Channelled practice: Indifferent doctors, making profits and keeping patients waiting

Many in the water sector in Sri Lanka believe that reforestation is going to increase the water availability in a river basin and as such it is better to convert barren lands to forests. The recent video conference held at the Distance Learning Centre Ltd, on Water Economics and Governance revealed that this belief needs to be revisited, according to a statement issued by Nishantha Kamaladasa, CEO, Distance Learning Centre Ltd. He said the conference brought experts from Australian National University to the virtual class room at the Distance Learning Centre. They were Professor Quentin Grafton, Director of the Center for Water Economics, Environment and Policy, Dr. Daniel Connell, Researcher and author of the book on Water Politics in the Murray-darling Basin and Dr. Jamie Pittock, Director of International Programs for UNESCO chair in Water Economics and Transboundary Governance.

In the subsequent local discussion after the video conferences there was agreement that Sri Lanka needs to undertake further research to support the water resource managers to take better and informed decisions. "The climate is changing and there is a necessity to mitigate global warming and every step need to be taken towards it. On the other hand some of the measures we adopt to reduce global warming, such as increasing tree cover, may reduce the water availability in a particular locality. Therefore we need to look at the environment as a whole than trying to manage its parts separately. As our development initiatives create a chain of reactions, there was also agreement that the whole chain has to be studied to decide the feasibility of a particular initiative," Mr Kamaladasa added.

This was a result of the exposure by Dr. Pittock, who noted that in Australia, subsequent to the adoption of rain water harvesting in a particular region there had been an increase in energy use. The research, he said, has revealed that a main supply would have consumed very much less energy than the individual households using inefficient pumps to distribute rain water. When the hydro power is used to generate the same energy, it amounts to waste of water in the name of preserving water which is also absurd.

The statement said the current Sri Lankan water resource development agenda is controlled by the riparian (interface between land and any other water body) rights. Any new developer has to first ensure that traditional users get the traditional supply of water before embarking on a new development initiative. Provided such is done, any developer is free to develop any river basin. "Hence earlier you enter into a basin and start developing it (without affecting the traditional users) you get an advantage, a right to claim for whatever you have started using. Even when the economics or any other factor suggests reallocation, it is not normally possible and when it is done it is only through negotiations with political hierarchy having the final say," Mr Kamaladasa said. Hence the private sector has to piggyback on politicians to enter into the picture if they seek reallocation. It eventually creates a "black market". One of the key points discussed was how this situation could be changed so that market forces can reallocate water from inefficient sectors to more efficient sectors. It was also agreed that water needs to be considered as a right of all humans and that it cannot be left alone to the market forces to control. It was specially emphasized that the marginal groups like indigenous communities, including women's concerns should be addressed in any governing mechanism that allows reallocation to take place, the statement added. As culture plays a crucial role in forming appropriate institutions, it was agreed that though global knowledge would be useful, local solutions need to be derived using global knowledge than copying the same. To facilitate all this there is a need to establish a platform where the stakeholders can share their concerns, knowledge, future plans, etc with others. This forum should be strengthened with global knowledge, through research inputs and other knowledge sharing mechanisms, with a larger number of countries sharing their experiences, Mr Kamaladasa said. It was also presumed that out of the debates, an appropriate governing structure could also emerge and appropriate judicial mechanisms could also be formed. There was also a strong view that a Water Resources Act, which is a pressing need, to address all these could also be formulated through such an initiative, the statement said.

As droughts approach slowly, there is time to react but the same flexibility is not available for responding to floods. As such dam safety should be a critical area of focus of future water resources managers than water management, with climate change creating unpredictable extreme weather conditions. The necessity of collecting data, invest on research and making such data and research outcomes available to all players were stressed. It was also agreed that in such an exercise not only quantitative but also the qualitative picture of the water resources has to be depicted and dealt with.

‘Physician heal thyself ’ is what came out of an interesting survey conducted this week by the Business Times (BT) and the Colombo-based Research Consultancy Bureau (RCB) on private channelled practice.

This form of healthcare has provided patients who don’t have the time to spent long hours in crowded state hospitals an opportunity to see a doctor of their choice in a private hospital but raised many issues and problems for patients – particularly in the hassle and wastage of valuable time.

The two surveys were done separately (BT on email and RCB through a street poll targeting an office/working class audience) and, interestingly, the responses differed between the two groups.

On the question of specifying minimum waiting times for patients (to see a doctor) and the minimum time spent to examine a patient, 85% of the group (generally urban professionals, middle and upper middle class) polled by email agreed that this should be done. Respondents in the street poll thought otherwise – 65.6% didn’t think this was necessary.

On other issues too, the responses differed which according to one sociologist is because “rural folk have more time to spend and waiting for a doctor is not an issue.”

The question of whether doctors, who swear by the Hippocratic Oath to practice medicine ethically, follow this principle was raised by many respondents in the BT poll. Here are two extracts of the Oath: “… to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction..”

“While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.”

Is this followed to the ‘letter’, some respondents from the BT poll asked.

The results of the BT poll are on Page one while the results of the RCB poll is on this page.

Comments received by both groups are listed below separately:

BT Poll On the need for a referral system:

This is okay if it’s for ongoing treatment of established medical problems which has to be dealt by a consultant anyway.

It would increase the cost to the patient.

A referral system is good but standards in all professions (medical being no exception) are so poor that mistakes at the GP (General Practitioner) stage could cause lives to be lost.

Only if the GP is experienced and has adequate qualifications. A good GP can decide on the need for specialist treatment.

This is a better way than the patient deciding on his/her own to consult a specialist since the patient may not have the ability to take such a decision. However the problem is that the physician may not refer the patient to a specialist in certain cases. That is why patients have lost faith in this system.

It won’t work unless the Health Department identifies the GPS in the area and assign the patients to a designated GP similar to the National Health Service in the UK. Moreover if the referral system is introduced under the present chaotic situation in Sri Lanka the GPS will have their favourites and direct all the patients to their favourite consultant or specialist. There will also be an understanding that the GP and the Consultant will share the fees as some of the Sri Lankan doctors are known to be dishonest and not following the Hippocratic Oath.

On minimum waiting times, and time spent by the doctor:

There are many good doctors too. A leading Endocrinologist who practices during the weekend in a leading private hospital has restricted consultation to only 20 patients devoting over 10 to 15 minutes for each patient, compared to the resident Endocrinologist in the same hospital who sees over double this number.

Limit the number of patients a doctor should see per hour.

It should be mandatory that the doctors keep to the stipulated guidelines. Today the doctor treats you like a commodity, not as a human being. Hospitals are also indifferent: if you complain, they give the patients the choice of leaving if they cannot wait for the doctor who is late.

Patients should not be taken for granted. Doctors still behave as if society is at their mercy. The waiting time is unbearable for patients with serious ailments.

Sometimes consultants don’t even look at the patient and write prescriptions in a jiffy while quickly calling in the next patient. Hospitals should insist that the consultants should spend at least 15 minutes for each patient thereby informing the consultant that he could see a specified number of patients within the time the consultant is in the hospital. If hospitals are strict in this time management, all doctors will adjust their schedules. However it should come as regulations from the state – otherwise all hospitals won’t follow this rule, fearing that the best doctors would go to another hospital.

A top consultant Rheumatologist visits a leading private hospital once a week, sees about 70 patients, charging Rs. 2500 per patient. If there are more patients the consultant charges Rs 3,000 for the remaining patients! Many consultants also charge fees even to show the reports. There is also a case of a Dermatologist practising at a leading hospital instructing the hospital pharmacy to restrict the issue of dermatological soap to one cake at a time prescribed by him so that the patient has to return for another pre- scription and pay the consultant’s fees again.

On complaining about waiting times:

Hospitals would never provide such information since they depend on the doctors for their income.

They are no longer caring organizations. It's big business and with less competition and more demand, the customer is at the receiving end.

Little that patients could do because in most cases, the back of the receipt implies that the hospital is not responsible for doctors not turning up in time. It’s a take- it- or- leave- it attitude.

Try asking hospitals this information? The response -- a ‘ gal ( indifferent and arrogant)’ stare!

On quality of service in hospitals:

The service and quality is good at a few hospitals. But the general problem is more to do with doctors rather than the hospitals.

Everything comes at a price, nothing is free. I am not happy with our hospital or health system since we cannot ask questions either from the doctor or the hospital staff. They don’t realize that we pay them their wages and upkeep.

Resident consultants at one particular hospital are extremely competent.

The quality in general is good. Patients are not sent from pillar to post, they do not have long waiting lists for services and doctors and nurses are more-friendly than in state hospitals. The hospitals are much cleaner and the better private hospitals have modern equipment which is better maintained than in state hospitals, However, private hospitals are too expensive and are also at the mercy of doctors. Nurses are not well trained.

Private hospitals have no standards related to cleanliness, and the toilets stink. Cleaners assigned to maintain the toilets are well dressed and avoid cleaning unless the supervisors pull them up.

Some of the nurses in hospitals are rude to the patients and their visitors. I know of an incident where a nurse from a leading private hospital in Colombo 3 used her finger to stir a cup of water containing a drug which was administered to a patient who had a heart valve replacement surgery!!

Government hospitals provide better services as the nurses are well trained.

The quality varies from hospital to hospital. But with increased competition it is much better than it was.

On prescribing both generic and branded drugs:

It’s good to prescribe both. The decision should be left to the doctor. He/she should give the generic name only if all the brands in the market are good in terms of quality and efficacy.

Not very practical if a doctor has to prescribe eight different drugs for a particular ailment.

It’s a good suggestion because some of the doctors prescribe particular brands for reasons other than its efficacy and quality.

Prescribing blood tests is also another racket. In some instances, a whole heap of tests are recommended to help the profitability of hospitals, though some of these tests may not been needed.

The government should allocate more funds for state hospitals and national health services so that poor patients can get proper medical attention. It is unfortunate that the government is more interested in beautifying the cities and its facilities such as roads without improving the basic needs of the people such as food, clothing shelter and health services.

RCB Poll comments On minimum waiting times, and time spent by the doctor:

Will this be like the timetable of private buses displayed inside buses which never works?

Some hospitals state the correct time of arrival of the relevant doctor while other hospitals give indicate a common time.

The time frame differs from patient to patient.

On the need for a referral system:

It is essential to consult a specialist if it is a critical ailment.

On quality of service in hospitals:

The government should streamline the private medical practice through legislation controlling the levy of high fees. The government-controlled charges by doctors should be displayed at hospitals and channeling centres.

The medical profession has become more of a money-spinning profession.

There are attempts to support the abolishing of the free health service in government hospitals which would help immensely channelled practice

These programmes will help rich people to get best medical facilities reducing facilities at public hospitals. On prescribing both generic and branded drugs:

We are unaware of any laws governing waiting times or how drugs should be prescribed.

Doctors prescribe drugs under brand name and not the generic name as they get benefits from drug companies through medical representatives.