Tuesday, July 29, 2014

Doctoring Medicine

The cancer of corruption eating into India’s medical sector is no secret. Reports of patients being prescribed unnecessary tests by unscrupulous doctors in league with labs abound. Alongside there are frequent reports of needless procedures — from caesarean births to the insertion of stents into healthy hearts and replacement of workable knees — thrust upon patients by doctors keen to make a killing off someone’s unease.
Such practices seriously harm the health and finances of Indian patients. In addition such malpractices are gaining India’s medical tourism industry — once tipped to hit six billion dollars by 2018 — infamy around the world. Transparency International ranks India’s medical industry as the second most corrupt institution citizens encounter following the police. This image, of a corrupt, cynical trade preying on patients, is seriously damaging medical tourism to India. Already hit by tight visa rules, a decaying ethical reputation could see India — visited by 350,000-plus overseas patients in 2012 — beaten flat by better-reputed destinations like Singapore, which saw over 600,000 overseas patients.
There are strong global practices and precedents to control medical corruption. In America, only this year, six hospitals have been fined millions of dollars for improper financial ties with diagnostic centres and recommending needless procedures. That included a Kentucky hospital fined 41 million dollars for prescribing unnecessary coronary stents. In contrast to America’s tough action, India’s response is laughable. Health minister Harsh Vardhan is himself a doctor who admits he’s worried by tests forced on patients by doctor-hospital-lab cartels, a recent sting operation showing eight reputed diagnostic centres involved in an alleged commissions scheme with doctors. Yet, his response has been to turn the matter to the ethics committee of the Medical Council of India — ironically, this body is itself in deep controversy over corruption, making it imperative MCI cleans its own reputation first.
For overseeing the medical industry’s practices, India needs a spotless body with professional weight and ethical credibility. If the government is serious about curing Indian medicine’s ills, it should listen to modern groups like The Society for Less Investigative Medicine, founded by AIIMS doctors to counter unnecessary testing. Meanwhile, quick and clear legal procedures for those ripped off by professionals supposed to aid them in their hour of need must be put in place. It is vital government clamps down, through better regulation and serious enforcement of rules, on individuals and institutions who abuse patients.

Wednesday, July 2, 2014

Born with a stethoscope

How do you learn to give injections? Join a nursing school, become a compounder or enrol for MBBS. But, if you ask the Sabharwals, a Delhi-based family of 140 doctors, chances are that they would hand you a banana stem instead. “Our grandfather Dr Bodhraj Sabharwal was so obsessed with making us doctors that, when we were young, he used to make us inject banana stems to teach how to administer injections,” says Dr Vijay Sabharwal, owner of Shree Jeewan Hospital, one of the five hospitals owned by the family in Delhi.
The 63-year-old eye surgeon does not believe in the method. Even without it, his 11-year-old granddaughter Diya has grown adept at giving injections. For the last five generations, every single member of the family has become a doctor. And Diya, too, has no other goal. The World Health Organisation says there is one doctor for 1,700 people in India. If you go by that estimate, the Sabharwals take care of 2,38,000 Indians.
The family entered the profession 95 years ago. Stirred by a speech of Mahatma Gandhi, Vijay's great-grandfather Lala Jeewanmal Sabharwal decided to become a doctor and serve the nation. A station master at Jakhal railway station in Gujrat district (now in Pakistan), he saw people suffering for lack of medical facilities. So he thought the best way to alleviate misery was by making all his children doctors. “He insisted that his four sons study medicine,” says Vijay.
His eldest son, Bodhraj, became a surgeon in 1919. His brothers Rajinder Nath, Trilok Nath and Mohinder Nath followed suit. In 1922, Jeewanlal quit his government job, sold all his property and wife Malan Devi's jewellery to open a hospital in Jalalpur Jattan in Gujrat district, in Khyber Pakhtunkhwa of present-day Pakistan. After the partition of India, the family moved to Delhi and opened five hospitals¯all named after their great-grandfather¯under the Jeewan Trust.
Bodhraj set up a hospital on Rohtak Road, which is now run by his son Ved Prakash's eldest son Vijay. Bodhraj's other two sons, Vinay and Vikesh, have their own hospitals nearby. Rajinder Nath established a hospital at Jeewan Nagar, which was taken over by his sons Ravinder, Davinder and Satinder¯all doctors. It is now run by Ravinder's son, Dr Arvinder. Satinder's son Dr Venu and Davinder's sons Dr Shailender and Dr Vitender have now opened a hospital adjacent to the original one.
The hospital set up by Trilok Nath at Rohtak Road was taken over by his son Dr Omprakash, whose son Dr Sandeep now heads it. Mohinder Nath set up a hospital at Pusa Road, which is now headed by his son Dr Vivek, who has four daughters¯all of them doctors. As the fourth generation Sabharwals hone their management skills, the third generation runs the family hospitals.
  
Call it the family's devotion for the profession, Dr Bodhraj even trained his wife Leelawanti, a homemaker, as his surgery assistant and anaesthetist. Leelawanti also used to cook for patients.

Vijay says when her mother, Sarla, a gynaecologist, came to their home after marriage, she was first taken to the hospital reception. As luck would have it, just before the new bahu could be welcomed, an emergency delivery case came. “My grandfather insisted that Sarla attend to the patient first and then perform the rituals. So, my mother performed the first delivery of her life here in this hospital,” he says.
Before his death, Bodhraj directed that every family member must study medicine and get married to a doctor. “You can find sons-in-law and daughters-in-law of several castes, states and communities in our family, because being a doctor is the only criterion to get married into our family,” says Dr Suman, Vijay's wife, who takes care of the gynaecology department with her daughter-in-law, Dr Ramneek, a Sikh.
Of course, there have been rebels in the family. But, perhaps because of the desire of the rebels to fit into the family or the encouragement they received from other members, “things never went out of hand,” says Vijay. For instance, one of the sons in the family recently married a biochemist. But, after two years, the daughter-in-law herself decided to study medicine.
“Your family and peers have such high expectations from you that, at times, it gets difficult to manage,” says Dr Ashish, the eldest son of Vijay. Though he respects the family's mission to serve patients, he is willing to let his two daughters take up any profession of their choice. “Their happiness matters most to me,” he says.
Thanks in part to luck and to the spurt in the number of private medical colleges, no Sabharwal has ever failed to get a medical degree. “So far, no one has ever flunked. When there are so many medical professionals to guide you at home, the exam result has to be good,” says Suman. The family believes that the members are “naturally tuned” to become doctors, but it does not stop them from taking coaching classes.
While the thought of visiting an operation theatre leaves most of us sweating, children of the Sabharwal family do their homework in the operation theatre. They are named keeping in mind the roll call in medical colleges, so that the teacher is not tired by the time their name comes in the attendance register. They also enjoy the benefit of being ahead of their classmates in knowledge of subjects like anatomy. “The biggest advantage is that in case of an emergency, a pool of doctors is just a phone call away. And they don't even charge for it,” says Vijay.
Suman recalls a particularly hectic day in the hospital. Twelve hours after giving birth to her younger son Akash, she was resting in the hospital when an emergency delivery case came early in the morning. “There was no gynaecologist in the hospital. So I attended to the patient, and then returned to my bed,” she says, laughing.
The benefit of marrying into such a family is that you have seniors to consult on critical matters, says Ramneek. Besides, as all women in the family are working doctors, it is easier to balance work and life. “Not everyone is lucky to have a mom-in-law who not only understands the pressures of your profession, but also helps you grow as a professional,” she says.
The fourth generation of the family is not keen to push the family tradition on the next generation, but the young Sabharwals are nevertheless determined to emulate their elders. Ask Ashish's three-year-old daughter her name, and she lisps “Dr Naina”. Bodhraj, perhaps, is smiling in heaven.

Black armband silent protest on Doctor’s Day by UCMS doctors

As India celebrated Doctors Day on July 1, doctors at the University College of Medical Sciences (UCMS) here sat quite gloomy while trying to find out reasons to celebrate.
“This observance is a way to show the society how important doctors are in our lives but has everybody thought how, even, we are denied our basic rights by the autocratic Delhi University administration,” said Dr Satendra Singh, assistant professor of physiology at the UCMS.
According to Dr Singh, the UCMS doctors are under the University of Delhi and henceforth the University Grants Commission (UGC) and the Ministry of Human Resource Development (MHRD), while other sister medical institutions like Maulana Azad Medical College (MAMC), Lady Hardinge Medical College (LHMC) and even all other state run medical colleges are under the Centre or State run Ministries of Health and Family Welfare (MOHFW). There the faculty can concentrate on quality of medical teaching and patient care as the promotions and pay scales of teaching medical faculty are determined by the Dynamic Assured Career Progression [DACP] scheme as laid down by the 6th Central Pay Commission Report, i.e. time bound promotions.
“The terms and conditions of DACP were brought into enforcement vide notification to UGC gazetted on 18th September 2010. The notification categorically directed UGC under clause no 1.1.1 that all medical faculties appointed medical teachers in Central Universities shall be governed by the norms of MOHFW i.e. time bound promotions. This was to be made effective for medical teachers of UCMS, AMU (Aligarh Muslim University) and BHU (Banaras Hindu University) from 31st December 2008. However, the dictatorial administrations of DU have not taken any heed to this constitutional right of medical teachers of UCMS,” he said.
Dr Singh further said, “Being under DU, no pay protection is given to doctors who have to join at salaries lower than what they were given under the residency scheme of MOHFW. Unlike medical colleges under MOHFW which safeguard the financial and promotional interests of medical faculty, DU equates medical faculty to any other faculty in colleges under DU.”
“The VC of BHU provided pay protection to medical faculty in BHU, but the VC of DU even denied that. Faculty members having completed even upto eight years of service are given salaries less than resident doctors. This has made UCMS one medical college with the highest faculty attrition rate. In the last three months, 17 permanent faculty members have left UCMS and joined as assistant professor by sacrificing their current experience on which they should have been either associate professor or professor. In the past three years, almost 25 faculty members have left for Centre or State run MOHFW medical institutes like MAMC, LHMC, new AIIMS, state medical colleges and even private practice,” said Dr Singh.
“The university system focuses purely on research for promotion of their faculty, while as medical teachers, faculty at UCMS and all medical colleges should be focussing on teaching medical students and patient care. Lack of transparency in the promotions in DU has made it one of the worst career options for medical faculty, who quit UCMS for greener pastures which offer them time bound promotions and better salaries. Every doctor is under the Hippocrates Oath, swearing for patient care and teaching his peers and juniors. But we are humans too and not demigods. Denial or delay of our constitutional rights has forced many to seek judicial help and tangent us away from the oath,” he added.

Wednesday, June 11, 2014

In a first, docs to kill patients to save their lives

Trauma patients arriving at an emergency room here after sustaining a gunshot or knife wound may find themselves enrolled in a startling medical experiment.
Surgeons will drain their blood and replace it with freezing saltwater. Without heartbeat and brain activity , the patients will be clinically dead.
And then the surgeons will try to save their lives.Researchers at the University of Pittsburgh Medical Center have begun a clinical trial that pushes the boundaries of conventional surgery -and, some say , medical ethics.
By inducing hypothermia and slowing metabolism in dying patients, doctors hope to buy valuable time in which to mend the victims' wounds.
But scientists have never tried anything like this in humans, and the unconscious patients will not be able to give consent for the procedure. Indeed, the medical centre has been providing free bracelets to be worn by skittish citizens here who do not want to participate should they somehow wind up in the ER. “This is `Star Wars' stuff,“ said Dr Thomas M Scalea, a trauma specialist at the University of Maryland. “If you told people we would be doing this a few years ago, they'd tell you to stop smoking whatever you're smoking, because you've clearly lost your mind.“
Submerged in a frozen lake or stowed away in the wheel well of a jumbo jet at 38,000 feet, people can survive for hours with little or no oxygen if their bodies are kept cold. In the 1960s, surgeons in Siberia began putting babies in snow banks before heart surgery to improve their chances of survival. Patients are routinely cooled before surgical procedures that involve stopping the heart. But so-called therapeutic hypothermia has never been tried in patients when the injury has already occurred, and until now doctors have never tried to replace a patient's blood entirely with cold saltwater. In their trial, funded by the department of defence, doctors at the University of Pittsburgh Medical Center will be performing the procedure only on patients who arrive at the ER with “catastrophic penetrating trauma“ and who have lost so much blood that they have gone into cardiac arrest.
At normal body temperatures, surgeons typically have less than five minutes to restore blood flow before brain damage occurs. “In these situations, less than one in 10 survive,“ said Dr Samuel A Tisherman, the lead researcher of the study . “We want to give people better odds.“ Dr Tisherman and his team will insert a tube called a cannula into the patient's aorta, flushing the circulatory system with a cold saline solution until body temperature falls to 50 degrees Fahrenheit. As the patient enters a sort of suspended animation, without vital signs, the surgeons will have perhaps one hour to repair the injuries before brain damage occurs.
After the operation, the team will use a heart-lung bypass machine with a heat exchanger to return blood to the patient. The blood will warm the body gradually , which should circumvent injuries that can happen when tissue is suddenly subjected to oxygen after a period of deprivation.
If the procedure works, the patient's heart should resume beating when body temperature reaches 85 to 90 degrees.
But regaining consciousness may take several hours or several days. Dr Tisherman and his colleagues plan to try the technique on 10 subjects, then review the data, consider changes in their approach, and enroll another 10. For every patient who has the operation, there will be a control subject for comparison.
The experiment officially began in April and the surgeons predict they will see about one qualifying patient a month. It may take a couple of years to complete the study .
Citing the preliminary nature of the research, Dr Tisherman declined to say whether he had already operated on a patient.


No control over IMA doctors, says MCI


After saying that medical associations were beyond its purview, the Medical Council of India (MCI) now seems to be suggesting that even doctors who are office bearers in these associations are beyond its jurisdiction.
The MCI has written to the health ministry claiming that it can't act against the officer bearers of the Indian Medical Association (IMA), even though all the office bearers are doctors and MCI has jurisdiction over the conduct of all registered medical practitioners.
The MCI ethics committee had last June recommended action against four IMA office bearers citing the fact that they were medical practitioners. Now, the executive committee of the coun cil seems to be going against the earlier decision.
The ethics committee had recommended that the names of four IMA office bearers be struck off the medical register for one year as they were harassing a doctor from Kerala, Dr K V Babu. The Kerala doctor had exposed how the office bearers of IMA were endorsing commercial products of companies like Pepsi and Dabur after taking money from them.
The committee said endorsement by the doctors/office bearers was against the MCI's code of ethics.
The MCI has been reiterating that it has no jurisdic tion over professional associations of doctors according to the Indian Medical Council (IMC) Act.
However, Dr Babu, many former MCI members and even a few current members insist that every office holder of a doctors' association, being a medical practitioner, was under the jurisdiction of the MCI.
In its letter to the health ministry , the MCI stated that since the IMA was a non-governmental organization, not under the purview of the council, it was not possible for the council to comment on showcause notice being issued to Dr Babu.

Tuesday, June 10, 2014

MCI scraps 32% of MBBS seats to safeguard quality

The Medical Council of India (MCI) has scrapped an astonishing 32% of MBBS seats nationwide in its attempt to safeguard the quality of medical education. As a result, competition for the seats left will now be more cut-throat than ever before. 
The MCI withdrew permission for 15,890 of the 49,950 MBBS seats nationwide. It cited failure of several colleges to arrange for minimum infrastructure required for ensuring proper education and training to future doctors.
“In order to run a medical college, one has to meet the minimum requirements and regulation set by the MCI,” president of MCI, Dr Jaishreeben Mehta told HT.
The biggest loser was Andhra Pradesh that had 2,100 seats scrapped from its colleges, followed byMaharashtra (1,675), Karnataka (1,650), Tamil Nadu (1,450), UP (1,400) and Bengal (1,200).
But there is still hope for the axed colleges. “June 15 is the cut-off date to send their compliance report to MCI. If we find that they have been able to meet our requirements, we might reconsider on a case-to-case basis,” said Mehta.
It is not yet known if MBBS seats have been scrapped from private colleges.
In 2011, the MCI in its vision document for 2031, had said the country needed to add 10,000 MBBS seats every year. The UPA 2 government added 10,000 seats in the next three years but MCI officials argued that most of these seats were added to colleges that lacked proper facilities.

Vulnerability of Doctors under Section 354 IPC


The arrest of a 70 year old doctor in Barnala on allegations made by female relative of a patient has opened a pandora’s box for medical professionals. Despite countless witnesses (other patients) the police in its wisdom has arrested the doctor pending grant of bail. The truth about the allegations and possibility of blackmail will come to be known later but it does expose the vulnerability of male doctors who examine and deal with female patients and their relatives.
What does section 354 state. It states that Whoever assaults or uses criminal force to any woman, intending to outrage or knowing it to be likely that he will thereby outrage her modesty, shall be punished.
354 A. Doctors are specially vulnerable to blackmail using this section as a tool since no exception of the kind given in section 354 D to sleuths has been provided to Doctors who need to touch a woman’s body during examination which may be misconstrued or deliberately projected as physical contact and advance involving unwelcome and explicit sexual overtures. Even clause iv ie making sexually coloured remarks, by a male urologist or gynaecologist could land him in jail for 3 yrs with fine.
354B. A doctor asking a female patient to disrobe for examination may similarly be charged with abetting use of force to any woman with the intention of disrobing or compelling her to be naked and shall be punishable with imprisonment for upto 7 years
354C. Doctors making video recordings of procedures, taking photographs where victims genitals, breasts or posterior is exposed will be vulnerable of being implicated under this section as a man who watches, or captures the image of a woman engaging in a private act in circumstances where she would usually have the expectation of not being observed either by the perpetrator or by any other person at the behest of the perpetrator or disseminates such image. Punishment is imprisonment for a term which extend to seven years, and shall also be liable to fine.
354D. Does not concern doctors as it involves stalking a woman but is interesting to note that sleuths have been included in exception and also excluded is if the conduct was "reasonable and justified".
It is important that medical associations and other bodies become proactive on the issue. During a video colonoscopy procedure a woman’s posterior is exposed, photographed and live display goes on in the endoscopy room which may contain more than 10 people. Tomorrow the endoscopist may be charged and face 7 years in jail for an act done as per medical ethics. A nurse removing the blouse of a patient for examination of breasts by the doctor may land the male doctor into trouble for “abetting in use of force to disrobe”. No exclusions have been made for male doctors under this Criminal Law Amendment Act 2013. The 70 year old doctor may have age on his side to defend him but the possibility of travesty of justice being committed under these sections against medical professionals is enormous