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.