Wednesday, July 29, 2015

The IMA Should Stop Playing Victim

Guest article by Dr Sanjay Nagral

The citizen is being shortchanged by the medical fraternity, but try telling the IMA that

A surgery in an Indian private hospital. (Photo-Asian Development Bank)
A surgery in an Indian private hospital. (Photo-Asian Development Bank)
A few paragraphs in a social sciences textbook of the NCERT for Class VII is hardly the kind of writing that makes major news. But when the Indian Medical Association (IMA) petitions the Prime Minister objecting to some sentences it should arouse curiosity not only because it seems like a trivial matter being blown out of proportion but because it suggests a lot about an organisation that has a critical role in health care discourse in India.
The issue is as follows. In the VIIth standard NCERT textbook chapter on the “Role of government in health”, under the sub-head “Private health facilities”, it says,
“In order to earn more money, these private services encourage practices that are incorrect. At times cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice”.
This is the bit that has provoked the IMA, the largest umbrella organisation of the practitioners of modern medicine in the country, to write to the Prime Minister and a host of other state functionaries demanding that it be deleted. In its letter the IMA warns, “The message which will go to the students is that “private sector fleeces money”. The letter goes on to explain how the cost of the public and private sector cannot be compared since the public sector is supported by state funds and hence the comparison is unfair.
In the narrowest sense what the IMA says is true but what the textbook has actually done with some clarity is to connect the basic logic of the private sector to unethical practices. What it is not doing is to locate the blame on the state, which over the years has encouraged an unregulated private sector by wilful neglect of the public sector, a point that the IMA misses in its rhetoric. It is, after all a 7th standard textbook and the authors were constrained by the need for simplicity and brevity.
IMA is pro private sector
The IMA has in its ambit all types of practitioners of modern medicine in India, public and private, specialist and general, rural and urban. Logically, therefore, it should represent the interests of all sectors. However, it is obvious that every time there is an attack on the private sector’s excesses, the IMA displays a prompt knee-jerk response, often in the form of victimhood. Whether it is the episode of ‘Satyameva Jayate’ on unethical practices where it called for an apology from Aamir Khan, or the nationwide strike the body called in 2012 to protest against the promulgation of the Clinical Establishment Act which sought to regulate the private sector, the IMA has consistently betrayed its bias towards the dominant entrepreneurial interests in health care. This obviously goes down well with its core constituency in the profession. On the other hand, the IMA has had nothing substantial to say about the complete decimation of the public health system with the resultant marginalisation of large sections of our people from access to decent care.
I was recently a member of a committee of the Maharashtra government which was set up to promulgate a modified state level version of the Clinical Establishment Act. Although it was one of the official briefs given to the committee, IMA representatives stonewalled all attempts to bring in some form of regulation of the fee structure in the private sector.
In many countries national medical associations have played stellar roles in promoting pro-people health policies, advocating patient’s rights and even resisting the state’s attempts to privatise health care as in the case of the British Medical Association during Margaret Thatcher’s time. Why is it then that the IMA has come to this sorry pass?
Control by market interests
One apparent explanation is that those with market interests are dominant in the leadership. Many office bearers of the IMA themselves own nursing homes and hospitals. But this has also been possible because the larger mass of medical professionals wittingly or otherwise have internalised the ideology of market medicine. Doctors from academia and those working in grassroots level NGOs who are capable of offering counter viewpoints have in a sense vacated this space. Many of them work and debate outside professional organisations offering alternatives but feeble internal resistance.
The state of the IMA may not be very different from other professional organisations in the country that primarily function as guilds to protect the narrow interest of their members, which can clash with the interests of the citizenry.
Many of these organisations are unable to think independently of the dominant market discourse as it applies to their profession. In that sense it may be unfair to single out the IMA. However, historically in India and across the world, medical professionals and organisations have provided resistance to dominant ideologies. Healthcare is one area of social endeavour where inequity is so stark that for medical professionals and organisations not to be concerned about the policies that nurture this would be shocking.
One wonders what Class VII students will remember from what has been taught to them as they grow up; some of them may even join the medical profession. It demands extreme innocence to assume that such textbook paragraphs will shape their long-term thinking. But when the principal association of lakhs of doctors across the country does not go beyond playing up to their constituency in response to a naive but important attempt to highlight the problems of private medicine in a school textbook, it reflects their lack of imagination – and more worryingly – their guilt.
Dr Sanjay Nagral is a surgeon practicing in Mumbai. He is a member of the Indian Medical Association and is on the editorial board of the Indian Journal of Medical Ethics

Don’t Allow the IMA to Tamper With School Textbook


Guest article by Sarada Gopalan
We, the undersigned, medical professionals, educationist, academics, teachers, civil society organisations ​and other concerned individuals are writing to express our deep concern over the recent demand by the Indian Medical Association (IMA) for “immediate remedial action” on content included in the National Council of Educational Research and Training (NCERT) Social Science textbook on Social and Political Life (SPL) for Grade 7. The IMA’s demand to rewrite or delete the chapter is clearly unreasonable and unacceptable, as are the threats that the IMA has issued against the NCERT and the authors.
Chapter Two on the “Role of the Government in Health” in the above-mentioned textbook, sections of which the IMA is raising objections to, is part of a series of textbooks that were developed through a consultative process initiated by the NCERT, involving academics, teachers, researchers, government school teachers and civil society organisations with substantive experience and expertise in the thematic areas covered in the textbooks​ ​during 2005-08.  These textbooks also underwent an independent process of systematic review prior to publication.
The SPL textbooks, as the name suggests, focus on themes related to social, economic and political life in contemporary India building on the well-recognized pedagogic principle that children learn best through concrete examples.  The SPL textbooks aim to develop the abilities of children to critically engage and analyze these realities in keeping with the tenets of the Constitution of India.  The chapter that is under contention, focuses​ on the critical role that equality exercises in Indian democracy and each of the five units of the book highlight a particular issue related to elucidating this theme. Health is one of the issues discussed and is included in Unit 2 on ‘State Government’, which contains two chapters on the “Role of the Government in Health” and “How the State Government Works”.
​ ​As the titles make clear, these chapters aim to present and discuss the government’s role and responsibilities around providing quality health care for all in a democracy.
Specifically, the chapters attempt to get students to begin thinking critically about inequities in health care, including concerns of availability, accessibility and quality. In presenting these concerns, the chapter includes a discussion of the private and public facilities, which comprise the health sector in India.  The objective of the chapter is not a comparison of the public and private health care sectors, rather the chapter seeks to reiterate the state’s responsibility in a democracy and emphasize the implications of the withdrawal / insufficient provisioning by the government for public goods, namely health care. Reference to this central idea can be found in the “The Story of Hakim Sheikh”, where many government hospitals refused to admit him for treatment. This real case study is used as a running thread through the chapter and illustrates that denial of health care violates the constitutional provision for the right to life. This landmark judgment by the Court would encourage the student to think of the wider public interest and not accept the implications of these situations as natural.
Illustration by Sorit. Credit: Down to Earth
Illustration by Sorit. Credit: Down to Earth
​​The IMA’s allegations and demands are unfortunate and based on a selective reading of the chapter. The IMA has raised objections to a couple of lines regarding the costs of treatment in the story board – however, following the story board are questions that invite students to look at it in an open ended manner, relate to the social context and bring their own experience in an illness to the classroom. The storyboard is an important educational tool that facilitates students’ understanding of the diversity and inequalities evident in access to health care (not a simple public versus private distinction as has been understood by IMA); and the government’s role in health care provisioning, governance and accountability.
Further, abundant evidence exists that indicates the severe costs of health care in the private sector. It is a known fact that private health care is largely unaffordable for the vast majority of Indians. Indeed, out of pocket expenditure on health in India is one of the highest in the world, and health care costs contribute to indebtedness for a significant portion of our population.  According to the World Health Organization (WHO) India National Health Accounts (NHA) data for 2013, out of pocket (OOP) expenditure as percentage of Private Health Expenditure in India, was 86 percent. On average, a much higher amount (four times) is spent for treatment per hospitalized case by people in the private (INR 25850) than in the public (INR 6120). The average cost of hospitalization for childbirth in rural areas is Rs. 1587 and Rs. 14778 and in the urban areas Rs. 2117 and Rs. 20328 in public and private hospitals respectively (NSSO). Health Surveys have also pointed to, for example, that the number of caesarean deliveries in private hospitals was almost three to 10 times more as compared to government hospitals (AHS2012-13). A World Health Organization study, which reviewed 1,10,000 births from nine countries in Asia including India in 2010, revealed more than 60 per cent of the hospitals studied, where these C-sections took place, did it for financial gains and not because it was required.
The IMA’s objection is to sentences which discuss the private sector and state:
“In order to earn more money, these private services encourage practices that are incorrect. At times, cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice.”
Evidence of such practices is widely available including in a recently released book-based on interviews with 78 doctors across India also includes narratives of “widespread irrational drug prescribing, kickbacks for referrals, and unnecessary investigations and surgical procedures”.
Further, IMA’s allegation that students will be “brainwashed” against the private health sector, is unfortunate and unfounded.  It has been long established that students, however young, bring to the classroom knowledge and experience that the classroom process needs to facilitate as part of the process of learning. The IMA’s objection to one frame from a storyboard is not only disingenuous but completely misunderstands and disregards the educational requirements of textbooks.
Undoubtedly, there are doctors who conduct ethical private practice, as there are government hospitals that are run effectively. The chapter as currently written provides enough questions in the text to enable students to engage in a discussion based on their health care experiences thereby allowing them to agree or contend with the information that the chapter makes available and to understand that there are implications for society that faces such inequality in access including costs for a basic need, especially given the current environment that is encouraging of privatisation- indeed corporatization of health.
As the above data show, a large section of society in our country is denied basic health care. The IMA’s demand will result in students receiving a distorted and incorrect representation of issues that the Indian health care sector continues to grapple with.  It would also work to stymie the development of critical thinking skills in students through engaging difficult concepts like ‘equality’ and ‘democracy’ through their own experiences. Sound and proven educational principles should not be allowed to be jettisoned by particular interest groups, irrespective of their political and ideological position.
We, therefore, reiterate the unacceptability of the demands by IMA and oppose any attempts to undermine the intent of these textbooks.  We urge the government to reject the demand by IMA to rewrite or delete Chapter 2 on ‘Role of the Government in Health’ in the Social and Political Life Class 7 textbook.
Signed by the Textbook writing team for the SPL textbook for Grade 7:
Dr. Sarada Balagopalan (Chief Advisor), Arvind Sardana (Advisor), Dipta Bhog,  N Sarojini, Malini Ghose, Prof Krishna Menon, Prof Mary John, Prof Anjali Monteiro and Sukanya Bose (Members)
and endorsed by 213 others

Is it a Crime to be a Doctor in India?


Guest article by Dr. Neeraj Nagpal

From the spirited defence of its gaffe the NCERT has planted a question in my mind that is it a crime to be a Doctor in India? Instead of apologizing for slanderous statements published in standard textbook they have sought justification in the form of 200 “eminent” persons’ support. The signature campaign to gather support for their obvious error is symptom of a much larger and a much widespread malady “hatred towards our healers”. I am surprised when such a simple option exists and it is so obvious to authors why then they and 75% of the population prefer private healthcare providers to Government facilities. According to the authors, the Government hospitals are paradise on earth but who drags them to private healthcare establishments.

A seventh standard child who is being fed such drivel is an innocent mind. He is in no position to understand that “cost of treatment” is not what is paid by the patient but the cost to cure. AIIMS conducted a study in 2012 on what it costs to get a laproscopic procedure in AIIMS. Including what the exchequer spends and what the patient pays they reported the cost to do a laproscopy procedure as Rs 50,000. I have a nursing home and in 2012 our cost for the same to the patient inclusive of everything was Rs 30,000. Even today anyone can get a laproscopic procedure done at our centre for much less than Rs 50,000 it cost in AIIMS 3-4 years ago. How then is the cost of treatment in a Government no profit center any cheaper.

Despite all allegations of kickbacks against all doctors the cost of any investigation today is atleast 10 times cheaper when compared with any developed country. This is when equipments used in USA and India are all of same manafacturers but are much more costly in India. We want compensations for medical negligence at par with the most developed nations but want to pay 1/10th the cost. Consultation fee of a private doctor in India is less than 50 times the cost in USA/Australia/UK. But the private doctor in India is a cheat as per those who decide what our children should be taught. I hope they are prepared to pay compensation if any child of a private doctor suffers trauma due to bullying and ragging which he has to undergo from friends and classmates who are taught such rubbish.

It is an open secret that a criminal can turn easily into politicians some of whom still continue to be criminals. A murder or two in the past is an asset for ticket seekers. Does the NCERT 7th standard textbook consider it necessary to teach the student who can “grapple with concrete experiences without being brainwashed” that all politicians are criminals. It is known that a nexus exists between lawyers and judiciary to get favourable judgments. Corruption in police, taxation authorities, is also well known. Casting couch is an established fact in our film and fashion industry. Electricity water supply connections cannot be gotten without greasing appropriate palms. How disputed properties are amassed by those in positions of power illegally is open secret. Does NCERT dare to publish such “facts known to all” in its 7th standard textbook. No it is simply the private doctors who will not retaliate who can be labelled as cheats in minds of a 7th standard student so that tomorrow when he assaults a doctor in the emergency ward of any hospital he does so with a justification.

My request to IMA, please do not go to press on this issue. Sue the NCERT authors, and NCERT for an exemplary amount. Take example from the HC judge who sued TOI for Rs 100 crore for erroneously publishing someone else’s photograph with his name. All states do not require the court fee to sue someone. The case can be filed in state where this issue of court fee will not be a hindrance.

Monday, July 27, 2015

20 Success Inspiring Quotes to Put On Your Study Wall

20 Success Inspiring Quotes to Put On Your Office Wall
Here are 20 of my most inspiring quotes related to success that may also help you if you are in the same position and want to get out with the help of other people’s words of wisdom:
1. “A successful man is one who can lay a firm foundation with the bricks others have thrown at him.” David Brinkley
2. “Success consists of going from failure to failure without loss of enthusiasm.” Winston Churchill
3. “To succeed in life you need two things: ignorance and confidence.” Mark Twain
4. “I don’t measure a man’s success by how high he climbs, but how high he bounces when he hits bottom.”George S. Patton
5. “The difference between a successful person and others is not lack of strength, or a lack of knowledge, but rather a lack of will.” Vince Lombardi
6. “Success is not measured by what you accomplish, but by the opposition you have encountered, and the courage with which you have maintained the struggle against overwhelming odds.” Orison Swett Marden
7. “The successful man will profit from his mistakes and try again in a different way.” Dale Carnegie
8. “Frustration, although quite painful at times, is a very positive and essential part of success.” Bo Bennett
9. “The ladder of success is best climbed by stepping on the rungs of opportunity.” Ayn Rand
10. “You don’t have to be a genius or a visionary or even a college graduate to be successful. You just need a framework and a dream.” Michael Dell
11. “If you have no critics, you’ll likely have no success.” Malcolm X

12. “There is little success where there is little laughter.” Andrew Carnegie
13. “To be successful, you have to have your heart in your business and your business in your heart.”Thomas J. Watson
14. “Success isn’t a result of spontaneous combustion. You must set yourself on fire.” Arnold H. Glasgow
15. “Pray that success will not come any faster than you are able to endure it.” Elbert Hubbard
16. “There is only one success – to be able to spend your life in your own way.” Christopher Morley
17. “Success seems to be largely a matter of hanging on after others have let go.” William Feather
18. “Don’t watch the clock; do what it does. Keep going.” Sam Levenson
19. “Expect problems and eat them for breakfast.” Alfred A. Montapert
20. “In life you have two options when it comes to being a success: make excuses or make changes.”Christina DeBusk (yes, this one is mine)
Just to throw one additional quote in here by Audrey Hepburn, “Success is like reaching an important birthday and finding out you’re exactly the same.” In other words, don’t wait for success to dramatically change your life. You’ll still be who you are when it happens, so do what you can to make that a good thing!

Sunday, July 26, 2015

IMA writes to PM requesting the Government to bring in amendments in PCPNDT Act




Indian Medical Association (IMA) has written a letter to Prime Minister Narendra Modi requesting the Government to bring in amendments in the PCPNDT Act, which is meant to prevent female foeticide, to make it more “user-friendly” and to retain ultrasound scan as the “cheapest, most accessible and important medical diagnostic tool”.
Expressing concerns about the declining sex ratio in India, IMA said it fully endorses the clause 23 of the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, which awards imprisonment and financial punishment on Doctors who abet female foeticide.
“At the same time, IMA is against the clause 25 which awards the same punishment on Doctors for non-conformity of the Act in terms of not-wearing the badge/apron, not displaying the registration certificate, not keeping copy of the PCPNDT Act in the diagnostic centre and deficiencies in the filling of the various forms,” said IMA.
“IMA requests the government to amend the clause 25 so that only fine is given for minor non-conformities and non-compliance,” said the letter signed by Dr A Marthanda Pillai, national president and Dr KK Aggarwal, honorary secretary general, Indian Medical Association.
“Already more than 4000 cases exist in this regard and many courts have ordered imprisonment of doctors for minor non-conformity. Thousands of ultrasound scan machines have been confiscated and diagnostic centres closed down,” according to the medical association.
“Ultrasonography has now become the cheapest and easily available, cost effective and user friendly diagnostic tool right from trauma and emergency management to every segment of medical diagnosis and care. Putting undue restrictions on the use of ultrasound could only be counter productive and it will definitely cause immense damage to healthcare,” the letter concluded.

Thursday, July 9, 2015

Doctor’s 35-hr shift on 8 bananas, a toilet in nearby cafe


It’s 15 days after their strike ended, and the 32-year-old is back at work at Ram Manohar Lohia Hospital, located on the bustling Baba Kharak Singh Marg in Central Delhi. The hospital gets around 20 lakh patients annually in OPD, 5 lakh in emergency, and the PG resident in surgery is among its 1,000-odd resident doctors, including non-academic junior residents.

Today Dr M’s (name withheld to protect his identity) duty begins in the surgical emergency, and he arrives at 8.50 am, bolstered for the next 36 hours that will follow with a change of shirt, his copy of the Sabiston Textbook of Surgery, three packets of glucose biscuits, eight bananas and two bottles of water.

Dr M is happy today. He has had five continuous hours of sleep.

There are 45 patients in the surgical emergency ward, sharing a total of 20 beds. Two beds are empty — left for patients who may show up with grave emergencies. Two to three patients share most of the occupied beds; a couple of them have up to four.

doc

Dr M and other senior residents begin their round checking on the patients admitted in the previous shift. The patients here are awaiting procedures, either because the operation theatre is not free or because essential pre-surgery investigation reports haven’t yet come in.

Dr M and a senior sort case sheets in decreasing order of priority. The emergency has a single major OT, shared between the departments of general surgery, gynaecology, paediatric surgery, burns and plastic surgery, ENT and opthalmology. And it is always occupied.

There is a minor OT but that is used for mostly sutures or cleaning of open wounds.

In his first round, Dr M does four catheterisations and changes canulas on six patients. Angry relatives of two patients, both awaiting prostrate surgery and sharing a bed, demand to know why their urine bags are leaking — it’s a common problem, the doctors pacify them.
In the next 24 hours of his duty in emergency, Dr M will do at least 500-600 cathetrisations and canula tweaks alone. In a private hospital ER, both these procedures are done by nurses.

Around 10 am, Dr M scrubs in for the first surgery of his shift. It is a 32-year-old abdominal tuberculosis patient who has been awaiting his turn in the OT for a week.

The surgery lasts five hours. A usual surgery in the emergency OT takes around two hours, and there is a restless crowd waiting outside by now. It’s nearly afternoon and no patient who has come this day has been admitted so far. Dr M is sent out to pacify the edgy relatives.

Dr M shouts out to a nurse that one of the “spider lights” — placed atop a surgery OT table — is not working again. The nurse, busy filling out the fast-depleting blood transfusion forms, barely listens.

Gobbling down two biscuits and a banana, Dr M braces himself for his next shift — at the desk — beginning 3.30 pm. Six chairs are placed around a normal-sized desk. Patients who report to casualty are divided into surgical, medicine and orthopaedic emergencies. Desk duty means reviewing an average of 50 cases in an hour to direct patients where they need to go — minor OT, major OT or admission.

Police bring in two patients who have been in a brawl — one has a cut below the eye, the other above. Dr M decides to handle the cut below the eyebrow himself, and assigns an intern to the second case. “How dare you put a junior doctor on my case? Is his vision more precious?” the other patient screams. Dr M tries to explain that a cut above the eye is far easier to stitch.

The lights in the minor OT are not working, and patient beds are placed along walls with regular house bulbs aligned to illuminate the room.

At 5 pm, Dr M shortlists a 26-year-old road accident victim with blunt trauma to his abdomen as the next surgical case. The family is reasonably well to do and agrees to get some pre-surgery essential tests done outside the hospital. These would take hours at the emergency ward. But when told that even a CT abdomen or a CECT abdomen — a radiological test to see the exact spot of the injury — was not available, the family erupts, hurling abuses at the junior doctors.

It is left to Dr M again to explain that only head CT is done in emergency. Meanwhile, the patient is slipping. Doctors decide against wasting any time and wheel him into the OT. They are used to waiving away protocols such as essential tests to save lives now.

It proves to be a case of spleen rupture. It takes two hours to remove the patient’s spleen.

As doctors start closing up the patient, Dr M is sent out to calm down a gynaecology resident who has been waiting for the OT for an emergency caesarean. Every two hours almost, the ward receives a caesarean case. Caesareans always get priority, with the principle brutally simple: it involves two lives instead of one.

So Dr M and an orderly wheel out a general surgery patient — with multiple stab wounds — to first get in the C-sec.

By 8 pm, the ward is overflowing, and patients are now being accommodated in trolleys and stretchers in corridors. Dr M quickly gulps down two more bananas while running in and out of the minor OT. His textbook is always by his side. In the minor OT, doctors use the five minutes or so between cases for a quick read. Dr M’s final year exam is a year away.

At 9 pm, now 12 hours after his duty started, he is preparing for his third major case of the day. A patient has come in bleeding with multiple cuts on his wrist — a suspected suicide attempt. However, a case of ruptured ectopic pregnancy — a pregnancy in the Fallopian tube instead of uterus — arrives just then. The gynaecologists need a general surgeon to assist them, but Dr M’s seniors need him in the suicide attempt case too. So while the gynaecology resident doctor argues with the sister in charge of the OT, Dr M finishes his case in 25 minutes.

Doctors, nurses, anaesthetists are all ready for the ectopic pregnancy now, but they have to wait half an hour for the mobile ECG machine and its technician. Two hours later, at around 1 am, the patient is finally out. But the foetus could not be saved.

Dr M’s next two hours are taken up by a household burns patient. At around 4 am, a six-year-old child who has gulped two beads is brought in. Dr M had been preparing a urology case who had been waiting six hours for his turn in the OT, but again, a child gets priority.

Next, around 5 am, a 13-year-old is wheeled in. She fell from the roof of her house two hours earlier and has already been to three government hospitals. Neurosurgery residents have operated on her concussion but there are multiple wounds in her abdomen and face. With her liver and spleen both ruptured, Dr M and his senior have to take over.

As he emerges from the OT at 7.30 am, Dr M conceals a yawn. He is thinking about his first meal in nearly 24 hours. However, the nurse catches him just as he is cleaning his hands. One of the patients he catheterised in the afternoon has a leak in the urine bag again. A senior calls him to also check on a pancreatitis patient who was brought in during the night.

At 8 am, Dr M is preparing for his next duty shift, finishing the last of his bananas, when he is again summoned. A patient with symptoms of twisting in his testes had arrived with acute pain at 3 am. Doctors needed a colour doppler test to determine if the testes was retrievable, and the patient had been sent to AIIMS. He had now come back with the tests done at a private centre.

By the time doctors finish on him, it is 10 am and Dr M is late for his next shift. It is OT day, his favourite, and he skips the meal he had been longing for. Instead, Dr M heads to the emergency duty room’s washroom to freshen up. It has not been cleaned as usual. With eight hours of OT without a break ahead of him, Dr M ignores the last patient who needs suturing — telling the nurse to wait for the next shift — and hurries out. He drives to a nearby coffee shop and, while his coffee is coming, uses the washroom there.

In 10 minutes, he is back in the car. By the time he is back at hospital, he is an hour late for his shift.

The next seven hours are spent in the OT. Till 5 pm, he assists a consultant on six cases. At 5.15 pm, Dr M sneaks out to the hostel canteen. He has been told his unit head wants to do a round of the wards before he calls it a day, and he has just about time to gulp down four bhaturas with lassi — his first meal in 34 hours. He usually has dinner between emergency cases, but last night was too busy.

Through the 15 minutes of his meal, he leafs through his Sabiston to read up on torsion (twisting) of the testes. By 5.40 pm, Dr M is back with his consultant.

At 8 pm, Dr M is finally off duty. For 12 hours, till his shift in the OPD the next day.

Back to Sabiston, he smiles.

How inhumanly long work hours are killing young doctors, literally

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One demand of doctors who went on strike in Delhi last week was for shorter duty hours. They are unregulated currently, and resident doctors in the capital’s public hospitals easily end up working 36-48-hour shifts. (See the Page 1 report in this paper’s July 7 edition.) In Emergency wards of private hospitals by contrast, doctors work, at the most, 8-10 hours at a stretch — and treat, by conservative estimates, about a tenth the number of patients at a government hospital Emergency.

Senior consultants or teaching professors are usually never on duty during Emergency hours in government hospitals. After 5 or 6 pm, Emergencies, Emergency operation theatres, and wards — often with two of three patients sharing a bed — and ICUs are left entirely to the resident doctors.

Rules say consultants must report to hospitals in grave emergencies, but rare is the day when a senior consultant is seen in a hospital after midnight. In private hospitals, consultants are on duty in ICUs and surgical wards through the night. Residents also juggle what should ideally be discrete duties. So, a resident in Anaesthesia posted at an ICU may have to handle emergency surgery, leaving the ICU to juniors or interns. And if a patient in a ward starts to collapse, the same resident may be asked to rush there.

What is the impact of putting in insanely long hours in a high-pressure environment on the resident doctors and their patients? While Indian research is scant, a landmark study published in the New England Journal of Medicine (NEJM) in 2005 produced alarming findings. The study by the Harvard Work Hours, Health and Safety Group found that resident doctors made 35.9 per cent more serious errors when working 24 hours-or-more schedules, compared to “every third night” call schedules. The study, based on 17,000 Internet questionnaires answered by over 2,700 doctors in their first year of post-graduate residency, also found that every time their work shifts overshot stipulated hours in a month, their risk of suffering a motor vehicle crash increased by 9.1 per cent, and the monthly risk of a crash during the commute from work to home by 16.2 per cent. In months with five or more extended shifts, “the risk that they would fall asleep while driving or while stopped in traffic was significantly increased” — by ratios of 2.39 and 3.69 respectively, the study found.

Another 2006 multi-institutional study published in the Journal of American Medical Association (JAMA) by the Harvard Medical School and Vancouver General Hospital, found accidental percutaneous injuries — needlestick or laceration injuries — common in residents who worked 24 hours. “Lapse in concentration and fatigue were the two most commonly reported contributing factors (64% and 31% of injuries, respectively),” the study noted. Needlestick pricks expose doctors to blood infections, which may be life-threatening, like HIV and HCV.

A third multi-institutional study, by the Kansas City School of Medicine, published in the journal Academic Emergency Medicine in 2008, found 8 per cent resident doctors posted in Trauma or Emergencies saw 96 motor vehicle crashes, and 58 per cent doctors reported 1,446 near crash injuries after duty hours. Nearly three-fourths of motor vehicle crashes and 80 per cent of near-crashes followed the night shift, according to the study.

In 2006, a study of gynaecology residents by Northwestern University’s Feinberg School of Medicine, published in the American Journal of Obstetrics and Gynecology, found 89.8 per cent “showed evidence of moderate burnout” and 34.2 per cent were “considered depressed”.

In the West, rules regulating work hours of junior doctors have been in place for the last 10-15 years. Studies in the United States have already quantified improvements in patient care, including significant reductions in mortality. In the UK, working hours for junior doctors are limited by the European Working Time Directive. A doctor can now work an average 48 hours per week (from the earlier 56 hours), calculated over 26 weeks. After continuous duty of 11 hours, a rest day is prescribed. A day off is mandated every week, and a 20-minute rest every 6 hours.

Dr Soumyadeep Bhaumik, Executive Editor, Journal of Family Medicine & Primary Care, says the US-based Accreditation Council for Graduate Medical Education has recognised long work hours as a safety hazard for interns. “The nation simply cannot afford to lose young doctors due to faulty regulations in place. The results of these studies have implications for medical residency programmes, which routinely schedule physicians to work more than 24 consecutive hours,” Dr Bhaumik said. Bodies of senior doctors in India, like the IMA or state councils, have rarely raised the issue of duty hours for junior doctors. The British Medical Association, by contrast had, in 2013-14, campaigned against the violations of these rules in the UK.