Press "Enter" to skip to content

Medical trespassing not strictly prohibited

Let me illustrate two situations.

Dr Chandrashekhar A Sohoni
Dr Chandrashekhar A Sohoni

Situation 1 –

The issue of non-allopathic doctors practising allopathy is being furiously debated these days. Whereas the central government wants to introduce a new, shortened course in allopathic medicine at graduate level, some state governments have already issued resolutions which empower non-allopathic doctors to practice allopathy. [1] The factors that enabled state governments to allow non-allopathic doctors to practice allopathy are as follows –
• Health is a state affair, and hence state governments have the authority to legislate health-related matters pertaining to the state.
• Even before the Maharashtra government issued a resolution in 1992 allowing non-allopathic practitioners to practice allopathy, the same was already a prevalent practice.
• With a serious crunch of allopathic doctors in rural areas, allowing non-allopathic doctors to practice allopathy was thought to be a possible solution for the deteriorating rural healthcare.

Situation 2 –

The Medical Council of India (MCI), at the behest of the Delhi High Court, defined the term sonologist in 2011. According to the definition, a post-graduate degree in radiology is not mandatory for practising sonography. Six-months training is all that is required for the practice of sonography by an MBBS registered medical practitioner. Despite sonography being considered traditionally a radiological modality, its treatment as a separate entity was enabled due to the following –
• MCI as an autonomous body has the legal authority to lay down the criteria for practice-eligibility of doctors.
• Even before the question of defining a sonologist was posed to MCI, many non-radiologist doctors were already practising ultrasound.
• There is a general opinion that compartmentalizing sonography practice will create deficiency of sonography services in rural areas and hence non-radiologist doctors should provide sonography services in such areas.

Similarities between situation 1 and 2 –

• The process of policy making and the reasoning behind the same – an authority with an opinion in favour of a particular action, legalization of a long-standing routine practice, and the dearth of doctors in rural areas – have striking similarities in both the situations.

Differences between situation 1 and 2 –

• The practice of allopathy by non-allopathic doctors has been labelled as “quackery” in various court judgments; whereas practice of speciality medicine by non-specialist doctors has not so far been pronounced in the same category. Courts rely upon MCI to define the practice boundaries of modern medicine practitioners.
• The practice of the speciality of radiology, specifically sonography, by non-radiologist doctors is acceptable to allopathic medical community; however, the community is opposed to the practice of allopathic medicine by non-allopathic doctors despite the government proposing a mandatory short-term training in pharmacology for non-allopathic doctors.

A radiologist’s personal perspective on both the situations –

Like any other specialist, a radiologist becomes a radiologist only after passing through a very laborious channel. After the gruelling task of getting admission into a medical school and then successfully negotiating the demanding years of graduate education, an MBBS doctor is in for even more hard work. Without a post-graduate degree, doctors in India find it extremely difficult to find good jobs or set-up private practice. Before becoming a specialist, an MBBS doctor goes through the process of an entrance exam, counselling for post-graduate admission, three years of full-time residency programme, thesis work and an exit exam. A medical student has to be in the top-ranks to earn a post-graduate radiology seat in a government medical college. The capitation fees charged by private medical colleges for a radiology seat is anywhere between Rs 1.5 crore and Rs 3.0 crore at present. Due to and despite the extremely poor success rate, hoards of post-graduate Diplomate of National Board (DNB) students appear for final exit-exam year after year simply because they realise that without a post-graduate qualification they do not stand a chance. It is no secret that the DNB exit-exam is an ordeal that is second to none. It is a fact that sonography, and not CT/MRI (Computed Tomography / Magnetic Resonance Imaging), forms the bread and butter of a vast majority of radiologists. For a cardiologist, echocardiography provides for a very small part of total income, whereas for a large number of radiologists, sonography is the only source of income. No wonder that radiologists feel wronged when their hard-earned post-graduate degree is made optional for the practice of sonography. While the eligibility criteria for teaching radiology, including sonography, in medical colleges are stringent, the criteria for radiology practice outside medical colleges are different.

The acceptance of an unofficial term like “sonologist” might just be the beginning. As an extension, we might soon have newer titles like “Magnetic Resonance Imagiologists” and “Computed Tomologists” being awarded after six months of so-called training, without the need for entrance exams and pain-staking residency programmes. As I see it, the only reason this has not happened so far is because CT and MRI machines are much more expensive, less accessible and not financially lucrative. The day this price-barrier breaks, CT and MRI will meet the same fate that x-ray, sonography and interventional radiology already have. It does not make much sense to field a speciality that does not have much exclusivity. Why not completely do away with the speciality of radiology and save many unsuspecting but intelligent students from falling into the trap?

It is really a chain-reaction. A non-allopathic doctor does what an allopathic general practitioner should ideally do; therefore an allopathic general practitioner does what a specialist physician should ideally do; a specialist physician in-turn does what another specialist from a different branch should ideally do. If all doctors were to be full-time employees working for fixed salaries commensurate with their degrees, most of the turf-wars would end overnight. That gives an indication as to why turf-wars exist in the first place.

No matter how good a driver one is, driving without a valid license is illegal because the life of people on road is priceless. Why don’t we realize the importance of medical licenses when the life of patients is at stake? While emphasizing the importance of a license, it seems appropriate to cite the example of pharmacy practice in India. Under the Drugs and Cosmetics Act 1940, and the Rules 1945, employing a full-time pharmacist is mandatory to run a pharmacy. The qualification of the pharmacist should be B. Pharm or D. Pharm. Even if a non-practising doctor with a master’s degree (MD) in Pharmacology wants to run a pharmacy as a business, he would have to necessarily employ a pharmacist. The argument as to why a non-practising doctor, that too one with an MD degree in pharmacology, should need a pharmacist to dispense drugs will not stand ground. This is an example of the strength of a license that is backed by effective legislation. When the policy-makers and Pharmacy Council feel the need for a specialist qualification in pharmacy, they also ensure that the privileges of pharmacists are protected via strong legislation. Whereas no one else can replace a pharmacist in a pharmacy, anyone possessing a basic degree of MBBS can potentially replace a radiologist in a sonography clinic. That is the weakness of a license in isolation.

The separation of sonography from radiology has been a matter of debate even in the western world. An article published by Auntminne.com titled “Turf wars in radiology IV” makes for interesting reading.[2] The article quotes Dr Beryl Benacerraf, a radiologist at Massachusetts General Hospital and Brigham and Women’s Hospital in Boston, as saying “Obstetricians need to be involved in obstetrical ultrasound because the patients are their patients. If radiologists dig their heels and block obstetricians’ participation, radiologists will lose business. We all have to work together.” [2] The same article quotes Dr F Ralph Dauterive, chair of obstetrics-gynaecology at Ochsner Clinic Foundation in Baton Rouge, as saying “Radiologists want everything done in their imaging centres. The clinicians are conflicting with the radiologists. I think their true expertise is interpreting complex studies. But the clinicians want routine procedures in their hands.” [2] That, more or less, is the essence of the matter. No matter which part of the world, referral-dependence and ability to influence policies seem to be inversely proportional. It is not surprising that while rest all sections of the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 are unforgiving, the section pertaining to the definition of a “sonologist” is lenient.

There is scientific evidence about the relationship between self-referral and overutilisation of imaging. [3] A research article titled “Turf Wars in radiology: updated evidence on the relationship between self-referral and overutilisation of Imaging” was published in the Journal of American College of Radiology in 2004. [3] The authors of the article — Dr David C Levin and Dr Vijay M Rao — concluded that various scientific studies clearly suggest that self-referral, as opposed to radiologist-referral, leads to higher utilization of imaging. [3] Two landmark studies by Hillman et al and Gazelle et al cited in the article also indicate that much of the additional imaging generated from self-referral is unnecessary. [4], [5] The authors state that it is not possible to know the true motive behind non-radiologist physicians installing imaging equipment in their offices.[3] The authors further state the following – “…It is important that radiologists who are interested in the self-referral problem, or who are confronted directly with it, be familiar with this evidence. State legislators, payers, and hospital credentials committees—the people who have the power to do something about it—will no longer accept the argument that radiologists have an inherent right to perform imaging just because they are the ones who are best trained or because they have exclusive services contracts with hospitals. They will want to see evidence, and you need to be prepared to give it to them.” [3] This is also precisely the state of allopathic practice in India – legislators and policy-makers no longer accept the argument that allopathic doctors have the exclusive right to practice allopathic medicine, especially when such exclusivity is depriving rural people of essential healthcare.

Today, we are practising in an era of knowledge explosion and Consumer Protection Act. Every medical speciality has grown so much in terms of knowledge and repertoire that doctors outside that speciality feel alienated. Patients are well-educated and seek expert opinions and second opinions for their ailments. With medical litigations increasing with each passing day, venturing outside one’s core expertise without the requisite knowledge is unethical and illegal. Still many of us indulge in the same, and our fraternity at-large does not oppose. Then, is it not equally natural that non-allopathic practitioners wish to widen their scope after adequate training and with backing from the government? Just give it a thought – if deficiency of allopathic doctors in rural areas does not justify the routine practice of allopathy by non-allopathic doctors in cities, does deficiency of radiologists in rural areas justify the routine practice of sonography by non-radiologist doctors in cities? To justify internal displacement and criticize external invasion simultaneously amounts to not just hypocrisy but tyranny. And injustice, like terrorism, has no colour.

References:
1. Allow Us To Practice Allopathy: Ayush Docs (August 27, 2013)
2. Turf Wars in Radiology IV: Radiologists, ob/gyns sound off on fetal imaging (September 26, 2002)
3. Turf Wars in Radiology: The Overutilization of Imaging Resulting from Self-Referral (March 3, 2004)
4. Frequency and Costs of Diagnostic Imaging in Office Practice — A Comparison of Self-Referring and Radiologist-Referring Physicians (December 6, 1990)
5. Utilization of Diagnostic Medical Imaging: Comparison of Radiologist Referral versus Same-Specialty Referral (November 2007)

Author Details
Name: Dr Chandrashekhar A Sohoni
Highest Qualification: DNB (Radiology)
Designation: Consultant Radiologist
Institution: Department of Radiology, Medcliniq Health Centre, Karve Road, Pune
Correspondence Address: B-5, Common Wealth Housing Society, Opp. Bund Garden, Pune – 411001, Maharashtra

10 Comments

  1. Arumeet Arumeet Monday, January 18, 2016

    Vast majoirty of Radiologists dont work in rural India’FOr rual population ony trianed radiologists do the work. DO not discourage them Let people get trianed and do sonography in rural areas.

  2. amol amol Saturday, April 4, 2015

    The Ground Reality
    Political Adjustments just for vote
    Well done CHANDU

  3. Gskingra Gskingra Sunday, January 25, 2015

    While the arguments against the use of ultrasound imaging by non radiologists is valid,there are situations where their use is Reasonble in certain situations.For instance using ultra sound to insert an intravenous catheter in the ER,when you can’t find a vein in an emergency situation is justified.Of course that can also be misused or overused for convenience and sometimes for monetary reasons.This situation cannot be legislated.And specially in India the government and medical societies are full of misuse of power and sometimes not even competent to make decisions.Ultimately,who does what should also be guided by a person,s ethical judgment.

  4. Dr. Anagha Dr. Anagha Saturday, January 17, 2015

    Conflict of interest is not inherent to and limited for any specific imaging modality. What is limited by the modality is the extent of malpractice in financial terms. CT / MRI self-referral malpractice results in higher financial losses as compared to x-ray / USG and hence these modalities stand-out more prominently. If a physician buying an ultrasound machine, self-referring ultrasound scans to recover that investment, himself performing a scan, making a so-called diagnosis and then himself operating based on that diagnosis does not sound like conflict of interest, then what does? Same goes for x-ray. As the author has correctly pointed out, as and when CT / MRI machines become cheaper, the same will happen to these modalities, under the familiar disguise of “useful diagnostic tool”, “limited skill”, “convenience of the patient” etc. Indian medical education has a buy-one-get-one-free scheme as of now; become an MBBS / MD / MS and you automatically get the title of “sonologist” for free!! And that is a more interesting “leapfrog”!!!

  5. Dr Sunil Dr Sunil Saturday, January 17, 2015

    Stark law addresses the issue of conflict of interest with respect to financial gains from the investigations and other designated health services. And the restriction pertains to reimbursement by Insurance companies. It does not preclude the use of ultrasound by non radiologists. In fact ,even if an ultrasound machine is manned by radiologist and referring doctor is having a financial stake in it, such referral is still not entitled to reimbursement by Medicaid and Medicare. So the argument that law implies that ultrasound is sole preserve of radiologist is factually incorrect and presumptive.From Stark law of America to ethics of medical education in India is an interesting leapfrog.

  6. Dr. Anagha Dr. Anagha Friday, January 16, 2015

    The misuse / abuse of imaging by non-radiologist physicians who self-refer cases has led the Obama administration in US to propose amendments in the Stark Law in year 2015. As per the proposal, the imaging ordered by physicians in the establishments where they have financial interests will not be reimbursed by Medicare. One can be sure that US govt. would not have thought of such a strong action unless there was irrefutable evidence to suggest malpractice via self-referral in imaging. The scientific data leading to this development is for everybody to see; except for those who prefer to close their eyes. India needs legislation on similar lines to curb imaging malpractice. If a half-baked physician performing a suboptimal scan and charging the patient for the same even when a qualified imaging expert is available nearby is not unethical, then what is? Wilfully denying a patient optimal care is unethical.Why not also self-administer anaesthesia and perform pathology tests for the ‘convenience’ of the patient? Taking short-cuts in medical education is unethical, no matter who does it.

  7. Dr Sunil Dr Sunil Tuesday, January 13, 2015

    For ultrasound doctors are charging ,and not for stethoscope, because former is little more expensive to procure and maintain. Let us rise above the considerations of ‘ who is charging what’ while determining the principled propriety of an issue. A diagnostic modality can not be denied to others just because a particular specialty perceives a monetary loss in such policy. The larger good of the patients can not be overruled. A gynecologist banking upon it in emergencies, casualty surgeon evaluating abdominal trauma by FAST, intraoperative ultrasound, endoluminal ultrasound etc are examples of such clinical circumstances , where interest of patient would be best served if clinician can use this modality ad libitum, and in process develop required skill in niche areas.
    Ultrasound is non invasive investigation unlike other imaging studies. No harm is done if the patients are selectively sent to radiologist for his invaluable expertise in cases of higher complexity and gravity. No clinician worth his salt and in his right mind would base decisions of very serious import on basis of his unsure interpretations. The apprehensions of its misuse or abuse are entirely baseless.

  8. Dr. Anagha Dr. Anagha Sunday, January 11, 2015

    I beg to differ on the comparison of ultrasound with a stethoscope. One doesn’t charge anything extra for using the stethoscope as part of the physical examination. Do clinicians include ultrasound as part of the physical examination without extra charges? And how do you know that a case is simple or not before the ultrasound is performed? Many apparently simple cases often come to radiologists when they become critical due to missed findings on earlier ultrasound. This only adds to the cost of healthcare.

  9. Dr Sunil Dr Sunil Saturday, January 10, 2015

    The specious argument that the ultrasound should be exclusive domain of qualified radiologist is as much off the mark as pleading that the scalpel can be used by a surgeon only or a stethoscope can be used by a cardiologist only. Ultrasound is a tool which may be used by any specialist in order to facilitate his diagnostic work up, but practicing it as specialty is prerogative of qualified radiologist only. Undoubtedly, the expertise of radiologist is holistic and hence his valuable input is indispensable in all but very straight forward cases. Regardless, there is no case for radiologists to appropriate a diagnostic tool to its inviolable domain and forbid other specialties to use it according to their need and skill. It is unfair for a radiologist to feel threatened by elementary use of sonography by other clinicians for simplest of the clinical situations.
    To drive home his point , the author goes off on a tangent and compares the cross-specialty use of a diagnostic tool with the sinister practice of crosspathy, that no sensible society should ever approve of. This comparison is misplaced , uncalled for and motivated. Even the honorable courts have deprecated crosspathy. it is really a great insult to our rural masses when we take a selective approach and say that in rural areas non-allopaths should be allowed to prescribe allopathic medicine, as if life is cheaper there.

  10. Dr Neeraj Nagpal Dr Neeraj Nagpal Saturday, January 10, 2015

    Unfortunately division of ranks among allopathic doctors is what has promoted quackery so far and it seems will continue to do so. While what Dr Sohoni has pointed out is ideal but in current scenario it is more representative of Turf war among practitioners of modern medicine. While he is discussing that a person with a railway ticket should travel only in the compartment of which he is entitled whereas my major concern is those without ticket who travel in any compartment of their choice. Why not also debate who owns spine; orthopedicians or neurosurgeons, who owns head and neck ; plastic surgeon, ENT surgeon, maxillofacial surgeon, or dentists, is liver no longer the domain of DM Gastroenterologists now that DM hepatologists are available.

Leave a Reply

Your email address will not be published. Required fields are marked *