I was in the office of my rich friend who also practices surgery like
me. As I entered, he was busy fixing up a patient for surgery. It was
embarrassing for me. I got up and said "Will come after some time."
He could read me.
"Nothing secret D.U. please have your seat. Have a Pepsi till
I finish this.
Temptation to witness his dealing was a greater attraction for me than
Patient was standing in front of him. He did not offer him a seat.
I became uneasy and tried to offer my own seat to the standing patient.
My friend asked me to be seated in a commanding voice. Probably that
was the start of my learning. If you ask the patient to sit, he comes
at your level; you loose supremacy. Patient should not dare to sit in
front of you. On the other extreme, I have another surgeon friend who
might offer his own seat to the patient and staff. Eats and goes out
to movies with them. No wonder none of them give him money or respect.
My friend gazed up with a slight tilt of his neck and took a long puff,
retained the smoke in his lungs for few seconds, gave an impression
to the patient that he is giving a deep thought to his problem, as if
he was asked to build new Indo-Us relations. After leisurely exhaling
the smoke, he spoke out in the tone of a sort of assurance "I will
try to manage in about Rs 8000/-".
He placed the cigarette in the ashtray and looked into patient's eyes.
When you see directly into any ones eyes, it reflects your genuineness
and confidence. When you demand an amount, which you know, is not justified,
you can never look into patient's eyes. In other words, if you can fine
courage to look into eyes of anybody, any amount becomes justified.
By placing the cigarette I the ashtray, he also gave a message to the
patient that I was smoking to concentrate on your problem, and how to
help you out. Since that is over, I do not need this remaining half
Some things- like a smoke, bifocal, fountain pen, at least two gems
in your middle and ring fingers, light colored cotton full shirt with
thin strips, aroma of men's perfume, that little paunch of the tummy,
the double chin and deep husky voice , takes you a long way in making
one confident to come under your knife. You may or may not be competent.
And money, also, is quite a secondary thing!
I was highly impressed with his gesture.
The patient was hypnotized. I could see obligation in his eyes.
He asked with hesitation "Will you provide me the medicines?"
"I do not like package deals with medicines. You see, no body
will like to be at a loss. Any surgeon, who promises you to provide
medicines, will always provide you with substandard cheap drugs that
he can save maximum out of it. I am not that sort of person. I feel
my patient should get the best. You can imagine the quality of the house
if you give total contract to your builder. It is always better to vive
only labour contract and provide him wit your own material".
Leave aside the poor patient, I was also getting mesmerized.
"Well, if you insist, I will arrange medicines for you."
By know, the fellow was so much convinced with the explanation of my
colleague about the sub standard drugs supplied by us, that he straight
away let go idea of accepting the medicines even free of cost from us.
He thought life is more precious than to save this amount. It is a game
of confidence, nothing else. Your speech should reflect that authority.
I remember, I attended a party in my hospital, where I am attached as
an honorary surgeon. It was a good gathering. Meal was delicious. Unfortunately
we had only one bottle of mineral water. At the end of the meals, the
topic of spurious filling of the mineral water popped up. One of my
physician friends convinced us that the mineral water, that you purchased,
was not genuine. One of us picked up the bottle and said "see this
is quite soft, it must be genuine." The physician friend said"
It is here you are mistaken, when the bottle crumbles on pressure, It
is the surest sign of adultery". That was the end of it. None of
us had courage to drink water from that factory sealed mineral water
bottle. Instead, all went for the water filled in the glasses and brought
by the peon with all five fingers dipped in, while bringing them. To
our utter surprise, when all of us settled down over dessert, he got
up, broke the seal and finished the same bottle, he was criticizing.
He said "I had to do that because there was only one bottle!"
So dear you can convince any body about any damn thing, If you speak
"I will purchase the medicines doctor."
"How much will I have to deposit initially? I am a poor fellow.
Can you not give me some concession?"
I have deep sympathy with poor, but in my practice I get irritated
with this question because whatever I quote is so reasonable, that I
do not have any scope to reduce it. One more thing, no matter, if I
ask Rs 600, 500 or 400 for an endoscopy, he will ask for concession.
It is not his fault. It is the rule of the market. In any financial
deal you get 10 to 15% of concession, and you then feel satisfied. Unfortunately
we do not have fixed any norms for any procedure. One who asks for an
exorbitant prices, he justifies himself by saying that he is doing an
extra ordinary job.
The real extra ordinary people do not practice. The patient gets confused,
like you get confused while purchasing a part for your vehicle. The
mechanic says, this is an original one, hence costly, though both look
alike. I wonder if really the originals are always good. If so, then
why the hell did the need arise to come to you? The vehicle is new and
no doubt, the part, which is broken, is original and was fitted in the
company. The other day I was purchasing a cell for my watch. He asked
for Rs 17. I became smart by saying that it should not cost so much.
The shop keeper had to justify himself. He took out another cell from
his drawer and said "see this is duplicate one. We sell this for
Rs 8 only. He thought I will go for the original one. Instead I picked
up the so called duplicate one. I could clearly see the defeat in his
eyes. It is now 2 years and my watch is doing fine. Both the cells were
The market has become very much confusing. It is the art of dealing,
which decides the amount of earning. 50% is your destiny, 30% your art
of dealing and of course the remaining, the least important, is your
competence in surgery, I feel.
Any way, I was eager to see, how my colleague deals with this matter
The overall dealing of my friend was very convincing; hence the patient
already was hesitating to ask for a concession. He had just asked to
complete that ritual of "See can you reduce the price?" So
that you do not repent later on, or your wife doesn't curse you that
you have a bad habit of paying whatever is asked without negotiating.
My friend looked straight into his eyes and laughed at him as if to
say don't be childish. As if, are you joking? How can you expect concession
in this amount? Do you expect me to pay from my pocket for your treatment?
That was enough to close the topic of concession.
About the deposit, see, I am not after money, but these hospitals have
become very commercial. They know only the language of money".
My friend was saying all that was going on in patient's mind.
"But don't you worry. Nobody will extract money from you in the
hospital, till I am behind you." (Because I will take all that
you have. There will be nothing left with you to extract).
"What you can do, is get admitted and then deposit the money here
in my clinic in the evening. I will look after the hospital bills. You
don't bother about that.(Hospital should not know what I have taken
from you, and you should not know what meager I have given to the hospital).
Just a minute, my friend held him back as he was leaving.
"Please keep this dealing a secret. These rates are only for you."
My shop keeper friends in the market always utter this when I go for
shopping. I realized one day that they were true. Those rates were only
for me. They were selling at cheaper rates to other routine customers.
"No sahib, don't you worry about that. I realize what you are
doing for me."
The patient went out, highly satisfied.
That was really wonderful.
"What are you going to do with him?" me.
"Oh! It's a simple appendix D.U." my friend.
I just could not believe that. None of my patient are ready to pay
me more than 4 or at the most 5 thousand rupees for the same job. Here
I was witnessing my incompetence. I was consoling myself that though
he is asking for Rs 8000, all of that is not going to be his. After
all he belongs to a big hospital, and will have to pay a major chunk
out of it to the hospital. Ultimately what remains will be less than
Rs 2000, which I usually earn. Perhaps he could read my thoughts.
"Just to tell you D.U, I was asking for my surgery only. The hospital
bill is going to be separate".
Now I was stunned.
"But you did not mention that to him?"
"If he takes it for granted, it is his mistake. He had asked me
only about the medicine part. If I explain him about the hospital charges
also, then the amount will not be palatable to him. As such every body
comes prepared and in case of any financial problem, his kin will help
him. You don't have to worry."
"Dear, don' t you feel, unspoken truth is also a sort of lie?"
"See D.U, I am following the trend."
He was right. I was reviewing my way of practice. I usually calculate
and add the expenses, which are other than surgery also, like transportation,
lodging and boarding of the family. I also make him aware of his loss
from being away from his job. I become sentimental. Few of them appreciate
me in spite of my abnormal behavior, but many go to another surgeon.
That way I do not deserve to earn more, because if you do not behave
in a professional way with your patient, if you make him your relative,
then naturally you should not expect to earn from him. Be happy, at
least he is not asking any money from you during this bad time.
"You are a fool. That is the reason you have not been able to
earn more. To do surgery is not a big thing. They train you for that
in college. More or less all are at par. What makes you big in practice
and society is, how much you earn. It hardly matters how you do it!"
"Apart from surgery, you have an opportunity to earn from pathology,
radiology and medicines also. Even if you don't take your share money
(this is decent word for commission), they are going to charge it from
the patient any way, because they have to keep it uniform. Then why
to leave our part?"
"But did he really have appendicitis? I doubt it. He was moving
about comfortably, and what I have read recently, there is no condition
as chronic appendicitis, and there is no role of interval appendicectomy."
"D.U, keep your academics and ethics to yourself. You a really
confused personality. Your concepts are not clear. Dear! What is the
harm if I take your normal appendix out? It is meant to be taken out.
I don't understand why few people like you make an issue about taking
out that otherwise useless organ from body? It has only nuisance value,
if at all. Lord God has created it as a job opportunity for we young
surgeons. And last but not the least, If don't take it out, some body
"Why do you talk of us surgeons? It's common in all branches.
Don't you attend the calls for unnecessary caeser?"
I had to accept his plea because I have really attended many caeser,
which made me suspicious. The gynecologist tried to justify by saying
"See that caput. (Caput is the collection of blood with boggy swelling
in the scalp if the child gets obstructed for some time at the outlet.
Blood continues to come in that area due to high arterial pressure,
but fails to return back due to venous obstruction by pressure). It
is not that uncommon, as I have read.
Probably the indication for caeser was capital, and not the caput!
The anesthetist and assistant receive the call in emergency, and the
reason for that dire emergency is supposed to be - come soon before
she delivers in a normal way. If you are late, the result is normal
labor. You can clearly see the glow on relative's face and the gloom
on the gynecologist's face, inside.
One more opportunity is, few doctors supply medicines of samples and
take charges from the patients. In the admitted educated patients they
take care to dispose off the packing after opening the strip. He is
made to purchase one or two capsules to make him realize the cost and
originality of the drug. Apart from hiding the identity, If you distribute
the medicines by peeling of wrapping, it becomes a sort of care taking
gesture also. Just as waiters of class hotels serve you personally.
Patients find great pleasure and satisfaction in spending lot of money
to get the job done. Expensive surgery becomes a major surgery. After
spending so much, smooth recovery comes as a pleasant surprise to him.
If you quote less for any surgery, either he takes the surgery to be
minor, or feels shaky about your competence.
There are a few things to be taken into account; the amount of money,
which any body will ask from his client , you will have to first realize
the nature of your job and your own skill. If you are the one, who always
underestimates yourself, then you will never demand a justified amount.
If you feel your surgery is worth Rs 10,000/-, then only you will ask
that much. Similarly, if you are immature, do not understand the gravity
of that case and do not anticipate it's consequences, then also you
ask for a very low amount. A good example is surgery for repair of a
peptic ulcer perforation. If you only see the surgery part, it is very
simple. You have to apply three stitches in the perforation, wash the
peritoneal cavity, put in a drain and come out. A job lasting for just
15 mts. A house officer can do it. In fact it is one of the preliminary
surgeries, we learn. It is surprising to see, why all experts in private
practice avoid these cases. I, initially, because of shortage of work
and immaturity, I accepted few cases, to realize the problems. They
give you lot of sleepless nights. It is not like a simple puncture repair.
The patient is very critical due to infection and toxicity of the acid
in intestinal contents, and is in shock. When you realize the implications
like mortality and the possibility of the relatives going to sue you
in consumer court, either you avoid accepting these cases, or if at
all you operate, you ask for a handsome amount, and stick to it. You
do not bother, rather feel happy, if the patient goes away. That is
Another factor is your own financial background. I hail from a middle
class family. I have certain norms about the worth of money. My children
will be having different values. In our sub conscious mind, we put ourselves
in the patient's shoes. We usually ask for the amount, which we ourselves
would have paid conveniently. May be you will ask for Rs 10 or even
15 thousand very casually, if you have a rich background. On the other
hand I have lot of hesitation to ask for more than Rs 5000/-. This hesitation
in your tone, while asking for money, is lethal. The patient will not
feel it justified.
To grow rich, you have to behave and think like a rich. You will have
to leave behind your middle class mentality.
What is it?
It is what makes you read the menu card from right to left. It is when
you inadvertently pick up the keys of the scooter, instead of the car,
while you go out alone. It is when you scold your kids for leaving a
bit of cold drink at the bottom of the bottle.
Any way, instead of accepting my ignorance for earning, I console my
self, by saying "See, since I come from a middle class family,
I am unable to earn more!"