Written by the doctors and public health advocates Arun Gadre and Abhay Shukla, Dissenting Diagnosis is based on a study conducted at Support for Advocacy and Training to Health Initiatives, a Pune-based non-governmental organisation. During the course of this study, Gadre and Shukla interviewed 78 doctors from across the nation in an effort to confront what they consider is an ongoing crisis of the medical profession: doctors, they write in their introduction to the book, are finding “their traditions of ‘keep patients foremost’ rapidly buried under the ruthless logic of ‘keep profits foremost.’” Gadre and Shukla discussed with these medical professionals issues such as lack of regularisation in the private sector, unlawful and unethical practices routinely followed by doctors, the influence of pharmaceutical companies, the state of medical education, and the possibility of a universal healthcare system.
In the following excerpt from the book, interviewees speak to the writers about the hold of the pharmaceutical companies over the medicines prescribed by doctors. They describe how, through offers of gifts and benefits, aggressive marketing and sheer persistence, representatives from pharmaceutical companies routinely entice doctors into prescribing expensive and often unnecessary medicines to their patients. The pharmaceutical companies, one of the doctors said, are "like a pack of wolves."
“Some of my doctor friends boast to me that they have travelled the world, sponsored by pharmaceutical companies. One was telling me with pride that even their shirts, pants, vests and underwear are given by pharmaceutical companies!” says an ophthalmologist from a medium-sized city.
Dr Suchitra, a general practitioner in Chennai, mentions, “The pharmaceutical companies offered to sponsor me for a conference, but I refused. I usually prescribe generic medicines or cheap, branded medicines. But the interesting thing is that once these pharmaceutical companies realized I don’t prescribe their medicines, they stopped visiting me.”
“I have been practising for thirty years. I have not given any ‘cuts,’” a super-specialist from a metropolis shares. “I did not encourage pharmaceutical companies. I change the medicines prescribed to my patients, prescribing cheaper medicines if expensive medicines have been prescribed. And what a big difference this makes to the patient! Sometimes the cost is reduced as much as Rs 35–40 per tablet! Patients are often unnecessarily prescribed expensive brands of medicines, for years on end, sometimes for life. The hapless patient keeps taking these medicines.
“Once, four medical representatives visited me with their bosses. They tried to convince me that I should not replace their brands, while prescribing cheaper brands to patients. We discussed the matter for an hour and their argument was that their company does a lot of research, on which they spend crores of rupees. That is why their brand is more expensive by Rs 30 per tablet.
“After they had finished their speech, I took Rs 1000 out of my pocket and handed it to one of the bosses. Surprised, he asked me what this was for. I answered: ‘You are doing such good work for humankind. This is my small contribution!’”
“After that I emphatically told them that I would help them, but how could I do this at the patients’ expense without telling the patients? Of course, they had no answer to that.”
A big-city surgeon remarks, “Pharmaceutical companies sponsor conferences where nobody bothers to listen to the lectures. Doctors just go to the stalls, and collect gifts. They enjoy the free drinks. It is a filthy business. What can one say?”
“Medical representatives influence the doctors. One of them offered me a trip to Singapore. I refused and told him that I would go at my own expense, and when I wanted,” said a general practitioner from a big city.
A super-specialist from a metropolitan city also shares, “The medical representatives are really persistent; they don’t leave you alone. Earlier, I would get angry at them. One of them pleaded with me, “Sir, you are the only one left. The other doctors, like you, who would earlier not take gifts, have all gradually succumbed. That’s why I am now meeting you too.” Since then, I don’t get angry with them.
“Recently, a medical representative brought along a diamond necklace as a gift, worth Rs 1 lakh.
“I asked him, ‘What’s this?’
“‘A diamond necklace, sir.’
“‘For whom?’
“‘It’s for your wife.’
“Controlling my temper, I asked him, ‘How do you dare to put a necklace on my wife’s neck?’
“The poor fellow was taken aback. ‘It is you . . . you will put the necklace on your wife’s neck.’
“Giving it back to him, I told him in a calm voice, ‘If that is so, then I will buy it with my own money. That is, if she wants a necklace at all!’
“The poor fellow left with the necklace.”
Dr Sumit Das, a psychiatrist from Kolkata notes, “Pharmaceutical companies exist to do business and make profits. But what about doctors? They too put pressure on pharmaceutical companies, telling them, ‘If I prescribe your medicines, send me on a tour to Europe.’
“In the field of psychiatry, pharmaceutical companies bring out new medications every day. There is no evidence that the new medications are better than the cheaper and effective medications that are already in use. And keep in mind the fact that our patients don’t take these medications for just a few days, but often for months or even longer. Yet these unnecessarily expensive medicines are sold and also prescribed.”
“Pharmaceutical companies could have donated money to our department and our institution by cheque. But instead of doing that, I would repeatedly be offered personal gifts, foreign trips, etc. Those salesmen would tell me openly that they are willing to spend on an individual, not on the institution,’ comments a general surgeon from a metropolitan city.
A paediatrician from a metropolitan city suggests, “The practice of pharma companies sponsoring doctors for conferences and CME (Continuing Medical Education) workshops must be stopped immediately.”
A gynaecologist from a big city observes, “The area manager of a pharmaceutical company once paid me a visit along with his army of representatives. He asked me why I regularly use a certain product manufactured by them.
“I answered, ‘It is cheap, it is effective. That’s why.’
“He was confused. He asked me in bewilderment, ‘Madam, we never give you any gifts.’
“I replied, ‘There is no need for that.’
“He just could not believe it. He kept asking, ‘How can this be, madam? Please tell me the reason.’
“This is the ridiculous situation that prevails. This is the reality.”
A paediatrician from a big city mentions, “Our branch [of a doctors’ association] was functioning well. We would organize CME workshops with our own funds. Gradually, the pharmaceutical companies pushed their way in. From 1995 onwards they began to organize their own CME workshops. Earlier, we would focus on the issues of importance that we had decided upon. But then the pharmaceutical companies began to select only those topics that would help them promote their new drugs. The workshops were free, with liquor thrown in. Finally the doctors in our city decided that all workshops henceforth would be organized by the pharmaceutical companies. I would ask them why they couldn’t spend Rs 1000 per year on their own education. Why do you want it free? Finally, through a secret ballot, my opposition was set aside and the basic principles of our [doctors’ association] branch were changed in favour of the pharma companies. Obviously, I withdrew from it. Now all workshops in our city are conducted by pharmaceutical companies.”
“A rampant malpractice is in the area of prescribing vaccines—it is organized, and takes place on a large-scale in planned fashion. The practitioner gets a cut on the Maximum Retail Price (MRP). The more expensive the vaccine, the higher the cut. The cut is even more than the consultation fee. The doctor gets both—the cut from the company and the fee from the patient,” notes Dr Vandana Prasad, a paediatrician from Delhi.
“The pharmaceutical companies are like a pack of wolves. They keep pestering you and encourage you to accept some incentives. Once you take anything from them, they immediately become arrogant. Now they begin to ask you directly, ‘Why don’t you prescribe our medicine?’ They start dictating terms, and because you have accepted money and gifts, you are morally bound to them,” Dr Sanjay Bhatnagar, a paediatrician from Delhi, also shares.
A surgeon from a megacity mentions, “The government cannot provide funds, and if the pharmaceutical companies therefore sponsor conferences in a transparent manner, there is nothing wrong with it. The MCI wanted to do something about this.”
A skin specialist from a big city says, “The pharmaceutical companies have created mayhem. Things like conference sponsorship by drug companies must be stopped. The MCI is aware of the problem, but there are lots of loopholes that can be exploited. Nowadays, doctors take money from pharmaceutical companies and prescribe ten to twenty medicines in a single prescription. There is always an antioxidant tablet prescribed, whether it serves any purpose or not.”
A skin specialist from Kolkata, Dr Jayant Das also remarks, ‘Now pharmaceutical companies are resorting to a new strategy. “For example, they don’t even produce Doxycycline (an established antibiotic) capsules, which cost less than Re 1 per capsule. Instead, they add a useless component like lactobacillus with Doxycycline, and then sell each of those capsules for Rs 5. And when the ordinary, cheap Doxycycline capsule is not even available in the market by design, one has no choice but to prescribe the expensive medicine. This is happening without any check with respect to many medications. One company recently withdrew a medication available for Rs 2. They made some token changes in the formulation and the same tablet is now sold by them for Rs 15!”
Another skin specialist from a big city observes, “Pharmaceutical companies try to give money to doctors under the pretext of conducting studies on their medicines. Such bogus clinical trials are conducted openly. The doctors lure the patients with the promise that the stated medication has come from abroad, and if you want to have it free, you would have to just sign this form, that’s all! Please sign here. Doctors collect the signatures on the forms. Sometimes they just fill up the details. Once they have given the papers for ten to twelve cases (even without prescribing the medication) they get a cheque from the pharmaceutical company.
“If one puts an end to the money pharmaceutical companies spend on doctors, medicines will definitely become much cheaper. That must be ensured, for the benefit of patients. Doctors should be legally compelled to prescribe only generic medicines.”
A general surgeon from a big city offers, “Take the example of Lactulose, which is used to treat constipation. It costs about Rs 180 for 200 ml, that is, around Rs 900 a litre. This is a by-product of the sugar industry. Actually, this should cost less than sugar, i.e., less than Rs 60 per kg. Elderly people will be taking this for years together. Shouldn’t the prices of such medicines be regulated? No. The loot continues.”
This is an excerpt from Dissenting Diagnosis, by Arun Gadre and Abhay Shukla, published by Random House India.