Correspondence Address:
Nitin S Kekre
Department of Urology, Unit II, Christian Medical College, Vellore, Tamil Nadu
India

Full Text

'The professions dominate our world. They heal our bodies, measure our profits and save our souls. Yet we are deeply ambivalent about them' - Abbott, 1988

The recent furore about a reality talk show about the malpractices of doctors hosted by noted actor Mr. Aamir khan has become the focal point of debate in the Indian medical fraternity. There is an air of indignation and a sense of being wronged among most doctors. Legal action is being contemplated by the Indian Medical Association.

We are in the cusp of an unprecedented growth in the health care sector in India. It is estimated to grow at 15 - 20% over the next few years powered by the increasing population, health tourism and the willingness of people to spend on health care. Even in these troubled times, it is unlikely to go into recession. Lured by the large profits, many large business houses have now ventured into the health care sector. However, several many troubling questions remain. The Medical Council of India (MCI) and the government are ill equipped to handle the situation. The numbers of medical schools are increasing everyday - mostly in the private sector. The motivation behind these institutions is not altruistic. They are for profit. The quality of education remains highly questionable. Medical schools which do not even have the infrastructure to run basic degree courses have been approved to run postgraduate courses. Experienced teachers lend their name to these institutions and are present only during the inspection by the MCI. A complete set of degrees up to sub- specialization can now be booked at the onset of MBBS for a fee. The cost is, of course, exorbitant by Indian standards. If the cost of a post graduate and a sub-specialization degree is included, it is more than what an average doctor can earn in a lifetime. Large hospitals expect the doctor to 'earn his/her pay'. The pressures of the new 'medical industrial complex' [1] result in adoption of therapies that are not adequately proven or the more expensive option when a cheaper and equally effective alternative exists (e.g. LHRH vs. surgical castration). Unfortunately the situation of industry driven medical practices coupled with insufficient training and imperfect skills are seriously compromising the moral and ethical fabric of this noble profession.

Another matter of serious concern is the gradual erosion of both the doctor - patient relationship and ethics in medicine. The relationship of the doctor and his/her patient is fiduciary - the physicians are expected to act in the interest of the patient even when those interests may be in conflict which their own. Providing health care therefore, is not merely a business. The patient often has heightened expectations from the physician. The doctor - patient relationship is unique because of the vulnerability of the patient and the necessity to trust the physician in a potentially life changing situation. This trust however is a fragile state. Deceptions or minor betrayals are given disproportionate weight because of the increased vulnerability of the patient. [2] The relationship between the physician and the patient is now that of a consumer and a provider. Collaboration of the surgeon and the ethicist, now so common in the western world is unknown in India. Record keeping that is highly important in today's world is neglected.

The Medical Council of India (MCI) as the regulatory body neither showed the initiative nor the imagination to deal with this crisis.

Medical errors occur even with adequate training. It has been estimated that as many as 98,000 patients die in the United States each year because of medical errors. [1],[2] This figure may underestimate the scope of the problem because an estimated 50% to 96% of errors go unreported. [3],[4],[5] For India, we have no data or systems for reporting medical errors. The need for a full disclosure is often not understood by the physician. With inadequately trained practitioners the number of errors is likely to increase.

In such a situation the public perception of physicians as healers and people of integrity is rapidly changing. The reaction of the general public to the recent television show about the health care situation in India was revealing. Despite the outcry from doctors and the Indian Medical association, the public perception was in support of the issues raised in the show. The anchor-person has now been invited to address the Indian parliament on health issues. [6] Despite being unpalatable many of the issues raised in the show have relevance. Instead of threatening legal action - which may be rather difficult to execute; we need to put corrective systems in place to avoid such situations. It remains a situation fraught with danger. Any procrastination and we may have populist, poorly thought out measures imposed on us. We also risk losing any residual trust the public has on us. While the IMA rightly speaks out for the doctors, it needs to spare a thought on the state of medical education in the country and the rights of the patients. There is a need to evolve a patient charter so that their grievances can be addressed. We need to reassure that the medical profession would rise to the occasion and take care of patient's interests before its own.

Medicine is a profession. It has been so, since the ancient days. Eliot Freidson in his book 'Professionalism, the Third Logic' defined professionalism as a set of institutions which permit the members to make a living while controlling their own work. [7] He considered a profession to be the best options modern society has for controlling and organizing work. The management of health by the free market and management by private organizations with no governmental controls are inherently unsuitable models as experienced by the United States of America. In spite of advanced medical technology it ranks lower than many other developed nations in the health care indices.

As a profession, it is important to ensure better education with a thrust on skills tempered with ethics. The doctor lives in the society and it will be unfair to expect him be insulated from its aspirations. It will be however be fitting we take it upon ourselves to maintain our standards and uphold the dignity of our profession by our conduct. We owe it to ourselves, our patients and to future generations of doctors.

Recurrent urinary tract infections in females remain an important cause of morbidity. Molecular research is now slowly unravelling the genetic basis behind such susceptibility. In this issue of the IJU Justice et al [8] review the molecular mechanisms behind urinary tract infections and the possibilities for the future. Sub urethral slings have become the gold standard for female incontinence being adopted universally. They are however not without complications. Badlani et al [9] review complications of sub-urethal meshes in pelvic floor reconstructive surgery.

We have planned several changes in the IJU. All accepted articles would be available on the website with a date of acceptance before being published in print. We also intend to fast track article of significance so they are available to our readers at the earliest.

With best wishes,

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