Should Doctors Need to Sport an Integrity Badge?
A leading hospital in Mumbai recently announced that it offered medical opinions without any “commissions”. The advertisement displayed prominently outside the Mumbai airport invited significant commentary from people within and outside the medical fraternity. The Indian Medical association called for the hoarding to be taken down. The hospital respectfully declined and urged the IMA to take steps to address the pernicious practice of cuts. Opinions, never in short supply in India, have been flying around.
Over the last few decades, cuts and commissions have become an entrenched part of India’s private healthcare system, that serves over 80% of her healthcare needs. These cuts refer to fees paid to doctors when they refer patients for an opinion to another doctor, or for testing to a diagnostic laboratory or for surgical intervention to another hospital. The practice is widespread though the extent of its penetration has never been documented. Despite the Medical Council of India explicitly prohibiting this practice, commissions have become a part of the healthcare supply chain. Several authors have written about this practice, and the Indian Journal of Medical Ethics has called it a “Pernicious practice, here to stay”.
Commissions have come to be demonized for two main reasons — they add to the total cost of healthcare. It is estimated that commissions between 2 parties may range from 20–40% and the patients inevitably end up bearing this additional cost out of their own pockets. More worrying is the taint or the perception of taint this practice places on the medical opinion provided by doctors. Patients start thinking — Do I really need another opinion, do I need that additional test or the surgery, or are these being advised to increase and share the increased cost amongst this cabal of doctors…The practice of commissions undermines the trust that patients should place in the opinions provided by their doctors.
The recent advertisement by the cardiology hospital is a bold move to call out the practice and also position itself as an honest provider of services. The medical community (including many of my own doctor friends) reacted strongly, taking umbrage over the suggestion that other doctors indulge in these practices. In painting themselves as the white sheep, did the hospital paint the other doctors as the black sheep.
Many other doctors (including this one) have applauded the willingness of the hospital to fight the practice of commissions. Their contention is that the practice exists, so its fair to place it under the spotlight in an attempt to eradicate it. The hospital itself has called for the Indian Medical Association and other doctors to join their campaign in eliminating the practice.
A brief Twitter poll I conducted showed that the integrity of the treating doctor was very important to 99% of patients. Only 1% of patients said they had never thought about integrity as an attribute for their doctors. Patients are also increasingly seeing themselves as healthcare consumers and so doctors are increasingly having to market themselves, as other businesses would. What is interesting is the choice of the messaging. The hospital could have chosen to differentiate itself based on the quality or the cost of treatment, the post-operative recovery time, the superior experience they provide, their low cost, or a variety of other attributes on which healthcare businesses usually differentiate themselves. By choosing to call out integrity as a differentiator, this advertisement has for the first time, perhaps, called out physician/ hospital integrity as a key attribute that patients value highly in their healthcare transactions.
Patients are increasingly treating their experiences as they would any other service. The rise of the healthcare consumer is an important step towards making health providers patient centric and is a trend that should be celebrated. We do have to be careful though of not reducing healthcare to the transactional status other consumer businesses can afford to be. Healthcare is not like other businesses.
I remain ambivalent about the entire episode, even as I mull through its pros and cons. Mainly, I feel a sense of sadness that doctors have to proclaim their integrity before offering a medical opinion. Having said that, its up to all of us to rebuild the trust between patients and doctors. Every time a patient goes looking for a doctor, they have lots of considerations to mine through. They shouldn’t have to look for an integrity badge.
A version of this article also appeared in the Connected Health Quarterly.
