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