Skip to main content

The Curious Case of Consultation Fees in General Practice

Today as I was returning home in metro two lawyers occupied the seats next to mine. I was reading A Reader on Reading by Alberto Manguel. But I distinctly heard one of them tell the other "I have two cases tomorrow evening". That set me thinking.

Advocates have "cases" and so do doctors. Advocates have "clients" and so do doctors. (Some doctors call their clients patients because some clients are indeed patients. But some doctors call even their patients clients, appreciating the fact that ultimately the people who come to them are dignified individuals seeking a service and with autonomy in choosing service providers.)

Advocates are also notorious for charging sometimes lakhs for an "appearance". But here doctors have itt slightly different. Doctors also get called money-minded and unscrupulous, but they get called so for charging much less than what advocates usually charge. Why is this so?

I came up with various possible reasons. One, the huge lawyer fees that we hear about usually are in big courts for defending big crimes. Perhaps the stakes are really high in those situations. To add to that, a court case is usually once in a lifetime situation for most people and one they probably have never encountered before. Therefore the clients are in a much more vulnerable situation and would be willing to pay a lot.

This "high stakes" reason appears correct because there is similarity in healthcare. When you go to a hospital with a heart attack, you don't care how much the hospital charges are going to be, you just want your (chest) pain free life back. But when you have a cold (which is probably the 14th time you are having it in your lifetime), you know it is going to be better in a few days and there is no real reason to spend lots of money.

That probably explains why the market rates in general practice is very small. People usually present with simple illnesses and a sense that their illness is a simple one. Therefore there is not much value they are seeking from the doctor - most clients are in for quick relief from symptoms, if possible.

Therein lies the complexity of general practice too. I'll explain that in a bit, but first let us look at one more difference between lawyers and doctors. Lawyers take money from clients and work for clients by being sharp witted and coming up with strong legal arguments. But their "appearance" is in front of a judge. The favorable outcome is defined by the client but realizing that outcome requires very little of the client's participation. Usually, the judgement made by the judge also unequivocally settles the judgement on the lawyer's performance.

Now let us talk about general practice. In general practice, your client does not just pay you, but also has to work with you for their own success. There is no third person involved. The client has to believe in the doctor, has to believe in the advice given by the doctor (that the advice is for their own good), has to follow the advice strictly, and also has to make a judgement about how good the entire process have been. This is where the previous point comes in.

The reason why clients come to a general practitioner is often for quick relief from their symptom. Most of the time in medicine there is no quick relief which is also good. For example, painkillers are quick relief from pain due to strain. But the good thing to do maybe in many cases to take rest and allow body to recover. Common cold may slightly improve with nasal decongestants, but overuse maybe harmful. Sometimes sticking to medicines which cause nausea, vomiting, diarrhea or many other tolerable side effects are required in the face of greater dangers like multi-drug resistant tuberculosis.

Sometimes the right thing to do in the view of a doctor maybe different from what the client thought would be the right thing to do. This would not be a problem for a lawyer as the client does not have a role in deciding the success of the lawyer's approach to the "case". But when doctors are in this situation they have to use all the skills they have in convincing the client about why there needs to be a change of expectations. And the success of the treatment itself relies on this "winning over" of the client.

And after all that exercise, the client has to pay. ICUs, OTs, and emergency departments have it easy. There is a lot of money to be paid, but most of the work is done by nurses or doctors and the sick person usually just has to lie down on a bed (conscious or not). General practice? Totally different ball game.

With that context, how much is a reasonable consultation fee in general practice? 50? 500? 1000?

Before locking our answer, let us look this from another side. The general practitioner is a small entrepreneur. The GP has a home and has a life. The GP needs to make money to survive. But the GP is also a doctor. No conscientious doctor can do injustice to their profession or their clients. They cannot simply symptomatically treat diseases without thinking about root causes. Diseases have to be managed correctly. Counseling is an important aspect of treatment. And all of that requires time - time to be spent in consultation. And time is money.

The question on consultation fee thus has to be somehow linked to the consultation duration. What is the minimum time a doctor should spend with their client to fulfill their obligation/duty? There can of course not be a single answer to this as every consultation is different. But practically, from my experience, in a single person clinic the doctor (who is the single person) has to spend at least 20 if not 30 minutes in a consultation for there to be some quality.

How much of that can be delegated? Whom to delegate to? Of course in a single doctor clinic the only person to delegate to is the client themselves. Can clients prefill questionnaires about their health condition? Can clients read informational pamphlets instead of having to listen it directly from the doctor? Does trust suffer in attempting such time saving measures? These are all questions with no definite answers.

Does building a healthcare team help? It can definitely help. At Restore Health we have a multi-disciplinary team where a lot of tasks are shared. But still there is considerable amount of time spent by each person of the team in providing care to a client. And we charge 500 in general practice consultations. Are there people who think that is too much? Definitely, yes. Including sometimes our own doctors. But there are times when we have saved the client a lot of money and good health and spent considerably more time in the process. We do not have "dynamic pricing".

Perhaps there needs to be more thought put into showcasing all the value that is created by a GP and monetizing some of that at least. All this while treading on the right side of ethics and not breaking the delicate thread of trust that connects a client to a doctor. Who says general practice is not challenging?

My train of thought was derailed when the train I was sitting in reached my destination. As I stood up to deboard, the lawyer next to me took my seat. Perhaps she was thinking about how much to charge her next client. Perhaps not.


Popular posts from this blog

What to Make of Itolizumab?

It is the worst of times. Science is suffering an identity crisis. The world is in dire need of science. Science isn't used to being rushed. "It is a giant and slow churn", said a friend once, "and spews a breakthrough once in a while". Is it possible to make the process faster? That's what everyone is wondering. And praying. And waiting, eagerly. Science isn't used to getting this attention.
"Coronil is 100% effective", said Patanjali folks. "Favipiravir is 88% effective", said Glenmark folks. How to know the truth? Seeking truth has never been easy. Never has it been easy for journalists, scientists, or the common person. In some sciences there are multiple truths. Is medicine one of those sciences? Can there be a single truth in medicine?
I won't use words like epistemology and ontology in this post. (Because I still can't remember which is which). But the question is essentially two:
1. Is there a single truth? 2. Is there a…

Public Health Was Always Broken, You Are Just Noticing It Now

There is this nytimes article about how one pregnant lady who was also breathless couldn't find appropriate care despite going to multiple hospitals. I find it nothing surprising. Our country's public health system has never been able to provide appropriate care to people with medical emergencies (or for that matter, any health issue). Maybe now people are noticing because it comes on news.
There is a limit to how many emergencies can be handled at a time by a small medical team. Even in tertiary care government hospitals, this "team" is a very small one. It usually includes a couple of young doctors - either doing their internship or their residency. And a couple of nurses. And a couple of janitors. It is the same whether you are talking about the ICU or the emergency room of any department. There are no mechanisms for requesting extra hands when there is a spike in cases at any moment. Crises are handled by expediting care (many a times at the expense of quality and…

Understanding Adrenaline Dosage

Have you ever administered adrenaline for anaphylactic shock? I've never had the unfortunate need to. I'm sure anyone who ever does will forever remember the correct dosage. But for me, it is always a confusion. Every time I vaccinate someone at my clinic, I look up the dose of adrenaline just to be sure.

The first problem is the dilutions. Dosages of adrenaline are (or were) mentioned in dilution. 1:1000 & 1:10000. There begins the confusion.

Firstly, let us understand where the 1000 comes from in 1:1000. Have you seen a small vial of adrenaline? That is 1mL. It has effectively 1mg of epinephrine/adrenaline. But why is it called 1:1000? Because 1mL of water = 1g of water = 1000mg. So, the 1:1000 actually refers to 1mg of adrenaline : 1000 mg of water. Unnecessarily complex!

All you had to say was 1mg in 1mL. And that is why this labeling is now being followed in some countries.

So, there you have a small vial - a 1mL vial - with 1mg of adrenaline in it.

Now, let us look a…

Glenmark Lies About Favipiravir

I received from a friend a PDF which happened to be Glenmark's press release about Favipiravir. The release is full of claims that make it sound like Favipiravir is a wonder drug that is going to solve COVID problems. It becomes my responsibility to refute some of these claims, considering how majority media outlets are doing what they're best at - exaggerating an already exaggerated PR claim.
Firstly, we have to verify the claim whether India's drug controller did approve the drug. The way to do that is visit CDSCO's website and navigate to approvals -> new drugs. And as per that, "Favipiravir bulk and Favipiravir film coated tablet 200mg" did in fact receive approval on 19th of June for "the treatment of patients with mild to moderate Covid-19 disease" as the 18th entry.
I do not think CDSCO publishes details of the approval process, about what evidence they considered for approval, etc. Making these processes transparent would be useful for avoi…