COCOON DAYCARE 2012- 2017

In 2012, I decided to start a daycare myself, taking SUNSHINE SMILES (Green Acres,Deonar) as the model.  It was mainly to provide care and companionship to my son. But I also wanted to start a business and this was what I found most interesting at that time.

I put my details on the net and passed the word around. I had an extra bedroom and that functioned as the daycare room.  I got a good response in the first month itself and my kid was thrilled to have companions through the day. I had to put in a lot of effort though; I did the cooking- and I also took care of the kids when the staff went home. But it was fun and I was able to implement a program that went beyond just warehousing the kids. Most kids were happy to be with us and we went on like that for a year. As the number of kids increased, I hired more staff and also a part-time manager to help me.

After a year I moved the daycare to a separate premises. In this location, I had my medical office and the inner part was for the children. By this time, I had full-time, part-time staff, visiting teachers and volunteers. As time went, I fine-tuned the system and schedule. The day care was generally much appreciated by the kids, parents and staff.

 After 5- 6 years my medical practice took off and I became busier in it. Therefore, it became difficult to maintain the personal involvement in the daycare. The daycare was occupying the space I had actually purchased for my medical practice and now with the expanded work I needed that space.  The economics were also dismal and the kids availing daycare were not in need of charity. My son stopped attending the daycare and even that benefit to me was lost. So actually there remained no good reason for me to remain in that business. The time had come when I had to choose between my medical practice and the daycare business.  And I chose my medical practice.

Cocoon Daycare is a lovely chapter in my life- full of happy moments, love and learning.

POST- SCRIPT- I rue the fact that nobody was ready to buy my business or run it for me. I know why that is so- the day-care I set up was a gross loss making enterprise because I never accounted for the cost of the premises which is the main investment. The money I made was exactly equal to the market rent plus cost of running (in fact fell short in some months). If I gave it to anyone else, I would have to charge that cost as well and then the whole system would become unsustainable. I am sad to note that this is the fate of most daycare centres in places with high real estate prices and cheap labour availability- and the kids of Parle cannot expect a decent daycare facility despite being born of educated, financially comfortable parents. The most feasible system here is to hire a reliable person to take care of the kids at home itself.

TRAINING TO BE A DOCTOR IN MUMBAI- PUNE- 4

Most doctors who have gone through all this will consider this to be a wild exaggeration and claim that hospital training was among the fondest period of their lives. Of course- it is.

All the suffering I have written about happens only for a maximum of 18- 24 months. That too, it is expected and accepted with resignation. Only few will have any desire to see the deeper moral problem in having 'dog eat dog' system. Because after those few months, suddenly you are on the other side. To accept that the system is wrong means that you have accept your share of the work, stop harassing your Resident/ Intern and generally shape up. If this happens, for every Consultant, the number of patients managed per day will go down and income will reduce.

Thus this is like labour for them- short period of agony and longest payback of passing the buck. Therefore, I dont see how things can or will ever change.

Any person who wants to investigate the veracity of my report can use following methodology
1. take data of patient numbers and doctor numbers and do the maths
2. take a daily work recall of doctors at different levels and do the math using a proper statistical method
3. tabulate the actual number of months/ days in a year worked
4. fact finding through random sampling and personal interview

Also why are the problems so frequent here only? even in other states they have numbers and financial issues. both in the North as well as the South Doctors have much better work conditions, training schedules and pay as compared to Maharashtra. Time to ponder why?

TRAINING TO BE A DOCTOR IN MUMBAI- PUNE- 3

 My personal experience is that the medical students, teachers, staff everyone is divided along several parameters. Upper caste vs lower caste. Girls vs Boys.  Brahmins vs other caste. Reserved vs open merit. North Maharashtra vs Rest of Maharashtra. North Indian vs Marathi speaking.  Marathi speaking vs non Marathi- speaking. Doctors’ child vs first generation doctor. Hostelite vs day scholars. Minority vs Majority community. Post graduate resident vs non PG resident. In Postgraduation married vs unmarried. With child vs without child. Pregnant vs non pregnant.  Native vs those from outside city. Urban vs rural. And modern medicine vs alternative medicine (yes, this started after folks from BAMS, BHMS courses began to be posted in Medical institutions for internship). MBBS vs para medics. (this list is indicative not complete)

 In the normal course of the day, when everyone is cool and calm these things are not so prominent (though not completely absent). At times of churning like exam time, admission time, at the start of the new academic year, shifting of units and social turmoil (like reservation announcements/ strikes) the medical community falls apart and people begin to needle each other on these issues.

Overwhelming work stress, intense competition, scarcity mentality and inflexibility are reasons why divisions and harassment get accentuated. It is felt by all those who work in the hospital. It is not merely the high work load, it is the unequal distribution and poor work culture that creates work stress. According to me, this is because of the structure of training and work. The mutual bullying and harassment is done with taunts along all of the above.  Unfortunately the harassment along caste lines and that too of ‘lower’ caste by ‘upper’ caste is alone newsworthy and punishable offence. The fact is- unfortunately and I am ashamed to admit that harassment is the norm in medicine. This harassment starts the moment you stand in line to submit your application form for admission and is unrelenting till death.  

Even patients indulge in harassment of doctors along these lines- I remember a patient refusing treatment for a dark complexioned colleague saying he was ‘BC’. Even now patients do not bother to ask me my qualifications or experience but frequently they are concerned about my caste and mother tongue (also worry about Belgao). I have personally been taunted about my religion, caste, gender and marital status on several occasions during my short period of working in Mumbai hospital for 6 months. Large number of times I was told in internship not to bother about studying for post- graduation and the job of girls is to manage family not to do PG and compete with male doctors. And I believe that though the taunts were based on my gender, caste etc; actually the irritation was provoked by my status as an ‘outsider’. The Gynec department and particularly women residents are the worst and relentlessly harass. 

The type of harassment in hospital could put Guatnamo to shame. Details are-

1. not allowing toilet breaks

2. gossiping, isolating, vicious taunting

3. purposely sending residents for references to different wards to get back at other resident. Once I accompanied a patient for pain in abdomen repeatedly to department of surgery when clearly it was menses pain. Upon reaching the surgery department both the patient and I  get a severe dressing down. Many times

4. not allowing break to change menstrual pad when having periods

5. tearing discharge card prepared by interns alleging poor handwriting and making them write same several times so that they cannot finish work and go home

6. denying them break to have lunch

7. borrowing personal items like pens, stethoscopes, two wheelers and misusing them or not returning/ replacing them

8. not allowing to wear gloves during conduct of procedures like delivery or suturing.

9. calling friends and relatives over and designating the resident/ intern as their caretaker. So the junior has to accompany the persons to all check ups, ensure they get their food etc by buying it and giving it to the relative and sometimes these relatives are not shy of making innuendos to the hapless person

10. making the intern accompany a serious patient to another hospital for further tests. Once I was made to accompany pregnant patient to another hospital for sonography. Something was not right with the patient and I was told to shut up and just do my job when I enquired. Upon reaching the other hospital the matter turned out to be serious and everyone from the consultant to the resident doctor from that hospital began mercilessly firing me and projecting different the serious consequences- one of which was that I may be required to deliver the patient outside the hospital gates in a little while. I was so frightened, that the patient’s husband (kind fellow) and patient themselves took me aside and fed me a cold drink to calm me down and then hired a taxi to return to the first place- all the while comforting me. This was not only once and not only for me.

11. making the intern or junior most resident explain the serious situation or death of patient to the relative. Once in the casualty I was monitoring an accident patient when he suddenly had a voluminous blood vomit and literally died in front of me. I reported the matter to my Resident. The Resident who was seated comfortably casually told me to inform the relatives about the death as I only was witness to same. It was the scariest day of my life- informing about 25 relatives that their young relative was dead

12. Insensitive ‘breaking- in rites’ or ragging. Leaving the intern or resident to deal with troublesome relatives alone, leaving them alone with threatening patients like prisoners/ mentally ill, purposely introducing them to people who are prone to be foul- mouthed or make sexual inappropriate behaviour.

13. Keeping one’s wet clothes on the mattress, hiding underwear and towels after removing them from clothesline, blocking access to bathroom for bath, forcing into drinks/ drugs parties, getting seminars- slides etc made are the ways to harass in hostel

 Anyone who protested would be labelled a ‘trouble maker’. Counseled that this is temporary. And seniors who were supposed to protect always said, ‘how come only YOU have problem? So many of us are working here peacefully. We admit such and such person is a bit rough- but you need to understand that it’s due to stress. Plus this person is bright and will bring good name to institute. So we need to support by tolerating some of the ‘quirks’ or ‘whacky’ behavior’. It is also believed that high intelligence is accompanied by abnormal and anti social behaviour so must be overlooked. I worked in 3 cities and I found that this type of harassment in worst in Mumbai, at all levels-maybe my experience because I was an ‘outsider’.

The medical community also has not figured out the proper way to deal with real troublemakers. Suppose one such is posted in the unit. The person constantly begins to complain about lots of things. They feel sensitive and isolated. So the unit responds by giving them less work or routine non challenging work. Then this person begins to allege of being deprived of training opportunities because no work is being allotted to them. So what should the unit do now? Give work or not give work? Guidelines are available to solve such problems- the medical colleges choose not to use them or even read them. There is no such thing as a human resource management principle in the medical training or profession. People are groomed only on two principles- survival of the fittest and get the work done anyhow.

The culture imbibed during training seeps into work and even in private hospitals. The Consultant doctor peeps in from the corridor and charges a visit fee. Consultants treat only test reports and act on second hand information from the resident doctors- because from the second year of residency they only cultivated this habit. I see that the Resident doctors are over worked, underpaid and taunted mercilessly. I have often advised Residents to seek jobs in other states, especially in the South. There the pay is better, regular and junior doctors are treated with greater dignity and respect.

It is time that Maharashtra doctors sit down and study the administrative part of Resident and Intern doctors training. They always focus only on the knowledge and skills part. Unless this is studied and remedied every year we are going to have things like suicides, drop outs, doctors’ strikes, violence against doctors, poor patient care and progressively worsening quality of medical graduates.

TRAINING TO BE A DOCTOR IN MUMBAI- PUNE- 2

RESIDENT DOCTORS

Post-graduation is of 3 years duration for MD.  In Maharashtra Resident doctors are called Junior first year, Senior in second year and Chief in third year (JR, SR and CR respectively). Resident doctors are supposed to be supervised by Registrars who have completed their post graduation.  These are further answerable to Lecturer who is a postgraduate with certain experience. Then come the faculty (typically assistant prof, additional prof, associate prof and prof and prof and head). A number of Departments are managed by Honorary Consultants (- this system unique to Mumbai has found to be a complete disaster and a mention of this fact is stated even in the Joseph Bhore Report which came before independence. But for the benefit of few doctors and to show that government is getting free service, the system still continues.) This forms a unit. 

When a patient comes in the JR sees and works up, then this work is corrected by the SR and then this work is presented in rounds by CR. Effectively ONLY JR does all the work. After the punishing ordeal of JR year, its over and done with, for a lifetime.  This actually is the crux of the problem- that the work of JR, SR and CR is done by the JR alone. It is also an unwritten rule that Registrars and Lecturers should not be disturbed outside working hours. Therefore, the CR becomes de facto supervisor which is an extremely dangerous thing for the patient.  Every Resident gets a full two months of exam leave during which they only study and do no work at all. A number of women doctors also get pregnant and graduate without availing any maternity leave (officially). On paper one has a huge number of people but considering that SR, CR, lecturer and no other doctors do any independent work other than only supervision and procedures, and even among them folks are AWOL- and cannot be replaced because it is unofficial. One can easily confirm this fact by dividing the number of patients with the number of Residents on paper and then seeing how much the workload actually amounts to. (Include the interns, who should be doing medical work instead are doing the work of fixers).

Basically every doctor is rushing madly- not staying still with the patient and concentrating. Every doctor is either butting into another’s work or getting harassed by a senior butting into their work. If an error happens, the junior-most member of the team is taken to task because really there is no way to figure out where the error crept in and no one will admit/ reveal due to hierarchy promoting a conspiracy of silence.

Ideally all Residents should be given independent responsibility to manage patients. Patients should be allotted according to the complexity of the case matched with the competence of the Resident. So a second year resident gets to manage more complex case than a first year resident. Every patient should be managed by the same doctor from the OPD upto discharge. At every stage such as examination, treatment planning, implementation and follow up the resident doctor should discuss the case with one senior resident (who has completed post graduation and is available on campus 24hours) and consultant who is a senior doctor.  Resident doctors should get 30 days paid leave every year and are required to avail of maternity leave and term grant as applicable. This ensures that all resident doctors get almost equal volume of work- more importantly they do not interfere in each other’s work. Quality control and accountability can be maintained as exactly who made the error can be tracked and consequences prevented due to close supervision (and lack of buck passing). In the event of shortage of doctors- due to maternity or other leave which is officially permitted- as things are official they can apply for extra hands in the form of non post graduate residents for short term. 

This system trains the Resident for the real world scenario where it is required to manage patients independently, ask for supervision if required. Finally no preparatory leave should be granted for exam. The logic is that a medical professional with specialist training is required to study all life- long and be prepared for exam any day of life- so it is expected that the Resident would have cultivated the habit of studying during working in the last 3 years so exam preparatory leave is unnecessary and in fact injurious to the development of a complete professional. Therefore the system of getting 'marks' should be stopped. Results should be only as pass and fail. Outstanding students can be given some award like a Gold Medal. Its a laughable system to mark professionals with marks.

Thus a lot more people are available to work, they get leave officially when required and become more confident. And people will give importance to training and learning rather than exam scores.

TRAINING TO BE A DOCTOR IN MUMBAI- PUNE- 1

I did my undergraduate and internship in Mumbai and Pune and these were some of my experiences and observations. These were true about 15years ago and some things may have changed- I hope for the better.

Three groups of doctors are particularly prone to be harassed. Interns, First year resident doctors (JR) and those perceived as ‘outsiders’ to the Mumbai clique.

INTERNS

NB- interns coming from outside Mumbai are called 'externs' by the native doctors. 

In all hospitals in Mumbai some of the orderlies, Nursing staff and other ancillaries are insincere in their work.  Plus there is a perpetual shortage of staff at this level and the shortage is often made up by contractual staff of poor quality and commitment. So work is left unfinished. These folks are protected by their Union and the law henceno action can be taken against them. Adding to this is a (?real/ imagined/ created) shortage of patient materials like needles, syringes, trays, dressing materials, cleaning and disinfectants, etc. But in medicine work has to be done. Now. So when the crunch happens in a particular ward or hospital (which is always happening) all the pending work is pushed on the medical interns.

The typical medical intern in Mumbai and Pune does not any training in medical skills. They actually get trained in how to become good orderlies, technicians, nurses and fixers to manage logistical failures. All they do is- collect blood and other pathology samples, label them, transport them to the laboratory and then keep follow up with the different departments to track the reports and collect them. They wheel the patients for different tests. They change dressings.  This work is usually done under continuous warnings and screams of nursing staff about availability of limited supplies- you cannot use even a centimetre more of dressing or be given another syringe if required.  All this work has to start early in the morning and continues until the Resident doctor in- charge permits the Intern to leave.  The only two things the Intern can hope for is to have a sensible Resident in charge and that the Resident will be responsive to his good work and conduct. The worst treatment is reserved for Interns who are perceived as ‘outsiders’ due to their caste, rural background, gender or being transferred in from other cities or institutions for internship. Usually interns do not live on the hospital campus so they also have to handle housing, commute, deal with dirty hospital toilets and zero resting facilities. They also are paid a pittance for their work. So while a Resident works several hours- the Intern is working the same hours without a salary, facilities or hope of learning any meaningful skills.

Ideally the work of the intern is to examine, work-up and plan treatment for simple cases which can be managed in a ‘primary care’ or general practitioner’s clinic. They are supposed to discuss this and implement the care and follow up the patient. They are supposed to observe the management of complex cases so that they understand when specialist treatment is needed and what it constitutes. They are supposed to attend rounds with Residents and Consultants to imbibe the thinking and management process. Under supervision, they are supposed to learn to perform simple and emergency procedures. At the end of the day they are supposed to go back and do case based reading so that the learning is consolidated. This is how interns are trained in other States, not in Maharashtra however.  As we use interns as spare labour for miscellaneous odd jobs in the hospitals we are compromising on their training- a typical doctor now has completed internship but has neither confidence nor skill to manage a primary care facility independently. (It is reported that interns are no longer keen to attend hospital because the Post graduate entrance exams require them to spend time mugging multiple choice questions- never mind if they have the skills of a doctor or not- but that is not being discussed here now).