More Cesarean in Private and Less in Government

Let us start with debunking the common whatsapp forward that many people who were advised Cesarean in Private Had Normal Delivery in Government Hospitals

Around 10 Lakh Deliveries happen each year in Tamil Nadu
Of these
If No Cesarean is done, 50000 mothers will die
To save this 50000 mothers, just 50000 cesareans won’t be enough
This is a concept most non medicos and even many medicos don’t understand
This applies to almost all indications
Health care is a Non-Cartesian Science
We just cannot accurately predict the correct persons to do it
In Any Surgery
We need to “overdo” the numbers to make sure that we don’t miss those who need it
If we want to save more people –> There will always be some one who underwent the surgery, even though they would have been cured without surgery
If we want to make sure that only those who absolutely need surgery are operated –> There will be always some one who died because of non surgery
There will be always people who were recommended surgery
Who refused surgery and got well without surgery
This does not mean
That the initial recommendation was wrong
In case of Cesarean
We are doing surgery not only for the mother
But also for the baby
“Normal Delivery” means delivery through Vagina
Does not always “guarantee” a “normal” Child

The above data is wrong
Even then
What is the cesarean was indicated for fetal reasons
The delivery would still be normal
Child would be abnormal
So Where does the question of ethics even rise here
Most of our patients are greedy and stupid
Not all
But Most
If I place a foot wide and twenty feet long wooden plank on the floor and ask people to walk from one end to another without feet touching the floor everyone will accept the challenge immediately and 90 percent will even complete it successfully in first attempt
If I place the same wooden plank between two buildings, say DMS annex and DPH building and ask to walk very few will volunteer
This is difference between taking a decision “surgery or not” in the nick of the moment
That is like walking from one building to another
If we analyse the case sheets leisurely (walking with plank on the floor) we can always says that certain percentage of surgeries are not needed

This applies to any emergency surgery, not just cesarean
It applies to CABG, It applies to debridement, it applies to thrombectomy, it applies to SDH evacuation (yeah I am a Neurosurgeon)
Assume there is a Road Traffic Accident Patient with Acute SDH and GCS 4/15
If operated his chance of survival is 1 %
That means
If I Operate on 100 people like this
99 will die
1 will live
What will happen if I Operate these 100 patients in Private Hospital
They will pay a bill of Rs 5 lakhs
99 will still die and 1 will live
The relatives of the 99 patients will blame me – They will say that even though the doctor knew that it is 1 percent chance, he operated for sake of money
The stupid and greedy patients who lack ethics will blame me
Come to GH
If I do not operate, they will ask why I did not give a change
The stupid and greedy patients who lack ethics will blame me
For the same disease
The patients will blame the doctor for operating in GH
The patients will blame the doctor for not operating in Pvt
Who lacks ethics
It is patients
There is a big question mark on medical ethics
It is patients who lack ethics
Sorry to say
Even you lack ethics
Your post here shows you lack ethics
before questioning ethics
You could have at least known about fetal indications of cesarean
But you did not care
You mere started a blame game (in guise of questioning)
I know you will get angry on this comment
You will say that “I just questioned, I did not blame” or some vague excuses like “Can’t we even question” blah Blah
The fact is what you did is wrong
Taking decision sitting with coffee and vadai in AC room with just case sheets where the decision is not going to impact a life (is walking in a wooden plank placed in the floor)
Is different from
taking a decision at bedside where a life (in case of LSCS, two lives) is at stake
Along with fear of assualt, enquiry, hospital violence, court case etc (is walking in a wooden plank placed between two buildings)
Doctors will of course lean to the side of caution and there will be more surgeries done
This is to be expected and to be accepted
I would be surprised and intrigued only if the post-discharge-analysis of case sheets found out that all surgeries are needed. In that case there is something wrong . . That would be a case of the Dog which did not bark…/The_Adventure_of_Silver_Blaze
// If someone posts such data we should know what is the truth//
Let me explain
1. This data is false
2. Even if there is a case of a woman who was asked to do cesarean, but she delivered normally –> The cesarean could have been because of fetal reasons
3. Even if there is a case of a woman who was asked to do cesarean for maternal reasons in one hosptial, but she delivered normally in others hospitals –> It was because the first hospital did not have facilities like Vaccuum or Forceps and the second hospital had
Just because
a surgery was advised first
It was not needed later
Does not mean the first decision is unethical
There are lots of factors sir
In RGGGH, we can take a patient to surgery in 30 minutes – The anaesthesiologist is on duty, the staff is on duty, the theatre technician is on duty, there are 4 tables in emergency OT
If I am working in say, Ambur GH, I won’t have this luxury
The number of surgeries I do in Ambur will be more than those of RGGGH because I will be more cautious in Ambur
Can you label this as a question of ethics Murthykarunanithi Bhuvaragha Sir
First and foremost you need to come out of the notion that doing surgery is unethical
In most cases
Not doing surgery is unethical and doing it is ethical

Why are doctors Appointments Delayed ?

One of the common Complaints raised by People in India is that Doctors Appointments are delayed

In fact, it is one of the very few True Allegations in Health Care. Most of Allegations against doctors and Hospitals in India are fake and frivolous

The reasons for delay in Appointments are

1. Emergency :
The Doctor would have planned to start the OP at 7 PM. But if a patient in throws fits or becomes unconscious, he has to be attended first. So the OP Appointments will be delayed

2. Emergency Surgeries :
The Doctor would have planned to start the OP at 7 PM. But if a patient from a two wheeler accident is brought at 5 PM he has to be operated. So the OP Appointments will be delayed

Now Comes a useless Question asked by people without common sense “Why can’t you inform”  When called to see a patient who is bleeding, has feeble pulse and requires immediate treatment, the entire focus of the doctor would be and must be on saving the life and not checking the appointment calendar and calling each person

It requires only minimal common sense to understand this
It requires Selfishness of the highest order to expect a doctor come to his OP, take his appointment diary, call each of those who have fixed appointment, and inform them and then go and treat the patient.

Health care resources not infinite. They are are scarce. The available doctors time and hospital infrastructure are limited and are not adequate for the demand. Hence, it is the duty of every citizen to share this meager resources with his fellow citizen. If you come to the hospital, please keep away your greed and selfishness.

As I have been writing again and again, most problems in health care in India are because the PATIENTS are GREEDY and SELFISH. They do not understand that a hospital or doctor is for every one. They want immediate and superlative treatment for them. This is the root cause of all problems in healthcare. Sadly, very few understand this. And even fewer people accept this. They are happy to level all blames on doctors and hospitals without even sparing a second to reflect what is the fault from patient’s side that is contributing to the mess


It goes without saying that any doctors appointment may be delayed by 2 hours

A Delay of 2 hours is the norm rather than exception

If you are not able to understand this and if you are not able to accept it
Please get treated from Countries like USA or UK
Specialists do not attend emergency on first call, and where you cannot have OP on Weekends and where you need to wait for 2 months to get a Specialist Appointment

It takes two months to get the appointment date, but the doctor will see you at the right minute

In India
You can see a specialist the same day, or at the maximum next day, but the appointment may be on time, or delayed by 5 minutes to 3 hours

Which is better ?

It requires only minimal common sense to know that the Indian setup is better


3. Patient Coming Late
A doctor may Consult in One Hospital from 5 to 7 AM and the next Hospital from 7:30 to 9:30 PM

A patient who has appointment at 6:30 will call him at 6:40 and say that he is delayed due to traffic jam and is just round the corner and will come by 5 minutes. The doctor will wait. The patient would then start from his home and come by 7:15
All the appointments in the Second Hospital will be delayed

Whose fault is this ?

4. Getting Appointment for one person, but consulting for five people
Lots of people get appointment. T for one person, but along with him, four other friends or family come in and they want to become healthy
What do you expect the doctor to do ?

To Treat them
To Bluntly Say that “I can see only one. The Other Four Get Lost”

Just ask your conscience ?


5. Patient shouting over 5 minutes delay
In many cases, there would have been a five minutes delay. But one Smarta** would make a big fuss and it will take doctors 15 minutes to calm him

In the end, the other appointments will be delayed by 20 (5+15) minutes

6. If there is a child or old age patient, or a patient with cancer the doctor has the right to attend to them first. If there is a follow up patient he or she may be called first.


If you are booking an appointment

1. Expect that to be delayed by 2 to 3 hours in case of unforeseen emergencies

2. Keep Calm. Don’t make a fuss. Don’t call the Doctor on Mobile. The delay is because doctor attending some other emergency. And If you have fixed an appointment for your friend and if your friend says that he or she is waiting in the hospital, please don’t call the doctor to enquire. It wastes everyone’s time. Patiently explain to the greedy and selfish friend and ask him to her to wait

3. Remember that you have come to become healthy. You cannot BUY Health like you buy Mobiles, Cars, Dress. In an hospital, the resources are scarce and will be used to save lives. If you have a big ego, keep it in home. Don’t expect the doctor or hospital staff to spend their valuable time in massaging your useless bloated egos instead of saving a live. And hence do not demand that you will be called and informed about few minutes delay like what they do in Civilian Flights.

Father of Gynaecology J Marion Sims : Was his Action Ethical or Not ?

James Marion Sims (January 25, 1813 – November 13, 1883) was an American physician and a pioneer in the field of surgery, known as the “father of modern gynaecology”.His most significant work was the development of a surgical technique for the repair of vesicovaginal fistula, a severe complication of obstructed childbirth. He is also remembered for inventing Sims’ speculum, Sims’ sigmoid catheter, the Sims’ position, use of silver wire as a suture, Insemination and postcoital test, and argued for the admission of cancer patients to the Woman’s Hospital, despite contemporary beliefs that the disease was contagious.

He also advocated a laparotomy to stop bleeding from bullet wounds to this area, repair the damage and drain the wound. His opinion was sought when President James Garfield was shot in an assassination attempt; Sims responded from Paris by telegram. Sims’ recommendations later gained acceptance.

In 1878, Sims drained a distended gallbladder and removed its stones. He published the case believing it was the first of its kind; however, a similar case had already been reported in Indianapolis in 1867

But, Of Late, There are many people who try to intentionally portray him in negative light
Here is one such Facebook post

Unthinkable! J. Marion Sims is called the “Father of Gynecology” due to his experiments on enslaved women in Alabama, who were often submitted as GUINEA PIGS by their plantation owners who could not use them for sexual pleasure. Anarcha was an African-American slave woman who was forced to regularly undergo surgical experiments while positioned on Sims’ table, squatting on all fours and FULLY AWAKE without the comfort of ANY anesthesia. It’s been calculated that Anarcha was operated on roughly 34 times between 1845 – 1849. These operations helped Dr. Sims hone his techniques and create his gynecological tools. It would be more than appropriate to credit Anarcha, along with other nameless slave women, as the “MOTHERS OF GYNECOLOGY”.

J. Marion Sims and Ethics
J. Marion Sims and Ethics

On Reading it, You will immediately Hate the Man because of the following issues

  • //his experiments on enslaved women //
  • //submitted as GUINEA PIGS //
  • //plantation owners who could not use them for sexual pleasure. //
  • //positioned on Sims’ table, squatting on all fours //
  • //FULLY AWAKE //
  • //comfort of ANY anesthesia. //
  • //roughly 34 times between 1845 – 1849. //
  • //hone his techniques and create his gynecological tools.//

The impression Any Lay Person as well as Few Doctors with low IQ Gets with this Writeup is that

Dr Sims Made Experiments on a slave, and was cruel that he made it when she was awake and the only reason the slave had to undergo the surgery is for the sexual pleasure of the slave’s owner

But, When we examinite it more carefully it is easy to conclude that it is a rubbish Writeup, itt is biased and written with a perverted intention to make some one hate SIMS

Let us examine the points one by one

//his experiments on enslaved women //
//submitted as GUINEA PIGS //

Guinea Pigs are used in Experimentation for various purposes
The Pigs are usually normal and are sacrificed for sake of trial
If the procedure is not done, the Guinea Pig does not have any problem

Clinical Trial is Different
Here the person already has a disease
and undergoes the procedure

Use of Guinea Pig and Experiments in this write up is malafide

//plantation owners who could not use them for sexual pleasure. //

As if the only indication for VVF is sexual Pleasure
And the woman is otherwise very happy with VVF and RVF?

What is Vesico Vaginal Fistula – It is a condition in which Urine will come via Vagina continously and without any control. What is Recto Vaginal Fistula – It is a condition in which Feces (Stool or Shit) will come via Vagina continously and without any control. Do you think a woman with such condition will like it. Do you think that she will have to be forced to undergo the surgery. Not at all. Women with such conditions were running from pillar to post to get cure. And there was NO CURE Available at the time, and one doctor offered to cure them, but said he also did not have any experience. So What should have been done ? To try the procedure or just to leave the women with urine and feces dribbling continously through their vagina ?

//positioned on Sims’ table, squatting on all fours //

You can also describe Lithotomy and give an grotesque impression to the lay public

//comfort of ANY anesthesia. //

These two lines actually take the cake
These will create immense anger and make blood boil
Isn’t it

But Wait
When were these done

//roughly 34 times between 1845 – 1849. //

So the surgeries were done before October 16, 1846 and also just two years after October 16, 1846

What is 16/10/1846 by the way
Find it yourself

Then you will understand the height of perversion the author had gone by using the words “FULLY AWAKE” and “comfort of ANY anesthesia”

//hone his techniques and create his gynecological tools.//

This is the only correct line in the writeup


This is how, You can fool an unsuspected reader Hate some one by making normal actions look like Big Crime

By the way
Did you find the significance of 16/10/1846 at least now
Well that was when Ether was FIRST used

What does this writeup do
It blames Sims of not using Anaesthesia for an surgery done before Anaesthesia was invented
This is why I call this writeup as peak of perversion and summit of lies

For the Serious Readers, there is a detailed writeup in Journal of Medical Ethics. You can also read it J Med Ethics. 2006 Jun; 32(6): 346–350. doi: 10.1136/jme.2005.012559 PMCID: PMC2563360 PMID: 16731734
I did not see the article when I wrote this post