‘Medicine is a humbling profession’

Shiv Kumar Sarin became a gastroenterologist at a time when this domain of medicine was relatively new in India. That he took to it in right earnest is evident from the fact that he has devoted 45 years of his life to it, while going on to be counted among the country’s top specialists in liver diseases.

A Padma Bhushan awardee and recipient of the Shanti Swarup Bhatnagar prize, Dr Sarin is also a translational scientist, a public-health expert and a lifelong researcher (in 2010, he set up the New Delhi-based Institute of Liver and Biliary Sciences, a superspeciality hospital that prioritises world class care and research).

Dr Sarin, who has served as chairman of the board of governors of the Medical Council of India — now known as the National Medical Commission — talks to Christabelle Noronha about the medical profession’s need in India for digitalisation, decentralised point-of-care and a healing of deteriorating doctor-patient relations.

You specialised in gastroenterology and then in liver diseases. What made you choose these two domains?

I joined the field of gastroenterology, back in 1978, when it was new and exciting; at that time most aspiring doctors were considering cardiology or neurology. After my training at the All India Institute of Medical Sciences, I chose liver diseases partly because of my training and the chance to work with people who were experts in the subject, and partly because I saw opportunity in what was a nascent discipline. I was privileged to be an early entrant in the field.

What has changed, in the Indian context, in gastrointestinal and liver disorders and their treatment procedures and protocols in the years since you became a doctor?

Since 1981, when I began to specialise in gastroenterology, a lot has changed in our understanding, diagnostic approaches and treatment protocols. In India we used to be concerned about tropical gastroenterology and believed that Indians have diseases that are different from those prevalent in the rest of the world because we live and eat differently. We have realised over time that this is not so. We have similar challenges and similar disease outcomes. Indians have a shorter life span, which means gastrointestinal diseases may occur earlier in us or manifest as more severe.

The spectrum in liver disorders has changed markedly. About four decades ago, up to 60% of liver cirrhosis cases were caused by hepatitis B. Over the years hepatitis B cases have reduced and been replaced by excessive alcohol consumption. At the Institute of Liver and Biliary Sciences [ILBS], almost 50% of admissions are for alcohol-related liver diseases and a majority of them require liver transplantation. A fair number of these patients are young, with obese or diabetic parents. The second major change has occurred because of fatty liver diseases. One in three Indians has a fatty liver problem.

Specialised medical care is a backbreaking burden for a vast majority of Indians, given the shortage of government facilities and the consequent dependence on private sector hospitals. How best can we, as a nation, ease this burden?

This is an important question. We spend more and more on both government and private-sector facilities, and then some more for specialised care. We can easily reduce this burden through policy change and by setting up digital health units. I don’t have to go and see every single liver patient; I can empower thousands of doctors to be as good, or even better, than me. Where is that ecosystem to decentralise point-of-care treatment by doctors, nurses and physicians? Furthermore, I strongly believe in preventive healthcare; in making every citizen of India responsible for his or her health.

We need doctors who can do different things. The way it is today, a neurosurgeon in India can only do neurosurgery; he can’t work in a design factory and build a device or a valve.”

The number of organ transplants in India remains miniscule despite plenty of efforts. What can be done to change this?

I can talk about liver transplants. We need 250,000 liver transplants a year in India, but we perform not more than 4,000-5,000 such transplants a year. That caters to just 1-2% of needy patients; the rest either die or continue to suffer. To get more deceased donors, which is the trend all over the world, we must change people’s mindsets and instil in them a desire to donate, a desire to have their DNA become immortal.

Somehow, in India living donor programmes have overtaken cadaver or deceased donor programmes. This is partly driven by the fraternity of surgeons and physicians and partly because our mindset has not changed. Every Indian citizen should necessarily say, “I will donate my organs”. In Spain there is an ‘opt out’ option for organ donors to choose not to donate after death; in India we need an ‘opt in’ option. We must also simplify the rules for road accident victims and every emergency or trauma care room should adjoin the organ donation centre.

As someone who was an outstanding student and teacher, what do you make of the state of medical education in India — the struggle to secure a seat, the quality of tutoring, the fee structure, the lack of colleges. The welter of woes seems endless…

Medical education in India has moved very slowly. The fact that two million students apply for 100,000 undergraduate seats means there are many more who want to become doctors. Since we do need more doctors, we should provide for them. Long ago the United States had 24,000 applicants for 30,000 seats at the undergraduate level, so everyone could study medicine, and there were 6,000 seats to spare for foreigners. We don’t have enough seats for even our own people. The first thing to do is increase the number of seats to correspond to a country of our size.

The quality of education can be enforced with the introduction of the National Eligibility cum Entrance Test, where eligibility is to be decided on a percentile basis. In recent times this has been dropping. The quality of tutoring, to me, is quite important, and a good teacher can train a large number of students. The bottom line remains: if your ‘raw material’ is good, your end product will be good.

Students struggle because we have a pyramid system. Everyone who is an undergraduate wants to become a postgraduate. In 2010 we created a ‘rocket model’ by which if you have 50,000 undergraduate seats then you must have the same number of postgraduate seats, and maybe another 10,000 for super specialists. But that has turned into a pyramid today, with 100,000 undergraduates and only one out of four-five of those becoming postgraduates. We must have an equal number of undergraduate and postgraduate seats with additional seats for super specialists.

‘Medicine is a humbling profession’

We need doctors who can do different things. The way it is today, a neurosurgeon in India can only do neurosurgery; he can’t work in a design factory and build a device or a valve. In my time at the Medical Council of India we had proposed six months of offshore training and work, where a medical student could work in engineering, management or some industry to learn different things. So in three years of specialised training, six months of offshore training could produce a different breed of doctors.

The third part of my medical education philosophy is to create hybrids. Our doctors must know many other things besides medicine. A medical professional should also know biotechnology and artificial intelligence. We at the National Academy of Medical Sciences are putting together a committee to rethink the current medical education model in India, its quality and future directions.

You were associated for a short period with the Medical Council of India (MCI), which has now been replaced by the National Medical Commission (NMC). Has that made a difference? Also, has there been progress on the reforms you advocated when you were chairman of the MCI’s board of governors?  

I had the privilege of working with MCI twice, first in 2010-11 and then again in 2015-16. In the first stint we developed what was called ‘vision 2015’, which was put together by 200 of India’s best brains, working every weekend. As for the change to NMC, MCI had faced some challenges due to partisan interests. NMC is structured in such a way as to have both a chairman and presidents; it is yet to be seen how the synergy between them will be.

One thing is clear: the profession must look after itself. If the government looks after the profession, things will be different. People in the profession should be aware of what their compatriots in America or Britain are doing and be able to tell whether we are doing better work than them, or whether we’re not quite there yet. I think the profession should regulate, scrutinise, evaluate, improvise and improve by itself; the government should just be a facilitator.

When it comes to medical research, how far has the country progressed in the years that you have been in the field? How can we accomplish more?

For me research is religion, but research is taking a back seat today; if you can’t ask good questions, you will never learn. India is not product-driven. We have descriptive science, but we must be product-driven, which will enable healthcare professionals to treat patients in an inexpensive manner.

Second, the ability of students to ask questions of their teachers has reduced; students lack initiative when conducting research. Teachers are also doing less research because they don’t get any incentives. In the United States you get paid to be a clinician or a researcher. You get more money — about one-and-a-half times more or double the salary — if you are both. We don’t offer any such incentives in this country.

In America a medical professional may start a company and declare that there is no conflict of interest [between his work and what he is selling] and that would be acceptable. In a similar situation in India, the government or nodal medical agency would always suspect some nexus between the doctor and his bid for commercialisation.

There has been a lot of debate around generic vs branded drugs following the NMC’s updated ethics code for Indian doctors. What’s your view on the code itself and the heartburn it appears to have caused, particularly in the medical fraternity?

My view is clear: the government must set up a committee, reliable and transparent, to certify that a generic drug is as effective as a branded one. If the generic drug passes the same tests as the branded one — and not just in pharmacology or formulation, but in efficacy — only then can we say it’s not necessary to go for branded drugs.

Brands have value because they have been tested. I’m sure generics are also tested, but perhaps not as vigorously. Hence I would agree with people who say use the best drug available if you are unwell.

The relationship that doctors and patients share is no longer what it used to be. Is medicine, as a profession, in need of a booster shot, given the growing trust deficit between doctors and patients?

For me research is religion, but research is taking a back seat today; if you can’t ask good questions, you will never learn ... the ability of students to ask questions of their teachers has reduced.”

Patients want quick answers and a rapid response, as if they are ordering fast food. That doesn’t happen. They have high expectations and half-baked knowledge, which is dangerous. Doctors, who are under great pressure at work, forget that compassion is more important than medication. We may not be able to cure everybody, but we can at least soothe their (and their relatives’) feelings.

That comes from training. You can learn surgery in three years but it may take you 30 years to learn when not to cut. If relations have worsened and patients have less faith in their doctors, I think we need to reboot ourselves. As doctors, we need to ask ourselves what more we should do. The white coat symbolises a person with ethical values. But since many doctors no longer wear the white coat, perhaps they are not mindful of this.

Doctors and other medical professionals are forever stressed, and probably more so in India. How have you coped with such pressure and what would you advise those in the field looking to keep a level head?

I was very lucky to be born in a family where frugality was the way of life. And second, the importance of having a healthy body and getting a good night’s sleep. I am fortunate that I have rarely been stressed, except when I have tried and tried and lost a patient. I have moved on from such situations by telling myself that maybe God has given me an experience to learn from. Medicine is a most humbling profession. We never say, “I treated.” We say, “God treated and I served.”