What's the story about?
This fictionalized account of the travails of MBBS aspirants is meant to highlight the ground realities and draw attention to some of the debilitating shortcomings in the healthcare system in India and the dilemmas facing aspirants and their families. This story is but a snapshot in time, capturing the image resulting from holding up a mirror to the education establishment and private hospitals in India.
Another Attempt
The Struggle for an MBBS Seat
By Sushant Devarachetty
Contents
Title Page
Copyright
Dedication
Acknowledgment
***
Prologue
1. Backdrop
2. Shameem
3. MBBS Entrance: Arms Race
4. All Work and No Play
5. Role of Parents
6. The Rote Method
7. Short-termism
8. Last Lap
9. D-Day(s)
10. Relief
11. Results
12. Shameem’s Family’s Dilemma
13. Shanta’s Overdose of Luck
14. Jobs
15. The Innards
16. Straight Talk
17. The Backlash
18. Shameem’s Family Situation
19. Unluckily Unlucky
20. The Last Straw
21. From Bad to Worse
22. Idealism’s Victim
***
Author
Publishing Workflow
This work, less cover art and EPUB code, is distributed under the Creative Commons License: “Attribution-NonCommercial 4.0 International” (CC BY-NC).
This is a cryptic copyright; to view the copyright page, click here.
FIRST EDITION | ONLINE EDITION: OCTOBER 2016
While this is a work of fiction, the theme derives from the way the healthcare system functions in India. The characters, while being fictional, hopefully typify some of the MBBS aspirants in India; in this sense, the standard disavowal of resemblance to people, places, and incidents does not apply: indeed, it is intentional.
Identifier (in lieu of ISBN): another-attempt-sushant-devarachetty-october-2016
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Note: The above links are persistent URLs redirecting via purl.org, a service of the non-profit Internet Archive.
Dedication
For
Thela Kamalamma,
Narsingam Shriyans,
Devarachetty Srithik,
The baby girl our extended family awaits,
and Devarachetty Sabitha Rao.
Acknowledgment
The seed for this story was planted during discussions with my maternal uncle, Thela Venugopal Rao, about the medical education system in India.
Prologue
Two professions dominate the desired career path of most educated Indians: engineering and medicine. There is intense competition to gain admission to the best institutes in both fields. And there ends the similarity. In fact, engineering and medicine are at opposite ends of the spectrum where it concerns the most critical aspect of seeking a career in these domains: the number of seats available at the under-graduate level. Admission into an engineering college is virtually assured to any student so long as the minimum score required to clear the entrance examination is obtained. Unfortunately for MBBS aspirants, the availability of colleges and seats is so constrained that the vast majority know beforehand that they are waging a losing battle.
This fictionalized account of the travails of MBBS aspirants is meant to highlight the ground realities and draw attention to some of the debilitating shortcomings in the healthcare system in India and the dilemmas facing aspirants and their families. This story is but a snapshot in time, capturing the image resulting from holding up a mirror to the education establishment and private hospitals in India. As a tribute to MBBS aspirants, it gives me pleasure to publish this novella under the liberal Creative Commons License: “Attribution-NonCommercial 4.0 International” (CC BY-NC).
The cover art, designed by Jigyasa Rangeen, captures the crux of the situation: money and medicine are entwined in an illicit relationship, one that is at the heart of the problems besetting the healthcare system of this great nation.
Backdrop
She was my best friend. Our friendship began within a few weeks of meeting at college while studying intermediate (post-secondary school education). What started with the two of us soon grew into a group of five classmates. We remain thick pals despite each of us going on a different path after those two years of studying together. Of course, we hoped and dreamt we would get admitted to the same medical college and spend another five years together. Now, that was one happy dream; only, it remained so. Each of us was starry eyed and while we shared many hopes and dreams, each of us also had our personal aspirations.
Shanta was a brat - her family had royal lineage and was awash in wealth. They were prominent members of society, be it in politics, business or in the bureaucracy. She chose biology to avoid numbers - anything to do with math was her bane. Given her family’s status, she experienced an unarticulated pressure to achieve something substantial. But she neither had artistic talent nor was interested in politics. Shanta hoped to protect herself behind the exalted social status afforded by the medical profession. However, she had the luxury of avoiding the rat race for MBBS admission. She only needed to cross the basic hurdles of passing the intermediate examination and scoring qualifying marks in the MBBS entrance test: a “management quota” seat was assured. Never mind that it would cost Rs. 30 lakhs or more in the form of “donation”, apart from the Rs. 9 lakhs fee per annum for five years. That was chump change for her folks.
Rama was a geek. No subject was too tough for her. She was the go-to-person for clarifying any doubt and she built this reputation within days of the academic session starting. We envied the effortlessness with which she studied - it appeared as though she was born with a memory chip embedded with all the biology, physics and chemistry we would ever need to study. Rama never had to burn the midnight oil; that was for mere mortals like the rest of us. But she was terribly insecure; it stemmed from her extreme consciousness about her appearance. Having been brought up in a deeply conservative family, Rama found it difficult to adjust to the chaos that our college represented. After all, we had students from all over the place, each with their own world view and personality type. We always protected her; she felt safe in the cocoon we represented. Cracking the MBBS entrance should be a no brainer for Rama.
That brings me to Tara the Great. She was an oddity even amongst the oddballs. It did not help that she was a thoroughbred Sikh with all the characteristic “bindaas” traits you associate with the community. Tara was instrumental in awakening our romantic urges. She could barely wait to reach marriageable age to settle down and start a family. She was consumed by that primary urge. And she seemed to have an overdose of hormones. It was a commendable achievement that she managed to find the time to study despite her many distractions. We soon realized there was no need for any of us to read another gossip mag - Tara would be our news feed.
It’s time to talk about Shameem the Firebrand. God knows where she got her perspective from but she had a radical take on anything remotely contentious. And you would never expect that from her appearance. Many a faculty member misinterpreted her appearance for her personality and some of them were visibly shocked to realize their fallacy. I vividly remember the instance when our Physics lecturer glossed over a topic and asked us to study it in our own time since unscheduled holidays declared by the government skewed the schedule. Shameem took the system to task and the administration instituted a new policy to conduct extra classes to bridge such gaps. We always felt secure with Shameem around, even if we were on edge not knowing how she might respond to provocation.
Now it’s my turn – I’m Martha. If there was one thing that helped me survive the education system, it was my capacity for hard work. Maybe it had to do with the constant awareness of my family’s frugal lifestyle and the urge to break out of the shackles of always being on the brink of poverty. My father made a living driving an auto-rickshaw and my mother worked as a household help. With three children to support, they were always at their wits end to provide us with the bare essentials. However, they were steadfast in their vision to extricate our family from the dumps. And they knew education was the only viable outlet. They scraped and scrounged to provide the best education their meager earnings could afford. This was supplemented by the unrelenting effort we siblings poured into studies. It provided the basis for our parents to approach the school management for fee concessions. I doubt all three of us would have completed education without those concessions. I joined the intermediate college with a single minded determination to study MBBS under the “free-seat” quota. There was no room for error and my family’s hopes were pinned on my performance: as the eldest child, the onus was on me to lead the way.
You must be wondering who was my best friend and why did I mention her in the past tense in the first sentence of my narrative. With a heavy heart, I must tell you it was Shameem. She died a week ago and I’ve barely recovered from the shock when I felt the powerful urge to tell her story. This is a story of our times and unless we understand the pressures which pushed Shameem to the brink there will be many more such innocent lives lost.
Shameem
If there is one word to describe Shameem, that would be Potential. She had that innate ability to dig deep into an issue until she reached the crux. With that firm grip, she could answer any question. Shameem was not interested in peripheral issues - they always had to be meaty topics, stuff to which we usually turn a blind eye and say Chalta-Hai. She hated the chalta-hai attitude. She once said something which effectively distilled her angst - Chalta-hai nahi chalta-hai. Not that she was your typical lakheer-ka-fakir. No, that was not her. She abhorred the way the powers-that-be take you for granted and you reciprocate with a lame chalta-hai. I always wondered if Shameem spent time thinking things through and then assumed a position over time but then it appeared so effortless I suspect it came naturally. Wish I had asked her.
Within a few months of our meeting, it became evident that if there is one person who deserves to become a doctor, that would be Shameem. We could easily imagine her doing her utmost at whatever job she would join and staying true to the Hippocratic Oath and everything society expects of the medical profession. Ah, society. It’s paradoxical that the same social interest that was the fount of her inspiration also took her life. But I’m getting ahead of myself here - we must retrace our steps. We must return to the college days and to our aspirations to crack the MBBS entrance examination.
Shameem had great potential to achieve anything she set her mind to. Those days it seemed obvious that she would easily gain admission into a premier MBBS college. We were quite surprised when she did not qualify for a free seat. In hindsight, it seems to have been due to exam preparation not being her only focus. She was doing so many other things - none of them irrelevant or trivial - so it is not difficult to rationalize her mediocre performance in the exam.
Unlike some students who hanker for a front row seat in class, Shameem preferred to be a back-bencher. When quizzed about her preference, she said something about symbolism: the front benches represented a set of urges which she considered superficial and the best way to express her disdain was to occupy the polar opposite space. This went completely overhead for all of us at that time and while we did not fully understand her perspective, we found ourselves nodding in agreement. Maybe she saw through our pretense on these issues and maybe she also understood why we would not know their significance just yet. She was decidedly mature beyond her age.
Having befriended Shameem, I found myself gravitating to the back benches to meet her during every break. It was but natural to shift next to her from my precious front row seat, which was gleefully taken up by someone else. I was struck by how different the classroom seemed from out back. I started gaining a new perspective on the goings-on in class too. It afforded a telescopic view into the personalities of my classmates. Most notably, I could discern their confidence levels from their behavior during lectures - something as simple as how a student raised her hand to proffer an answer to the lecturer’s question was a reflection of her intentions and motivations.
We had our share of myriad personality types in the class. The most prominent were those firmly in the race for merit ranks. They did anything and everything to catch the lecturer’s attention. Some of these students did have the substance to backup their performances; and there were some who were mere pretenders. But it was difficult to sift the wheat from the chaff during the first year. The pace of the course was such that the baton of merit ranks kept passing between many claimants per subject. Only one or two students were consistent and they obviously had what it takes. This fuzziness cleared up by the end of the first academic year. Everyone had enough of track record for making an informed assessment of their capabilities. I truly enjoyed my time in the last row with Shameem making sharp comments about each pretender. In a way, our location provided objectivity and I greatly benefited from the experience.
MBBS Entrance: Arms Race
To say that we were in a rat race for MBBS admission is to put it mildly. The cold war era “arms-race” metaphor was more appropriate when the extent of competition was scaled up to the national level. After all, we were being equipped with lethal marks-maximizing weapons and not only our college but our state itself had a reputation for cornering the most number of MBBS seats. This aspect is significant enough to pause and ponder. The implication was that the types of weaponry an MBBS aspirant had was contingent upon the quality of the intermediate college or coaching center and not limited to the student’s capability. In this hierarchy of coaching establishments, differentiation was based on the prowess of the faculty. It was an open secret that some of our lecturers were paid Rs. 1 crore per annum. Undoubtedly, these lecturers were masters of their subjects where it concerned the MBBS entrance exam. They were expected to deliver “ranks” to the institute, which in turn served to attract more students when the colleges advertized their results.
The college fee was directly related to its reputation and ours was amongst the highest charged in comparable institutes. Not everyone could afford the fee but most parents who were aware about the arms-race were willing to go to great lengths to admit their child. Some lucky families had enough money and those students were under much lesser pressure to perform. The rest of us were under varying degrees of pressure depending on how much our families were sacrificing to feed the MBBS exam monster.
The vast majority of MBBS aspirants, who could not afford the fee or were based in cities without such colleges, were relegated to the lower rungs of the coaching industry. Undoubtedly, it was an unequal competition. Notwithstanding where you studied up to the 10th standard, the two year intermediate course played a crucial role in determining your future. I felt very lucky to have the best education money could buy - it was a confidence boost. Those days we were too engrossed in our own lives to even think of the plight of students who could not afford access to the premier coaching institutes and colleges. There would surely have been many a capable student who missed gaining admission to an MBBS college solely because of where they completed intermediate education.
Yes, this is pure elitism. While a few meritorious students were admitted to our college for free, the vast majority paid the full fee. Free education for meritorious students was not for charity but to serve the narrow vested interests of the management - to corner as many high ranks as possible. After all, when the advertisements were published, they did not mention how much fee the rank holder paid. They surely acted as a suction pump for channeling the hopes and money of hard working, struggling families. It bordered on the promise of Moksha. It was irresistible.
I can only imagine the frustration of those who could not even think of affording such education. They must have felt like they were in a battlefield equipped with bows and arrows while other students were armed to the teeth with the equivalent of Weapons of Mass Destruction. Imagine fighting a war in which your destruction is assured. Maybe they were willing volunteers for such destruction because it did no bodily harm, only psychological, by shattering their hopes of a better life.
All Work and No Play
Given the significance of those two years and the elaborate trappings of entrance exam preparation, our college schedule was totally lopsided. Classes began at 8am and finished at 7pm, six days a week. That left no time for anything other than travel to or from home and completing homework; many of us squeezed out a few precious hours of additional preparation either by staying up late or by waking early. In fact, many of us were already used to such a schedule right from the 7th standard at school. Most schools had separate batches for students aiming for the MBBS and engineering entrance exams. That served as vaccination for the even more grueling schedule during intermediate.
The most prominent side effect of the academics focused schedule was the complete lack of motivation for extra-curricular activities. You know, stuff “normal” kids are supposed to do growing up. The impact was evident in the high levels of obesity amongst students. True, the lack of adequate playing areas near homes and the growing safety concerns in urban areas contributed to this malaise. However, I feel the main issue was the lack of motivation. And it was practically not possible to have the energy and interest to play after a long and weary day sitting in the classroom.
Does that mean none of us even tried? That was certainly not the case. Tara was always fitness conscious and made it a point to either jog or play basketball near her home early in the morning. That came at the cost of not putting in extra time studying at home. In fact Tara barely studied at home. For her, the day long grind at college was itself too much effort. She made a convincing argument to her parents about why added study time would only result in a burn-out. Tara completely switched off from studies once classes ended for the day. To my mind, she had managed a semblance of balance between studies and everything else in life. No wonder I only have recollections of her being happy and content with no signs of the stress most of us experienced every day.
Shameem was never under schedule related stress either. There were other triggers for her stress levels, as I mentioned previously. This assessment is based on rationalization in hindsight. During the college days, we never realized when Shameem was under stress. She never let it show.
Role of Parents
Our parents did their best to boost our morale. They went to great lengths to minimize the distractions from academics. Most parents did not have the time or knowledge to help with our studies. Even in cases where a parent had passed a similar entrance exam during their time, our system was completely different. Their inability to help with our academics only served to heighten their anxiety. They essentially felt powerless to do anything other than providing administrative and financial support and hoping for the best.
Some parents actively participated in the monthly parent-teacher meetings. They usually used the forum to channel their child’s complaints about an ineffective faculty member. The standard demand was for the faculty to be changed. The management had an equally standard approach to such problems, which basically involved creating a smoke screen by promising to try their best. Once this pattern was established, the number of complaints reduced. If this hopelessness was common in our college, I shudder to think of the plight of students in run-of-the-mill colleges.
The Rote Method
I once visited the Chiclets factory in Hyderabad - it was a popular brand of chewing gum. Like a well oiled machine, each operation meshed with the next step in the process. No machine was idle and Chiclets steadily flowed out the other end. I was told there was no scope for error in the system - if one step was faulty, the entire assembly line would abruptly stop. Every machine was optimized to sync with the previous and next step and this created a steady hum in the factory. We experienced a similar hum at college, just that we were the Chiclets.
While the syllabus for the MBBS entrance was limited to Biology, Physics and Chemistry, a vast expanse of topics were included. Additionally, we had to study English and a second language for the Intermediate Public Examination. The languages were second grade citizens compared to biology, physics, and chemistry. Many of us opted for Sanskrit as a second language solely because it was easy to score high marks.
Given the need to cover biology, physics, and chemistry both in breadth and depth, the curriculum was always jam packed. Each lecture was for 60 minutes and the lecturer raced from one topic to another. We had to be on our toes, sprinting along just to keep pace. A brief lapse of attention meant you were left behind. While we could seek clarifications, there was an implicit expectation to avoid asking “silly” doubts. There was the added peer pressure of not wanting to appear dumb by virtue of your doubts.
Despite the apparently highly competent faculty, not all of them were equal in their teaching abilities. Our chemistry lecturer was not fluent in English and this had a telling effect on his effectiveness. He was very knowledgeable about the subject itself but the lack of communication skills hit us hard. The physics lecturer was at the other extreme. She was both well versed with the subject and had excellent communication skills. In fact, she was equally at ease teaching us in English, Telugu, or Hindi. We thoroughly enjoyed her lectures and greatly benefited from the ease with which she explained concepts.
The combination of the fast paced syllabus and varying faculty quality meant we had to find other means to clarify basic doubts. The college had appointed teaching assistants - they were usually MSc students working part time at our college - but they were under paid and ineffective. Instead, some of our classmates were helpful in clarifying doubts. There were a handful of students who were considered masters in one of the subjects. Rama was one of those - she could clarify a doubt in any subject, even Sanskrit. However, it was not always possible to clarify every doubt from our classmates. A few students went to the extent of joining a coaching center for the subject in which they were weak. A chemistry coaching institute proved to be quite popular and many of those who were tortured by the subject opted for extra coaching.
Irrespective of the challenges in teaching and learning, every aspect of the curriculum was entrance exam oriented, which was based on multiple choice questions. Be it study material issued by the college or the test papers we purchased, they were all presented as multiple choice questions. The exam design meant it did not matter whether we actually understood a concept so long as the correct answer was selected. The combination of these factors led most of us to adopt the rote method of learning. Some of us were experts at mugging up entire test papers just by repeatedly solving the problems. The funny thing is it worked - these students were amongst those who scored the highest. These very same students also paid their obeisance to the likes of Rama when they were stymied by a concept.
In our group, Tara diligently followed the rote method - she thought it best to be practical and in any case she had no additional time for studies beyond college hours. Shanta suffered the chemistry handicap and decided to join the coaching institute; for her, money and logistics were no constraint and she was motivated enough to make the extra effort if it translated into achieving qualifying marks. Rama was our resource person to clarify any doubt, in any subject. We made the most of her patience and knowledge and always had privileged access to her time. I was also affected by the chemistry shortcoming but could not even dream of affording extra coaching - there was no option but to choose the rote method for chemistry. Shameem cared two hoots for the exam format and, by corollary, the rote method. If she did not understand a concept, she applied herself to it until she figured it, no matter the time it took. All of us secretly admired her approach but completely lacked the courage to adopt the method.
In retrospect, our differing approaches to studies in those two years generally continued into our careers. For those of us who became doctors, we still occasionally contact Rama for the challenging cases. Shameem was a reliable alternative to the extent that even Rama had occasion to seek her help - Shameem would deep dive into that topic and get back with the required insights.
Short-termism
During those two years, we were focused solely on the goal of cracking the MBBS entrance exam. We were aware of the exorbitant capitation fees for management quota seats and hoped we could score a merit seat. However, we and our parents were well aware of the level of competition for a merit seat. Students like me did not consider a management quota seat as an option because of our economic situation. Most other parents had factored in the possibility of having to pay the capitation fee. While a few like Shanta could easily afford it, the vast majority knew they would have a struggle at hand if that situation panned out. Invariably, such families based their plans on being able to sell their property.
Owing to the uncertainty of knowing whether and how much capitation fee would be required, there was only so much planning possible. None of us, our parents included, seemed to think about whether it was a worthwhile investment. The status of the medical profession was enough motivation to take a shot. I am now amazed by our myopic thinking since just an MBBS degree is insufficient to build a successful career, success being defined by the earnings. Unlike most professions, the advanced MD degree is essential to join the career rat race. All considered it would take from seven to ten years for the MBBS and MD qualifications.
I don’t recollect hearing from our seniors at the intermediate college or from the faculty about the salaries of doctors. But I doubt any of our families were viewing it as a rational decision from the perspective of economics. A doctor’s qualification meant different things to different students and their families. For some like Shanta, it was a badge to show off; for the likes of Tara, it was yet another job; for the Ramas, it was a means to serve society - they were the rare ones; for Shameem - and only her - it was a means to effect change in society, starting with changing the way the health care industry works; for myself, it was a ray of hope to extricate my family from our dire economic straits.
Last Lap
By January of the second academic year, we were well and truly on the last lap of preparation. The entrance exams would start in April and the Intermediate Public Exam in March. And we had to tackle both demons. Having paid minimal attention to languages and lab work, the lecturers were playing catch-up. We were given indirect hints that lab exams would be “taken care of” and this was in line with what our senior’s already shared about their experience. Nevertheless, we had to make the bare minimum effort required for these subjects and topics. By this time, all of us were primed to perform and we were willing to do what it takes - we were sprinting flat out.
This phase was akin to a litmus test of personality types. Rama was always composed as she was well and truly in command of all the subjects. Shameem was equally composed even though the reason was not the same - she was comfortable with her general approach towards studies, that of focusing on concepts rather than scores. Shanta was still struggling with chemistry and was usually on tenterhooks. Tara’s composure stemmed from realism - for her the attempt for an MBBS seat was just that, an attempt; there was much more to life than being bogged down by one career option. I was extremely nervous at that time because my challenge was to make it to a merit seat and I shuddered to think what might happen if I failed. Most of the students fell into one of these personality types.
The government had changed the MBBS ranking process in the previous academic session. Previously, only the marks in the entrance exam were used as a basis for admission. That was changed to include 25% weightage for the public examination scores. Thus, we had no option but to score high marks in the public examination. Luckily, the public examination is relatively easy when compared to the MBBS entrance exam and most students at my college scored high marks – scores higher than 90% were common. Of course, the same was not true of the lower rung colleges.
With the public examination behind us, there was nothing to distract from the final goal. Each of us went into a cocoon, brushing-up on topics which were strong points and trying desperately to pick up on concepts in weak areas. Classmates who previously helped us understand these concepts now had no time to spare and we knew not to approach them. Regular classes had been stopped and lecturers were available for clarifying doubts. We had mock tests on a daily basis.
D-Day(s)
It was common knowledge that a key determinant of entrance exam results was how the student performed on exam day. In most cases, this was multiple days since we appeared for at least four entrance exams conducted by different university systems. Despite the increased stress levels, the exposure to a grueling routine at college and the repeated mock tests prepared us for this scenario. I recollect meeting students from other colleges with lesser rigor who found this phase extremely challenging. Some of them were visibly shaking in their seats when the test booklets were being distributed. Parents waiting outside were equally tense - all their hopes and efforts were also being put to the test.
There was a stark contrast in how students and their parents behaved prior to a test as compared to after a test. Pre-test, everyone was ensconced in their cocoon and avoided any unnecessary conversation. Once we emerged from the exam room and after the furtive enquiries about our performance, people visibly relaxed and were more open to banter. We had a fair idea how we fared and this was clearly visible from our behavior when we exited. Those who may have performed below expectations left the venue in a hurry while the others hung around the venue for some time.
Barring exceptions like Rama who exuded confidence for every exam, most of us suffered initial shocks as we adjusted to the exam-day pressures. We quickly adapted after the first exam and gradually gained confidence in our approach. Still, we waited with bated breath for all the exams to be completed. If anyone would have asked us whether we would repeat the performance in case we didn’t get admitted that year, I suppose the unanimous reply would have been NO. We desperately wanted to break free of the shackles of slavery we experienced in the education system.
Relief
After the last entrance exam, our group decided to meet and celebrate. The results would be declared after a few weeks and the intervening time was a great opportunity to let off steam. We met at a bakery near the college campus and had great fun talking about the past two years.
Tara had already planned to apply to colleges offering regular graduation courses and this was quite in line with her pragmatism. She later revealed that she knew she would not be ranked high enough for a merit seat and her family had decided it was not worth paying the capitation fee, even though they could afford the amount with some difficulty. The rest of us had our hopes pinned on the results and dared not think of an alternative plan. Even our parents were keeping their fingers crossed. Shameem was at the other extreme - she was prepared to give another attempt in case she did not get a merit seat, even though her parents were hopeful about managing the capitation fee. Again, this was just like her - for Shameem, the capitation fee represented an evil in the system. As usual, we barely understood her perspective.
Results
Once the results began trickling in, we realized the extent of competition. Except for students like Rama, who scored good ranks in most of the entrance exams, most of us were ranked much lower than our expectations. Of course, we were still eligible for admission but in most cases it was difficult to estimate our chances prior to the admission counseling sessions. Shanta was unaffected by these uncertainties because she had qualified in the state entrance and her parents were already in conversation with select colleges for a management quota seat.
Once the counseling sessions began, we started hearing about the status of our classmates. As she had anticipated, Tara did not rank high enough for a merit seat and wasted no time in joining a regular college. Rama was offered admission in all the MBBS colleges where she applied and was in the envious position of being able to pick and choose. I was lucky to cross the merit seat threshold and was ecstatic.
Shameem’s rank left her as a borderline case for a merit seat and this surprised everyone. Her performance was certainly below potential. Oddly, Shameem seemed the least perturbed. When I quizzed her about this reaction, she said there was no harm in making another attempt. With no distractions inherent in the college environment, she would be able to focus on exam preparation. She felt that it was important to place the extra year of preparation in perspective - MBBS and MD would require at least seven years and an additional year would be inconsequential. Her argument seemed logically sound. It made me think about how we end up creating unnecessary pressure on ourselves and ignore the control we have over important life changing decisions.
Frankly, there was no particular rush to join any random college when a student had the potential to score a much better rank. This was especially true considering the weightage given to the alma-mater during job interviews. Oddly, literally no other student or parent viewed the situation from this perspective. They were all blinded by the race for admission, even if it came with a hefty price tag in the form of a capitation fee. Eventually, those who did not gain admission confronted the “another attempt” decision. Only a few were prepared to sacrifice one more year and make the effort required.
Shameem's Family's Dilemma
While Shameem was clear about making another attempt, her family thought otherwise. They felt sacrificing one year was not worth it since a merit seat was not guaranteed. During the admission counseling process, they gained a clear understanding of the extent of competition, especially for merit seats. While interacting with other students and parents, they realized that even the best students were not guaranteed a high enough score to secure a merit seat. Apart from conversations with MBBS college management, faculty, other parents and students, Shameem’s father read almost every news article about MBBS admission he could find online. He was convinced that notwithstanding the intelligence and extent of hard work expended by a student, there was absolutely no guarantee of scoring a merit seat. At best, it was a gamble, at worst it was foolhardiness since the capitation fee was increasing every year. He was worried about the similar situation repeating next year and thought it best to acknowledge the ground realities and admit Shameeem in the management seat quota.
The situation was further complicated by Shameem’s family situation. Her younger brother would be appearing for engineering entrance exams next year and there was no guarantee her brother would secure a merit seat. Their expenditure on education would be unmanageable if both children’s admission fees were to be paid simultaneously. Her parents felt the only way to deal with the uncertainty was by admitting Shameem this year as it would give them the visibility to plan since her fee would be fixed. Her parents were also burdened by Shameem’s youngest sister’s condition - she was born with a congenital ailment, Hypoplastic Left Heart Syndrome. Apart from the constant worry about her health, they also had recurring expenditure for her treatment.
When Shameem got to know of her parents’ agenda, she went ballistic. She took everyone to task for not discussing their plans. Her parents gave a patient hearing and allowed her to vent her anger. When she calmed down, they patiently explained their concern for her well being and their constraints. Shameem was torn between her urge to stay true to her ideals - in this case, of studying on a merit seat - and her empathy for her parents and their situation. She found herself caving in to their imploration and kept cursing herself for getting them into this situation. If only she had not been swayed by her idealism during the college days, she would have easily scored a merit seat. Shameem wondered whether she should never have wanted to become a doctor in the first place; life would have comprised of simpler decisions for everyone involved.
When she failed to convince her parents, Shameem agreed to defer to their wishes. However, she insisted on repaying the capitation fee once she was employed. Her parents laughed it away but Shameem stood her ground and even threatened to discontinue studying if they did not agree. Realizing the extent of her stubbornness, Shameem’s parents agreed with her plan. They thought it best to avoid any situation which would cause Shameem to deviate from her ambition to study MBBS. They also hoped she would eventually stop insisting on this matter.
Shanta's Overdose of Luck
Shanta’s parents had zeroed in on a reputed MBBS college for admission in management quota. One of her relatives was a local politician and he offered to accompany her father to meet the college management. On the appointed date, her relative was accompanied by other local politicians for the meeting. During the discussions, they were pleasantly surprised when the management offered them a 50% discount on the usual capitation fee.
The irony of Shanta’s admission is symptomatic of a larger malaise in our country. The rich not only have the wherewithal to pay the steep capitation fee but they are also offered concessions by virtue of their political connections. On the other hand, the Tara’s of our country have to choose the path of pragmatism and the Shameem’s the path of sacrifice. I have pondered long and hard about this and am yet to find anything fair in such a system. The vast majority of students grapple with the capitation fee dilemma every year, especially for MBBS admission. The meritorious few are spared.
Jobs
Some experiences in life prove to be reality checks and cause us to review our assumptions. Two such events stood out for us. The first was the MBBS admission counseling process when we realized the extent of competition. Though we had an intuitive idea about the competition, it was not until we experienced it first-hand that we could fully relate to its significance. I think our mental maturity levels got a booster dose in those few weeks. It also helped us realize how sought after MBBS education is in our society.
The second event which proved to be a reality check was when we were being recruited for our first jobs post-MBBS It was quite a sobering experience when we were exposed to the way the health care business quantifies the value of an entry level doctor. Again, while we were aware of the numbers, it was not until we were offered those salaries that we realized its significance. Where we felt relief after the 5 year marathon of MBBS education, we also became acutely aware of the even tougher race to build a “successful” career.
As was the case during admissions, the realities experienced by merit seat holders was quite different from that faced by management quota students. Merit seat holders had the option to choose a career path in line with the ideal of the medical profession being a service to society. In contrast, management seat candidates were in recovery mode: they began angling for the highly paid job opportunities because they had to make up for the high capitation fee. Only the rare student like Shanta did not feel the immediate urge to do so. Of course, just because these students hoped to land the well paying jobs did not mean they were hired. In most cases, they had to compromise and accept much lower salaries than they hoped for.
Shameem was caught in this quandary, what with her family’s increasingly precarious financial situation. Her urge had increased manifold since her family never recovered from the significant dent coughing up the capitation fee made to their finances and assets. They were always cutting corners and being stingy with money in an effort to rebuild their finances. Luckily for her, Shameem was selected by a hospital offering one of the highest salaries. She deserved the pay since her performance during the MBBS course was excellent, having ranked third in the university merit list.
The Innards
We learnt about the healthcare industry’s profit making machinations from our seniors during the MBBS course. Some of the students accepted it at face value and were willing to go with the system. At best, the rare conscientious student from this category hoped to change the system when they reached the stage of being able to establish their own health care facility. A few others planned to offer free consultation to the poor on weekends in an effort to balance out their morally flawed profit focused work-place practices.
The extent of malaise in the health care system is shocking. While the government sector has its share of severe shortcomings, the private sector has devised dubious means of profiting from the ignorance of patients. The most common malpractice is to over-diagnose. This manifests in different ways - from prescribing unnecessary lab tests to asking patients to return for additional unwarranted consultations to prolong the process. The under-hand bribes demanded from and paid by the pharmaceutical and medical equipment industry were another face of this malaise. For instance, a nationally renowned cardiac surgeon once suggested that a medical equipment company pitching him products sponsor his son’s honeymoon!
We were exposed to these innards of the healthcare system soon after we started working. I was highly motivated to use my skills to serve the downtrodden in society and opted for a government job - I was posted to NIMS Hospital in Hyderabad. Like all government hospitals, there was a long waiting list of patients at NIMS. Even patients in need of urgent surgeries had to suffer the ordeal of awaiting their turn because the system was designed on a first-come, first-serve basis and almost all patients were severely ill. I was terribly frustrated at my helplessness - even if a doctor were willing to work overtime, unless a bed was vacant, treatment could not begin. Since most patients arriving at NIMS required surgery or intensive care, the shortfall in hospital beds was an insurmountable bottleneck.
Shameem was exposed to the other end of the spectrum at the premier hospital group which employed her. Firstly, there was rarely a situation of scarcity of beds. The high fee ensured only the wealthy or those who were suitably insured arrived for treatment. In fact, the hospital’s treatment regimen was conducted rather unhurriedly - there was an implicit understanding between the management and staff that the longer a patient stays, the more profitable they would prove. Shameem was unaware that it was actually an explicit understanding between the management and the department heads. Since junior doctors were expected to follow instructions in their departments, they did not need to be specifically co-opted into this nefarious arrangement.
Being unaware of these machinations, Shameem performed her job diligently and prescribed only the essential tests and treatments. Three months after joining, she was summoned by the department head. He bluntly told her that the revenue generated from her patients in the past three months was well below her peer group in the hospital and did not justify her salary. He made sure she saw the linkage between her pay and the revenue she generated. Shameem was taken aback. When she said that such practices were unethical, he abruptly cut her off saying there was nothing unethical about prescribing detailed tests since they were related to the patient’s ailment. He said it was the doctor’s prerogative to decide the type and duration of diagnosis and treatment and the patient did not have a say in the matter.
Shameem decided to seek a meeting with the CEO. During the meeting, she narrated the sequence of events and asked whether this was the hospital’s policy. The CEO circumvented her question by placing the onus on the doctor - they were the best judges of the specifics of the treatment to be given. He asked Shameem whether any patient had complained to her about the duration of treatment or types of tests. She had never encountered such a situation. He pointed out that patients visit the hospital voluntarily and when they were willing to pay for the tests, why should she have a problem? He said some patients derive reassurance from the number of interactions with the doctor and this is akin to visiting a psychologist - not every session results in an improvement of the patient but the overall process results in an outcome, hopefully positive. While his argument seemed logical, Shameem was not convinced. The department head’s rebuke was in stark contrast to the CEO’s explanation.
Shameem called me after work that day and asked for my opinion - was she over reacting? At NIMS, I never came across a case of over diagnosis or artificially prolonged admission of patients. On the contrary, it appeared the system at NIMS was geared to discharge patients in a hurry even when they would have benefited from remaining admitted for a few more days. The choice we faced was between keeping a bed occupied by a patient who had been stabilized and whose recovery was more or less assured versus using the same bed for a patient in dire need of treatment. In our case, it seemed morally justifiable to admit another patient. It was not uncommon for patients whose recovery was incomplete to get admitted in private clinics for further monitoring and treatment. Since their stay would be of limited duration, these patients were willing to bear the financial burden.
Shameem recollected an instance of a Central Government Health Scheme (CGHS) beneficiary being abruptly discharged from her hospital and the family deciding to admit the patient in a nearby clinic to complete the treatment. In this case, the hospital had hit the upper limit of amount they could bill the CGHS - again, this was an implicit understanding between the CGHS and the hospital. The patient was indirectly conveyed this information and advised that the hospital could readmit the patient after a few days but could not bill any more amount for the current phase of treatment. Eventually, that patient’s family brought him back because the condition deteriorated at the clinic and the hospital promptly readmitted the patient on the CGHS’ tab. Owing to the skewed nature of CGHS reimbursement policies, the patient was put to unnecessary hardship.
During that conversation, we realized that the health care delivery system was morally ambiguous and skewed in favor of the providers. Patients and their families were usually at the receiving end, whether it was because of willful exploitation by the provider or by virtue of the unequal bargaining power - after all, patients were literally at the mercy of the doctor for accurate diagnosis. Of course, there was a nascent but growing trend of patients seeking a second opinion as a reassurance. However, in the vast majority of cases, patients and their families unquestioningly followed the doctor’s advice, to the extent of purchasing the prescribed branded medicines even when they were aware of low priced generics. This nexus between pharmacies and hospitals was yet another dimension of the systemic exploitation of patients.
While Shameem felt better at the end of our rather long conversation, both of us were unsettled. Shameem seemed more perturbed than me, possibly because she would face all these scenarios again the next day while my situation at NIMS was quite different. I had the luxury of ignoring these moral grey zones purely because I did not confront them directly on a daily basis.
Straight Talk
One morning I was pleasantly surprised to read a newspaper article which included quotes from Shameem:
An Incurable Malaise
Tourism in our country is largely driven by the domestic tourist. Inbound foreign tourism pales in comparison. I am not referring to recreational tourism, but to medical tourism. This will not come as a surprise if you consider the significantly skewed distribution of health care infrastructure. Tier-1 cities and metros corner most of the capital investment in the health care sector. In turn, this is because the source of investment is the private sector. A for-profit hospital is established for a simple reason – For Profit. They have no financial justification to risk ROI by investing in the hinterland. After all, patients will have no option but to visit cities for treatment.
Despite the profit motive driven growth in the domestic health care industry, the doctor - patient ratio is at a dismal 6:10,000 at the national level. This ratio would be much worse when only tier-2 towns and below are considered. No wonder the health ministry has made one year rural service compulsory for MBBS students.
And this is just the start point for identifying the rot in the health care system. The private health care providers are no paragon of fairness. Patients are increasingly becoming aware of their crassly exploitative practices. Unfortunately, the vast majority of patients are either unaware or feel powerless about this situation. The simplest form of exploitation is to ask a patient to undergo tests whose result is immaterial for diagnosing the ailment. At the other extreme is the asymmetric bargaining power between patients and hospitals - the power equation is such that the doctor/hospital is superior to the patient. Patients usually feel the doctor is doing them a favor by treating them and doctors tend to talk down to patients.
This writer interviewed a few doctors in Hyderabad and the following quotes provide an insight into the system. Names of hospitals have been withheld:
Dr. Nagaraj: “Patients are given all the information they want - I answer all their questions. There is no basis to say they are exploited.”
Dr. Rajesh: “Nobody forces patients to join a particular hospital. Even the insurance providers provide a long list of hospitals where the patient could seek admission under their health insurance policies. Patients have the freedom to pick and choose which doctor to consult. I disagree that patients have no bargaining power.”
Dr. Rashid: “Poor patients know they have no alternative but to visit government hospitals or those established by charitable organizations. Many even rely on quacks out of their superstitious belief systems. Government and charity hospitals have a good reputation with regard to prescribing affordable medicines and only the essential tests. I have no comment about the private hospitals.”
Dr. Thomas: “We always have the patient’s interest uppermost in the mind. There is no question of exploitation. The relationship between a patient and doctor is sacred.”
Dr. Shameem: “The pressures on the private and government hospitals are very different. Government hospitals always have more patients than they can handle and their focus is on discharging patients as soon as possible. Private hospitals do the exact opposite. Because of the high cost, they rarely have full occupancy and the incentive is to keep the patient admitted as long as possible. I feel the owners of private hospitals deliberately resort to such tactics.”
Dr. Shiny: “The reputation of charitable hospitals is clean in this regard. Our staff is highly motivated to serve society and we are above the materialism which drives such practices.”
As you can see, there are a variety of views from the doctors themselves about their industry. Glaringly, there is no consensus of opinion. It is up to you, the reader, to decide which perspective to believe. The slogan Buyer Beware is apt for the domestic health care industry.
The Backlash
I called Shameem to congratulate her immediately after reading the article. She did not receive the call. She called back after an hour. When I congratulated her, she broke down. I was taken aback and asked her what had happened. Shameem said she was reprimanded by the head of department and the CEO for her comments. They said she had no right to speak to the press without prior permission. They even handed her a counseling letter for violating hospital policy on communicating with the press. When she pointed out that even Dr. Thomas had spoken to the same journalist and was quoted in the article, they said he had sought prior permission. Shameem knew this was untrue because the journalist spoke to both of them in the hospital cafeteria one after the other. Thomas had no opportunity to apply for permission to speak to the press. Shameem met Thomas after the counseling but he said he did not want to get involved in the matter anymore. Shameem felt cornered and humiliated.
We met that evening after work. Shameem said she had no motivation to continue at the hospital. She tried to stand her ground and spoke to the HOD and CEO once more that day but they again spoke tersely and asked her to quit the job if she did not want to obey the rules. None of her colleagues were willing to support her and they were all playing it safe now that news about her last conversation with the HOD and CEO was doing the rounds. I reassured Shameem that she would easily get a job in any hospital in the country. There was no reason to worry about the job - she must decide whether it was possible to continue working given the day’s incidents. She was convinced there was no basis to continue and decided to resign the next morning.
Shameem returned to a hostile environment in the hospital the next day. Both staff and colleagues ignored her. When she submitted the resignation letter, it was promptly accepted. She asked that her salary and documents be processed. She was told this would take a few days but she was not an employee of the hospital anymore. While on the one hand she was distraught, Shameem also resolved not to give in to the unfair system. She returned home and worked on her resume to start applying for a job. She was called for interviews beginning the same evening. They asked for references from her last workplace and about the reason she had resigned. When Shameem gave the details, they immediately became hesitant and told her they would get back with the results of the interview. It was as though they were being influenced about her candidature.
In the meantime, I had told our MBBS batch mates about Shameem’s job hunt and the background. Some of them assured to help but many others were unsure if they could help by recommending Shameem for recruitment in their hospital given the circumstances. I contacted an MBBS faculty member, Prof. Charles, who owned a hospital. He immediately recollected Shameem and asked her to contact him, saying there was no reason to be perturbed by the issue surrounding the newspaper article. I promptly contacted Shameem and passed on the contact details. Having been shaken by the reactions of our friends in the medical fraternity, Shameem was relieved that there was finally some hope.
When she met Prof. Charles, he immediately offered her the job. He asked her to put the incidents of the recent past behind her: she was meant to serve patients and that should be the focus. He joked that his hospital had no restriction on speaking to the press and she could invite the journalist to speak to all the staff. A wave of relief washed over Shameem. Prof. Charles was upfront and said he could not match her previous salary; the best he could offer was 50% of what she was earning. Shameem felt grateful for the opportunity and accepted the offer.
Shameem's Family Situation
Shameem wanted to treat me to lunch for helping her navigate the past week’s incidents. We met on Sunday and spent a few hours chatting. Shameem’s younger brother, Abrar, was in the final year of engineering. He did not perform well enough to be admitted to a premier institute and had joined one of the lower ranked colleges. He seemed to have gotten distracted from studies and her family was worried about the company he was keeping. Abrar was increasingly spending time with his friends, even late into the night. When his parents confronted him, he became aggressive. Abrar wanted them to stop interfering in his personal life. Her father was deeply concerned whether Abrar would complete his education. Shameem had told her parents about the dismal campus placements in engineering colleges with many companies attributing the ongoing recession as the reason for curtailing recruitment. She also warned Abrar that unless he mended his ways it would be tough to land a good job. He asked her to mind her own business.
Shameem’s sister, Rabia’s health remained a concern for the family. Even though she was successfully operated for the Hypoplastic Left Heart Syndrome as an infant, Rabia was susceptible to chronic health issues for the rest of her life. Shameem had gone to great lengths to learn about congenital heart defect in general and HLHS in particular during and after the MBBS course. Unfortunately, there was no alternative but for the current treatment regimen. Rabia was an enthusiastic child notwithstanding her condition and the family loved her dearly.
The combination of Abrar’s changing attitude and Rabia’s lifelong condition was weighing on Shameem’s mind. Unless Abrar began contributing to the family, it would become challenging to make ends meet. Even though she was grateful for her new job, Shameem could not ignore the impact of the 50% pay cut. She felt a sense of déjà-vu: just as her idealism during the intermediate college days led to missing a merit seat, it also led to the loss of a lucrative job. Not that Shameem regretted her stance at the previous work place. The money was a motivation to the extent of contributing to her family’s well being and no more. She fervently hoped Abrar would mend his ways and that she would be able to gradually earn more.
Unluckily Unlucky
There are four shades of luck - you could be luckily lucky, luckily unlucky, unluckily lucky or unluckily unlucky. I was luckily lucky - lucky to have parents who knew the value of education and lucky to have what it takes to win a merit seat. Tara was luckily unlucky - though she did not become a doctor, Tara joined a PR firm and has been successful career wise, financially and in matters of the heart. She recently married her boyfriend of two years who happens to be a reputed doctor. Shanta is unluckily lucky - even though she succeeded in becoming a doctor, she chose not to pursue the profession itself. It was just not her calling. Shanta is marrying into a wealthy family which owns a chain of hospitals, though I doubt her qualification had anything to do with the alliance. Shameem, unfortunately, is the epitome of being unluckily unlucky. Personally, she has everything it takes to have a well rounded life. But the complexities of her family situation and the conflict between her idealism and the ground realities combine to create an unfulfilled life. Shameem was contented, it’s just that she deserved much better. She was capable of much more in life.
Her ill luck manifested in another form when Abrar’s college was able to attract only two companies for campus placement. No amount of goading by Shameem and her father pushed him to apply elsewhere in advance. Abrar seemed to have no motivation to work. He whiled away time in inane activities with his degenerate friends. The advancing age of her parents and the complications of her siblings weighed down Shameem’s enthusiasm. I saw her demeanor change during the last 12 months. Her enthusiastic nature was replaced by disillusionment; determination by resignation; optimism by passive-aggressive pessimism. The only thing which spurred her was the job at Prof. Charles’ hospital. They provided genuine service to society and while profitability was important, it was not paramount. Shameem always lit-up describing the satisfaction of her patients when the treatment was successful. She was learning something every day under Prof. Charles’ tutelage. Indeed, I was frequently amazed at the depth of her knowledge even on ailments where I had handled many more cases than Shameem.
The Last Straw
Prof. Charles was in his seventies and his advancing age began telling upon his health, given his grueling work schedule. His family began pressurizing him to retire and enjoy the fruits of his efforts. His children - all doctors - were settled in the USA and in line with the thinking of their peers, had opted for American citizenship. They had no inclination to take over their father’s hospital though they were willing to contribute in an advisory capacity. When word got out, Prof. Charles began receiving offers to buy him out of the hospital. Given the circumstances, he finally acceded to his family’s wishes and agreed to sell the hospital to a hospital chain. They were in expansion mode and were eager to acquire a locally reputed brand name.
Immediately after taking over, the new management began rewriting work-place policies. As a corporate entity, they were driven by the profit motive and Shameem was visibly worried when she began noticing the work culture change. It reminded her of her first job and all her latent fears resurfaced. The hospital’s incentive structure was changed and salaries of the medical staff were increased across the board to bring them on par with the group’s compensation policies. Shameem had mixed feelings about her raise - she was happy to have more money to support her family but she was also wary about the changing expectations at the hospital. For now, she put aside her apprehensions and adopted a wait-and-watch approach.
Everything seemed to move smoothly in the first few months and despite the occasional discomfiting situation she encountered where profiteering superseded patient interest, she was not directly affected. After about 6 months, she started receiving indirect hints about the link between her salary and the revenue her patients generated. It was an all too familiar feeling, one she detested. During his address at a monthly in-house meeting, the group CEO made an oblique reference about the need to balance personal ideologies with ground realities. He emphasized that revenue maximization was the responsibility of every doctor in the hospital.
Shameem chose to ignore that generic admonition. Soon, some patients began demanding to consult only with Shameem even when another doctor’s schedule was open. The management took notice and presently realized the reason was the minimal tests prescribed by Shameem which resulted in lower fees patients paid for similar consultation with two different doctors in the same hospital. Shameem was summoned by the HOD and asked to explain the reason for not complying with their procedure of prescribing tests and diagnosis. Shameem stated that the outcome which mattered was whether the patient recovered and not the number of tests prescribed. She tried to state this calmly but her angst came through and the HOD ended the meeting without further comment. She knew it was not the end of the matter.
Shameem had also developed a reputation for being impossible to bend to the ways of the pharmaceutical sales channel. Medical representatives had already given up on trying to convince her to prescribe their brands in return for a commission. While this approach did not draw any untoward attention during Prof. Charles’ time, the current management took cognizance of her approach.
Her ideological stance meant Shameem was increasingly isolated under the changed ownership. Her colleagues had quickly changed their allegiances and seemed more than pleased to follow the management’s diktats, both implicit and explicit. Shameem used to vent during our increasingly frequent conversations. I advised her to be realistic and to try following at least some of the guidelines else her job would be at risk once again. I was fully aware of her family’s financial needs and advised her not to consider joining a government hospital to avoid such pressures. Her situation warranted a relatively high paying private sector job and it was almost impossible to find a hospital similar to the one Prof. Charles’ managed. Even if she were lucky to find one, a pay cut was inevitable. I had a fair idea of Shameem’s predicament but was equally helpless in helping her find a lasting solution.
From Bad to Worse
One afternoon just as she was starting to have lunch, Shameem received a frantic call from her father. Rabia’s condition had suddenly deteriorated and she was gasping for breath. Shameem immediately dialed the 108 ambulance service and asked her father to bring Rabia to the hospital. She then contacted the hospital’s administrative officer and sought permission to admit her sister under the hospital’s concessionary tariff for employees. She was immediately granted permission and Shameem spoke to the resident cardiologist and explained Rabia’s case. They decided to operate on her if the situation warranted.
In the meantime, Rabia was being shifted into the ambulance. Shameem spoke to the nurse in the ambulance and instructed him about Rabia’s condition and the parameters to be monitored. The ambulance reached the hospital within 30 minutes and Rabia was immediately moved to the ICU. They first stabilized her condition and began diagnostic tests. After studying the reports, the cardiologist recommended immediate surgery. The operation lasted four hours and was successful. Rabia would have to remain in the ICU for a few days after which she would be shifted to a regular ward for further monitoring.
Rabia was discharged after a fortnight’s stay at the hospital. While the operation was timely and helped save her life, it also meant her condition had worsened. She would now require greater care and management. Despite the concessionary fee and the hospital staff not tacking-on unnecessary expenses for consumables during treatment, the operation and post-operative stay in the hospital cost Rs. 7 lakh. After pooling all their savings and investments, Shameem’s family still faced a shortfall of Rs. 1.5 lakh. Shameem had to raise a personal loan from the bank to make up the shortfall. If not for the concession, the bill would have been over Rs. 10 lakh. Shameem’s family felt grateful to the hospital for helping them during the emergency.
Despite Shameem’s relatively limited interaction with the hospital staff in recent months owing to her ideological stance, they were very helpful during Rabia’s hospitalization. Shameem had the opportunity to become familiar with some of her colleagues with whom she only had a passing acquaintance. These interactions proved confusing to Shameem. She was unable to reconcile their behavior with the hard-nosed profit orientation in the normal course. They seemed to be good natured at heart but morphed into compliant personalities when faced with authority figures. Even the HOD and CEO reassured her about Rabia’s treatment when they visited the ICU.
Just prior to her discharge, the HOD met Shameem to enquire about Rabia’s condition. At the end of the conversation, he mentioned that just as the hospital came forth during her family’s exigency, so also Shameem should understand the needs of the organization and contribute her might. Since the hospital took care of its employees, it was good form to reciprocate. And so Shameem began feeling the pressure to fall in line soon after Rabia’s discharge. During their next meeting, the HOD made it a point to remind her of their last conversation, saying he looked forward to a changed approach.
Shameem felt as if she had been gently guided into a well laid trap. She immediately brushed the thought aside because it was obviously due to her hyperactive imagination. She confided that had she known such a situation would result, she might not have brought Rabia to the hospital. But then, she also knew that was wishful thinking - every aspect of Rabia’s treatment during the emergency was effective only because of Shameem’s employment at the hospital. Shameem was trying her best to stop short of accepting she had no choice but to violate her ideological stance. She wistfully envisaged a situation where she could give it all up and not be obliged to surrender to others’ whims.
Idealism's Victim
Shameem felt the vice tightening around her ideals. She could not envisage a life of passive compliance, as if she were an automaton to be steered at will. Such an existence would be absolutely demeaning. Despite her deep reservations, Shameem saw no option but to comply. She reluctantly began prescribing superfluous lab tests to her patients. On the first occasion she did so, the HOD went out of the way to visit her and express his happiness. To Shameem, it was nothing other than a slap in the face.
I noticed Shameem’s personality alter significantly during those days. She became less sure of herself and was not as emphatic about contentious current affairs topics we sometimes discussed. It felt as if she was slowly being deflated. I now realize it was her idealism that was being ripped from her being. I often see Shameem in my dreams - her melancholy eyes are a reflection of the abject sense of powerlessness she must have felt through those weeks of soul searing ego-ripping. When she averted meeting my eyes, I could sense the deep sense of shame she must have felt facing herself. Knowing Shameem over those years, I could clearly see that she was not herself any more. The System had violated her and ruthlessly bent her into submission. It must have been a deeply destabilizing experience. Shameem’s suicide has no other explanation.
Author
I have this story to thank for my affair with writing fiction. What started in August 2014 has turned into a passion. I’ve been fortunate to have a steady flow of story ideas and the time and space to complete them. Having decided to self publish some of my creative writing, I set up this website to distribute the content.
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Copyright
Self published by Sushant Devarachetty in 2016
Text copyright © Sushant Devarachetty, 2014 onwards
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BISAC (2015 Edition): FICTION / Medical. | MEDICAL / General. | MEDICAL / Education & Training. | SELF-HELP / Death, Grief, Bereavement.
Classification: UDC 82-32