Comparing airline industry & health care is fallacious, an oversimplification; apples to musk-melons


 

 

The issue of patient safety has been gaining increased traction year on year and the issue is in right direction.  Hospitals, doctors and administration need to vigorously address shortcomings and strive toward minimum errors and desired goals of safety.   Patient safety is of paramount importance; therefore it is an serious issue. It should be achieved by good ground work and not by sensationalizing and mischaracterizing the real basic issues, transparent safety culture, adequate number of staff and resources.

There is a recurrent old argument and temptation to ask about why healthcare can’t be as safe as airline travel.   There can be many apt comparisons that may be possible between aviation and health care especially taking into account the risk involved. But the doctors who treat critical emergencies,  have  insight looking at life and death situations directly,  know  that comparing both would be just an oversimplification of the real basic issues.

  At most of the points, the comparison is a complete fallacy; and like comparing apples to musk-melons.

It is beyond doubt that air-industry maintains truly an impressive system which is well-designed to achieve the safety results that it does.  But , the kind of  comparison  that  some health care safety leaders make in which they compare the  mortality data of acute hospital care and airline fatal accident rates is more of a word play and not so appropriate. This comparison is dangerous because it misses the key points for improvement. Such comparisons  merely present over-simplified and convenient tool for the health quality experts, who themselves have never been a front line health workers at any point of time, but still pretend to pioneer the  quality in health industry.  For the quality improvement the leaders need to be grounded in the reality of emergency front line medicine to be really effective.

  1. Aircrafts  are engineered to be in the best possible shape before they fly. Patients, on the other hand, patients  are in the worst shape when they enter the emergency of the hospital.

Medicine is by nature, a much more risky work than flying along with vulnerability to death always.

  1. The aircrafts are required to regularly demonstrate that the performance of their critical systems meets or exceeds strict standards. If systems are not operating well the plane will not be allowed to fly.

But all the patients, (aeroplane metaphor) are already sick; doctors are expected to fly such aeroplanes, who are in crashed condition universally. Doctors do not have the luxury to replace any part.  For example, when doctors treat an elderly with heart failure, chronic kidney failure and pneumonia, they try to keep them “flying” despite multiple sub optimally functioning critical systems.

  1.  In other words, doctors have to fly crashed planes always on every day basis, something that never happens even once in aviation industry.
  2. Has any Pilot ever tried to fly  a plane in which engine power is only 25 percent of normal with  other systems are functioning  sub optimally  and  the fuel tank is leaking?  What will be standard procedure (SOP)  for Pilot to fly this plane? But everyday doctors try to fly such planes and they have to fly it no matter how many systems are non-functional.  Moreover, doctors can be sued on some flimsy grounds in case they fail or an accident happens in an effort to keep this plane in the air.  Treating a critical illness is like an effort to keep such planes in air with suboptimal functioning systems.

Obviously the comparison is a bit overzealous.

  1.   What would be chances that a fully checked plane with a trained pilot will crash after flight takes off. Now compare the chances of patient who lands in emergency, and treatment is started.

By a simple common sense, are two situations comparable?

Former has no chance (almost Zero percent) of crash whereas in a critical emergency patient, the chances of crash are 100 % to start with.

  1. Communication of passengers to the pilot about what he should do and what he should not while flying the plane is nil. Whereas doctors are continuously bombarded with google knowledge of patients and interference by relatives and questioned about every action.
  2.   Doctors are expected to make future prediction about what can happen, how he will be able to keep the crashed plane in the air and take consent, based on few assumptions. Doctors can be harassed and dragged to courts if such predictions fail.
  3. Airlines will always have full staff to serve promptly during a flight. The pilot will be totally dedicated to flying the plane, and will not fly without the co-pilot and crew. On the other hand, front line healthcare workers know it well the fact that patient safety incidents and errors tend to occur when they are struggling with staffing levels and feel grossly overworked.

Fatigue and overwork is too common scenario among front line healthcare staff in clinical settings.

  1. A pilot is also only ever going to fly one plane at a time. It is not realistic for a doctor or nurse to be allocated to just one patient, but the workflow is very different, with healthcare tasks frequently interrupted with new clinical issues and emergency situations. Consequently, insufficient staffing can have an acute effect on outcomes and the ability to perform safely.
  2. Aviation industry is too predictable and on the contrary, health care is combination of uncountable unpredictable risk factors, be it allocation of staff or risk of death or resource prediction and complexity of communication.
  3. Aviation is more of mechanical milieu, whereas health care deals with emotion and compassion. The two industries are vastly heterogeneous, and to say that safety in medicine should follow in the path of flying airplanes, grossly oversimplifies a complex problem.
  4.    Last but not the least; health care involves lot of financial uncertainties and arrangements. Needless to say, doctors carry the blame for financial hardship of the patients, even if they are not responsible for costs. The mammoth industry remains hidden and doctors are blamed as they are the only front man visible.
  5. Basic difference lies in the fact that patients are real living people, whereas airplanes are simply machines, whose codes and protocols are well defined and limited to within human capabilities. The importance of human contact, empathy, compassion, interact and listen to concerns, and the ability to spend adequate time with patients,  should be  always be the first pillar of promoting a culture of safety.
  6.   Exhortations by armchair preachers to learn oversimplified improvement examples from aviation can provoke considerable frustration and skepticism among clinicians exposed to the unique challenges, difficult working conditions and everyday complexities.  Patients are not aeroplanes, and hospitals are not production lines.

Most unfortunate part is the assumption that every sick person who dies in a hospital from an adverse event is an example of a truly preventable death rather than clinicians trying their best to keep someone alive and eventually failing.

  1.  Checklists and documentation to improve systems are wonderful in mechanical areas like operative care and inserting central lines, but have limited role and can only go so far without the most important virtues of being a doctor or nurse. It means more than mechanically following protocols and doing paper work in real sense.

In health care merely providing check list and doing extra- paper work may be counterproductive for many reasons.  Increase in time for voluminous documentations will consume time and forces health care workers to focus on paper work and takes them away from patient’s real issues.

Completed paper work and excessive documentation provides a false assurance of quality work, which may or may not reflect true picture of patient care. Even after full documentation,  still  it will be required  to be carried out in a diligent manner, a  task which is different from mechanical  task of mere check list  of other  industries . Learning from other industries seems to offer a simple shortcut to anyone trying to improve healthcare, but its utility is limited only for documentation purposes and not real quality. Caring for patients is radically different from flying aeroplanes. Healthcare is unique in the intimacy, complexity, and sensitivity of the services it provides as well as the trust, compassion, and empathy that underpin it.

Merely completing protocols mechanically and excessive documentation will result in decline in quality actually.  Simply importing and applying a ready-made tool will lead to situation, where quality will exist only on papers and merely  reduced to a number to the satisfaction of so called ‘pioneers’ of quality.

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The  Myth  of  cost of  spending  on  medical  education needs to be made  transparent.

Syndicate Supplying Fake Cancer drug Busted #Spurious-Medicine


The rise in “falsified and substandard medicines” has become a “public health emergency”. A surge in counterfeit and poor quality medicines means that thousands of patient  a year are thought to die after receiving shoddy or outright fake drugs intended to treat ailments. Most of the deaths are in countries where a high demand for drugs combines with poor surveillance, quality control and regulations to make it easy for criminal gangs and cartels to infiltrate the market.

There is an  urgent  need for  effort to combat a “pandemic of bad drugs” that is thought to kill hundreds of thousands of people globally every year.

More are thought to die from poor or counterfeit vaccines and antibiotics used to treat or prevent acute infections and diseases. Beyond the fakes that are made and sold by criminal gangs are poor-quality medicines that lack sufficient active ingredients to work properly, or fail to dissolve correctly when taken. Sloppy manufacturing is often to blame, but others are sold past their shelf life or have degraded in poor storage conditions.

    Governments and pharmaceutical companies had to improve the security of the drug supply chain in all countries from the point of manufacture to the patient. Regarding online pharmacies, there is poor public understanding of how to differentiate between a legitimate online pharmacy and an illegal one. Illegal online pharmacies and the sale of medicines via social media platforms pose the greatest risk to the  public.

Deadly Cocktail: to Make  Fake Cancer Drugs- Syndicate Manufacturing & supplying over 21 Spurious Medicines

To make big money, Pradhan got his cousin Shubham Manna and Ram Kumar involved in his plan and started making spurious cancer drugs. “He had been providing spurious medicines at a discounted 50% of market prices. He was manufacturing and supplying more than 21 spurious cancer medicines of various companies of different countries,” special commissioner (crime) Ravindra Yadav said. The syndicate comprised highly-qualified and well-earning individuals. Manna had completed his BTech and served in MNCs before joining hands with Pradhan. Police said his job was to generate barcodes, emboss batch numbers and expiry dates on medicines. He also looked after overall packaging of the spurious medicines. International syndicate used to procure capsules and manufactured fake medicines by filling them with starch.

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     25 factors- why health care is expensive

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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?

NEET- Not so Neat- percentile system

The  Myth  of  cost of  spending  on  medical  education needs to be made  transparent.

Compare Reaction to  Death of “Hundreds of healthy people” to  single “perceived negligence” in Hospital  #Morbi-Gujarat


Reaction to ‘Death’ in this  new era  of consumerism has become a story of paradox. Massive civil negligence  and 141 deaths but there are no punching bags  as are  doctors  for revenge in case of a hospitalized death.     Just Compare the media  projection, burden of negligence and accountability of  hundreds of healthy deaths by civic negligence   to the  one hospital death by disease. 

     Death is the inevitable conclusion of life, a universal destiny that all living creatures share.   Death can occur through conflict, accident, natural disaster, pandemic, violence, suicide, neglect, or disease. 

Multiple Deaths in healthy people by civic negligence:

Large numbers of death and morbidity happen amongst absolutely healthy population due to preventable causes like open manholes, drains, live electric wires, water contamination, dengue, malaria, recurring floods  etc. The number of   people dying are in hundreds and thousands, and are almost entirely of healthy people, who otherwise were not at risk of death. In fact the burden of   negligence here is massive and these deaths are unpardonable.  Timely action could have prevented these normal people from death. 

Collapse of a pedestrian bridge that killed at least 141 people. #Morbi-Gujarat.

Police in the Indian state of Gujarat have arrested nine people in connection with the collapse of a pedestrian bridge that killed at least 141 people. Four of those detained are employees of a firm contracted to maintain the bridge in the town of Morbi.

Hundreds were on the structure when it gave way, sending people screaming for help into the river below in the dark.

Hopes of finding more survivors are fading. Many children, women and elderly people are among the dead.

The 140-year-old suspension bridge – a major local tourist attraction – had been reopened only last week after being repaired.

Single  Death in Hospital due to disease:

      Reaction to single “in Hospital” medicalized death  is a paradox.   The media has instead, focused on the stray and occasional incidents of perceived alleged negligence in hospital deaths which could have occurred due to critical medical condition of patient.  However an impression is created as if the doctors have killed a healthy person. It is assumed without any investigation that it was doctor’s fault. 

     In present era, the expectation of medicalized death has come to be seen as a civic right and Doctors’ responsibility. People now have less understanding and acceptance of hospital  death. The death is more perceived as failure of medical treatment rather than an invincible power or a certain final event.

Point to ponder-Misplaced priorities:

Who is to be blamed for the deaths of healthy people which occur because of civic negligence?  Here relatives are actually  helpless and the vital questions may go unanswered .  There are no punching bags  as are  doctors  for revenge. Any stray incident of death of an already ill patient is blown out of proportion by media  forgetting the fact that thousands of patients are saved everyday by  Doctors.   

      It is time to check the  emotional reactions to single hospital death due to a disease as compared to hundreds of death  of healthy people due to civil negligence.

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   Medical-Consumer protection Act- Pros and Cons

Expensive Medical College  seat- Is it worth it?

NEET- Not so Neat- percentile system

Projection of  Inflated Cost of Medical Education- Global Exploitation of Young Doctors


The  Myth  of  cost of  spending  on  medical  education needs to be made  transparent.

Educating a doctor cost less what   medical colleges  claim- a global phenomenon.

   Instead of   often  repeated statements  about high expense on running medical college and  projecting it   as a  hard  fact, the amount spent  on  medical students by all medical colleges should be made transparent by all institutions. The  frequent  statement  is made that  cost of  making a doctor is very high and  gleefully  propagated  by  the  private medical colleges to extract millions out of  young  medical students . 

Such statements without any actual public data  is repeated  to the   extent  that  it  is  firmly  entrenched  in  public  mind without any real evidence.

     High cost  is  the  reason    with an intention  to  exploit the young doctors in various ways to get cheap labour and extract  millions from aspiring doctors  by private medical colleges.

      The  basis  of  such calculation should be transparent for every medical college and all institutions. 

       In any medical college,  only the   Departments  of  Anatomy and Physiology  are purely for medical students. The  remaining  subjects  taught  in  medical  colleges  across  the  country  are  related  to  patient 

care  and  medical  education  is only  a  by-product.  All the medical teachers are actually doctors involved in treatment of patients, running  the hospital  and students observe the treatment and learn medicine. The interns and  postgraduate  students  provide the cheap and labour and actually save the costs of running the hospital.

 Therefore   if  some college   is  actually  spending  millions   to  produce  one  MBBS  doctor ,  it  is  a  either an   inefficient  model   or costs are inflated and exaggerated to exploit the young doctors.

Educating a doctor cost less what   medical colleges claim

The average cost of producing a doctor or nurse went down across most parts of the world between 2008 and 2018, but almost tripled in China and doubled in India, a Lancet study shows. Despite this, the estimated expenditure per medical graduate in China at $41,000 is higher only than in sub-Saharan Africa and about 42% lower than in India ($70,000) against a global average of $114,000. The pattern was the same for nurses with the estimated expenditure per nursing graduate dropping across the world while it went up by 167% in China and doubled in India. The only other region where the per graduate cost went up was in North Africa, where cost per doctor went up by 47% and by 25% for nurses. Approximately $110 billion was invested globally by governments and students’ families in medical and nursing education in 2018. Of this, $60.9 billion was invested in doctors and $48.8 billion was invested in nurses and midwives, the study estimated.

The paper looks at important developments in medical education to assess potential progress and issues with education of health professionals after the Covid-19 pandemic. Mean costs in 2018 were $114,000 per doctor and $32,000 per nurse. In 2008, China had the lowest estimated expenditure per medical graduate at just $14,000 (Rs 6 lakh) followed by India, where it was just $35,000 (Rs 15 lakh at the 2008 exchange rate of Rs 43 to a dollar). This is much lower than the estimate of Rs 1 crore or more that Indian colleges widely claim as expenditure per medical graduate.

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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.

     Advantages-Disadvantage of being a doctor

     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?

Sale of breast milk- Ayush licence- Dairy product -Lucrative business- Any Ethical Question?


Commercial sale of mother’s milk under Ayush licence has thrown up ethical questions.  You can buy literally anything these days, even human breast milk. India is home to the only company in Asia that sells mother’s milk for profit, Bengaluru-based Neolacta Lifesciences Pvt Ltd. After activists objected to the commercialization of mother’s milk, the Food Safety and Standards Authority of India (FSSAI) cancelled the company’s licence stating that sale of mother’s milk was not permitted under its regulations. However, an FSSAI inspection revealed that the company continues to sell mother’s milk by obtaining an Ayush licence in November 2021 for its product dubbed ‘Naariksheera’ (breast milk). Neolacta, which was established in 2016, had originally obtained a licence from the Karnataka office of the FSSAI in the category of dairy products. “It is absolutely shocking that a company is being allowed to collect breast milk from young mothers and sell it like a dairy product with a huge price tag claiming to have added value to it,” said Nupur Bidla of the Breastfeeding Promotion Network of India (BPNI), which had alerted the government to this in 2020.

       Saurabh Aggarwal, MD of Neolacta, told TOI that the company has significant experience in the human milk space supplying technology to set up the first milk bank in Australia. He said that NeoLacta had, over the past five years, “benefited over 51,000 plus premature babies across 450 hospitals.” Donated breast milk is mainly used to feed premature or sick babies when mothers are unable to nurse them for a variety of reasons. Usually, the milk is sourced through milk banks set up as non-profits. Milk collected from donors (healthy lactating mothers) is pasteurised, analysed for nutrient content and checked for contamination of any kind and is then frozen and stored. In most milk banks, especially those attached to government hospitals, the donated milk is given free of cost. However, in many others it might be free for a few poor patients but those who can afford it are usually charged a few hundred rupees for 50 ml of donated breast milk. There are over 80 non-profit human milk banks in India. Neolacta charges Rs 4,500 for 300 ml of frozen breast milk. A pre-term baby could require about 30 ml per day while a baby on full feed could need as much as 150 ml per day. It also sells human milk-derived powder that is readily available on ecommerce sites as well as its own. President of the National Neonatology Forum (NNF).

     Dr Siddarth Ramji told TOI that “as a principle we do not support commercialisation of breast milk” but pointed out that NNF was not a regulatory body. Dr Satish Tiwari, national convenor of the Human Milk Banking Association of India, described it as a shame. “Does the company pay the mothers who are donors? Do they take it free and sell it at such a high cost? No one knows. The government should look into this.” In a research article published in December 2020 titled, ‘Nurture commodified? An investigation into commercial human milk supply chains’, social scientist Dr Michal Nahman and economist Prof Susan Newman from the UK examined the way Neolacta functioned. Speaking to TOI, Prof Newman said their research consultants had found evidence that women, mainly in rural areas, were actively being pursued by NGOs and associated ‘health workers’ and paid either with cash or with food packets. She pointed out that in the initial news reports on Neolacta, they freely admitted to collecting milk from women across four states but have since become more cagey about how they source the milk. The article adding that in 2016, an attempt by NeoLacta to collect breast milk from the largest government hospital for women and children in Bengaluru, Vani Vilas, was abandoned after serious concerns over the “commercial exploitation of breast milk”. “It was evident from our interviews with NeoLacta donors, intermediaries such as NGOs and community health workers and NeoLacta employees,  donor milk is not framed as a commodity in spite of the marketisation of NeoLacta product. Rather, the way in which donor milk is operationalised as a ‘gift’ (or ‘daan’ in the Indian context) is built in to how it is commodified,” stated the article. Remuneration would depend upon the volume that women provide and 80% of the revenue would be paid to the mother with the NGO worker taking a 20% cut, it added.

 At the time of going to press, the Ayush ministry had not responded to this reporter’s queries. BPNI wrote to the health ministry in February 2020 that “Neolacta has been involved in commercializing human milk” even though the guiding principles for using donor human milk in India in the health ministry’s ‘National Guidelines on Lactation Management Centers in Public Health Facilities’ clearly states, “DHM (donated human milk) cannot be used for any commercial purpose”. With the ministry not responding, BPNI wrote to FSSAI asking how the licence was issued. Neolacta was established in 2016, a year after Cambodia banned selling of breastmilk after a public outcry about an American for-profit company Ambrosia sourcing breast milk from poor women in Cambodia and selling it in the US. A letter from the Cambodian government was quoted as stating: “Although Cambodia is poor and (life is) difficult, it is not at the level that it will sell breast milk from mothers.” In the context of Cambodia, UNICEF had said in a statement that the trade in breastmilk was “exploiting vulnerable and poor women for profit and commercial purposes”. Most countries do not allow the commercial sale of breastmilk.

    Dr Arun Gupta of BPNI alleges that Neolacta aggressively markets its products on social media. “It is using the tactics of the infant formula industry in the way it is targeting healthcare providers to gain legitimacy. Infant formula companies harp on mothers not having enough milk and Neolacta goes on about mothers producing ‘excess breastmilk’ which they can donate. It claims that its products do not come under the IMS Act, which regulates the marketing of infant milk substitutes, but it does,” said. BPNI complained to the National Neonatology Forum (NNF) in February 2021. The NNF responded in April 2021 to state that the NNF had already taken a decision in its executive board meeting to abstain from providing any form of encouragement to Neolacta Lifesciences and that a letter communicating this decision had been sent to all the members of the forum. Officials from the Bengaluru branch of FSSAI inspected the Neolacta unit on April 22 and found stocks of packing materials bearing the suspended FSSAI License, which they seized. The local FSSAI office has also asked the company to recall from the market all its products which have used the FSSAI licence and to disable online selling of such products. The company was also issued a notice for carrying out food business without a valid FSSAI license. A commercial company selling breast milk would court healthcare providers including doctors and hospitals to become their suppliers, which would increase the cost to the healthcare system and create ethical dilemmas, warned public health researcher Sarah Steele of the University of Cambridge in a piece she wrote about commercial human milk banks in October 2021. She added that if mothers moved from donating to non-profit milk banks to such companies, healthcare providers would be forced to enter into contracts with such companies and this could result in the privatization of a previously public service. Dr Sushma Nangia, professor and head of the neonatology department in Lady Hardinge Medical college who established a human milk bank, explained that donated breast milk might be better than infant formula but was inferior to mother’s own milk. “Even for pre-term babies their own mother’s milk is best for them to thrive. Donated human milk is inferior to mother’s milk as milk from different sources is pooled and vital nutrients are lost when it is pasteurized. Obviously, there are cases where donated breast milk is needed and that is why we started a bank but we do not prescribe it for all pre-term or sick babies. Neonatologists and the increase in the business of neonatal ICUs in the private sector are behind the push for donated breastmilk. It has become a lucrative business. This menace (push for commercial donor milk) can be curbed if neonatologists invest time and resources in ensuring mother’s own milk for her baby rather than going for commercial donor milk and also providing unambiguous information to families that donor milk is not the same as their own mother’s milk. The government needs to step in and enquire where the milk is being sourced from,” said Dr Nangia.

     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

Expensive Medical College  seat- Is it worth it?

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. 

     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

Expensive Medical College  seat- Is it worth it?

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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‘Warning’ Label, Not Health Star Rating on Junk Food: Experts to FSSAI


A triple burden of malnutrition – under-nutrition, micro-nutrient malnutrition, as well as overweight and obesity – is rising in India. Paradoxically, these forms of poor nutrition often have the same nutritional root cause. More nourishing freshly cooked home-foods or more natural foods are being replaced by cheaper pre-processed packaged alternatives with high levels of salt, sugar and fat that fill the stomach, but do not nourish and in fact promote ill health and disease.

India is the diabetic capital of the world, with the highest concentration of diabetics in any single country. Hypertension closely follows, leading to an overall non-communicable disease (NCD) burden reaching epidemic proportions. A major pathway leading here is the rise of overweight and obesity, as a consequence of poor diets combining with sedentary lifestyles.

      Health star ratings are designed by the powerful food industry to mislead the consumer. If the government is serious about the epidemic of obesity and non-communicable diseases, the consumer needs to be cautioned about junk foods through warning’ labels, public health experts gathered at the National Conclave on Sustainable Food Systems’, organized by the Centre for Science and Environment (CSE) in Nimli, Rajasthan, said.

      The government should issue a warning’ label on packaged junk foods instead of health star ratings as they are misleading and doing more harm to customers than good, health experts said on Wednesday. Health star rating is a labelling system that grades packaged foods on the scale of one to five stars.

    By pushing these, the Food Safety and Standards Authority of India (FSSAI) will give license to glorify junk foods, which is the opposite of what should be done, Director General, CSE, said while leading the expert deliberation on the Need for front-of-pack warning labels on ultra-processed junk foods’. Health star ratings are designed by the powerful food industry to mislead the consumer.

 Front-of-pack labelling on packaged foods was first recommended by  the FSSAI-led committee formed in 2013. CSE was part of this committee. FSSAI then came up with a draft regulation in 2018, which had strict thresholds limits to know unhealthy levels based on those developed by the WHO for countries like India in the South-East Asia Region.Due to industry pressure, FSSAI came up with another draft in 2019.

  what does junk food deserve stars or warnings times of india

The food industry was still not pleased and this draft was repealed.

From January-June 2021, stakeholder consultations were held on the labelling design to be adopted, thresholds to made applicable and nutrients to be displayed.

CSE has documented all delays and dilutions until June 2021, the organisation alleged in a statement.

The latest consultation took place in February during which it was made clear that FSSAI plans to go ahead with the Health Star Rating’.

The sole objective of the stakeholder consultations, which were heavily dominated by the packaged food industry, was to come up with a labelling system, which is industry-friendly, said Khurana, who was part of these consultations, adding that all this while, FSSAI has been insensitive to the information needs of the consumer.

He alleged that the statutory body also ignored the global best practices and evidence around it. Instead, in an orchestrated way, through the scientific panel and commissioned studies, it is now getting ready to adopt a labelling system which is considered least effective and rejected across the world, he said.

Health star ratings are depicted based on an algorithm at the back-end, which is not known to consumers, CSE said, adding that it is only adopted voluntarily in few countries such as Australia and New Zealand and only some food products carry it.

It has been rejected in several other countries as it can mislead the consumer and be easily manipulated by the industry, the CSE said.The proven best practice in front-of-pack labelling is nutrient specific warning’ labels, experts said.They have been simple and effective in discouraging junk food consumption. Several Latin American countries, Canada and Israel have already adopted warning labels.Many other countries are considering them.

Among them, the best known are symbol-based warning labels such as that of Israel. These will be most suitable for India, as it would transcend the literature and language barriers, the CSE said.We have submitted our concerns to FSSAI. It can’t allow a system that will effectively nudge the consumer to make unhealthy choices. It will mislead the consumer because of its design, algorithm and inclusion of positive nutrients in the calculation. It can’t allow relaxed limits and voluntary adoption, Narain said.

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Expensive Medical College  seat- Is it worth it?

Why buying a medical college seat & paying millions may be a blunder?


    The painful incident of Dr Archana Sharma’s Suicide unmasks the everyday struggle of the doctors in the present era. Her supreme sacrifice depicts the plight of doctors- being undervalued and demonized, forced to work as a sub-servant to bureaucrats, irresponsible policing, blackmail by goons and vulture journalism-all have become an accepted form of harassment.  Her suicide has unveiled the despondency, moral burden of mistrust that doctors carry. Her death is the result of the apathy of fair justice that eludes medical community. Sadly, the society is unable to realize its loss.

    Negligent police, indifference of Government and venomous media has made it impossible for health care workers to work in a peaceful environment.  It may not be a good idea to opt for a medical career any more. In the present circumstances, when doctors themselves are doubtful about the advice for choosing medical career, some people are naïve enough to spend millions on securing an expensive medical college seat.  Problems faced by doctors are not only innumerable but are also so exceedingly complex that they are difficult to be analysed. Doctors feel so disgusted   about the entire system that they do not encourage their children to take up this profession which until now was one of the coveted ones, there must be something going terribly wrong with the profession.

Disadvantages of being a doctor, Drawbacks of Medical profession: 

Choosing medical career  or being a medical professional  a disadvantage to doctor in comparison to other professions?

  1. Medical courses are comparatively lengthy and expansive study course and difficult training with slave like duties. “enslavement of doctors”.
  2. Uncertain future for aspiring doctors at time of training: Nowadays, doing just MBBS is not enough and it is important to specialize. Because of lesser seats in post-graduation, poor regulation of medical education, uneven criteria, ultimately very few people get the branch and college of their choice.  They have to just flow with system ultimately.

3.Hostile environment for doctors to begin: Suddenly young and bright children complete  training and find themselves working in a hostile environment, at the receiving end of public wrath, law, media for reasons they can’t fathom. They face continuous negative publicity, poor infrastructure and preoccupied negative beliefs of society.

  • Difficult start of career: After a difficult time at medical college, an unsettled family life and with no money, these brilliant doctors begin their struggle. Even before they start earning a penny, the society already has its preconceived notions because of negative media publicity and half treats them as cheats and dishonest. Their work is seen with suspicion and often criticised.
  • The fear and anxiety about the actual treatment, favourable and unfavourable prognosis of patient, keeps mind of a doctor occupied.
  • Blamed for all malaise: The society gets biased because of the   media reports and some celebrity talking glib against medical profession. The blame for inept medical system, administrative failure and complexity of medical industry is conveniently loaded on doctors. These lead to formation of generalised sentiment against all doctors and are then unfortunately blamed for all the malaise in the entire healthcare system.
  • Personal and family life suffers: Large number of patients with lesser number of doctors is a cause of difficult working circumstances, and the frequent odd hour duties have a very negative impact on the family and personal life of the doctor.
  • Risk to doctor himself: Repeated exposure to infected patients in addition to long work hours without proper meals make them prone to certain health hazards, like infections which commonly include   tuberculosis and other bacterial and viral illnesses. Radiologists get radiation exposure. Because of difficult working conditions, some doctors are prone to depression, anxiety and may start on substance abuse.
  • Unrealistic expectations of society:  Every patient is not salvageable but commonly the relatives do not accept this reality. Pressure is mounted on doctor to do more while alleging that he is not working properly. Allegations of incompetency and negligence are quite common in such circumstances. These painful discussions can go to any extent and a single such relative every day is enough to spoil the mood for the day.
  • Retrospective analysis of doctor’s every action continues all the life: It could be by patients and relatives every day in the form of “Why this was not done before?” Every day irritating discussions, arguments, complaints, disagreements add to further pain and discontentment, in case the patient is not improving. Or it could be by courts and so many regulatory bodies. If unfortunately there is a lawsuit against a doctor, he will be wasting all his time with lawyers and courts, which will takes years to sort out.

The decision taken in split seconds will be questioned, which  in retrospect  may not turn out to be the best one. But later retrospective analysis along with wisdom of hindsight with luxury of time  (in courts) may be labelled as wrong if a fault-finding approach is used. This along with general sentiment and sympathy with patients makes medical profession a sitting duck for lawsuit and punishments. Even if the doctor is proved to be not guilty, his harassment and tarnishing of reputation would be full and almost permanent.

  1. Physical assault, routine instances of verbal abuse and threat are common for no fault of theirs. Many become punching bags for the inept medical system and invisible medical industry. Recently, even female doctors have not been spared by mobs. Silence of prominent people, celebrities and society icons on this issue is a pointer towards increasing uncivilized mind-set of society.
  2. Medical industry may be rich but not the doctors: The belief that doctor’s is a rich community is not correct. Although decent or average earnings may be there, but earnings of most doctors is still not commiserate with their hard work viz-a-viz other professions. Doctors who also work like investor, a manager or collaborate with industry may be richer. But definitely most of doctors who are just doing medical care are not really rich.
  3. Windfall profits for lawyers and law industry at the cost of doctors is a disadvantage for medical profession:  It is heart-breaking to watch  zero fee and fixed commission ads on television by lawyers in health systems in certain developed countries. They lure patients to file law suits and promise them hefty reimbursements. There is no dearth of such   relatives, lawyers who are ready to try their luck, sometimes in vengeance and sometimes for lure of money received in compensations.  This encouragement and instigations of lawsuit against doctors is a major disadvantage for medical profession.
  4. Overall, a complex scenario for doctors: There is increasing discontentment amongst doctors because of this complex and punishing system. They are bound by so many factors that they finally end up at the receiving end all the time. They are under Hippocratic Oath and therefore expected to work with very high morality, goodwill and kindness for the sufferings of mankind and dying patients.  They are also supposed to maintain meticulous documentation and also supposed to work under norms of medical industry. They are supposed to see large number of patients with fewer staff and nursing support while still giving excellent care in these circumstances. And if these were not enough, the fear of courts and medico-legal cases, verbal threats, abuses, and physical assaults and show of distrust by patient and relatives further makes working difficult. Additionally there may be bullying by certain administrative systems at places, which use pressure tactics to get their own way.

       It may be a  naïve idea  or just a blunder to pay millions to be a doctor.

     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

Expensive Medical College  seat- Is it worth it?

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