Why I will never allow my child to become a doctor in India

A pup was walking down the street when it came across a group of young boys. The leader of the group spotted the dog and pointed it out to his friends. Seeing the boys, the dog too wagged his tail and barked, looking forward to being petted and making new friends. 

However,even as the pup wagged his tail, one of the boys picked up a stone. The boy turned to the others and told them how dogs are bad because another dog had bitten his grandfather years ago. As he nodded, a second boy picked up another stone even as he spoke of the incessant barking of stray dogs in his neighbourhood at night, disturbing the sleep of his family. A third spoke of how dogs are bad because of religious reasons. The others realized the wisdom in their friends' words and each picked up a stone, aware now that breeds like this could not be trusted. The pup stood where he was, confused as he watched the boys come closer to him.

By the time night had descended upon the land, the boys had dispersed and gone to their individual homes. There was a sense of accomplishment, having stopped a menace from entering their streets. Lying bloodied and brutalized, the pup that had wagged his tail in hope of giving and receiving love licked its wounds. It was too young to know that the physical wounds would heal in due time... but it was now old enough to have learned to distrust the species of stone throwers. The most selfless creature since time immemorial now knew to hate... because that was what it received for no fault of its own. For the crimes of others, it had paid with its body and soul. 

That, in a nutshell, is the reason why I will never allow you, my child, to become a doctor in India.

Still confused, I guess? It is okay. Take a chair and sit down... this is going to take awhile.

Increasingly, I find myself watching and talking to doctors across two generations and various specialties these days. And increasingly, that sense of despair and disillusionment is writ large in their words. They find themselves wondering where things went wrong even as they struggle to bring a smile on their faces. 

With 0.7 doctors per 1000 Indians, the doctor:patient ratio is far below that of other comparable countries like China (1.9), United Kingdom (2.8) and United States (2.5). Spain's 4.9 seems like an absolute luxury in comparison, I must admit. What this means in layman's terms is simply this - that you are always going to be swamped with patients beyond the logical human capacity in India. 

Thou shalt sacrifice your time, parents, spouse and child.

Getting a 63 hour a week schedule (7 days x 9 hours) is a blessing and most of the young guns who join in fresh after post graduation know fully well that a 100 hour a week schedule is par for the course once you begin working. 
And sadly, this is advocated and in fact encouraged by most hospitals too - who wouldn't want to have workers in a contract which states 8 hours a day and then get them to work 14, stating that 'this is how it is for all doctors and besides, we are in the business of selfless service.' 

You would never allow a taxi driver to drive you for 24 hours continuously but asking surgeons to do that every third day is fair game in India, apparently. 

Wanting to do the allotted number of hours in your contract and then come home to your family is now frowned upon in our field... it implies weakness. Nay, it implies a a lack of professionalism. 

Thou shalt sacrifice thy life dream... 

This came in my Facebook timeline. It is

actually quite accurate, when I think of it

It is a sacrifice that will take away your twenties and eat away at your thirties. You may enter the field bright-eyed at 18 but I must ask you - what happens if the dream to become a heart surgeon does not reach fruition? 

If for some reason, you find yourself unable to get the coveted seat or devote the fifteen odd years I assume it will take to become the junior most in your department, would you be happy with your life? Would you be able to live with losing the dream or would the disappointment eat you up from within?

Who cares for the doctor?

A young surgeon working in one of the premier institutes in India spoke to me the other day. This was a doctor who was so passionate a year ago about becoming even better, working hard to get into a super specialty course. She had joined the hospital because of its awe-inspiring reputation across India, aware that the hard hours she put in would sharpen her skills and broaden her knowledge of the specialty. The woman I spoke to had lost that drive altogether. 

Walking out of her home at 7 AM and returning home at 10 PM just to fall into bed and then wake up again at 5 in the morning to restart the cycle, she wondered what was the point of it all. She was losing touch with her loved ones and had become a zombie, lost between the politics within the hospital and a total lack of social life. 

All this for a handsome salary of 50,000/- a month (in Mumbai. 2015) which she knew would not buy her two nights in the ICU of the very hospital she was working in. There would be a pot of gold at the end of the rainbow, I wanted to tell her. She would earn more in her forties than her techie friends earned in their thirties, I could have consoled her. But I did not. Because I know how she feels. 

Another doctor spoke out recently on a public forum, talking of his experience of doing six years of rural service for the government. When he finally left it two years ago, the man in his thirties had less than Rs 15,000/- in his bank balance with no extravagant purchases or trips to boast off. He needed his parents help at that age to still pay for his rent. It all came to a head when the guy at the shop recharging his mobile revealed how his monthly takeaway was more than the doctor's... without any risk whatsoever.

His one plea to all the doctors listening? Do not be a sentimental fool and get blackmailed by the medical system to go work like he did... because nobody cares for your service at the end of the day. And I totally agree with him. If after more than a decade in the medical field, he cannot provide as much for his family as an mobile shop owner, then why did he need to go through so much of an effort at all? 

If India considers it a crime for doctors to earn money while closing their eyes when judges, lawyers and uneducated politicians magically accumulate crores, is it not the folly of the person aspiring to be a doctor? How dare he dream of providing for his family? 

More statues, less healthcare is the solution (apparently)

The very fact that our stats are comparable
with Nigeria speaks for itself

The medical field we entered is not the one we are in today. Even the generations before us acknowledge this. And it is only getting worse. 

For a field like ours in a country like ours which is overpopulated and has a major portion of that hovering below or around the poverty line, having the support of the government to ensure the benefits of health care reach everyone is vital to our success. They needed to make medicines more affordable at the very least. Sadly, rather than increase the amount, they decided to cut the budget allotted to health care by nearly 20 percent. 

Key sectors like HIV/AIDS lost funding rather than having it increased. This at a time when we spend a mere 1% as it is on public health care in India as opposed to 3% in China and 8% in United States. What can I say, my child? I guess India is healthier than those other poor nations, are we not? 

Defensive Medicine

I wish it were JUST about losing your family life, working twice the allotted hours and taking home the pitiably disproportionate salary though. But sadly, it isn't even that anymore. Now, it is about getting home in one piece. From stopping patients from dying, the medical field is now being forced to worry about not being killed by the patients bystanders.

  

The essence of being a doctor - to do the best we can to heal - is being taken away from us because now we need to be on the defensive. 

You remember that cute little thing we've been talking about called selfless social service? 

Guess what? It comes with riders, apparently.

• Selfless service means you do the extra hours because the hospital is perpetually understaffed. 
• Selfless service means you take home a call centre worker's salary because the healing you do is a service, remember?
• Selfless service means you adjust with the lack of drugs and instruments available and still save people because there is no other hospital nearby.
• But that line stops there. If the patient collapses while in your care, suddenly all these boundaries vanish. 

You are then the monster that the public reads in the papers - the one who killed their loved one because of your greed to steal their money/harvest their organs/molest their ailing mother or child. Then the very same people who demanded that doctors take home a salary in 5 digits will have no problems in demanding compensation in six or seven digits. It does not matter if they are wrong... what is important is that by spoiling the doctor's reputation, you succeed in blackmailing him or the hospital into a compromise. If every death inside a hospital were to be called a case of medical negligence, why would doctors admit the patient at all? 

Are you willing to die for your profession?

The Indian Medical Association confirmed in May 2015 that over 75% of the doctors in India have faced some form of violence at the patient's hands in India.

75%. This is after admitting that not all cases of violence get reported to them. There are even instances of doctors being actually killed for following the law.  How do you explain that to his widowed wife? When was the last time you saw a software techie being killed off for not making an app properly? Still feel like using the 'Selfless service' card again? That's a pretty thin card to keep playing while beating every 3 out of 4 doctors, don't you think?

The recent verdict in the Joseph Eye Hospital case brought the reality of the Indian mindset home to many doctors. Handing down verdicts of imprisonment to 3 doctors for the loss of vision of 66 patients following an eye surgery camp, the judicial system showed an amazing lack of comprehension about what was going on. 
It does not need a rocket scientist to realize that a single trained doctor cannot make the same mistake 66 times in 66 different eyes on the same day. The obvious answer to such incidence of mass endophthalmitis is in the use of unsterile solutions used - the unsterile part being a fault of the pharmaceutical company that manufactures the solution. 

There is no way for a doctor to know (without opening every individual bottle and testing them!) if the solution contains microscopic bacteria just as there is no way for you to know if there are any in your coffee before drinking it. And yet, to please a crowd baying for blood and money, even though it was obvious the fault lay with the tainted solution, the doctors were sent to prison. Sounds familiar, does it not? 

Remember the Chattisgarh sterilization deaths of 2014? 
Everyone knows the doctor's name in that case. It was later proven that the fault was with the tainted medicines which were made in rodent infested factories. So tell me, what was the name of the pharmaceutical company and what action has been taken against it since then? You don't know? How shocking!

It raised the obvious question to many doctors though. 

Why would we do such a service at all when we are being cheated? 
By doing a single private patient for Rs 60,000 (which is still cheaper than the Dhs 15,000/- charged abroad), the doctor can choose to use the best drugs from reliable companies instead of the generic substandard ones and make a hundred times more money doing one case while being totally ethical. Can you call them cheats then? No. Except that by doing so, we all know as doctors that nobody would then care for the treatment of the poor, if we give up on them too. 

That is what being a doctor in India is all about, in the end.

1. You are forced to go to the India that India forgot, the most rural crevices and cul-de-sacs where healthcare is actually needed. 
2. You are asked to bang on doors and seek out the ailing. 
3. You are asked to bring as many of them as you can back with you. 
4. And then you operate on them all for the handsome fees provided by the government (Rs 650/- is given to most hospitals, I hear, though I will gladly accept any revised figure too.) 
5. The government cuts its costs by making you do Rs 60,000 surgeries for 600, citing rural service (which naturally does not apply to engineers and lawyers - because these areas don't need them at all.) 
6. The doctor carries the moral responsibility of helping as many patients as possible and so is asked to do work well beyond his physical and mental capacity. 
7. Generic pharmaceutical companies will pawn off their goods made in unsterile conditions at a lesser rate. 
8. When things go bad, the crowd will calmly ignore the government and pharmacy that cut corners for a profit and be at the doctor's doorstep with stakes and pitchforks. And celebrities will be there to tut-tut on national television about how doctors are corrupt and cutting off organs for their own profits.

The Malaise Within

Are all doctors good? My dear child, surely even you at this tender age cannot be so naive. Of course not. The one factor that holds good across all walks of humanity is our tendency to be a mix of good and evil. This extends across religions and Godmen to politicians and doctors and everything in between. 

Before we were doctors, we were normal people too. And we have inculcated values from our family and peers for over two decades before we earned the right to wear that stethoscope. And whether we want to or not, that does show in the way we carry on. 

• So yes, there are going to be doctors working beside you who will promote a medicine not necessarily because it is good but because the pharmaceutical rep gives him a good incentive. And you will see that doctor taking home more than you do for doing the same work as you and the devil on your shoulder will smile. He will positively grin, in fact, as you stare at the price of the new smartphone which is beyond your financial reach because social service and respect do not pay the bills. 
• There will be those who need to make back the money spent on getting a seat... I hear certain post grad seats now go for 4 crores. Well, damned if I know why people would take it up when you could just as well earn more with the interest from the bank for that amount but hey... to each his own. 
• You will find doctors who are forced to do the extra procedure because, working in a private hospital, they need to answer to the heads above. They need to make a profit for their bosses who shrug as they remind you that if the hospital runs into losses and shuts down, the loser is the patient himself. And when you think about it, they are right, are they not? Private hospitals (which still cater to a huge percentage of the population) need to make a profit to continue. If they shut down, the healthcare of the country would collapse in months simply because government hospitals would never be able to manage the volume. Again, the arrow of your moral compass will tremble as you grapple between the inner desire to treat people in pain and the requirement of forcing them away to a less safer center because they (like you!) cannot afford this hospital. 
• Know that you are not God. 'Feeling like a God' when you see a patient open his eyes after a successful surgery is different from believing you are a God. It only need one mishap for such Gods to fall... and fall hard.  
• Professional competition exists too, as though you didn't have enough on your plate. Being competitive probably exists in every field but here the game is played with people's lives. But when someone discredits you to sway the patient to leave you, you wonder what the point really is. Was it not supposed to be about healing people? 

The imbecilic outsiders

Cases in point: 

• When one state was unable to deal with the number of patients in the rural areas who needed health care, doctors from the neighbouring state stepped in and conducted camps there, helping the poor get the treatment they needed. How did the former state respond? By banning all the doctors from the other hospital for THE CRIME of providing health care to people in need. They could not provide it themselves but they would not allow the other state to lend a helping hand. This was the stand of the elected ministers in the end - we would rather our folk suffer than allow you to take credit for helping them when we cannot do it ourselves. 
• You have ministers running tobacco empires who head committees on health and undo all the work of doctors by claiming that tobacco is good for health. 
• You have self-proclaimed fakirs and saints telling to raise the population manifold at a time when we are stretched at the seams due to overpopulation. 

You as a doctor are caught in the moral ineptitude of such politicians and film stars who never attend government hospitals themselves and yet decide how hospitals must be run.

This is what every young doctor in India today is struggling with - the disillusionment of it all. 

We want to heal... we want that satisfaction of being able to save lives and see a cheerful smile on the face of someone who came to us in anguish. But not like this. 

Not dictated by the whims of businessmen who demand profits, not by the fear of being beaten up by relatives of patients who cannot accept death as an eventuality, not while worrying about how to pay the next electricity bill and not by losing our touch with everyone who matters to us just because a nation chooses not to strengthen its own healthcare system. 

The fear you feel as a doctor should be because you think you have missed a differential diagnosis when a patient comes to you, not that you will be beaten up if the patient's condition worsens. 

Depending on where you work, you will face some permutation or combination of the above ills of being a doctor in India. 

And it will eat you from the inside. 

You will wonder how to strike the balance between being there for those you love personally and those who need you professionally. 

You will ask yourself how everyone demands you have a dozen degrees beyond your name and yet does not seem to think it necessary that you be paid equivalent to the effort you put in to reach here. 

You will see your peers do everything by the book and get beaten down by hospital politics or physically by patients and you will wonder - should I save the next critical patient who comes into the hospital or refer him elsewhere to save myself, knowing that the law has failed me.

And in that moment, you stop being the doctor you set out to be. 

'Selfless Service' does not require that you give up your soul and life.

People only use that term when they want doctors to go the extra mile. That selfless service tag stops when the time comes to pay the bill. When it is time to beat up a doctor or insult the entire fraternity based on one doctor or sometimes, pure ignorance. 

You can choose to be selfless in so many ways. 

donate to the needy, adopt a child, participate actively in programs by worthy NGOs... heck, just by not harming or cheating anyone, you are basically being selfless in today's world, I reckon. Why, you can run over innocent people sleeping on the pavement and still be called selfless, as long as you have money to donate in front of the media for a worthy cause, as I found out recently.

Understand this:
Ligating pulsating blood vessels is not a service. 
Restarting a heart is not a service. 
Suturing meticulously with threads thinner than the hair on your eyebrow is not a service. Identifying the extent of a tumour in the brain right down to the last millimeter while operating to remove it is not a service. 

It is an art. 
It is a specialized skill. It is a test of your endurance because at the end of the 25th hour of straight duty, you better save that 20th patient on your operation table or else everything you have done before this does not matter. Above all else, it is a sacrifice.

As a father, you will find me as broad minded and tolerant as they get. 

You will have every opportunity to choose whether you want to retain your religion or change it based on what resonates within your mind. You will have every opportunity to choose the love of your life irrespective of caste, creed or even gender (though if you choose to go lesbian, may I just point out that Ellen Degeneres would be a lovely role model to emulate - kind hearted, hilariously, smart... plus Portia for a life partner!) 

I will let you have every choice in life and I will be there to support you and guide you along the way.  You can be a wildlife photographer trekking through the Amazons or dance the poles at Las Vegas. But I will never allow you to become a doctor in India. Because I did not raise my child for two decades just to watch her lose her sense of right and wrong - of humanity - or worse, watch her die. 

And I don't mean just physically.

Broken arm? Pfft... There's still one arm left!

P.S. Yes, That is me in case you are wondering!

Authors note:

I have been conversing with a lot of doctors recently and the sound of disillusionment about the field has never been as loud as it is today. Even doctors of generations past and heads of departments acknowledge the shift, stating that they are happy that they are not starting off their careers in today's India. One line which many of them said and one which I also agree with entirely is the basis of this article - "I will never allow my children to join this field."

There is also an email sitting in my inbox asking me to sign and share a petition demanding that applications for licensed guns be fast tracked for doctors. I have read it and placed a 'star' across the mail. I do not intend to sign it because I don't advocate guns as a rule... I see children cry everyday when I bring an intravenous cannula near their tiny arms. I do not wish to have them worry about the gun in the doctor's pocket too. But I empathize with the sorrow of the doctors who made the petition. And I know one day, I too may find myself revisiting this petition should a calamity befall me. As its is, hospitals have started employing bouncers now.

I would love to hear from doctors here as well. Even if you disagree with my thoughts entirely, I do not mind. I just want to see how far the disillusionment lies and whether the "Hippocrates Oath" and "selfless service" tag are still as strong in your hearts today as it was the day you joined your medical college. Where do you think it is all going wrong in India? 

Update (16 May 2015):
I would like to thank Dailyrounds.org (for republishing my article) and all the others who shared this across social media on their timelines for helping get the word across. 

Update (18 May 2015): 
Thanks to Scroll.In, Scoopwhoop, Ndtv, Docplexus  and Quartz too now, I guess. As for a popular news media site which shared the blogpost, I guess I should specify here - This is a letter to my future kids. I DONT have a child yet. :) 

Update (19 May 2015): 
Okay, I have lost track now of who all have shared. HuffingtonPost, Deccan Chronicle, Navbharat, Asianet... Thank you all.

Some people have asked me to comment on the fun headlines of the media sites which published this post, focusing on the 'pole dancer' bit. Frankly, I realize that it is a bit much to use that as a headline but if it serves the purpose and gets doctors engaging in a discussion, I will gladly take the hit for it :) 

Update (22 May 2015): Do you have a solution to offer for the ailments here? 

For those interested, the follow up post to this one is now online here where we ask everyone for their ideas on fixing the system.

Update (28 August 2015): 

As I have updated my commenting system from the highly restrictive G+ , the 330 odd comments which were here previously are no longer visible.  But don't worry, they are still there online and someday if Google Plus makes integration of their comments to other formats possible, will reappear here. For now, if you wish to see the 500 plus comments from doctors across India and even abroad, do visit the links at DocPlexus and DailyRounds.

Update (23 October 2015):
Leading medical Journal, the Lancet, points out the same lacunae I did regarding the terrible healthcare policies by the Indian government. The question is, will anybody finally stand up and make the change or are we doomed to watch the Indian healthcare system deteriorate even further?