much publicized incidents of high compensations granted by courts.

     Medical lawsuits and complaints (right or wrong) are breaking medical professionals from within, not to mention the toll it takes on their confidence and belief, which takes a lifetime to build.

     Whenever there is adverse outcome in any patient, all the doctors involved start looking for whom to blame among themselves. Due to legal pressure they try to pinpoint each other’s mistakes.  Mutual understanding takes a back seat and the teamwork is spoiled permanently. Administrators in a bid to be safe, encourage putting doctor’s concerns against each other,  creating a strange sense of enmity among medical professionals.

    The ease with which doctors can be harassed has led to rampant misuse of medical consumer protection act and it has instilled a sense of deep fear and insecurity in the mind of medical professionals. The act has been used as a whip against the  doctors by all, including  medical industry, law industry and administrators.  Only doctors are visible as those who deliver care, so they remain at receiving end for poor outcomes and all these industries remain invisible.    The industry has used the protective systems against medicolegal cases to gain  maximum benefits  out of doctors’ hard work.   

      In court cases, a certain element of doubt always remains in mind of a doctor whether he will get justice in the long run, or will end up being  a victim of sympathy towards patient or clever lawyering.  So taking medical decisions in critical situations is becoming more difficult  in view of the future uncertainty of disease.

             Windfall profits for lawyers is a strong  incentive   for  law industry to promote   instigation  of patients by against doctors .  One can see zero fee and fixed commission advertisements on television by lawyers in health systems even in developed countries. They lure and instigate patients to file law suits and promise them hefty reimbursements on ‘sharing and commission basis’. There is no dearth of such relatives and lawyers who are ready to try their luck sometimes in vengeance and sometimes for the lure of money received in compensations. 

       Consequently doctors are now an easily punishable human link for poor outcomes.  Medical professionals work with continuous negative publicity, poor infrastructure, and preoccupied negative beliefs of society and burden of mistrust.

  Strangely  Medical Consumer Protection Act applies  only to doctors, that too selectively. All  other professions and services  are   out of it, not even other constituents of health services. Selective application is what is  demoralizing the doctors.  Considering the uncertainty and kind of work done by  medical professionals, actually it should be other way around.Mistakes are always easy to be picked with retrospective analysis and with lawyers pondering over it for years. In such situations, doctors are sitting ducks for any kind of blackmail.

            Nothing else has ever distracted doctors more than medico-legal cases and punishments. In certain circumstances, saving themselves becomes more important than saving a patient. Decision making also becomes difficult  by uncertainty of prognosis,  grave emergencies, split second lifesaving and risky decisions that may later be proved wrong by retrospective analysis with wisdom of hindsight with luxury of time and fault-finding approach.  The possibility of complex medico-legal situations in doctor’s  mind are enough to distract doctors from their primary point of intentions ‘the treatment’.

          Therefore increasingly, financially secure doctors are staying away from the riskier jobs. No wise person will like to face medicolegal complexities in older age. Taken to court for a genuine decision is enough to spoil and tarnish health, wealth and fame that was earned by  slogging  the  entire  life.     

     Patients can have poor outcomes for many reasons. It can be severe disease, poor prognosis, rare or genuine complications or even unintentional mistake or human errors, system errors or deficiency. Whatever court decides,  while consuming years, the harassment of doctor is full and permanent. Even if court decides in favour of the doctor, there is no compensation possible for the sufferings and agony spanning over years.  Therefore, a single mistake can undo all the good work of past, and the illustrious future work that could have been accomplished.

        If the decision to decide or act or help someone in an emergency situation, puts one’s own life and career at risk, why would anyone put himself in that difficult  position?  

         Medical Consumer Protection Act  has become a tool to harass doctors and money making tool for lawyers, medical industry or administrators. But  it would be naïve to assume that by whipping doctors and regulating them in such a harsh manner will be helpful to patients in long run.  The consequent insecurity among doctors, practise of defensive medicine, enhanced costs, excessive documentation and the distraction from the primary point of intention (treatment)  are few of the  side effects, which will  definitely be passed on to the patients inadvertently.  After all doctors have to save themselves as well. As a result,  now the battle of life and death will be fought with less zeal, with subdued and demoralized soldiers.

          Patients are unable to realize their loss for punishing their saviours. For doctors, no rewards if you win, but sword hanging if one loses.  Fear factors on doctors and impact of present legal complexities is already at par with that of Hammurabi’s era. Consequently being consumer may be overall a loss making deal for the patients.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

Moral bankruptcy of administrators #unpaid doctors


     In an era when doctors are being punished for small mistakes or merely perceived negligence, the blunders committed by administrators are not even noticed. Doctors are not paid for four months and for protesting the same, they were given termination letters.  It seems that doctors need to live with blatant injustice all their lives.

 Any punishment for the  administrators for mismanagement? Looks impossible but punishment to the sufferers is on the cards.

     Medical students or aspiring doctors should be carefully watching the behaviour and cruelty by which doctors are governed, regulated and treated by administrators. Mere few words of respect and false lip service during Covid-pandemic  should not mask the real face of administrators, indifference of courts and harshness of Government towards medical profession. Choosing medical careers can land anyone into the situations, which are unimaginable in a civilized world.

    Doctors pleadings even for their rightful issues and routine problems are paid deaf and indifferent ears. It is disheartening to see that they receive apathetic attitude and dealt with stick or false assurances even for the issues which should have been solved automatically in routine even by average application of governance.

             It is discouraging for the whole medical fraternity to see that even the rightful is not being given what to expect the gratitude and respect.

         The indifferent behaviour has also unveiled the approach of  tokenism such as ‘mere lip service’  showing respect to corona warriors.

      The strong political and legal will is absent to solve Doctors’ problems.

 Unpaid doctors; Medical staff protest on- termination order?

New Delhi: Doctors, nurses and paramedical staff of East Delhi Municipal Corporation-run hospitals continued their protest on Thursday as well over non-payment of salaries for four months.
Meanwhile, an order issued by the medical superintendent of Swami Dayanand Hospital, Dr Rajni Khedwal, stated that services of all senior and junior resident doctors would be considered terminated from February 4 and fresh interviews would be conducted accordingly. The order also stated that all Diplomate of National Board (DNB) residents and contractual doctors would be marked absent.

“We all were there in the protest, none of us went for our duties. We have also asked the administration to speak on our behalf because they are too part of the hospital. Maybe the matter will be resolved tomorrow. Unless we get a concrete statement regarding salary, we will continue the protest,” said Dr Atul Jain, president of the hospital’s resident doctors’ association.

Meanwhile, EDMC commissioner Vikas Anand said that no order had been issued regarding the termination/suspension of the striking doctors’ services so far. The termination order is only for the DNB workers and for the rest of the medical staff, it is based on ‘no work no pay’ as per the SC rule, he clarified.

“The salaries will be provided at the earliest. We have a very good team of doctors at Swami Dayanand Hospital. The only request is that they should join back and resume services,” said the commissioner.


Anand also said that the salaries for the months of February and March would be paid on time. “EDMC is going through a financial crisis and even in such difficult times, the corporation is sensitive towards the interests of its employees. Their due arrears will be paid in the month of May as per the availability of the funds,” he added.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons


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