Category: medical regulation

Dr Manjula Case NHS-UK: Semantics-Regulator’s own Fitness to Practice Doubtful? #GMC-UK

Dr Manjula case NHS-UK: Semantics-Regulator’s own Fitness to Practice Doubtful? #GMC-UK Regulation of the medical profession has become a tool to oppress medical profession. Dr Manjula Arora case (NHS-UK) unmasks the everyday struggle of the doctors in present era. Being undervalued and demonized, forced to work as sub-servant to administrators and regulators are considered new normal and has become an accepted form of harassment. Fatigue and burnout are thought to be routine side effects of being a doctor or nurse. The unhindered overregulation has left no stone unturned in spreading hatred and creating an environment of mistrust against the medical profession. Single stray or a trivial incident is projected as an example to portray poor image of medical profession as generalization and as a token of the ‘excellent’ work done by administrators and regulators. Doctors have become soft targets because of their nature of work as they deal with life and death. Any trivial issues such

Regulation of the medical profession has become a tool to oppress doctors.

  Dr Manjula Arora case (NHS-UK) unmasks the everyday struggle of the doctors in present era. Being undervalued and demonized, forced to work as sub-servant to administrators and regulators are considered new normal and has become an accepted form of harassment.  Fatigue and burnout are thought to be routine side effects of being a doctor or nurse.   The unhindered over-regulation has left no stone unturned in spreading hatred and creating an environment of mistrust against the medical profession.  Single stray or a trivial incident   is projected    as an example to portray poor image of medical profession as generalization and as a token of the ‘excellent’ work done by administrators and regulators.   Doctors have become soft targets because of their nature of work as they deal with life and death.   Any trivial issues such as semantics used by Dr Manjula Arora (in this case) were blown out of proportion  and   GMC finds this  as an  opportunity  to send a strict message to the whole profession.  Such incidence  show that regulators and administrators  can use the nature of doctors’ work to be  used against medical profession to make saviours as an  easy prey for  punishments   on the pretext of  dishonesty, negligence or semantics being used  as  legal weapons by law-enforcers, even in case of a perceived bias. In the process of such ‘tokenism’ administrators prove their relevance to the system.

       Regulation of the medical profession has become a tool to oppress doctors. Driving the narrative of doctors as “perfect” beings causes more harm to the doctor-patient relationship than not. Constantly seeking to attain perfection is the very approach that leads to burn out, and more mistakes- causing patient harm.

Dr Manjula Arora’s case

Dr Manjula Arora’s case

Dr Arora has been a doctor since 1988 and is of good character. She asked her employer for a laptop. For context, most employees would reasonably expect their employer to provide work-related IT equipment. She was told that none were available, but her interest would be noted for the next roll-out. Many people would interpret this positive response to mean that they would get a laptop in due course. Clearly if her employer did not intend for her to have a laptop, they could simply have said so. Dr Arora spoke to her IT department about getting a laptop and said she had been ‘promised’ one.

And that’s it. That is the entire extent of her ‘misconduct’.

One could regard her statement as a minor exaggeration, or loose terminology, or careless language or verbal shorthand over a trivial subject.  But no one  should consider it to amount to ‘dishonesty’ unless interpret it in biased manner.

The tribunal took a different view. They concluded that ordinary, decent people would consider her use of the single word ‘promised’ as dishonest.  The tribunal further decided that this so-called dishonesty amounted to misconduct.

They also considered that the misconduct was serious.

They decided her fitness to practice was impaired, and that it was necessary to suspend her to send a message to the profession.The regulator has a difficult task. Good regulation protects patients. Poor regulation harms patients, because doctors will run away from a toxic regulatory environment.

Manjula Arora case: the GMC stumbles again? -BMJ

      The case of Manjula Arora, a GP in Manchester, who has been suspended for a month for supposed “dishonesty” about a laptop, was picked up by a few colleagues, and social media did its work of ensuring the pick-up rate increased exponentially.  One always worries about the latest “MedTwitter” controversy. But this one has come on back of seething annoyance among many doctors about our regulator—the General Medical Council (GMC)—and its perceived bias, with cases such as those of Hadiza Bawa-Garba and Omer Karim still fresh in our memories.

Couple this with the recent Medical Workforce Race Equality Standard (MWRES) data confirming a clear association of increased referrals and convictions on the basis of racial background—or indeed country of origin as regards training—and this case lit the touch paper.

If one considers the publicly available details of the whole trial, you have to scratch your head and wonder how it got to this stage?   Would this happen if the name of the individual was, for example, Michael Andrews?  

The relevance of this case stood on two things—any harm to the patient population, which, to me, should be the primary aim of the GMC, and then dishonesty and disrepute brought upon the medical community.

This ruling makes it clear that there is no risk of harm to the public: “The Tribunal considered that no issues in relation to patient safety had been identified in this case. Dr Arora is a competent clinician, and there is no necessity to protect the public.” That should have ended the issue. But the complications started when interpretation about honesty came into the picture.

“The Tribunal attached significant weight to the fact that Dr Arora’s misconduct was a single incident in relation to the use of a single word, with no evidence of any other similar episodes of dishonesty before or after the event.” If you go into the details of the case, it becomes even more murky, as it’s the interpretation of a word—subjective at best— against the background of someone for whom English is not their first language. But it was deemed enough to warrant a month’s suspension according to the tribunal: “this period would send an appropriate message to the medical profession and to the wider public that Dr Arora’s misconduct, albeit relating to a single fleeting moment of dishonesty and not a planned deception.”

This raises a multitude of questions. Firstly, there is the principle that one fleeting moment of dishonesty could result in suspension. If that’s the standard, then the profession is indeed in trouble, with the GMC now making subjective judgements and being an arbiter of what is deemed to be honest or not. Where does the line get drawn? Discussions about patients or conversations about whether Santa exists or not?

Secondly, and more importantly, there is the suspicion of bias in how that law is being applied. Daniel Sokol has written a recent column which discusses the notion of doctors as the “saintly being”; the epitome of perfection at all times. Yet, within all of us exist the same prejudices and flaws as for the rest of the population. Sokol suggests that doctors have to be “scrupulously honest—in and out of work—unless the situation obviously allows for ethical dishonesty.” Yet he makes no mention of the fact that the GMC seems to apply that principle unevenly across the board. I accept that it can be difficult to see the “problem” others are complaining about, but I can assure you there are very few international medical graduates who have read about Arora’s case and not thought “I know why this has happened.”

There is professionalism, but there is humanity too, and I would propose that driving the narrative of doctors as “perfect” beings causes more harm to the doctor-patient relationship than not. What is honesty? Saying to patients that they need to wait for another 16 hours to get a bed, or holding the hand of the elderly frail lady, comforting her and saying “I am sure something will come up shortly”? It brings back the concept that being a doctor is a vocation. Constantly seeking to attain perfection is the very approach that leads to burn out, and more mistakes—causing patient harm.

Finally, if the role of the GMC is to protect the public from “single moments of untruth,” as this destroys the view among the public that doctors are saints (although I am pretty sure the public don’t see doctors like that in modern life), then there needs to be a discussion of that concept, of the overreach into personal lives, and of where the line is drawn as regards the GMC’s intrusion and inordinate application of that principle. I would suggest the role of the regulator should be for the rare circumstances when there is an interest in behaviour not being repeated or where it cannot be dealt with effectively by an employer.

I work with the GMC closely these days, and I find it immensely frustrating to see such cases as they undermine some significant hard work that is being done by individuals who are determined to change the narrative that the GMC is biased. I would encourage all concerned to look into this case, review it, learn from it, and offer support to Arora. There is a lot of work in hand to repair the damage from the Bawa Garba case, and this case could reinforce those sentiments, which we must avoid.

The intention may once have been for doctors to be Superman, but modern times and the foibles of individuals only permit a Batman. It’s worth remembering neither of them work to harm the public.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

REEL Heroes Vs Real Heroes

 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

Expensive Medical College  seat- Is it worth it?

1

Fish Bile ‘Treatment’ Lands Woman in Hospital- Folly of Fringe Theories in medicine

Fish bile ‘treatment’ lands woman in hospital A 52-year-old homemaker from Dum Dum had to undergo a few rounds of dialysis and was put under intense critical care for a renal failure, triggered by ‘fish bile poisoning’. The

    It has become a common practice to advertise health products or therapies that claim to be panacea for all ailments enhance immunity, to increase power and health by creating an impression on minds on various platforms. Instead of producing scientific evidence, such products and therapies are sold under disguise of natural therapies or alternate medicines. Needless to say, the objective evidence or global neutral trial for the claimed efficacy or about real side effects is always missing.

    Companies have created huge fortunes based on circulation of such pedagogic narratives and social knowledge. But in real sense, these are actually chemical and have biological actions and reactions. Chemical derived from natural sources can have side effects and contain impurities.  Global neutral trials to validate effects and side effects remain an urgent need of the hour for all health products.

   Suffering for the common public is immense. Doctors’  sincere warning had no effect rather they were called as medicine mafia.   Unfortunately  false beliefs  like local religious figures can cure cancer and kidney diseases  cause they could communicate with invisible spirits  and gain knowledge. Unsurprisingly the cranks  have been  wrong and innocent patients suffer.   Doctors objecting to  elevation of  crank theories were painted as  western medicine agents,  or nattering nabobs of negativity.

 Here is an example of the folly of following fringe  theories.

Fish bile ‘treatment’ lands woman in hospital

Fish bile ‘treatment’ lands woman in hospital

 A 52-year-old homemaker from Dum Dum had to undergo a few rounds of dialysis and was put under intense critical care for a renal failure, triggered by ‘fish bile poisoning’. The patient had ingested raw fish bile for four consecutive days as a treatment to cure her diabetes prior to being rushed to Manipal Hospitals Kolkata with acute abdominal pain. Doctors at the Salt Lake hospital found the patient had low blood pressure and was in a state of shock. Initial reports showed a significant derangement of liver and kidney functions. It led doctors to treat common causes of liver and kidney injuries or drug induced organ damage. When further tests didn’t match with these diagnoses, the team started looking for a possible cause. The patient then revealed she had ingested bile of Rohu fish for four days to control her diabetes. “Consuming fish bile causes acute kidney and liver injury with the need to go for long term dialysis. This patient had to be put under dialysis within 72 hours of admission,” said internal medicine and critical care consultant. She was discharged from hospital after a month.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

REEL Heroes Vs Real Heroes

 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

Expensive Medical College  seat- Is it worth it?

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Online Health Service Aggregators- New Commission Agents in Medical Business: Increase Cost

Online health aggregators are nothing more than sophisticated commission agents. The medical business model thrives on advertisement and commission. Government rules prevent doctors from advertising or soliciting for surgeries, but these companies live on advertising. Any doctor or hospital can get advertised through these companies. In lieu of some money, anyone can be declared as the best and hence misguidance to the patients cannot be ruled out. The flow of patients to a health care facility can be enhanced by financing the advertisements and not by actual quality work and results in increasing medical business manifold. They do not contribute to much needed medical infrastructure and merely redirect patients to existing facilities. They may at the best be able to become facilitators of the process that attract patients by advertisements and result in skyrocketing cost to patients. Any of the Hospitals and doctors can be projected as the best, who tie up with these online aggregators in lieu of some money. Therefore the misguidance as well as increased costs is the two main drawbacks of such a lucrative arrangement of this new medical business. They charge hospitals and doctors for advertisements ( sending more patients) and patients for channelizing them. In the resulting Zig-Zag path, patients are treated more on the basis of advertisements that are many times aired by our ‘Filmy Superstars’.

 

India features a mixed-market health system where chronically low investment in public health systems has led to the proliferation of private care providers.  In last few years, a bevy of apps and service aggregators have starting operating brazenly in the country, pushing aggressively for tests and surgeries and delivering drugs, often advertised by Superstars and Celebrities. Patient often zigzags between health providers with unclear referral pathways, and ends up receiving questionable quality of care that may typically neither be safe nor affordable.   

       Online health aggregators are nothing more than sophisticated commission agents. The medical business model thrives on advertisement and commission. Government rules prevent doctors from advertising or soliciting for surgeries, but these companies live on advertising. Any doctor or hospital can get advertised through these companies. In lieu of some money, anyone can be declared as the best and hence misguidance to the patients cannot be ruled out. The flow of patients to a health care facility can be enhanced by financing the advertisements and not by actual quality work and results in increasing medical business manifold.  They do not contribute to much needed medical infrastructure and merely redirect patients to existing facilities. They may at the best be able to  become facilitators of the process that attract patients by advertisements and  result in skyrocketing cost to patients. Any of the Hospitals and doctors can be projected as the best, who tie up with these online aggregators in lieu of some money. Therefore the misguidance as well as increased costs is the two main drawbacks of such a lucrative arrangement of this new medical business.  They charge hospitals and doctors for advertisements ( sending more patients) and patients for channelizing them. In the resulting Zig-Zag path, patients are treated more on the basis of advertisements that are many times aired by our ‘Filmy Superstars’.

The health service aggregators have no skin in the game. Neither do they invest in hospitals nor do they have the responsibility of running a hospital, but they want the money which a patient will spend on their health in a hospital. They have conveniently created online apps and are ranked top on search websites. This whole process is against the values and ethics, which healthcare delivery is supposed to be.

Unregulated operations by unscrupulous online health service aggregators pose grave risk to public health.

   

Unregulated operations by unscrupulous online health service aggregators pose grave risk to public health.

  The damage caused by the unchecked presence of health service aggregators online is snowballing into a major healthcare crisis which the Union and state governments can ill afford to ignore. Instead of becoming a part of the solution, they have added to the problem by pushing aggressively for tests, surgeries and healthcare services without any medical requirement or prescription.

  There are plenty of  such apps which advertise about doctor consultations, quick surgeries and direct-to-consumer laboratory tests.

       This is where the trouble begins.

In one  case, the  healthcare aggregator suggested surgery for constipation. The mention of surgery scared the patient, who then approached a hospital where they advised him to improve his diet.

For a kidney stone issue, a healthcare aggregator suggested a laser surgery  to a patient without consulting a urologist. The laser surgery was done and the stones got stuck in his pelvi-uretery junction of the kidney-uretery track. He  became aware of it two weeks later when he had severe pain in his flank, because of which he walked in to a hospital after the app refused to acknowledge his concerns.

In all of these cases, the apps charged almost double the existing rates for surgeries. For a piles operation, in a general ward, a hospital charges between Rs 50,000-70,000, inclusive of medicines in a patient without co-morbidities. The apps charged between 1.25 lakh to 1.5 lakh, while the national public health insurance scheme Ayushman Bharat rates for such surgeries begin at Rs 10,000.

Ads are being run by online health service aggregators in newspapers and all  kind of  media.

For removal of kidney stones, hospitals charge Rs 50,000, while the apps charge upwards of Rs 1 lakh, while on the government’s Ayushman Bharat scheme, it is Rs 33,000.

Circumcision is priced at Rs 60,000 by the healthcare aggregators, when hospitals charge Rs 10,000 for a surgery such as this and it is Rs 3,000 for those availing it using Ayushman Bharat.

Their modus operandi? The healthcare aggregators have tie-ups with certain departments in certain hospitals, where after the app does the diagnosis, a doctor on their payroll is sent to the hospital to perform the surgery. After the surgery, the doctor walks away without any care and the patient is left at the hospital until he gains consciousness. At which point, if there is any immediate post-operative care, the nurse concerned does it based on the instructions of the doctor who left. Then the patient checks out.

    A fee is paid by these healthcare aggregators to these hospitals for use of the premises for the surgery. In most cases, they approach smaller hospitals where either the top administration turns a blind eye towards these activities.    Sometimes, the  doctor who performed the surgery may not be  on their rolls, but that from a healthcare aggregator.

 “The health service aggregators  have no skin in the game. Neither do they invest in hospitals nor do they have the responsibility of running a hospital, but they want the money which a patient will spend on their health in a hospital. They have conveniently created online apps and are ranked top on search websites. This whole process is against what healthcare delivery is supposed to be,” said Dr Jagadish Hiremath, CEO of ACE Suhas Hospital in Bengaluru.

Government rules prevent hospitals from advertising or soliciting for surgeries, pointed out Hiremath, but these companies live on advertising.

Such health care aggregators are feeding off hospitals and they need to be regulated. “If you remove the advertisements, these companies don’t exist. They have no physical presence except for a few labs or clinics,” he added.

“The problem is getting compounded by these discounts and offers for unnecessary medically and unwarranted testing in the name of wellness/immunity packages. It is a price war to offer maximum number of tests at lowest prices which is totally meaningless,” highlighted Malini Aisola, co-convenor of All India Drug Action Network (AIDAN)

These online health service aggregators have added to issue of illegal pathology laboratories mushrooming all over, pointed out Dr Jagadish Keskar of the Maharashtra Association of Pathologists and Microbiologists

  Almost all of them have roped in big names as brand ambassadors – actor Hrithik Roshan, Amitabh Bachchan, singer Guru Randhawa, Rahul Dravid, actor Sonu Sood, actor Rajat Kapoor,  Neha Dhupia, Yuvraj Singh and Randeep Hooda to talk about specific health issues and MS Dhoni.

   “They have all these famous names as brand ambassadors as if they will perform the surgeries or look at your blood in a lab. This confuses the public, who are already bombarded with too much information,” quipped Hiremath.

     Consumer Drug Advocacy group All India Drug Action Network (AIDAN) argued that the direct-to-consumer advertising has to stop completely. “It is too dangerous in healthcare. Aggregators are inducing demand when people are at their most vulnerable due to the pandemic. They are pushing promotions and offers on tests and surgeries and healthcare services without medical assessment or prescription,” said Aisola.

There is a danger particularly with surgeries, contended Aisola, because this could lead to bypassing medical opinions and identifying alternative treatments. When doctors, hospitals and labs associate themselves with the aggregators, there are ethical issues too, she pointed out.

The practice of doctors associating themselves with these healthcare aggregators have alarmed several doctors’ associations. Association of Minimal Access Surgeons of India (AMASI) wrote to its members stating that any member who has made such a contract with healthcare aggregators should disengage immediately failing which a member found to be in contract thereafter may be liable for disciplinary action by regulatory authorities.

They warned that any litigation arising from such practices will not be defended by the association during legal process by way of expert opinion or otherwise.

“It jeopardizes adequate clinical judgment by a trained person regarding need for surgery and decision as to the type of surgery that would be optimum for the particular patient. The apps are made for the sole purpose of making money,” said the AMASI notification.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

REEL Heroes Vs Real Heroes

 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

Expensive Medical College  seat- Is it worth it?

2

Medical Consumer Protection Act: A Loss making deal for patients too?

With the evolving medical science and health care getting intertwined with business, braided changes in medical regulation and law are not an unexpected development. New models of medical regulation, business and law in health care have emerged and progressed in last few decades. Despite a wish to govern and regulate medical profession strictly, the laws and regulations still have to go a long way to provide real justice to everyone. No one really knows how to regulate this difficult area, which encompasses life and death, deals with extremes of poverty and riches, mortality and morbidity, pain and relief , sadness and happiness, smiles and sorrow and other uncountable emotions, all intertwined with financial aspects. But the wish of administrators to govern medical profession strictly with punishments is not new. Hammurabi (5000 years back) at the start of civilization believed that doctors needed to be punished in case there was a poor outcome. Strangely it was at a time, when no one understood the complexity of human body and the limitations of medical science; even basic anatomy and physiology of body was not discovered.

       With the evolving medical science and health care getting intertwined with business, braided changes in medical regulation and law are not an unexpected development. New models of medical regulation, business and law in health care have emerged and progressed in last few decades.  Despite a wish to govern and regulate medical profession strictly, the laws and regulations still have to go a long way to provide real justice to everyone.   No one really knows how to regulate this difficult area,  which encompasses life and death, deals with extremes of poverty and riches, mortality and morbidity, pain and  relief , sadness and happiness, smiles and sorrow and other uncountable emotions, all intertwined with financial aspects.But the wish of administrators to govern medical profession strictly with punishments is not new.  Hammurabi (5000 years back) at the start of civilization believed that doctors needed to be punished in case there was a poor outcome. Strangely it was at a time, when no one understood the complexity of human body and the limitations of medical science; even basic anatomy and physiology of body was not discovered.  

      Considering the limitations of medical science along with uncertainties and complexities of human body, regulation of medical profession and system of punishments still remains somewhat unfair to doctors, even after 5000 years.  It is still based on principles of revenge and retributions rather than developing a robust system by learning from mistakes. By application of an average wisdom, doctors can be easily blamed for poor outcomes, as they are always and universal a common visible link between treatment and poor outcome. 

           One of the examples of easy punishments for doctors is Medical consumer protection act that was implemented in 1995 for medical services. Patients were defined as consumers and hence doctors were converted to service providers in lieu of some money.  Consequently the changed definitions altered the doctor-patient relationship in an irreversible way.   

    The reality is that neither doctors, nor patients are ready for such a legal relationship. More-over   the system is not robust enough for such a change.   To work with weak infrastructure, non-uniform medical education, poor numbers of support staff, inept health system along with legal complexities has pushed doctors into a shell and predisposed them to harassment. 

          Rather than   developing a system to promote   good doctor-patient relationship, Medical Consumer Protection Act has created a situation of ‘us versus them syndrome’. It caused erosion of doctor-patient relationship and escalated cost of care.   Propagation of stray and occasional incidents about negligence case in court or their outcomes are given disproportionate wide publicity in media. The patients are unable to understand the correct application of such stray incidents to themselves. Such cases may be frivolous,  just one in million or a rarity, but people always try to imagine themselves being in the hospital chaos due to the   scenario projected.  It gives a negative projection about medical services and enhances patients’ fear to seek treatment at right time.

    There is a growing mutual mistrust; doctors too have started looking at every patient as a potential litigant. Especially while dealing with very sick ones, practice of defensive medicine is a natural consequence. This may manifest as excessive investigations, more use of drugs, antibiotics and even reluctance or refusal to treat very sick patients. 

    With the mandate to practise evidence based medicine, doctors need to document everything and to offer everything possible, leading to skyrocketing medical costs.  To save themselves, doctors have to do mammoth paper work, leading to consumption of time that was meant for real deliberations for the benefit of patients.

           Consequently insurance companies, medical industry and lawyers have become indispensable and have positioned themselves in between doctor and patients. Besides creating a rift between doctor and patient, they charge heavily from both sides; from patients (medical insurance, lawyer fee) and doctors (indemnity insurance, lawyer’s fee) alike. The vicious cycle of rising costs, need for insurance, medicolegal suits, and high lawyer fee (for patients and doctors) goes on unabated. All these contribute significantly to overall inflated cost of health care.

       Not uncommonly doctors are used as scape goats to have a concession on the patient’s treatment from administrators.  

       Medical consumer protection act has increased the anxiety and insecurity among   medical professionals.   Doctors can be dragged to courts for trivial reasons, for example the sense of revenge, simply for non-satisfaction, to extract money or simply for avoiding paying for services.  In an era where family members, brothers and sisters fight for money, it will be naïve to think that idea of making money from doctors does not exist. These money-making ideas are further stoked by the much publicized incidents of high compensations granted by courts.

     Medical lawsuits and complaints (right or wrong) are breaking medical professionals from within, not to mention the toll it takes on their confidence and belief, which takes a lifetime to build.

     Whenever there is adverse outcome in any patient, all the doctors involved start looking for whom to blame among themselves. Due to legal pressure they try to pinpoint each other’s mistakes.  Mutual understanding takes a back seat and the teamwork is spoiled permanently. Administrators in a bid to be safe, encourage putting doctor’s concerns against each other,  creating a strange sense of enmity among medical professionals.

    The ease with which doctors can be harassed has led to rampant misuse of medical consumer protection act and it has instilled a sense of deep fear and insecurity in the mind of medical professionals. The act has been used as a whip against the  doctors by all, including  medical industry, law industry and administrators.  Only doctors are visible as those who deliver care, so they remain at receiving end for poor outcomes and all these industries remain invisible.    The industry has used the protective systems against medicolegal cases to gain  maximum benefits  out of doctors’ hard work.   

      In court cases, a certain element of doubt always remains in mind of a doctor whether he will get justice in the long run, or will end up being  a victim of sympathy towards patient or clever lawyering.  So taking medical decisions in critical situations is becoming more difficult  in view of the future uncertainty of disease.

             Windfall profits for lawyers is a strong  incentive   for  law industry to promote   instigation  of patients by against doctors .  One can see zero fee and fixed commission advertisements on television by lawyers in health systems even in developed countries. They lure and instigate patients to file law suits and promise them hefty reimbursements on ‘sharing and commission basis’. There is no dearth of such relatives and lawyers who are ready to try their luck sometimes in vengeance and sometimes for the lure of money received in compensations. 

       Consequently doctors are now an easily punishable human link for poor outcomes.  Medical professionals work with continuous negative publicity, poor infrastructure, and preoccupied negative beliefs of society and burden of mistrust.

  Strangely  Medical Consumer Protection Act applies  only to doctors, that too selectively. All  other professions and services  are   out of it, not even other constituents of health services. Selective application is what is  demoralizing the doctors.  Considering the uncertainty and kind of work done by  medical professionals, actually it should be other way around.Mistakes are always easy to be picked with retrospective analysis and with lawyers pondering over it for years. In such situations, doctors are sitting ducks for any kind of blackmail.

            Nothing else has ever distracted doctors more than medico-legal cases and punishments. In certain circumstances, saving themselves becomes more important than saving a patient. Decision making also becomes difficult  by uncertainty of prognosis,  grave emergencies, split second lifesaving and risky decisions that may later be proved wrong by retrospective analysis with wisdom of hindsight with luxury of time and fault-finding approach.  The possibility of complex medico-legal situations in doctor’s  mind are enough to distract doctors from their primary point of intentions ‘the treatment’.

          Therefore increasingly, financially secure doctors are staying away from the riskier jobs. No wise person will like to face medicolegal complexities in older age. Taken to court for a genuine decision is enough to spoil and tarnish health, wealth and fame that was earned by  slogging  the  entire  life.     

     Patients can have poor outcomes for many reasons. It can be severe disease, poor prognosis, rare or genuine complications or even unintentional mistake or human errors, system errors or deficiency. Whatever court decides,  while consuming years, the harassment of doctor is full and permanent. Even if court decides in favour of the doctor, there is no compensation possible for the sufferings and agony spanning over years.  Therefore, a single mistake can undo all the good work of past, and the illustrious future work that could have been accomplished.

        If the decision to decide or act or help someone in an emergency situation, puts one’s own life and career at risk, why would anyone put himself in that difficult  position?  

         Medical Consumer Protection Act  has become a tool to harass doctors and money making tool for lawyers, medical industry or administrators. But  it would be naïve to assume that by whipping doctors and regulating them in such a harsh manner will be helpful to patients in long run.  The consequent insecurity among doctors, practise of defensive medicine, enhanced costs, excessive documentation and the distraction from the primary point of intention (treatment)  are few of the  side effects, which will  definitely be passed on to the patients inadvertently.  After all doctors have to save themselves as well. As a result,  now the battle of life and death will be fought with less zeal, with subdued and demoralized soldiers.

          Patients are unable to realize their loss for punishing their saviours. For doctors, no rewards if you win, but sword hanging if one loses.  Fear factors on doctors and impact of present legal complexities is already at par with that of Hammurabi’s era. Consequently being consumer may be overall a loss making deal for the patients.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

2

Moral bankruptcy of administrators #unpaid doctors

New Delhi: Doctors, nurses and paramedical staff of East Delhi Municipal Corporation-run hospitals continued their protest on Thursday as well over non-payment of salaries for four months. Meanwhile, an order issued by the medical superintendent of Swami Dayanand Hospital,

     In an era when doctors are being punished for small mistakes or merely perceived negligence, the blunders committed by administrators are not even noticed. Doctors are not paid for four months and for protesting the same, they were given termination letters.  It seems that doctors need to live with blatant injustice all their lives.

 Any punishment for the  administrators for mismanagement? Looks impossible but punishment to the sufferers is on the cards.

     Medical students or aspiring doctors should be carefully watching the behaviour and cruelty by which doctors are governed, regulated and treated by administrators. Mere few words of respect and false lip service during Covid-pandemic  should not mask the real face of administrators, indifference of courts and harshness of Government towards medical profession. Choosing medical careers can land anyone into the situations, which are unimaginable in a civilized world.

    Doctors pleadings even for their rightful issues and routine problems are paid deaf and indifferent ears. It is disheartening to see that they receive apathetic attitude and dealt with stick or false assurances even for the issues which should have been solved automatically in routine even by average application of governance.

             It is discouraging for the whole medical fraternity to see that even the rightful is not being given what to expect the gratitude and respect.

         The indifferent behaviour has also unveiled the approach of  tokenism such as ‘mere lip service’  showing respect to corona warriors.

      The strong political and legal will is absent to solve Doctors’ problems.

 Unpaid doctors; Medical staff protest on- termination order?

New Delhi: Doctors, nurses and paramedical staff of East Delhi Municipal Corporation-run hospitals continued their protest on Thursday as well over non-payment of salaries for four months.
Meanwhile, an order issued by the medical superintendent of Swami Dayanand Hospital, Dr Rajni Khedwal, stated that services of all senior and junior resident doctors would be considered terminated from February 4 and fresh interviews would be conducted accordingly. The order also stated that all Diplomate of National Board (DNB) residents and contractual doctors would be marked absent.

“We all were there in the protest, none of us went for our duties. We have also asked the administration to speak on our behalf because they are too part of the hospital. Maybe the matter will be resolved tomorrow. Unless we get a concrete statement regarding salary, we will continue the protest,” said Dr Atul Jain, president of the hospital’s resident doctors’ association.

Meanwhile, EDMC commissioner Vikas Anand said that no order had been issued regarding the termination/suspension of the striking doctors’ services so far. The termination order is only for the DNB workers and for the rest of the medical staff, it is based on ‘no work no pay’ as per the SC rule, he clarified.

“The salaries will be provided at the earliest. We have a very good team of doctors at Swami Dayanand Hospital. The only request is that they should join back and resume services,” said the commissioner.


Anand also said that the salaries for the months of February and March would be paid on time. “EDMC is going through a financial crisis and even in such difficult times, the corporation is sensitive towards the interests of its employees. Their due arrears will be paid in the month of May as per the availability of the funds,” he added.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons


0

Quack Menace: Infant loses glans in botched circumcision


Infant loses glans in botched circumcision done by quack

        In an era, when even licensed and qualified doctors are finding it difficult to practice medicine, it is strange that unqualified and unlicensed are having a field day. Why strict regulations do not apply to them, is beyond any reasoning and logic. If a medical facility or clinic is functional, it is difficult for the patient, especially in emergency, to check or even doubt its credentials. How such facilities are open, functional and thriving. Sadly our regulation is trying to regulate, who are already regulated. It is trying to punish those who are qualified and licensed, but turns a blind eye towards unlicensed and unqualified doctors.

     Such fake doctors own medical set ups, may conduct surgeries, sometimes run hospitals with little help from qualified doctors  and do procedures. Another problem is that they   promote fake rumours about genuinely qualified doctors and create a mist of mistrust to propagate their fake medical business.

A toddler has died Australia after circumcision

Quack Menace: Infant loses glans in botched circumcision

 The glans of an infant’s penis shrivelled and fell off after a quack tied a horse’s hair around it ‘to prevent bleeding’ after a ritual of circumcision. The child was rushed to hospital, where a surgery was performed to ensure that the baby will be able to urinate normally, but the boy has lost his glans.. A quack had conducted the religious ritual of circumcision on November 22, 2021, and tied a horse hair to the child’s penis. He then bandaged it and told the family to go home.

The child was born in October 2021. Ten days later, the family members noticed that the glans had come off along with the dressing. Families choose to get their male infants circumcised by neighbourhood quacks. This is not just unhygienic, but can lead to major complications as well. Other unhealthy practices like sprinkling ash on the wound after circumcision are also prevalent.

A toddler has died in Australia after circumcision

A toddler has died and his baby brother has required life-saving surgery in hospital after a medical procedure, understood to have been a circumcision, went horribly wrong in Perth’s south-east. The brothers were rushed to hospital in Armadale by family Tuesday evening following the surgeries. The West Australian reports a two-year-old boy was pronounced dead at the hospital’s emergency department. His infant brother – aged between seven and eight months – was rushed to Perth Children’s Hospital for emergency surgery.7NEWS reports he has since been discharged from hospital. WA Police have confirmed the toddler’s death is not being treated as suspicious. “It can be confirmed the boy underwent a medical procedure at a registered medical centre prior to his death,” a police spokeswoman said.

Circumcision is one of the oldest surgical procedures and one of the most commonly performed surgical procedures in practice today. Descriptions of ritual circumcision span across cultures, and have been described in ancient Egyptian texts as well as the Old Testament. In the United States, circumcision is a commonly performed procedure. It is a relatively safe procedure with a low overall complication rate. Most complications are minor and can be managed easily. Though uncommon, complications of circumcision do represent a significant percentage of cases seen by paediatric urologists. Often they require surgical correction that results in a significant cost to the health care system. Severe complications are quite rare, but death has been reported as a result in some cases. A thorough and complete preoperative evaluation, focusing on bleeding history and birth history, is imperative. Proper selection of patients based on age and anatomic considerations as well as proper sterile surgical technique are critical to prevent future circumcision-related adverse events.

Complications of circumcision

Bleeding- Bleeding is the most commonly encountered complication of circumcision.

Infection, Insufficient Foreskin Removed, Excessive foreskin removed, Adhesions / Skin , Bridges, Inclusion Cysts, abnormal Healing

Meatitis, Meatal Stenosis, Urinary Retention, Phimosis, Chordee, Hypospadias, Epispadias

Urethrocutaneous Fistula, Necrosis of the Penis, Amputation of the Glans

Death—    death is an extremely unlikely complication of neonatal circumcision, but it has been reported.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

0

Overuse of Antibiotics: Wrong analysis # Rebuttal Times of India


     The Times of India today   carries an editorial by Mr Sandeep Bansal on over prescription of antibiotics. Although there are few points which may be correct, but the article fails to highlight the basic reasons for the problem, which it was supposed to address.

    The reason for failure to find the correct reasons can be the distant analysis. Someone working in London and trying to analyse the grass root problem of India may not be a perfect idea. People need to work at ground level to identify the real issues. Otherwise the analysis remains half-baked and gives a glimpse  of the bias, which celebrities use commonly for gaining popularity by finding faults of doctors.

 

     The overall picture has to be understood to identify real reasons and hence the proper solution to the problem. The correct steps taken would settle the issue; otherwise the analytical article would   just remain a piece of paper and an matter of discussions for Arm chair preachers.

over prescription of antibiotics

   The author failed to highlight the factors like easy availability of antibiotics. People can directly approach pharmacist and get whatever antibiotic they want.  Pharmacist can sell whatever brand, doses and kind of antibiotic. The uncountable quacks, doctors of alternate medicines use all kind of antibiotics with impunity. Tons of antibiotics are consumed without any proper medical advice. Self-medication by people themselves, as it is easily available can’t be ignored as an important cause.  

       The reasons written by the author in TOI, actually constitute a minuscule fraction (5-10%), as far as use of antibiotics is concerned. By writing imperfect article, without knowing actual problems by a distant analysis, such article provides real misguidance rather than actual solutions to the problems.

         Someone to do justice to such complex and important issues, one has to work at the place and be aware about real issues and ground problems. Otherwise it just remains a method to gain cheap popularity.

   Sadly, in present era, people who do not treat patients,  are away from  truth, but they can influence the treatment of thousands of patients  just by doing an ‘On Table’ analysis.

        Wrong analysis, hence incorrect conclusions can lead to wrong decisions.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

3

Facilitators turn administrators: Biggest tragedy to medical profession in present era

Facilitators turn administrators: Biggest tragedy to medical profession in present era

14 Doctors in rural Unnao resign alleging mental harassment and misbehaviour by administrative officers over COVID-19 work.

       Administrators, who have never treated  a patient in their lifetimes, but control treatment of thousands of patients. The  biggest tragedy to the medical profession in present era, causing discouragement and demoralization of medical profession.
         Their role should not have been more than facilitators, but they have become medical  administrators. They are so distant from the ground reality.  To control the health system, administrators have a tendency to pretend that shortcomings in the patient care can be rectified by punishing the doctors and nurses.
The vulnerability that is  intrinsic to the  doctors’ working makes them sitting ducks, an easy target for harassment and punishments and  is exploited by everyone to  their advantage. Administrators use this vulnerability to  suppress them. It is used by  media and   celebrities who projected  themselves as Messiah for the cause of patients, and  sell their news and shows by labeling the whole community of doctors as dystopian community based on just one stray incident.

     The blame for deficiencies of inept system, powerful industry, inadequate infrastructure and poor outcomes of serious diseases is shifted conveniently to doctors, who were unable to retaliate to the powerful administrative machinery.   

        The demonstration of the cleft that separated doctors from the actual overpowering controlling medical industry  and administrators is  not given, in order to maintain the prejudice  with its dangerous bias towards doctors, who are in forefront and are visible to public. Clearly separating the role of health workers and the hidden administrators would not only settle the matter, but is actually essential to project the reality. The correct perception of two fundamentally different components would reveal a real gulf and would help to address the core issues.

    A wish to govern, regulate and punish the medical professional by administrators is not new. Hammurabi 4000 years back had initiated to write the cruel rules of the game, which possibly initiated a change in the global perception and regulatory system and formed the basis for cruel regulation in radical and unprecedented ways.

      In  a quest to control  this difficult area,  which encompasses life and death, deals with extremes of poverty and riches, mortality and morbidity, pain and relief, sadness and happiness, smiles and sorrows and uncountable emotions, intertwines with financial aspects and  the  amalgamation of intricacies of science with legal complexity, doctors are burdened with over-regulation and administrative pressures.

               Consequently the  doctors are the sufferers, as they feel enslaved and suffocated. But ultimately who would be the sufferer, does not need an Einstein brain to guess.

14 doctors resigned, alleging harassment and misbehaviour by administrative officials.

More than a dozen doctors posted in rural hospitals in Unnao district of Uttar Pradesh collectively resigned, alleging harassment and misbehaviour by administrative officials.

The doctors, numbering 14, posted at community health centres and primary health centres submitted their resignation letters to the chief medical officer (CMO) of the district on Wednesday. Speaking to the media, one them said that while their teams would work on the field from noon to 4-5 p.m., isolating COVID-19 positive cases in their home, distributing medicine and carrying out sampling, the local SDM would summon them after that seeking a report of their work. The doctors would have to drive back several km to the tehsil from their place of work just to “prove that they are working,” said the doctor. “Despite continuously working, it has been made to appear like we are not working and that due to this, the COVID-19 situation is going out of control,” he said. The doctors also alleged that they were not provided sufficient drug supply from the government and often faced verbal harassment at the hands of the CMO and the CMS. If the field teams were unable to trace down patients because of submission of wrong phone numbers and addresses, they should not be held responsible for it, said the doctors.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

0

Ayurvedic Surgery: who should be concerned?

Ayurveda surgery, Ima

         A strange situation has cropped up after the claim of Ayurvedic doctors doing surgeries has got the CCIM approval. Serious doubts has been raised by Allopathic medical organizations about the consequent safety issues.

       There would always be claims or counter claims about who should be allowed to do surgeries.  But there has to be a neutral and competent authority to decide, rather than claiming the competence.  After all it is question about safety issues of millions of  people.

      Who should really decide about it?

     NABH  has raised concerns about the issue.

    Although it has limitations and can be applicable only to a fraction of hospitals, but still a larger network of hospitals or clinics are not covered by NABH.

      In such situation, who should be worried about the safety? Strangely the stakeholders, who would be affected most are silent on the issue: the patients.

      If patients  have nothing to protest and they feel safe or do not anticipate any danger, why allopathic doctors should make a noise about it? They would be seen as a Jealous cat.

     Use Ayush docs for clinical work and you could lose ACCREDITATION: NABH TO HOSPITALS

         The National Accreditation Board for Hospitals and Healthcare providers (NABH) has warned allopathic hospitals accredited with it that they could face withdrawal of accreditation if they were found employing Ayush doctors for performing clinical duties in ICUs and other patient care areas in place of MBBS resident medical officers (RMOs) and emergency doctors. A “cautionary notice” the board issued on Thursday said, “This is a blatant violation of NABH standards for healthcare accreditation and very much against patient safety norms and compromise quality of modern medicine clinical care outcomes.” TOI had, in October, reported on the use of Ayush doctors in ICUs for night duty being a fairly common practice in many private hospitals, particularly in Maharashtra and Gujarat. Thursday’s notice stated that the NABH has taken a serious note of the matter and reiterated that deploying of Ayush doctors in allopathic hospitals for writing independent orders and clinical work without the supervision of allopathic doctors is not permitted. In case the allopathic hospitals are employing such doctors to work as clinical assistants, under applicable state laws, they should not be involved in direct patient care and should strictly follow job responsibilities as defined by hospital management, it added.  Ayush doctors working in allopathic hospitals will not be considered by the NABH as RMOs during the process of assessment and for the purpose of grant of accreditation, stated the notice, adding that any violation may invite adverse decision by NABH, including withdrawal of accreditation. However, even as the NABH has been carrying out surprise inspections in hospitals in this matter, it is yet to have a definite list of states that allow Ayush doctors to be employed in allopathic hospitals to either prescribe a pre-defined set of allopathic medicines or to do clinical procedures after completing a bridge course. NABH officials clarified that the board’s legal team was in the process of determining the status of the law in different states.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

0

Ayurvedic Surgery: 10 Technical Questions? About safety concerns


      If there are certain doubts about the safety of the patient, the apprehension needs to be addressed.

      The government has issued a notification which authorises post-graduate practitioners in specified streams of Ayurveda to be trained to perform surgical procedures such as excisions of benign tumours, amputation of gangrene, nasal and cataract surgeries.

    The notification by the Central Council of Indian Medicine, a statutory body under the AYUSH Ministry to regulate the Indian systems of medicine, listed 39 general surgery procedures and around 19 procedures involving the eye, ear, nose and throat by amending the Indian Medicine Central Council (Post Graduate Ayurveda Education) Regulations, 2016.

     Any  Surgery, how-so-ever simple it may look to the people sitting on fence, carries some  risk and needs  some kind of precautions and regulations to make it risk free.  Therefore if there are certain doubts about the safety of the patient, the apprehension needs to be addressed. If the service of surgery by Ayurveda surgeon has to be availed by public, a certain confidence needs to be generated about the safety and quality assurance. Mere push by an enforced law will not lead to genesis of trust and confidence. So there needs to be technical analysis of some kind, whether  it is a genuine original  strategy or merely  an imposed law.

     If it was an accepted practice till now, there was no need for such notification. So apparently,  if the need was felt  to be said in a forceful manner, there has to be something unusual about the practice.

      No doubt, ancient Ayurvedic text referred to surgical practices. But  in present era of consumerism, patients need to know, how it was being practiced for last 200 to 300 years. What are the results and data about complications.

  There are two main categories for the purpose of discussion.

A. Existence of a robust system

B. Individual competencies.

    Firstly, there should be basic robust system  that will generate Ayurvedic surgeons.

To start with, the  CCIM need to  satisfy on following questions. Following are the basic requirements of surgery.

1. What  kind of Anaesthesia  will be used in surgeries by Ayurveda surgeons? Who will be the anaesthesiologist?

2. What are post op pain killers be used in surgeries by Ayurveda surgeons?

3. What antibiotics  will be  used;. Allopathic or ayurvedic?

4. What are principles of pre-op evaluation?

5. How surgical techniques are different. Are they same used in allopathic surgery or different ones described in Ayurveda?

6. How the post op complications are being managed. Is it by using allopathic medications and investigations?

7.  Data of surgeries done in last decade or two in all of  Ayurvedic medical colleges, especially those done by Ayurvedic surgeons.

8. Who is teaching Ayurveda doctors about the  surgeries? Are there ayurvedic teachers  or being taught by allopathic surgeons?

9. Will  the people in higher positions and government  officials be availing such facilities or it is only for the  poor people? 

10. Will the patients be given enough information or an informed consent about such Ayurvedic surgeons before  surgery?

         More than a law, the whole exercise   will require a trust building   in public  along with quality assurance and something unique to make such surgeries practically happen.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

     REEL Heroes Vs Real Heroes

     21 occupational risks to doctors and nurses

     Covid paradox: salary cut for doctors other paid at home

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