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What makes a good doctor good is the fact that he has good clinical judgment. This is a term which is hard to define, but basically a good doctor is one has seen and treated and learned from lots of patients, each of whom adds to his knowledgebase and clinical wisdom. As the saying goes, "Good judgment comes from experience. Experience comes from bad judgment."

However, the mere passage of time does not provide good judgment . After all, 20 years of being a doctor could simply mean 20 years of doing the wrong thing ! It's important that doctors learn from their experience - and the only way they can do so is by tracking the outcomes of the patients they treat.

Unfortunately, this rarely happens in real life ! Let's take 2 patients whom a family physician treats for abdominal pain. One gets better and moves on with his life. He does not tell the doctor he is better, because who goes to a doctor when they are fine ? The other may get worse and may end up needing an appendectomy. However, he's not likely to go back to the doctor either ( unless he is angry and wants to sue !). This means that both patients who get better and those who don't rarely provide feedback to their doctor in real life.

However, without this feedback, how is the poor doctor going to learn ? He naively assumes all his patients have got better - and he loses track of those who do not improve , because unhappy patients will do their best to find another doctor.

How can doctors practise evidence based medicine ( EBM) without any evidence ? They need feedback from patients, so that can learn whether what they are doing doing is useful or not ?

EMRs can be a great tool in facilitating this kind of patient feedback ! One week after every clinical encounter, the system can automatically send an email to the patient, asking for feedback. This will provide very useful data - for which each doctor can learn about what he did right - and what he messed up.

Many doctors will agree that it can be very frustrating to treat an "interesting patient" - and then never find out how the story ends, because the patient never comes back and is "lost to followup" !

Not only will this data help doctors to learn and improve , it can also be very useful as a clinical practice builder , because patients are touched when their doctor reaches out to them proactively. Patients are happy when they learn that the doctor is interested in finding out how they are doing - and happy patients make for happy doctors !

There are major disadvantages to the cut system. For one, this system increases the cost to the patient. It also promotes malpractice, because family physicians often pressurise specialists to do surgery in order to maximise their revenue, which means that procedures are done, which are not always in the patient's best interests. Because this practice is hidden, it's never discussed openly, and this creates a lot of resentment amongst patients.

The fact that doctors indulge in giving kickbacks is an open secret - and hiding this reality creates a lot of suspicion in the patient's mind. “This is one of the major reasons patients do not trust their doctors, and why the reputation of entire medical profession has taken such a beating in recent years,” says Dr. Malpani.

Traditionally, medical care was always provided face to face. If you had a medical problem, you went and saw your doctor for a consultation. He would take a history; examine you; and then decide on what treatment you needed.

This was and is still a good model, because it allows doctors to provide the "human touch" , which is often a key ingredient in providing good medical care. However, as time evolved, doctors realised that not all their patients needed to come and see them for each and every problem.

Many problems are self-limited and resolve on their own, so that they can be effectively managed by reassuring the patient; while others simply need a renewal of a prescription ( for example, for managing a stable patient with a chronic illness). This is why "telephone medicine" is an integral part of medical care today.

As technology has evolved, the internet provides a more efficient way of communicating with a doctor than the telephone, so that online consultations are now standard in many fields.

While there is no doubt that seeing a doctor is very important in a medical emergency; or when the diagnosis is unclear, it's also true that not all medical problems require you to visit your doctor.

There are many downsides to a doctor visit. Doctors are busy - and it can take 2-6 weeks to get an appointment to see a leading physician. Also, a visit to the clinic can be quite disruptive , and may need you take a day off because travelling to the clinic can be quite a time consuming chore. A doctor's clinic can be quite chaotic - and long wait times ( surrounded by sick patients) is hardly conducive to healing.

Also, many times patients know what their diagnosis is. They just need a second opinion; or need to find out the cost of a particular treatment option - information which they should be able to get without having to go through the inconvenience and expense of actually going to the doctor.

Online consultations offer a lot of benefits - and in fact, the quality of care can actually be better in some cases ! An online consultation allows you to get an opinion from a world-renowned expert, without having to travel half way across the world to meet him ! Because the doctor's opinion is based on a review of your medical records, you have to make sure all your tests and treatments are well documented - helping you to become better organised, and thus become a better-informed patient. Also, you do not need to waste time waiting for an open consultation slot , because the doctor's clinic timings are no longer a bottleneck, as a result of which the turnaround time can be much quicker.

When you email your questions, do not need to worry about the fact that the doctor is in a hurry and another 20 restive patients waiting in line to see him. It's possible to ask well-crafted questions to clarify your doubts , so that you have a clearer picture of your options. Often email consultations are more productive because you are not stressed out . When sitting in front of the doctor, many patients forget half their questions - and after the visit, many cannot remember half of what the doctor told them. This can cause of a lot of unhappiness for both doctors and patients. An emailed opinion is in black and while - and you can verify this advise with other specialists and your family doctor ; and also share it with your loved ones, to confirm that you are on the right track ! Finally, an online consultation can ensure you get a more objective honest opinion ! Since the doctor does not know you, he has no hidden agenda, and will not want to push you into doing surgery, for example !

Can online consultations have a downside ? Yes, of course ! There is no personal rapport; and the online " expert " may not be trustworthy or reliable. This is why you need to use this option intelligently ! Also, doctors may not be willing to offer this option, because they are not sure how to bill for their time ( though I am sure this will change, as patients are quite willing to pay for phone consultations and online consultations as well !)

In my opinion, it's very good for both doctors and patients that additional options are now available, thanks to the internet . This option is especially useful for getting a second opinion and we do this routinely at www.drmalpani.com !

It saves me a lot of time and energy; and keeps my patients happy, because they can tap into my expert knowledgebase, without having to come and see me !

Cuts and kickbacks have become the norm in medical practise in India today. In public forums, most doctors frown on this practise as being unethical and unprofessional ( even though they continue giving cuts in their own practise). This is hypocritical and just adds more dishonour to the medical profession.

Let's take a fresh look at the subject. The question we need to ask ourselves is - Is there anything wrong with doctors giving cuts ? Is this really such a bad thing ?

Cuts and kickbacks are pretty much standard practise in many areas of life today, such as politics and commerce. Greasing palms is considered established practise if you want your file to move in the government office , and if it's okay to give bribes and kickbacks in other fields, what's wrong when doctors do the same ?

Let's see why the practise evolved in the first place - after all, the fact that it has spread like a cancer means it must have some plus points ! Rather than turn a blind eye to these , let's look at some of the benefits this offers.

The advantages to the family physician ( primary care doctor ) are obvious ! It's a fact that family physicians are underpaid as compared to specialists. Doctors who do procedures command an unfair premium and these kickbacks helps to reduce the disparity in their incomes.

Also, primary care doctors play a very useful complementary role to the specialist, but this is often not explicitly acknowledged or reimbursed . They don't just refer the patient to the specialist and then walk off after collecting their commission ! They help to identify the "best specialist"; help the patient to get a timely appointment; counsel and handhold the patient
( something which most specialists just don't have the time or energy to do !) ; explain what the specialist is saying ; and demystify the medical journey for the family. They are always available for assistance ( for example , in the middle of the night, when the specialist has disappeared) ; and because they have an ongoing long-term relationship with the family, they are able to provide emotional support much more effectively than the specialist . Equally important, they are better at taking a holistic view of the medical problem, as compared to specialists, who have a very narrow viewpoint - and who may know a lot about the technical minutiae of their specialty , but know precious little about the person who has the disease !

Family physicians act as a useful bridge between the specialist and the patient - how are they going to reimbursed for their efforts in a fair fashion ? In my opinion, the cut which the specialist gives for the referral is their reimbursement. Taking a share of the spoils is the most effective way for them to earn money.

So it all hunky-dory ? No ! There are major disadvantages to this system ( which is why we do not give cuts in our private practise !). For one, this system increases the cost to the patient. It also promotes malpractise , because family physicians will often pressurise specialists to do surgery in order to maximise their revenue, which means that procedures are done which are not always in the patient's best interests. Also, because this is unaccounted for black money , which is paid in cash, under the table, it encourages a parallel underground economy.

Because this practise is hidden, it's never discussed openly , and this creates a lot of resentment amongst patients. The fact that doctors indulge in giving kickbacks is an open secret - and hiding this reality creates a lot of suspicion in the patient's mind. This is one of the major reasons patients do not trust their doctors , and why the reputation of entire medical profession has taken such a beating in recent years.

So what's the solution ? Can we ban kickbacks ? While the Code of Medical Ethics explicitly bans cuts, unfortunately this does not work in real life. We need to find a realistic solution !

I feel the major danger with the kickback is the fact that is done in an underhand secretive fashion. Because the doctor hides the fact that he is giving a kickback to the referring family , he has to be dishonest - and this damages the doctor-patient relationship, which should ideally be based on trust !

Large corporate hospitals routinely give referral fees to doctors. This is considered to be part of the "cost of doing business" and is usually given as a cheque payment. If we accept this practise
( because a hospital is a business and needs to fill its bed), then why not level the playing field and allow doctors to give referring doctors a commission as well ( which can be claimed as a tax-deductible expense ? ) Similarly, doctors give referral / commission fees to medical tourism companies which refer patients to them. What's wrong if they give this to the family doctors who send patients to them ?

I feel it's far better to make this an open and transparent system, so the patient knows what the truth is ! The specialist can add a " surcharge" to his fees, and this can be paid to the family physician by cheque , as a "patient management fee" . This transparency will keep everyone honest and help to align the doctor's interests with that of the patient !

I agree that doctors need to improve their ethical standards, but what really upsets me is the double standards which have now been institutionalised, with the entry of corporate hospitals into the medical field.

While everyone is happy to loudly criticise the specialist who gives kickbacks to the family physician for referring patents to him, why is everyone so mute when it comes to the kickbacks which the hospitals give to doctors for filling their hospital beds ? All corporate hospitals give these cuts and commissions openly and shamelessly. They employ a large number of very presentable executives ( mostly female) in their Dept of Public Relations, and cleverly call it a "patient management fee", when the only management involved is writing the referral note !

It's the same story with the medical tourism companies. All hospitals are happy to give large commissions to these tourism companies for the "facilitation services" they provide, but these are costs which then get passed onto the poor unsuspecting patient !

Why should we allow double standards in medicine ? After all, both doctors in private practise and hospitals are competing for the same patient - let's have a level playing field; and not be hypocritical ! If it's OK for hospitals to give kickbacks ( which they treat as " the cost of doing business") , then let's allow doctors to do this as well ! In fact , doing it openly will help to improve transparency !