Yousuf Raza – Wounded Healthcare Deeper into Big Pharma
AI: Summary ©
The speakers discuss the professionalization of the professional side of medicine, including the importance of avoiding privacy and avoiding confusion. They emphasize the need for a strong emphasis on the clinical side of medicine, which is a social interaction between the patient and the physician. The responsibility of a psychiatrist is crucial, and the power imbalance between the physician and patient is crucial. The speakers stress the importance of clinical trials and evidence-based medicine, and emphasize the need for a clear framework for patient safety and patient outcomes. They also emphasize the importance of building a system for patient safety and the importance of documenting patient responses to drugs.
AI: Summary ©
Thank you everyone for joining us again.
We are very honored to have Professor Murad
Musa here with us again.
We had a session a long time ago,
Azam, in the name of Big Pharma, you
and I.
We tried to talk about it.
Precisely, that's why we're having that again.
Somebody who's been dealing with it and trying
to address that issue for the greater part
of his professional career.
We have the honor of having him with
us.
So, without further ado, Professor Murad Musa Khan.
Sir, Assalam-o-Alaikum.
Sir, as doctors, as psychiatrists, it's very disconcerting.
When we get to know about these things,
and this is something that was discussed with
our team as well, and they're all doctors
and they're like, it's so depressing how convoluted
these interactions with the pharmaceutical companies become and
their involvement and then what is going around
in our profession.
It's very bad for us as professionals.
How do we come to terms with what's
going on?
Well, thank you once again for inviting me.
The topic, pharmaceutical physicians, ethics, pharmaceutical physician
relationship, is a very controversial one.
And it's controversial because whenever professional needs or
commercial needs clash, controversy is always generated.
So, that goes without saying.
So, that's the first point I want to
make.
The second is that it's an issue that
confronts the medical profession everywhere in the world.
It's not just in Pakistan.
Obviously, in countries where you have good, strong,
robust systems, this is addressed very differently from
a society, a country where systems don't exist.
But if they do exist, then systems are
not applied, policies are not applied or implemented.
So, that's the second point.
Third point I want to make, and this
is very important.
The third point is really important.
As psychiatrists, particularly, as psychiatrists, we have to
always look at, like we do in psychiatry,
look at patients' complaints, symptoms in its context.
So, this whole huge field of cultural psychiatry
is based on this premise that when you
see, you've got to see people's problems, their
distress, the symptoms in their cultural background.
Otherwise, you lose meaning of that.
So, with that in mind, it's very important
to look at this issue in context.
I really want to emphasize this point.
And what is the context here that we're
talking about?
It is not simply a question of, a
pharma rep comes to you, he tells you
something about his medicine, gives you some inducements,
gives you a pen, a pad, a calendar,
or he gives you a ticket to go
to a conference or a drug launch.
This is not the issue, simply.
The issue is much wider, and every physician
who is confronted with that has to see
what is the principle at stake.
And in my talks, in my presentations, I
emphasize this very much.
The context is the practice of ethical medicine.
This is the most important thing.
So, the practice of ethical medicine is how
you should really see this issue, because the
pharmaceutical physician relationship is only one issue that
is confronting physicians or the medical profession.
There are many other issues of confidentiality, of
privacy, of exploitation of patients, of how much
fees you charge, and there are many other
ethical issues that confront the medical profession.
And all of these have to be seen
in the context of the practice of ethical
medicine.
Now, for that, we will have to read,
whoever is listening and who is interested, what
are the ethics of the medical profession?
What does it actually mean to do that?
So, I want to set the stage.
There are 3-4 points.
It is very important to see it in
context.
It is very important that it is happening
everywhere.
But in countries, in places where the systems
don't exist, then it becomes even much more
of a problem.
So, I will stop here, and then, you
know, as we proceed, we can unpack what
I mean by the practice of ethical medicine.
So, sir, the intro that you gave us,
does that mean that the psychiatrist who is
becoming a psychiatrist, the supervisor and his training,
because that ethical prescription of medicine, that necessarily
entails that the student who is a PGR,
he or she should have a good sound
knowledge of what he is doing.
Absolutely.
You are absolutely right.
So, in the 5-6 years that we
study medicine, we study the technical side of
medicine very deeply.
What are the diseases, what are the symptoms,
how to investigate them, how to diagnose them,
how to treat them.
But medicine is much more than just this.
Medicine is an interaction between the physician and
the patient.
It's an interaction.
It's a social interaction.
When I say social, I don't mean that
you socialize with the patient, but I mean
that you have a relationship with the patient.
The sanctity of that relationship is very important
to understand.
What is it that brings a patient to
the doctor, a relationship is formed with him,
and what are the elements in that relationship.
Why is it given so much preference from
some other profession?
Why is medicine known as a moral enterprise?
Why is it called a noble profession?
You must have heard this a lot.
I want to serve humanity because it's a
noble profession.
What does it mean to be a noble
profession?
Someone has unpacked it, someone has gone deep
into it.
Think about it, understand its core values.
This is very important.
We don't study the history of medicine.
Why is medicine so different from other professions?
It's not that other professions are not good.
There are professions of teaching, law, theology.
These are all great professions.
But what is medicine?
What does it mean to be a physician?
This is very important.
We falter because we have really not delved
into these things.
In the Pakistani society, every conversation is very
superficial.
In medicine, we are not exposed to these
things in our five years at all.
If someone is interested, they do it, but
not in an organized manner.
That is why it's very important.
You were talking about the supervisor.
The supervisor is also a product of the
same system.
When he practices and sees his trainee, and
sees how the doctor is talking to the
patient, how many patients he is seeing in
his clinic, what kind of medicines he is
writing, the supervisor has also not gone through
all of these exposures.
He may have studied abroad.
He may have been exposed to these things
in England or America.
This is very rare in postgraduates.
I will tell you about it at the
postgraduate level.
Therefore, if the trainee is fortunate enough to
work with the supervisor, he may be exposed
to some of these principles of the practice
of ethical medicine.
Otherwise, he will do exactly the same thing
his supervisor is doing.
He will come into the field and the
profession with the same practices and the same
habits, whether it's polypharmacy, or whether it is
seeing medical reps and prescribing the medicines, or
going on the trips, the free trips that
these people give.
Because in his case, the supervisor has no
problem.
The supervisor will do the right thing.
Why should I not do it?
So it's a vicious cycle that has gone
on.
It is perpetuated through generations.
This is why psychiatry is very important.
You know that psychiatry is not taught in
Pakistani medical schools.
There is no exam for it.
You know that in MBBS, it's not a
certified exam.
And no one really bothers about psychiatry.
Psychiatry does not feature on the radar at
all.
So it's a kind of a neglected speciality.
The patient is already ignoring the patient.
So even if the patient is having side
effects of the medicines, no one bothers about
it.
If something goes wrong in surgery, like there
was a case in Karachi where a cataract
operation was done.
Sahiba had some eye problems.
When she came for post-op, she spoke
to the eye surgeon and her husband.
And it ended up in a scuffle.
I don't know if you saw it or
not.
It was going on a lot on social
media last week.
He hit her.
So this kind of thing will never happen
in psychiatry.
It never happens because psychiatry or psychiatric patients
are completely neglected.
And that's why in a neglected thing, no
matter how many wrong things you do, no
one will notice.
And that is why when I sit in
my clinic, and I see patients coming with
a file full of prescriptions, and I see
the same medicine, two brands of Risperidone are
written on the same prescription.
Bison is written and so is RISP.
One milligram of this and two milligrams of
that.
And these psychiatrists, whether they are MCPS or
FCPS, they are psychiatrists.
They have written it.
And you must have seen it too.
I am not telling you anything new.
But no one will bother about that.
So unlike other fields of medicine, where there
is surgery or there is a cardiac surgeon
or a cardiologist, their mistakes or negligence is
caught because it comes to the fore.
No one does it in psychiatry.
So that is why the responsibility on us
is even more so.
Something that is totally neglected, no one will
take care of that.
It then becomes imperative for psychiatrists, for supervisors,
to be well-trained in these things.
And again, I emphasize, the pharmaceutical physician thing
is only a part of that, not the
only issue that confronts the profession and the
specialty.
Sir, can I ask a follow-up question?
As you said in the beginning, is it
safe to make an argument that a physician
is doing something that is a social action
in the social sphere, or it is serving
a social purpose, being that actor?
Can we say that he is serving or
he is doing his part in a social
responsibility?
What is that responsibility that a physician is
serving?
The responsibility of a physician is very great.
When a patient comes to a doctor, not
only his health, but his life is also
in danger.
Not only his health, but his life may
be at stake.
So when you are dealing with something so
precious, everything that we do in the world
from the time we are born till we
die is to sustain life.
All the hard work, work, study, study, is
to sustain life.
So if that is the ultimate thing, it's
not like a property dealer is dealing with
your house, or your lawyer is dealing with
an issue.
It is the physician who is dealing with
the person's health and life.
That gives it a very special prominence, because
when you do that, there is a huge
power imbalance between the physician and the patient.
The patient is weak.
He needs help.
His life, his health is at stake.
The physician has the knowledge, the expertise, he
has the skills, and he can fix the
patient.
He can help the patient become better.
When there is a power imbalance, the chances
of exploitation or the potential of exploitation is
very huge.
If one person is very strong, and the
other person is very weak, then the strong
person can't do anything to the other person.
Let me give you an example.
A patient comes, whether he is a police
officer or a customs officer, if you have
a case, whether it is a customs case
or a police case, you can use that
person very easily, and he will be more
than happy to oblige you to fix your
case, to deal with your case, to help
you out.
Otherwise, if you were to go and see
him as a normal citizen, you will run
into all sorts of problems.
You can bribe him, you can do this,
you can do that.
So, it is the power that the physician
has, and the health organizations have, that can
exploit the patient.
However, the fundamental thing in medicine, the clinical
decision-making of medicine, it is supposed to
be absolutely objective and impartial, based on the
best available evidence.
The scientific evidence of that time.
There should be no influence of anything.
If I am giving this antibiotic, this analgesic,
it is not because I went to Bangkok
for a drug launch of that company, I
will use this brand, not this one.
It has to be completely impartial, and it
has to be completely objective as far as
possible.
So, this is a fundamental thing, where you
have to do and avoid everything.
You have to exclude everything from that clinical
interaction with the patient.
There should be no influence of anything.
And the decision that you will make for
that, whether to put him on a stand
or send him to a cardiac surgeon, whether
to remove the gallbladder or not mature yet,
whatever decision you make, it is based on
this.
And if you are influenced by external factors,
then your decision-making becomes compromised, and the
patient will suffer.
And in this regard, the whole game of
pharmaceuticals comes because they push you to prescribe
their medicine.
And in that push, the kind of incentives
they give you, the kind of bribe they
give you, I call it bribe, this is
legalized bribery.
It is legalized because they are doing it
directly.
Whether they send you on a trip, or
give you some stuff in your clinic, or
get you a water cooler or air conditioner
on the pretext of patient welfare, all these
things, this is all one aim.
And what is the aim?
The aim is to make a relationship with
the physician so that you can then manipulate
them to prescribe your medicine.
That then increases their sales.
They get the bonus.
And obviously the company makes huge profits.
The physicians get these things easily.
So it's a win-win situation for both.
But the things we forget are two things.
In Pakistan, healthcare is mostly private.
The patient is paying from his pocket.
And the doctor's objective clinical decision-making is
compromised.
So that is why this...
Sir, one argument we get to hear from
doctors is that I am going to write
a brand.
So why not write a brand from where
I get some incentive.
And if I don't take that incentive, it
will go to the company's pocket.
So what's wrong with that?
Because I have to write a brand for
Covino.
Sir, what's wrong with that is...
I will answer the same way again.
If you talk at this level and keep
this argument, the doctor is right.
And that's the end of the argument.
You don't need to discuss anything more.
You have three brands.
You have Vizin, you have Rise, and there
must be something else.
You have Risperidone.
You can write whatever you want.
And if the company favors it, you can
give it to them.
It's as effective.
So the argument just stops there.
You don't have to go beyond that.
However, if you have this background reading, you
understand what the medicine is about.
And that's why I was giving you the
context again and again.
If you have all these things in your
reference, then this makes sense.
How do I choose between these three brands?
Should I let the medical rep come and
tell me?
Or should I make my own inquiries?
Should I take the trouble of looking at...
If it's a Pakistani company, are they following
good manufacturing practices, GMB of the WHO?
What is it?
I mean, of course, doctors won't do that.
But what I'm saying is, one, if you'd
understand what medicine is about, what are the
ethical principles of medicine?
Where are these principles compromised?
And secondly, if you take a little time
to research about medicine, and nowadays you can
get everything online, you can come to your
own decision without having to learn your pharmacology
from a medical rep.
Somebody coming and showing you this glossy brochure,
they're showing their research selectively.
And they say, look, this is better than
this, and this is that.
And they take it to seminars.
They won't take it to a foreigner from
Germany or the U.K. or the U
.S. They'll come and show you an impressive
slide, and say, this is better than this.
Then there's nothing wrong with it.
Or they publish the supplements, BMJ, Lancet, and
NEMJ.
In the supplements, they publish their clinical trials.
And they pay for the supplements themselves.
Because Lancet and NEMJ also need money, right?
So BJ Psyche, the British Journal of Psychiatry,
publishes a supplement on some medicine.
And these are their studies in it.
And the funding for that supplement is provided
by these people.
Who then come and give it to you.
There's a BJ Psyche stamp.
They don't see that these studies, these multi
-centre trials, where they get wrong results, they
remove them.
They hide them.
Where they get positive results, they remove them.
And if the results are negative, either they
hide them, they don't include them, or they
mix them with the positives in such a
way that they get diluted.
So 60-70% of the research that's
being done on trials, most of the funding
is from these people.
Governments don't fund clinical trials.
They have the money to fund it.
And the studies that are published, 60-70
% in these high-flown journals, the world's
leading journals, are their studies.
So we are caught up.
I will read an article on a new
antidepressant which is published in Lancet or BJ
Psyche, and I see a positive result compared
to some of the older ones.
What else do they need?
In a supplement or what?
So there's a big game going on in
which doctors, because they are so ignorant of
the core values of the medical profession, they
are very easily going around doing these things.
In Pakistan, there's no such thing as Pakal
Zagat.
It's completely in their field.
Both the pharmaceuticals and the doctors.
Sir, there are two answers that you gave.
One to the previous question and one to
the current one.
If we...
Again, the more we go into the layers
of these issues, it's so convoluted.
A practice of a medical practitioner or psychiatrist
or any physician or surgeon for that matter,
is supposed to be unbiased as best as
possible.
It's supposed to be evidence-based.
But now you just referred to how that
evidence itself is doctored.
It is rife with biases.
It is inundated with a very different motivation.
Values are not motivating, or ethical values of
the medical profession are not motivating the generation
of that evidence.
It is the same economic motivation.
That leaves us in that conundrum.
Evidence is not evidence.
Absolutely.
I absolutely agree with you.
And that's why as physicians, you have taken
on the responsibility of another person's, like you
said, not just health, but one's life.
Then if you've taken on that responsibility, then
you've got to really take it very seriously.
It's not a small thing to do so.
And for that, then you have to work
hard to do that.
We don't train doctors for any humanities or
social sciences.
Not at all.
What is it to be a human?
What is this thing called humanism in medicine?
If William Osler used to say that the
humanistic values of medicine are as important as
the scientific side of medicine, then what did
he actually mean?
Or if John Gregory used to say that
physicians are the moral fiduciary of patients.
Many people may not have heard of fiduciary.
They may not have understood the word.
Fiduciary means to hold something of someone in
trust.
That is what it means fiduciary.
John Gregory was an English physician.
He said physicians are the moral fiduciary of
patients.
And then William Osler, who is known as
the father of humanistic medicine, he has written
a lot about this.
That scientific knowledge is very important, but you
should also look at the values of medicine.
Why is it a calling?
It's not something that is for everyone, but
why is it a calling?
Calling is something that is felt by a
person deep inside them, that this is what
I want to do.
It's not the church's calling or a judiciary's
calling.
Medicine also has a calling.
Please read William Osler, John Gregory, read Tinsley
Harrison.
He was the first editor of Harrison's textbook
of internal medicine.
And read his famous quotation, Edifice of Character.
It's a very important quotation.
It is quoted a lot in everything.
When you read it, understand it, imbibe it,
inculcate it, internalize it, then all of these
things, whether it's looking at the evidence, whether
it's doing pharmaceuticals, whether it's prescribing or not,
it starts to make sense.
And at a certain point in time, it
then becomes really automatic.
So when I started my medical career, I
also used to go to medical schools, to
conferences, I used to run to the stalls,
took pens, pads, calendars, and so on.
After that, when I came into the profession,
I also went on trips like this.
They sponsored conferences.
I liked it a lot.
But then, fortunately, very early on in my
career, I found out what is happening and
I started reading.
And once you start reading and knowing what
are the complexities, what are the different layers
in this, what is happening, then it starts
to make sense.
And then you read about the bioethical principles,
and ethics, and so on.
So the evidence that you were talking about,
I'm sorry, the answer was a little winded.
It is a huge problem.
But we are very fortunate, we are living
in the age of IT, where you can
really get good, objective information that is not
biased, to help you in your clinical decision
-making.
And you have sites now where you can
go, and that's where you can pick up
all of these different things to do so.
Let me tell you one more thing about
psychiatry.
In psychiatry, the absence of a biopsychosocial approach
has been a major failing.
And the push towards the biomedical model, which
is hugely supported by the pharmaceutical industry, has
completely shifted the the Kibla of the psychiatrist.
It has completely reversed it.
So, for psychiatry, the challenge really is, how
can you not just contextualize the people's problems,
but really how to widen the model that
we are using.
The biopsychosocial, spiritual model, rather than the biomedical
model.
And so if you combine both of these
things, the bioethical principle, the biopsychosocial model, particularly
for psychiatry, you'll be a much better physician
to help your patients.
Sir, if we can dig a little deeper,
you talked about values, calling, ethics.
Now, and at the same time, we are
banking on all of these to be more
objective in our practice as medical practitioners.
Now, when we go to the university, or
the university from which the objective knowledge or
the evidence generates, which forms the corpus of
our education, and we understandably, Pakistan can, their
medical schools will be third-rate imitations of
medical schools where the evidence is actually being
generated.
Nevertheless, even within the Western University, this bifurcation
of the objective and meaning, calling, values, ethics,
this polarity has permeated and it's been pervasive
within the structures of the Western institutions for
the longest time as well.
It's not that a med school student in
the U.S. will have an orientation around
sociology or medical ethics, and perhaps more so
than we do, fair enough.
But nevertheless, it is so deeply inundated.
The objective is so superior, that the ethics,
values, meaning, and calling is subjective.
In evidence, its level is at an inferior
position.
So, in the long run, if in the
community and the society, a pharmaceutical company is
saying that we're going for life-saving drugs
because it's good for money, and we're not
worried about antibiotics, or rather the other way
around, we're not going for life-saving drugs,
we're going for drugs that are going to
beat the patients, that they're going to take
lifelong.
There's more money there.
There's no money in life-saving drugs.
So, it can be seen that this dichotomy,
a bifurcation of objective, subjective, of values, and
concrete evidence, is manifesting in society at a
higher level.
Yeah, I agree.
I mean, you're right.
Because as doctors, as a medical profession, it
also survives in a system.
And you're right.
I mean, what you're saying, really, is the
capitalistic system drives towards commercialization, towards profit-making.
The problem is that it is not how
much profits you make, but how do you
make them.
That is very important.
So, in pharmaceutical companies, where they spend a
lot of funding in research and development, there's
a huge budget for R&D, how do
you fund that?
So, one way is that the more drugs
you sell, the more stocks you have, the
more new molecules you can make, and that's
how you get funding.
Now, the question is, this is there, but
how do you increase your sales?
And to increase, one is that your quality
is so good that everyone will recognize it
and will use it, like the current COVID
vaccine, and there are four or five vaccines
in the market.
Everyone knows that they've been well-tested.
Mera, EMS, EMA, and FDA have approved it.
You don't have a problem.
You just go and use it.
And you will not see pharma reps coming
and selling these vaccines because there is so
much need for them.
And you don't have to.
They are self-advertised.
But you also have a huge number of
diseases in which there is competition.
And the competition will start now.
You'll see.
The negative publicity of AstraZeneca is still coming.
It has started.
And you'll see, things will start happening in
this as well.
It will happen in Chinese and Russian as
well.
But it's not that much.
But there is competition in other medicines because
you have four companies making the same medicine
under different brands, and they will all want
the maximum sales of their drug.
And that is where the physician then becomes
an important role player because patients don't go
and buy the medicines themselves.
There are very few over-the-counter drugs.
The majority of them have to be prescribed.
So that is very important.
So capitalism, you are absolutely right that we
survive in a system.
And if capitalism is something that promotes profit
-making, then medicine and pharmaceutical industry is part
of that also.
And they will do it also.
However, as a profession, we have to be
not only aware of these things, but we
also have to see what does a profession,
even in a capitalistic system, what does the
profession demand of us?
Should we completely sell our souls?
Or should we forget about it?
Or should we just get immersed in it
because everyone else is making huge profit?
Why should we be left behind?
Or if we have taken the task of
becoming a physician, then how should we lead
ourselves?
And that is why it comes later that
what are the core values of your core
values of your institution, your profession, and your
individual core values?
Anyone who is coming into medicine to become
rich, that is what the thing is.
The doctor means that you will earn a
lot of money in it.
If you come into that profession because you
want to get rich, then you are in
the wrong profession.
And that is why this profession is being
denigrated so much.
How can we not bring the profession down?
So again, this goes back to the same
thing that how can you train students from
the beginning?
What do you tell them?
How do you do it?
What values do you show them?
What are the values of the profession?
What are the individual values?
And how important is it to take both
of them along?
You are talking about the West, I totally
agree with you.
I do not see West as the moral
authority in this world or the authority for
the medical profession that what they say will
be right.
All this filth has come from the West,
from this area that I am talking about.
And that is why they have systems that
keep evolving.
So what has happened in the US?
There was so much filth in this area,
in the pharmaceutical positions, there was so much
filth, they had to act.
And they have brought out what is known
as the Sunshine Act.
The Iowa Senator, Charles McCaskey, and one of
his colleagues, they fought for many years and
they brought out the Sunshine Act.
And what is the Sunshine Act?
They said, we want the sun to shine
on this very, very secretive relationship between the
physician and the pharmaceutical industry.
So that is why it is called the
Sunshine Act.
And what does it say?
It says any physician getting any sponsorship worth
more than $25, they have to declare it.
And it has to be on there.
Everything is online there, not just the doctor's
qualification, but also the patient's feedback.
And they have to do this as well.
This has become the law in the US.
And you can check it up on Google.
So the Sunshine Act came.
So this is the difference between the West
and here.
The filth starts from there.
All the commercialization of medicine started from there,
particularly the US.
There is still socialized medicine in Europe.
So there is no such filth there as
far as pharmaceuticals are concerned.
But it is on a different level there.
But they also acted on that.
And with time, this will become more and
more strong.
And so the pushback will be there.
And they are regulating not just the physician
and pharmaceuticals, but also how much funding is
coming from the pharmaceutical industry for research, for
conferences, and so on and so forth.
So with time, they will keep on improving
those things.
We are 50, 100 years behind those countries
as far as systems are concerned.
So we will keep on.
We will keep these kind of practices going
on for much longer, I'm afraid.
Sir, whatever we have discussed so far was
relevant for medical professionals or doctors.
Sir, how can a layperson decide which doctor
he wants to go to?
How can he decide which doctor is doing
ethical practice and which one is not?
It is very difficult for patients to find
out about this in Pakistan.
You know, we don't have a system.
There's no gatekeeping in the community.
There's no screening.
Patients are not referred, except maybe a very
small number.
Patients pick up the doctor because of what
they've been told, word of mouth, or they
know of somebody who's been to a certain
doctor, or they may have heard about someone.
You know, I remember when I used to
go on the television for any kind of
program related to mental health or any social
issue, usually mental health or medicine, I would
get a flurry of referrals in the weeks
following that.
And the reason is because if they have
a chance to actually see and hear somebody
and they think this person looks reasonable and
he may be okay, or qualifications, they used
to search and get them.
So, there's no system in Pakistan.
It's very difficult for patients.
You know, as practitioners yourself, you would know
how a doctor can find a patient by
word of mouth.
We studied this in Pakistan, looking at the
first onset of symptoms of depression and the
patient reaching a qualified psychiatrist.
This was in Karachi, a qualified psychiatrist.
And this was a student from Canada.
The average was 4.5 years, okay?
I'm not saying...
But average time of patients reaching a qualified
psychiatrist in a city like Karachi was 4
.5 years.
So, you can imagine...
I can tell you, even in big hospitals,
private big hospitals, a patient with headache can
end up with a neurologist, a neurosurgeon, internal
medicine, a family physician, or a psychiatrist.
The headache might be tension headache, it may
be cluster headache, it may be migraine, we
don't know.
But just simply, he may have headache and
he can end up with any of these
people and will be totally dependent on how
much information he has and who's guided him.
I'm telling you, in big hospitals, this happens.
Because there's no one to guide them.
And that's why it's unscrupulous.
And I'm saying this because as a psychiatrist,
I would be the last stop for many
patients.
And I would see patients having gone to
the neurologist, he gave them all kinds of
medicines, he gave them Serc, he gave them
Amitriptyline, and I don't know what else he
gave them.
He gave it to the neurosurgeon as well.
Everyone took a fee from him.
Not a single one of them said, this
is not my case, this is a tension
headache, this is your stress, I won't take
a fee because of this.
Go to your psychiatrist.
So, this is the problem with Pakistan.
Unfortunately, there is no way to find out
who's ethical, who's well-qualified, who is very
professional in his dealing.
You will have to try it.
Or if someone recommends you, that is probably
the second best thing you can do.
We are at the mercy.
Sir, you gave an example of a headache.
Referral, in a sense, becomes a moral decision.
That this is not my case and I
have to refer it somewhere else.
And, sir, it is referred in such a
way that my fees are not paid.
That I am not advising you anything, but
this is not my case.
So, it becomes a moral decision in itself.
And the moral decision is being required off
of people who were supposed to be given
a value-free education.
That's the ultimate value of the modern university.
Yeah.
I mean, you can still have a system
whereby, a system at the primary care, where
a primary care physician does the screening.
If he's well-trained, he or she is
well-trained, they can manage the patient at
their own level.
Not every case of headache has to be
referred or any other case.
Manages them at their own level, well-trained.
And if it is more complex, then you
refer them on to a specialist.
But, of course, the physician, depending on the
system he or she is working in, can
charge or be paid a fee for that,
for providing that service.
But if you are not referring because you
feel, and I give you the example of
depression, because when I talk to many family
physicians in Karachi, when I talk to them,
and some of them are my patients, or
their family members are my patients, I always
ask them, so they say, yeah, Dr. Sahab,
you get a lot of attention for depression,
you can't sleep, this and that.
And I say, then what do you do?
So, Dr. Sahab, these medicines, sometimes Lexotinil, sometimes
Alps, then we use this medicine, mostly SSRIs,
branded SSRIs.
I say, why don't you send them to
a specialist?
Dr. Sahab, first of all, they won't go,
then there is a fee of Rs.
3,000, and they will also give this
medicine, right?
They will give this, they will also give
RISE, they will give Flux, they will give
Deprecab, so what's the point?
I can see them for Rs.
500, so why should I send them?
And the same thing holds for many other
conditions.
So, when there is an economic gain, or
an economic loss, if you were to refer
patients, in Pakistan, unfortunately, the system is such,
that the patient is your source of revenue,
or physician, then these things will happen.
And they're not entirely wrong.
A lot of psychiatrists will just do that.
Yeah, yeah, they're absolutely, I totally agree with
you.
So, a lot of things have to be
seen in context, and the context, again, is
we are also victims of the system, or
the victims of the lack of system that
we have.
So, if we have to make, meet our
monthly requirements, whatever our outgoings are, and patients
are the source of our income, then obviously,
we will start cutting corners.
So, in a system which is totally fee
-for-service, or largely fee-for-service, these
kind of practices do go on.
So, I don't completely blame the physicians, who
have become a system, because they're also victims.
But at the same time, where they can,
and there's no incentive, and the patient is
going to suffer because of their suffering, of
their practices and behavior, then I think it's
a moral obligation for physicians to do so.
So, before we sum up, there's one area
that I really wanted to hear your opinion
about, and that is as convoluted as everything
else.
Generic medications.
In Pakistan, and we're being very ambitious, in
which we are hoping that whatever noise and
clamor we're trying to make, it reaches the
right corridors, and they take the responsible decision,
and at least taking these topics seriously, whatever
policymaking is necessary.
But, how do we see that?
Generics are there, but in Pakistan, there are
branded generics, and they're resulting in the same,
there's a discrepancy of prices between one branded
generic and the other branded generic, and there
is no government regulation between quality and cost,
that the non-affordability of a lot of
brands, that a lot of patients will have
problems with, that can be controlled in some
way.
I don't think we have generics in Pakistan,
we do have B2 brands.
So, for example, if it's Floxetine, we don't
have any medicine just by the name of
Floxetine.
Yes, that won't be generic, that's also a
brand.
Exactly, so they're not generics at all.
In the past, in Pakistan, for a very
short time, I think it was in the
70s, that there were generics.
But I think for a country like Pakistan,
generics is really the way out.
But generics cannot be sustained without a health
system, it becomes virtually impossible.
So you've got to have a system, in
the UK for example, because of the NHS,
they have no brands.
If you write a medicine, you're writing the
generic.
You're not writing Effexor, you're writing Venlafaxine.
Now the pharmacy of that hospital, of their
trust, might have got a certain brand, you
don't know which brand they have got.
You fully trust them that they have, they
must have looked at all the standards of
quality, and that is why they may have
chosen this, and costs and everything else.
So you write only Venlafaxine, and that's it.
You write Peroxetine, whether it's Roxet, or whether
some other brand, it's entirely up to them.
But they are able to do so in
the UK, because they have a National Health
Service, and it's very well established, and so
on.
So in Pakistan, with a system that is
largely private, generics, you can't just fix one
thing.
You have to build a system, in which,
and I think we're moving towards that, the
medical cards, Sir, your voice, we can start
doing that.
We can't hear you.
Yeah, sorry.
I had a call.
So for generics, it's very important for a
system to improve.
Right.
Okay, so when you talk about the MeToo
brands, look, the quality, and their standards, they're
usually dubious.
We don't know.
At Aga Khan, because we also ran into
this problem, and what we said, okay, we
can't have all these different brands, let's choose
a few brands of each of the classes
of drugs, you know, anti-psychotics, anti-depressant,
tranquilizers, hypnotics, and mood stabilizers.
So what did we do with the pharmacy
department?
It's hard work, it doesn't happen so easily.
Because our pharmacy was very advanced, they knew
about all of these things.
We said, okay, so we actually got these
GMP or CGMP, WHO questionnaires, we sent them
to a few companies, Pakistani companies, because obviously
the Pakistani companies are much cheaper than the
multinationals, and we got them filled up.
Then we went and inspected these factories to
satisfy ourselves.
And then again, led by a pharmacist, we
were able to then select a few, balancing
the cost as well as the quality.
And then we introduced that into a formulary.
So if someone came and he required, say,
an SSRI, then we would write that.
So getting into a formulary, they had to
pass these stringent measures, that will then enable.
So before introducing any new medicine, we would
go through that practice.
Is there some access that we can have?
Not every hospital can do that.
But within that very, very fractured system that
we have in Pakistan, you can still put
in some effort, and you can still build
certain mechanisms that can protect you from this
free-for-all.
So these are some of the very important
issues that you have to go.
You really have to go a little deeper
into that, to really see what is happening.
And then you will begin to understand, and
then you can make your own informed decision
of how you want to, where do you
want to place yourself in this whole game?
Where do you want to place yourself?
Many years ago, after those initial few years,
when I went on these trips, I decided,
I researched, I discussed, I read a lot.
Then I decided, I will not interact with
them at any level.
So I've completely cut themselves.
I do not receive any literature, telephone call,
go on trips.
I get invited to very few conferences in
Pakistan.
But when I do, I make sure.
I don't think I've lost out on anything.
And I sleep well at night.
So that's the most important thing.
What you and your department did with respect
to this little research and how many companies
are complying.
You can't hear me?
Azam, can you hear me?
Sir, can you hear us?
So can you hear us now?
Can you hear us?
No, I can't hear you.
You still can't hear us?
I can't hear you.
Can you read the chat?
So if you can log off and rejoin.
So can you hear us now?
Yeah, it's okay now.
Yeah, I can hear you now.
So, sir, that's why early in my training,
I was advised by one of my seniors
to leave your Facebook group.
Because for, for, unformed and immature mind that
I was having at that time as a
PGR, it was not good to read your
posts.
Sir, like Socrates, you're corrupting the mind of
the youth.
I was advised by someone to leave that
group.
Churchill had said this a long time ago.
Someone asked Churchill, Mr. Churchill, please, please help
me.
I've got, I've made too many enemies.
So he said that you've got enemies.
Good.
That means you've, you've done something good in
your life.
So we wish you a whole lot more
enemies.
And for ourselves, I don't know if that
counts as a good wish.
I said, a research that you said you
and your pharmacy did at your department.
Is there some sort of an access that
we can have on that?
And that'll help us in our prescriptions as
well.
We have other doctors like us, who would
want to make recommendations of prescriptions that, that,
you know, difficult.
So I don't want to promote any, any
company or any, not publicly, because in a
system like that, you have to make your
own decisions.
So, if they keep two or three brands
of SSRIs, and another says, SSRI, you don't
want to promote that.
Unfortunately, you know, physicians like yourself, you'll have
to make your own decision.
You'll have to collect data of your own
patients.
You're prescribing a brand A to a patient
with depression, monitor that, collect data, see how
they respond.
And after a year, if you've got you
know a caseload of say 50 patients and
you look and analyze the data you can
come to a good conclusion yourself.
So that is the best advice I can
give you.
Document everything, make databases for every patient that
you see, what symptoms are they coming with,
what medicine you've given them, if you've not
given them why not and what has been
the response when they come to you.
You will be amazed how much information you
can get from the data that is collected
routinely.
We don't do that because again we are
not taught how to you know make databases,
how to how to set up systems and
how to analyze our own data.
We set up four databases at AQ.
For self-harm, all cases of self-harm
that come to AQ, this is the only
database in the whole country.
No institution, private, public, government department, self-harm
you know is criminalized.
No one does it.
We have been doing it for 20 years.
Of course we don't get too many cases,
60-70 a year come to us.
But we have been doing it for 20
years.
We've done it for all the outpatients.
Every outpatient, initial patient comes, he's logged into
the system we put into the database.
We have an enormous amount of information.
Because we started late, we've got about 30
,000-35,000 patients at the moment.
So all the consults that come from the
general wards, that's their database.
And for inpatients, we've got four really good
databases and these are registries.
And the information you get from the registries
is so important that if all the doctors
start doing it, all the hospitals, just the
basic information that we take, if you organize
it properly, you'll get an enormous amount of
information.
So the best thing I would advise you
when you're prescribing a certain brand, document the
response, keep documenting for each patient.
And then at the end of the year,
you will have a good idea of what
works and what doesn't work.
But don't ask me, you know, I'm not
going to share that with anyone because these
are all brands.
The university that we're at, we have teaching
classes here at West Georgia in our psychology
department.
There's a discussion that they're like good teachers
are good cheaters.
So wherever they can get stuff that's already
been done by somebody else, they jump to
it.
So sir, can we sum up that our
professionals have to personally work hard to make
something out of this mess.
Or secondly, for any professional, the meaning of
his individual acts is tied with the purpose
of his profession.
It is not that he can do whatever
he wants to do, but every act should
be meaningful in the light of the purpose
of that profession.
Right.
And if I were to add to that
conclusion that Azam drew, parallel with that, individual
conscience, our values, how our practice is tied
in and the purpose of our profession.
And along with that, an advocacy to take
ourselves to develop, to gather the individuals that
are concerned about this and push ourselves and
our societies to the point that those systems
can be developed in which that evidence, that
data and values are given the proper place
so as to meaningfully guide our choices and
how we act as professionals.
Absolutely.
I think you summed up really well.
And what you said, Azam, that personal values
or professional values, the importance of both is
very important.
And I totally agree with you.
And so we also have to reflect what
kind of life do we need and do
we want to lead?
What are our needs and what are our
wants?
You know that our needs are fulfilled very
quickly.
But our wants, what we want, there is
no limit to that.
And if you don't tie it with your
professional obligation, professional responsibility, and if your personal
demands and wants are so high, when the
profession says that you cannot earn more than
this from medicine, but you are saying that
I will do it in some way.
And then you start cutting corners.
Now, systems like the US, where doctors are
really well paid, they work for HMOs.
Doctors can lead a very luxurious life, which
is okay.
They're part of that system.
But in a place like Pakistan, where they
flash themselves and then they make us feel
bad for not being as good as they
are doing.
Exactly.
In Pakistan, there are other challenges and that's
why these things become really, really pertinent in
a place like Pakistan.
So thank you so much for your time,
for sharing your thoughts.
And we really didn't get a chance to
talk about your struggle that you have personally
taken on yourself all this time.
With these complications and controversies, we never really
got for you to share from that that
much, maybe at another time and many other
topics.
Thank you so much for your time.
Sure.
Thank you very much for having me.
Thank you.
Thank you, sir.
Thank you, Azam.
Thank you.
All right, Ji.
Thank you so much, everyone.
Thank you, Azam.
Any concluding words?
Okay.
Allah Hafiz.
Everyone, Allah Hafiz.
Best concluding words ever.
Thank you so much, people.