HEALTH ISSUES DURING RESIDENCY TRAINING

Post graduate residency training will be a time with lots of work, study, responsibility and most doctors will fall prey to some or the other health problems during this time. If not anything else, poor management of health will lower your immunity and make you prone to frequent mild infections. It is also the most enjoyable time in life and losing out on any fun due to health reasons will be a pity. Therefore every doctor entering Residency training should work out a comprehensive healthcare self-management program and practice it throughout Residency.

Environment modification is out of the question, the poor environment itself is cause of most health problems. So one should work on prevention and strengthening immunity.

Get used to waking up early and having bath everyday- thats the only time bathrooms in hostels are available so that you may have a clean proper bath. Bath is necessary- poor hygiene leads to infections and infestations. Remember all hospitals are dens of very bad infections like TB and malaria. All living quarters and workplaces are full of scabies, bed bugs and lice. One can never over-emphasize the need to be clean and hygienic. Also wearing clean clothes is important. Always wear ironed clothes- heat can kill lots of germs and wash your own underwear. I also used insect repellant cream and spray everyday almost like lipstick and other cosmetics. I regard it as being more important than 'Fair and Lovely'. It is really effective in keeping away mosquitoes and bed bugs.

Never miss breakfast. Always have a heavy and nutritious breakfast. I got used to adding Horlicks to my milk/ coffee- I believed it gave me extra nutrients. Try to go out of the hostel at least once a week to have a good breakfast- all hostels provide pathetic breakfast which is nutritionally very poor. The least we can do is go out a buy something healthy. Always make it a habit to make healthy choices in food- such as idli, paranthas, rice-dal, pulses, sambar, etc. Definitely stay away from alcohol, cigarrettes, drugs, sleeping pills, stimulating pills, excess tea/ coffee. These things will surely ruin your health in the short-term itself and your Residency training will be a disaster.

Most doctors neglect exercise because they believe that hard work is equal to exercise. It is not true. One should purposely exercise, even if it is irregular. I had made it a habit to grab my swimming costume and head to the pool whenever I got a break between 3 and 5 pm. This would be about 5-6 times a month (other than Sundays), which is good enough frequency. Many excellent bending-stretching exercise modules for workplace are easily available on internet and doctors should use one of these. Doctors can always take 10-15 mins break during the day to do these. This helps to tone and strengthen your muscles. This is very important as long hours bending over microscopes, standing in OT or even doing Op consultations can cause lot of unnecessary pain and discomfort.

Although most of your time will be spent working/ studying and rest of it .....resting- do cultivate at least one hobby. You can devote even 1-2 hours a week doing this activity. I have a great passion for needlework and I regularly worked on my pieces during Residency. It helped me to really cool down and feel calm after hectic day of work.

Learn the art of time and people management. These two will help you to minimise the stress that is part of Residency. In every hospital you will meet seniors who will appear to persecute you endlessly and juniors who appear to be lazy and incompetent. Remember that you are not in Residency training to assert labour rights or to avail of human kindness. You are here to learn to deal with problems as they are in the real world. Therefore you are always going to be short of time and help and you are always going to receive critical feedback. So give a thought to how you are spending your days, how you are dealing with people and try to devise solutions that will help you to improve your own situation.

Make it a practice to study regularly on a case-to-case basis. Later during practice, this habit comes handy. It is abnormal habit to work for 2.5 years and then devote the last few months to exam preparations. Ideally you should be ready to face your exam anytime after completion of the second year. This also minimises exam stress- which should be redundant term with respect to MD exams.

A lot of young doctors get married and start a family right away (Particularly Gynecologists). I think it is the foolishest thing to do. Both men and women should realise that parenting is a great responsibility- and you need to put aside proper 5-6 months for it. If you happen to take the plunge, be prepared to delay your graduation by a term. It is unfair on the child to give birth and then dump it on your parents or the maid- when you clearly know that you have to focus on your training and studies. Unplanned pregnancies are a source of severe stress- even to your clinical team. So preventing it is very important. If you must have a baby during Residency, the least you can do is to plan it. Hence knowledge and practice of contraception and safe sexual practices is as important to doctors as it is to their patients.

A lot of doctors do stupid things like riding dangerously without helmets when they have to reach fast, start examining a patient without gloves because he looks very sick or neglecting early signs of ill-health. Being intellectually smart and a having a good knowledge of disease will not protect you from the consequences of your stupidity. It will also not protect you from disease. So is the case about mental health problems. A lot of doctors who attempt to kill themselves will do so during Residency. That is also the peak age for onset of all mental illnesses. Dont be so ridiculous as to deny yourself treatment for depression/ anxiety/ ocd/ alcoholism just because you believe you cannot get mental illness. All hospitals with Residency training programs have at least one in-house Psychiatrist. And all of them will be more than willing to provide you with excellent, confidential treatment free of charge.

I feel very sad when I see that Resident doctors falling sick and wasting some days/ months of the best years of any doctors life. It should not happen. Residency training is a rare and special opportunity to grow into an independent professional. Keep a watch on your health and make the most of it.

PRACTICE MANAGEMENT

One must study and make plans on at least a few points before starting out in private practice. The following must be considered absolutely necessary:

Mission statement

This is a description of what your practice means to you. It should include your aims and objectives in starting practice. An outline of the type of set-up and the materials and resources should be included. Your values and ideals should also be stated. This mission statement should have validity for a fixed time period after which it will need to be revised.

Finances

There will be three financial stages roughly

1.     Starting phase- your earning will be less than expenses and you will make a loss.

2.     Middle phase- Your earning will generate income covering your expenses but you will not be able to satisfy financial commitments required for running your family

3.     Income phase- Your profits will give you enough money to live comfortably.

One has to make a sound plan for all three phases.

You will also have to decide your fees and make a plan a budget of expenses.

Team building

Even if you are a single-person unit, you will need to hire people to assist you in various tasks. This is your ‘team’. You will need a sweeper, cleaner, nurse, receptionist and locum and you must hire everybody very carefully. There is a tendency to hire the person who comes the cheapest. This is the riskiest way to choose your team. Even if it is for a task like sweeping check the person for expertise, regularity, integrity and then fix the remuneration. 

Marketing

In marketing one has to make efforts to inform target audience of your presence and availability. As medical practice is a professional and noble work, one must do the marketing ethically and gracefully. If you have to keep all these things in mind, a marketing strategy will have to be thought out in advance. Think out every minute thing: where you will put your board, what type of board, how will you describe your work to others, what type of stationery you will have, will you advertise (within permitted limits), etc

Initially you will have to visit other nearby doctors, educational institutions, NGOs, etc and introduce yourself. Your good work will advertised by the patients who have benefitted from your expertise.  Even if you do not get patients as soon as you expect, don’t get upset. Medical practice is largely a function of time and your good work. Always do your work with utmost sincerity and competence. This is the most effective marketing strategy.

Administration

A good administration allows you to remain in control of your practice. It adds experiential learning to your practice. Merely by doing your practice administration you will learn as much as no MBA course in the world can teach you. You should be able to have a system of recording and managing your expenses, time and manpower. Nowadays everybody has a computer. You can even use simple excel worksheets. You must maintain data base of expenses, income, travel, time spent, patients, employee attendance and performance, at the least. After getting the data, you will become aware of the assets and liabilities of each domain of your practice in the earliest stages. Then you can plan out how to deal with these intelligently.

Self management

This involves managing both physical and mental aspects of yourself.  Your appearance represents your practice in a concrete visual form.  You are to convey to the patients that you are competent, confident, sincere and reliable in your work. Doctors should decide on a type of dress that is smart, comfortable and culturally accepted. You should learn to speak in the local language and also in reasonably good jargon-free and slang-free English. Practice a polite, soft, clear way of speaking.

Take very good care of your health. A healthy doctor makes for a great role-model; an admiring clientele is the best type you could wish for. Choose a reliable and competent colleague as your family physician, steer clear of the tendency to self treat.

Most doctors are prone neglecting their mental health. Have a regular stress management strategy. Find someone to talk to, or to guide you in times of crises. Learn to deal with difficult situations in a systematic and logical way.

The first few years of practice are extremely stressful- they will test not only your expertise but also your character and human-ness. Plan as much as you can and take care. We need lots of competent, ethically motivated doctors to survive in practice.

Cut-practice- The role of consumer awareness

Cut-practice is such a thing that the 'victim' or patients have no means to protect themselves from it. Therefore consumer awareness has a very limited role to play in deterring this practice.

Consumer awareness will only make the patient suspicious and add to his/ her stress levels; there is no way to confirm whether the doctor is doing cut-practice or not. Even if I myself am a doctor, there is no way even I can tell that I am being charged for cuts or not. So how will any ordinary non-medical person figure out that and protect himself/ herself?

Hence, it is absolutely essential that doctors only have to cultivate the good sense not to get into this practice and fight against it.

 I feel whistle-blowers have a tremendous role in reducing this problem. Other than doctors, individuals like chartered accountants who give suggestions, professionals who supply software to automatically route the cuts, income tax officers who scrutinise, and such other stake-holders in this system should expose their clients/ write about it. At least stop contributing to it in any way. 

Lancet- Covering the case of cut-practice in medicine

Tackling corruption in Indian medicine
Some doctors and non-governmental organisations are taking up the fi ght against corruption in
Indian medicine, which many observers claim is widespread in the country. Dinsa Sachan reports.
When a cheque landed on the desk of
63-year-old doctor Himmatrao Saluba
Bawaskar, from a diagnostic centre
under the guise of “professional fee”,
Bawaskar not only returned it, but
he also fi led a complaint against the
centre with the Medical Council of
India (MCI), the national watchdog
for medical education and doctors.
His case is currently being heard by the
state medical council of Maharashtra.
Kickbacks have been part of the
Indian medical practice since the
beginning, says Puneet Bedi, a leading
gynaecologist based in New Delhi
who has appeared on Indian television
to speak about medical ethics in the
country. He notes that many hospitals
and clinics routinely issue cheques to
doctors under sanitised names such as
“professional fee” to encourage them
to recommend their services to their
patients.
K K Aggarwal, a Delhi-based physician
on the ethics committee of MCI,
says there’s no method at present to
document the percentage of doctors
taking kickbacks, but he admits that
the practice exists.
Recent trends may have accentuated
the problem. Bedi explains by citing
an example: out of some 17 million
inhabitants of Delhi, barely 1 million
can dream of getting treated at a
private hospital. “So all the hospitals
are vying for patients from that small
percentage of people”, he explains.
“If they’re not going to use kickbacks,
they won’t stay in business.” Bawaskar
adds that hospitals sometimes put
doctors under tremendous pressure
to reach a certain target number
of patients, and offering bribes for
patient referrals becomes the only way
to achieve that target.
Amar Jesani, editor of the Indian
Journal of Medical Ethics (IJME), says,
“It’s the patient who ends up paying
extra money [in medical fees] to cover
for the kickbacks.” Amit Sengupta, of
People’s Health Movement (India),
says people want to practise honestly
but they get sucked into the system.
“The system throws those out who
don’t conform to its rules”, he says.
Experts, including Jesani and
Sengupta, believe that one reason
malpractice flourishes is because of
MCI’s lethargy in cracking down on
wrongdoers. In 1996, a Chennai-based
nephrologist M K Mani wrote to MCI
and reproduced his correspondence
with a diagnostic centre that had
offered him a “professional fee” in
the IJME. The diagnostic centre had
repeatedly sent cheques to the doctor,
and even though Mani continued to
write to the Council, no action was
taken by the organisation.
Jesani adds that state medical councils
are also slow to act on issues. However,
last year, in response to a question in
parliament, the government said that
the MCI had received 1948 complaints
against doctors between 2008–09
and 2010–11. Of these, 718 were
referred to the relevant state medical
council, while the remaining
1230 complaints were dealt with by the
MCI itself. As a result, 32 doctors had
their licenses temporarily suspended
and 14 doctors were given a caution.
Still, Sengupta says, “In its current
form, the organisation is more
like a closed club consisting only
of doctors.” He advocates a more
democratised approach in choosing
its administrators. “There is a need
for more legal experts, administrators,
and civil society people in their
committees”, he argues.
Moreover, MCI has invited public
scrutiny and notoriety in the past
few years. MCI chairman Ketan Desai
was arrested and dismissed from the
organisation in 2010 on charges of
accepting a bribe. However, he was
later found to be not guilty. Following
this case, the government disbanded
the MCI’s governing body and
brought in a board of governors to
look after its aff airs. In a bid to restore
MCI’s functioning to its previous
format, elections will be staged
in early December to select a new
council, consisting of the president,
vice president, and the executive
committee.
S K Sarin, former MCI chairman,
defends MCI. “The MCI rules are quite
robust, but enforcement is a problem.
In my time, we cracked down on
plenty of doctors for misconduct. The
ethics committee used to take legal
action on its own in response to tipoff
s. There were several instances of
doctors making their own foundations
and getting donations from pharma
companies, accepting foreign trips for
themselves and their families. These
were thoroughly investigated and due
“...many hospitals and clinics
routinely issue cheques to
doctors under sanitised names
such as ‘professional fee’ to
encourage them to use their
services.”
Tom Grill/Corbis

CUT-PRACTICE- An organised 'white-collar' economic offense

A few days ago someone objected to my saying that practitioners of cut-practice should be booked under MCOCA. The argument was that you cannot compare this with acts like terrorism or money-laundering that are actually covered under this Act. Besides it could antagonise doctors and make them into adversaries. I absolutely dont buy these arguments. I still hold that cut-practice doctors should be booked under MCOCA only.

The way cut-practice harms unsuspecting patients and undermines the fabric of our country- it is no less than any act of terrorism or treason. Just that our perpetrators are educated, sauve and respected members of the community. Having a much sought-after qualification and practicing a 'Noble' profession cannot redeem the fact that you are robbing someone because you believe you deserve more money. In other words it is just a 'white collar' crime.

Cut-practice cannot be done singly. It always depends on good teamwork. That is why it is an organised crime. The hold of this system is so strong (at least in Mumbai) that some doctors have been completely unable to establish their practice without getting into it (so they claim).

I really have no desire to offend anybody. The truth is that among the practitioners of cut-practice are my closest friends, admired colleagues and such other individuals whom I actually value and respect. Thats besides the point. Cut-practice is a crime against humanity. If my associates feel offended by me and want me to change; I would expect the same from them- Cut practice offends me, so stop it.

Someone may say that if you cannot convince your close ones, then why are you eating our head. My approach is that I dont want to tell anyone about doing or not doing cut-practice. I just want the community to know that cut-practice is harmful for the community and that I dont do cut-practice. And my refusal to do cut-practice did put me at a disadvantage in my work, and I am not okay with that. If it were that more and more people stop doing cut-practice of their own will, it will benefit all doctors and patients. I just want everybody, including the administration to see this point. Booking the doctors under stringent laws will help in this direction.

A life without cuts

'Dr Vani, you are such a bright Psychiatrist. But I am sad to tell you, you are not practical-minded'. 'Just go with the flow- give cuts and concentrate on treating patients' 'Changing the World is not a Doctor's job. Look at it this way- Our job is to treat patients and if you dont give cuts you dont get patients......then whats the use of all this learning and commitment?' Words of wisdom from a senior Family Physician. Spoken with genuine feeling and a desire to see me succeed. But Sir, its not like that. Its about the means as much as the end.
        Initially I did not participate in cut-practice because MCI rules said not to do cut-practice. After 10 yrs in private practice, I agree and genuinely feel that one should not do cut-practice.
         After I finished my MD, I joined Dr Harish Shetty's practice as Part-time Assistant. For 2 months I searched for 'jobs' in the mornings and worked with Dr Shetty in the evenings. Within 2 months, he encouraged me to start a morning OPD and told me it was possible to do so without being in cut-practice. So 3 times a week I would be in my clinic, whereas the other 3 days I roamed in Andheri, Santacruz and Parle East and West introducing myself to every doctor, school principal, business owner, etc.
         My job helped me cover my costs. Some people were referred by Dr Shetty, some by my Family Physician, highly esteemed Dr Pingle. A very significant number were sent by my alma mater, NIMHANS. Very few patients walked-in. But the numbers were pathetic. In my first year, I managed a royal number of about 150 consultations in my private practice! But I was present in my clinic punctually, taking every chance to promote my work. Because of trying this and that, and maternity leave and other female-related challenges, I had about 4 false starts in my practice over the last ten years. Only the last 14 months have seen some stability.
         Over the years its built up to sustainable levels. Now I dont need a job to pay my bills. I can cover my costs and also meet my financial goals. I admit that the latter are modest because hubbie dear is the primary breadwinner. It is also true that I am the housewife in my family and spend much less time working. But my hourly earnings are comparable to my hyperactive full-time colleagues. I dont know what I would do if I had to work full-time, as I really do not have those numbers in my practice. Being a part-timer is really a boon for my self esteem right now. But I am confident I could have worked out something, if I had to work full time and generate that much work- I dont want to worry myself over hypothetical failures.
          As I never gave cuts- I could earn as much by working less. I spend my waiting time studying Psychiatry and keep myself up-to-date. As I never took cuts, I was never under obligation to waste my Sundays and Holidays attending mindless programmes arranged by diagnostic centres and pharma companies. I generally relaxed and recovered my health and spirits.
                I am Queen of my domain. I decide how my time should be spent. I give a receipt for EVERY transaction. I have filed honest IT returns and feel very proud when the income tax amount increases every year. Anyway I dont like taxable income, because it is so difficult to get IT Refunds. So I am not afraid of IT department, and my CA is happy because he has a straightforward job of presenting my accounts.
        I cannot tell you how confident I feel that I am surviving on my own steam and the sense of superiority I get. Right from the beginning I have placed a high value on 'perfection' 'excellence' 'achievement' and even from my school days have always tried to distinguish myself in my studies and work. I am immensely proud of getting my education from all good institutes through path of merit.
         Cut-practice is nothing but corruption. Corruption is for persons who are less in some way. Among doctors, is may be due to poor confidence or if you dont have a proper degree from a good institution. Or even if you have all that, it is possible that you are greedy or simply so weak-willed that you are unable to think for yourself.
           I never thought I was ever among any of the above. Thats why I chose never to be in cut-practice. Over the years the clinical work I have done, the friends I have made and the respect I have earned- have vindicated my stand. It is true that Changing the World is a very difficult thing for a doctor, as we are very busy and dealing with individual problems of our patients. But if you have a strong ethical value-based thought process and the will to survive the challenges and the maturity to suffer for your beliefs- why Should I change for the World? No Sir, I dont want to change the world. But I just dont want to change myself too. Is that okay with you?

A COLUMN IN IMA MAGAZINE- ABT CUT PRACTICE

Several years ago, I did a monthly column in the monthly magazine of IMA Mumbai West "Medical Image". It involved publishing opinions of doctors on different issues and the column was named 'WHITEQUOTES'. 

Once I asked the doctors about Cut practice and following is the article:

IMA-NOVEMBER

IMA-NOV.

WHITEQUOTES

According to the MCI Act of 2002, splitting of fees (cut-practice) is designated as illegal and unethical. One study done in Ahmedabad (Bhat, IIM-A, 2003) found that 40% doctors engaged in this practice. Many doctors are probably not aware of the legal and ethical implications of this practice and regard it as a ‘necessary evil’. So we asked some members to respond to this contentious issue, and following are their responses:

Ideally while giving referrals, the primary consideration should be the expertise of the consultant. However, in cut-practice this is overtaken by monetary considerations. So, merit and skill are compromised. Ultimately patient loses out on good care.

Dr Sudhir Warrier, Orthopaedic surgeon, Dadar

It is widespread practice nowadays. In my opinion established consultants do not need to oblige anyone for referrals, but for fresh consultants it becomes difficult to get any work. The young specialists do not get work, not because they are worse doctors, but because they are raw and not known. So, to get referrals they offer financial incentives. By and large it is not right, but it becomes a question of survival for some.

Dr Ashok Shetty, Family Physician, Marol

I am against cut-practice as it is totally against medical ethics. We (doctors) should all come out in open against it- let the patient decide where to go for treatment. I don’t know about other fields, but in our field where we deal with life and death, this is completely unjustifiable.

Dr Neemish Kamat, Radiologist, Vile Parle West

There are two outlooks to it: Some people regard it as a professional kind of sharing of money, without any other connotation. The second aspect is that it may affect transparency in work, increases cost to patient and creates unnecessary obligations to the consultant. Patients may become suspicious and the Family Physician may lose the patient’s trust, which is not such a pleasant thing.

Dr Priyadarshini Gokhale, Family Physician, Bandra West

It is a current trend, so much so that it is becoming impossible for young doctors to establish practice without this system. So some consultants are forced to accept it, even though it is unethical.  Maybe, some senior consultants with an independent practice should leave this system. This practice has started as all the consultants are competing for attention of the limited number of patients who are capable of paying for their treatment.

Dr Rajiv Tungare, Consultant Physician, Goregaon.                                                                                

-Compiled by Dr Vani Kulhalli