This was first published in the print edition of Manushi journal, Issue no. 114 of 1999.
As part of 19th and early 20th century social reform movements, many regions in India witnessed vigorous efforts by reformers of both sexes to promote medical education among women. This was seen as an important measure to improve the health of Indian women, especially those who observed purdah and lived in seclusion. They also argued that female doctors would be far more sensitive to women’s needs and concerns. During the last century, female doctors have become commonplace in India- not just in big cities but also in small towns and even some villages. A large proportion of them have gravitated towards gynaecology, so much so that a “lady doctor” is popularly assumed to be a gynaecologist. However, these doctors don’t seem to have lived up to the expectations the reform movement had of them.
In recent years, several cases have come to our notice whereby women allege that they were needlessly subjected to caesarian deliveries in private nursing homes. The primary reason for performing these caesareans is apparently that doctors receive more money for a caesarian delivery than a normal one. Similarly, we have encountered cases of women who were made to undergo hysterectomies (the removal of their uterus’ and sometimes even ovaries) for minor complaints like menstrual irregularities or the appearance of fibroids in the uterus. These complaints can often be easily handled through simple treatment and medication. And yet many doctors are known to subject their patients to invasive surgeries, often without giving them an informed choice in the matter. Many women succumb to such forms of medical abuse due to a lack of knowledge about their own biological process, as well as a lack of information about the options available to them. In this interview, Dr. Bedi, a practicing gynaecologist in Delhi, describes the kinds of manipulation indulged in by a growing number of doctors and the need for women to become enlightened consumers of the medical services. — Editor
Since many women experience some amount of menstrual irregularity after the age of forty, what course of action do you recommend in such cases?
Amongst the various disorders that occur in this age group, the commonest are chronic endometriosis, that is an infection of the uterine lining, and a hormonal imbalance which is likely to occur as hormonal changes begin after 37 years of age. A pelvic examination and a hormonal test, coupled with an ultrasound examination if required, would tell us why a patient had been bleeding irregularly in most circumstances. Invasive procedures such as diagnostic laparoscopy are meant for cases where all other tests fail to determine the causes of irregular and excessive bleeding. But the urgency of the operation in most cases has to be guaged according to the severity of the ailment. It is urgent only if there is a reasonable certainty that a given disease, such as cancer, will occur. She has to be told about her situation in detail and if the primary complaint doesn’t bother her much, there is certainly no reason to rush into any operative treatment or procedure, including diagnostic laparoscopy. After a first consultation she should be put through routine blood and urine tests, ultrasonography and other examinations like hormonal tests, that are both cost effective and do not involve any invasive measures such as cutting and stitching or inserting instruments inside the body.
When is extensive surgery required?
I am sure many surgeons all over the world would argue about when to recommend extensive surgery. However, this whole approach where you assume that sooner or later a hysterectomy will be required is based on a very presumptuous form of medical practice in which the uterus is believed to be just a reproductive organ and therefore useless after a certain age. But we know for certain that the uterus is not just a reproductive organ, useless after a certain age, and that it has its own role in maintaining a balance in a woman’s body. Almost every woman goes through some sort of uterine bleeding abnormalities—heavy bleeding, light bleeding, etc in her lifetime. They get scared and generally go to a doctor, who would almost make them feel guilty that they have not had a hysterectomy done already, particularly if the patient is over 40. The patients would then be sent to an ultra-sonologist who would confirm the findings of the gynaecologist. They would be made to go through lab tests. The uterus would be taken out and sent to a pathologist who would in turn make some kind of a report. In the end, the patient will never know what was wrong with her in the first place except that she would certainly stop bleeding. This is like chopping off someone’s head to cure a headache!
When is a hysterectomy absolutely necessary?
A hysterectomy is never really absolutely necessary, but it is recommended in a number of cases of prolapsed uterus (in this condition the uterus comes out of the body), and in certain kinds of cancers of the uterus, especially at an early stage where a hysterectomy may cure the cancer. It is also performed as a lifesaving procedure in cases of life-threatening bleeding from the uterus, as may occasionally occur following childbirth. In most other cases, including endometriosis and fibroids, it is a relative indication and should be decided upon as a last resort, never a first line of treatment.
Often, however, doctors try to create alarm by using non-medical terms to describe a patient’s condition, saying “you have a fairly large, apple-sized or lemon-sized fibroid”, or something to that effect. These adjectives are designed to create a sense of alarm and frighten the woman into opting for a surgical procedure. This is totally unprofessional and has no place in the medical practice. We are trained not to use adjectives such as large, small, exquisite, medium, etc. If, for example, we say moderate or grade II endometriosis, it is according to international guidelines followed all over the world. We cannot concoct our own criteria of small, medium or large because they are very affective terms. If I say that it is a 5 cm fibroid it would mean the same to 10,000 gynaecologists in a hundred countries. But if I want to remove the uterus, I could just say that it is a very large fibroid. If I want to leave the decision to my patient, I could say that it is a medium-sized fibroid, and if I don’t want to remove it at all, I could just say that it is a small fibroid. So all these terms hardly mean anything at all. In all forms of objective evaluation, we have to use the exact metric or nonmetric measurements and not such obscure adjectives as small, medium, etc
Similarly, in another instance a doctor might subtly say, “Maybe it’s cancer” to scare the wits out of a patient. Professionals deliberately misuse their status for this kind of malpractice. Only three out of 1,000 fibroids do ever become cancerous. But if a patient asks me if fibroids become cancerous, then I might affirm the possibility so emphatically that the already anxious patient would agree to anything I say, including surgery
What is the extent of this particular kind of malpractice?
It is not a gender issue here. It is not a woman talking to another woman, but a doctor sitting on a high pedestal talking to a patient. Similar logic is used when surgeons remove appendices, or ENT specialists remove tonsils or orthopaedic surgeons remove discs
What should women do to prevent such a case from happening?
Lately, doctors are scared of patients who assert themselves rather than blindly follow advice. So, if a patient asks pertinent questions, does her own market survey rather than go by somebody else’s opinion and takes informed second opinions, it would always be safer.
How much truth is there to the charge that needless surgery and organ removals are routinely taking place?
The amount of money a surgeon makes is directly proportional to the number of surgeries he/she performs per month. For instance, I earn about Rs 200 after spending an hour with a woman trying to convince her not to get a hysterectomy done or try out other options like hormonal treatment. In the one or two hours that it would take me to perform a hysterectomy, I would earn about Rs 10,000 to Rs 20,000 per case. Of course, the entire surgery would cost her anywhere between Rs 20,000 and Rs 80,000. So, the more caesarians or surgeries I perform the more I earn.
Similarly, it is much more convenient for the surgeon to perform a caesarian. For example, I may have to forsake a couple of nights sleep to deliver one woman through the normal process of childbirth and I get less money. But it takes maybe 45 minutes to perform a caesarian, everyone goes back to sleep and you get twice or thrice the money that you would for a normal delivery. Cutting a patient and stitching her up adds a lot of glamour to it. Instead of an obstetrician, you become a surgeon in a common man’s eye. About 30 or 40 years ago the concept was that since babies were born every year, one here or there did not matter as long as you could save the mother. If the baby could not be born through the normal passage, you just did a caesarian and delivered the baby.
Caesarian was performed as a life-saving procedure for the mother. As childbearing became safer for the mother and fewer children were born in planned families, the main reason for performing caesarian changed to rescuing the baby. The focus shifted on to producing a “perfect baby” and caesarian was offered as a choice, to avoid the “risks”, both genuine and presumed, involved in a normal delivery. Most of the reasons for which caesarians were performed for the sake of the baby remain unproven. For example, in the 1970s caesarian was touted as the safest method of delivery, even safer than normal delivery.
Now we know that caesarians could have many more complications than we anticipated. It is not safe even for the foetus let alone the mother. It is more common for caesarian babies to have complications than babies who have been born through the normal vaginal delivery.
In your estimate, what percentage of deliveries are being done through the caesarian method in a city like Delhi?
Statistics have been very carefully concealed or moulded by doctors. It is only after legal provisions are made necessitating each doctor to audit his or her practice that one can expect any realistic estimates on the subject. But the demand for this has to come from the consumers. Internationally, medical auditing was made mandatory only after there was a demand for it by the people that are affected by it. It started in the West because there it is the insurance companies that pay the medical bills. So they have a vested interest in asking for medical auditing. In India, even if the employers are paying the bill, they don’t have the resources to monitor the professional competence or ethics of every doctor. But in the West, the charging patterns, and how many surgeries you perform, are often monitored by the insurance companies. They actually come to your clinic, and go through your records. If they find too many irregularities, they stop covering your bills. In these cases, the doctor is practically unemployed. These companies have the resources, the money, and the vested interests to hire other doctors- and lawyers- to check auditing for them.
Here, unfortunately, it is very difficult to get doctors to speak against their co-professionals in public or in courts. Though they are very fond of running each other down in the privacy of their clinics, they do not take a stand in public or give evidence in court fearing ostracism and thereby loss in practice.
So we have to build a monitoring system in our country from scratch. For example, even by auditing financial accounts, one can ascertain whether or not a doctor is taking his job seriously. If I were to say that I have made Rs 10 lakh over the past 10 years, and spent Rs 2 to Rs 3 lakh on books, I would receive a lot of credit for my desire to upgrade my knowledge. Say another doctor has a personal money audit of Rs 10 lakh of income and not even Rs 10 has been spent on the purchase of a book, then at least I would be very wary of going to such a doctor.
Most doctors don’t upgrade their skills and knowledge because in India their success does not depend on the quality of work that they deliver. So they continue to practise what they learnt in their college many years ago. Secondly, doctors are handling cases they are not qualified for because there is no referral system. In a typical setup, it is a budget-regulated medical practice. Most families do not have a health budget. Suddenly somebody needs a hysterectomy to be done. They would have to make do with whatever amount of money they have. A hysterectomy cannot be performed for say Rs 7,000 unless you cut corners—i.e., use inferior suture material in a certain procedure. So if a patient comes with just Rs 7,000 or Rs 10,000 then there are two ways of managing the case. Tell her to go to a government hospital where the operation could be done for free, or tell her that I can somehow manage with the amount. In which case I will just use poor quality suture materials, cut corners, cut the length of stay in the nursing home, economising not for the patient but for myself. Here the money is made only for the surgeon. Nobody is there to question you as to whether such and such surgery is required or not. Even if you cut 90 out of the 100 patients you see in a month, nobody monitors you. Here I must add that the failing public health system, and the long periods of waiting in public hospitals, help the cause of private practice. The patients prefer to go to private doctors because they do not have enough confidence in the government-run institutions.
The biggest scandal in gynaecology is in infertility. It is not a medical disease but an economic condition. It depends on how much money you have or how much you are willing to spend on treatment. All the infertility clinics sell is hope, and it is for a price. They would perform any kind of test, and give you any kind of statistic. They would then tell you that there is 70 to 80 per cent chance of getting a baby, which means nothing either for the person who does get pregnant or for the person who doesn’t. If you don’t, then you fall into 20 per cent who don’t get pregnant. Sooner or later a patient gets weary of one doctor and goes to another, where the whole game is replayed. No doctor says that a certain specialist would be able to handle your case better.
Most practice is personality based and works by public relations and publicity. A patient who does get pregnant, brings in 10 more patients. Nobody is told the full cost of the treatment. It is told in installments. They give their assurances to the patients verbally. Suppose I tell a patient that there is a 90 per cent chance that she will conceive, there is no way to check unless there has been an audit of my performance in the past years.
How does a woman find out whether a caesarian was needed or not?
It is impossible for an individual patient to find out whether or not she needs a caesarian. But a group like the Medical Council of India should be monitoring the doctors because it is their job.
How do you define “malpractice” within the medical profession ?
The term malpractice is not something obscure which is subject to someone’s individual opinion. It is a very precise scientific term, an evaluation of your own work. Every doctor is supposed to review his practice at the end of the day, and if he is not doing so, he is not doing justice to his practice. Some of what was established practice 30 years ago would be considered malpractice today and vice-versa. For example, a small foetus was reason enough to do a caesarian about 20 years ago. But after 20 years of performing caesarians on small foetuses they found out that they were not saving any more by performing caesarians. Therefore, they stopped it. In 1974, if you did a caesarian on a small foetus, it was justified. But in 1994, if you did the same it would be considered unjustified. Similarly, if no hormones were available and the woman was bleeding for months, one did a hysterectomy just to prevent the blood loss. But today hormones are available and in 90 per cent of the cases it is possible to stop the blood loss. For the same reason, removing a uterus at the outset without trying other simpler alternatives today would be considered malpractice in most cases. But then in isolated cases every professional is entitled to an error of judgement. Though in the case of doctors unfortunately, it is at the cost of the patient. For that the law and the society have given a very long arm to the doctors. We have mystified our profession with very liberal use of Latin and Greek and with a ‘we know best’ kind of attitude. Sooner or later it becomes very difficult to hide your incompetence, however.
Essentially it is just a game of numbers. If you make the same mistake too often then something is wrong somewhere. Doctors with medical degrees, organisations such as the Delhi Medical Association or the Indian Medical Association are fond of condemning quackery. Whenever you talk about malpractice, the professionals will try to convince you that malpractice is done mainly by quacks. In their eyes, a quack is someone who does not have a modern medical degree, an MBBS or an MD. I wish it were as simple as that where if you just noted down all the quacks and removed them, quackery would be over. In my view, quackery is practised unfortunately by some of the highest paid and the most qualified professionals of this country. For instance, as a gynaecologist, if I decide to perform a brain surgery or a heart surgery, we both know it would be quackery. So society or law would have to develop some sort of system which would stop me from overstepping my limits in terms of training or experience.
The reality is very sinister. Technically, any person with an MBBS or an MD can perform any surgery in this country. For a patient to know who is qualified and who isn’t to perform the kind of surgery he or she is about to undergo is almost impossible. And our past
history shows that the statutory bodies like the Medical Council of India or the state medical councils that proclaim themselves to be the official watchdogs do hardly any work and it is impossible to even get a reply from them to your complaint, let alone their pursuing a case. They are quasi-nominated, quasi-elected bodies and they would never take a stand against fellow doctors. In other words, doctors are organised and patients are not. To get any kind of propatient judgement is impossible. It was in 1958 that the Medical Council of India was established and since then they have never once taken any action against a doctor for malpractice.
What are the cases of malpractice that you know of?
It starts with inadequate professional training. For instance, say you are training in a medical college to be a gynaecologist. When you are training to be a specialist and studying for an MD in college, there is absolutely no protocol to which a resident must be trained. If you go abroad, and are training in some specialised field, you are required to do a certain specified number of cases but that is not the practice here. There are no guidelines at all.
To get an MD in this country, you are required to produce a thesis under a guide. You follow the guide for two years like a faithful dog at the end of which, he or she signs your thesis as if doing a great favour to you and sends it to the university. Then there is a written examination and a viva voce, which is very subjective, and you get your MD. The next day, you are entitled to cut up anyone. There is no minimal standard set to attain a medical degree. After getting an MD, we are supposed to do a medical registrar’s training in which we perform surgical procedures and work under supervision. You do independent as well as supervised duties with cover from a consultant. Any or all of these steps can be bypassed in this country and you would still be a specialist. There is no regulation whatsoever on the quality of the professional produced.
Most of us come into practice without any conscious choice. For instance, if you don’t get admission to an MD course after the MBBS or if you don’t get a registrarship after MD, you get into practice. Here you are thrown into the jungle of private practice. When there has been no medical practitioner in your family, you are ignorant about many things. You don’t know about the charges, you don’t know about the private health set up at all. You have no controls over the operation theatres you work in, which are owned by some businessman. Then there is a complicated referral and counter-referral system with labs having their own say. In other words, it is absolutely unorganised. If any other private sector company had to work like this sector does, it would have to close down within 15 days. But here, under the garb of serving humanity, with the gift of the gab that we do pick up, we manage to convince people that we are “treating” them. Most patients, thanks to God and the healing powers of nature, do pretty well. It is only in cases where things go wrong that relatives crib. Even then they hardly ever scream. When your criterion of a successful private practice becomes your monthly paycheck, sooner or later people are bound to try to enhance it by hook or by crook.
Along with the lack of regulations, patients are kept in the dark about the details of their treatment while the myth of doctors as the do-gooders of society continues and malpractice is sustained by the implicit support of the co-professionals. For instance, the Medical Council of India clearly states in our mandatory oath that “I will work to expose the incompetence of my coprofessionals”. This oath was initiated because no lay person would be able to prove professional malpractice. Despite this oath that the Medical Council of India requires all doctors to take, no doctor has ever stood in court to give incriminating evidence against a co-professional. Loyalty towards the profession is curiously confused with loyalty towards the co-professional. Any case brought up against a doctor falls flat mostly because the “experts” called refuse to corroborate the allegations made against their co-professional.
I don’t know if it is the incompetence of the doctors or the greed to earn more that leads to this kind of malpractice. But one thing I am sure of is that sooner or later doctors start believing in the myth that they are gods. That is when they start behaving abnormally, performing surgeries that wouldn’t be accepted anywhere else in the world. If I had to perform 100 caeserians in a year, and if seventy out of them ended up with complications, then something is wrong with me. That is where the concept of medical auditing is brought in elsewhere in the world. In fact, it was for the defence of doctors that we started the system of auditing our own results. The term “medical audit” is not like financial auditing, though it is similar. A medical audit is not a raid or a sort of inspection by an outside authority. What it essentially means is selfmonitoring whereby each doctor is expected to keep detailed records of their work so that they maintain accounts of the actual outcome of their interventions. For example, if a patient accuses me of doing an unnecessary caesarian, I could just go to the court and tell them that out of the 1,000 deliveries that I have done so far, only 70 were caesarians. That is, my caesarian rate has been lower than 8 per cent so far. Anywhere in the world a 10 per cent caesarian rate is acceptable for a doctor. On the other hand if I say that out of 1,000 deliveries I have done 700 caesarians, then obviously no amount of arguing that this caesarian was needed would hold up in court. It would be evident that I had been cutting up too many patients. In the same way, if a person bleeds to death, and my past record shows that there has been one death in 1,000 deliveries or caesarians, there would be no cause for surprise. I could be given the benefit of doubt. But if 50 or 100 patients had died, then I should have my license revoked.
Complication or error of judgement rates for any surgery are well-published and well-known. As a trained independent consultant, any doctor’s record should fall at least within the range of internationally accepted safety standards. But in India, because there are no regulations, there is no need for me to upgrade or review my techniques. Today it is almost a status symbol to go to a certain doctor. If you want to make money, then you have to project yourself as a God and soon you start thinking of yourself as one. That is when your error of judgement rates start going up. The laws are so liberal anyway that it is very difficult to catch a doctor by the horns.
How are the laws liberal?
There is such a wide range of error of judgement allowed by the law that a doctor can get away with anything. For instance, it would be nearly impossible to prove in court that an infection following a caesarian was caused by a doctor. Except government doctors, you can sue any doctor for malpractice under the Consumer Protection Act. But the doctors were not protesting against that. What they managed to change through their protests was the whole orientation of the argument. They made even very highly qualified, sensitive individuals believe that malpractice was actually an error of judgement. About the issue of malpractice, the doctors are actually afraid of the cases going to the consumer courts instead of the normal court. The law is not what they are against. Doctors who indulge in malpractice are protesting against being “covered” under the Consumer Protection Act, but actually they are afraid of being “uncovered” by it or the cases tried under the act. In fact, the law has not been changed at all. Only now it is possible to have a judgement enforceable in the future. They are against the cases being tried in the consumer courts where they will take less time to be dealt with. In the normal courts it takes years for a case to finish. But if you are not guilty, you should be happy that your case would end soon. This proves how afraid they are of being proven guilty.
Malpractice takes many forms— overcharging, taking cuts and commissions, obliging your coprofessionals by doing an MRI or too many tests that are not required. All these would be swept under the carpet except for cases where somebody sues you. In these instances, knowing the kind of people these doctors are, they would first lay the blame on each other. For instance, doctors who do not feel confident performing certain surgeries may call in a “ghost surgeon” to do the job. In ghost surgery, the actual person who performs the surgery does not even see the face of the patient and vice-versa, as the patient is under anaesthesia. For example, a case questions why the caesarian was performed at all. A doctor might say that it was performed because of a breech presentation. Somebody else may produce an x-ray and ultrasound proving that it was not due to a breech presentation. Then who is at fault? The actual performing surgeon, or the one whom the relatives think performed the surgery? The surgeon would produce the ghost surgeon in a court case. This ghost surgeon would then be tried for committing a tax offence because he would not have declared his income that he made because of the surgery. There are just too many things under the carpet.
Is ghost surgery very common?
Yes, it is very common in all forms of medicine. Because not all doctors who claim to be specialists in a certain field are necessarily so. But they cannot admit that fact to their patients. For instance, I can do caesarians. But for a hysterectomy, I send my patient to another doctor. Then the next time someone from her family has a gynaecological problem, she would ask her to go directly to the other doctor and not to me. So the alternate procedure is, I book the patient in my name while somebody else slips in from the back, performs the surgery and slips away. All this time the patient is made to believe that I am the one who performed the surgery. Even in some of the poshest clinics of Delhi, some of the gynaecological surgeries are performed by general surgeons who are not even trained for it. The doctor would be very happy as long as he is being paid for it.
But once something goes wrong, and the patient decides to sue you, then you don’t know who will face the music. The payments are done in cash without receipts or names. So once one case is exposed by the revenue officials there will be thousands of them. One never knows where all the money went, who was keeping all the accounts, etc. So, the doctors were scared of being uncovered by the Consumer Protection Act.
The second stand that the doctors took was that non-medical people cannot decide on medical incompetence. But I don’t agree with that. Even if it is true that a medical person is required to judge whether a caesarian was required or not, a medical person is not required to judge whether the fee was appropriate or whether it was right for a host surgeon to perform a certain surgery in place of the person who was pretending to do it himself, whether the payment was receipted or not, who got the cut. In a case where you paid Rs 6,500 for a MRI scan and out of that a certain amount was given to the prescribing doctor as a commission, you do not need a medical person to say that this was malpractice.
This is so rampant that people who do not take a commission are singled out and considered threats to the profession. They are either threatened or given expensive gifts as bribes or just flattered with eulogies by other malpractioners.
Didn’t the doctors successfully resist being brought under the Consumer Protection Act?
No, they did not successfully resist the Consumer Protection Act, though they made a lot of noise about it. Anyway they do not even need to protest much since the law is already anti-patient and prodoctor.
I believe that they even went on strike against the arrest of a doctor for malpractice?
This doctor was arrested for trading in kidneys. For that the Indian Medical Association and all the private doctors went on strike without ever finding out what were the criminal cases that were filed against the doctor. Their whole issue was how can you arrest a doctor irrespective of the fact that he might be a rapist or a criminal. Getting an MBBS degree here automatically gives you an immunity against any criminal malpractice that you might indulge in.
So what happened to that doctor?
All I know is that he was released after some time in jail.
The fellow doctors did not take any disciplinary action against him?
We all know people who have killed their wives, gone to jail for 14 years and still resumed practice.
You mean Dr N.S. Jain, the eye specialist who had even been conferred the Padma Shri?
Yes. In almost all the rape cases that cannot be proved it is the medical reports that are ambiguous. No doctor has ever been pulled up because he has made an ambiguous report. In a governmental set-up under various pressures, they do constitute a tailor-made ambiguous report for a rape case so that hardly anyone can be prosecuted on the basis of the report. This is how most alleged rapists go scot-free. So at every step the medical profession has failed the society and it is ironic that the society still gives it so much respect.
When one woman doctor in Maulana Azad Medical College complained of sexual harassment, there were 2,000 doctors protesting against it. It is ironic that in the last 40 years, no medical body has taken any action in any sexual harassment case anywhere in the country even though such cases are rampant. This was the only case that bothered them because the costudents of the girl took to the streets to protest against the doctor accused in the sexual harassment case. Even then, the Medical Council of India didn’t bother to issue a statement against him. I have never heard of any case where the doctors went on strike because there wasn’t enough oxygen in the hospital. Whenever they go on strike, it is because they want better pay or something for themselves.
What books would you reccomend for further information on these topics?
I would strongly reccomend the following three books* in order for women to exercise an informed choice about the treatment they are about to undergo. What is extremely important is that women should believe in the healing powers of nature, the natural processes like labour and keeping their organs intact. If nature has placed certain organs inside the body, then why remove them undless there is a real danger to one’s life from their malfunctioning.