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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 !

Medical Flying squads were created in order to handle medical emergencies . They were first developed by obstetricians, and a team of medical personnel was rushed to help women with complicated labours and childbirths. They were very useful and were responsible for saving many lives .

While flying squads are no longer very common, the Ahmedabad Medical Association has created a new concept of medical flying squads to help doctors who are faced with unexpected complications or emergencies.

One of the nightmares for any doctor in practise is an intraoperative emergency or complication. Unfortunately, no matter how careful and competent the doctor, it is a sad fact of life that complications will occur. For example, a patient may have a cardiac arrest during a minor surgical procedure; or a patient may die because of uncontrolled bleeding during a caesarean section.

When this happens, angry relatives and friends ( often goaded by goons ) will take matters in their own hands. There are now many instances where doctors have been beaten up and hospitals have been damaged, when these kinds of incidents occur. Doctors feel vulnerable and defenceless - and this has led to a rift between doctors and patients. Doctors will often turn away emergency cases because they do not want to take a risk in case the patient does not do well.

Unfortunately, the police are of little help in such emergencies. They will often fail to turn up - or even when they do, they often refuse to intervene or protect the doctor.

Even more significant than the physical damage these incidents cause, it is the irreparable harm they do to the doctor's psyche and his reputation which are especially worrisome. The doctor's broken bones will heal - but a good reputation created over a lifetime of providing good medical care goes down the drain in a few minutes. The media is quite happy to add fuel to fire, by reporting on the " doctor's gross medical negligence", without ever bothering to find the facts.

These incidents have an impact on other doctors as well, who then develop an patient-unfriendly attitude. Rather than treat each patient encounter as an opportunity to serve and heal, each patient is seen to be a potential adversary !

On a recent visit to Ahmedabad, I was very impressed to learn about a very clever initiative which the Ahmedabad Medical Association, an organisation which is now over 108 years old, has developed. Rather than depend upon the police to help them in their time of need, doctors have banded together to help each other.

The Association is remarkable for the sense of unity and camaraderie which exists amongst its members ! Practically all doctors in Ahmedabad are members - both family physicians and specialists. They have set up a medical flying squad, which consists of a group of senior doctors, who will rush to the aid of any doctor, no matter what time it is, whenever they receive a distress call.

An intraoperative emergency or complication is every doctor's nightmare - especially when this occurs in a small private nursing home. With this kind of backup service available, doctors in private practise can rest assured that help is just a phone call away !

Not only does the squad provide valuable medical assistance and a useful second opinion in handling the emergency, they provide a cool head to assist the doctor, who is often scared witless when the patient has a complication. This group of doctors provides reassurance to the relatives, that their patient is getting the best possible medical care from the leading specialists. They help to maintain peace and order - and can also organise police support if needed, as they are respected citizens who are held in high regard.

I think this is a great service and this is a model all Medical Associations all over the country can learn from. Senior doctors - including those who have retired, can offer to serve on these Flying Squads. Not only will this help them to keep gainfully occupied, it will also help them to earn a lot of respect and goodwill. After all, if doctors do not help each other, then who will ?