Tuesday, September 28, 2010

Is BBT charting of any use for infertile couples

Ovulation type medical thermometer

During the luteal phase of the cycle, the corpus luteum produces the hormone progestrone, which elevates the basal body temperature ( BBT) . When the basal body temperature has gone up for several days, one can assume that ovulation has occurred. However, it is important to remember that the BBT chart cannot predict ovulation - it cannot tell you when it is going to occur !

In the past, doctors felt the basal temperature chart was a useful tool. It allowed the patient to determine for herself if she is ovulating as well as the approximate date of ovulation, but only in retrospect. Basal body temperature charts are easy to obtain and the only equipment required is a special BBT thermometer.

General instructions for keeping a basal body temperature chart include the following :

  1. The chart starts on the first day of menstrual flow. Enter the date here.
  2. Each morning immediately after awakening, and before getting out of bed or doing anything else, the thermometer is placed under the tongue for at least two minutes. This must be done every morning, except during the period.
  3. Accurately record the temperature reading on the graph by placing a dot in the proper location. Indicate days of intercourse with a cross.
  4. Note any obvious reason for temperature variation such as colds, or fever on the graph above the reading for that day.

However, the major limitation of the BBT is that it does not tell you in advance when you are going to ovulate - therefore its utility in timing sex during the fertile period is small. Interpreting the BBT chart can be tricky for many patients - rarely do the charts look like those you see in textbooks!

Also, keeping a BBT chart can be very stressful - taking your temperature as the first thing you do when you get up in the morning is not much fun. What is worse is that you start to let the BBT chart dictate your sex life. This is why though the BBT chart used to be a useful method in the past, it's utility is limited today - and newer methods are available which are more accurate are available. We advise our patients never to chart their BBTs - we feel they are just a waste of time.

Want to find out what your fertile time is ? You can use our free online fertility calculator to determine when you ovulate !

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Monday, September 27, 2010

Hospitals, CRM and PRM

CRM ( customer relation management ) is a tool which all service industries to keep their customers happy. While one would expect hospitals to use CRM routinely, unfortunately, most hospitals still do not bother. Given the large patient:hospital bed ratio in India, most hospitals continue to take the approach that patients do not have a choice as to where they can go for their treatment, which is why most hospital staff adopt a high-handed attitude towards patients . Stories of hospital staff rudeness and arrogance are innumerable - and this is reflected in the increasing number of incidents of violence against doctors and hospitals.

Progressive hospitals are willing to learn lessons from the hospitality industry , and are willing to implement CRM to help their patients have a better experience when they come to the hospital. However, when I am talking about PRM, I am referring not to Patient Relationship Management ( something which all hospitals need to learn to do, but most still do badly !), but rather to Patient Relative Management.

The need for this is much more acute in Indian hospitals ! When most patients come to a hospital in India, they are accompanied by a bevy of friends, neighbours and relatives ! These people are extremely important in India, but sadly, they are often ignored and neglected by the hospital staff and management. Most hospital staff members consider them to be a nuisance and tolerate relatives as a necessary evil - and there are very few amenities available for family members , even for those who are on a 24-hour vigil outside the ICUs !

This is a very short-sighted approach ! Relatives are understandably concerned and worried about their patient's health. They are key decision makers, and need to be educated and informed about what to expect. They need to be addressed politely and kept updated about the clinical status of their patient.

Unfortunately, this is rarely done. Doctors ( and sometimes, the more senior they are, the worse their habits !) seem to take a perverse pride in making relatives wait for ever and ever ( often for completely flimsy reasons). They are not willing to share information about what goes on behind the intimidating doors of the Operation Theater and ICU. This is why family members often get angry with doctors, and when their patient dies, are eager to vent their frustration by burning down the hospital or beating up the doctors.

Doctors are very busy - and many may not have enough time to talk to even their patients, leave alone their relatives ! This lack of communication can cause frustration; and after bottling it up, relatives will often vent their resentment when a mishap occurs - even if the doctor was not to blame.

This is a systemic problem, which can be addresses proactively by the hospital management. In order to protect doctors, who are now feeling very vulnerable, the government is passing laws and hospitals are beefing up their security. However, this is a very short-sighted fix.

It's far more important that hospitals start investing time, money and energy in educating patient's relatives, so they have realistic expectations of the outcome of the medical treatment.
Dissatisfaction arises when there is a mismatch between expectations and reality - and helping relatives to have realistic expectations will help in reducing dissatisfaction with doctors and hospitals !

The most effective way of doing so is by setting up Patient Education Resource Centers in the hospital. The PERC will be run by nurses and librarians; and will help to educate patients and their relatives, so they know what to expect during their hospital stay.

As Indian hospitals strive to attract medical tourists and match global standards ( for example, by getting JCAHO accreditaion), documenting that patient education has been provided is going to be an integral part of patient care. The PERC will become an important department of the hospital . In the Mayo Clinic, the Dept of Patient Education occupies an entire building !

Not only are PERCs important for risk management, they are also very cost effective. All these relatives are prospective future customers for the hospital ( after all, we are all going to fall ill some day !) If they are treated with respect, they are likely to come back to the same hospital for their own medical care when they need this !

We all know that the best kind of marketing is word of mouth marketing . Instead of wasting money on advertising in the press , it makes much more sense for hospitals to invest it in PRM ! Relatives ( and the patient's visitors ) are potentially a captive customer base - why not educate them about health and illness ? In a hospital, everyone has a much more heightened sense of their own mortality. When you visit a friend who is sick, you are much more acutely aware of your own frailty - and much more health conscious ! ( What can I do to make sure my husband does not get a heart attack like his elder brother did ?) Reaching out to these relatives through a Patient Education Resource Center to help them learn more about their health can pay big dividends for the hospital , because they are much more likely to seek medical assistance in a hospital which has taken the time and trouble to educate them !

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Friday, September 24, 2010

Missed periods , infertility and mind games

Missing a period is difficult for all women. Regular cycles suggest that the body is working properly and that the hormones are in sync. A missed period creates a lot of anxiety for fertile women as well , but it's much more difficult for infertile women ! Every time you miss a period, you hope ( against hope) that maybe you are finally pregnant ! However , you are worried about getting your hopes up too high, because you are scared that they will come dashing down again - after all, false hope can be very cruel !

Most women know there are are many reasons for missing a period, including stress ; side effects of medications you are taking; and a systemic illness.

Even after many years, however, the first thought hope is - maybe I am pregnant ! At last ! ( Maybe the holiday in Goa did the trick ? Or was it the trip to Shirdi ?)

And then the worries start !

Is this really a pregnancy ?

You scrutinise your past cycle ; look for patterns; and try to remember when you last had sex.
( Was it during the "fertile time " ? ) Each hour takes as long as a day to pass. Should I do a pregnancy test ? When ? Is today a good day ? Should I wait till tomorrow ?

You obsess over every symptom. My breasts never feel so full and tender normally, do they ? I wonder why I need to go to the bathroom again and again ? Maybe I am finally pregnant ! You google " early symptoms of pregnancy" every 5 min to try to make sense of what's happening to you.

You buy lots of pregnancy test kits - and even if the result is negative, you always hope that this was a false negative. Maybe I didn't do the test right ? Maybe the kit is old ? unreliable ? Maybe I should get one of the newer digital kits ? Is that a faint blue ? Am I imagining things ?

And if and when the period does start , you scrutinise the flow very carefully. Is there tissue in
it ? Was that a baby ? Is the flow dark ? heavy ? with clots ? Does it look different from my regular flow ? Does this mean I was pregnant and I miscarried ?

This line of thought just adds to your guilt ! Oh, God - did I do something wrong to cause the miscarriage ? Ate something hot ? cold ? Went to the gym ? Worked out too hard ? Fought with my husband ?

How do you find the answers to your doubts ? Who do I ask ? Who should I compare notes with ?
You are very reluctant to ask the doctor , because you don't want to look like a fool ! And your husband can get quite fed up of your obsessing over every minor ache and twinge and spot of blood.

My only advise is - Be kind to yourself. It's a difficult situation to be in, so please understand this and don't beat up on yourself. This just makes a bad situation worse !

Tuesday, September 21, 2010

How should I prepare for my IVF cycle ?

" What can I do to improve my chances of success ? " As an IVF specialist, this is the commonest question patients ask me.

The following are the 5 key ingredients which you can contribute to the success of your IVF cycle.

1. Faith and trust. It's important that you be able to trust your doctor. Not only should you be confident about your doctor's technical competence, you should also feel secure that he cares for you; respects your desires; listens to your fears and worries; and will be available to give you a shoulder to cry on when you need this . Make sure your chemistry with your doctor is good. Does your doctor encourage you to ask questions ? Takes time to clear your doubts ? This is a tall list, and most doctors are human , so they are likely to fall short. However, in a good clinic, the IVF team should be able to bolster your confidence that you are in good hands.

Remember that your doctor needs to earn your trust . Don't give it away easily ! " Trust - but verify " should be your philosophy !

2. Smiles. Being optimistic helps to improve success rates. It's not that pessimistic patients don't get pregnant - it's just that patients who smile get better care from the medical team - and everything you can do to improve your odds is worth doing !

3. Being well informed ! Do your homework, so you have realistic expectations from your treatment. Ask questions and take a guided tour of the facility. Request your doctor to show your follicles on each scan - and ask to see photos of your embryos. Well informed patients get better medical care because they ask intelligent questions. Insist on a medical treatment summary at the end of the IVF clinic - this is valuable documentation and keeps everyone's interests aligned . Poor documentation suggests you have received poor medical care !

4. Money. It's true that IVF treatment can be expensive, and you need to be prepared for this. Selecting an IVF clinic which offers a shared risk/ refund program can help you reduce your
risk !

5. Good eggs, good sperm and a good uterus. I know this is asking for a lot, but patients who have good protoplasm have a much better chance of success. It's true that if you are 43, there's little you may be able to do to turn back the biological clock. However, simple self-help measures can make a world of a difference ! Stop smoking; make sure you are fit and have a healthy diet; and take supplements to help optimise your egg and sperm quality. Every little bit helps !

If your eggs and sperm are just not up to the mark, keeping an open mind and exploring the possibility of using third part reproduction can help you achieve your goal of having your baby.

The outcome for any IVF cycle is always uncertain - but taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

Monday, September 20, 2010

Infertility Support Groups - Self Help is the Best Help

What every infertile woman needs to know about missed periods

Missing a period can be very difficult for infertile women ! Every time you miss a period, you hope ( against hope) that maybe you are finally pregnant ! However , you are worried about getting your hopes up too high, because you are scared that they will come dashing down again – and you remember all the false alarms you have had in the past !

There are many reasons for missing a period, including stress ; side effects of medications you are taking; and a systemic illness. The first step, of course, is to rule out a pregnancy. You can do this by checking with a urine pregnancy test kit. The new ones are very reliable, and a negative test result usually means that you are not pregnant. If you are unsure, you can repeat the test in 2 days. A better option is to do a blood test to check your HCG level. This is much more reliable ( but it’s also much more expensive !) . A blood level of less than 10 mIU/ml confirms you are not pregnant.

If you miss three menstrual periods in a row, your doctor will make the diagnosis of “secondary amenorrhea “. This is just medical jargon for – “ has missed more than three menstrual periods”. It’s not really a diagnosis – just a description of your problem.

So what are the reasons for a missed period ? And what can you do about this ?

Let’s review some basic biology first. The reason women who ovulate get a natural menstrual period is because of a drop in the circulating blood levels of the reproductive hormones, estrogen and progesterone hormones. When these levels drop, the uterine lining loses its hormonal support, as a result of which it is shed as a menstrual period. This is called a estrogen primed progesterone withdrawal bleed.

A missed period means there is a problem with the normal balance between estrogen and progesterone in your body. This usually happens when you do not ovulate. This is called anovulation.

Most women ( for example, those with PCOD) have high estrogen levels, but because you have not ovulated, your progesterone levels remain low, as a result of which you do not get a withdrawal bleed.

In other cases, the corpus luteum forms a functional cyst. Because this continues to produce estrogen and progesterone, there is no progesterone withdrawal, and the lining remains thick and does not shed.

Others have low estrogen levels ( as a result of which your uterine lining remains thin and does not develop at all). This is commonly seen in lean athletic women who exercise a lot. The missed period in these women is called hypothalamic amenorrhea.

In order to come to the right diagnosis, the doctor may need to do a vaginal ultrasound scan .
This should check for the following.
a. Is there a cyst in the ovaries ? Are the ovaries small ? What’s their volume ? The antral follicle count ?
b. The endometrial thickness and texture.

Patients with PCOD will have a thick uterine lining, which suggests they have high estrogen levels. Women with hypothalamic amenorrhea have small ovaries with a thin lining; as do perimenopausal women who have reached the oopause and whose ovaries are failing. A functional cyst will be easily apparent on the scan.

It’s also possible to confirm this diagnosis by checking the blood levels of estrogen and progesterone.

After making a diagnosis, it’s easy to induce a period, based on the problem.

If the uterine lining ( endometrium) is thick, this means that the level of estrogen in the body is already high ; and it's easy to induce a period by taking 5 days of progestins, such as medroxyprogesterone acetate. There are many options available. These include:Tab Provera ( medroxyprogesterone acetate), 10 mg, twice a day. The period will usually start 3-7 days after taking the last tablet. This is called inducing a withdrawal bleed with progestins.

On the other hand, in women with low estrogen levels who have a thin uterine lining, we first need to build up the lining with estrogens and then induce a period with progesterone . We give the estrogen and progesterone hormones sequentially, thus mimicking a natural cycle. This is what a typical prescription would look like.

Estrogen tablets from Day 1 - Day 25. There are many options available. The least expensive is Tab Ethinyl estradiol ( Lynoral), 0.05 mg daily. Other choices include:
Tab Premarin, 1.25 mg daily; or
Tab Progynova ( estradiol valerate, 2 mg), 2 tab daily. You may feel some nausea and have some temporary fluid retention while taking the estrogen.

Progestin tablets, from Day 16 - Day 25. There are many options available. These include:Tab Provera ( medroxyprogesterone acetate), 10 mg, twice a day.

This regimen is called Hormone Replacement Therapy , and is available commercially in some countries in the form of a pack, called CycloProgynova.
The withdrawal period ( menstrual period) will start approximately 3-6 days after you take the last tablet, as the levels of the administered hormones decline in your body because they get excreted in the urine.

It’s also possible to achieve the same results with a 21 day course of birth control pills, since these contain both estrogen and progesterone. It's best to take the old-fashioned monophasic birth control pills, which contain a sufficient amount of estrogen and progestins ( combined together in one "active" tablet). A typical choice would be Ovral, which contains 50 ug of ethinyl estradiol and 500 ug of norgestrel ( a type of progestin). The withdrawal bleeding induced when you take birth control pills may be scanty as compared to a regular period. This is normal.

If the reason for the missed period is a functional cyst, you may have to wait till it resolves. It will usually do so on its own. If needed, the doctor can induce a period with mifegest ( RU-486), a very powerful antiprogestin.

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Infertility - Myths and Misconceptions

Saturday, September 18, 2010

Three in Ten Americans Would Use Their Cell Phone to Track Personal Health,... -- SAN DIEGO, Sept. 8 /PRNewswire/ --

Three in Ten Americans Would Use Their Cell Phone to Track Personal Health.

Three in ten Americans recently surveyed by PricewaterhouseCoopers' Health Research Institute said they would use their cell or smart phone to track and monitor their personal health, and 40 percent would be willing to pay for a remote monitoring device that sends health information directly to their doctor. Their interest reflects the nascent but fast-growing market for remote and mobile health and significant business opportunities for organizations using consumer technologies to support preventative, acute and chronic care.

The findings of the survey and new report entitled Healthcare Unwired were presented today by PricewaterhouseCoopers at the mHealth Initiative 2nd International mHealth Conference in San Diego. According to the report, wireless technology, remote monitoring and mobile devices are changing the nature of healthcare, making it possible to deliver care anywhere in ways that are proving to reduce healthcare costs and keep people healthier.

Patients ? or Paperwork ?

For most good doctors, taking good care of patients means just that - providing high quality clinical care, so patients get better sooner. While they understand that it's important to keep good quality medical records, they are much more focussed on meeting the patient's human needs by holding their hand; talking to them ; providing emotional support ; and counselling. Most good doctors would rather spend time talking to the patient, rather than filling up a form. And this is true of patients as well - they want doctors who will spend time with them, rather than with a form.

For most outsiders, however, who do not understand much about medicine, sadly the paperwork is far important than the quality of the care actually provided to the patient.

This is true because of many reasons. For one, non-clinicians are not doctors, and do not understand much about medicine or clinical care. All they understand is paperwork and forms - and therefore will judge the doctor's activities by the only metric they can measure - the paperwork !

For most bureaucrats , the only thing they are good at handling is papers, which is why medical records become so important to them . Similarly, from a lawyer's point of view, if a particular action was not documented, this means it was not done , which is why they believe that the best protection against a lawsuit for medical negligence is not good quality medical care, but a well-kept medical record ! This is true for health insurance companies as well, who will provide reimbursement based on how well the "patient encounter" has been coded by the billing clerk - and not by the time the doctor spent with the patient; or how happy the patient is with the doctor ! ( After all, you cannot measure this, so why bother ?) But, as Einstein said, not everything which can be measured is important - and not everything which is important can be measured !

For government officials as well , paperwork is far more important than patient care. In fact, in India , not keeping proper records is considered to be a criminal offence under the PNDT Act ! If a doctor does not fill in the Form F properly, this means that he is indulging in female feticide and should be jailed !

The tragedy is that this focus on the paperwork means that doctors have much less time to spend with their patients. Doctors will now spend more time checking off boxes on a paper form - or glued to a computer screen, filling in data. They will lose eye contact - and thus the chance to establish an emotional rapport with the patient or display empathy ! What a shame !

Friday, September 17, 2010

Patient education videos in Indian languages - proudly made in India !

I am an angel investor in PEAS, which makes patient educational videos for Indian patients in Indian languages - Hindi , Marathi, Tamil, Telugu, Kannada, Malyalam, and Bengali !

They now have an extensive library, which is growing weekly ! Because they use an animated format, they can get the message across to patients with low-literacy as well !

Thanks to the flexibility of the audio-visual media format, P.E.A.S™ offers both customers and potential users the benefits of enjoying highly engaging patient education series on multiple channels - whether for personal viewing, online viewing or group sessions.

You can watch many of their videos free online - for example the Angioplasty video !

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Treatment independent pregnancies

Many IVF specialists have seen couples who do not get pregnant in the IVF cycle and then promptly conceive in the next month ! Even couples whom we think have no business getting pregnant do so all the time ( for example, those with very low sperm counts or poor ovarian reserve ) !

This is why IVF specialists no longer use the word sterility. We prefer the description, infertility, because this emphasises the fact that fertility is a relative term !

So are all these pregnancies miracles ? Not really ! When some patients fail an IVF cycle, they just give up. They believe - " If the IVF cycle failed, this means I am never going to get pregnant on my own , so why bother ? "

Others take a completely different approach. " If Dr Malpani can make embryos for me in his lab, I can do so for myself in my own bedroom ! " They become even more determined to have a baby on their own ! This phenomenon is well documented and these are called treatment independent pregnancies.

Why do they occur ?

I think there are many reasons for this. Even if the IVF cycle fails, we can explain to patients what we have learnt from the IVF cycle. Going through an IVF cycle makes patients much more aware of their body's signals and their fertile time, so they are better able to optimise their chances of having a baby !

For many, the IVF failure pushes them to put baby making high on their priority list and they spend much more time and energy on this , than they did in the past. They focus on improving their nutrition; body weight; overall health; and stop smoking. In some ways, the IVF cycle acts like a wake up call which spurs them into action !

Sometimes, there is also a spillover effect of the drugs used for superovulation in the previous cycle. These may have a residual effect, which helps boost ovulation in the next cycle ( though this has never been documented).

Also, when the IVF cycle fails, many patients turn to alternative medicine for assistance. They do yoga and acupuncture, and these may help them improve their fertility. A good example of this kind of success story is the heartwarming first person story, Inconceivable ( a book I tell all my patients to read !)

The truth is that doctors don't have all the answers ! Often we do not know or understand why these pregnancies occur ( even though we are quite happy to take the credit for them !) These pregnancies are a fact of life - we should study these, and try to increase the probability of their occurring ! This is the kind of study which is best done by patients themselves ( no pharmaceutical company will be willing to fund this kind of research !)

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Thursday, September 16, 2010

Google Health Speaks at HELP !

25 Sep 2010 - 10 am - 3.00pm

Learn to Translate from English to Hindi using Google Translation Toolkit !

Learn a smart way to translate articles straight from the masters - GOOGLE.

HELP Library is proud to host the Health Speaks Event at Mumbai on 25th September, 2010 - at 10 am sharp.

To register please send us an email with your name, address, and confirmation latest by 20th September 2010. Registrations will be accepted on a first come first basis - only limited seats available.

We will provide you with the laptop - and also give you a Google certificate for your
participation !

This event is about Google.org's health team which is currently working on a project that is exploring ways to increase the quantity of high-quality health information online, particularly in languages other than English.

One way that we are working on this is through the creation of a community of volunteer health translators who will translate high-quality Wikipedia health articles from English to other languages, including Hindi.

We are reaching out to bilingual Medical/Nursing/Public Health Professors & Students, Health NGOs and Medical Professional Associations to help build this community of volunteer health translators. We will hold trainings & events and have online training available to facilitate the community.

We have selected roughly 500 articles that are on important health topics and are of high quality.

Online translation is going to become increasingly important as the world becomes flatter ! This is a great opportunity to learn more about how to translate - and contribute to the health of Indians by sharing your knowledge !

Why don't patients educate their doctors ?

Traditionally, the term patient education refers to the act of doctors teaching patients about their disease. However, it could as well refer to an equally important activity - one in which patients teach doctors about their illness !

Why don't more patients educate their doctors ? This kind of patient education has a long and respected history ! While writers have shared what it's like to be a patient for hundreds of years, one of the most important books which taught doctors to re-look at things from the patient's perspective was Norman Cousin's classic, Anatomy of an Illness.

In fact, there is now an entire a genre of books which does this very well. This is called pathography - a " narrative that gives voice and face to the illness experience, by putting the person behind the disease in the forefront " !

Pathography is a very useful teaching tool ! It helps doctors to learn empathy, so they can learn to see things from the patient's perspective ! For example, though I am an IVF specialist, I am not infertile myself. By reading first person accounts of the trials and tribulations faced by infertile couples, I learn a lot about the difficulties my patients have to deal with - stuff they may not be willing to talk about when they meet me for the first time .

All doctors learn medicine from their patients. They usually remember their most technically challenging patients or their most complex and difficult cases. It's true that these exceptional patients teach us a lot and good doctors treasure these exceptions , because they learn the most from them. These are a doctor's " memorable " patients - many of whom teach us what not to
do !

Good doctors learn from patients all the time, but this can only happen if patients are willing to teach them ! These are the " expert patients" - those who are articulate and treat their doctors as partners in their medical care.

However, doctors can learn from all patients - if only they would learn to speak up , and we would learn to listen . Patient feedback helps doctors to improve their services - and even complaints are gifts, when taken in the right spirit !

Unfortunately, there are still many barriers to getting feedback from patients. Most patients are inhibited and scared and do not have the courage to displease their doctor by telling him the unpleasant truth. Similarly, most doctors are too busy to ask for feedback - and most continue deluding themselves that they do a perfect job with every patient !

Hopefully, the internet will allow patients to offer critiques and criticism more easily. There are now many doctor - rating websites, where patients are encouraged to provide their opinion about their doctor. This kind of patient- generated content will help doctors to get their act together, if they are willing to keep an open mind and try to correct problems.

If patients want their doctors to do a better job, they need to learn to speak up. Most dis-satisfied patients today just walk out of the doctor's clinic and never return . They find a better doctor - but by failing to give the doctor frank feedback, they have lost an opportunity to help him to improve and do a better job with his next patient.

How will doctors learn , unless patients teach them ?

Wednesday, September 15, 2010

Is there anything wrong with specialists giving referring doctors a kickback ?

Cuts and kickbacks have become the norm in medical practise in India today. In public forums, most doctors frown on this practise as being unethical and unprofessional ( even though they continue giving cuts in their own practise). This is hypocritical and just adds more dishonour to the medical profession.

Let's take a fresh look at the subject. The question we need to ask ourselves is - Is there anything wrong with doctors giving cuts ? Is this really such a bad thing ?

Cuts and kickbacks are pretty much standard practise in many areas of life today, such as politics and commerce. Greasing palms is considered established practise if you want your file to move in the government office , and if it's okay to give bribes and kickbacks in other fields, what's wrong when doctors do the same ?

Let's see why the practise evolved in the first place - after all, the fact that it has spread like a cancer means it must have some plus points ! Rather than turn a blind eye to these , let's look at some of the benefits this offers.

The advantages to the family physician ( primary care doctor ) are obvious ! It's a fact that family physicians are underpaid as compared to specialists. Doctors who do procedures command an unfair premium and these kickbacks helps to reduce the disparity in their incomes.

Also, primary care doctors play a very useful complementary role to the specialist, but this is often not explicitly acknowledged or reimbursed . They don't just refer the patient to the specialist and then walk off after collecting their commission ! They help to identify the "best specialist"; help the patient to get a timely appointment; counsel and handhold the patient
( something which most specialists just don't have the time or energy to do !) ; explain what the specialist is saying ; and demystify the medical journey for the family. They are always available for assistance ( for example , in the middle of the night, when the specialist has disappeared) ; and because they have an ongoing long-term relationship with the family, they are able to provide emotional support much more effectively than the specialist . Equally important, they are better at taking a holistic view of the medical problem, as compared to specialists, who have a very narrow viewpoint - and who may know a lot about the technical minutiae of their specialty , but know precious little about the person who has the disease !

Family physicians act as a useful bridge between the specialist and the patient - how are they going to reimbursed for their efforts in a fair fashion ? In my opinion, the cut which the specialist gives for the referral is their reimbursement. Taking a share of the spoils is the most effective way for them to earn money.

So it all hunky-dory ? No ! There are major disadvantages to this system ( which is why we do not give cuts in our private practise !). For one, this system increases the cost to the patient. It also promotes malpractise , because family physicians will often pressurise specialists to do surgery in order to maximise their revenue, which means that procedures are done which are not always in the patient's best interests. Also, because this is unaccounted for black money , which is paid in cash, under the table, it encourages a parallel underground economy.

Because this practise is hidden, it's never discussed openly , and this creates a lot of resentment amongst patients. The fact that doctors indulge in giving kickbacks is an open secret - and hiding this reality creates a lot of suspicion in the patient's mind. This is one of the major reasons patients do not trust their doctors , and why the reputation of entire medical profession has taken such a beating in recent years.

So what's the solution ? Can we ban kickbacks ? While the Code of Medical Ethics explicitly bans cuts, unfortunately this does not work in real life. We need to find a realistic solution !

I feel the major danger with the kickback is the fact that is done in an underhand secretive fashion. Because the doctor hides the fact that he is giving a kickback to the referring family , he has to be dishonest - and this damages the doctor-patient relationship, which should ideally be based on trust !

Large corporate hospitals routinely give referral fees to doctors. This is considered to be part of the "cost of doing business" and is usually given as a cheque payment. If we accept this practise
( because a hospital is a business and needs to fill its bed), then why not level the playing field and allow doctors to give referring doctors a commission as well ( which can be claimed as a tax-deductible expense ? ) Similarly, doctors give referral / commission fees to medical tourism companies which refer patients to them. What's wrong if they give this to the family doctors who send patients to them ?

I feel it's far better to make this an open and transparent system, so the patient knows what the truth is ! The specialist can add a " surcharge" to his fees, and this can be paid to the family physician by cheque , as a "patient management fee" . This transparency will keep everyone honest and help to align the doctor's interests with that of the patient !

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Friday, September 10, 2010

Doctor power

There are lots of websites which talk about the empowered patient , but there's surprisingly little about the power which the doctor yields.

Part of this is because it's so obvious that the doctor has much more power than the patient in any medical encounter. But what is the source of this power ? and how can it be used ? or misused ?

In his excellent text book, The Doctor's Communication Handbook, Dr Peter Tate talks about three 3 types of doctor power

1. The power which the doctor has because of his medical expertise. He calls this "sapient power". In the past , this was the major reason why patients looked upto doctors . Doctors had access to medical information, which only they could understand - and patients needed to tap into this expertise if they wanted to get better. With the advent of the internet, however, this variable in the power equation has changed dramatically - and many patients are now even better informed than their doctor about their particular medical problem.

2. Social power , or moral power. This is a result of the doctor belonging to the elite medical profession - a guild which controls medical power . Modern society has handed over the social role of the healer to the doctor; and when the patient adopts the sick role, he hands over some of his autonomy to the doctor.

3. Charisma - or the personal power of the doctor. This is an intangible, which varies considerably from doctor to doctor. Some doctors ooze charm; some radiate confidence - while others inspire patients with the length of their retinue ! This is part of the "magic" which a good healer has - something which cannot be easily defined or transmitted.

Patients need to understand the source of the doctor's power, so they know how to make the most of their doctor. Each doctor has a different style - and patients will need to adapt to this - or find another doctor who is more in tune with their needs !

Thus, younger enlightened doctors will share their expertise and try to forge a partnership with their patients. However, not all patients want this additional responsibility ( which also comes with chores and duties). They prefer a more authoritarian doctor who will tell them what to do, so they can follow his orders, and get better sooner, rather than break their head over making complex decisions about things they do not understand ( and would prefer not understanding !)

I do not feel any style is good or bad - they are all different - and they all work for certain doctors and certain patients. The trick is for you to find a doctor who has a style you are comfortable with !

Wednesday, September 08, 2010

How to increase your stress levels when doing IVF

Being infertile is stressful and going through an IVF cycle can be even more so because so much is riding on the outcome of the treatment. An IVF treatment cycle is much more than just a medical procedure, because there are so many hopes, dreams and desires wrapped up in the treatment.

However, the biggest emotion is often that of fear ! What will I do if the IVF cycle fails ? Is there any hope of my ever having my own baby if even IVF fails ?

I feel it's the unrealistic expectations which cause the most stress . Most patients who start an IVF cycle refuse to even consider the possibility that the treatment may not work. They have been brainwashed into " thinking positive" , so they refuse to remember that the chances of the IVF failing for a given patient in any cycle are more than the chances of success !

Most of them keep on repeating the mantra - It's got to work ! It will work ! There are lots of family-members and friends who are hoping and praying for success as well, so everyone is on an emotional high during the treatment cycle, because they need to keep each other's hopes up. The truth is that no one would ever start an IVF cycle if they did not feel in their heart of hearts that it was going to work for them.

This is why patients arm themselves with prayers and lucky charms before and during the IVF treatment. While the IVF process is straightforward - grow eggs; make embryos; and then transfer these into the uterus , the outcome is always uncertain. This is because implantation - whether the transferred embryo will become a baby or not - is a biological process which no one can influence. Along with medical expertise and good protoplasm, it also requires a large dose of luck - the one intangible no one can control !

The truth is that no one can ever be sure of the outcome of the IVF cycle, which is why you need to keep your expectations realistic ! While you cannot control the final outcome, if you have peace of mind you did your best, you will find it much easier to manage your stress levels during your IVF treatment !

Please remember the Serenity Prayer
God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

How to improve the Medical Curriculum - from Dr Nadkarni's book, How to heal the sick healthcare system

I would not like to go too much into the details about the curriculum for the undergraduates. Basically a student used to spend 1 1\2 year to learn normal structure and function of the body i.e. the studies of anatomy, physiology and biochemistry during the period of first MBBS. Another 11/2 year in second MBBS was devoted to the study of diseases of the body and drugs and medicines to be used for the patients – pathology and pharmacology. He also studied medico legal aspects in the subject of forensic medicine. The students are posted in the hospital in the morning hours from 9.00 am to 12.00 noon after the completion of the first M.B.B.S. for a continuous period of 3 years. They attend various departments as per the schedule recommended by the Indian Medical Council. It is here that they get maximum practical experience by observing patients being treated both in the ward as well as in the out patients department, through bedside clinics by the senior teachers. The knowledge of preventive medicine, ENT (Ear, Nose and Throat) and ophthalmology (eye disease) are studied in the 3rd MBBS during the fourth year while in the final examination 41/2 years later, the student appears for Medicine, Surgery, Obstetric & Gynaecology and Paediatrics. If the student passes the examination, he is excepted to work as an internee for a period of one year, working in the department of medicine, surgery, obstetrics and gynaecology and preventive medicine wherein he works at urban and rural health centres. Thus, it is long course of 51/2 years. There is a craze amongst experts of several new branches in the medical field to insist on including their portion in the curriculum of the M.B.B.S. course. Yet, despite criticism and shortfalls, and insistence of new branches to add to the course, I personally feel that the medical course as implemented for the last 50 to 60years or more is quite adequate. Unfortunately the Medical Council has decided, of late, to reduce the first M.B.B.S. course to just one year. One year is too short a period to learn the normal structure and function of the body. The period gets shorter due to the fact that admission process gets prolonged every year and the students get admitted to the college as late as in September instead of in June. Thus, the period for the actual study of anatomy and physiology turns out to be hardly 7 to 8 months. Unless the basic knowledge of normal is sound, the abnormal cannot be grasped. It is the opinion of almost all teachers that shortening the course to one year for first M.B.B.S. is not adequate. It should be reverted back to 11/2 year at least. Secondly, the habit of condoning the shortfall in the period of education must be strictly prohibited. If the students get admitted in the month of September they cannot appear for the examination in the month of April of the next year and will have to appear at the next term namely October (or November). It is true that admissions are delayed for no fault of the students but the fact remains that the period of training was not completed. The same thing is true when the absence is condoned for final M.B.B.S. examination for reasons such as illness, strike and such other circumstances. It is unpardonable. Period of training as scheduled is the most minimum that is required to train him to become a good matured doctor. Hence prolonged absence due to any reason, however genuine, is not pardonable. The ill effects of partial training are finally suffered by the population at large. As regards the curriculum of the other branches of medical faculties-Ayurvedic, Homeopathic, Unani etc.. It is an established fact that most of them do practise allopathy to a very large extent. To some extent this has helped the community because 80% of the general practitioners now belong to these other faculties of the medicine. Therefore, it is imperative that their curriculum is adjusted to include at least two years of allopathic medicine during their course. The exposure to the allopathic system for these students at present is too inadequate. Exposure to allopathy for two years would be akin to creation of a ‘basic’ doctor with the training which is much below the standard of M.B.B.S.; however, adequate for basic needs of the large poor population.

The Indian Medical Council is strongly opposed to the idea of training an ‘inferior’ type of doctor and has thwarted the efforts of the politicians to create three years, four years programme at various times. However, the same council stands helpless when the graduates of the other faculties practice allopathy freely as mentioned earlier. Therefore, I feel that increasing their exposure to the allopathy for a period of at least two years is a good compromise-solution to the present problem of shortage of general practitioners for the community especially in rural and semi-urban areas.

After completion of internship, the M.B.B.S. graduates are now compelled to appear for a common competitive test if they desire to enter into postgraduation studies and become specialists in various branches. Nearly 80% of the students desire to do postgraduation. Earlier there was no such competitive (C.E.T.) test and the students were selected as postgraduate students in various branches as per the marks obtained by them at M.B.B.S. examination. The competitive test has now added a new burden on the students during the period of internship. Actually this period of internship was the best time in the life of a medical professional; some ‘donkey’ work but almost no responsibility and no examination to face! It would have been the best time, when they could have been made to develop a deep interest in social and administrative aspects of clinical practice, so that they would be better prepared to face the competition in actual life and give proper service to the community when they are thrown into the field of medical practice as full-fledged responsible doctors. Men, money and material are the three ‘M’s, every body has to learn to manage to become a professional. A glimpse of training of financial and personnel administration and administration of medical store could have been usefully included during this period of internship, through lectures, seminars, visits to these departments and discussion with the officers in the various departments of the hospital – if only they did not have the burden of competitive tests. A good perspective about socio-economic conditions and the psychology of the people in rural and urban areas and of the poor and lower middle class would also help to make these doctors more sympathetic to the needs of the common man, through lectures by competent social workers and teachers in social studies. As I mentioned earlier, majority of students are now from the upper strata of the society and have very little idea of how 60-70% of the population manage to live. Therefore, I suggest that the competitive test (C.E.T.) should be taken immediately after M.B.B.S. – say within 3 months after the M.B.B.S. examination. The portion for the competitive test is not different from the portion for the M.B.B.S. test. The student has to choose the subject in which he wants to specialize. Therefore, for this test examination, three months period after the final M.B.B.S. examination is quite adequate. It would be an ideal timing when the graduate is quite fresh with his M.B.B.S knowledge and can take another examination easily in his stride. The management course and socio-economic awareness course can now be conducted in the remaining 9 months. Even the students are aware of the importance of the subjects I mentioned above, namely financial and personnel administration and socio economic aspects of society and most of them are very keen to undergo this training.

There is no need to have any examination. If one is taken, it would be optional – for an individual to know the proficiency he has reached. Lack of knowledge of the socio–economic problems of the poor society is one of the root–causes of the alienation of the doctors from the masses; greed for money being the next important cause.

However, there is an absolute and urgent need to introduce a post–graduate course in General Practice. Like the other P. G. courses, this course will also be for the duration of three years. Today, there is no special training for a general practitioner. Not only that, it is a tragedy of sorts, that those students who are unable to secure a post graduate seat in any specialty, finally decide to go in for general practice without any special training. No wonder, the most important primary health care remains the most neglected aspect of health care system. with more and more emphasis on 'super specialty modern medicine.' If specialization was provided for 'General Practice' - M. D. (G. P.) it is quite likely that good students with good marks would opt for general practice.

Like all other P. G. students, these students also will have a three year residency program. In the morning hours, from 8 am to 1 pm they will be posted, by rotation, in various departments, like Medicine, Surgery, Ob & Gyn. Paediatrics Orthopaedic in one unit or the other, for a period of 4 months each and will have an option of choosing any three minor specialties for a period of 3 months each, like E. N. T., ophthalmology, dermatology, psychiatry, preventive medicine, etc.. Last 6 months, they will return back to general medicine. While attending these specialties, they will learn more about when to admit and what is to be done after discharge as much as what is being actually done for the patients in the wards. Naturally O. P. D. and follow-up clinics are mandatory. And in the evening, they will attend attached dispensaries, from 4 to 9 or do a Night duty in the dispensary.

Even after passing the M. D. examination and starting general practice, they could continue to work for a further period of 3 years in any non-teaching secondary care hospital. The society will gain a lot, if such matured doctors enter general practice after due formal training.

Finally, I firmly believe that super specialty departments should have no place in the medical college premises. They hamper the flow of patients in general specialties. Also the general specialists develop a tendency to refer and push, even the cases that they could have handled easily. This tendency would no doubt, be curled to some extent, by evolving the charges for consultants, as mentioned elsewhere. It would be wiser to establish super specialty centres, close to but not within the medical college and hospital premises.

Tuesday, September 07, 2010

The Dean - from Dr Nadkarni's book, Healing the Sick Healthcare System

The head of the medical college hospital is Dean. A person who holds the post of professor is eligible to compete for the post of the Dean after five years of experience. The Dean is an academic post. He comes from amongst professors who are expected to be masters in their own subjects. As I had discussed previously, these professors ought to be good either in their professional work or teaching or research. It is pertinent to note that the teaching staff does not have any formal training in administration. They do not attend any training course-not even a few lectures-to understand administration. The professor who heads the department i.e. senior most amongst professors in each department learns some administration out of compulsion because he is forced to take part in the administration. All this clearly proves that the post of Dean is an academic post and his primary duty is to promote good medical education, research and provide good medical services to the patients through properly supervised system of clinical practice. It is surprising, therefore, that such an academic person is suddenly forced to spend 90% of his time in purely administrative aspects of running the hospital. On the other hand, there are administrative posts in the colleges and hospitals like Assistant Medical Officer (A.M.O) or Assistant Dean. (now a days called Assistant Commissioner) who look after all the administrative aspects. For them the ladder stops at the post of Assistant Dean. They are not eligible to apply for the post of Dean. Similarly, now people are getting trained and qualified in hospital administration and/or business administration, and others obtain degrees in I.I.M.s. or do financial management etc. or become masters in administration. It is a crime to waste medical talent on the administrative duties which he normally does not understand fully and to waste the talents of qualified administrators by not appointing them to do the administration.

Even in India, in Triruanantapuram, Kerala e.g. the Dean has his office in the medical college which is about 2 to 3 kms away from the campus of medical college hospital. The hospital campus is managed by hospital superintendent. In institutions like All India Institute of Medical Science (AIIMS) of Delhi or Chandigarh, the Dean is an Academic Head and is not burdened so heavily with the administrative duties. The hospital is looked after by another person. It is high time that the hospital management should be entrusted to the qualified hospital administrators; MBAs or even graduates from Institute of management. The problems and solutions which I am trying to emphasize here will be easily understood by the IIM graduate and they would easily surpass the ideas mentioned herein.

The Deans, apart from the academic activities, should be involved in the administration only to the extent of major policy decisions like budgetary provision for each department, purchase of additional equipments for various departments either to maintain the present services or for expanding the services. Day-to- day routine administrative problems must be dealt with by the administrative person appointed for that purpose. He need not be a medical professional.

What is true for the Dean ought to be true for medical superintendents in secondary care hospitals in municipalities or district hospitals in the state governments. The medical superintendent ought to be concerned with the clinical aspects of administration namely, appointment, supervision and maintaining performance records of all medical and paramedical personnel. He has to plan the schedule of working, emergency duties, etc. of clinical departments, as also the need for more equipments for modernising the medical services. But all the purely administrative functions of the hospital like maintainence and repairs of buildings and equipments, electrical and civil work administration of the entire staff, salaries and leaves must be the function of an administrative officer who may be suitably called hospital superintendent or chief administrator.

Similarly, the financial management of the hospital must be entirely relegated to the Chief Accountant or Financial Manager. The entire staff at the registration, billing and medicine supply counters must work under the chief accountant, In the government and municipal set-up. The accountant in not answerable to the Dean and has almost the same independent powers as the judiciary has, in respect to the collector of the district. At present, this semi-independent authority of the accountant is playing more obstructive role than constructive role in the hospital management. They are not responsible for any short-falls in the services. Yet they have the full authority to raise audit objections for purchases - for that matter - for any expenditure proposed by the superintendents. I have already suggested, in an another chapter, that the registration and billing department should work under the accountant, so that the department will be responsible to show adequate collection of the charge from the patients. If the Dean or the superintendent is not answerable for the collection of the fees for medical services or the charges of investigations or medicines supplied, they will also be freed from the pressures from politicians and relatives to reduce the charge. And the chief accountant will become answerable to show adequate collection of charge on the one hand, and purchase of essential in terms for clinical services on the other. The obstructionist will now become practical and constructive. Their answerability towards proper functioning of the hospital will increase. A major problem of successfully running medical services will be solved.

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How to improve the medical colleges in Mumbai - Chap 11 from Dr Nadkarni's book, Healing a Sick Healthcare Ssystem

It is evident from all the discussion so far that to run a good medical college, it is absolutely essential to run a good hospital. The administration of the hospital, therefore, assumes great importance in determining the standard of education in the institution. Unfortunately the importance of the ‘system’ or ‘management’ is not realized even by the very educated class - leave apart the politicians and journalists. Individuals are blamed for shortfalls, but the system under which individuals are working is not even remotely discussed. So the blame falls on individual doctors if the services are poor. Occasionally individuals are glamorized if they perform something exceptional but the system of working which enabled the individuals to work properly is totally ignored, if indeed it was contributory. It must be realized that it is the system of working that promotes good workers or makes them to leave the institution and it is the system which gives a wide scope to the inefficient, corrupt persons if it is faulty. Therefore, we have to look more closely as to how the hospital works or must work.

Every employee-and medical teachers or doctors are no exception-wishes to minimize his work and find idle space during his own working hours; though he wishes to earn the maximum. Minimum work for maximum salary is an accepted principle in the present scenario. The task of the management, therefore, is to work against this tendency and ensure that every worker gives his optimum, if not the maximum, output of the work entrusted to him and to offer him incentives if he gives more output than the average. Let’s look at the working of a clinical unit. Every unit has only one day in a week for attending the outpatients. Emergency i.e. serious patients coming out-of-turn for urgent treatment to the hospital, are also treated by the same unit on that very day. Thus, resident doctors and junior consultants remain busy examining large number of patients that come to the outpatients department, while at the same time they are called to attend to urgent cases admitted directly to the ward (or through the critical care units, if such were established in the hospital). In addition patients are referred from other branches, for example, the surgeon may be called to see a patient in the medical ward or a female patient in a medical ward may require an opinion from a gynecologist. The cross references are plenty everyday. Again the same doctors of the same unit attend to these references of other branches. On the surgical side small urgent operations like incision of an abscess or reduction of a fracture have to be performed on the same day in the evening hours. Some patients in the outpatients department may require small non-urgent operations and could be sent home without being admitted like a biopsy or removal of a cyst and so on. Again these operations are done on the same O.P.D. day after the O.P.D. hours are closed (the cards are given to the outpatients generally from 8.00 a.m. to 11.00 a.m. and the last patient is seen by about 12.30 p.m. to 1.00 p.m. Thus, the team is engaged with multiple duties on the same day. At the same time many patients are admitted from O.P.D. and yet some more serious patients are admitted as emergencies from Casualty department. Therefore, the day becomes too heavy as the patients are being admitted whole day long till 8.00 a.m. next day. All these patients as well as emergency cases must be examined and treated, their histories are to be recorded, investigations are to be done and so on. Therefore, the next day becomes heavy too. But for the next four days, the juniors and seniors in the non surgical units, have no other specified duty except a round of indoor patients which may last about two to three hours. So, they are relatively free on all the four remaining days of the week. In the surgical department there are two operation days in a week which keep them busy. But again at least two days remain when the specified duties are very few and the team has a lot of time to spare. The senior residents and the lecturers are expected to take tutorials for the under graduate students and it is strange that they prefer the same emergency day for taking tutorials as ‘they have to stay the whole day in the premises in any case.’ Thus, the pattern of working has been made most suitable for the doctors but not necessarily suitable either for the patients or for the medical students. Seniors and residents are always busy, everyday, somewhere between 9.00 a.m. and 12.00 noon, when they take a round to see and decide the treatment of all indoor patients. The medical students too are given bedside clinics during the same hours right in the wards and as mentioned earlier, this is the main part of the teaching of the medical students. Nine a.m. to twelve noon is the time specifically reserved for indoor or outdoor patients and for teaching undergraduate students in the hospital. But there are many allied activities like clinical meetings, functions like hospital annual day, guest lectures by eminent professionals from other parts of the country or from the foreign institutions, or there are meetings of the various committees like Drug Committee, purchase committee with the Dean. Invariably all these lectures as well as administrative meetings and hospital functions etc. are all held in the morning hours somewhere between 10.00 a.m. and 12.00 p.m. it is exactly this time which is easily spared for any function or lecture or meeting etc. Afternoon hours are more or less left free, so every one retains these leisure 'working' hours. When described in details, it looks obvious that the working system is not proper and needs correction. The various functions need to be redistributed over the whole week. Yet I am surprised that enough attention is not given to change the system. In the modern days the need for hospitals is becoming less and less and many patients can be treated without being admitted. Such procedures are termed as ‘Office Procedure’ or ‘Day Care Surgeries’. Therefore, the outpatients department needs to be expanded a great deal. It is no longer just a room for consultants. There is a need to have a minor operation theatre or procedure room and a few beds to keep the patients for a few hours right in the OPD. If such a system is to be followed, it is obvious that the team of doctors attending the OPD cannot have any other duty like attending emergencies. There is also a need to group the patients and call them at different hours so that every one gets proper attention. For example, patients referred from peripheral hospital or primary health centre, dispensary etc. have to be given a specified time as they are refereed by qualified doctors and from the same government administrative machinery. So it is advisable that patients coming directly to the hospital may be attended say from 8.00 a.m. to 10.30 a.m. while patients referred from various peripheral centres be attended from 10.30 a.m.to 1.00 p.m. Non urgent minor operations need not be rushed through on the same day. These minor operations can be conveniently done by appointment, on a day prior to O.P.D./Admission day. The team is relatively free after morning rounds in the wards and the patients will be easily followed up next day in the O.P.D.. Urgent minor surgical procedures have to be completed in the evening on the O.P.D. day as is the practice today. But this clinical unit which is attending to the outpatients department will not have any emergency duties nor will it examine any referred cases on that day. This way the team will also have adequate time to examine the cases which have been admitted as routine admissions from the OPD and write their history properly and plan their investigations. Emergencies will be attended and referred cases will be seen by a unit which has only the routine hospital round duty i.e. by the corresponding unit. For example If ‘A’ unit has outpatients duty on Monday, ‘D’ unit will be on the emergency duty on Monday Again, ‘D’ unit will have OPD on Thursday and ‘A’ unit will attend emergencies. Mondays and Thursdays are corresponding days. This way emergencies will be looked after promptly and immediately because the team has no other specified duties. Similarly it must be a strict rule that senior residents or lecturers will not have any routine teaching programme like tutorials, demonstrations, lectures etc. on their OPD and emergency days. Tutorials will be taken in the afternoon hours, on any of the non – OPD / non – emergency days. Secondly it is unclear why the doctors of a unit are available to his O.P.D. patients only once a week – that too for just 2 hours. In private hospitals, consultants are available almost daily for the patients for their follow up treatment. So it is paradoxical that in the medical college hospital, the patient can see his own doctor only after one week, as there is only one OPD day for each unit. This is intolerable. There is a definite need to have afternoon OPD clinics of about two hours twice a week for the old patients for their follow-up advice and treatment. This is especially needed in the medical departments, where they can have follow-up specialized clinics like ‘diabetes clinic’, ‘cardiac clinic’ and so on, in addition to the general follow–up clinic.

In short, every clinical unit has multiple duties
1) OPD duty
2) care of indoor patients,
3) looking after emergency and referred cases,
4) formal teaching duties like tutorials, lectures etc.
5) writing histories and keeping proper medical records and
6) follow up of old patients.
In the surgical departments, the unit has to perform actual surgeries
a) minor day care emergency operations;
b) minor day care routine operations;
c) routine major operations on the indoor patients and
d) the emergency operations.

These duties and operations, must be conveniently spaced in the whole week so that the team is answerable to one duty at a time. This also ensures that the team is busy in its clinical work every day for all the working hours. As this increases the answerability of the team, clinical services are bound to improve a good deal without many modern equipments. Medical education would also improve simultaneously, if only the system is changed and accountability is increased. If 25% of the beds are reserved for paying class, obviously the seniors in the team will have their paying OPD clinic and operations in the evening hours, twice or thrice a week. However, they will not have any (private) paying clinic on their emergency day and only follow-up clinics on their operation days. No new cases on these days. They can see all new cases on any of the other days. In short, the specific duties of every clinical unit must be specified. No one can perform two duties at a time. If allotted multiple duties at the same time the answerability of any worker not only doctors-is reduced. Hence, the time table should be arranged in such a way that every one is entrusted with only one of the duties at a time.

Selection of Medical Teachers for medical education - Chap 11 from Dr Nadkarni's book, How to heal the sick healthcare system

The choice of the medical teachers leaves much to be desired. As per the Indian Medical Council rules, there are broadly three categories of medical teachers – lecturer, reader (variously called assistant professor, Reader, Associate professor etc. from time to time) and the professor. Post graduation in the subject and the teaching experience of three years as a senior resident or equivalent are the minimum qualifications to become lecturer. Three years' experience as a lecturer qualifies him to become a reader / Associate professor and after five years as Associate professor he can aspire to be a professor. Generally this appear to be on par with the stipulations in the western countries. There is always a big rush of qualified post graduates to become a lecturer, not because they like the teaching profession but because they wish to gain further experience in their own field of specialty. The applications for the post of reader / associate professor are far less and sometimes it is difficult to get the post of a professor filled; the applications are so few. Meager salary, bureaucratic attitude, lack of incentive and poor job satisfaction are the main reasons why the consultant doctors are not attracted to the field of education. I have also suggested that if these consultants from the level of Associate professor onwards, are allowed practice within the premises, that may be sufficient incentive for many of the consultants who are academically oriented or are not happy with the many gimmicks and marketing and unfair methods they have to adopt in private practice. But today it is a discredited field because of lack of incentive and inappropriate infrastructure. But not every one is inclined to practice and there are a few who are genuinely interested in teaching and research and it is necessary that the medical college hospitals-government or private – should encourage those who are truly interested in teaching and / or research. The lure of private practice within the premises for such consultants is unproductive. For them some other incentives must be available.
There are three desirable types of medical teachers. The first one is 'practice oriented'. They mix the art and science of clinical practice and render good medical service to the patients. This category is in the largest number. But as I mentioned earlier, many of them leave medical college hospital and enter into private practice which is more lucrative and more satisfying though more intriguing. Actually these teachers would have been an ideal example for the students to learn from and it is for the sake of retaining such consultants in the field of medical education that I have suggested private practice within the premises with 25% of the beds reserved for the paying class, Private practice allowed outside hospital premises is disastrous not only because the medical teachers are out of the premises for practice but, in addition, they develop too much of commercialization. In turn, they neglect their duties in the medical college hospital and thus become the worst examples for the students to learn from. Unfortunately, such a system of allowing private practice outside the premises is advocated and allowed in most of the government and private colleges due to the advice of the accountants and bureaucrats who are highly satisfied by the reduction of expenditure on the medical teachers. Besides, it relieves them of a big administrative burden. In the municipal medical colleges, for example, nearly Rs. 15,000/- to Rs. 20,000/- per month are saved per each consultant if he opts for private practice. Totally, in the eyes of the accountant, the corporation would save around Rs. six to eight crores. But they forget that the same teachers would have earned much more than these 20.000/- rupees per month and further brought another two lakhs of income to the hospital, if practice was allowed within the premises. In addition, the true benefit is the improvement in the medical education which will benefit the society for the next 2 generations in the form of better doctors coming out from the hospitals. This has been discussed in great details earlier. But the administrative burden on the accountants and bureaucrats would rise five fold. The second type of teachers who are equally desirable are teachers who read a lot and are truly interested in teaching. Every good teacher may not be a good practicing clinician, just as the best directors are not the best actors and the best coaches are not the best players. Teaching is a different art altogether and such teachers who are academically oriented and have enough art of teaching must be sought after. Similarly some amongst them may be deeply interested in research work and should become assets for the institution. The teachers who have truly come for teaching or for research are very few in Mumbai. Hardly 20 percent of the teachers at the most can be expected to belong to these two categories. They need different incentive. As mentioned earlier research workers can be encouraged to utilize the grants from the pharmaceuticals or I.C.M.R. funds and the college itself must have enough funds available for research. Foreign institutions are pouring funds for good research. Unfortunately in the present system, while every worker under him is adequately compensated, the consultant teacher, himself, who undertakes the project is not allowed a single rupee for the work he undertakes. This is most unfair and may be the root– cause why most of the teachers are reluctant to take research projects. This also leads to clandestine practice of the pharmaceutical companies paying in the form of gifts, foreign tour and so on to the Chief Investigator, thus inducing research workers to give favourable results for the company. The disastrous results of such corruption in research are obvious and drugs and medicines which can be harmful are finding their way easily into the market. Substantial payment to the research worker directly through the grant will help to make research more fruitful and honest. Similarly a good teacher must get adequate facilities to write books and monographs. Writing books and monographs separately for students, nurses, technicians etc. is a task in itself and apart from too much time consumed for it, it is also very expensive. Hence, he should be provided with adequate facilities to write such books. Such incentives would go a long way to improve the standard of medical education in the medical college. Both these classes of teachers deserve non–practising allowance and other perqisites, subject to performance. Therefore the performance of the medical teachers must be assessed, as per the specific expectations from each category.

Performance Assessment of Teachers

Unfortunately today there is no assessment of the performance of the medical teachers. It is only a confidential report of each staff member. The confidential reports submitted every year are a big farce. Basically the annual confidential report was meant to ensure at least the minimum output of work from every worker. If there were no adverse remarks, he / she was considered satisfactory. There was no added credit if the person worked more satisfactorily i.e. if he gave very good or excellent performance. The next promotion usually went with seniority. Of late, competitive selection (for example by M.P.S.C.or U.P.S.C. interview) has been introduced and 50% of the posts are filled by promotion and 50 % are filled by competitive selection. However, if one looks closely into the method of the so called competitive selection, it would be realized that there are no performance criteria and no performance records on which the selection is based as mentioned earlier. The ability of medical teachers needs to be assessed (a) by his clinical ability i.e. record of number of patients treated, number of different diseases tackled with their ultimate results. or (b) by his ability of teaching; the performance of the students in different examinations; under- graduates and post-graduates or (c) by the research work that the teacher has done. This last i.e. research papers read or published is no doubt considered during the assessment for competitive selection, but the quality of these publications is not analyzed at all. In fact, ‘The papers read or published’ being an important column in the application form, everyone tries to write or read some paper or the other in some journal or some regional conference. Most of them are trash. There is no distinction between the papers published in ordinary journals as compared to the papers published in well known journals or international journals. It is necessary, therefore, to substitute the system of confidential report by a performance record. It is important that the performance assessment must be done separately for each of the above three qualities required of a medical teacher. Administrative compliance, complaints or compliments from students or patients, ability to organize and conduct allied activities like seminars, lay education, participation in socially important events. clinical programs etc. could be the other facets considered in the assessment of the teacher. Unless such records are maintained and submitted to the selection committee in such a form with objective data, the competitive selection would remain a farce and at best, lead to the selection of more vocal street–smart applicants. The recent cases of massive corruption in these (MPSC) selection boards are eye-openers which have failed to open our eyes. The M.P.S.C. is so slow in its selection process that the posts are not filled for years together and thus the vacant posts are once again occupied, by seniority alone on temporary basis from the junior cadre. These ‘temporary seniors’ are continued for a decade or more. It would be preferable if the M.P.S.C. is substituted by another formal organization specifically appointed by government to enroll medical personnel and other professionals in the government organization. The confidential reports must definitely be replaced by the more objective performance record in which the performance of each would be graded as excellent, very good, good, satisfactory and unsatisfactory. It would be an excellent idea to inform every employee his / her performance report. This will help him-if he is dissatisfied, to protest and to put forth the objective data to get his report corrected. On the other hand, if he knows that his performance is good it will encourage him to do better. If his unsatisfactory report is confirmed, he knows definitely that he has to improve or perish. Such report once confirmed by the senior authority must be seriously considered at the time of competitive selection. This way some junior teachers may supersede the senior inactive teachers; and that will help to improve the medical service and medical education. It will create a fair competition amongst the teachers. During my tenure as Dean, I had done a small experiment and adopted this procedure. The then assistant commissioner Mr. Karandikar was also very keen to promote merit. Those employees whose work was declared just ‘satisfactory’ but did not have a record of ‘good’ or ‘very good’ for at least 2/3 rd of the period in their present post were denied promotion. The result was dramatic. Every lecturer and reader stepped up his/her performance and was keen to prove his/her mettle. Personally I conveyed the performance record to each and every member of the medical faculty. Those reports were personally prepared by me and were given as confidential letters personally to each of them. Thus, the confidentiality was also maintained, as required under the present rules. It was only the employee himself who could divulge his performance report to others-otherwise it remained confidential. There was another unexpected but highly desirable result. Earlier when only the adverse remarks were conveyed to a few of the members, they raised a lot of noise and complained bitterly about ‘partiality’ ‘corruption’ and so on in their conversation with other colleagues in the common room. All other members of the staff, not knowing what their own report was, promptly sympathized and the association of the teachers jumped on the authorities concerned namely, the Dean or the Commissioner to get the reports annulled. When I gave their performance reports stating clearly where they stand, a large majority, who now definitely knew about their own good report, were totally reluctant to join those few who received adverse remarks. Thus, it was much easier to discipline the teachers and make them perform their duties well. Unfortunately, after Mr. Karandikar left, as usual, senior committee members raised many objections and the practice reversed back to promotion seniority-wise. The committee doubted every adverse report. Yet this small experiment-even for a couple of years-has convinced me that if objective data are recorded, performance reports are prepared and submitted to each member separately (and confidentially if necessary) and if these reports are used seriously at the time of promotion, it ha a highly desirable effect. A competitive spirit develops and medical services improve. Besides the whole process is extremely transparent as rightly demanded by the association of the employees. As discussed earlier every one need not to be a good clinician but every teacher must show proficiency at least in one or two desirable qualities of a teacher namely, clinical work and / or teaching and / or research. This will also help in ensuring the balance between academically oriented teachers and practice oriented teachers.

Mandatory number of medical teachers required are clearly notified by Indian Medical council. In large cities where the work load in the hospital is high, the number of clinical teachers is short of the real need in clinical subjects. At present one professor, one associate professor and two lecturers, together form one unit and are allotted 30 to 40 beds for their clinical work. There are at least 6 to 7 resident doctors who are doing their post-graduation; 2 students every year for a 3 years’ course.They work and move around together all the while. Therefore, the total numbers in a unit are too many. Actually, they were not meant to be flocking. It would be more advantageous to have one professor, one lecturer along with 3 resident doctors to form a compact sub unit and the associate professor along with one lecturer and three residents to form another sub unit. This way
the role of each member will become more defined and all of them will have adequately defined work. However, in general it can be safely assumed that the number is too small to cater to the large number of patients attending medical college hospitals. As the pay scales of the teachers are being raised from time to time and as the hospital earns zero revenue, managements including those in the government become reluctant to appoint even one additional teacher than required by M.C.I. and if at all more teachers are enrolled, the expenses rise. That results in higher fees for medical students. This peculiar vicious cycle naturally affects the quality of medical care given to the patients in medical college hospitals. Regrettably no one is worried and the authorities point their fingers to the Indian Medical Council rules in justification of less number of teachers. The only exception appears to be the large reputed hospitals of medical colleges in Mumbai where number of teachers have gone up much above the stipulated numbers of Indian Medical Council due to the public pressure. This inadequacy of qualified professionals in the medical college hospitals can be corrected by appointing part-time or honorary qualified professionals to help in the services in the hospitals. The Medical Council strongly objects to the appointment of part-time or honorary doctors as teachers. I, therefore, make amply clear that qualified doctors thus appointed will not be called ‘Lecturer’, ‘Associated Professor’ or ‘professor’. They will merely work as ‘Honorary Surgeon’ or ‘Honorary Physician’. the appointment of the honorary or part time consultant – one in each unit –will help a lot both in improving the medical service as well as medical education. There are many successful consultants in the city doing good medical practice. They cannot be successful unless they have proper grasp of the art and science of the branch in which they practise. No doubt that there are some successful consultants whose success depends only on their business acumen. These are ‘commercially successful’ doctors. It will not be difficult for a good management to differentiate between the really competent doctors and the commercially successful doctors. Experience of these competent doctors or the skill in their hands and their capacity to observe and interpret the signs and symptoms of the patients will make an excellent example for the medical students to watch and learn from. As mentioned earlier, good teachers may not be skilled clinicians or surgeons but even their own teaching ability will increase by observing such skilled colleagues right in their own unit. Similarly retired or most eminent consultants who have highly specialized knowledge could be invited as emeritus professors. They will examine and treat such patients as are specifically referred to them by the concerned unit. The idea is to have the actual demonstration in their respective highly specialized field for the under-graduates and post-graduate students. In fact, such a practice exits in engineering, law colleges and IITs. Many industrialists or professional experts are invited to give lectures, and many visits to successful industries / institutions are arranged. There is no reason why similar practice could not be started in medical colleges. Today jealousy and the bureaucratic stiffness are the only reasons why this is not practiced in medical colleges but it is high time we do so. The addition of honorary consultant in the unit will help to minimize the expenditure as well as to relieve the burden of increased workload in the hospital. Besides, they will be able to claim teaching experience and become eligible to be lecturers, associate professors or even professors at the end of ten years. The availability of such senior teachers will enable the teaching institution to overcome the acute shortage (of senior qualified teachers). It will help to replace 'old dead-wood' by fresh competent professors and associate professors. Thus, there will be three consultants including three resident doctors, and an honorary surgeon or physician in each sub-unit. Highly specialized emeritus professors can also help and guide the unit in their more complicated cases and impart deeper knowledge in complicated cases.
As emphasized earlier they are not designated as teachers, therefore, they cannot set the question papers or become examiners. Beyond demonstrating and imparting their knowledge and skills to the students who desire to learn from them, they play no direct role in the mandatory medical education system. Yet they will contribute a lot to the standard of treatment and education in the medical college hospitals. The service will improve and the education will become more practically oriented. To me this step is as important as 25% paying beds in each unit. I do not expect Indian Medical Council to agree easily to such a modification. Technically and legally I see no reason why the Medical Council should object to the appointment of additional consultant doctor in each of the teaching unit. However, if council does object I feel it is time that the students, teachers and the management stand up and go to the court of law against the Indian Medical Council to support this system.

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