Recently, my niece gingerly confided that she was going to study engineering rather than medicine. I was certain she’d become a doctor – so deep was her love for biology and her deference to our family tradition. But she calculated, as would anyone with common sense, that with an engineering degree and an MBA, she’d be working for a multinational company making a comfortable income by twenty-eight. If she stuck with tradition and altruism, as a doctor she’d still be untrained and preparing for examinations at twenty-eight. Despite the truism in India that doctors are the only professionals never at risk of starving, the rational case for becoming a physician never was strong. Doctors always needed a dose of the irrational, an assumption of integrity, and unbridled goodwill to keep going. Once, doctors commanded both the mystery of science and the magic of metaphysics. As medicine became for-profit, the metaphysics slowly disappeared. Indians are becoming more prosperous. They’re also less fatalistic and expect less from their gods and more from their doctors. In the beginning, they treated their doctors as gods, now they see that doctors have feet of clay, too. Doctors, who once outsourced the limitations of medicine to the will of Gods, summarized by the famous Bollywood line “inko dawa ki nahin dua ki zaroorat hai” (patient needs prayers not drugs), now must internalize medicine’s limitations. And there are many – medicine is still an imperfect science, a stubborn art, often an optimistic breeze fighting forlornly against nature’s implacable gale. As their sheen recedes doctors face a new tide – mob attacks for undesirable patient outcomes. The strike by doctors in Calcutta in protest of a junior doctor seriously injured by an angry family of a seventy-five-year-old patient who passed away, is just the tip of the iceberg. There’s more trouble brewing. As people are living longer, they have more diseases and are on more drugs. Medicine has become more complex, but the infrastructure to support junior doctors is still rudimentary. Death is still inevitable, but medicine keeps promising death’s postponement, and when death isn’t postponed to the degree families expect for their loved ones, they suspect negligence. The suspicion of medical malpractice places unsupported junior doctors, the face of hospitals, most at-risk from angry mobs. One of my most harrowing memories in India as a child was when I saw a mob pour kerosene on a bus. My grandfather pulled me away before the bus was set alight, but I knew what was happening. The mob had tied the driver and conductor to the steering wheel. The mob was angry because the bus had crashed into a pedestrian fatally injuring her. The mob formed spontaneously and dispersed spontaneously. Mobs are as capricious as India’s legal system. It was only years later that I understood the price of stopping mobs. When I arrived in Philadelphia for my medical training, I couldn’t afford a car because I couldn’t afford auto insurance, which was unaffordable because the costs of litigating auto-accidents were so high, which were high because of the generous compensation for a range of injuries including the nebulous “whiplash.” The United States is famously litigious, particularly in medical malpractice, where millions are awarded for bad patient outcomes which may or may not be caused by negligence. The net effect of litigation is defensive medicine where doctors over-order tests to avoid lawsuits. Defensive medicine has made healthcare costlier. For many years I rued medicine’s litigation problem, particularly its effect on physician decision making. Now I wonder if overlitigation is the lesser of two evils. Mobs attempt to correct for failures of institutions to make systems safer. Though mob violence is a blunt tool, unhelpful at making systems safer, their expression signals a void – the paucity of confidence in civil courts. If patients’ families had confidence in the legal system and were sufficiently compensated, over time they’d be less likely to be violent against doctors when they perceived real or imaginary medical negligence. Compensation doesn’t bring back the deceased, but it’s an apology of sorts. Though dreadfully cynical to say – money is balm to the grieving soul. In its absence, retribution rears its ugly head. Mobs exact retribution in lieu of compensation. The mob problem faced by doctors in India won’t be cheap to solve. The government must invest a fair amount in courts, medical malpractice insurance, and hospital infrastructure. Due process is expensive. Safety costs. Fatalism subsidized the Indian healthcare for far too long, but the gods are no longer willing to pick up the slack of politicians. Lawyers will no doubt thrive. And medicine will surely become more defensive and costlier. Overlitigation is inevitable because pendulums rarely settle in the middle. But overlitigation is the price we pay for keeping medicine civil. The alternative? If mob justice continues unabated medicine will become even less popular, and fewer doctors will elect to help the sickest and most disenfranchised in India. The mobs will turn even more viciously against the few brave doctors who remain in government-run hospitals, brave enough to weather their expectations. Though I didn’t let on, I was secretly pleased that my niece decided not to become a doctor. Medicine is stressful enough without doctors being worried about their personal safety. Safety beats tradition. Altruism be damned. Source
