Do you know what is defensive medicine? Well it is more an American concept, it is a concept where a doctor does some procedures which are unnecessary, just to protect himself from prosecution in the future. Sounds difficult to believe? One famous Indian doctor said “when a doctor is extremely successful as a surgeon..remember he may have done many operations which are unnecessary, but done just in self defense”. I was not shocked, but was worried about the costs – financial and physical inconvenience. Overtreatment adds billions of dollars of extra costs to the healthcare system. One estimate puts the number at $45.6 billion dollars in the United States alone. Ironically, this figure is 80 per cent of the $55.6 billion annual cost of the medical liability system. Sadly there is no such research in Indian conditions, but could we be really far away from such percentage? Maybe we are at 50%, but even that is driving our insurance costs higher. Much higher.

Is it possible to blame the doctor? the answer is no. Every industry does this – the insurance industry does by over insuring, the fund management industry does by giving you a rosy picture – so that you invest more, the banking industry has such huge margins by scaring you about why you should have an emergency fund,…etc. YOU have to be careful about this excess information, and this insatiable appetite for action. YOU cannot sit calmly and that is the reason for this defensive medicine, defensive insurance, ….etc.

So why do doctors do it? Rather than say doctors, why do HOSPITALS do this? Because they routinely think that the cost of one extra test is not so high, so let me play defensive. When I meet 70 year old doctors, they trust their own diagnostic skills more than some piece of paper from a pathology lab. The medical system does not UNDERSTAND the impact of an additional test – the cash cost, the inconvenience, the infection risk, the increased cost of insurance FOR ALL US outside the system. Sometimes the doctor is trying to hide his poor decision making skills – only a robust internal audit system by the hospital will be able to tell you how much of the tests are necessary and how many are defensive. Obviously the more competent the doctor, the less chances of unnecessary tests. Now come to the reward mechanism. Even for a honest doctor, he feels less guilty about increasing the hospital’s revenue with a test than with an unnecessary procedure. Hence defensive medicine in India in a big hospital is far more likely than in a smaller doctor run hospital. Ha, the incentive system again.

Can you please use your OWN brain and apply all this to the financial service industry?

if you are wondering why this post in a finance blog let met tell you – we suffer similar biases – a) The curse of knowledge b) Too much data and information and noise c) Hindsight bias d) worry of Performance Evaluation e) Information projection f) Illusion of control  – and all this impacts our financial decision making. I only hope that somebody is doing a lot of research on how the medical system behaves in a particular way.

More? you will have to wait…

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  1. An honest experienced doctor is likely to order lesser tests in his own clinic as compared to if he sees the same patient in a big hospital .
    India still has excellent primary care with still a few good doctors who are holding the system together but probably this is the last generation of such people .
    So choose your doctor well , more tests does not translate into better diagnosis .

  2. I am a honest and experienced doctor and I know what I am doing. There is always a huge difference in costs in achieving a 90% success rate, a 99% success rate, a 99.9% success rate and a 99.99% success rate. The incremental increase in that 9% extra success over the existing 90% needs is about 5 times more expensive (more manpower, more machinery, more stress to be endured by physicians, more time spent etc). The additional 0.9% success rate over 99% too is achieved with only similar incremental costs.

    So long as patients are happy with only a 90% success rate (that is 10% chance of death or complications) healthcare can be accomplished at dirt cheap rates. Anything beyond that will need exponential increase in costs. But the problem with Indian public is that they want 99.9% success rates but they are willing to pay only the costs incurred on the 90% success model.

    Just like lawyers make a living out of divorce cases, lawyers make a living out of healthcare litigations too. These lawyers instigate patients into during doctors for negligence, even in cases where there is none. They even try to pass off the ” complications” of a procedure as mentioned in textbooks as “negligence”. That is if a procedure has a risk of 0.1% complication, there is a realistic chance that 1 in 1000 patients will end up having it, despite the doctor not being negligence. The compensation claimed in such cases is several hundred times his professional fees so that the doctor ends up losing his entire lives’ savings and more if he/she ends up losing such a case, despite no fault of his. Hence more more doctors are resorting to practicing defensive medicine, trying to minimise their chance of landing up with a complication as much as they can. The result? Healthcate costs shoot up.

    Unless patients and their families start having realistic expectations, the healthcare costs are only going to increase

  3. Typo: These lawyers instigate patients into *sueing* doctors for negligence, even in cases where there is none.

  4. Completely agree with Kalyan. Defensive medicine is a result of Consumer Protection Act applicability on Health care. When this got applied, the health care became a business. Nobody understood that healthcare should not be treated like a business. The patient should not expect perfect results and perfect delivery as expected in other businesses. The Hospital managers – MBAs should also understand this. It is the poor doctor who gets sandwiched between the hospital management and patient.
    A case of fever could be due to many causes- Dengue, Viral fever, Chikungunya, Malaria, Common cold/Flu, are few to name. Some of them are self-limiting, and just require reassurance so that it cures naturally with just supportive therapy. But some require investigations further so that deadly complications can be prevented.
    A doctor is now faced with a dilemma – if he orders investigations and it turns out to be negative for deadlier disease s/he is called a crooked doctor who prescribes investigations unnecessarily. If he does not investigate and it lands up to be a deadly disease- he may be sued for negligence.
    What does the doctor do?
    Getting a bad name is preferable to getting sued. Result – the doctor take the first route. Investigated further so as to prevent getting sued. Healthcare costs go up.
    For the own kith and kin, the doctor may take a slower route, because there is no chance of legal problems, but it is not possible to apply the same to general public. Patient is not a consumer. And doctor is not a shopkeeper. Their relation is not a business relation. But Alas, this is not understood by many.

  5. @Kishan: I completely agree with the points you have made. I would like to add a few points.

    This week a young anaesthesiologist committed suicide in Karnataka as the consumer court ordered her to pay a compensation of Rs 1 Crore to the family of a dead patient. The patient apparently had come for a caesarean section and the anesthesiologist’s net professional fee wouldn’t have been more than Rs 5000. The compensation ordered was 2000 times her professional fee!! Ridiculous.

    May I ask,
    If a bridge collapses killing 100 people, does the court order the engineering company to pay Rs 1 Crore compensation to the family of each of the people who died?

    If a car catches fire killing the driver, does the court order the car manufacturer to pay Rs 1 crore compensation for the family of the deceased?

    If a rash driver causes an accident killing people, does the court ask him to pay Rs 1 Crore as compensation to the victim? (Over and above the victim’s insurance money, as is the case with medical deaths)

    If substandard generic medicines don’t work and the patient dies, will the court direct the pharma company manufacturing the medicine to pay Rs 1 Crore per victim?

    If a lawyer loses a case, or if a sessions court judge gives a wrong verdict which got reversed by a higher court, can the losing party sue the lawyer/judge in the consumer court for professional negligence?

    Lastly, why can’t politicians and government officials be tried under consumer protection act?

  6. doctors should consider getting good legal help and keeping good records. They should also do good legal/medical record keeping. Lots of tax and investment planning also required. Such decisions have to be fought sensibly..with good records. Hospitals will only protect themselves – the doctors are at risk EVEN when they are attached to big hospitals.

  7. This morning I received this forwarded message on WhatsApp:

    “If compensation for a mistake of a doctor can be rupees 1 crore, why isn’t his fee for saving a life the same??”

    This sums up the situation perfectly.
    Thanks.

  8. doctors should work less – Just 4 days. One day should be spent on record keeping, and 2 days in hobby and leisure. That is the ONLY way to avoid depression. They should go through a 2 day training in CONSENT and RECORD KEEPING. They should make use of technology – voice recognizing software, and cameras. Consent should be recorded and preserved for 7 years. Sadly nothing like this is taught in medicine school. You must attend Dr. Shenoy’s lectures…he is soon going around the country talking about this, Make sure that you attend this course. He is the guru for doctors and lawyers !!!

  9. who decides the fees? demand and supply..so if one doc quotes Rs 10k for a procedure…there will be another willing to do it for 9k…hence the price of 1 crore will not sustain…at all.

  10. @Subra Sir, Completely agree. Therefore even the concept of working for only 4 days will not be sustainable, since there will be a doctor who will be ready to work for 5 days and so on. And there are MBAs in corporate hospitals who are ready to squeeze out every drop of blood and sweat from the doctors and other employees.

    As you might be seeing all the big and small hospitals are now being gobbled up by big time investors. Few years back the hospitals were headed by doctors who had an element of humanity. Now all these hospitals are being bought by foreign investors. The humanity aspect of healthcare is set to go down further and healthcare costs will go up.

    By the way, will a regulatory authority have any effect?

  11. Dr Koustubh Chakraborty

    Completely agree with Dr Kishan and Dr Kalyan. Without a cap on the amount of compensation for alleged medical negligence, defensive medicine and cost of healthcare will keep spiralling up. Even if we accept Subra’s suggestion of working only 4 days a week, in order to attain the same level of income, the fees would have to be raised by 50% (assuming one day off in a week now).

    With the (Medical Indemnity) Insurance industry and the legal system making so much money off these cases, it is unfathomable how Medical Care can be taken off the CPA list by any government. A possible way out might be like the Air Insurance of yesteryears — a fixed (capped) amount would be given to the next-of-kin in the event of any mishap, and if the patients want more, they’ll have to purchase addiional insurance themselves.

  12. No monetary compensation can bring back the loss of life or any disability caused to the patient due to negligence on doctor’s part.
    Doctors are considered next to God for saving numerous lives. High penalties are levied so that such mishaps won’t happen or can be avoided in future.
    What would happen to a family who is dependent on a single bread earner and that person loses his or her life due to negligence of doctor/hospital?
    Negligent Doctors should be happy that they can get away by just paying penalties and they are not sent to jail for the death due to negligence.
    Let’s say if a soldier kills a civilian by mistake then won’t he has to face court martial. He can claim that he had killed many terrorists or saved hundreds of lives by putting his life in danger. However, still his mistake won’t go unpunished.
    Put yourself in patients shoes and you will realize the loss when something like this happen with your own family member.

    Read this old article how a US based indian doctor won a case against doctor and hospital for negligence.
    https://www.thehindu.com/news/national/Kolkata-hospital-3-doctors-told-to-pay-Rs.-5.96-cr.-for-negligence/article11818410.ece

  13. @Amit Gupta: Point taken. Yes, Doctors will compensate in crores for a death due to their negligence provided:

    1) the same rule is applicable universaly in all professions. For eg: if a bus driver causes an accident which results in death of 40 peopel, he should compensate all the victims family by paying them Rs 1 Crore each.

    2) If the cost of losing a life is Rs 1 Crore, the cost of saving it too should be the same. Hence if a doctor saves a life, the patient should pay him Rs 1 Crore. Fair deal, isnt it?

    Lastly, We doctors are scientific people who have been trained to scientifically understand a disease and provide the best solution for it. We are not interested in playing God. We are perfectly fine if you don’t equate us with God. In fact we hate to be compared to God, as after all, it was the “God” who gave you the disease in the first place….

    If you are unhappy with the Doctor’s treatment, you can always approach God to revoke the disease.

    By the same logic, if God wants the patient to suffer, he will naturally make the Doctor negligent too, won’t He?

    @Subra sir: my previous comment was rhetorical, not to be understood and replied verbatim. Yes, I know that ppl cant pay Rs 1 crore as fee for saving a life. But my point was how can they be miserly when giving and be greedy while receiving. If somebody wants to have a right to sue a doctor in consumer court, the doctor should have a right of charging him either his annual income or 10% of his net worth, whichever is higher. If the patient cant afford that, the doctor can treat him for a nominal fee (as charged today) but the patient will have to forego his right to go to consumer court. Fair deal, isn’t it?

  14. @Kalyan you can raise your fee in crores and see if the patients whom you are treating would like to continue with your treatment. If yes then good for you.
    Fees is decided by market, demand and supply. There are pvt hospitals which charge 10-20x of what is charged in avg hospitals. Rich people who can afford such treatment will visit pvt hospital and those who can’t afford will get treated somewhere else.
    However, even in any of the above case, if there is a case of negligence then neither rich nor poor people will forego their right to justice.
    If you were in the patient shoes, you will know how does it feel to lose someone due to others negligence.
    Actually, the case I shared above happened to a doctor’s family. He himself was a doctor but felt helpless that his wife died due to negligence of other doctors.
    He sued them and got a compensation above 5 crore. According to you, he should have let the culprits go unpunished.
    We don’t have strict law to file criminal cases against such cases. Only monetary compensation is offered. If it were US or somewhere else then that person would not only lose his practice license but would have to serve in prison for his actions.
    There are many honest and dedicated doctors who serve beyond the call of their duty and patients family bless them for saving their life.

  15. @Amit: Completely agree with you. I don’t at all oppose the idea that a negligent professional should be punished to the maximum so that other professionals are cautious. There is no doubt – what you say is completely correct

    The question arises – What is “ negligence”. In medicine – All diseases and the treatments come with complications. The doctor generally does whatever is best known to him. But all doctors are not equal. Neither does the same disease have similar symptoms in every patient. For eg Dengue in all patients does not lead to same amount of platelet depletion. But if the doctor does not investigate thoroughly, a deadly complication may be missed. Therefore it is prudent that the doctor investigates thoroughly. Another example- when an abnormality is seen in a Chest X Ray of a patient we the doctors in India have to keep Tuberculosis as a possibility. But the same Chest X Ray if shown to a doctor of USA, Tuberculosis will not be thought of at all. What I want to imply here is that medicine is not 2+2= 4 at all. It can be anything. And sometimes the diseases present in such a pattern that not even the greatest doctor will be able to diagnose or treat the disease correctly and perfectly. Human disease and it’s treatment has never been, and it will never be predictable. There is a lot of “gut feeling”, “individual experience” “local disease pattern” involved.

    Also- There are many restrictions for a doctor. Finances of patient, infrastructural problems and many more. And it is humanly impossible to ascertain whether a particular complication will occur in a particular person or not. If a particular disease is studied and it’s treatment is reviewed you will find innumerable complications and side effects. Now if law / media does not take this into consideration and labels a known complication of a procedure as a negligent behaviour then there is a problem. Here the doctor is not responsible. A known complication cannot and should not be labelled as Negligence.
    You must have known a recent issue where a journalist of a renowned channel barged into the ICU of a govt hospital and started accusing the doctor of negligent behaviour- that is a problem. Treating a patient on a stretcher can be called negligent behaviour. Keeping two patients on a single bed can be called a negligent behaviour. On the other side of that doctor had refused admission since he did not have enough beds, even then he would have been called negligent. What should one do? Accusing a doctor for things beyond his control just to earn some TRP is one of the worst behaviours I simply pray to god that I never face such a situation.

    But regarding other professions – they are more predictable- a bus driver, if follows a set of traffic rules, will not cause an accident in majority of times. Recently a driver dozed off while driving and about 30 lives were lost in that accident. Why did the driver do overtime and risk so many lives. Will he be punished( if alive), or will the bus company be punished for over working the driver?
    A law person if follows some set of instructions and system should arrive at a correct and predictable judgement. But still they don’t. A lower court judgement can be completely opposite of a higher court judgement. Why?? There are so many cases where a person is given punishment by a judge without his mistake and later on it is known that original judgment was incorrect. In this case will the original judge be punished for the undue punishment? When the process is predictable and even then there is a mistake the professional should be punished. But it does not happen in these cases. And when the process is unpredictable in medicine the professional is asked to compensate.
    Is that logical??
    Just recently a doctor in UK was suspended for few months. Do you know why? He did duty for 12 hours continuously rather than the allotted 6 hours to him. The authorities concluded that he risked life of patients by working more than required. It was negligent behaviour according to the authorities.
    I tell you we all doctors in India would be behind jails and all the hospitals would be shut down for ever it such rules come to India. Working 12 hours at a stretch is nothing for a doctor in India. I have worked for 48 hours continuously without sleep during my PG. This is not just me. Almost all doctors go through such work schedules. It was not for money nor fame. Money and fame does not matter when you don’t enough sleep. I did it because the patient load is like that. That is why an avg Indian doctor’s life’s expectancy is about 5 years less than general population. The emergency of any avg hospital in India is always full. Patients wait years for the disease to get critical before attending hospitals but want immediate perfect treatment when they reach the emergency. In the west, if people get attended to in 5-6 hours after reaching emergency room, they feel blessed.
    Go to any pharmacy shop and spend some 15 min there. You will see so many Schedule H drugs being sold there over the counter. People don’t want to go to doctors for diagnosis. They just explain the symptoms to the pharmacist there and take treatment.
    The west is altogether different. Their rules, work conditions, patient ethics, everything is different. We better not compare ourselves with the west. If all the rules of the west were applied in India and to the Indian patient load, the average patient will have to wait weeks before he could be seen by a doctor.
    I see around 25 OPD patients every day. In the west they see 8-10 per day and don’t do any procedure on their OPD days. After OPD, I do one cardiac surgery per day (avg) and do night duties for 5-6 times per month. When a night duty is there, I am in hospital for 36 hours continuously. And mind you I do not – DO NOT get any extra benefit for night duties. It is the need of the patients. This is at an age of 43 after being in the field for about 16 years. In the west the avg surgeon does not do more than 10 surgeries per month. And they are paid about 5-7 times per case as compared to Indian surgeons. The surgeon does not any night duties because overworking is negligent behaviour according to their rules. Here if I don’t attend to a patient after doing surgery I am called negligent.
    By western standards I am extremely negligent. But can’t help it. If I don’t do in such a way, the patients have risk of dying without surgery. In that way I will be negligent by Indian standards.

    Try to enter the shoes of an average Indian doctor in a neutral manner. I bet you will thank god and your luck that you are not a doctor

  16. @DrKishan I am not a doctor. But I understand the stress you go through to deliver the best you can.

    But the problem here is that people treating medical profession as a commodity.
    An average Indian seeking for health care may be thinking like this…..

    1. I am feeling hungry. I order a pizza. I eat. I am satisfied.
    2. I am feeling sick. I go to this hospital. I pay money. I will be alright.

    As in every field, few bad people bring bad name to every profession.
    There will be bad doctors, good doctors, better and best doctors. Painting everyone with the same brush is the problem.
    And best doctors may not always come cheap. Also one has to understand that doctor does not gain anything by making a patient die.

    The problem here is defining ‘negligence’. It is ironic that in India where everything is neglected, doctor’s negligence is getting most attention.

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