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).

ANOTHER WAY OF LIFE-

DEAR DOCTOR COLLEAGUES,

William Osler described medicine as not a profession or a calling but a way of life. Psychiatry is a way of life for us. Psychiatry has come a long way now. Yet there is a lot of distance to be covered. The most crucial journey is into the hearts and minds of medical colleagues and that is still a work in progress. Among all the reactions I get from people, the most baffling are those from doctors.  They reflect not only ignorance, but also prejudice, superstition and sometimes contempt. Here are the commonest:

WHY DID YOU TAKE UP PSYCHIATRY? (usualy accompanied by a wink and chuckle)

Somehow there is a myth that folks who did not do well academically took up Psychiatry, because of lack of options. Or worse, that people with ‘inner conflicts’, ‘perverse desire to pry ’or otherwise maladjusted in life are drawn towards Psychiatry. Most Psychiatrists of today have an outstanding academic record and have chosen to train in the subject on account of their passion for patient care. They are well rounded personalities being gifted writers, artists, musicians, social workers, researchers- in addition to being full-time clinicians. People take up Psychiatry because they are sensitive and want to make a difference to the quality of life of their patients; not just cure them or treat test reports.

PSYCHIATRISTS KNOW NOTHING AND DO NOTHING

This is a famous adage told to undergraduate classes. The fallacy of this statement reveals itself to doctors when they or their loved ones have to suffer from emotional issues or psychological disorders. Eventually whatever is the specialty chosen by a doctor- at least 15-20 pc of the work turns out to be psychological intervention and that is the time most people realise the value of what psychiatrists know and can do. Unfortunately having learnt that Psychiatry is useful and lucrative, some people will start practising psychiatry after a perfunctory course in Counseling (usually long distance or part-time).

YOU GET THEM ADDICTED TO DRUGS/ MAKE SURE YOU DONT MEDICATE MY PATIENT

This is an incredible statement considering that the knowledge about chronic nature and biological basis of Psychiatric disorders is in the public domain and even laypersons know about it. I cannot understand the difference between putting a patient on an anti hypertensive drug and an anti depressant drug- both are chronic medical problems requiring lifelong medication. Next is the insistence to treat ‘my patient’ with only therapy.  It is like insisting that normal delivery should be done even if there is severe cephalic pelvic disproportion or that patient should be treated with physiotherapy even if there is a fracture. I think you all need to back off and respect Psychiatrists as experts of their domain. They will deliver the results- subject to the prognosis as in all specialties.

SPEND SOME TIME, HE/ SHE NEEDS TO TALK

These are the doctors who confuse Psychiatry as a sort of ‘escort service’ embedded in the medical profession.  Just for the record, Psychiatrists are qualified medical professionals who diagnose and treat mental illnesses. Psychiatrists (and for that matter psychologists or counsellors) will not be able to ‘spend time’ to ‘talk’ to someone who is merely lonely and bored.  In case you come across persons who are not mentally ill and require no treatment; definitely don’t refer them to Psychiatrists. They can look up the net for more productive diversions and hobbies.

TELL THE PSYCHIATRIST TO STOP THE MEDICATION, THEN YOU TAKE TREATMENT FROM ME

Some doctors have either Psychiatry or my treatment approach which makes life very difficult for the patient. Some doctors feel that it is natural for a patient with a serious illness like infertility, cancer or heart disease to be depressed, and in the scheme of things it is sufficient to treat the ‘serious illness’ ONLY. Actually psychiatric treatments including medications are perfectly compatible with all kinds of treatments including infertility treatment, pregnancy and cancers and that too, in all age groups. And they add much to the quality of life of the patient (and bottom-line of hospital by reducing ALOS).  Psychiatric treatments are safe, cost effective, efficacious and increasingly accepted by patients. So, what's your problem, doctor?

IN LEAVING

The essential service in medicine is to save life and alleviate suffering. There are many ways to do that. In Psychiatry, it is done calmly and through the agency of the patient himself. It requires a different kind of judgement and courage to believe that the patient will transcend his predicament and to motivate him to do so. We Psychiatrists understand this and respect each other for it. Among Psychiatrists you will rarely see competition or bad blood- all of us know that the task before us is monumental and all hands are required to accomplish it.  That is why, rarely will a Psychiatrist discourage anyone from taking up medicine or Psychiatry.  It is another way of life.

Careless whispers

I am sitting across someone who is extremely depressed, suicidal and in a very miserable and dangerous situation. Things were not always like this......about 6 months ago this person was a well adjusted happy person going about life smoothly- inspite of the many challenges.
That he was on one anti depressant pill was not common knowledge. He went to fill his prescription at a new chemist- the chemist advised him not to take pills. He told him that Psychiatrists do this 'business' purposely to enrich themselves. One must take as less of these medications as possible and meditation is a better remedy for mental illness. This unnecessary intrusion caused stopping medications resulting in a severe relapse. Now I will have to probably give a course of ECTs to save the patient's life. And how he is suffering!

Then yesterday I have a call from a distressed mother. Her 9 year old has obsessive compulsive disorder. He spends several hours a day doing meaningless rituals. When the mother gets in the way, even by mistake she is severely assaulted by slaps and verbal abuse. Their family has not slept properly for 3 years because the rituals continue well past midnight. After trying homeopathy for 6 months she has come to a Psychiatrist who gave her pills and put the child on therapy. But her family physician, who is a homeopath has said that she is an impatient mother- his opinion- 'medications are harmful and being given in high doses so that the childs brain gets damaged and he gets addicted to it for life. What kind of mother gives such medicine to her child?' I am really upset at this shooting from the hip of a person who has no idea about how qualified I am versus him in this field. And about how indifferent he is to the childs and familys suffering. OCD needs higher doses (definitely higher than homeopathy, where the medicine is only a memory not actually present). I have put in decades of painstaking effort to acquire the expertise to treat this kid. And if this kid is not treated now he will have to drop out of life and his family will be devastated. Taking a pill is a small price to pay to be able to live a reasonable life.

Then the third call is from a Physician who practises in the neighbourhood. She is enquiring about phobia, suspects that one of her hypertensive patients aged 36 years may be having it. At the end of the discussion, though she says she will try her her best to convince him that he does not have phobia, so that he stops worrying about it....because she doesnt want her patient to be put on any life-long medication! She could have knocked me down with a feather! He is already on antihypertensives which are far more expensive and dangerous than anti depressants. And by convincing, will the phobia go away?

Really people should stop advising on mental health unless they have reliable information. Please consider that the Psychiatrist is a qualified responsible person. We will not only treat the patient, but also take responsibility and manage if anything unexpected like side effects occur. For God's sake, if someone is looking better after Psychiatric treatment do not make them stop it. And please get proper information about the Psychiatrist and medication before carelessly insinuating malafide intention.

CAN I WORK LESS?

I just read the literature about doctors' suicides and I am not surprised. Doctors have the highest rates of suicide in among all professions and worse....nothing gets done about it such as for others like
1. some sensible rules or laws for doctors working conditions
2. some sensible guidelines for welfare during training
3. any way to access help confidentially when they need it

One of the things that makes doctors breakdown so much is the continuous and unrelenting work schedule- designed to kill the most robust individual. So the most useful intervention could be to reduce the working hours, if a doctor can afford to do it. But the mobile phone works like a leash and a doctor continues to work outside of the declared working hours too.

In India- a combination of patient unsophistication (sometimes a plain lack of good manners) and easy availability of the doctor's mobile phone number has made it impossible for doctors to get away and get some peace of mind. Patients are constantly trying to get that little bit more of the doctors attention easily and possibly without paying. And even if one charged for the telephonic consultation, how much should be reimbursed for disruption of activities like a much-needed nap, playing with your child or simply a good scene in a movie. Once the patient starts calling, the calls are repeated till you answer them- no sense of keeping the phone on silent mode. Being human we tend to get worried by the time its a second call from the same number flashing and will drop everything to answer it. 99pc of the times it is some silly question like when can we meet you or are you coming to the clinic tomorrow. This is all the more vexing when one has hired the services of a 24hour helpline to answer exactly these queries. Patients always fail to save this number but unerringly save the doctors mobile number.

The psychological warfare unleashed by patients if you fail to answer their calls is persistent, subtle and chips away at the morale. They will make sure to let you know how you were responsible for their horrible suffering, responsible for not getting timely help, abandoned them in their time of need, etc etc etc. The truth is that no emergency treatment can be given on phone as proper examination is not possible and it is also illegal. And why bother the doctor and insist for immediate attention when there is no emergency? So emergency or no emergency, telephoning the doctor is not required unless it is by prior arrangement for specific non- emergency purpose only.

 So one has to be really quite firm and unwavering about deciding the boundaries between business hours and personal life. The trojan horse called telephone notwithstanding. The telephone assisted beck and call system enforced upon Indian doctors will kill many of them some day.

CUT PRACTICE ISSUE- A MILESTONE REACHED

Happy to note they have tabled the law and passed it.
So finally cut practice is not merely unethical but also illegal. This is what I wanted.
I understand that implementation is going to be a challenge. But enacting the law changes the whole paradigm and perspective- which is in a positive direction.

So its is a great milestone on Medical Ethics. I hope the international journals give positive coverage to this as well.

Good News!

A LAW....and much ado

First a disclaimer- about one month ago the Indian Medical Association and Association of Medical Consultants of Mumbai- sent across a strong protest against a hoarding by Asian Heart Institute saying that they do not indulge in cut practice. Well, though I am a member of both these associations and strongly against cut practice- I did not see anything worth reacting against in this hoarding. At best, the associations made a fool of themselves by giving more publicity than the promoters paid for.

The upside- a committee set up to make a law against cut- practice so that it becomes illegal. This is what I was really hoping for. But I have some worries on the way in which it is being done

Firstly, the great rush. What law has ever been made within a few meetings and a couple of months of setting up a committee to draft it? The deliberations have just started and the bill is being aimed to be tabled in the monsoon session itself. 

The committee is full of doctors- we need more representation from lawyers (the scholars I mean, who understand the spirit of the law), activists and representatives patients' welfare organisations. 

It is good that the public suggestions are going to be elicited. I will surely respond and encourage others to respond

A TALE OF TWO CITIES

The first time I went out of Maharashtra for work was to join NIMHANS. Before that I had to clear the entrance exam and interview. The scene at the entrance exam made me think that I was lucky to have chosen to work out side Maharashtra. Firstly, I was among the youngest- only among the handful fresh graduates. Everyone else was older and much more relaxed- they had put in a couple of years working as medical officers for fat salaries (unheard of in Maharashtra). They were totally cool and relaxed, unlike my classmates in Maharashtra who were just waiting to kill themselves if they missed even one year. Many were happily married.

When we started work as Junior Residents, each was given complete responsibility for their own patient. Nothing like in Maharashtra, where an elaborate pecking order ensures that the freshest and junior most Resident does ALL the work while all others just give suggestions and present the work done by this hapless resident in the clinical rounds. My supervising doctor called ‘Senior Resident’ made a fair distribution of the work and Consultants had a close eye on our performance. The first day itself we were told to take days off to manage our stress and to not ever believe that we were indispensable to the hospital. Contrast this to the attitude when I did my internship- both in KEM Pune where I hardly was allowed to do any work as it was a private set up and in J J Hospital where loads of work used to happen- any mention of even going for lunch break or pee break would invite horrible cold stares and wicked jibes from the supervising Residents. On most days, I had no option but to leg it on the sly.

 Yes, and there in J J they had an issue with ‘extern’ as well. In NIMHANS- all are equal and equally welcome. During my posting in St John’s hospital, I noticed that the interns were also treated like equal professionals. In Pune as well as in Mumbai the only work interns did was the work of ward boys technicians and staff nurses....collect blood samples, transport them, make appointments, dress patients, label samples, accompany patients to tests, record blood pressure. Only work done as doctors was suturing wounds and securing iv lines. Pune was better- at least important skills like performing normal delivery, closing wounds, reducing dislocations were taught generously to us. In Mumbai, lesser said the better. Or maybe because I came with the label of ‘extern’ as Mumbaites love to function in closed cliques.

 My personal experience does not matter- I understand it takes two hands to make a clap. It is more important to understand that precious opportunity to train doctors and make them confident is lost due to the extreme hierarchy, mutual parasitism and faulty method of delegating work in Maharashtra. The medical graduates of Maharashtra can rattle large lists from thick textbooks- but in practical situations they really are never taught to function as professional. This I feel is the key fault of the medical training here. I feel that the duties for interns and postgraduate students have to be clearly spelt. And how will we know that these have been done? Hence an exit exam at the end of internship and end of bond period is essential. For Psychiatry I will say every graduate doctor should be able to do a mental status examination, rule out common organic factors, manage common substance abuse, do emotional first aid, manage simple cases of depression and psychosis, screen for psychiatric disorders of children and elders. Every doctor needs to be given mandatory leave and learn to function within set working hours. Medical training is long and strenuous, doctors will need to learn their manners on the job. How will it happen when they are given tasks of paramedicals and harassed endlessly during training?

DOCTOR'S WORK- Behind the curtains

I generally make a chart of my working hours and put in my clinic. The schedule usually amounts to about 5- 6 hours of work daily. Seeing this, one full- time working friend of mine remarked, “I really envy you, you work so few hours”. Well, its true that my time- management could be the envy of most of my colleagues- but the declared business hours is not the only work I do. Most patients also labour under the impression that when the doctor is not available for consultation, the doctor is generally enjoying or maybe swatting flies! One patient has gone as far as suggesting that it should be made compulsory that doctors are available for consultation certain number of hours; after all the Government subsidizes their education and they need to pay back.

Firstly, a number of patients are regularly seen by doctors outside their declared working hours. Patients arriving late due to genuine reasons have to be accommodated. Patients arriving with emergency or alleged emergency problem have to be seen (without seeing one cannot determine if its emergency or not). Patients admitted in hospital have to be reviewed one or multiple times in a day. Surgeons have to do operations and deliveries have to be conducted, etc. All outside ‘declared’ outpatient timings.

Besides, seeing patients is only the ‘performance’ part of our work. For this a number of background activities have to be maintained on regular basis. It’s like the Abraham Lincoln saying- ‘Give me 10 hours to cut a tree and I will spend 9 hours sharpening my axe’. A very large amount of time, at least about 10-15 hours a week, has to be spent in reading up, attending educational programmes just to keep up with the latest developments in the medical field.  It has to be done continuously and regularly. No matter how small a practice, every doctor has to spend time studying their own practice so that one can respond intelligently to the needs of clientele. This is called research. This takes up at least 2 hours every week. Necessary administrative work like filing tax returns, getting different licences, staff recruitment and management, estate management also is part of private doctor’s professional work. This is really quite time- consuming work and takes almost an hour or two of the doctor’s time daily.

So the declared business hours (OPD timings) are actually just a part of your doctor’s work. Make the best of that time by scheduling appointment and arriving on time for it.

ESCAPE THE CAREER TRAP

For a very long time after I graduated, I desperately wanted a job. Actually at that time I needed one too- for financial and emotional reasons. But as things happen, I could not get any job. In that time I managed to keep afloat professionally and personally.... And right at the time when I did not need the job, I got one. Of course, I wanted it- very badly so I jumped into it. It made me happy for exactly 5 days. After that I kept hearing ‘this is a job not a career’...’this is a career not a life’......’this is work not passion’. The day I understood what all these platitudes meant I gave my notice and quit....and escaped the trap called ‘career’.

For the last 50 years, men and women, boys and girls have been brought up on the myth of a ‘career’. The word evokes such a mix of accomplishment, status, affluence and sheer snobbery that a majority fall for it. Everybody is supposed to decide and understand something called their ‘identity’ and stick to it. Young women with little babies become depressed because they have been unceremoniously shut out of their ‘career’. Kareena gets a thumbs up because she does not let motherhood interfere with her career. Men are expected to relocate to wherever their jobs are because they have a career to make. This is not a gender issue at all....the myth affects all who are naive enough to be drawn into it.

Gender equality is the phrase used to fire young women into giving up everything in the service of industry. Men are expected to settle for no less than 16 hours of work and aspirations to be the CEO. So even if some people would rather choose needlework or to spend time with family, they are made to feel stupid about these choices. To assuage their guilt we invent childcare centres with cctv camera, quality time parenting, certified elder care manpower, spouse- dating and art exhibitions. Actually all these amount to nothing if you are doing it just to further your career.

A career is meant only for three categories of people- people who are competitive by nature need it to remain sane. People who have poor social and financial support need it to make something of their lives. And a third category is people who have nothing else in their life to look forward to....this last category need career only for a while though. All other folks should look at education only as a means to acquire the wherewithal to do what they like so that it can start paying them. Then proceed to work as few hours as possible working to earn money and rest of it to enjoy the work. One must be able to cut down on the working hours to be able to do anything that one needs to do or wants to do....including non-remunerative tasks like being with one’s children and parents, or doing embroidery or painting one’s bicycle.

A person without a career could be a lucky person.....for this person has a life                                                  

Consumer is king.....but what about patients?

The Tide of corporatisation of healthcare has swept over India in the last decade. From being sanctuaries in the middle ages to being temples of healing in the last century, hospitals are now evolving into commercial centres. Patient is cast as a ‘consumer’ while healthcare professionals are ‘service- providers’. Today the hospital is designed like a factory with its staff as workers. Unfortunately, health can neither be manufactured nor be bought. In this fact lies the irony- while patients’ narcissism is massaged by advertising spiel- the larger population have not understood what to really expect. 

Consumer- patient

No human willingly chooses to become a patient. (Only exception, being the cases of psychological disorders in which persons are fascinated by doctors and treatments. Let’s leave this category aside.) For illness is an unwanted imposition to be got rid of as soon as possible. In the best cases it is treated as a character- building adversity.  So a person just happens to become a patient. A patient becomes a consumer when he chooses to ‘buy’ healthcare ‘products’. This product maybe an investigation, treatment, therapy, convalescence or palliation.

Service- providers or expert professionals

 The difference between corporate medicine and rest of corporate India is vast. Except few administrators and expert doctors all other staff are either contracted, interns, students or observers. Every corporate hospital runs its own nurses training, post graduate medical training and other courses- the students provide free or cheap labour to run the hospitals. While rest of corporate India enjoys a 5- day week, corporate hospitals work 6 days (the hospitals are manned by rotation duties. These rotations are done every 6 days with one day off). Mandatory 36 days paid leave, maternity leave, on site child care, medical facilities- are not usually given.

The problem is the problem

Common complaint against corporatisation is high expenses. This is a genuine problem and activists are working on it. Bigger concern is changing framework of illness and its treatment. The reality about illness and treatment is this- one cannot choose the illness, its timing or intensity. Similarly no patient can hope to recover by mere administration of treatment without an interest or effort on part of the patients. Corporate healthcare is trying to actively hide these facts.

Advertisements make tall claims about prevention of illness by undergoing battery of diagnostic procedures. No tests can prevent illness. If you become ill at an inconvenient time, the corporate hospital promises to give you treatment without a break in your commitments. A part of this is the active encouragement given to patients to arrive late for appointments and to not be compliant towards treatment recommendations which get in the way of their life (eg alcohol use during treatment). Has anyone ever heard of a running car being repaired? But corporate healthcare promises that to humans.

As stated earlier, health is a commodity that can neither be manufactured nor bought. A few lucky people are born with good health and continue to enjoy its benefits without much effort. Many of us are able to cultivate healthful habits. Yet for most of us illness is inevitable. Patients have to approach for help. The responsibility of arriving on time, reporting problems honestly, taking treatments as advised- is completely with the patient. Going to a corporate hospital with excellent quality ratings alone, never helps. Patients should learn to differentiate between hospital and hospitality and between treatment and pampering. In this lies the difference between a common patient and a wise one.

Conclusions

The trend of corporatisation has given a false sense of security that they will be assured of good health with payment of steep charges. But no illness can be treated just from the outside without participation of the patient. Patients should be willing to do their part of the hard work to recover, merely throwing money will get them nowhere.

MENTAL HEALTH PROFESSIONAL AS A LIFE COACH

Lately I come across a number of business cards of my colleague Psychiatrists where they mention their work as being ‘Life Coach’. In general, I have been sceptical of the concept of life coach- I think it’s just a modern version of ‘Guru’, ‘Baba’, etc. It appears that talented, accomplished people cannot trust their own judgements at some point of their lives and the above category of persons fill the need so created. I wonder if there are any courses to become a life coach and I have heard of highly questionable methods like ‘whats your favourite colour today?’ being used to guide the person by life coaches. Anyway, this post is not about life coaches- but about mental health professionals functioning as life coaches.

Mental health professionals like Psychiatrists, Psychologists or Psychiatric Social workers are trained in the diagnosis and treatment of mental disorders. During training, their exposure to problems of ‘normal’ life is limited- at least in India. Most of the times the number of mentally ill is in such excess to the people dealing with problems of daily living- so critical and professional evaluation of persons with functioning lives is quite rare. Professionals in private practice may have a greater chance, but again I have my doubts. Psychiatrists spend about 5 mins with one patient, while psychologists have simultaneous tests running in 3 cabins. Very few professionals actually see their patients for long durations. And then there is the problem of doctor- shopping by the capricious patient, because of which the drop-out rate of patients in therapy is considerable. So I doubt how many mental health professionals are really doing therapy and have accumulated the diverse, rich and deep experience to be able to contemplate on the problem that is ‘LIFE’.

So when I see life coach printed on the business card- I am prone to be sceptical- particularly if the professional is young, has a busy practice and not known to be contemplative (through lack of writing/ presenting/ researching).

ATTENTION- FORMER CHIEF JUSTICE, SUPREME COURT OF INDIA

To,

Justice R S Lodha,

Supreme Court committee,

Overseeing working of Medical Council of India,

Delhi.

Subject-  Requesting your intervention in matter of ‘cut- practice’ in medicine

Respected Sir,

I read in the newspaper that a committee under your able chairmanship has been set up to study and monitor the working of Medical Council of India, with particular reference to corrupt practices. I am writing this letter with the hope that something may be done about  ‘cut- practice’ in the medical profession.

‘Cut practice’ is the system of earning commission for referring patients to a particular doctor or medical organisation. It undermines medical care and harms the patient. Hence, it must be stopped as soon as possible. Cut- practice is labelled ‘unethical’ but the MCI or Maharashtra Medical Council have no set procedures to investigate or punish violations. It is not ‘illegal’ as there is no law against it.

 In 2013 Dr Bawaskar filed a complaint in the Maharashtra Medical Council about one such instance. Though the fact of giving cuts in this case was proved and admitted to by the defendent, no action can be taken on basis of a technicality- that the cut was issued not by an individual doctor but by a medical organisation. In effect, it seems that cut-practice is unethical for individuals but a legitimate business practice for groups of individuals. This can only be termed as a travesty. The case is now stuck at this point at the Mumbai High Court. Meanwhile, the Medical Council of India has passed a circular stating expressly that its mandate is only to act against individual registered doctors and not against organised group of doctors, further bolstering the above case. (I can provide you the details, if you wish. Meanwhile, you may see them on my blog mentordoc@blogspot.com)

 These developments are dangerous for the public. It endangers the ability to choose medical treatment that is competent and affordable. The most important intervention would be to bring medical organisations, associations and commercial healthcare entities under regulation by making registration under medical councils mandatory. Medical ethics and laws should be the same for individuals and groups.

I, therefore request you to study this matter deeply. With your knowledge, experience and authority you may be able to suggest a suitable remedy to stem this rot. Sir, an effective action will bring succour to all Indians. I exhort you to please do something in this matter.

I also request you to kindly acknowledge this letter, at least through email.

With much anticipation

Sincerely,

Dr Vani Kulhalli

(I HAVE POSTED ON BLOG BECAUSE EVEN AFTER 3 mts of SEARCHING I WAS UNABLE TO GET THE POSTAL OR MAIL ADDRESS. I JUST HOPE THIS WORKS.)

TIME MANAGEMENT IN PRACTICE

http://bmjopen.bmj.com/content/4/5/e004679.full

This is a continuation of my previous piece about time management in medical practice.

There is a lot of anger among the public over waiting in the doctor’s clinic. As  patient is in discomfort and pain, there is an expectation of relief at the earliest. When this expectation is not met- anger is likely. Some doctors do not care to organise their practice leading to time mismanagement and delays. The worst offenders are doctors who call all patients at the same time, so that they can arrive after a sizeable number assembles and then proceed to rush through the que. This is wilful waste of the patient’s time which is completely unforgiveable. Some doctors have given up on time management thinking it is a hopeless attempt and just announce their working hours. Any patient arriving within that time is seen on a first come first served basis. So essentially there is no appointment given. In all these scenarios the doctor has designed a schedule which is heavily weighted in the doctor’s favour and in favour of a patient who is disorganised consumer. Yes, some patients do feel reassured taking treatment from a busy doctor who makes them wait for hours- these patients are welcome to wait.

Working by appointments is by far the best way to work. It is good for the doctor as well as for the patient. It is the doctor’s responsibility to implement a system that ensures time management. The most important intervention to reserve the first two slots of the day to patients who are known to be punctual. Work must BEGIN ON TIME.  Second important intervention is to turn back and reschedule appointments of patients who come late. Patients should be accommodated for reasonable delay which may be upto 15 mins. Beyond that appointment stands cancelled. Thirdly, after every 4-5 appointments, an empty slot should be kept to accommodate delays and extended sessions. On certain days, when time- consuming interventions like therapy are to be done , patients come prepared to wait because I inform them in advance- so that is okay by them. I keep my side of the deal by not charging patients if I make them wait excessively, irrespective of who is at fault. Majority of patients appreciate the doctor’s punctuality. There are some patients who cannot understand all the fuss- but well the doctor has to take responsibility for clinic management not the patient.

After doing this for 15 years, I have a beautiful practice which allows me to start my day as planned and end it on time. 

UPDATE ON CASE

The case Dr Bawaskar vs N M Medical Centre reached the hearing stage this Saturday, that is on 16th April afternoon.

Justice Kanade and Justice Dharmadhikari heard the case and admitted the petition and have granted a stay to the defendent.

I can only hope for an outcome that benefits the common person who is unable to take any measures to protect himself/ herself from the systematic crime of cut- practice.

MCI, PLEASE OBLIGE

When we were students, we had to learn medicine, surgery, obstetrics and gynecology, ophthalmology, ear-nose-throat diseases, orthopediacs and paediatrics as separate clinical subjects. Psychiatry was dealt with in 1-2 lectures, 15 days in the second year and about 15 days of posting in internship. The medicine paper was supposed to have a question on Psychiatry which was usually a short note on one of five favourite topics (which unfortunately did not include depression).

This was 15 years ago. Now when I meet my classmates, irrespective of speciality or area of practice or even if some of them have switched their professions- all my classmates rue the lack of special training in Psychiatry. Most of my non- psychiatry colleagues have told me how a significant portion of their practice is actually psychological intervention or psychiatric treatment. One family physician joked to me that he will have very minimal practice left if he begins to refer patients with psychological problems to Psychiatrists instead of treating them himself! Considering all these experiences, it is very clear that a special training in Psychology and Psychiatry would have been indispensible.

All things cannot be covered in undergraduate medical education because of the vast and changing nature of medical science. Invariably, some amount of learning happens on the job when the doctor actually settles down to start work. So some authorities have argued that psychology and psychiatry will be ‘automatically’ learned by doctors when they need it. So we see a good attendance at CME programs of medical associations when the topics are related to psychiatry. But what about clinical skills? CME programes are only lectures and I don’t know how doctors will learn the clinical skills of mental health care.

Unless the MCI mandates that clinical skills have to be learned, the students will not be able to do so during MBBS. After MBBS, even if they want to pick up these skills, who will teach them? Technical knowledge in psychiatry can be picked up in the CMEs but clinical skills have to be learnt during undergraduate clinical training only. So our MCI should include testing of clinical skills in psychiatry and psychology during exams. Then there is a higher probability that students will imbibe these skills. Leaving market forces to create motivation for this learning is not the right approach. I hope the MCI will oblige.

" Depression in young adolescents" A review

CITED AS-

KULHALLI, V.. Depression in Young Adolescents. The Indian Practitioner, [S.l.], p. 63-65, aug. 2015. ISSN 2394-3017. Available at: <http://theindianpractitioner.com/index.php/tip/article/view/77499>. Date accessed: 14 Sep. 2015.

http://theindianpractitioner.com/index.php/tip/article/view/77499