ACCOUNTABILITY OF MEDICAL TEACHERS/ COLLEGES

was at the IACAM conference in Blore recently and they were having a symposium on training in Child Psychiatry. I raised the issue that the current training is sound in (clinical) theory but gives no thought to the context of work. Where we are talking of Individualised Education Programs for our patients, we have missed that point completely for our own workforce. Further, most child psychiatrists are going to be women, who really have not much say in where they will work. Eventually you will create a psychiatrist who is full to the brim with psychiatric knowledge but very unprepared for the 'practice' of psychiatry in the real world. With the result that people get intimidated by the prospect of working in India, and take the easy way out-that is migrate abroad. I told the audience that it is sad to see that more that 80% NIMHANS alumni work abroad-and my reasoning that this is because they have not been inculcated the thought of 'career-planning'.

I suggested 2 things for this

Firstly, to divide syllabus into two parts-A). core competence which includes everything about psychiatry and B). electives, which includes subjects like enterprise development, financial managment, health care systems etc. these could be managed by visiting faculty and students can choose which subjects to take up. Even things like social marketing, documentary film making, etc can be helpful while working as a Psychiatrist

And Secondly, an active engagement with alumni-they can give a feedback to adjust the training in keeping with 'market' requirments' and also maybe teach the others what they have learnt. they can take up mentoring also

I also told them that the teaching in IITs and IIMs is dynamic and along the above lines, these institutes support their alumni not only to become engineers; but also to become employers and enterpreneurs and contribute to the development of the country. So we also need to emulate their practices, and also because we also deserve to get good education AS WELL AS encouragement. I am very ashamed to say that the alumni of these institutes have created more value for our country than we have. They also may work abroad, but their work is such that it has caused development for us. Personally, I want to get aboard the gravy train and feel part of national wealth-only I have no idea how to do it except for being a medical 'labourer'!

All I want to say is: If you are sitting in a national institute and 80% of your alumni migrate abroad and are not happy about it-then does it not worry you? Mostly the reason to go abroad is to 'stay there for few years' because the propspects here are not good enough, right now. In my private discussions, most faculty and medical teachers blame migration to personal factors-like not getting alongwith elders at home, lure of easy money, lack of research atmosphere, gender issues,etc

The national institutes and medical colleges are using the taxpayer's money to impart subsidized education tailored to their (a few government doctors') idea of the 'perfect child psychiatrist'. But is it not their duty to think of how this manpower may be retained and used for the good of the taxpayer? How can they abdicate this responsibility by holding each person (the migrating doctor-student) responsible when the large majority of theirr alumni are leaving? Either their selection process is faulty, or their training is-in both scenarios something has to be done by these institutes only.

I am really very upset about this smugness and that our education policy is in the hands of people whose psychological boundary ends at the threshold of their inpatient wards. To change the healthcare system we need people who may really not be very good at psychiatry, but maybe need to be visionaries with the aim of transformation. Good psychiatrists may be hired to teach psychiatry and leave, which is just what they seem to be eager to do. I wonder if has anything changed between when the previous generation of Psychiatrists did their MD and now;  in terms of practice skills of fresh MDs and opportunities available to them? -I am now accusing that generation of not doing enough

WHY DOCTORS INDULGE IN CUT-PRACTICE?

More than 90% doctors in India do 'cut-practice'. In my 8 years of work, I have interacted with many doctors of different sepcialities, and tried to elicit their views on this practice. Majority were completely candid , about their involvement and each had their 'reasons'. Well, they are only excuses or justifications, really. Following is the list-: (This is written in first person, just as the doctors told me, but with some alterations to improve clarity)

1. It is impossible to get patients without giving cuts to neighbouring general practitioners. If I have to give cuts and have enough money to do so, I have to also take cuts-just plain logical maths!

2. I have spent so many of my best years and a lot of my father's money on my education. I do not have further time or patience to wait till I set my practice. So this is a good short-cut.

3. Everybody is doing it. So why should I lose out on a great opportunity by staying out. Consensus is a great way to solve ethical dilemnas!

4. I got 99% in standard 12 and stood 5th in the merit list (In those days). I took up medicine. My neighbour's son got only 90% (in these days) and he took up BMM. Now he earns in lakhs in the beginning itself, while I dont earn so much. This is unfair-I have more proved intelligence (sic), I should earn more

5.I wanted to do specialisation but could not do it. See these specialists-charging so much right out of college. This is not fair-they have to learn to respect me and I am going to make sure they realise my importance in their life by controlling their practice- and charging for it

6.

6. I am an Ayurvedic physician but I don’t have the patience to practice Ayurvedic diagnosis. My Homeopathy colleague also feels that Homeopathic history taking is a long and painful job. Better to use modern diagnostic methods. Besides, the diagnostic centres and specialists pay handsome (cuts) money

7. When I can earn more through cut-practice than through actual practice, then why not participate in it? Only a fool will take the stairs when an elevator is available.

8. The best part of cut-practice is that- the patient won’t know and the income-tax department won’t know (very soon I will get so used to it that even I wont know)

9. The cut-practice which I do is completely legal- I pay “my” GPs by cheque and claim the amount as business-expense. Do you think I would have been spared, if this was not very legal and legitimate?

10. Most doctors have cars and send their kids to ICSE schools. I don’t want to appear inept and unsuccessful by not matching up to them. By doing cut-practice, I can fulfill my aspirations faster

11. I don’t believe in ethics, law and all that garbage. I do what works for me-and cut-practice works very well in bringing business (sic). In fact, to tide over the festival season slack, I have announced a special festival offer of “100% cuts”. One has to do SOME marketing.

12. It is all the Government’s fault-we are not allowed to advertise, so how will anyone know that I am here? This job is done by “my” GP and it only right that I have to pay him. By keeping it on a percentage basis, I can keep up his motivation to work hard for me and send more patients . (This HR management!)

13. I don’t believe in patient’s right to choose. A patient cannot even understand the difference between spondylitis and spondylolisthesis, how do you expect them to choose the proper person to treat? I make this choice for them. Now the problem is: there are too many specialists with complicated degrees that I find difficult to decipher. Cut-practice makes it very easy. Percentage is the real winner. After all, a doctor willing to invest so much in his practice and sacrifice his income for setting it up must be really serious and committed and it is my duty to encourage him.

14. I have a medical degree, and have studied my specialization through correspondence course. But believe me, I can treat any complicated case with full confidence. In fact, I feel I am much better than many of these ‘qualified specialists’. Till I make an impression, I will give cuts to the local GPs. For some time at least, I will have to use this method to make up for my lack of ‘proper’ qualification

15. I have practiced for 35 years, and now everything is so expensive. Patients are in constant denial and expect me to charge them the same rates, as I did in the 70s. The problem with family practice is that you know your patients so long, and so intimately that it becomes difficult to charge proper fees for fear of offending them. However, I found that patients are highly appreciative of tests and specialist opinions, while all these specialists and diagnostic centres are competing amongst themselves to get patients. So the common solution for fulfilling all the above problems is cut-practice and everybody remains happy. A newspaper even featured me once for my low fees and ‘community-spiritedness’

ALL are welcome to add to this list

VALUE AND PRICE

I read with great interest an article about low pay of doctors in the HINDUSTAN TIMES of Chandigarh, on the 28-05-2011. " Doctors do not produce large financial profits while engineering/ business management students do', was one of the arguments put forth for paying low salaries to doctors. I wonder how this can be substantiated.

For various reasons, we do not value our health until we fall sick. We do not hesitate to buy kgs of gold, or change our mobile phones every week, but we haggle shamelessly at the doctor's clinic.

One has to understand the role of good healthcare in producing good finances-both personal and at the workplace. Everybody should be able to understand and calculate the cost of being unwell-it means not being able to engage in income-generation that day plus having to hire help to do one's necessary work for the day plus continuing low efficiency and need for support for few more days. This is the daily cost of ill-health. By shortening this period as much as possible, your doctor makes you less of an economic liability. Is this not a form of profit, for the individual and his employer?

Other than not valuing health, we also dont realise the cost of ill-health and are prone to be carried away by the trend of bargaining for everything. So there is cut=throat competition based only on the price and the cheapest doctor wins. Thus invariably, the value of something and its price do not match. (The other other profession which suffers from this mismatch is teaching.)

I wish to ask, that if the economic value of medicine and teaching are not so great, then why are more and more schools and hospitals coming up? And why are their investors getting richer and richer?

The fact is that both these professionals generate huge profits through their work, but their lack of knowledge of business as well as tendency to believe in the 'noble=poverty' myth makes them unble to demand their rightful share of the profits-that is- the true price of healthcare.

WORKING FOR CHARITY

Many doctors wish to work in set-ups where (poor) patients can avail of their consultations at low fees or no fees. Charitable clinics and hospitals claim to provide this opportunity. My experience is that the ambience, location and general set-up of these clinics is such that poor patients feel intimidated and seldom come to such places. My pet grouse is that these clinics are crowded with typical middle-class and upper middle-class persons who can actually afford healthcare at market rates.

I wonder why the charitable hospitals do nothing to reach out to the really poor clientele, who would benefit from charity. I wish the doctors were also more judicious in committing themselves to such enitities. It is very sad that a doctor enters the facility with an intention of helping an economically challenged person, and what he/she encounters there is a banker/ business consultant/ wholesale magnate takng treatment at cut-rates. This situation is sure to drive any doctor to frustration.

It also frustrates the really needy patients, who get displaced by the affording persons. The poor patients have nowhere else to go.Generally the affording class are more educated, aware and therefore more assertive and demanding of the doctor's time and patience.

Therefore, I feel it is best for doctors to work independently and give generous discount to the economically backward patient who comes for treatment. This is the lesson I learnt from experience, no one told me about it. And I would request affording patients to enquire about the doctor's private clinic and seek consultation there and not to occupy the time and space meant for their less fortunate fellow-beings.