Doctors are frustrated, patients are angry, hospitals in the west are going broke, insurance companies that are there only to make money are also declaring Chapter eleven by the day. Time to get back to the old, trusted tradition of family doctors?
“The time has come," the Walrus said,
"To talk of many things:
Of shoes--and ships--and sealing-wax--
Of cabbages--and kings--
And why the sea is boiling hot--
And whether pigs have wings."
-Lewis Carroll 1872.
“If one does not learn from history, one will have to relive history,” wrote Cicero, the great Roman thinker. Medicine has been branching into innumerable specialties and sub-specialties (super-specialties in Hinglish). It has reached a point where the whole modern medical world is standing at the threshold of losing its sway over the common man. A recent survey in the US showed that sixty-two per cent of upper middle class Americans could not afford to go to hospitals there as medicine has become prohibitively expensive despite patients having more than one Medicare insurance policy. Many a time the small print in the insurance policy denies them help when the chips are down. Fifty-seven per cent of the British do not want to go to a modern medical facility, if they could help it, despite the free National Health Service there. “Modern medicine” said Prince Philip, the heir to the British throne, recently “is slightly off balance like the Tower of Pisa for all its breath-taking advances.” He could not be more accurate in his assessment. The alternative medicines have been a $70 billion business last year! Most of that is not proven to be useful, though. There seems to be confusion all over.
In the last half a century medicine has gone to the market place riding piggyback on technology and, consequently, market forces act on it in a big way today. Time was when a patient came to the doctor with all faith (faith heals) and felt that doctor is God and would do his/her best for the hapless patient. Not anymore! Today the doctor is a seller of medical technology and the patient a buyer. Consumerism rules the roost, making doctors practise expensive defensive medicine. Doctors are frustrated, patients are angry, hospitals in the west are going broke, insurance companies that are there only to make money are also declaring Chapter eleven by the day. The administrators seem to be groping in the dark with no clear end in sight. Reminds one of the First Law of Thermodynamics which states that “anything that disintegrates eventually disappears.” Thinking people in the medical world will have to do something before it is too late. Doctors should remember that a patient could live without the help of doctors but a doctor cannot live without patients.
When a patient goes directly to a super specialist any symptom that the patient might have looks like the rare presentation of a disease in the specialist’s own field. The hapless patient gets a battery of tests and interventions only to be told at the end that he/ she does not have a disease of that particular organ! By then the patient has lost most of his/ her earnings. Patient did not get any solace and has had no answer to his problems, either. Most of these interventions are not only unnecessary but could be potentially dangerous. The specialist is like the man with the hammer in the hand wanting to use it badly. For such a man everything looks like a nail needing hammering, wrote Mark Twain years ago.
The only solution is to go back to the time tested family physician system with necessary modifications in the training period to make the family physician truly useful to the sick. The emphasis should be to seek second opinion when in doubt. Time was when medicine was practised only in the patient’s homes. Hospitals were not there. The family physician made his diagnosis at the bedside and did what he could with very little technology. Some indications today point to the fact that there has not been any marked improvement in the per capita deaths today compared to the good old days except that the dying could feel that their life has been prolonged today because of the way they are being intervened in the last ten days of their lives. Death has lost its dignity. Ninety per cent of the medical care budget in the USA goes to keep seriously ill patients alive in the last ten days of their sojourn on this planet.
Even today a double blind prospective study in London did show that eighty per cent of the accurate final diagnosis and one hundred per cent of the future management strategies could be chalked out at the end of carefully listening to the patient! Family medicine, therefore, is very useful and affordable, if practised scientifically. Only in rare cases a specialist might be needed to intervene at the behest of the family physician. Such specialists must be classed as medical technologists and not true doctors. They should have very little to do with diagnosis of illnesses. A specialist should be like a laboratory supplying the investigation data to the family doctor when in doubt. He could also assist the family doctor to manage the illness using his tools only when needed.
Family Physician in the new Avatar:
After graduation one should take postgraduate training for at least three years in this specialty, before being let loose on the gullible public. The entry criteria for being admitted to this PG course should be the following, in addition to the marks obtained in a replicative entry examination preceding the selection:
• Can he/she smile naturally at some one?
• Can he/she touch someone comfortably?
• Does he/she have an insight into another’s suffering?
If the answer to any of the above questions is in the negative he/ she is debarred from this specialty. They could go into some other area where human direct contact is minimal.
The curriculum for this course should be drawn up very carefully keeping the human being as the supreme commander of all else. True humanism, medical humanism included, is simple the primacy of man in every distress situation. The family physician should be a sort of jack of all trades and he should have a good grounding in human psychology. The recent revelation to modern medicine that all ills from common cold to cancer originate in the human mind and regress also with the help of the mind makes it imperative that the new family physician should have a very thorough understanding of the human psyche. Clinical psychology should occupy a large space in the course.
The next stress should be on health promotive activities and behaviours that help keep healthy people well as long as they live. The doctor should have instructions in interpersonal relations, the social realities of the area where he/she proposes to practise later, other alternative systems of medicine being practiced in the area, as also the religious and cultural beliefs of the patients. Intense training in bedside methods of diagnosis and management are to be stressed, technology being given very limited role. Clinical research methodologies should be thoroughly understood by these doctors as most of the milestone studies were done by family doctors practicing bedside medicine and using their curiosity being organized properly with logical scepticism.
Nutrition and exercise physiology must also be taught in detail. Spirituality, not religion, in its true form should be taught. Spirituality is the same in every religion-sharing and caring, its role in healing has to be stressed in this course. Many studies recently have proved that spirituality does help in disease set up. The new science of CHAOS and fractals using non-linear mathematics should be a part of the curriculum although detailed instructions in this area might be beyond the reach of most medical graduates. This latter is very essential as time evolution in a dynamic system like the human body does not depend on reductionist rules. The time evolution follows the holistic laws of uncertainty. A touch of quantum physics could be taught for the doctor to understand the sub-atomic world and thereby understand the role played by human consciousness in illness and healing. Yoga and meditation should be a part of this course.
Elementary knowledge of statistics and research methodologies is a must for the family doctor to be able to critically look at published data as also to design his/her personal studies of problems in their practice.
Just as fashions change in society and many a time the old fashion becomes the most modern, family medicine, the foundation of the medical consultation, the coming together of two human beings-the patient and the doctor could be the best institution for the sick. This needs to be quickly revived. It is that foundation, which developed into the first “clinic” and later developed into hospitals of modern era. The latter hi-tech five-star hospital care has gone beyond the reach of most people in society. Hence, there is an urgent need to re-invent that sacred doctor-patient relationship which is the basis of the placebo effect, the shot in the arm for the human immune repair mechanism in all disease conditions. The kingpin in the game is the first contact doctor, the family physician. He needs to be re-equipped for his changing role in the present set up, having been born again as a specialist in his own right. He is the true doctor that “cures rarely, comforts mostly, but consoles always.” The earlier it is done the better for mankind. This is not the most celebrated specialty today, though.
“No less in war as elsewhere, the most beautiful and most virtuous deeds are not always the most celebrated ones.”
(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS. He is also Editor-in-Chief of the Journal of the Science of Healing Outcomes, Chairman of the State Health Society's Expert Committee, Govt of Bihar, Patna. He is former Vice Chancellor of Manipal University at Mangalore and former professor for Cardiology of the Middlesex Hospital Medical School, University of London.)
National Consumer Disputes Redressal Commission (NCDRC) has found that Sahara India’s books are in such as mess that it did not record properly a particular loan given, repayment and accounting thereof. It then tried to pass on the blame to the complainant
The National Consumer Disputes Redressal Commission (NCDRC) directed Sahara India to pay Rs25,000 to its investor as compensation and deposit Rs25,000 in the Consumer Welfare Fund in a case that showed how shoddy Sahara’s accounting is.
On 31 March 2003, Orissa-based Jatakishore Das invested Rs1 lakh in Sahara Swarna Yojana Scheme Certificate. This was a 10-year scheme. However, Das took a loan of Rs80,000 against his investment certificate from Sahara for medical treatment. On 28 December 2006, Das repaid the loan of Rs80,000 along with an interest of Rs1,289.
The branch manager at Sahara India Commercial Corp's office in Deogarh recorded the repayment of loan and interest in Das' passbook-cum-certificate. The same however was not entered into the company's accounts. When Das came to know about this, he visited Sahara's office for about 20 times, but the company refused to make any changes and continued to show Rs80,000 as outstanding loan against his name.
In its submission before the District Consumer Disputes Redressal Forum at Deogarh, the Subrato Roy group company stated that, "Sahara India Parivar is a financial institution to the creditors/borrowers to the customers undertaken by the Reserve Bank of India (RBI). Further, it is admitted that the petitioner/opposite party has introduced a scheme ‘Sahara Swarna Yojana’ for the benefit of the customer subject to payment of dues as per the terms and conditions provided under the scheme."
"The endorsement made by the then Branch Manager of Sahara India, Deogarh Branch regarding clearance of loan amount is unknown to the present opposite party (new branch manager). No such documents show in the official records that the respondent (Das) has cleared up the loan amount. The endorsement made in the passbook of the respondent is not clear nor does it bear any meaning. There is no such provision provided under that scheme to clear up the loan amount by way of putting such type of endorsement made in the pass book. The claim of the respondent is fictitious and frivolous. Therefore, the opposite party is not in any way liable for the same," Sahara claimed.
The District Consumer Forum, however, said, the said passbook-cum-certificate bears endorsement to the effect that a sum of Rs81,287. "The endorsement bears the official seal of the opposite party along with the signature of the Branch Manager, nor have they averred that the endorsement is a forged one. In the aforesaid circumstances, it can safely be concluded that the endorsement of the pass book has been made by the then Branch Manager of the opposite parties (OPs-Sahara) after the receipt of the loan amount along with the interest. The OPs have claimed that is was not according to the proper procedure. It is not expected that all should be aware of the procedure practice by all the financial institution. An investor is expected to believe the Branch head of the Institution and thus the complainant has made no mistake in believing the Branch Manager of the OPs," the Forum said.
It then directed Sahara India "to reflect the payment made by the respondent in the loan account and to pay Rs10,000 towards the compensation and Rs1,000 towards the litigation expenses within one month."
Aggrieved by the decision of the District Forum, Sahara India filed an appeal before the State Commission. Sahara also filed an application for filing additional evidence. “That it is respectfully stated that subsequently (after the order passed by the District Forum) the petitioner invented the payment advice of loan bearing no. BLLE 11020459 dated 9 May 2006 from the office where it has been found that on 11 May 2006 the claimant (respondent herein) has taken a loan of Rs1 lakh vide cheque no 882974 dated 11 May 2006,” the company said in its miscellaneous application.
On 15 January 2013, the State Commission while dismissing the miscellaneous application recorded that “on the contrary learned counsel for the opposite party-loanee (Das) contents that in their written version the petitioner who was the opposite party before the District Forum admitted that the present opposite party – loanee (complainant before the District Forum) took Rs80,000 as loan. So once, it has been so admitted, the document in question should not be taken as additional evidence. Moreover, the signature found in the said documents does not tally with the admitted signature of the opposite party – loanee."
"Considering the rival submissions of the parties, we are of the view that since the petitioner admitted in the written version before the District Forum that the opposite party – loanee took Rs80,000 as loan and in fact the signature said to be that of the opposite party – loanee as found in the documents sought to be admitted as additional evidence does not tally with his admitted signature and further, since it appears improbable that while putting his signature a person would omit some alphabets of his first name which has been found in the so called signature of the opposite party – loanee and those alphabets have been written below his signature, the document should not be admitted as additional evidence," the State Commission said.
Later, while upholding the order of the District Consumer Forum, the State Commission said that "The innocent customer should not suffer for the illegality/ irregularity committed by the agent that too not less than a Branch Manager of the appellant company (Sahara). So there is deficiency of service on the part of the appellants in not reflecting the repayment of the loan amount in the loan account/ledger of the respondent. The amount awarded towards compensation and litigation expenses is also not exorbitant."
Sahara India then filed a revision petition before the National Commission. A Bench of Justice VB Gupta and Rekha Gupta, said, "...it is worthwhile mentioning that if the respondent (Das) had deposited the loan amount he would have received a payment receipt. In the absence of any ‘payment receipt’ both the District Forum and the State Commission committed an error of relying solely on an alleged endorsement made by the then Branch Manager."
"The State Commission should have taken the additional evidence on record and remitted the matter back to the District Forum for fresh consideration. The first appellate court fell into an error of adjudging the genuineness of the document itself when it could have avoided the same by referring the document in question to a handwriting expert," the Bench said.
The NCDRC stated, "The State Commission failed to appreciate the fact that the respondent has not repaid the loan amount and thus the same was not reflected in his account statement. It is humbly pointed out that in all financial sectors, whenever any kind of payment is made such a payment corresponds to a payment receipt. In the present case the absence of such payment receipts shows to proof that such payment was never made by the respondent herein."
"The State Commission failed to appreciate that pass book of an account holder is not a conclusive evidence for determination of balance in the account of the account holder. The correct balance is to be determined from the ledger and not from the pass book. Furthermore, it is well settled principle in banking law that the pass book cannot be called conclusive proof of any payment as the same is always in the custody of the account holder and entries made therein are capable of being tampered with, thus entries made in the pass book cannot be called as conclusive proof of any payment," it added.
During the hearing, counsel for Sahara India stated that as per the policy of the company, the pass book cannot be used for the purpose of acknowledging the repayment of loans.
The Bench, after a scrutiny of the document, however, found that the said document was not only a pass book but pass book-cum- certificate. Some of the important instructions to the applicant as printed in the passbook read as under: “After paying the monthly instalment please tender the pass book- cum-certificate to the Branch office for the purpose of updation. Please verify the entries in the pass-book-cum-certificate with receipt issued by the company and in case of any discrepancy please report the same to the branch office immediately."
The NCDRC also noted that all the entries entered in the passbook-cum-certificated were endorsed by the concerned official. "Similarly receipts towards repayment of loan of Rs80,000 and interest of Rs1,289 has also been recorded in the pass book-cum-certificate and signed by the scheme officer with his code no. 06641-226081.
Sahara India further stated that the pass book of the account holder is not conclusive evidence for determination of balance in the account of the account holder. The correct balance is to be determined from the ledger and not from the pass book. "Here it should be appreciated that the individual depositing any amount in a bank or a financial institution or any with other body can only ensure that entry is made in the pass book given to him or take formal receipt if given. He cannot ensure that the thereafter necessary entries are made in the ledger and other related accounts, the Bench said.
Earlier in the miscellaneous application Sahara India admitted that they had filed the written statement before the District Forum to avoid delay and wherein it has been stated that the claimant has obtained loan of Rs80,000/- and that subsequently “the petitioner (Sahara) invented the payment advice of loan bearing no. BLLE11020459 dated 9 May 2006 from the office where it has been found that on 11 May 2006 the claimant (Das) has taken a loan of Rs1 lakh vide cheque no.882974 dated 11 March 2006”.
Dismissing the application, the State Commission in its order on 15 January 2013, had stated, “Considering the rival submissions of the parties, we are of the view that since the petitioner (Sahara) admitted in the written version before the District Forum that the opposite party – loanee (Das) took Rs80,000 as loan and in fact the signature said to be that of the opposite party – loanee as found in the documents sought to be admitted as additional evidence does not tally with his admitted signature and further since it appears improbable that while putting his signature a person would omit some alphabets of his first name which has been found in the so called signature of the opposite party – loanee and those alphabets have been written below his signature, the document should not be admitted as additional evidence”.
In its judgement on 7 May 2013, the NCDRC bench said, "It would be quite apparent that the petitioner company (Sahara) has not been zealously and scrupulously following any prescribed system for accounting or maintenance of accounts. They have chosen to distance themselves and disown the entries made in the said pass book-cum-certificate and signed by the Branch Manager/scheme officer. They have sought to cover up their lapses with regard to amount of loan given, repayment thereof by the respondent and accounting thereof behaving in a most irresponsible manner and trying to pass on the blame to the respondent for not having produced a receipt to validate the entry in the passbook-cum-certificate. If they had indeed been keeping their accounts accurate they would not need to plead ignorance of the entries regarding respondent’s loan in the pass book-cum-certificate due to lack of corresponding entry in the ledger book of the petitioner."
"Instead of instituting an enquiry against the then Branch Manager of Deogarh Branch to ascertain the exact circumstances of the case and enquire from the then Manager as to why he appended his signature on the pass book-cum-certificate in receipt of Rs81,287, they (Sahara) have sought to penalise the respondent (Das). There is no affidavit on record from the then Branch Manager with regard to the facts of the case. Even the written statement contains the verification of Bipin Chandra Patnaik, presently working as the Branch Manager, Sahara India Pariwar, Deogarh. The affidavit attached to the revision petition has also been signed by Bipin Chandra Patnaik, Junior Executive."
"It is indeed a sad state of affairs where the petitioner was taking money for the scheme launched by them for the benefit of the customers and they failed to put in place a proper accounting system to support this scheme. They have thereafter failed to order an enquiry into the actions of their official for failing to record the exact amount of loan, repayment of the same, updating of records and following a system for ensuring accountability and transparency with regard to amounts collected from the public and held in trust," the Bench said.
While upholding the decision of the State Commission, the NCDRC asked Sahara India to pay a cost of Rs50,000. It directed the company to pay Rs25,000 to Das directly by way of demand draft and to deposit the balance amount of Rs25,000/- by way of demand draft in the name of ‘Consumer Welfare Fund’ as per Rule 10 A of Consumer Protection Rules, 1987, within four weeks.
The central bank would shortly come out with its clarifications on issuing licences for more private sector banks
The Reserve Bank of India (RBI) has received queries from different individuals and entities on various aspects of 'guidelines for Licensing of New Banks in the Private Sector' issued on 22nd February and would soon come out with its clarifications.
Minister of State for Finance Namo Narain Meena, in a written reply to the Rajya Sabha, said, "RBI is currently examining the queries, and clarifications on the same will be placed on the RBI's website shortly."
The minister said the RBI has reported it has not received any application for opening of new banks till date.
To promote financial inclusion and further infuse competition in the banking sector, the RBI had issued the guidelines and invited applications from public and private sector entities for setting up banks by 1 July 2013.
Later in March, RBI asked the interested parties to seek clarifications they might have on the issue, by 10th April.