Dr Sunil K Pandya is a neurosurgeon and “a student of medical ethics”. He studied medicine at Grant Medical College and Sir JJ Group of Hospitals, Mumbai. He began his career under Dr Homi Dastur at the department of neurosurgery, Seth GS Medical College and KEM Hospital in 1967 as a pool officer and became an assistant neurosurgeon in 1968. When Dr Dastur retired in 1975, he was appointed as professor and head, department of neurosurgery. Since his retirement in 1998, Dr Pandya has been working at Jaslok Hospital and Research Centre, Mumbai as an honorary neurosurgeon. He is also editor emeritus of the Indian Journal of Medical Ethics (IJME).
In an email interview with India Medical Times, Dr Sunil Pandya talks about his journey as a neurosurgeon and various issues associated with Medical Ethics. Hopefully, this would serve as an inspiration to young doctors to do ethical practice and help washout at least some of the existing black marks on the doctors and medical profession.
You completed MBBS in 1961, and MS in 1965. Since then you are in the field of medicine as a neurosurgeon, it’s about 50 years now. Please tell us about your journey as a doctor.
The journey has been exciting. As an undergraduate and as a resident in neurosurgery I did not even dream of the advances that have become reality over the past four decades. In my field of the neurosciences, the ability to see the inside of the living brain and spinal cord on computerised tomography and magnetic resonance tomography has been revolutionary and has made diagnosis and treatment much more accurate and rewarding for the patient. With the advent of functional magnetic resonance imaging we are able to correlate structure with function and identify precisely the area within the brain that formulates thoughts and ideas and carries out specific tasks.
In surgery, our techniques have gained sophistication with the use of electrophysiology monitors, the operating microscope, endoscope and delicate instruments. These have added to the safety of the operations and facilitated faster recovery of the patient from surgery. These advances have also brought into the realm of surgery diseases earlier considered inoperable or operable with unacceptably high risks.
How neurosurgery has developed in India so far? What have been the major challenges in this field?
Neurosurgery in the better hospitals in India is now on par with that in any other centre in the developed countries. We have access to the finest equipment and facilities. Our younger specialists have trained with some of the world’s best neurosurgeons and have brought back with them the latest in operative techniques.
The great advantage in India has always been the numbers of patients and variety of diseases. These give our neurosurgeons, especially those in teaching hospitals and tertiary centres, unrivalled experience.
You are known as a great thinker on Medical Ethics. Was there any specific incident that made you focus on this much-neglected area of medicine?
I am not a thinker on medical ethics. I am merely a student of this subject. I have had the good fortunate of learning medical ethics from teachers such as Dr H S Mehta, police surgeon and professor of forensic medicine and medical jurisprudence at the Grant Medical College and Sir Jamsetjee Jejeebhoy Group of Hospitals in the 1950s and 1960s.
I have also been very fortunate in working with teachers who practised ethically. They gained academic renown and lived comfortably, proving that success is compatible with integrity.
I have merely striven to follow their examples.
I was also fortunate in being part of a group that decided to do our best to restore medical ethics in the medical profession about two decades ago. This group remains active though its success in achieving its goals has been limited. It has to its credit the only indexed journal on medical ethics in India that has been published continuously for almost twenty years.
What are the major factors behind Ethics not getting so much attention of more doctors these days?
Medical students at their most impressionable stage see their teachers preach ethics but practise marketplace medicine where principles are inconvenient and thus discarded. These students find it easy to mimic their teachers’ practices and ignore their oral advice.
Young doctors have considerable difficulty in settling in practice. They face hurdles such as having to pay undeclared sums of money to obtain premises to practise and at almost every step of their professional activity.
Under these circumstances, many find it difficult to stick to principles. They take refuge in the fact that society in general is in decay with widespread corruption in all professions and trades. ‘When everyone around me is corrupt, how can I remain true to principles at the expense of my earnings?’ is a not uncommon argument.
With the mushrooming of private medical colleges and increasing corporatization of healthcare institutions in the country, how difficult it is to practise medicine ethically these days?
It is not difficult. There are several examples of physicians, surgeons and others who have remained true to principles and reached high positions in academia, lived comfortably and are respected by all. If there is a will, there are many ways.
However, it remains true that those discarding ethical principles get rich faster, acquire large quantities of filthy lucre and are lauded by those who value riches over principles.
In recent days the mainline media has raised issues like kickbacks in doctors’ referrals to specialists and diagnostics centres? Another major concern raised by the media is about the so-called ‘unnecessary’ diagnostic tests and medical procedures? How serious is the issue? How best this can be addressed?
Several doctors expect to be paid part of your earnings if they refer patients to you. If you pay them, they refer more patients. If you don’t, the references dry up.
This malpractice cuts down the income of the consultant as he gives away a significant part of his earnings.
On the other hand, there is the temptation offered by laboratories, imaging centres and doctors who offer you a part of their earnings from every patient you refer to them. This is easy money for no effort at all. Many find it easy to overrule the little voice within that protests at such actions and refer patients to the laboratory, imaging centre or doctor that offers the biggest slice of their earnings without any attention to the quality of their services.
A certain doctor has recently raised the issue of deteriorating quality of medical conferences? Do you think the organisers of medical conferences these days have lost their focus from academic matters?
I feel this doctor has pronounced an important truth.
Some decades ago, medical conferences were places of pilgrimage where delegates sought learning and interactions with the masters in their field. The primary motive that stimulated their attendance at conferences was to enhance their understanding of medicine and acquire means for the better treatment of their patients.
Today, many consider the medical conference as the modern equivalent of the mela or fair where much time is spent in stalls set up by a host of companies, vying with each other on the number of plastic bags full of goodies that are collected from these stalls and staggering around with these bags till it is time for lunch/cocktails/dinner. The number of delegates in the halls where papers are presented dwindles after the inauguration and reaches the lowest level on the last day.
The rampant commercialization in the lecture halls does not help. The projection of advertisements between papers and sessions further degrades the atmospheres. Sessions where alcohol flows freely appears to stimulate male delegates the most. It almost appears that they have been starved of alcohol and do not possess the means to indulge themselves at home. The rush to the bars is astonishing, indeed!
What’s your comment on the doctor-pharma nexus in over prescribing drugs, and prescribing costly drugs when less-priced similar drugs might be available?
When thinking of the interests of the patient at all times is replaced by thinking of your own income, it is inevitable that the physician will tend to practise what the medical representative offering the highest incentive advises.
The noises made by the Medical Council of India and the government notwithstanding, doctors continue to avail themselves of five-star holidays sponsored by commercial organisations marketing drugs, surgical implements and other such items under the guise of ‘continuing medical education programmes’. The powers that be do not appear to be serious in their efforts at instilling the principles of medical ethics into practitioners.
From patients’ point of view, most people feel it is better to tolerate mild ailments than visiting a doctor because of the fear of undergoing various tests. What do you think about this? Is the ‘trust’ element diminishing from doctor-patient relationships? How to stem the tide?
It is wise to treat minor ailments using common sense and remedies recommended by senior members of the family. There is much to be gained from grandmothers’ remedies. Likewise, measures at preserving health are always preferable to seeking out doctors.
The difficulty lies in identifying what is a mild ailment from the early stage of a serious and potentially life-threatening illness. Persistence of symptoms despite a couple of days of domestic remedies should alert the patient and the family.
The respected family physician of yesteryears was the saviour in such cases. He knew the family almost as though he was one of them. Wisdom gained over decades and the sincere interest of the welfare of the family at heart enabled him to offer timely advice and recommend a trusted and good physician or surgeon.
Alas! This is a dying species.
Consequently, the patient and family go by word of mouth from friends and relatives or are swayed by the physician or surgeon most talked about by press and television.
Most of our public hospitals have failed the middle and lower classes who were earlier prone to trust their medical personnel.
Doctors claim they do not have the time to take a detailed history or conduct a painstaking clinical examination. Many do not spend more than five to ten minutes on a patient on the first consultation. Patients and families are left dis-satisfied as they are unable to voice concerns or obtain information on matters that worry them.
Information on corrupt medical practices is now widespread and easily obtained through the media and the internet.
These features tend to make the patient view each doctor with suspicion instead of hope and trust. ‘Is this doctor advising this step because it benefits him financially?’ ‘Is his advice for the need of an operation based solely on his need to relieve my purse of its contents or is the surgery really justified?’
Such questions hardly ever troubled the patient four decades or more ago. They knew that their doctor sought their welfare.
The cure? Greater awareness among patients and their families and a return to ethical practices by every member of the medical profession. Are these Utopian ideals and the fancies of an opium eater?
How do you think the budding doctors can be best prepared for practising medicine ethically? What role medical education and medical education regulators can play in this?
Medical students are at their most pliant stage when they enter medical college. The struggle involved in getting entry to medical college ensures that most of them are highly intelligent and hard working. (Those forcing their entry through the brute force of political manipulations or the payment of huge sums of money may not fall into this category.)
The single most important element in ensuring that they retain their ideals and stay true to them is what they witness and encounter in the practices of their teachers. Evidence of wisdom, concern for the patient, kindness, courtesy and an urge to help (especially patients who are very poor) in each and every teacher enhances their ideals.
The inculcation of ethical principles can be augmented by discussions on them. An awareness of the evolution of medicine and the trials and tribulations undergone by those who gave our profession the competence it possesses provides inspiration. The personalities of the students can be rounded off by immersing them in the medical humanities.
Medical regulators have proved a dismal failure in our country and the reasons are public knowledge. The sterling example provided to us by the General Medical Council of Great Britain – which formed the model for the Medical Council of India and the state medical councils – has been consigned to the garbage can.
What’s your message to young doctors?
I offer the advice handed down to us by some great masters:
Hippocrates of Kos commanded us ‘Primum non nocere’. First of all, do no harm.
In the last century, that beloved physician, Sir William Osler, advised young doctors:
‘The choice lies open, the paths are plain before you. Always seek your own interests, make of a high and sacred calling a sordid business, regard your fellow creatures as so many tools of trade and, if your heart’s desire is for riches, they may be yours; but you will have bartered away the birthright of a noble heritage, traduced the physician’s well-deserved title of Friend Of Man and falsified the best traditions of an ancient and honourable guild.’
Nearer home, the words of Gandhiji and that ancient seer Charaka are relevant.
Gandhiji offered us a talisman: ‘Recall the face of the poorest and weakest man whom you may have seen and ask yourself if the step you contemplate is going to be of use to him. Then you will find your doubt and yourself melting away.’
Finally, I commend the injunction offered by Charaka in his Samhita:
• ‘Learning by rote, without understanding the meaning of what is thus committed to memory is like an ass carrying a load of sandalwood and is labour without profit.
• ‘Do not devote your words, mind, understanding and senses to anything other than that calculated to do good to the patient and ensure his recovery.’
• ‘There is no end to medical science, hence, heedfully devote yourself to it.’
by Usha Nandini M