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PERSONAL VIEW bmj.com  Feature: Corruption and murder in a key Indian state (BMJ ;:e)  Letter: Why the NHS should take an interest (BMJ ;:g) Corruption ruins the doctor-patient relationship in Kickbacks and bribes oil every part of the country’s healthcare machinery, writes David Berger. If India cannot make improvements, international agencies should act

he corruption strangles eve- three months, a totally unnecessary investigation. A possibly in response to his resistance to moves to rything, . It’s like a cancer.” senior doctor in another hospital a couple of hours reappoint Desai to the reconstituted MCI.  Accompanied by apologetic away was renowned for using ultrasonography as has globally accepted standards of shrugs and half smiles, state- a pro igate, revenue earning procedure, charging conduct. The Indian profession should want to ments like this are commonly desperately poor people  rupees (; ; adhere and be held accountable to these. Currently, “Theard in India. I knew this was the case before I ) each time. Everyone who works in healthcare however, it seems to be failing in this regard. This went to work as a volunteer in a small in India knows this kind of thing is widespread. is not only bad for India but bad for other countries charitable hospital in the Himalayas, but what I There is also widespread corruption in the that take doctors trained in India. In wanting to didn’t realise was how far the corruption perme- pharmaceutical industry, with doctors bribed to draw attention to these problems, I am holding my ates the world of medicine and the corrosive e ect prescribe particular drugs. Tales are common of Indian colleagues to the same standards of ethical it has on the doctor-patient relationship. hospital directors being given top of the range behaviour as I would my colleagues at home. The latest in technological medicine is avail- cars and other inducements when their hospitals So what can be done? One place to start would able to people who can pay, albeit at a high price, sign contracts to prescribe particular antibiotics be to reform the private medical colleges, the but the vast underclass,  million people or preferentially. number of which is burgeoning as the Indian more, has little or no access to healthcare, and It is no wonder, therefore, that a common com- government tries to expand the number of medi- what access it does have is mostly to limited sub- plaint I heard from poor and middle class people is cal graduates. As long as places are available for standard government care or to quacks, who seem that they don’t trust their doctors. They don’t trust sale at astronomical prices at these institutions,  to operate with near impunity. There is one level- them to be competent or to be honest, and they live and as long as they resort to fraudulent practices ler, however: corruption is rife at all levels, from in fear of having to consult them, which results in and bribery to pass their inspections,  then the the richest to the poorest. high levels of doctor shopping. integrity and competence of their graduates will One day in the outpatient department I was writ- Endemic corruption extends to medical stud- remain questionable and the cycle of corruption ing a request for an exercise electrocardiogram at a ies themselves. In another “unvirtuous circle,” will remain unbreakable. private heart clinic when the devout young resident students can have to pay very large “donations” If prompt reform is not forthcoming from within consulting beside me said, “Give me that. I have to (perhaps   or more, some  times the the country (and the will seems to be lacking  ), sign it.” Perplexed, I handed it over, and the story average doctor’s annual salary) to get into medi- then the spotlight needs to turn global. The medi- unfolded: all investigations attract a -% kick- cal college and to get on to postgraduate training cal licensing authorities of the , back to the referring doctor. One day, the marketing schemes. This means that doctors can have high the US, Canada, , and could executive for this clinic had turned up at the hospi- levels of debt or family obligation when qualify- withdraw recognition from all suspect private tal with an envelope full of cash—the commission ing, which is a strong incentive against working as Indian medical colleges, sending a signal that for investigations ordered generalists in rural areas and there is no longer such a thing as “local corrup- in the past few months. The A senior doctor renowned for favours them practising tech- tion.” These countries are popular foreign desti- senior doctor refused it and using ultrasonography as a nological medicine for maxi- nations for Indian medical graduates, but they stipulated that in future the profligate, revenue earning mum pro t in urban areas to do not want to accommodate potentially corrupt commission was to be paid procedure, was charging try to recoup their investment. doctors of uncertain competence, and neither do back to patients, which is why desperately poor people Many Indian doctors have the people of India. the resident had to sign the 1000 rupees each time huge expertise, and many are David Berger is district medical officer, emergency medicine, form. The country’s doctors honourable and treat their Broome Hospital, Robinson Road, Broome, WA , and medical institutions live in an “unvirtuous patients well, but as a group, doctors have a poor Australia [email protected] circle” of referral and kickback that poisons their reputation. Competing interests: See bmj.com. integrity and destroys any chance of a trusting rela- The arrest on bribery allegations in  of the I am a UK trained who was volunteering at tionship with their patients. Medical Council of India’s (MCI) president Ketan a small hospital in northern India in  -. I thank I Z Bhatty, a Given these practices, it is no surprise that inves- Desai, and the subsequent dissolution of the coun- retired economist who provided invaluable feedback and who tigations and procedures are abused as a means of cil by the president of India, were indicative of the died shortly a er this article was submitted. milking patients. I saw one patient with no appar- crisis in probity among the Indian medical profes- Provenance and peer review: Not commissioned; not externally peer reviewed. ent structural heart disease and uncomplicated sion. Subsequently, there has been controversy over References are in the version on bmj.com. essential hypertension who had been followed up the surprise removal, on the day India was declared Cite this as: BMJ ;:g by a city cardiologist with an echocardiogram every polio-free, of the health secretary Keshav Desirajus,  EDITORIAL, p 

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NO HOLDS BARRED Margaret McCartney Is discussing futile treatments really best for dying patients?

When US doctors were asked if Tracey’s condition deteriorated though it would be useless? Is this kind? they would want cardiopulmonary but, despite efforts, she “did not wish The judgment says that it would resuscitation (CPR) in the case of major to discuss the issue.” Her husband only be “inappropriate to involve the cerebral injury, 90% of them said no thought that she had felt “badgered” by patient . . . if the clinician considers thank you.1 CPR, as with all treatments, doctors to discuss end of life treatment. that to do so is likely to cause her to has limitations and side effects, causing A second DNACPR order was discussed suffer physical or psychological harm.” bodily injury and, in terminal illness, a with her family and written in her Communication is all; the default medicalised death. It changes our last notes. She died shortly after. should be sharing all information. minutes from what could be a peaceful The judgment states that CPR In the real world, however, patients process into a medical battleground. is “potentially life saving” and present semiconscious and with And it’s been found to be “futile” in Does every that therefore “there should be a recent terminal diagnoses; families patients receiving palliative care for decision not to presumption in favour of patient disagree; and imparting and checking cancer.2 offer ineffective involvement” in a DNACPR decision. the understanding of information may So it’s a concern that the Court treatment—organ Indeed, but does every decision not require days when there are only hours of Appeal has found that doctors transplant, to offer ineffective treatment—organ left. Doctors are human, and we seldom breached a British patient’s right chemotherapy, transplant, chemotherapy, dialysis— have just one patient requiring our to a private life when they added a need to become “patient informed” to attention. “Do not attempt cardiopulmonary dialysis—need to absolve doctors from potential future Meantime, CPR is becoming resuscitation” (DNACPR) order to her become “patient blame? Should “badgering” be the fetishised. Doctors withholding it will notes without her knowledge.3 4 informed” norm? have to explain themselves. But doctors Janet Tracey had terminal lung How informed must patients be? who break ribs and bruise the lips of cancer, a “serious” cervical fracture The judgment says that the words terminally ill people, even knowing its after a road crash, and chronic “slip away” were inadequate because futility, will not. Can this really be what respiratory problems, and was not ̻̻News: Doctors should they were not “fully understood.” I too patients want? improving. There was a discussion consult patients before have used such words for the likely Margaret McCartney is general practitioner, Glasgow and the first, contested, DNACPR imposing non-resusitation form of death without CPR. Should we [email protected] Competing interests: see bmj.com order given. A few days later Tracey’s notices (BMJ 2014; now ensure that every patient whom 348:g4094) Provenance and peer review: Commissioned; not daughter looked up DNACPR on the we think is near death—and their externally peer reviewed. internet, was “horrified,” and asked relatives—understands in gritty detail References are in the version on bmj.com. that the order be removed. ̻̻@mgtmccartney that they will not be offered CPR even Cite this as: BMJ 2014;348:g4180

BMJ BLOG OF THE WEEK Anujeet Panesar Playing the patient As a healthy person, I have rarely concerns. I was given a script that frustrated me, right down to how In the art of active listening, rather needed to see my GP. Hence, allowed me to contextualise this they used their BNF and phone. I than distracted listening. In finding I already suspected my own person, give her a background, and was a patient, an observer, a critic, how turning my whole body away experience as a patient would be ultimately help me immerse myself while also wanting to point them from my computer and toward my different from that of many others in the role. As my primary purpose in the right direction when I knew patient, instead of just my head, who go to see their GP. I recently was to help students, I felt a sense they were wandering off course. had such a positive response. had an unexpected opportunity of responsibility to provide them That day I was not a doctor, yet, In the simple actions I had to compare my own and another with the best learning experience in a matter of hours, it changed otherwise considered of negligible person’s experience of consulting I could. And, in trying to remove how I see and present myself as importance, until I had witnessed a doctor as part of a simulated the power my medical knowledge a doctor. I saw my own strengths and critically appraised the same GP surgery for medical students. provides me with, my eyes were and weaknesses as a medical for myself. I allowed myself to be drafted as opened in a way that they have practitioner reflected back at me. This was such an invaluable a simulated patient, made quite never been open before. I saw how I could improve my own experience, I may just venture into giddy at the prospect of being Every aspect of every practice and interactions with my a world of method acting. But, able to harness my underutilised consultation with four students patients. So I took that learning most startlingly, I realised that we am-dram skills, as well as being resonated with me. How they away with me and applied it. are not so different, my patient told that at 33, I could pass for a 25 walked, how they talked, how their Since then, I’ve felt like my and I. year old. Flattery never fails. eyes seemed to regard me. Each surgeries have been transformed Anujeet Panesar is a GP and clinical I was asked to portray a woman facial expression, every word, every from the simple courtesies that I teaching fellow at Keele . who was struggling with moderate pause, every silence. How they took for granted previously. In the ̻̻Read this blog in full and other blogs anxiety and myriad associated placated or soothed me, how they value of a smile at the right time. at bmj.com/blogs

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