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.