Friday, October 24, 2014

PG Times launches free mini Mock Tests

Keeping in view the upcoming PG entrance exams, PG Times has come up with a unique concept of free online mini mock tests.
  • In order to help thousands of PG aspiring medicos get a seat of their choice, PG Times has launched free mini Mock Tests on its website. 
  • Ten questions (including image-based questions) will be published daily based on all the subjects asked in different PG medical entrance exams. 
  • Questions will be framed simulating the latest NBE-based All India Pattern.
  • Students can attend these free tests to get an idea of their preparation.
  • No registration is required to take the tests. 
  • The test would remain online till a new test is published. 
  • Candidates will get the correct answers and their scores immediately after completing the test.

PM announces Rs 175 crore relief for Kashmir’s flood-hit hospitals

Prime Minister Narendra Modi on Thursday met various groups of flood-affected people here to understand their problems and listen to their suggestions on the rehabilitation process following the recent floods.
These included delegations from chambers of commerce and industry, social organizations and NGOs, civil society organizations, transport operators, tour and travel operators, fruit growers, dealers and horticulture institutions, educational institutions, youth organizations, religious communities and political groups, according to an official statement.
The Prime Minister said that a common thread running through the interaction with all groups was the suggestion that affected people should be given help directly. He said this request would be seriously considered. For instance, he said, it could be considered that assistance for rebuilding houses could be given directly to bank accounts of beneficiaries.
Over and above the special central assistance of Rs 1000 crore that was announced during the Prime Minister’s visit to Srinagar in September, Narendra Modi announced Rs 570 crore assistance for housing. He said six major hospitals in the state of Jammu and Kashmir were in poor condition and required immediate intervention. For this he announced assistance of Rs 175 crore.
The Prime Minister assured the people of Jammu and Kashmir that the entire nation stood with them in the rebuilding process, after the floods.

Monday, October 20, 2014

Keep the student in you alive, says PM Modi at AIIMS convocation

The 42nd convocation of AIIMS was a memorable occasion as for the first time the premier institute initiated the tradition of presenting lifetime achievement awards to medical professionals associated with it.
Prime Minister Narendra Modi, who gave away the lifetime achievement awards to former senior faculty members of AIIMS who have contributed immensely to the development of the institution and also to medical science in the country, advised the passing out graduates to keep the student in themselves alive.
"Keep the student in you alive. These people whom I have honoured today with the lifetime achievement awards, they belong to the age group of 70-80 years. But if you meet them, you will find that they are very much aware of the latest developments of medical science, not because they need patients but because the student in them is still alive," said Modi.
Reminding the award winners of their days at the institute, Modi said, "You had so many people to turn to here in your institute to solve your problems and satisfy your curiosity. There was always someone who would protect you and take responsibility for what you do and you were aware of that. But today from a four walled closed classroom you will be entering a huge classroom.
"The moment, people especially those belonging to the medical profession fraternity feel that their learning period is over, I fell they stagnate and get stuck in all kind of obstacles. The student mindset keeps the life alive and the moment we stop to learn, we should realise that we have taken a step towards death," he said.
Modi further said that when he had come to the function, a gentleman said that people are astounded by his energy.
"I say there is nothing to feel surprised about. People from medical science fraternity are present here and they know that the urge to learn something new and do something new every time fills us with energy and zeal," he said.
Six persons who were honoured with the lifetime achievement award include Prof GP Talwar, Founder Director of National Institute of Immunology (NII), Dr JS Guleria, former Dean of faculty and former head of department for general medicine at AIIMS, Professor PN Tandon, Founder President of the National Brain Research Centre (NBRC) and also former President of Indian National Science Academy. Tandon had founded the Neurosurgery department of AIIMS.
The lifetime achievement awards were also given to Dr Sneh Bhargava, eminent radiologist and former director of AIIMS, Dr IK Dhawan, Former Head department of Surgical disciplines who initiated the renal transplant programme in India and P Venugopal, founder chief of Cardio-thoracic centre and former Director AIIMS. He also did the first heart transplant in India and is known as the doyen of cardiac care in India.
Venugopal said, "It feels great. I had joined this institute as an undergraduate in 1959. We have lived for the institute and getting a recognition and honour at our own institute is the biggest achievement.
As for Talwar, it was a very emotional moment. "I spent 27 years here in AIIMS. This honour has put new chains of binding and I feel my love for the institute renewed," he told PTI.
Tandon found the initiative very endearing and encouraging as he said, "It is a sort of symbol for the younger generation to see what the people associated with it have contributed to the Medical Science of our country.
"As our Prime Minister said we owe gratitude to this country and its people who have invested on us," he said.
Text of Prime Minister Narendra Modi’s speech at the 42nd Annual Convocation Ceremony of AIIMS, New Delhi

मंत्रिपरिषद के मेरे साथी डॉ. हर्षवर्द्धन, मंचस्‍थ सभी महानुभाव और आज के दिवस के केंद्र बिन्‍दु वे सभी डिग्रीधारी जो आज इस कैंपस को छोड़ करके एक नई जिम्‍मेदारी की ओर कदम रख रहे हैं।

मैं आप सबको हृदय से बहुत-बहुत शुभकामनाएं देता हूं।

मैं कभी अच्‍छा स्‍टूडेंट नहीं रहा हूं, और न ही मुझे इस प्रकार से कभी अवॉर्ड प्राप्‍त करने का सौभाग्‍य मिला है। इसलिए मुझे बहुत बारीकियों का ज्ञान नहीं है। लेकिन इतनी समझ जरूर है कि विद्यार्थी का जब Exam होता है, उस हफ्ते बड़ा ही टेंशन में रहता है, बड़ा ही गंभीर रहता है। खाना भी जमता नहीं, बड़े तनाव में रहता है। लेकिन आज एक प्रकार से वो सारी झंझटों से मुक्ति का पर्व है और आप इतने गंभीर क्‍यों हैं?

मैं कब से देख रहा था, कि क्‍या कारण है यहां! क्या, मिश्राजी, क्‍या कारण है? मैं आपसे आग्रह करूंगा कि आप अपने दायित्‍व पर उससे भी ज्‍यादा गंभीर हों - अच्छी चीज़ है - लेकिन जीवन को गंभीर मत बना देना। जिंदगी को हंसते-खेलते, संकटों से गुजरने की आदत बनाते हुए चलना, और उसका जो आनंद है, वह बड़ा ही अलग होता है। हमारे देश में, अगर पुराने शास्‍त्रों की तरफ देखें, तो पहला convocation, इसका उल्‍लेख तेत्रैय उपनिषद में आता है। वेद काल में गुरू-शिष्‍य जब परंपरा थी, और शिष्‍य जब विद्यार्थी काल समाप्‍त करके जाता था, तो उसका प्रथम उल्‍लेख तैत्रेय उपनिषद में आता है कि कैसे Convocation की क्‍या कल्‍पना थी।

वो परंपरा अब भी चल रही है, नए रंग-रूप के साथ चल रही है। मेरा एक-दो सुझाव जरूर है। क्‍या कभी हम इस Convocation में एक Special guest की परंपरा खड़ी कर सकते हैं क्‍या? और Special guest का मेरा मतलब है कि गरीब बस्‍ती में जो Schools हैं, गरीब परिवार के बच्‍चे जहां पढ़ते हैं, ऐसे एक Selected 8वीं 9वीं कक्षा वे बच्‍चे, 30, 40, 50 जो भी आपकी Capacity में हो, उनको ये Convocation में Special guest के रूप में बुलाया जाए, बिठाया जाए, और वे देखें, ये दुनिया क्‍या है। जो काम शायद उसका टीचर नहीं कर पाएगा, उस बालक मन में एक घंटे-डेढ़ घंटे का ये अवसर उसके मन में जिज्ञासा पैदा करेगा। उसके मन में भी सपने जगाएगा। उसको भी लगेगा कि कभी मेरी जिंदगी में ये अवसर आए।

आप कल्‍पना कर सकते हैं, कितना बड़ा इसका impact हो सकता है। चीज बहुत छोटी है। लेकिन ताकत बहुत गहरी है और यही चीजें हैं जो बदलाव लाती है। मेरा आग्रह रहेगा, वे गरीब बच्‍चे। डॉक्‍टर का बच्‍चा आएगा तो उसको लगेगा कि मेरे पिताजी ने भी ये किया है, उसको नहीं लगेगा। समाज जीवन में अपने सामान्‍य बातों से हम कैसे बदलाव ला सकते हैं। उस पर हम सोचें। जो डॉक्‍टर बनकर आज जा रहे हैं, अपने जीवन में अचीवमेंट किया है, मेरे जाने के बाद भी शायद हर्षवर्द्धन जी कईयों को अवॉर्ड देने वाले हैं, सर्टिफिकेट देने वाले हैं। लेकिन आज आप जा रहे हैं, बीता हुआ कल और आने वाला कल के बीच कितना बड़ा अंतर है।

आपने जब पहली बार AIIMS में कदम रखा होगा तो घर से बहुत सारी सूचनाएं दी गई होंगी, मां ने कहा होगा, पिताजी ने कहा होगा। चाचा ने कहा होगा, देखो ऐसा करना, ऐसा मत करना। ट्रेन में बैठे होंगे तो कहा होगा कि देख खिड़की के बाहर मत देखना। कोई अनजान व्‍यक्ति कुछ देता है तो मत लेना। बहुत कुछ कहा होगा। एक प्रकार से आज भी वही पल है। Convocation एक प्रकार से आखिरी कदम रखते समय परामर्श देने का एक पल होता है।

कभी आप सोचे हैं कि जब आप क्‍लासरूम में थे, Institute में थे, जब आप पढ़ रहे थे, तब आप कितने protected थे? कोई कठिनाई आई तो सीनियर साथी मिल जाता था, बताता था। समाधान नहीं हुआ तो प्रोफेसर मिल जाते थे। प्रोफेसर नहीं मिले तो डीन मिल जाते थे। बहुत avenues रहते थे कि जहां पर आप आपकी समस्‍याओं का, आपकी जिज्ञासा का समाधान खोज सकते थे। आप कभी यहां काम करते थे, आपका हॉस्‍टल लाइफ रहा होगा। परिवार का कोई नहीं होगा, जो आपको हर पल ये कहता होगा, ये करो, ये मत करो। लेकिन कोई तो कोई होगा आरे यार क्‍या कर रहे हो भाई ? किसी ने कहा होगा भाई तुम्‍हारे पिताजी ने कितनी मेहनत करके भेजा है, तुम ये कर हो क्‍या ? बहुत कुछ सुना होगा आपने। और तब आपको बुरा भी लगा होगा कि क्‍या ये मास्‍टर जी देते हैं, हमें मालूम नहीं है क्‍या हमारी जिंदगी का? लेकिन कोई तो था जो आपको कहता था कि ये करो, ये मत करो।

आप उस अवस्‍था से गुजरे हैं और काफी लंबा समय गुजरे हैं, जहां, आपको स्‍वयं को निर्णय करने की नौबत बहुत कम आई होगी और निर्णय करने की नौबत आई होगी, तब भी protected environment में आई होगी, जहां पर आपको पूरा Confidence था कि मेरे निर्णय को इधर-उधर कुछ भी हो जाएगा तो कोई तो बैठा है जो मुझे मदद करेगा, बचा लेगा मुझे या मेरा हाथ पकड़ लेगा। इसके बाद आप एक ऐसी दुनिया में प्रवेश कर रहे हैं, जहां कोई आपका हाथ पकड़ने वाला नहीं है। जहां पर कोई आपको ये करो, ये मत करो, कहने वाला नहीं है। जहां आपका कोई protected environment नहीं है। आप एक चारदीवारी वाले classroom से एक बहुत बड़े विशाल classroom में enter हो रहे हैं। और तब जाकर के एकलव्‍य की मानसिकता आवश्‍यक होती है। एकलव्‍य को protected environment नहीं मिला था, लेकिन उसका लक्ष्‍य था achievement का। और उसने अपने काल्‍पनिक सृष्टि की रचना की और काल्‍पनिक सृष्टि के माध्‍यम से ज्ञान अर्जित करने का प्रयास किया था।

जिस पल, खास करके medical protection के लोग या professional क्षेत्र में जाने वाले लोग, विद्यार्थी काल की समाप्ति मानते हैं, मैं समझता हूं, अगर हमारे मन में यह अहसास हो कि चलो यार, छुट्टी हुई, बहुत दिन बिता लिए। वही Hostel, वहीं gown, वहीं stethoscopes, इधर दौड़ो, उधर दौड़ो। चलो मुक्ति हो गई। जो ये मानता है कि आज end of the journey है उसकी और एक नई journey में entry कर रहा है, मैं समझता हूं, अगर ये मन का भाव आया, तो मेरा निश्चित मत है, कि आप ठहराव की ओर जा करके फंस जाएंगे। रूकावटों की झंझटों में उलझ जाएंगे।

लेकिन अगर आप एक बंद classroom से एक विशाल classroom में जा रहे हैं। विद्यार्थी अवस्‍था भीतर हमेशा रहती है। जिन लोगों को आज सम्‍मानित करने का सौभाग्‍य आज मिला, 70-80 साल की आयु वाले सभी हैं। लेकिन अज उनसे आप मिलेगा तो मुझे विश्‍वास है, आज भी medical science के latest Development के बारे में उनको पता होगा। इसलिए नहीं कि उनको किसी पेशेंट की जरूरत है, इसलिए कि उनके भीतर का विद्यार्थी जिंदा है। जिसके भीतर का विद्यार्थी जिंदा होता है, वही जीवन में कुछ कर पाता है, कर गुजरता है। लेकिन अगर यहां से जाने के बाद इंस्‍टीट्यूट पूरी हुई तो विद्यार्थी जीवन भी पूरा हुआ। अगर ये सोच है तो मैं समझता हूं कि उससे बड़ा कोई ठहराव नहीं हो सकता है। विद्यार्थी अवस्‍था, मन की विद्यार्थी अवस्‍था जीवन के अंत काल तक जीवन को प्राणवान बनाती है, ऊर्जावान बनाती है। और जिस पल मन की विद्यार्थी अवस्‍था समाप्‍त हो जाती है, मृत्‍यु की ओर पहला कदम शुरू हो जाता है।

अभी मैं आया तो वो सज्‍जन बता रहे थे, कि लोगों को अचरज है, मोदीजी की energy का। अचरज जैसा कुछ है नहीं, आप लोग medical science के लोग हैं, थोड़ा इतना जोड़ दीजिए, हर पल नया करने की, सीखने की इच्‍छा आपके भीतर की ऊर्जा कभी समाप्‍त नहीं होती है। कभी energy समाप्‍त नहीं होती। आपकी स्थिति कुछ और भी बनेगी, जब आप hostel में रहते होंगे, OPD में आपको कई पेशेंट को डील करना होता होगा। कभी दोपहर को दोस्‍तों के साथ मूवी देखना तय किया है तो मन करता था कि OPD ऐसा करो निकालो। हमें सिनेमा देखने जाना है। मैं आपकी बात नहीं बता रहा हूं, ये तो मैं कहीं और की बात बता रहा हूं।

आपने पेशेंट को कहा होगा ये खाना चाहिए, ये नहीं चाहिए। इतना खाना चाहिए, इतना नहीं खाना चाहिए। लेकिन जैसे ही आप मेस में पहुंचते होंगे, सब साथियों ने मिलके स्‍पर्धा लगाई होगी, आज तो special Dish है। Sweet है, देखते हैं कौन ज्‍यादा खाता है। ये सब किया होगा। और वही तो जिंदगी होती है, दोस्‍तो। लेकिन आपने किसी को कहा होगा, ये खाओ, ये मत खाओ। तब जा करके अपनी आत्‍मा से पूछा है, मैंने उसको तो ये कहा था, मैं ये कर रहा हूं। इसलिए सफलता की पहली शर्त होती है। कल तक की बात अच्‍छी थी, किया, अच्‍छा किया। मैं उसको appreciate करता हूं। लेकिन आने वाले कल में, मैं कैंसर का डॉक्‍टर हूं और शाम को धुंआधार सिगरेट जलाता रहता हूं और मैं दुनिया को कहूंगा कि भाई इससे कैंसर होता है तो किसी को गले नहीं उतरेगा। ऊपर से हम एक उदाहरण बन जाएंगे- हां यार, कैंसर के डॉक्‍टर सिगरेट पीते हैं तो मुझे क्‍या फर्क पड़ता है।

इसलिए मैं एक ऐसे व्‍यवसाय में हूं, मैं एक ऐसे क्षेत्र में कदम रख रहा हूं, जहां मेरा जीवन मेरे पेशेंट की जिंदगी बन सकता है। शायद हमने बहुत कम लोगों ने सोचा होगा कि क्‍या एक डॉक्‍टर का जीवन एक पेशेंट की जिंदगी बन सकता है? आप कभी सोचना, आपका हर मिनट, हर बात, हर संपर्क पेशेंट की जिंदगी बन सकती है। कभी सोच करके देखिए, बहुत कम लोग हैं, जो जीवन को इस रूप में देखते हैं। मैं आशा करता हूं, आज जो नई पीढ़ी जा रही है, वो इस पर सोचेगी।

उसी प्रकार से, हम डॉक्‍टर बने हैं, कभी अपनी ओर देखें - क्‍या आपके पिताजी के पास पैसे थे, इसलिए आपने पाया? क्‍या आपके प्रोफेसर बहुत अच्‍छे थे, इसलिए ये सब हुआ? क्‍या सरकार ने बहुत बढि़या इमारत बनाई थी, AIIMS बन गया था, इसके कारण हुआ? आप थोड़े मेहनती थे, इसलिए हुआ? अगर यही सोच हमारी सीमित रही तो शायद जिंदगी की ओर देखने का दृष्टिकोण पूर्णता की ओर हमें नहीं ले जाएगा। कभी सोचिये, यहां पर जब आप पहले दिन आए होंगे तो एक ऑटो-रिक्‍शा वाला या टैक्‍सी वाला होगा जिसने आपकी मदद की होगी। बहुत अच्‍छे ढंग से यहां लाया होगा, पहली बार दिल्‍ली में कदम रखा होगा, बहुतों ने। तो क्‍या आज स्थिति को प्राप्‍त करते समय आपकी जीवन की यात्रा का पहला चरण जिस ऑटो ड्राइवर के साथ किया, या उस टैक्‍सी वाले के साथ किया, क्‍या कभी स्‍मरण आता है?

Exam के दिन रहे होंगे, थकान महसूस हुई होगी, रात के 12 बजे पढ़ते-पढ़ते कमरे से बाहर निकले होंगे, ठंड का मौसम होगा और एक पेड़ के नीचे कोई चाय बेचने वाला बैठा होगा। आपका मन करता होगा, चाय मिल जाए तो अच्‍छा हो, क्‍योंकि रात भर पढ़ना है। और उस ठंडी रात में सोये हुए, उस पेड़ के नीचे सोये हुए उस चाय बेचेने वाले को आपके जगाया होगा, कि चाय पिला दे यार। और उसने अपना चेहरा बिगाड़े बिना, आप डॉक्‍टर बने इसलिए, आपका Exam अच्‍छा जाए, इसलिए, ठंड में भी जग करके कही से दूध लाके आपको चाय पिलाई होगी। तब जा करके आपकी जिंदगी की सफलता का आरंभ हुआ होगा।

कभी-कभार एकाध peon भी, कोई paramedical staff का बूढ़ा व्‍यक्ति, जिसके पास जीवन के अनुभव वा तर्जुबा रहा होगा, उसने कहा होगा, नहीं साब, सिरींज को ऐसे नहीं पकड़ते हैं, ऐसे पकड़ते हैं। हो सकता है, classroom का वह teacher नहीं होगा, लेकिन जिंदगी का वह Teacher बना होगा। कितने-कितने लोग होंगे, जिन्‍होंने आपकी जिंदगी को बनाया होगा। एक प्रकार से बहुत बड़ा क़र्ज़ लेकर के आप जा रहे हैं।

अब तक तो स्थिति ऐसी थी कि कर्ज लेना आपका हक भी था, लेकिन अब कर्ज चुकाना जिम्‍मेवारी है। और इसलिए भली-भांति उस हक का उपयोग किया है, अच्‍छा किया है। लेकिन अब भली-भांति उस कर्ज को चुकाना हमारा दायित्‍व बन जाता है। और उस दायित्‍व को हम पूरा करें। मुझे विश्‍वास है कि हम समाज के प्रति हमारा दायित्‍व अपने profession में आगे बढ़ते हुए भी निभा सकते हैं। आप अमीर घर के बेटे हो सकते हैं, गरीब परिवार के बेटे हो सकते हैं, मध्‍यम वर्ग के परिवार के बेटे / बेटी हो सकते हैं, लेकिन क्‍या कभी सोचा है कि आपकी पढ़ाई कैसे हुई है? क्‍या आपके फीस के कारण पढ़ाई हुई है? नहीं, क्‍या scholarship के कारण हुई है? नहीं।

इन व्‍यवस्‍थाओं का विकास तब हुआ होगा, जब किसी गरीब के स्‍कूल बनाने का बजट यहां divert हुआ होगा। किसी गांव के अंदर बस जाए तो गांव वालों की सुविधा बढ़े, हो सकता है कि वह बस चालू नहीं हुई होगी, वह बजट यहां divert किया गया होगा। समाज के कई क्षेत्रों के विकास की संभावनाओं को रोक करके इसे develop करने के लिए कभी न कभी प्रयास हुआ होगा। एक प्रकार से उसका हक छिन कर हमारे पास पहुंचा है, जिसके कारण हम लाभान्वित हुए हैं। और ये जरूरत थी, इसलिए यहां करना पड़ा होगा। क्‍योंकि अगर इतने बड़े देश में medical profession को बढ़ावा नहीं देते हैं तो बहुत बड़ा संकट आ सकता है, अनिवार्य रहा होगा। लेकिन कोई तो कारण होगा कि समाज के किसी न किसी का हक मैने लिया है, तब जाकर आज इस स्‍तर तक पहुंचा हूं। क्‍या मैं हर पल अपने जीवन में उस बात को याद करूंगा कि हां भाई, मैं सिर्फ डॉक्‍टर बना हूं, ऐसा नहीं है? ये मेरे सामने आया हर व्‍यक्ति किसी न किसी तरीके से योगदान दिया है, तब जाकर मैं इस अवस्‍था को पहुंचा हूं। मुझ पर उसका अधिकार है।

मैं नहीं जानता हूं, जो लोग यहां से पढ़ाई की और विदेश चले गए, उनके दिल में यह बात पहुंचेगी कि नहीं पहुंचेगी। कभी-कभार, अपने profession में बहुत आगे निकल गए और निकलना भी है। हम नहीं चाहते हैं कि सब पिछड़ेपन की अवस्‍था में हमारे साथी रहें। लेकिन कभी हम भी तो यार दोस्‍तों के साथ छुट्टी मनाने जाते हैं। कितने भी पेशेंट क्‍यों न हो, कितनी भी बीमारियों की संभावना क्‍यों न हो, लेकिन जिंदगी ऐसी है कि कभी न कभी उसकी चेतना अगले 7 दिन, 10 दिन अपने साथियों के साथ बाहर जाते हैं। कभी-कभार ये भी तो सोचिये कि भले ही बहुत बड़ी जगह पर बैठेंगे, लेकिन कम से कम सब साथियों को ले करके साल में एक बार पांच दिन, सात दिन दूर-सुदूर जंगलों में जा करके, गरीबों के साथ बैठ करके, मेरे पास जो ज्ञान है, अनुभव है, कहीं उनके लिए भी तो कर पाएं। मैं सात दिन, 365 दिन करने की जरूरत नहीं है, न कर पाएं, लेकिन ये तो कर सकते हैं। अगर इस प्रकार का हम संकल्‍प करके जाते हैं तो इतनी बड़ी शक्ति अगर लगती है। समाज की शक्ति से बड़ी कोई शक्ति नहीं हो सकती है। हम एक समाज के बहुत चेतनमंद ऊर्जा है। हम क्‍या कुछ नहीं कर सकते है इस भाव को लेकर अगर हम चलते हैं तो हम बहुत बड़ी सेवा समाज की कर सकते हैं।

कभी-कभार मैंने देखा है, सफल डॉक्‍टर और विफल डॉक्‍टर के बीच में आपने अंतर कभी देखा है क्‍या? कुछ डॉक्‍टर होते हैं जो बीमारी के संबंध में बहुत focused होते हैं, और इतनी गहराई से उन चीजों को handle करते हैं, और उनके profession में उनकी बड़ी तारीफ होती है। भाई, देखिए इस विषय में तो इन्‍हीं को पूछिए। consult करना है तो उनको पूछिए। लेकिन कभी-कभार उसकी सीमा आ जाती है।

दूसरे प्रकार के डॉक्‍टर होते हैं। वे बीमारी से ज्‍यादा बीमार के साथ जुड़ते हैं। यह बहुत बड़ा फर्क होता है। बीमारी से जुड़ने वाला बहुत Focused activity करके बीमारी को Treat करता है, लेकिन वो डॉक्‍टर जो बीमार से जुड़ता है, वो उसके भीतर बीमारी से लड़ने की बहुत बड़ी ताकत पैदा कर देता है। और इसलिए डॉक्‍टर के लिए यह बहुत बड़ी आवश्‍यकता होती है कि वह उस इंसान को इंसान के रूप में Treat कर रहा है, कि उसके उस पुर्जे को हाथ लगा रहा है, जिस पुर्जे की तकलीफ है? मैं नहीं मानता हूं कि वो डॉक्‍टर लोकप्रिय हो सकता है। वह सफल हो सकता है। डॉक्‍टर का लोकप्रिय होना बहुत आवश्‍यक होता है, क्‍योंकि सामान्‍य व्‍यक्ति डॉक्‍टर के शब्‍दों पे भरोसा करता है।

हमें भी अंदाज नहीं होता है। हम कहते है तो कह देते हैं कि देखो भई, जरा इतना संभाल लेना। बहुत पेशेंट होते हैं जो, उस एक शब्द को घोष वाक्‍य मान करके जिंदगी भर के लिए स्‍वीकार कर लेते हैं। तब जा करके हमारा दायित्‍व कितना बढ़ जाता है। और इसलिए हमें उस डॉक्‍टर समूहों की आवश्‍यकता है, जो सिर्फ बीमारों की नहीं, बीमारी की नहीं, लेकिन पेशेंट के confidence level को Build up करने की दृष्टि से जो कदम उठाए जाएं। और मैं नहीं जानता कि जब आप पढ़ते होंगे, तब classroom में ये बातें आई होगी। क्‍योकि आपको इतनी चीजें देखनी होती होगी, क्‍योंकि भगवान ने शरीर में इतनी चीजें भर रखी हैं, कि उसी को समझते-समझते ही कोर्स पूरा हो जाता है। सारे गली-मोहल्‍ले में Travel करते-करते पता नहीं कहां निकलोगे आप? इसलिए ये बहुत बड़ी आवश्‍यकता होती है कि मैं इस क्षेत्र में जा रहा हूं, तो मैं एक समाज की जिम्‍मेवारी ले रहा हूं। और समाज की जिम्‍मेवारी ने निभाने के लिए हम कोशिश कर रहे हैं।

हमारे देश में by and large, पहले के लोग थे, जो रात में भी मेहनत कर करके रिकॉर्ड मेंटेन करते थे। और वो पेशेंट की history, बीमारी की history, कभी-कभार भविष्‍य के लिए बहुत काम आती है। आज युग बदल चुका है। Digital Revolution एक बहुत बड़ी ताकत है। एक डॉक्‍टर के नाते मैं अभी से दो या तीन क्षेत्रों में focus करके case history के रिकॉर्ड्स बनाता चलूं, बनाता चलूं, बनाता चलूं। उसका analysis करता चलूं। कभी-कभार मेरे सीनियरों से उसका debate करूं, चर्चा करूं। science Magazines के अंदर मेरे Article छापे, इसके लिए आग्रही बनो।

भारत के लिए बहुत अनिवार्य है दोस्‍तों कि हमारे Medical Profession के लोग, अमेरिका के अंदर उसका बड़ा दबदबा है। दुनिया के कई देश ऐसे हैं, कि गंभीर से गंभीर बीमारी हो, अस्‍पताल में आपरेशन थियेटर में ले जाते हों, लेकिन जब तक वो हिन्‍दुस्‍तानी डॉक्टर का चेहरा नहीं देखते हैं, तब तक उनका विश्‍वास नहीं बढ़ता है। यह हमने achieve किया है। By and large, हर पेशेंट विश्‍व में जहां भी उसको परिचय आया, कुछ ऐसा नहीं यार, आप तो हैं, लेकिन जरा उनको बुला लीजिए। ये कोई छोटी बात नहीं है। लेकिन, हम Research के क्षेत्र में बहुत पीछे है। और Research के क्षेत्र में यह आवश्‍यक है कि हम Case history के प्रति ज्‍यादा Conscious बनें। हम पेशेंट की हर चीज को बारीकी से लिखते रहें, analysis करते रहें, 10 पेशेंट को देखते रहें। हो सकता है कि धीरे-धीरे 2-4 साल की आपकी इस मेहनत का परिणाम यह आएगा कि आप मानव जाति के लिए बहुत बड़ा Contribute कर सकते हैं। और हो सकता है कि आपमें से कोई Medical Science का Research Scientist बन सकता है।

मानव जाति के कल्‍याण के लिए मैं समस्‍याओं को Treat करता रहूं, एक रास्‍ता है, लेकिन मैं मानव जाति की संभावित समस्‍याओं के समाधान के लिए कुछ नई चीजें खोज कर दे दूं। हो सकता है, मेरा Contribution बहुत बड़ा हो सकता है। और ये काम कोई दूसरा नहीं करेगा। और आज Medical Science, आज से 10 साल पहले और आज में बहुत बड़ा बदलाव आया है। Technology ने बहुत बड़ी जगह ले ली है, Medical Science में।

एक जमाना था, जब गांव में एक वैद्यराज हुआ करते थे, और गांव स्‍वस्‍थ होता था। गांव बीमार नहीं होता था। आज आंख का डॉक्‍टर अलग है, कान का अलग है। वो दिन भी दूर नहीं, बाईं आंख वाला एक होगा, दाईं आंख वाला दूसरा होगा। लेकिन एक वैद्यराज से गांव स्‍वस्‍थ रहता था और बायें-दायें होने के बावजूद भी स्‍वस्‍थता के संबंध में सवालिया निशान लगा रहता है। तब जा करके बदले हुए समय में Research में कहीं न कहीं हमारी कमी महसूस होती है। Technological development इतना हो रहा है, आप मुझे बताइए, अगर Robot ही ऑपरेशन करने वाला है तो आपका क्‍या होगा? एक programming हो जाएगा, programme के मुताबिक robot जाएगा जहां भी काटना-वाटना है, काट करके बाहर निकल जाएगा, बाद में paramedical staff हैं, वहीं देखता रहेगा। आप तो कहीं निकल ही जाएंगे।

मैं आपको डरा नहीं रहा हूं। लेकिन इतना तेजी से बदलाव आ रहा है, आपमें से कितने लोग जानते हैं, मुझे मालूम नहीं है। एक बहुत बड़ा साइंस, जो कि हम सदियों पहले जिसके विषय में जानकारी रखते थे, बताई जाती थी हमारे पूर्वजों को, वह आज medical science में जगह बना रहा है। पुराने जमाने में ऋषि-मुनियों की तस्‍वीर होती थी, उसके ऊपर एक aura हुआ करता था, कभी हमको लगता था कि aura अच्‍छी designing के लिए शायद paint किया गया हो। लेकिन आज विज्ञान स्‍वीकार करने लगा है कि aura Medical Science के लिए सबसे बड़ा input बन सकता है। Kirlian Photography शुरू हुई, जिसके कारण aura की फोटोग्राफी शुरू हो गई। Aura की photography से पता चलने लगा कि इस व्‍यक्ति के जीवन में ये Deficiency है, शरीर में 25 साल के बाद ये बीमारी आ सकती है, 30 साल के बाद ये बीमारी आ सकती है, ओरा साइंस बहुत बड़ी बात है, वो develop हो रहा है।

आज के हमारे Medical Science के सबसे जुड़ा हुआ Aura Science नहीं है। Full Proof भले ही नहीं होगा, पर एक वर्ग है दुनिया में, विदेशों में, जो लोग इसी पर बहुत बड़ा काम कर रहे हैं। अगर ये Aura Science की स्‍वीकृति हो गई तो शायद Medical Science की Terminology बदल जाएगी। एक बहुत बड़े Revolution की संभावना पड़ी है। हम Revolution से डरते नहीं है। हम चाहते हैं, Innovations होते रहने चाहिए। लेकिन चिंता ये है कि हम उसके अपने आप के साथ मेल बिठा रहे हैं कि हम उन पुरानी किताबों को पढ़ें, क्‍योंकि हमारे professor भी आए होंगे, वो भी वही पुरानी किताब लेके आए होंगे। उनके टीचर ने उनको दी होगी। और हम भी शायद प्रोफेसर बन गए तो आगे किसी को सरका देंगे कि देख यार, मैं यहीं पढ़ाता रहा हूं, तुम भी यही पढ़ाते रहो। तो शायद बदलाव नहीं आ सकता है।

इसलिए नित नूतन प्राणवान व्‍यवस्‍था की ओर हमारा मन रहता है, तो हम Relevant रहते हैं। हम समाज के बदलाव की स्थिति में जगह बना सकते हैं। उसे बनाने की दिशा में अगर प्रयास करते हैं तो मैं मानता हूं कि हम बहुत बड़ी सेवा कर सकते हैं। आप एक ऐसे Institution के Students हैं, जिसने हिन्‍दुस्‍तान में अपना एक Trademark सिद्ध किया हुआ है। आज हिन्‍दुस्‍तान में कहीं पर भी अच्‍छा अस्‍पताल बनाना हो, या Medical Science में कुछ काम करना हो, कॉलेज अच्‍छे बनाने हो तो लोग क्‍या कहते हैं? पूरे देश के हर कोने में। हमारे यहां एक AIIMS बना दो। और कुछ उसे मालूम नहीं है। इतना कह दिया मतलब सब आ गया। उसको मालूम है AIIMS आया, मतलब सब आया।

इसका मतलब, आप कितने भाग्‍यवान हैं कि पूरा हिन्‍दुस्‍तान जिस AIIMS के साथ जुड़ना चाहता है, हर कोने में कोई कहता है, पेशेंट भी चाहता है कि यार मुझे AIIMS में Admission मिल जाए तो अच्‍छा होगा, Students भी चाहता है कि पढ़ने को यदि AIIMS में मिल जाए तो exposure बहुत अच्‍छा मिलेगा, Faculty अच्‍छी मिल जाए, बहुत बड़ा जीवन में सीखने को मिलेगा। आप भाग्‍यवान हैं, आप एक ऐसे Institution से निकल रहे है, जिस Institution ने देश और दुनिया में अपनी जगह बनाई है। ये बहुत बड़ा सौभाग्‍य ले करके आप जा रहे हैं।

मुझे विश्‍वास है कि आपके जीवन में माध्‍यम से भविष्‍य में समाज को कुछ न कुछ मिलता रहेगा और “स्‍वस्‍थ भारत” के सपने को पूरा करने में आप भी भारत माता की संतान के रूप में, जिस समाज ने आपको इतना सारा दिया है, उस समाज को आप भी कुछ देंगे। इस अपेक्षा के साथ में आज, जिन्‍होंने यह अचीवमेंट पाई है, उन सबको हृदय से बहुत-बहुत अभिनंदन करता हूं। मेरी शुभकामनाएं हैं, और मैं आपका साथी हूं। आपके कुछ सुझाव होंगे, जरूर मुझे बताइए। हम सब मिल करके अच्‍छे रास्‍ते पर जाने की कोशिश करेंगे।

आपके बीच आने का मुझे अवसर मिला, मैं भी हैरान हूं कि मुझे क्‍यों बुलाया? ना मैं अच्‍छा पेशेंट हूं। भगवान करे, ना बनूं। डॉक्‍टर तो हूं ही नहीं। लेकिन मुझे इसलिए बुलाया कि मैं प्रधानमंत्री हूं। और हमारे देश का दुर्भाग्‍य ऐसा है कि हम लोग सब जगह पे चलते हैं। खैर, मुझे आप लोगों से मिलने का अवसर मिला, मैं आपका आभारी हूं।


Sunday, October 19, 2014

India has 3rd-highest number of HIV-infected people: UN

India has the third-highest number of people living with HIV in the world with 2.1 million Indians accounting for about four out of 10 people infected with the deadly virus in the Asia—Pacific region, according to a UN report.
The report by UNAIDS, the United Nations programme on HIV/AIDS, said that 19 million of the 35 million people living with the virus globally do not know their HIV—positive status and so ending the AIDS epidemic by 2030 will require smart scale—up to close the gap.
The first—ever UNAIDS ‘Gap Report’ said after sub—Saharan Africa, the region with the largest number of people living with HIV is Asia and the Pacific.
At the end of 2013, there were an estimated 4.8 million people living with HIV across the region.
Six countries - China, India, Indonesia, Myanmar, Thailand, and Vietnam - account for more than 90 per cent of the people living with HIV in the region.
“India has the third largest number of people living with HIV in the world — 2.1 million at the end of 2013 — and accounts for about 4 out of 10 people living with HIV in the region,” the report said.
It said HIV treatment coverage is only 36 per cent in India, where 51 per cent of AIDS—related deaths occur.
In India, the numbers of new HIV infections declined by 19 per cent, yet it still accounted for 38 per cent of all new HIV infections in the region.
The proportions of people who do not have access to antiretroviral therapy treatment are 64 per cent in India.
In Asia and the Pacific, the number of AIDS—related deaths fell by 37 per cent between 2005 and 2013, the report said.
India recorded a 38 per cent decline in AIDS—related deaths between 2005 and 2013. During this period, there was a major scale up of access to HIV treatment, it said.
At the end of 2013, more than 700,000 people were on antiretroviral therapy, the second largest number of people on treatment in any single country.
In India, HIV prevalence among female sex workers dropped from 10.3 per cent to 2.7 per cent but it increased in the states of Assam, Bihar and Madhya Pradesh, the report said.
A look at the HIV prevalence among sex workers:
(Source: UN GAP report)
The estimated population size of sex workers is 868,000, of which 2.8 per cent is HIV—positive. In India, HIV prevalence among women who inject drugs was nearly twice that or more than the figures for their male counterparts, it said.

Wednesday, October 15, 2014

Fighting India’s silent epidemic

ECONOMIC AND CLINICAL CRISIS: There are 2.2 million new cases and close to 3,00,000 deaths each year according to the Government of India’s TB India 2014 report. Picture shows the x-ray of a patient in New Delhi suffering from both TB and HIV.

Tackling TB requires both strengthening the public sector and engaging the private sector

Over 60 per cent of all Indians seek health care in the private sector according to India’s last National Family Health Survey. This undoubtedly makes the private sector the largest provider of health services in India. The government health system, though vast and well-intentioned, continues to be overburdened with multiple challenges including long waiting hours, an ageing infrastructure, limited funding and human resources. Even though parallel providers of health services, the absence of partnerships between the public and private sector has disastrous implications for patients and for disease control. A striking case study is that of TB.
With 2.2 million new cases and close to 3,00,000 deaths each year, TB is India’s silent epidemic. The 60 per cent of all TB patients who first go to the private sector receive care whose quality varies enormously, often leading to delays in diagnosis and no assurance of cure. As a result, a large proportion of these patients move — sicker and poorer — from one provider to another, infecting others in the process.
Treatment access and reliability

While TB can affect anybody, studies have shown that it is four times more common in people in the lowest socio-economic quintile compared to the highest. A recent systematic review found that the total costs of TB for patients and affected families on average corresponded to more than half their yearly income. This makes it a clinical as well as an economic crisis.

How can India address this crisis? Tackling TB in India requires both strengthening the public sector and engaging the private sector. For a disease like TB, early diagnosis and correct treatment are the easiest ways to reduce transmission. India needs to give every patient, irrespective of whether they go to the public or private sector, access to quick and reliable diagnosis and treatment.
 Studies have shown that TB is four times more common in people in the lowest socio-economic quintile compared to the highest 
For the government, this means that every primary health centre (urban and rural) — the first point of care for the patient — should be capable of making a diagnosis of TB and initiating treatment.
For this, diagnostic facilities need to be upgraded and clinical and laboratory staff given training. Private services could be utilised for some of these investigations in PHCs where these facilities may not be available (for example imaging studies, paediatrician opinions and rapid molecular tests). Patients should not need to travel long distances to get a diagnosis.
Ultimately, the quality of health care provided and a “satisfied client” are the most successful advertisements for the health system. At the same time, we must actively engage the private sector in a mutually acceptable way — while patients continue to remain with the individual doctor, both diagnosis and treatment could be provided free through the public sector.
Brazilian example

Here, Brazil offers an excellent example, where TB drugs are offered only by the public health system and are unavailable in the private sector. TB drugs are bought through a centralised mechanism of acquisition and distribution, ensuring drug quality.

Such a model could easily work in India if combined with effective use of technology. Each patient diagnosed in the private sector could avail drugs through the use of a paper or electronic voucher valid at designated pharmacies. This would ensure that patients receive appropriate and quality-assured drug regimens reducing patient costs. Further, it would ensure notification of all patients and help in monitoring and follow-up to ensure cure.
There is obvious reluctance in the private sector to engage with the government because of the fear of losing their patients, excessive monitoring, delayed payments, etc. Hence, we must be flexible in our approach to treatment (as long as standards are followed) and create more transparency, accompanied by use of technology to address systemic delays.
Changes in TB programme

Rapid reduction in TB burden is not possible without significant changes in India’s TB programme. It requires uniform and equitable implementation of the diagnostic, treatment, public health and social support guidelines laid down in the Indian Standards of TB care, strengthening of human resources both at the Central and State level, using novel methods of monitoring patient compliance (e.g. mobile phone based) and launching a massive public awareness campaign. Procedures for procurement and distribution of drugs need to be streamlined to ensure a constant supply of quality-assured drugs. More flexibility in programme delivery needs to be given to State and district-level implementing officers. Alongside inputs to achieve universal health coverage, social protection interventions that address out-of-pocket expenses and the food and nutritional requirements of TB patients are also critical — an innovative example is the free breakfast scheme for TB patients launched by the Chennai Corporation.

India may take a cue from China, where TB prevalence declined by half as the government invested heavily in systemic improvements, modernisation and changing approaches to diagnosis and treatment. This revitalisation of TB services led to millions being able to access timely, high-quality TB treatment which considerably reducing the number of new TB cases.
India urgently needs similar investment in the health system combined with innovative strategies to address TB and drug resistant TB.
In 2013, the World Health Organization identified 3 million missing TB cases globally of which 1 million were in India. These 1 million missing cases fall somewhere between the public and the private sector and lack access to free care. If India wishes to end its TB crisis, we must begin by providing prompt diagnosis and treatment to our missing million. Yet this is unlikely to happen unless we transform our current TB programme while simultaneously engaging the vast private sector. If we do not act now, our inaction will make us responsible for continued suffering of patients and deaths.
(Soumya Swaminathan is director, National Institute for Research in Tuberculosis, Chennai, and Chapal Mehra is an independent New Delhi-based writer.)

For public health as political priority

A systemic reform of the health sector in order to meet the key objectives of equity, efficiency and quality is long overdue. In this, the Central and State governments need to make interventions intelligently, decisively and strategically so that the poor reap the benefits

How does Prime Minister Narendra Modi’s focus on population, health and subjects like public hygiene, the facilitation of toilets and ensuring preventive health through yoga fit in with his party, the Bharatiya Janata Party’s manifesto; one which promises a National Health Assurance (NHA) mission, with its aim of providing cashless hospitalisation in order to reduce out-of-pocket expenses? Why do these concerns seem contradictory? Does pursuing one necessarily hurt the other? These are legitimate questions and concerns. This must be looked at in a global context where there is discussion on Universal Health Coverage (or National Health Assurance) widening inequity in the short and medium term.
In seeking the maximisation of the health and well-being of every individual, the NHA subsumes the essentiality of access to those elements that constitute the foundation of good health — tap water (where conveyance of contamination is reduced by 99 per cent), a toilet and sewerage system, environmental hygiene, nutrition and basic primary care — and in the process, reduce 90 per cent of all morbidities and a substantial proportion of mortality. Evidence of efforts in the United Kingdom to contain tuberculosis by ensuring better housing and nutrition, the successful eradication by India of guinea worm infestation using improved water systems, or eradicating polio through improved sanitation and universal immunisation are some useful reminders of the interconnectivity between disease and environment, and between public health and clinical science.
Addressing inter-State disparities

In India, public health has been severely neglected with about 44 per cent of the population having access to tap water and toilets, 42 per cent of children being malnourished and a majority of people being treated by quacks. Setting right these issues requires an expenditure of an estimated Rs.10.7 lakh crore (recurring and non-recurring) against which the 12th Plan has allocated Rs.3.8 lakh crore. The most challenging of these is in bridging inter-State disparities, with 70 per cent of this investment required by the northern States that have restricted fiscal space, three quarters of the disease burden (preventable with effective primary health care) and weak implementation capacity, making inadequate funding not the only constraint. For example, in Bihar, 2.5 per cent of its rural population has access to tap water, 23 per cent of its people to toilets and a battered primary care system. Should such a State then invest in providing these basic services or in buying expensive care from private hospitals through insurance? What are the moral and ethical imperatives that must guide State action?

The Andhra Pradesh experience

In this regard, a review of the impact of the Rajiv Aarogyasri Health Insurance Scheme (RAS) in former Andhra Pradesh is illustrative of how the State consciously chose to abandon primary care for universal coverage of a select set of tertiary and secondary care conditions.

In 2007, RAS, a State sponsored health insurance scheme (covering 85 per cent of the population, with sum assured of Rs.1.5 per family for cashless treatment in 486 hospitals involving 938 procedures) was launched to provide risk protection against catastrophic illnesses that “have the potential to wipe out a lifetime savings of poor families.” The justification was that there was effective demand for treatment for non-communicable and chronic diseases, low investment in public hospitals and a burgeoning private sector, unaffordable to most.
RAS was perceived to be a popular programme. But there is a thin line between perception and reality. Several commentators have critiqued it as having boosted the revenue streams of private corporate hospitals without necessarily reducing health expenditures or improving health outcomes.
 Scaling-up the National Rural Health Mission’s efforts to revive the primary health-care system would be far cheaper and more sustainable than buying care from private hospitals. 
While there are no systematic evaluations to assess the impact of RAS, a recently conducted household survey in Andhra Pradesh by Access International covering 8,623 households offers interesting insights. While it showed an overall reduction in out-of-pocket expenditure and increased hospitalisation, it had limited impact in reducing impoverishment or indebtedness among the two lowest quintile groups. For example, while per capita expenditures for inpatient treatment nearly trebled from Rs.391 in 2004 to Rs.1,083 (2012) for the poorest quintile, it was down to Rs.1,174 from Rs.1,819 for the fourth quintile group. Likewise, while the proportion of those incurring catastrophic expenditures more than doubled from 1.1 per cent to 2.8 per cent and 1.2 per cent to 3.4 per cent for the two lowest quintiles, the richer quintiles faced reductions. Such wide disparities are attributed to the concentration of half the accredited hospitals in seven districts (towns) resulting in an inequitable distribution of and gross deficiencies in the supply side, making access difficult and unaffordable for those residing in backward districts.
Impact on poor

Second, 49 per cent of reimbursement was for cardiac, cancer and kidney failure (38 per cent of patients or 0.5 per cent of population), while the two bottom quintiles suffered impoverishment, premature mortality and disability due to lower respiratory infections, diarrhoeal diseases, tuberculosis (TB), ischemic heart diseases and malaria — conditions eminently preventable and treatable with effective primary care.

Besides, partaking RAS benefits implies forced hospitalisation for outpatient care, increasing the risk of hospital acquired infections and higher indirect expenditures that the poor cannot bear.
Third, the primary health-care system that the earlier Telugu Desam Party government had accorded high priority to has all but collapsed. Among 19 major States, Andhra Pradesh incurred the lowest expenditure of Central grants (National Rural Health Mission and disease control programmes) as proportional to its total health spending during 2011; 16 per cent against 31 and 28 percentages by Maharashtra and Karnataka respectively and the only State to slash its primary care budgets from 53 per cent to 46 per cent and allocate just 9 per cent for secondary care down from 12 per cent during 2007-12. In comparison, RAS was provided 23 per cent of the health budget for less than 1 per cent of the population (not necessarily poor) or 11.3 per cent of total hospitalisation. In the absence of cost containment measures and generous pricing, costs are likely to escalate further, impinging on the fiscal space of the two new States of Telangana and Andhra Pradesh. RAS reimbursement rates, say for hysterectomy, laparoscopy, appendectomy or coronary bypass are higher when compared to other schemes in the country. Prices set through negotiations with private hospitals by committees without professionals — like chartered accountants, health economists or systematic unit costing methodologies — can only be arbitrary. Further, package rates provide scope for gaming the system. In the absence of standards to measure quality and regulations to control provider behaviour and fraud, perverse incentives are created, as reflected in unnecessary diagnostics, procedures and surgeries.
RAS was a bold initiative to address the problem of impoverishment that has been partially addressed. Contrary to Tamil Nadu, which witnessed a 10 per cent shift in institutional deliveries from private to public sector, the increase in Andhra Pradesh is in the private sector, resulting in huge borrowings. Access to social determinants and the substantial load of preventable diseases like diarrhoea, TB, sexually transmitted diseases and HIV, are bouncing back due to policy neglect and mismanagement and continue to be issues requiring attention.
Policy corrections

The Andhra Pradesh story shows that lessons need to be learnt in order to reboot health policy along a more sustainable path. Scaling-up the NRHM’s efforts to revive the primary health-care system; incentivising lifestyle changes; universalising access to social determinants; revamping and embedding the primary care system within the community; increasing investments in public sector hospitals, along with improving incentive structures, employing requisite staff and upgrading infrastructure would be far cheaper and more sustainable than buying care from private hospitals for services that are available in the public hospitals at a third of the price. Private care must supplement, not substitute public care. Finally, in order to ensure patient well-being and value for money, standard treatment protocols and guidelines need to be developed; costing of procedures undertaken, monitoring systems for quality such as rates of survival, hospital acquired infections and readmissions developed and regulations enforced alongside establishment of grievance redress systems, with fair compensation and penalties against malpractice.

A systemic reform of the health sector in order to achieve the three principal objectives of equity, efficiency and quality is long overdue. This will require skilful political management and stakeholder negotiations. Governments at the national and State levels need to give up rhetoric and knee-jerk responses as substitutes for real action. Instead, they need to make interventions intelligently, decisively and strategically to ensure that solving one problem does not give rise to another. They also need to stay focussed on doing the simple things right in the first instance so that disparities reduce and the poor reap the benefits in real terms.
(Sujatha Rao was Health Secretary in the Government of India.)

Sunday, October 12, 2014

WBPGMAT 2015 Notification

Doctors in the dock

Dear Dr Kalra, I am reporting against Dr ****** of ***** hospital. He did a renal transplant on my uncle. But it led to complications and uncle was in hospital for long. I watched the surgery on YouTube. Now I know doctor used wrong technique. Please take action against doctor.
Dr K.K. Kalra staggered when he read the email. Open proclamation of 'guilt' against a doctor based on an Internet search? "This will only get worse," muttered the chief of the National Accreditation Board for Hospitals (NABH), India's quality control body for hospitals. He received far too many complaints these days, 50 per cent of all, from disgruntled families and friends of patients. He shuddered at the thought of what the future might hold.
Doctors are in the dock. Lawsuits filed by aggrieved patients are jamming up courtrooms across the country. Their names get splashed day after day across front pages of newspapers, on computer and television screens across the nation. It is the kind of exposure every doctor dreads. Chastened by medical litigation and intimidated by negative publicity, a culture of defensive medicine of unnecessary tests and medications or refusing patients with complex illnesses as a safeguard against future litigation, hangs over our hospitals.

Here's an alarming statistic: 98,000 deaths from medical injuries occur in India every year, reports an ongoing NABH study. Here's another: medico-legal cases have gone up by 400 per cent in the Supreme Court in the last 10 years, according to legal resource, Manupatra. Patients are afraid of an uncaring medical system. Doctors are terrified of assertive patients. Hospital life is under scrutiny, and with it the authority and autonomy of doctors. "Doctors are afraid," says Dr Arvind Kumar, chief of robotic and chest surgery at Sir Ganga Ram Hospital in Delhi. "The trust factor between doctors and patients is slowly coming down and there is no solution in sight." 


Every day, the headlines get worse, although in reality just 10-15 per cent cases are ever proved against doctors. Check out 2014: in January, a premature baby in Meerut died of burn injuries from an overheated incubator. In May, a hospital was asked to pay Rs.7 lakh after a woman lost her uterus during a caesarean section. In July, a Chandigarh doctor was asked to pay up Rs.70 lakh for amputating the wrong leg of a teenager. In June, a newborn in Coimbatore lost eyesight while in hospital. In July, a Bangalore woman with uterus tumour died of anaesthesia allergy. In August, a patient declared dead by a doctor was found alive when grieving relatives went to collect his body in Malda, West Bengal.
Who is at fault? Ask forensic experts, who ultimately determine if a medical malpractice case has merit. Four such doctors from Mysore Medical College and Grant Medical College, Mumbai, have drawn up a profile of medical negligence cases with the National Consumer Disputes Redressal Commission, this year: medical negligence cases involving surgery account for 80 per cent of all cases, of which obstetrics and gynaecology (29 per cent) top the list, followed by orthopedics (22 per cent). "Hospitals are found to be negligent, along with doctors, in 34 per cent cases," says lead researcher Dr Anand P. Rayamane. Of the various reasons for death, negligence of doctors (49 per cent) is cited the most.
"Negligent doctors need to be punished. But medical errors are also often 'system errors' and not the result of an individual physician's negligence," says Dr K. Srinath Reddy, former head of cardiology with AIIMS and currently president of Public Health Foundation of India. The scientific basis of good clinical practice depends on combining a well-gathered history of illness, physical signs and results of tests into an estimation of probabilities of possible diagnoses, he explains. While medicine is not an exact science, which always gives a 'yes' or 'no' answer, the 'art' of medicine lies in converting scientific evidence to standard management guidelines created by expert bodies, for all practitioners to follow. "Apart from minimising errors and avoiding unnecessary tests and treatments, adherence to guidelines forms the best defence against allegations of medical negligence," he adds.

The buzz among doctors is also on crippling compensations. In the latest issue of the British Medical Journal, Indian doctors have come head to head. "In India, healthcare is supposed to be regulated by a quasi-judicial medical council that has failed to protect against widespread negligent and irrational treatment," writes Dr Kunal Saha, a US-based doctor who received 'historic' justice-an unprecedented compensation of Rs.11.5 crore-in October 2013, for medical negligence that caused his 36-yearold wife Anuradha's death in 1998. "Large payouts awarded by the courts of law may be the only way to instill accountability for wayward doctors and to save lives."

"In 2030 BC, the code of Hammurabi, the king of Babylon, was to chop off a doctor's hand for making a mistake. This approach may prevent future mistakes but after some time few doctors would be left with hands to operate. India's current legal position on medical negligence is not vastly different from Hammurabi's code," says Dr Devi Shetty, cardiac surgeon and chairman of Narayana Hrudayalaya in Bangalore. Although the Supreme Court of India has rightly upheld the law of the land in Kunal Saha's case, he explains, punishing negligent doctors financially will encourage them to practise what is called defensive medicine.
What is defensive medicine? Consider this: an elderly man was rushed to a hospital in Kolkata after he collapsed from what was suspected to be a stroke. His daughter came out of the critical care unit, crying aloud that one sentence that sets nerves on edge in hospitals: "They have left him unattended." Her family huddled in worry: "We will shift him to another hospital." He was too sick to move but she created a fuss, clicking his medical reports on her cell phone and bringing in doctors from outside for a second opinion. That sealed their case. The hospital went tight-lipped, doctors became brusque and evasive. The daily question, "How is he?" met with the daily answer, "The same." As soon as the feeding tube was removed from the patient's nose, the hospital discharged him on just a 24-hour notice, without giving the family the leeway to set up alternative plans or room to appeal.
It doesn't have to be a life-and-death situation. Defensive medicine can corrode the basic trust between doctors and patients in an everyday setting and lead to unnecessary expense. For example, a middle-aged couple comes to a doctor. The man complains of a burning sensation in his chest right after eating, which radiates all the way to his neck. The doctor diagnoses him with indigestion, suggesting a change in diet and some pills. But the patient and his wife continue to look anxious. The doctor, although convinced that his diagnosis is right, orders a barrage of tests to rule out a heart attack: an echocardiogram, a tread mill test, a homosysteine and lipoprotein test, a 64-slice CT angio scan. The tests cost Rs.15,000 and, although not medically necessary, they protect the doctor in case of any future claims of insufficient advice. 


Have doctors become more negligent? The kinds of malpractice hitting the headlines are not new: in 1953, a boy with a fractured limb died in Pune as a doctor operated on him without proper anaesthesia (Joshi vs Godbole, SC). Sixty years later, in 2013, a three-year-old boy died in Bangalore during a dental procedure from wrong dosage of anaesthesia. But for so long, no one really knew how many such cases occurred. Now the numbers are what first stand out, and what also make the questions necessary. According to a 2013 study (Global Burden of Unsafe Medical Care) by Dr Ashish Jha of Harvard School of Public Health, of the 421 million hospitalisations in the world annually, about 42.7 million adverse events of medical injury take place, two-thirds of which are from low-income and middle-income countries. India records approximately 5.2 million cases a year, ranging from incorrect prescription, wrong dose, wrong patient, wrong surgery, wrong time to wrong drug.
With public awareness, claims and litigation are rising. In the country's consumer courts, they now top the list of 3.5 lakh pending cases. According to Dr Girish Tyagi, registrar of Delhi Medical Council, the appellate authority for dealing with such cases, the number of cases from overcharging, needless procedures, wrong doctors to wrong decisions has zoomed in the last two years, from about 15 complaints a month to 40 now. A report by the Association of Medical Consultants shows that there were 910 medico-legal cases against doctors between 1998 and 2006 in Mumbai. Now they are going up by 150-200 cases every year.
The laws are problematic, entangling patients, doctors and hospitals in an unholy mess. "Doctors and judiciary speak in very different language," says Samuel Abraham, law officer with the Christian Medical College in Vellore. "Typically, doctors respond to court summons by apologising. But to the judiciary, that's an admission of guilt." Most hospitals do not have their own legal officers. Hence cases become complicated and continue for long. Hospitals also do not have advocacy cells, to communicate with patients amicably, without getting into litigation. "The problem with most hospitals is that they never have settlement in mind. If there's even an iota of deficiency in service, it's best to compensate," he says. "But hospitals lose a case, appeal repeatedly, and litigation carries on for years, wasting everyone's time, energy and money."
But it's the gap in the law that seems to leave both patients and doctors at a dead end. "For the longest time in India, medical negligence was not seen as compensable," says barrister Sushil Bajaj of The Integrated Law Consultancy, Delhi. "It was extremely limited in scope and not really codified." The two ways of getting compensation are now through the law of torts (personal injury) and the recently introduced Consumer Protection Act of 1995 (CPA). "But there are problems with both," he explains. The CPA is for all consumers of goods and services-broken toasters to patients dying of medical negligence all balled up in the same can of worms and the language is "quality of service provided" not, strictly speaking medical negligence. "As a result, there's an enormous volume of work for the judges," he says. "They neither have the time nor the expertise to go deep into medico-legal cases. There is no scope for cross-examination. Judges just go by affidavits or reports."
In regular civil courts, patient-doctor relationship is governed by the tort law (personal injuries). "Again this law is not codified in India," adds Bajaj. The biggest problem of the law is that it does not clearly address what is 'adequate compensation'. "Kunal Saha's case is a benchmark because for the first time we recognised that there are other heads of compensation, the modern trends in tort that need to be expanded." These range from "loss of consortium" for deprivation of family relationship, "punitive damages" for gross negligence to "exemplary damages" to punish and deter shocking conduct. For Bajaj, whatever the end result, if the best doctor in the world errors even once he must pay compensation as a professional. And it should be adequate. "A person who has suffered cannot be without remedy."


"My experience would make doctors afraid of giving their opinion. This is called defensive medicine." That's the famous first reaction of oncologist Dr Praful B. Desai, Padma Bhushan awardee and former director of Tata Memorial Hospital, Mumbai, after he was absolved of all charges of medical negligence by the Supreme Court in 2013, in India's longest medical lawsuit that dragged on for 26 years. The legal battle had been started in 1989 by a former bureaucrat after his wife, a cancer patient, had died.

As the number of negligence lawsuits against physicians escalates, it takes a terrible toll on doctors. "The alarming increase in litigation has triggered a widespread fear," says Dr Kumar. "All doctors are keenly aware of the risks and even the hardworking, conscientious ones feel vulnerable to litigation." Many hesitate to touch patients with complications and those involved in lawsuits suffer from depression, burnout, emotional exhaustion and often become suicidal, he explains.

The obvious fallout is that the doctor-patient relationship is turning adversarial. It has become an article of faith among many doctors that patients kick up a fuss as an easy way to settle spiralling bills. "This is one of the most common things we see and this is true across the country, especially the metros," says Dr Kumar. "Doctors are under tremendous pressure. Any bad outcome today gets labelled as 'medical negligence', with friends and family of the patient threatening to call television channels to scare a hospital into waiving off their bills."
It's also pushing doctors toward heavy professional indemnity policies. "It is usually around Rs.10 lakh, with a premium of Rs.3,000-Rs.5,000 per annum," says Dr Neeraj Nagpal, convenor, Medicos Legal Action Group, Chandigarh. If a doctor wants to cover himself against a claim of Rs.11.5 crore, the amount awarded to Saha, the premium will be between Rs.300,000 and Rs.600,000 annually. For that a doctor will have to attend to a large number of patients every day and raise his fees substantially. "With rising litigation, everyone will have to pay through their nose."
There are good doctors and there are bad doctors, just as there are good patients and bad patients. And it's hard to know whom to feel more sorry for: the Mumbai cancer surgeon last year who said, "My successful career is ruined for no fault of mine," when a patient he had declared dead suddenly started moving? Or the Delhi man who kept harassing a doctor with lawsuits for years because he had not said, "I'm sorry," after his wife died of cancer at his hospital?
The sign of the time is getting clearer every day: public demand. "That's the biggest driver of change. Doctors and hospitals have to do what they want," says Dr Kalra. That can be a good thing: it can improve accountability of doctors and hospitals. But so long as patients recognise the dangers in this shifting balance of power. Does anyone gain if the trust that makes doctors and patients a team is shattered?
Once sued, most doctors are twice shy. But four years ago, in 2010, the Supreme Court held out a ray of hope for doctors. A bench of Justices Dalveer Bhandari and H.S. Bedi had pointed out the need to protect doctors from "malicious prosecution": "It is our bounden duty and obligation of the civil society to ensure that medical professionals are not unnecessarily harassed or humiliated so that they can perform their professional duties without fear and apprehension."
Change will require looking at medical practice and malpractice in a new light: not just at material costs, but that the trust that exists between patients and doctors remains sacred.

Wednesday, October 8, 2014

Don’t force young doctors to serve in rural areas

The acute shortage of doctors in India, especially in rural areas, is a nuisance for the government, a problem that has not been successfully tackled till now. The forced compulsion of one year of rural service after five and a half years MBBS course, just to be merely eligible to apply for a PG seat is however a futile, ineffective and vastly unpopular method to fill this shortage. The primary reason being no priority was given to students voluntarily opting for rural service, in PG entrance exams. Also worse, it would made it much more difficult for them to prepare for the PG entrance test when they are in a very demanding job without adequate facilities. Not surprisingly, the new government has decided to scrap the proposal of one-year compulsory rural-service after completion of MBBS and asked the Medical Council of India (MCI) to include it instead as a part of the PG course.
But that alone is not the solution. There has been a nationwide agitation under different banners like ‘Save the Doctor’ and ‘Doctors for Villages’ etc with medical students and established doctors from premiere medical colleges, hospitals protesting actively against numerous other problems which are evident even to the common man with average intelligence. Lack of proper infrastructure at primary health centres (PHCs), unhygienic sanitation, shortage of medicine and emergency equipment, malfunctioning labs, absence of lab assistants, nurses and experienced doctors for mentoring, adequate security of female doctors, deprivation of residential quarters due to unavailability etc are the most common and undeniable laggings which require immediate addressing.
There is undoubtedly an utter dearth of qualified allopathic doctors throughout the country. Considering the norm of one doctor per thousand, there should be a minimum of 12 lakh doctors for 120 crore Indians. However, currently there are only around 7 lakh allopathic doctors in India. There are just a meagre 32,000 sanctioned posts of MBBS doctors roughly with 50,000 new MBBS graduates every year. The government needs to find a permanent solution for this immense shortcoming instead of making scapegoats out of budding doctors. Temporarily posting them in rural areas will not serve any purpose unless they willingly subscribe to the same.
Various methods can be tried and tested to resolve this issue at hand. There were suggestions to start a new three-year BSc-CH (Community Health) degree course, whose graduates would serve in rural areas. This was vehemently opposed by doctors and experts alike, and correctly so, because promoting MBBS for urban people and BSc-CH for rural population is not a great idea, as it may create double standards in treatment culture, which can lead to utter chaos and confusion.
Even the new government’s latest decision to introduce one-year compulsory rural service as a part of the postgraduate medical course is not without its flaws. This is opposed on the ground that for one year, the PG students would be deprived of studying, acquiring skills that would help them later practice as a specialist. Also, many PHCs, by their very nature, won’t provide avenues for PG students to learn or practice their specialized skills. Further, if we increase the PG course duration by one-year, it will unnecessarily lengthen the study duration which is already more than nine years – five and half for MBBS and three for PG, not to mention the years spent between the two for PG entrance test preparation. The seemingly ever-declining interest of school students in medicine as a career option will only be further bolstered by such measures.
Another idea is to start 50-seat MBBS medical colleges at district level by upgrading the existing district hospitals and train the students mainly as general practitioners (GPs) in a way to make them more suitable for the local needs. This will address the uneven spread of medical colleges in the country, bring more doctors in the system and encourage the medical students to learn more about the diseases/problems at the local level. If necessary, these seats may be reserved for meritorious students within the district so that they continue to serve locally. A major concern in this regard is finding enough teachers for these medical colleges. However, it should not be much of a problem for clinical subjects, as district hospitals already have necessary doctors. For the non-clinical subjects like Anatomy, Pharmacology etc one teacher might be assigned to 2-3 adjoining district medical colleges with travelling/accommodation allowances etc. The conduction of supervised video lectures from experts all over the country may also be probed and adapted depending on results and response.
For achieving the same, a substantial amount of the financial budget needs to be allotted and expended for a complete makeover of the medical facilities, thus popularizing the desire of doctors all over to happily serve wherever they are posted. This should not be too much of an ask, especially when we have been spending almost twice the money allotted to the health sector for minority welfare, around 20 times for the agriculture credit scheme and much larger amounts for urban development and loan waivers. However, it remains to be seen whether these old political gimmicks are finally abandoned and the real problem at hand is dealt with once and for all amidst innumerable promises.