Sunday, August 29, 2010

Why medical college hospitals should admit private patients - Chap 9 from Dr Nadkarni's book

Indian Medical Council is very ambiguous about recognizing the affording class of patient as clinical material for the students. If the hospital keeps a section where patients pay for the treatment, that section is not recognized by the Medical Council as teaching beds. One reason given by the Council is that these beds form a section like a Nursing Home and the same bed may be occupied by a medical case under a physician one day, by a surgical case for the few days and a pediatric case at yet another time. Therefore, such beds cannot be allotted to any specific branch. The argument is quite valid but if the hospital was to have paying beds in each of the wards which are allotted to the specific teacher, then these beds ought to be considered as teaching beds. In U.S.A. almost all patients do pay for their treatment and yet form part of teaching material for the medical students. Even in attached hospital of Kasturba Medical College, Manipal, all patients pay. If 25% of the beds of each teaching unit were allotted to paying patients, it would have many advantages. First, obviously the hospital will have a source of income to run the hospital and thus will indirectly help the institution to reduce the fees for the medical students. But a bigger advantage is for the students in their medical education.
A paying patient is more health conscious and more aware of his rights. His expectations of treatment are higher and in generalhe is well–informed and more easily available for follow-up. Besides he often comes with an early and possibly curable disease. Therefore, he is an excellent clinical material for the medical students. In addition and most importantly the students learn good bedside manners almost automatically. The patient being educated, health–conscious, affording, he or she is automatically treated with due respect by the student. The students do not pounce upon him or examine him roughly as they almost always do in the case of poor general ward patients. In contrast the general ward patients suffer from more advanced disease and often do not turn up for long term follow up. They form, at best, experimental material like animals. It is regrettable to say so but it is the common experience of each and sundry who have observed the plight of these patients in our country. Every clinical unit in a medical college hospital must have about 40 beds with a recognized team of medical teachers / consultants in charge as per the medical council rules. Usually each such unit has a separate ward; sometimes two units share a ward. It is suggested that all such wards should have at least 25% of these patient-beds for paying class patients. That means out of 40 beds at least 10 beds should be paying beds where the patient pays for his / her treatment. One part of the ward could be converted into rooms with extra facilities like separate toilet, a separate access and a few facilities for relatives while remaining 30 beds would be either free or partially subsidized-generally called the general ward beds. The medical students will necessarily be allowed to examine and observe the treatment of all these paying class patients and as stated above I expect the students to learn proper bedside manners and also observe the signs, symptoms and clinical picture of a relatively early disease in the special rooms in contrast to what he observes in the general ward, namely signs symptoms and clinical picture of a relatively advanced disease in a patient whom he may not be able to observe in the follow-up period. As these beds are specifically allotted to the teaching unit, there is no reason why the Indian Medical Council should have any objection to consider them as part of the teaching beds. Such a system has an added advantage of assessing the capability of the teacher to attract patients. The patients in the general ward have no choice but to come to these ‘free’ hospitals and their number does not reflect the clinical ability of the teacher. It is only a competent teacher who can attract patients in the paying class. The incompetent teacher will thus be easily exposed. There are many more additional advantages in having this system. The out-patients department, laboratory and the operation theatre, all remain closed after the morning shift. The whole hospital works only in one shift from 8.00 a.m. till 3.00. p.m. Hospital services are closed after 3.00 p.m. except for emergencies during the rest of the day and night. If paying class of patients are to be treated. in this same hospital as mentioned, it will become necessary to use the evening hours to have such pay-clinics for the paying patients. The O.P.D. the laboratory and investigative facilities will also naturally remain open during these evening hours and in order not to disturb the treatment of the poor class, the operations and procedures for these paying class patients will also have to be performed in the evening. In short, the whole hospital will have morning hours reserved for the general class of patients while the whole infrastructure will be put to full use again in the evening hours for the paying class of patients. Double utilization of the available infrastructure, and therefore the standing expenses, will be better utilized. In addition, of course, the hospital will earn a very large income from these beds and that will cover a major part of the hospital expenses. That these patients may refuse to allow the students to examine them is a common objection raised by those who are against it or have fixed ideas. But it must be remembered that it is obligatory for every patient who goes to a teaching hospital to allow the students to examine him. As per the rules of the council, a notice has to be put up prominently and even signatures can be obtained from the patients before they are admitted and any treatment is initiated. This is the practice in the western world.

This has a further advantage in that medical teachers or seniors remain available in the premises right upto evening time even upto 8.00 p.m. or 9.00 p.m. At present the seniors leave the hospital by 4.00 p.m. maximum and they are approachable only on phones thereafter. If and when private practice is allowed to these teachers outside the premises (legal or illegal) as is often the case to-day, they are busy elsewhere in their private practice and are reluctant to come to the hospital even when the situation so demands. They manage the situation by giving telephoning advice or telling the junior to go ahead and perform or advice the juniors to keep the case pending till morning. Such negligence ill also be minimized by having the paying class in the hospital because the senior doctors are readily available within the premises even upto late evening and (b) they have no external interest in terms of private patients elsewhere and, therefore, are necessarily and truyly available for the patients within the premises-whether general ward or paying class. After some years almost every doctor develops a certain philosophy and ethics of practice. Therefore, it is unthinkable that such a senior medical teacher will attend only to the paying class patients and ignore the general class patients, when both these classes of patients are in the same premises and the consultant is available there. Therefore, the general ward patients also will get better attention in this system. Even otherwise, the attention to the general ward patients i.e. poor class of patients will improve automatically, even in the out patients department because of yet another factor. At present, if the medical teacher is competent, he attracts many patients who are either very influential or affording. They seek treatment here, for various other reasons apart from cheap or free treatment, mainly because of the competance of the consultant teacher. In the present system, these affording patients attend the same O.P.D. during the same morning hours as the poor general class patients. Inevitably this influential or affording class of patients get preference over the poor and if the medical teacher is very popular, it may happen that he hardly gets time to see any general class patient. They are all seen by resident doctors or juniors and the senior teacher is consulted only if the juniors consider it necessary to show him such a case. The same thing happens in the investigation department and in the operation theatre. The rich or influential patients easily supercede the poor and the investigations and/or operations of the poor general class patients keep getting postponed for want of time to accommodate the rich or the affording. Everyone is a loser except this crooked class, which exploits the facilities meant for the poor. The senior medical teachers in the unit do not object much because their own share of influence in the society increases by treating these people. On the other hand, he has nothing to loose, as his salaries are fixed. There are a few exceptional techers who do object on moral ground to such entries of privileged class. But they are far and few between. They lose their sphere of influence in the society and remain static, irritable and generally not appreciated by anyone.
All this would be prevented if the scheme of 25% paying bedsis properly implemented. As the medical teacher will gain in actual terms as and when he treats paying class patient, he will now be more reluctant to adjust him in the morning hours and will insist on him coming during the hours of paying clinic. Therefore, the general ward patients will have the full attention of the medical teachers during the morning hours. The investigation time and the operation time being so reserved specifically for the general ward patients till 3.00 p.m. and for the paying class in the evening, there is no interference between the two classes, thus, giving indirect benefit to the general class patients. The more competent medical teacher will earn more than the teacher who is relatively incompetent. Thus, the need of 25% paying beds in a teaching hospital is so important that, in my opinion, the students, the university and or the state government should be willing to fight for it in the court of law, if the Indian Medical Council raises any objection to such a system on any ground.

Free medical treatment should be abolished . As I emphasized earlier there is nothing which is really free. When a patient gets treatment free of charge, it only means that somebody else has borne these expenses directly or indirectly. In the case of govt. hospitals, it means that every citizen is paying for the treatment of that patient through direct or indirect taxes. Besides neither the patient nor the student nor the senior medical teacher becomes aware of the expenses incurred in the treatment of the patient and thus, does not even think whether the expenses could be minimized. Therefore, it is my firm opinion that the patient must pay at least some percentage of the expenses incurred for his treatment.

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