BOVINE SPONGIFORM ENCEPHALOPATHY

PUBLISHED IN GOLDEN JUBILEE SOUVENIR OF BYJEMEC, B J MEDICAL COLLEGE, PUNE IN 1996.

THE WORLD AROUND YOU

I have worked in private practice as well as in an institute. My impression is that the amount of work a psychiatrist gets does depend on the setting of work.

In an institute, I have observed that the threshold for asking a Psychiatrist to get involved is rather low. We get referred any case and every case. Hence the workload is considerably high. Whereas, in private practice the referrals are slow to come. Even serious and purely 'Psyhciatric case' like suicide attempts and psychoses are retained by doctors from other specialties. Thus cases are fewer.

One explanation for this is due to the desire to work less and also to make more money; both being at the cost of the patient's welfare.

 In the first instance, the patient would benefit from continuing care of the Physician/ orthopedician, etc. But the salary remaining constant, this doctor has nothing to gain from keeping the patient in the wards and increasing his/ her workload. This doctor also has a culture of concrete thinking, where seeing ONLY is beleiving and quality of life has no meaning. But if patient is not accepting his explanation that everything is ok, and the relatives refuse to take the patient as he/ she is still distressed or troublesome, the doctor bounces off the patient to the Psychiatrist. No Psychiatrist can refuse to take care of a patient who is obviously uncomfortable. So the patient with many medical problems, and just mental symptoms (not mental illness) gets shifted to the Psychiatry ward. Now the Psychiatrist and the patient have to keep begging the referring doctor to come  regularly and have a look to maintian the physical status. This gives the additional incentive of 'ego massage' to the referring doctor, who believes that Psychiatrists are lesser mortals and anyway dont have any work to do.

The scenario is much different in private practice. Every doctor believes that Psychiatric disorders are not disorders at all and counseling will set everything alright. They are scared to use psychiatric drugs in proper doses, but since they are so intelligent they will open some book, find a few names of psychotropics and discharge the patient with a scolding and 'good advice' (which is their version of counseling). After all by treating the patients themselves, and keeping them ill as long as possible, there is money to be made. When the patient becomes fed-up or very ill, they will, very reluctantly refer to the Psychiatrist. By this time the disease has progressed to such an extent that it is a tuff situation even for a Psychiatrist and the improvement proceeds slowly, partially or not at all. Then they confirm their delusion that 'Psychiatrist know nothing and do nothing' and malign them.

I feel every professional should spend some time educating themselves about the thresholds for referral to Psychiatrists. They can just make it a habit to talk to the Psychiatrists about the cases they have referred; over the years they will learn. Of course, one can do nothing aboout unscrupulous persons who dont want to refer patients.

I am sure this discussion applies to referrals between other specialties also.

WHAT THIS BLOG IS ABOUT?

This blog is for doctors and about doctors. It will contain topics about the medical profession, and about psychiatry.

PROPOSED BILL ONHUMAN RESOURCES IN HEALTH

PROPOSED BILL ON

HUMAN RESOURCES IN HEALTH

AND IT’S IMPLICATIONS

THIS BILL IS SUPPOSED TO REPLACE EXISTING MCI

The National Council for Human Resources in Health Draft Bill, 2009

No. -- Of 2009

An Act To provide for the constitution of the National Council for Human Resources in Health for prescribing standards with a view to the proper planning and co-ordinate development of medical and allied health education throughout the country, the promotion of qualitative improvement of such education in relation to planned quantitative growth, the maintenance of a national live electronic register of medical and allied health professionals and to provide for an overarching framework for the regulation of human resources in health in the country and proper maintenance of norms and matters connected therewith or incidental thereto.

CHAPTER II

 NATIONAL COUNCIL FOR HUMAN RESOURCES IN HEALTH

            Establishment and incorporation of Council - (1) with effect from such date as the Central Government may, by notification appoint, there shall be established for the purposes of this Act, the National Council for Human Resources in Health.

(2) The Council shall be a body corporate by the name aforesaid, having perpetual succession and a common seal, with power, subject to the provisions of this Act to acquire, hold and dispose of property, both movable and immovable, and to contract, and shall, by the said name, sue or be sued.

(3) The Council shall consist of a whole time Chairperson, and not more than four whole time members, to be appointed by the Central Government in accordance with section 5 of this Act.

(4) The head office of the Council shall be at New Delhi.

Qualification for appointment of Chairperson and other members - (1) Before appointing any person as the Chairperson or member, the Central Government shall satisfy itself that the person is an Indian citizen of eminent ability, integrity, social commitment and professional standing with adequate knowledge and experience, at least of 10 years, in dealing with medical or health education, regulation of university level professional education or leadership of non-medical academic institutions imparting education in disciplines such as law, management or public administration.

            Appointment of Chairperson and Members – (1) The appointment of Chairperson and Members of the Council shall be made by the Central Government through Appointments Committee of the Cabinet on the recommendation of a Selection Committee.

(2) The Selection Committee shall consist of the Cabinet Secretary, Principal Secretary to Prime Minister, Union Secretary for Health & Family Welfare and two technical experts drawn from the Search Committee.

(3)   The Search Committee shall consist of the following, namely.

a.       Secretary, MoHFW, GOI as the Convenor

b.      Four other members of eminence in the field of health, education, social development and public administration as may be appointed by the Central Government.

c.       Secretary, Department of Health Research, ex-officio member

(4)   The Search Committee shall recommend suitable names for consideration of the Selection Committee on a ratio of 1:3.

(5)   The Selection Committee shall recommend five names, to the Appointments Committee of the Cabinet, for appointments and three other names for a reserve panel of selected members for appointments in case of any vacancies in the Council for reason other than temporary absence.

            Terms and conditions of office:–

(1)               The Chairperson and other Members shall hold office for a term not exceeding three years, as the Central Government may notify in this behalf, from the date on which they enter upon their offices or until they attain the age of seventy years, whichever is earlier.

Provided such term may, on a recommendation made by the Selection Committee, be extended to another 3 years.

(2)               The salary and allowances payable to and the other terms and conditions of service of the Chairperson and whole-time members shall be such as may be prescribed by the Central Government.

(3)               The salary, allowances and other conditions of service of the Chairperson or of a member shall not be varied to his disadvantage after appointment.

(4)               A vacancy caused to the office of the Chairperson or any other member shall be filled up within a period of one month from the date on which such vacancy occurs.

(5)               Notwithstanding anything contained in sub-section (1), a member may—

(a)        Relinquish his office by giving in writing to the Central Government notice of not less than three months; or

(b) Be removed from his office in accordance with the provisions of section 7.

            Powers of Chairperson – The Chairperson shall have powers of general superintendence and directions in the conduct of the affairs of the Council and shall preside over the meetings of the Council.

            Removal of Chairperson or Member –  (1) The Central government may by order remove from office the Chairperson or any Member if the Chairperson or the Member, as the case may be,—

a)      is adjudged an insolvent; or

b)      has been convicted of an offence which, in the opinion of the Central Government, involves moral turpitude; or

c)      is, in the opinion of the Central Government, unfit to continue in office by reason of infirmity of mind or body; or

d)     has acquired such financial or other interest as is likely to affect prejudicially his functions as the Chairperson or a Member; or

e)      Has so abused his position as to render his continuance in office prejudicial to the public interest.

(2) No such member shall be removed from his office under clause (d) or clause (e) of sub-section (1) unless he has been given a reasonable opportunity of being heard in the matter.

            Meetings of the Council

            Vacancies etc., not to invalidate proceedings of the Council

                                   

POWERS AND FUNCTIONS OF THE AUTHORITY

            Permission to establish new institution or new course of study etc.

            Recognition and approval of courses

            Recognition of qualifications

            Recognition of foreign degrees/qualifications

            Withdrawal of recognition

            Maintenance of world class medical and health education

            Monitor institutions and bodies constituted under the Act

            National Register of Human Resources in Health –

            Professional conducts

            Power to require information as to courses of study and examinations

Visit and inspection of examinations

            Powers of central government-Can override any decision of council

NATIONAL LEVEL EXAMINATION

            National level exit examination – (1) The Council shall conduct a national level exit examination for broad and super speciality post graduate in medical and/or health education as a standardised examination that may be taken by anyone with a postgraduate qualification recognised by the Council.

                                

(3) The national exit exam will be equivalent to an MD/MS awarded by any recognised university in the country.

(4) The Council may conduct a national standardisation examination for undergraduate programmes and mandatory screening test for candidates having successfully completed undergraduate program from a foreign institution that is not recognised by the Council.

(5)Notwithstanding anything contained in this chapter all central and state universities shall continue to conduct their own examinations and award degrees thereon.

(6) The National Board of Examinations (NBE) shall be abolished with the coming into force of this Act

(7) The national exit examinations shall be conducted online through the internet, and will mostly follow a multiple choice format including the clinical aspect of medical practice as may be prescribed.

(8) Individuals possessing the requisite criteria, as prescribed by the Council, for appearing for the national exit exam will be classified as ‘board eligible’, upon passing the exam, an individual will be classified as ‘board certified’.

(9) In order to be ‘board certified’ one must qualify within 3 years of being ‘board eligible’.

(10) All ‘board eligible’ candidates may practice in non-academic institutions. To be appointed in an academic institution, an individual will need to either possess a post graduate degree from a recognised university or be ‘board certified’.

STATE REGISTRATION BOARDS

Similar to central council state councils will be established

IMPLICATIONS TO MEDICAL FRATERNITY

1)NO REPRESENTATION TO MEDICAL FRATERNITY

2)OVER CENTRALISED

3)GOVT CONTROLLED,BUEROCRATIC,UNDEMOCRATIC

4)EXIT EXAMINATION-ANOTHER EXAM !!

5)ACCREDATION POLICY

WHAT NEEDS TO BE DONE

1)CONCERTED SYSTEMATIC OPPOSITION

2)MEET ALL MP’S

3)ALL DOCTORS ASSOCIATION SHOULD COME TOGETHER

4)ALL ASSOCIATIONS SHOULD EDUCATE THEIR MEMBERS ABOUT SUCH DRACONIAN LAWS

5) IMA OWN ACCREDITION

NATIONAL COMMISSSION FOR HUMAN RESOURCES IN HEALTH BILL 2011

HIGHLIGHTS

NATIONAL COMMISSSION FOR HUMAN RESOURCES IN HEALTH BILL 2011                                                                           (NCHRH)

·        Decentralization is a slogan of the Union Government for better organization and achievements.  But it is unfortunate to learn that the benign Government is proposing for centralization of powers by forming National Commission and by taking away the autonomy of all the concerned Board, Councils and other wings of the Union Government for health.

·        The Bill in preamble – States to supervise and regulate professional councils in various disciplines of health sector. Page (1) However, subsequently it dissolves all the existing Councils and takes away all their duties and fund. 

·        The statement of object and reason for the bill section (2) page 53 says “……. to reduce shortage, standardize quality and bridge the uneven distribution of existing work force in the health sector”.

-      With No roadmap.  How is the Government going to reduce the shortage of manpower by forming this Commission?

-      Use of attractive words will not solve the problem. 

-      There is no need to dissolve the existing health Councils to achieve this purpose. 

-      Health is a State subject and resources cannot be redistributed by the Central Government.

For example - “There is acute shortage of water & electricity in various parts of the country.  Will the Central Government constitute the Commission to make even distribution?”

·        Hon’ble Prime Minister of India said “India needs more Family physicians and efforts will be taken to increase the importance of Family physician.

Contradicting to this the bill says 4(c) page 53 “….to ensure uniform augmentation of trained specialist and super specialist” as its priority. 

·        The seventh schedule in continuation of section 68 in Part I (30) (page 50) says getting engaged in any business (or) occupation other than health professions is misconduct.

This prohibits all career opportunities for health professionals.

·        National Commission, the proposed supreme body with vested powers will not have elected members and State representatives to represent their needs and demands.

Professionals from other discipline of Management technology and law are given place in this Commission which will pave way for dilution and nepotism.

It is unfortunate that in a democratic country elected representative Council is brought under power of non democratic body.

-      Health is a State subject.

-      Independent Councils is the need of Medical Professions.

-      NCHRH will do more harm to health education and health care of India. 

-      In short NCHRH is of the Government by the Government and for the Government and not for health care and medical education.

IMA’s View Point on BRMS / BRHC

IMA’s View Point on BRMS / BRHC

·         Government of India has decided to introduce a short 3 years course in modern medicine  called BRHC(Bachelor of Rural Health and Care) exclusively to serve the villages. Originally it was named BRMS (Bachelor of Rural Medicine and Surgery)

·         This decision is under the pretext that doctors are not available in villages and with the full connivance of MCI (Medical Council of India), purportedly follows a  questionable Delhi High Court directive.

·         IMA strongly opposes this ill advised move.IMA questions the bonafides of such a decision.

·         The full 5 ½ years M.B.B.S course equips the medical graduates to function as competent practitioners of modern medicine. Any deviation from the exacting standards and schedules will certainly pose danger to the society.

·         It is understood that for this purpose medical schools will be started in District Hospitals. The recruitment of the students will be from rural areas and on completion of the course they will be obliged to serve in the native rural areas for five years. It is also proposed to give license to practice for one year which is liable to be renewed every year for a period of five years. At the end of the fifth year of service in the rural area, the graduate will be given permanent license to practice. Such graduates will also be given an option to undergo a bridge course so as to enable them to obtain the regular M.B.B.S degree.

·         The value of human life in all areas is one and the same. Life of persons living in rural areas is as important as the life of persons living in the urban areas .There is no disease confined exclusively to the rural or the urban area either.

·          There are better ways to overcome the shortage of modern medicine professionals in the rural area. Lowering the standard of medical education and producing low quality professionals is not the solution.

·         In the process of introducing separate set of medical professionals exclusively for the rural India, the Government is infact resorting to discrimination against rural citizens treating them as second-class citizens. The same will be in flagrant violation of the fundamental right of the rural citizens of India to have quality health care. The discrimination could sow the seeds of discontent.

·         Instead of rendering medical service to the rural population in a manner equivalent to that is available to the urban population, the Government itself is bringing out an inequality and irrational discrimination. This is violative of Article 14 of the Constitution of India. 

·         Since the matter relates to the life and healthy living of a human being, this infraction of the basic feature is also bringing about a violation of Art 21 of the Constitution of India.

·         Any legislation in this regard which will be brought by the Union of India will be a colorable exercise of power and will be vitiated by lack of legislative competence.  Any such course will be against the mandate of Sec 15(2) (b) of the Indian Medical Council Act.

·         Any legislation that may be brought will not be in consonance with the directive principles of State policy enshrined under Art 38(2) and 47 of the Constitution of India.

·         Public health being a state subject under Entry 6 List II of the Constitution of India, Government of India have no right to take any such policy decision to employ the BRHC professionals in the sub-centers, PHCs and District Hospitals situated in the rural part of India. It is for the state Governments to take decision in this regard. The decision taken by the Govt of India to introduce the course named Bachelor of Rural Health Care, which will enable the graduates of the said course to practice modern medicine in the rural areas is beyond the competence of Govt of India. It is unconstitutional, illegal and unenforceable.

·          New medical colleges can be started with the same effort of establishing medical schools for introducing BRHC course.The existing medical colleges are hamstrung due to paucity of qualified faculty. Certainly it will be a difficult task to find trained faculty for the new course in medicine attached to the District Hospitals.

·         It will dissuade regular doctors from serving in rural areas. If the service of qualified doctors is denied to the rural population, early detection of complicated diseases and providing appropriate treatment will be impacted.

·         Suboptimal impact on disease burden in rural areas is not due to shortage in human resources alone. Vacillation of policy makers and their  inability to choose between primary health care and vertical programmes is a serious flaw. More over inadequate strengthening of referral mechanism has resulted in a system failure.

·         The Bhore Committee way back in 1946 recommended the abolition of LMP, to lay the foundation for the present day health care delivery system. The objective was to ensure same standard of health care to all citizens of India.  The move to start three year short term BRHC course puts the clock back by sixty years.

·         The responsibility of district health authorities is preventive and curative health care. Burdening them with training and teaching programme will lead to collapse of the existing system.

·         The notion that over 20-30% of PHCs do not have a MBBS qualified doctor is not supported by statistics provided by Government of India. Only 5.3 percent of PHCs went without a qualified doctor. Even this is due  to administrative inefficiency and exigencies. Efficient  administrative practices by concerned Health department should suffice.

·         To say that none of the 1,46,000 sub centers have a qualified MBBS doctor is a misrepresentation of fact to create a false case. The sub centers have been programmed to be staffed with one ANM and one male health worker only.

·         For whatever small shortfall that exists compulsory rural health posting of MBBS  graduates for one year  after internship  as practiced in Kerala would make available 30,000 MBBS graduates every year.

·         It may be noted that none of the health documents of the country have asked for  or planned a short term medical undergraduate course(Health policy 2002,Report of the national commission on macroeconomics and health 2005,National Rural Health Mission document 2005).

·         One has to have a holistic view of the situation rather than making scape goat of MBBS doctors. Poverty, Illiteracy, demography and good governance play a crucial role in  the disparity and inequity in health care between urban and rural areas.

·         In National Family Health survey-3, 84.5% of women in rural areas said institutional delivery was not necessary or customary or the family did not permit and only 1.1% complained about lack of female attendant in facility. This points to lack of health awareness rather than lack of MBBS doctors.

·         National Human Rights commission has come out strongly against such a course and has termed it as discrimination.

·         IMA strongly contends that there is any credible shortage of MBBS doctors to serve in PHCs. This has not been substantiated by data. There is no rationale need for creation of a short term course in modern medicine. This will only lead onto dilution of medical standards and will endanger patient safety.

·         A qualified and practicing doctor is not the only person responsible for health care delivery. The role of the nursing staff,paramedical staff,health workers,laboratory technicians,pharmacists and other catagories of health workers is equally important. Producing substandard doctors in large numbers will only create mismatch of human resources. It is not the panacea for large shortfall in health workers, paramedics and laboratory technicians.

·         Safe drinking water, sanitary toilets, environmental cleanliness, shelter, nutrition, personal hygiene, basic educational status of the public, social customs and habits and disease preventive measures are also major factors in improving the health conditions  of the citizens of rural India.

·         15 (2) (b) of the Indian Medical Council Act, 1956 is the most decisive clause as far as setting standards for the practice of modern medicine. It is also pertinent to mention here that the requirement under Section 15(2) (b) of the IMC Act is similar to the requirement of medical qualification world over. Section 15(2) (b) of the IMC Act actually protects the fundamental rights of every citizen by ensuring adequate access to quality health care.

·         Registered practitioners under other systems of medicine and the modern medical practitioners in the private sector have not been taken into consideration.

·         50% of the  seats in postgraduates diploma courses are being reserved for medical officers in the Government Health services in all the states, who have served for at least three years in remote and difficult areas. After acquiring the PG diploma of two years duration, the medical officers shall serve for two more years in remote and or difficult areas.

·         In determining the merit and the entrance test for postgraduate admissions, weightage in the marks may be given as an incentive at the rate of 10% of the marks obtained for each year in service in remote or difficult areas upto the maximum of 30% of the marks obtained.

• MCI has already approved the decision of its postgraduate committee with regard to reservation of 25% of the seats in postgraduate degree courses being  filled through all India examination for doctors who have served for at least 3 years in remote and difficult areas  with a rider that after acquiring the postgraduate qualification they shall serve for 3 more years in remote and difficult areas.

·         Adequate allowances and facilities like rural service allowances, proper free accommodation, education allowances for children, vehicle or vehicle allowances, appropriate reservation for education and employment for their children, sabbatical leave for academic enhancement of Doctors, allowances for attending academic conferences for updating their knowledge, facility for interest free personal loans should be provided to doctors serving in rural areas.

·         Full utilization of the private medical sector including out sourcing of investigative/ Diagnostic facilities and  part time service in Primary/ Rural Health Centers. 

·         Encourage private participation in Rural Health care by offering free land, interest free loan, preference in water, electricity and other support facilities at concessional rates.

·         Increasing the number of seats for MBBS and Post Graduate Courses in the existing Medical Colleges is also an option.

·         Enhance budgetary allotment for Health care from the present 2.1% to 12% of GDP. If the funds are adequately allotted and effectively utilized manpower deficiency can be overcome and better health care can be provided. Wherever NRHM is working efficiently there is no dearth of manpower even now and health care delivery in the rural area has improved remarkably. 

·         Say no to BHRC and save our villagers.