(Note: This is a Case Study exclusively for training purposes. The contents and characters are fictitious and have no similarity with any real case or person. Any similarity is unintentional and purely coincidental)
Background:
After completing his education from Harvard Medical School, Dr. Kabir Shively worked for 15 years as a senior Oncologist in Washington General Hospital. His area of specialization is research in Stem Cell Therapy as a non-invasive and permanent cure for all types of cancers. He has authored several research papers and received many awards. His pioneering work has been appreciated by the medical fraternity all over the world.
Kabir is married to Valsa, who hails from Kerala and now works as a senior journalist with CNN. She currently holds the prestigious assignment of White House correspondent. They have two school-going children.
Despite his success, Kabir had been distressed and saddened by the huge increase of cancer cases in the country of his birth, India. He had a gnawing urge to help them and therefore decided to take up a limited 3 year assignment as Chief Oncologist of a leading hospital “Sir Yamuna Das Hospital” in Delhi. This century-old hospital is run by a Trust which, apart from private entrepreneurs, also has representatives from both the central and state Governments.
Kabir and Valsa decided that she and the children would stay back in Washington and exchange visits every three months.
Kabir had received a very warm welcome from the hospital’s Director Dr. Surya Rao and the entire management. The doctors and the hospital staff were not only very cooperative but genuinely proud to have Kabir amongst them. Even the Health Ministry was pleased that Kabir had decided to serve the country. The entire medical fraternity in India believed that it was only a question of time before Kabir would receive the coveted Nobel Prize.
The hospital had left no stone unturned to make Kabir’s stay comfortable. He had been provided with a nice furnished apartment next to the Director’s residence. Full-time household help, including an experienced cook, was assigned to him. The Director’s wife, a retired teacher, treated Kabir like a son and would personally ensure that he was looked after well.
Within three months of his arrival, Kabir had started extensive research activities in the hospital. Seven doctors were initiated into full-time research on Stem Cell therapy under his guidance. Kabir’s new line of treatment quickly started showing better results than conventional Chemotherapy and radiation treatments.
The initial results of the research confirmed Kabir’s hypothesis that the composition of the imported drug ‘Carciorev’ for Stem Cell therapy needed to be suitably altered to adapt to the genetic structures of South Asians. Being the patent owner for Carciorev, Kabir decided to get a modified version (Carciorev-SA) manufactured by a leading local pharmaceutical company ‘Pluto Pharma’, popularly known as PP. With the enthusiastic support of the hospital authorities, PP produced a pilot version of the drug for clinical trials within a month. Within two months thereafter, the Indian Authorities accorded approval to Carciorev-SA for sale in India.
Kabir was convinced that the locally produced version would be at least 10% lower in cost than the imported one. Before releasing the order for commercial production, PP was asked to provide the cost structure of Carciorev-SA. The offer from PP came as a disappointment. The Indian drug was in fact costing almost 10% more than the imported version. Kabir immediately called for a meeting with the hospital’s procurement department and the General Manager of PP. After checking various costs and multipliers such as overheads and profits, he was surprised to see a final add-on factor of 15%. He asked for an explanation and was told that this 15% was meant to be paid as a kickback by the Pharma Company to the prescribing doctor. In a casual manner, the GM of PP went on to add that this was the usual practice for all drugs sold to the hospital and the money transfer was managed smoothly and discreetly by his medical representatives.
Kabir was angry to hear this but maintained his composure. He quietly closed the meeting and immediately sought an appointment with Dr. Surya Rao, the Director.
After Kabir had explained the situation to Dr. Rao, the following conversation takes place between them.
Present:
Kabir: Sir, this unethical practice must be stopped forthwith. We are inflating the cost of treatment. No wonder, the poor in India are unable to afford treatment and are doomed to die in suffering.
Dr. Rao: You are right, Kabir. I have also inherited this system and am not in favour of it. But there’s nothing much we can do about it. Unfortunately, this is the practice prevalent in many hospitals in our country. They say this kickback is a small compensation for the hard work and sacrifices being made by our doctors. You know it yourself that our doctors work much longer than their official duty hours and under the most difficult and stressful situations. This overwork takes a toll on their health and personal life. Many of them could have got lucrative opportunities abroad but they have sacrificed wealth and comfort to serve their country. Interestingly, Kabir, this malpractice is known to the Board of Trustees, the Medical Ombudsman as well as the Health Authorities but everyone prefers to turn a blind eye in the interest of the doctors and good medical treatment.
Kabir: I agree that the Indian doctors work extremely hard under very adverse conditions but somehow this does not justify a wrong doing. There are also many other professions in India where one has to slog very hard to earn a living. Besides, there’s another problem associated with these kickbacks. Our doctors often have a tendency to overprescribe i.e. prescribe more medicines than are actually needed by the patient. For example, I found that many of the patients, referred to me, had been prescribed excessive doses of multivitamins, minerals and micro-nutrients. It was tough to convince some of them to reduce or even drop these supplements completely. I’d rather have my patients eat a banana, an apple and some almonds daily than all that fancy stuff, whose efficacy is not even proven. In fact, as you know, excess of these supplements has harmful effects.
Dr. Rao: I take your suggestion and will call a meeting of all the senior doctors and ask them to stop over prescription. I’ll also ask our Medical Superintendent and Procurement Head to keep a tab on the quantity of supplements being used in our hospital.
Further, I will ensure that there will be no kickbacks for Carciorev-SA. This would bring down the price by 15%. Also, I will insist that our Procurement negotiates hard with PP and gets us an additional special discount of at least 10%.
Kabir: That good but how do we put an end to this systemic malpractice? I feel that it’s like a cancer which afflicts our hospital and I, as an oncologist, feel helpless.
Dr. Rao: Kabir, you have a very bright future ahead of you. I have observed your work closely and am convinced that one day very soon you will bring us glory and there will be a quantum improvement in affordable medical treatment. My sincere advice to you is to simply ignore this issue, look beyond and move on. I myself feel helpless and frustrated that I cannot stop this malpractice. If I were to, it would create an upheaval and many doctors would get demotivated and leave. The entire organizational structure would be changed which could also mean a completely new management.
Kabir (with a heavy sigh): Okay, Sir. I understand your point. I think I’ll sleep over it and maybe we can continue our discussion on this unpleasant topic tomorrow.
Dilemma:
For the first time since landing in India, Kabir is feeling genuinely distressed as he slowly walks back to his house. A painful conflict is brewing in his mind.
A part of his brain, the rational one, urges him to blow the whistle and expose this scam. There is no justification for cheating patients just because greedy doctors have to be compensated for their hard work. Moreover, he feels that if he does not do so, he automatically becomes a party to this corrupt practice. This would make him feel guilty and ashamed for the rest of his life even if he remains unscathed in the whole mess. To blow the lid, all he needed to do was to write a couple of lines on Twitter or Facebook and the whole world would know.
The other side of his brain is the emotional part which tells him to desist from any such action. The director and the entire staff of the hospital had been so good to him. If he blows the whistle, the director and most of the doctors would certainly be sacked. The whole hospital would have to be reorganized under a new management with new rules. The research work could come to a grinding halt. Eventually, this would only add to the suffering of the patients. He would hate to see all that.
There was also a personal angle. The director and his wife had been so kind to him. About a month back when Valsa and the kids had visited Delhi, they had looked after them with lot of love and care. Mrs. Rao had personally cooked the choicest Indian cuisine and even shared with Valsa some of her finest culinary recipes. Kabir had lost both his parents early in life but his kids seemed to have found their grandparents again in Mrs. and Dr. Rao. In fact, while Kabir had to attend to some urgent work in the hospital, Dr. Rao had taken a few days off and the elderly couple had taken his family on a memorable holiday covering Agra and Jaipur. The families had become so fond of each other that Valsa had invited them next year to Washington.
Dr. and Mrs. Rao were a good, honest and God-fearing couple and Kabir could vouch for that. They had lost their only son to cancer about 30 years back and thereafter had immersed themselves into work and public service to tide over their sorrow. Dr. Rao was due for retirement in two years and was already looking forward to going back to his native costal town near Vishakhapatnam where he owned a small house with a garden. Kabir knows that he would never be able to forgive himself or face his family if he brings misery to this elderly couple.
What should Kabir do? Please think over this problem and suggest possible solutions.
Author: Rajiv Sachdeva