Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 1, 2003, pp. 68-72

Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 68-72

Personal Viewpoint

J.K. Banerjee

F-23, Hauz Khas, New Delhi-110 016
Address for correspondence: Dr. J.K. Banerjee, F-23, Hauz Khas, New Delhi-110 016 tel: 011 686 4171 Email-dali - f23@yahoo.com

Paper received: June 2002
Paper accepted: November 2002

Code Number: is03014

INTRODUCTION

Every new tool of surgical technology that develops in the western world, we in India imbibe and put into practice with the expectation of improving the quality of care of our patients. Improved and sophisticated intensive care facilities, improved investigative procedures, minimal access surgery and organ transplantation are some such tools which have come into India within the last twenty years.

Albeit, every new tool has come with a price tag. In Western Europe and USA, where most of these tools have developed, the price has led to a revolt by the payers, be it their governments or the insurance companies. And these payers challenged the surgeon-industry nexus to find out how much of it benefited the consumer and how much of it was to promote the profit of the industry and glamorization of the surgeon.

EVOLUTION OF THE CONCEPT OF OUTCOME ANALYSIS

This challenge led to developing various types of cost effectiveness or cost benefit analyses. The social impact of this spending had to be weighed against the benefits this spending would accrue in terms of either improving the quality of life of the individual, or improving the productivity and utility in society. Surgeons held world congress on surgical efficiency and economy, and prioritization in health care. The WHO started holding workshops on ethics and equity in health care since this body had already sponsored the concept of "HEALTH FOR ALL" by 2000 AD¹.

In the surgical world, came the concepts of medical decision making (MDM), then evience based medicine (EBM), followed by patient-oriented evidence that matters (POEMS), patient centered medicine (PCM) and finally, "outcome analysis"². Just as every moving vehicle is fitted with suitable brakes to control its speed lest it harm the user, the healthcare industry also had to be fitted with brakes lest it harm the society. The spending had to be curtailed by its judicious use of money.

All these concepts were of course developed by doctors, including surgeons themselves. Their main concern was social benefits besides to the individual patient. Guidelines were published in books pertaining to surgical research to analyse outcomes in their own societies³. Technological excellence was not being considered any more as the last word in the area of surgical development. The social impact and ethics of application were being given the name priority as technology. Relman wrote about three revolutions in medical care in the twentieth century:-

1. the era of expansion of technology-1950 to 1970
2. the revolt by the payers-1971 to 1985
3. the outcome movement from 1986 up to the present⁴

In 1987 Prof. Stig Bengmark held the first world congress of surgical efficiency and economy in Lund in Sweden. And in that conference Willis Goldbleck presented in his lecture how the insurance companies in the US had become clever enough to clamp down on heavy spending by surgeons and how they are making strategies to curtail the high tech fancy aspirations of the practicing surgeons. (The author heard this lecture in silence).

Let us look at history a little bit. The seventh century was known as the century of enlightment in Europe and then Francis Bacon defined "science" as a "service for welfare"⁵. Surgical development was an uphill struggle in those days against social stigma and was lead by a group of people totally devoted to this "service for welfare" concept of science. Ambrose pare, Joseph Lister, Semmelweiss, Theodore Billroth, John Hunter and such others struggled against social norms to establish scientific truths, which had far reaching impacts on surgical development⁶. The concern for the people was of such importance to them, that some of them turned to evolving the science of economics, which did not exist till then in the western world. Sir William Petty, professor of anatomy and surgery at Oxford, and later physician to Oliver Cromwell did so. In France, François Quesnay, surgeon to the Royal Court introduced the concept of Laissez Faire as a keystone in developing the concept of "economics"⁷.

In the second half of the twentieth century, however, industry took this process of development away from such dedicated people; the concepts of the cost of research and development and intellectual property rights invaded the scene. And this necessitated development of tools for the control of human greed. The concept of Francis Bacon had to be revived. The surgeons of the western world came with the concept of MDM, EBM, PCM, POEMS, outcome analysis and so on. Prioritization became an important issue both to the health economists and surgeons.

Prof. Bryan Jennet of the University of Glasgow defined the role of the surgeon of the seventies as the triad of scientist, scholar and manager in his Simpson memorial lecture at the Royal College of Surgeons of Edinburgh in 1973. Prof. Wilfried Lorenz of the university of Marburg, Germany wrote in his chapter on analyzing outcomes in the book on surgical research, the following⁴:- "the role of the scientist is no longer simply that of a precise methodologist or a sophisticated thinker but also of the provider, a person whose primary concern reflects the needs of the individual and of society."(1997)

Today, societies of medical decision making have been formed in different countries, Europe and USA. Surgery has also evolved to a state of teamwork across multiple disciplines and into multiple disciplines and into multiple specialties. All this has occurred on the background of a planned economic growth and a supportive and unbridled industrial growth in these developed countries mainly due to the concern of the practicing surgeons for their societies. In the meantime, the world shrunk to a much smaller size due to improved communication systems. The unbridled industrial growth of the western world started facing resistance from practitioners of ethical medicine in their own countries. They formed "Multinationals" and started to try and maximize profits through an invasion of the "developing" countries in the garb of "development". Surgical industry was no exception. Governments motivated by the profit formed the world trade organization and mechanisms were developed by them as already mentioned above (intellectual property rights etc) to protect the interests of the industry.

Thus an economic war has been started today between the haves and have-nots in the world. Out of the six billion population of our planet, one billion are the "haves" and five billion are the "have-nots" spread across South America, Africa and Southeast Asia. After breaking national barriers, new economic barriers have been developed between the rich and the poor.

THE INDIAN SCENE

Against this international background, let us examine the scene in India, specially, the evolution of the concept of "rural surgery". We must note that:-

1. The per capita GNP of India is 370 US dollars while that in the countries of Western Europe and North America varies from 20,000 US dollars to 44,000 US dollars.
2. Four hundred million people of our country out of total of one billion have no access to basic surgical and medical care according to the last census.
3. Our country has a total of 0.6 beds per thousand of population. The WHO recommendation is 4 beds per thousand.
4. 80 percent of these beds are in large cities while seventy percent of the country's population lives in the rural area.
5. People residing in rural areas who have come to the city specially for treatment⁸ occupy 80 percent of these beds in large cities.
6. With increasing privatization, and professionals succumbing to pressure from the industry there is increased marginalization of the poorer sections of the people leading to increasing inaccessibility of sophisticated medical care for them.
7. Only 0.3 percent of the population has any access to any form of medical insurance. There is no worthwhile social security. In addition the government is decreasing spending on medical facilities in the name of so called "economic reforms".
8. In spite of ten five-year plans, the government facilities of second level surgical care and emergency care have hardly developed. The community health centers (CHC), which in principle are thirty bedded hospitals providing specialist cover and most of the district hospitals are so impoverished that people barely use them.
9. Surgical education is western oriented. While our colleges are producing excellent super specialists fit to work in the best-equipped hospitals, they do not produce multi-skilled surgeons fit to work with limited resources in impoverished hospitals in our countryside. While people in the countryside die of perforations and obstructions, sophisticated tertiary surgery is being performed successfully in corporate hospitals in cities.
10. Our country has very few hospital beds to meet the country's total requirements. Yet, state governments enact legislations (at the behest of these multinationals) which have become a deterrent to starting new hospital facilities even by voluntary agencies who wish to provide, what the WHO calls "essential surgical care" to the poorer rural population.
11. 80 percent of our gross domestic product is consumed by 20 percent of the upper crust of our society. Whether the farmer or the majority industrial labour, or the infrastructure workers. The situation has thus become dismal.

THE OUTCOME IN INDIA: AN ANALYSIS

Let us analyse the outcome of this dismal state. People have started revolting in various forms. Declaring hospitals as industry, and promulgation of the consumer protection act are examples of this revolt. Even the slightest negligence of the doctor is inflated by the media and reported in capital letters. Every alternate day there is a write-up in newspapers against the very costly services of the mushrooming private and corporate hospitals of large cities. Worst of all, doctors are often physically manhandled and hospital furniture broken up by irate public on the slightest pretexts⁹. It is a pity that in every surgical conference, the political bigwig in his address, exhorts the surgeons to take care of the poor. Today the reputation of the western oriented surgeon is at stake in our country.

We need to turn round this corner. And to do so, a self audit is essential. The surgeon has to control his greed for money, name and fame. He has to be able to analyse the outcome of his work in relation to the society. For instance, in legal transplants also, in the private sector, often, the "first liver transplant" and so on are reported in the media to give the surgeon and his institution a temporary glamour. The long-term result of this transplant is never reported. Near and dear ones see the slow deterioration of the patient mainly due to poor immuno-suppression and the non-affordability of the extremely costly medication. Finally, the doctor gets his share of silent curses. Often proper informed consent is never taken and it is often clouded by marketing pressures. The morbidity and disability following surgery is not properly explained to the illiterate and uneducated patient curses continue to be heaped on the surgeon after surgery after surgery. The cumulative effect leads to various types of revolt. There have been instances of kidnapping of rich doctors for ransom in poverty-stricken areas.

In our socio-economics and cultural setup, it is not difficult to perform a self-audit, if we change our mindset. After a six Sigma Analysis of health services in the USA, a report was published in 2000 AD, that 98,000 deaths occurred every year due to "medical errors"¹⁰. This report led to a furor and the then president Bill Clinton appointed a committee to look into the causes of these errors and how to minimize them. And this in a country, which has no dearth of drugs, equipment, teaching and other technical facilities to assist the professionals in performing their tasks correctly!

Errors can be minimized only by a "higher trained mind". One tends to conclude that the mind is the most important factor, which has to use all these tools judiciously to maximize their usefulness in curing an ailment and to improve the quality of life of an individual. Albeit, the greed factor has to be taken out of the minds for its optimum functioning.

Another example. After the discovery of X-rays, obstetric care was considered "unscientific" by the western world, and papers were published on this. Once the adverse biological effects of radiation on the foetus were found out the X-ray examination of pregnant mothers was totally stopped or done with caution. And now, gradually, the harmful effects of Ultrasonography on the foetus are being discovered. Many children's lives are endangered in the process of "successful" scanning practice by many ultrasonologists who do not even bother to analyse the outcome of their practice¹¹.

The concept of "service for welfare" will automatically follow when a mind does not look at money, name and fame as the criteria of success. Only a change in our attitudes will help in restoring the dignity of our profession.

Analyzing outcomes will then become a simple matter. In the west, according to Epstein¹², outcome analysis denotes a change in the direction of analysis results. He mentions that formerly mortality, re-admissions, complications etc. were the criteria of assessing outcomes. Today it has changed to assessing functional status, emotional health, social interactions, cognitive functions, degree of residual disability etc. these factors are totally neglected in our interactions with a majority of our population, whose social and financial status have an enormous bearing on their emotional health and cognitive function.

RURAL SURGERY AS AN OUTCOME

The Association of Surgeons of India was born in 1938. it filled a very important gap, which existed till then in the growth of surgical services and teaching in our country. But now with development, an increase in medical colleges, service hospitals, advent of super-specialities, increase in the population and above all with the changing role of the surgeon worldwide, the same surgical services will have to be tailored to the needs of our people. (the population of our country is more than one billion. This is more than that of the whole of North America and western Europe put together). The Indian surgeon has already taken one step in this direction in accepting "rural surgery" as a speciality. This obviously, is a "directional change" as mentioned by Epstein, and the result of a great movement in India amongst the surgeons who are rising to meet the needs of our impoverished society. One can safely say that this evolution of rural surgery is the outcome of surgical development in India.

Together with higher surgical research and training in its teaching institutions, the Indian surgeon by creating the speciality of rural surgery, has also taken upon himself the responsibility of disseminating its benefits to the poorer people, not only in India, but also around the world, mainly through international interactions, conferences, newsletters, distance education courses, and through surgeons practicing in underdeveloped communities.

The Indian rural surgeon is learning how to practice multiple skills, how to innovate appropriate management systems, how to set up and run a rural hospital with limited resources, how to analyse his own outcomes. He is learning about principles of health economics and cost effective analyses etc., and methods of updating technological knowledge. He learns team building with colleagues of other specialities appropriate to his area of practice, trains village boys and girls to do paramedical work, and in general works to improve the health status of the community. He is not adverse to imbibing higher technology, but would prefer to use it only judiciously. The patient's benefits are uppermost in his mind. He takes the glamour of being a surgeon only as a by-product of his practice.

For this the rural surgeon and the professor of surgery have to work in close cooperation. The onus on the professor in India is to conduct research and training to evolve and bring newer and higher technologies of surgical care that suit our country's needs. The onus on the rural surgeon is to put them into practice in his rural hospital and then give a feedback to the professor. Based on this feedback, the professor has to be able to modify his approach, independent of western teaching. For the benefit of the majority population, the professor has to understand the concept of "limited resources". Nowadays, rural surgeons are performing many so-called obsolete procedures with immense benefits to the rural population. The rural surgeon is, for instance, using mosquito net for hernia repair very successfully as seen in the multicentric studies over the last four years13. one stage choledochoduodenostomy has come to stay for CBD stones, again though multicentric studies, specially since the waiting list for ERCP in teaching institutions and in private setups is too long for these patients of obstructive jaundice, besides being too expensive. Railroad repair of urethra, open prostatectomy, plaster immobilization and skeletal traction even at homes, early detection of cancer through trained paramedics, simple and cheaper suture materials are some instances of appropriate technology used by the rural surgeons. Both learning and teaching have to be a two way process and not a one side flow of technological knowledge from the professor to the rural surgeon. Together we should be able to launch multicentric studies with rural surgeons of different surgical procedures independent of western teaching. Unless learning is made into a two way process between the professor and the rural surgeon, this dismal situation in the country is not going to change in the near future. The professor in India will therefore have to play a double role. He will have to involve himself in both high-tech as well as appropriate surgery.

CONCLUSION

Today industry-based high technology is missing out on five billion people of the world. Multinational industries are siphoning out money to the tune of Rs. 80,000 crores annually from our country (healthcare personnel being big partners of the industry in this game)¹⁴. The rural surgeon aspires to serve this five billion people round the world with appropriate surgical care and the judicious use of technology so important for the creation of a sustainable "one earth" in the twenty-first century.

REFERENCES

1. Bankowicz Z. Ethics, quality and the renewal of WHO health for all strategy. Proceedings of the XXIX CIOMS Conference. Genevea: WHO: 1997.
2. Bensing J. Bridging the gap. The separate worlds of evidence-based medicine and patient-centered medicine. Patient Educ Couns 2000; 39:17-25.
3. Surgical research: Basic principles and clinical practice. Troidl H, McKneally MF, Mulder DS, editors. 3rd ed. New York: Springer Verlag: 1998.
4. Relman AS. Assessment and accountability: the third revolution in medical care. N Engl J Med 1988; 319 : 1220-2.
5. Lorenz W. Outcome, definition, methods and ealuation. In: Surgical research: Basic principles and clinical practice. Troidl H, McKneally MF, Mulder DS, editors. 3rd ed. New York: Springer Verlag: 1998: p 513-519.
6. Burnand KG. Young AE. The new Aird's companion to surgical studies. 2nd ed. London: Churchill Livingstone: 1995.
7. Capra F. The turning point. Science, society and the rising culture reissue. 1st ed. Glasgow: Harper Collins: 1982. p 204-7.
8. Krishnan TN. Centre of development of economics. Paper read at 2nd National conference of rural surgery, Shimoga, 1994.
9. Mob Burns hospital. News from here, there and everywhere. Natl Med J India 2001;14: 317.
10. Letter from USA. Natl Med J India 2000;13:150.
11. Basu SK. Unsung sounds of ultrasound, discordant note in obstretics. Paper presented at Ixth National conference of rural surgery. Puri, 2001.
12. Epstein AM. The outcomes movement-will it get us where we want to go? N Engl J Med 1990; 323: 266-70.
13. Reddy VB. A new material for hernia repair. Rural Surg. 2001; 1: 19-20.
14. Rebello L. Personal communication. 2000.

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