Sir, no surgery?

The agent brought her in on a Tuesday afternoon. A middle-aged Tamil lady from Malaysia, quiet, slightly nervous, clutching an MRI report like it was a court summons. "Sir, this is a patient for knee surgery," the agent announced before I'd even looked at her. He said it the way you'd hand a file to a clerk — the conclusion already written, just needed a stamp.

I examined her knee. No swelling. No instability. No catching, no locking, no giving way. I asked her what bothered her. She said she had occasional pain, the kind that comes and goes, worse when she thinks about it, better when she forgets. The MRI showed a small meniscal tear.

That's all it took. Once that word — tear — appeared on a report, the machinery activated. A GP referred her to a facilitator. The facilitator booked her a flight to Chennai. The facilitator found a hospital. The hospital found me. And somewhere in this assembly line, a middle-aged woman who needed reassurance was repackaged as a patient who needed arthroscopy.

I told her she didn't need surgery.

Her face changed. Not relief — liberation. Like someone had lifted a physical weight off her chest. She'd been carrying that MRI report across borders and time zones, convinced something inside her knee was broken, convinced it would only get worse, convinced that surgery was inevitable. She asked me twice more. "Confirm, doctor? No surgery?" I confirmed. She walked out of that room lighter than she'd walked in, thanking me as if I'd done something extraordinary. I hadn't. I'd done the ordinary thing — examined a patient and given an honest opinion. The system around her had made that extraordinary.

You've been in that room. Maybe not with a Malaysian patient and maybe not with an agent standing outside. But you've had a referral — from a GP, a colleague, an agent, a hospital coordinator — and you've known within the first three minutes that this patient doesn't need what they've been told they need. And you've felt it: that knot in your stomach that has nothing to do with the clinical decision and everything to do with what saying no will cost you.

As the patient walked out, the agent peeped back into my consulting room. His face was tight. "Sir, no surgery?"

"No," I said. "No surgery."

He stared at me for a moment — the kind of stare that, on a street, might have preceded something physical. But this was a hospital. He left. I never saw him again. And within the week, the word had spread through the agent network: this doctor is not interested in doing surgery.

That was the hardest sentence I ever had to carry. Not because it was true — I've done thousands of surgeries when surgery was indicated. But because in a system where the agent decides who gets patients and the surgeon's only job is to say yes, "not interested in doing surgery" is a professional death sentence.

The Referral Economy

Here's the math nobody does.

A knee replacement at the corporate hospital in Chennai cost the patient approximately ₹2.5 lakhs. The agent's commission was 20%. Standard. Sometimes unstated, but one Bengali agent — an MBA graduate who'd drifted into medical tourism because the commissions were better than consulting — stated it plainly: "I'll get you patients. But I want 20% of the total bill." That's ₹50,000 per case. For introducing a patient to a hospital.

My share, after the hospital took its cut, after taxes, after the deductions and adjustments that every surgeon in a corporate chain knows intimately but never discusses publicly, came to less than what the agent made. Let that settle for a moment. A surgeon with 12 years of medical education, performing a procedure that demands precision measured in millimetres, took home less from that surgery than the person who made a phone call and booked a flight.

I watched agents grow in stature during my time in Chennai. One man had been a tea boy — serving chai to doctors in the hospital corridor. He understood the system, understood where the money moved, and within a year, he was bringing patients from across Northeast . His life changed overnight. Not because he acquired a clinical skill. Because he positioned himself at the chokepoint of a referral pipeline where surgery was the product and commission was the currency. Why did I study so much and receive less than what an agent would receive? I asked myself that question every month. I never found a satisfying answer.

But the agent wasn't the problem. The agent was a symptom.

The hospital ran 15 orthopaedic surgeons on 10 beds. Think about that arithmetic. Fifteen surgeons competing for ten beds means five are idle on any given day — not because there aren't patients, but because the system is designed to create scarcity. Scarcity creates desperation. Desperation creates compliance.

When you're fighting your own colleagues for OT time, you'll take the agent's patient. You'll say yes to the borderline case. You'll operate on the meniscal tear that doesn't need operating because the alternative is an empty OT and an EMI payment that doesn't care about your integrity. When surgeons fight among themselves, they don't question how the hospital is run. That's not a bug in the system. That's the design.