Wednesday, April 27, 2016

When doctors take bribes

Guest article by Dr. Sumit Ray, senior consultant & vice-chairperson, Critical Care & Emergency Medicine, Sir Gangaram Hospital, New Delhi.

When your doctor prescribes a medicine saying it’s the best for you, are you sure it’s in your best interest, or was he taken on a luxury cruise last summer by the pharmaceutical company which sells that medication? If he refers you to a particular hospital or diagnostic facility, is it your best interest he has in mind? Or is he getting a “cut” or commission (euphemistically called “facilitation fees”) for it?
Doctors might say they cannot be bought with expensive meals and holidays but there is strong evidence that even the smallest of gifts or favours can alter their prescribing practices. A study by Dr Ashley Wazana, published in the Journal of the American Medical Association (JAMA), established that gifts, sponsored meals, conference travel, funding for conferences, all significantly alter the prescribing practices of doctors in favour of the sponsoring pharmaceutical or medical device industry.
A 2013 study by Marrisse King in the British Medical Journal (BMJ) found that students graduating from US medical schools that had strong conflict of interest policies against gifts from industry, had a 55-75% reduced chance of prescribing more expensive medication compared to cheaper medication that was equally good. Similar studies may not have been done in India, but they prove the point (unless Indian doctors would like to claim they are more honest/ honourable/ morally incorruptible than their counterparts in the rest of the world).
A conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest. Primary interest refers to the principal goals of the profession, such as health of patients and integrity of research. Secondary interest includes not only financial gain but also such motives as the desire for professional advancement and the wish to do favours for family and friends.
Gifts, travel grants, “cut-practice” are absolutely illegal for doctors according to the Medical Council of India (MCI) rule book. MCI also states: “The personal financial interests of a physician should not conflict with the medical interests of patients.”
There is a reason why the medical profession has always been held up to higher ethical standards than any other. The 2009 Manual of Ethics of the World Medical Association states, “People come to physicians for help with their most pressing needs – relief from pain and suffering and restoration of health and well-being. They allow physicians to see, touch and manipulate every part of their bodies, even the most intimate. They do this because they trust their physicians to act in their best interests.” A doctor has to have way more empathy and understanding than in any other profession. This expectation is neither recent, nor restricted to any particular country.
Unfortunately enforcement by MCI has been very poor, leading to entrenched corruption in healthcare delivery systems in India. Rather than strengthening controls on these corrupt practices, MCI amended its code of ethics to allow institutions and associations to be exempt from the rules on gifts, grants and funds from pharmaceutical and device industries.
The law allows seven or more people to form a society or foundation. So, if you are not allowed to take what constitutes a pure and simple bribe from industry as an individual doctor, you shall be allowed to do so as a group of seven or more! We are already seeing a rapid rise in the number of “societies”, “foundations” and “associations” among doctors to make use of this loophole, as this amendment has been in the works since 2010. This will have disastrous consequences for an already corrupt healthcare system and you, as a patient, will pay for it.
The parliamentary standing committee on health observed that exempting professional associations of doctors from the ambit of ethics regulations is nothing short of legitimising such associations indulging in unethical and corrupt practices. It added, “It seems that the MCI has become captive to private commercial interests.”
Even today a majority of medical practitioners uphold true values and ethics. Unfortunately, their voices and ideas have been drowned by a more vociferous group who believe that success is determined by profit margins, or rather profiteering by healthcare delivery organisations, rather than by high quality ethical care. And yet, they puzzle over rising violence against doctors across the country.
They don’t seem to see that the violence is a direct fallout of the erosion of the trust that doctors take decisions in the patient’s interest and of a sense of helplessness. The US and India report the highest number of attacks on doctors by patients (physical violence in India and “litigational violence” in the US). It is no coincidence that both are countries where healthcare delivery is dominated by a profit-driven private sector.
As doctors we need to be aware of these facts and put public pressure to ensure that the government acts on the recommendations of the parliamentary committee to strengthen the code of ethics for doctors by bringing healthcare institutions, foundations, societies and associations under its ambit. MCI will also have to ensure better and stricter implementation so that justice is seen to be done in cases where the code is flouted. Else, Indians’ health will suffer even more than at present.

DISCLAIMER : Views expressed above are the author's own.

Friday, April 22, 2016

How to prepare for PG entrance exam?

Guest article by Dr. Gobind Rai Garg.

One of the very commonly asked questions from me is HOW TO PREPARE FOR THE PG ENTRANCE EXAM? Dear friends, although I feel that the study strategy should be individualized and varies from person to person. The general points that should be considered are:
1. The syllabus should be finished at least once (with crisp study material for final revision, mostly notes) around one month before the exams.
2. Keep last one month for revision only
3. An average of 6 to 8 hours (focussed) per day is sufficient for studies. There should be no use of facebook, whatsapp or any other distraction during these hours. Take small breaks after every 1.5 to 2 hours of study. 
4. Keep ONE DAY OFF EVERY WEEK. It increases the productivity of remaining 6 days.
5. Most importantly give around HALF AN HOUR FOR REVISION DAILY for the topics you have studied in that particular day. Revising same day help in incorporating that topic in long term memory. 
6. Try to practice around 100 MCQs daily WITHOUT SEEING THE ANSWERS. You should match the answers after solving these. Seeing the answer side by side is likely to miss many concepts which are unlikely if you answer using your memory and concepts.
7. The most important part of the preparation is to remember so many facts and concepts. One of the very effective methods for this is DISCUSSION. Keep on asking (the fact or concept which you feel is difficult) to everyone you meet. If you ask 5 people the same question, you are sure to remember this as you have revised it 5 times.
8. Another common mistake students tend to do is to target all the questions asked in previous years. You must be knowing, that even toppers never get 100 percent of marks in any competitive exams. So just keep in mind that if you know 80 to 90 percent of the questions in any competitive examination, it is good enough. The reason I am specifically focusing on this is that I have seen many students wasting time on many topics which are useless but have been asked once in some examination. E.g. once a question was asked on speed of some mosquito, it is totally illogical to remember the speed of all the mosquitos because once it was asked on Anopheles, so it can be asked on Culex next time. In every exam, around 20 percent questions are asked which are unlikely to be repeated again ever. So, concentrate more on those topics which are frequently repeated and know them thoroughly and such type of questions should be just crammed.
9. One more area where most of the students waste a lot of time without any gain is regarding CONTROVERSIAL QUESTIONS. For some questions, different books mention different answers. Please don’t waste time on these questions and just remember any one which seems logical to you. Students keep on searching n number of books for these questions and still are confused. Even if you are able to find out some source, you still won’t be sure that whether the examiner has made question from that book or not. Remember, that’s why these questions are controversial. So, I will suggest not to waste time on these questions.
10. In any competitive examination, even if there is negative marking, attempt all the questions in which you have zeroed down to 2 options.
11. SPECIAL MARKING PATTERN IN PGI CHANDIGARH exam needs special mention.
a. Marks in PGI are calculated as 
a/A – b/B
a: No of correct options you marked
A: Total no of correct options
b: No of wrong options you marked
B: Total no of wrong options
Every option in PGI exam is thus considered as a separate question. So, rather than 250 questions with 5 options each, consider them as 1250 questions. 
• Logically analyzing this pattern, your marks depend upon something (a/A) minus something (b/B). If the first factor (a/A) is say 70 means that your marks will be less than 70 percent because something is being deducted from 70. So, for getting a good rank, at least first factor should be 100 or as close to it as possible. 
• Normally in most of the exams in PGI, out of 1250 options, around 500 are correct whereas rest (around 750) is wrong. Again if we analyse it, suppose you tick a doubtful option, if it is wrong, then you lose 1/750 marks whereas if it is correct, you will get 1/500 marks. So leaving a doubtful option should never be done.
12. Our greatest weakness lies in giving up. The most certain way to succeed is always to try just one more time. Certainly GIVING UP IS NOT AN OPTION one must have. 
13. BOOKS AND NOTES recommended by me are:

First Professional: 
Anatomy: Phybians by Dr Vivek Jain and class plus class notes of Dr Rajesh Kaushal
Physiology: Phybians
Biochemistry: Phybians or Biochemistry by Dr Rebecca James
Second Professional:
• Pharmacology: Review of Pharmacology by Dr Gobind Rai Garg and Sparsh Gupta and classes of Dr Gobind and the class notes
• Microbiology: Microbiology made easy by Dr Akhilesh or Book by Dr Apurba shastry
• Forensic Medicine: Sumit seth book plus Dr Akhilesh Jhamad classes
• Pathology: Review of Pathology and Genetics by Dr Gobind Rai Garg and Dr Sparsh Gupta 
Third Professional
• PSM: Dr vivek Jain book + Class + Class notes
• ENT: Dr Manisha Budhiraja or Dr Sakshi Arora
• Optha: Dr Vineet Sehgal and class notes of Dr Shaswat
Final Professional:
• Medicine: Dr Thameem class notes plus selected topics of Mudit Khanna
• Surgery: Class notes of Dr Deepak Guliani plus minus Dr Pritesh surgery book
• Obs and Gynae: Dr Puneet Bhojani
• Orthopaedics: Dr Apurv Mehra Plus Ortho dhoom dhadaka
• Radiology: Dr Sumer seth
• Psychiatry, Anaesthesia, Dermatology: PROAFS by Dr Vivek Jain

Wednesday, April 20, 2016

Beti Bachao drive has improved sex ratio: Maneka

Beti Bachao drive has improved : About 49 of 100 districts where government's ambitious 'Beti Bachao, Beti Padhao' campaign to save and empower the girl child was launched last year has recorded significant improvement in child sex-ratio at birth, Union minister Maneka Gandhi said on Tuesday. "There has been significant improvement in child sex-ratio at birth in 49 districts which is much beyond our expectation," she said.
Maneka who holds charge of the women and child development said speaking at the launch of the campaign in 61 additional districts. Districts in Haryana and Uttarkhand are among the ones that have registered positive results, the ministry claimed.
Maneka emphasised on the need for compulsory registration and monitoring of pregnant women by village panchayats to curb female foeticide. "Sarpanches (village heads) should be made the nodal person in every village for monitoring pregnant women," she said.
Setting a target for improving child sex-ratio at birth by 10 points minimum every year, Gandhi asked the deputy commissioners and district magistrates to adopt a "proactive approach" by launching creative initiatives to change the mentality of the people towards girl child. "Our goal is to improve sex ratio at birth by 10 points minimum every year. It will lead to 50 points in five years bringing it upto par," she said. A 10 point raise would mean the number of girls going up by ten vis-a-vis every 1000 births of male children.
She appealed to the states to achieve 100% institutional deliveries and put boards displaying number of girls and boys in every village. "It is very difficult to kill a child in hospital, but easier through midwives at home and then say the child was born dead. So, 100% institutional delivery is very important," she said.
The minister also asked them to map and register all the ultrasound machines to keep a check on illegal sex selection and monitoring of Pre-Conception and Pre-Natal Diagnostic Techniques Act.

Monday, April 11, 2016

SC allows common entrance test for medical courses, recalls its 2013 order

Image result for supreme court

The Supreme Court on Monday paved the way for implementation of National Eligibility Entrance Test (NEET) for medical courses across the country.

The top court set aside its 2013 order by which the common entrance test for admissions to MBBS, BDS and PG courses in all medical colleges was quashed.

Hearing a review petition on NEET, the top court said it will hear the case afresh on validity of the common entrance test. "Till the matter is decided NEET can be implemented," the top court said.

The Supreme Court had, in June 2013, had ruled that the Medical Council of India (MCI)'s notification for holding common entrance tests for MBBS, BDS and post-graduate medical courses as invalid. A three-judge bench by a 2:1 verdict held that the notification was against the Constitution.

The court had ruled that the MCI did not have the jurisdiction to enforce common entrance test (CET) on private medical colleges and that the move could also violate constitutional guarantee to minority communities to establish and manage their own educational institutions.

MCI had opposed the verdict and had moved the court for a review.

Apart from students being forced to cough up thousands towards the fee for appearing in multiple exams and travel expenses, many students are robbed of the opportunity to stake admission claim to different colleges, an MCI official said.

Over 90 medical entrance tests are held across India.

Tuesday, April 5, 2016

Super-specialty blocks to come up in 70 medical colleges: Nadda

Union Health Minister J.P Nadda on Monday said that the government has started setting up super specialty blocks in 70 of its existing medical colleges across the country.

"The government encourages the setting up of new medical colleges and strengthening the existing ones. Existing medical colleges are being upgraded by setting up of super specialty blocks in 70 such medical colleges in the entire country," he said in his address at the sixth Convocation of PGIMER at RML hospital here.

Nadda also said that the government is expanding the network of the medical colleges in a big way by upgrading 58 district hospitals to medical colleges, while 20 state cancer institutes and 50 tertiary cancer care centre will also be set up.

Urging the hospital administration to harness the tremendous potential of IT services in medical education and health care delivery, he said his ministry is "taking concrete steps to expand the scope of telemedicine -- bringing in tele-education, tele-consultation, tele-radiology".

Friday, April 1, 2016

Poor remuneration haunting health sector in India

Importance of a decent remuneration in any job cannot be undermined. Though the nature of the medical profession is such that concerns of remuneration take a backseat in general, yet there is a vast difference of pay scales existing in the public and private sector for the same posts, preventing the youth from joining public sector health institutions.
Similar notions have been voiced by the recent Parliamentary committee on health, which noted with serious concern that medicine is no longer a priority for the brightest among the youth. This issue has also become glaringly visible with the increase in the disinterest of the country’s brightest to opt for teaching jobs in the public sector health institutions. The commitee pointed out that pay structure for the medical profession should be designed specifically to make the remuneration commensurate to the commitement, skills and accountability
Why is this happening?
Medical Profession at one point was the most coveted one in India. However, with the passage of time lesser and lesser of the brighter youth is showing interest in Medicine today. An expert deposing before the committee clearly pointed out
“……the medical profession should be made more attractive.  In 2011 or 2012, there used to appear three lakh candidates in the Rajasthan, for the PMT examination. In the very next year, less than 50,000 students appeared.  Nobody wants to join medicine stream today….”
The primary reasons as pointed out by the committee for this can be into the following
Long Duration of Study to Livelihood Period
“.. an MBBS and an MD or a DM requires 12 years of study. By then, he ( a doctor) will be around 30 or 31 years old. He is already married with children, while he is doing his DM.  And, on the other side, an engineering or a business school guy has four years plus two years. At twenty-five, he is good. He is an earning member of the family.”
Vastness of the study of medicine
“The medical courses are voluminous because the doctors can get patient with any type of medical problem, and the teachers have the habit of asking most difficult things. So, students keep reading…..But if you compare medicine with other branches, the courses are very limited in other branches.  Medicine is unlimited.”
Lack of Commensurate pay in relation to other sectors
“When the student passes out, after his super-specialization, he gets Rs. 70,000 to Rs. 1,00,000, while the other guy (other fields) gets close to five lakh rupees, three lakh rupees immediately. As far as working hours are concerned, doctors have to be there all the time. The others have flexi hours. You can work from home. All the time, there are chances of litigations on doctors. There is nobody to save them. The profession is under deep trouble because of this.
And then there is public distrust
“Doctors are beaten up. So, the students are not trying to become doctors today.”
Not only this, there is an even sharper downfall in the young doctors joining the public sector. An  governement expert appearing before the parliamentary panel summarised the problem beautifully by giving his own example
“Today, Government colleges do not have teachers. Everyone is in private. My student who passes out gets four times more pay after my thirty-five years of work—four times more pay on the day he passes.  So, why should he continue in Government service? So, what we want, in Government service, give him increments as it is.  Second, anybody who is doing clinical, teaching and research—there are three heads—pay him three times. Believe me, this is the biggest fear that I have.  Tomorrow, five years down the line, there will be no good teachers in the medical colleges. You will have colleges. But the new AIIMS would not have teachers. To keep teachers there, you must pay them their worth”.
Solution- Nowhere in sight
Although these issues have been visible to the medical sector as well as the authorities for a long time, not much has been done about it. Already the country is dedicating a decresingly meagre share of the GDP to the health sector, showing it’s lack of committment to the growth of the health sector in the country. No special position has been awarded to the remuneration in health sector that still runs on UGC payscales
An IMA representative pointed out
“We make a big hue and cry that people are not opting for teaching posts.But, there are various considerations where there is no regulatory mechanism.  Even today, when we are talking of payment of scales and service conditions, it is the UGC scales that become accruable and there is nothing with the MCI or any mechanism associated with the medical education for the purposes of regulating the service conditions of medical teachers, accruable pay-scales of medical teachers and all other incentives and benefits which, of course, would be adding as a big incentive for people to take up the assignment as full-time faculty in medical education”.
MCI, in the year 2011 set up a committee under the chairmanship of Narayan Murthy on the agenda of remuneration packages in health. The commitee clearly summarised one point “PAY THE DOCTOR HIS WORTH
What are three main things? Medical profession needs higher commitment, skills, accountability than any other stream. So, the pay should be as per the number of years of training. Suppose the engineer or an MBA is trained for six years. When he starts his service, he gets amount equal to six years of training. The medical student, if has read for nine years for his M.S., give him three additional increments in UPSC, when he joins.  If he has become a super-specialist by putting six extra years, give him six increments at the time he joins. This was a clear recommendation, and I think, if you implement it, this will make a huge change in our profession.”
Sadly, the report was never picked up and is currently gathering dust at the office of the health ministry.
Even the current parliamentary committee in health has recently stressed upon the adequate remuneration packages for government doctors and teachers if the medical sector has to sustain itself
that the whole medical education system will collapse if there are not good teachers for our medical colleges. Let us also not forget that today’s medical student is tomorrow’s physician and no society can afford to leave healthcare in the hands of mediocre doctors.All these facts warrant that measures to attract good talent towards medical profession and retain them, by way of offering attractive remuneration packages are required to be immediately initiated. The Committee fully endorses the view that medical profession demands much higher commitment, knowledge, skills, competence and accountability and doctors have to work under very trying conditions. It is, therefore, imperative that the pay structure of doctors and faculty should be so designed as to provide compensation to medical fraternity commensurate to their years of training and research.”

Monday, March 28, 2016

Plan to overhaul MCI set in motion

The BJP government has begun work on a major overhaul of the Medical Council of India as it looks to create more medical colleges and produce more doctors to cater to growing healthcare needs.

Sources said during a review meeting of the health sector, Prime Minister Narendra Modi and the health ministry had discussed the option of even scrapping the country's apex medical education regulator which has been shrouded in controversy in recent years.

Although sources ruled out such a drastic meas- ure, the government has set up a three-member committee to prepare a blueprint to revamp the current setup. The high-powered committee has Niti Aayog vice-chairman Arvind Panagariya, PM's additional principal secretary P K Mishra and Niti Aayog chief executive officer Amitabh Kant as members.

Sources said that at the meeting it was pointed out that the MCI is one of the major stumbling blocks towards a faster expansion, especially when it comes to ensuring quality education.

The development came after the parliamentary standing committee on health and family welfare too had called for a complete overhaul of the medical council as it has repeatedly failed in its mandate as a regulator of medical education and profession.

In its report presented in Parliament last month, the panel has recommended that the Act under which the council was established be scrapped and a new legislation be brought in Parliament "at the earliest".

Sources said that at the PM's meeting, the need for a major focus on increasing the availability of doctors and paramedical staff, es- pecially in the poor per- forming states such as Bihar, Uttar Pradesh, Jharkhand, Chhattisgarh and Odisha, was emphasised.