Jharkhand News Network: Re: Sexually abuse of illiterate female patients by the unqualified medical practitioners (quack

Such stray incidences do occur as doctos qualified or not qualified are also human beings with emotions good and bad though there is standard practice that a female nurse should be while examining a lady however many times it is not possible and also the lady does not want to open up her true problems before a third person, the lady nurse.. It takes any doctor to come up such situations with time and I feel they need to be excused for human faults however a social wisdom is that doctors should be married early and provided family accomodation at any posting on riority which is not possible due to their long study period and lack of proper quarters.

True, doctors are exposed more to opposite sex and in fact they are vulnerable to such incidences.

In this world of business, doctors only to have respect and very sympathy is a wish ful thinking. True, the training system has flaws medical colleges.

But mere addition of human values and undrestanding,caring and communication skills as part of the curriculum will not work till society is changing its materialistic concept to altruistic.

1. It is worthless to register all practioners in particular quaks whop need punishment for illegal practice however, LMP (liike Diploma in Medical Sciences should be reintroduced-- see my whole view point in attachment recently I proposed to the MCI as a guest lecture).

2. I agree with -Restrict the sales of medicines from the pharmacists and chemists by prescription only by qualified practiotioners only except some simle medications.

3. It is icovered in 2 above--Intravenous therapy should only be advised by qualified and registerd doctors.

4 I agree--.Vacant doctors' posts at the Block and PHC levels should be filled and make sure they stay there and for that give sufficient infrastructuire and emoluments.

5. Agree- Primary health care workers in village level should advise and offer help and support to the poor villagers and direct them to the appropriate practitioners available there.

Why restructuring our Medical Education is essential?

Problems of public and Government

• A majority of the doctors, settle in urban parts of India or even abroad. Very few go to rural places and serve the society.

• Doctor population ratio is erratic

• Metros having a doctor for few hundred while states like UP have one for several thousand

Major issues before health providers:

• Whether doctors are not willing to serve to rural area or do not have infrastructure and incentives?

• Medical Teachers, particularly in pre- and paramedical subjects are difficult to get

• Whether to achieve uniformity in the distribution increasing perks/allowances, or faster promotions for doctors working in the rural hospitals will do?

• Whether the Health ministry's attempts to make compulsory for a medical student to take one year in-house training in rural areas will deliver good?

• Or a Restructuring Medical Education is essential because people, government and doctors all are dissatisfied

• and that when India has a tradition of medical teaching since the days of Charaka and Shushruta for medical and surgical disciplines.

Systems/Pathys:
Modern- Medical colleges-233, Dental Colleges- 220

• Indigenous system-Ayurvdic , Siddha Colleges-

• Almost Indianised but foreign -Homeopathic Colleges
Unani & Tibbi Colleges
PARAMEDICAL Training Institutes:

• Nursing
Pharmacy
Physiotherapy
Biochemists,

• Biotechnology, etc.

• High patient-doctor ratio in India needs attention
Eight years of rigorous studies without any surety for a lucrative job has made the medical profession unattractive. This has resulted in an increased patient-doctor ratio in India. The situation demands immediate attention..

• CJ: Md Jamilur Rahman , 1 May 2008

Global scenario of patient-doctor ratio:

• The ratio is not constant across the globe.

• Very high in the underdeveloped countries (sub-Saharan countries)

• to a bit lower in the economically developing countries,

• to very low in the developed countries (the UK, Germany, the US, etc).

• Cuba has the best doctor-to-patient ratio and about ten per cent of its annual spending goes on health.

The doctor-per-person ratio

• (Including practitioners of Western medicine, Homeopathy, and Indian systems of medicine) is 1: 870, according to GOI.

• If the practitioners of non-Western medicine are exclude, the ratio increases to 1: 1,634.

• Ideally this should be around 1:200;the ratio is different for emergency,( ICU and Critical Care Unit where ideally the doctor-patient ratio should be 1:2).

• The ratio depends on the number of medical colleges, infrastructure, government planning, lucrative opportunities following course completion, etc.

• India, the term doctor generally means Allopathic doctors.

• However, there are other systems of medicine like Unani, Homeopathic, Ayurvedic, etc.

• Except Allopathic, professionals of other medicinal sciences are not eligible to prescribe all the medicines. They can prescribe only a few (probably 79).

How can we improve the ratio?

• Whether number of medical colleges and its intake should be increased in accordance with the patient-doctor ratio of different states?

• Increasing enrollments, the number of medical specialists cannot be achieved immediately.

• India, a country of 1.3 billion people (as reported on March 10, 2008), has only 233 medical colleges with an annual intake of 26,192 students according to the Medical Council of India (MCI).

• For better health care, this number has to be doubled in next few years which is not feasible. Even recognition of foreign degrees is not a practical answer to it.

Pharmaceuticals, etc.

• Thousands of national and multinational companies

• Most of the formulations erratic

• Many banned drugs, toxic drugs, internationally are floating in India.

Problems of Medicos

• Longer study period than other professionals with less reward than IT, Management, IAS, etc.

• Even less privileged than their friends who could not compete in PMT.

• In 2006 in Hindu a news appeared 17 boys selected for prestigious Chennai Medical College and Kilpauk Medical college preferred to go to engineering colleges

Medical Teaching and Health services

• Whether failed to deliver? – No, but not satisfactory too.

• Remedial correctives?

• How it can attract brilliant students again?

Problem of doctors

• As per various reports the Health department topped the corruption charts among all the state ministries.

• Delayed posting, transfer as a tool for corruption

Indian realities

• Rural area around 70 per cent

• 67 per cent on agriculture having 23 per cent of GDP only

• Urbanization of India by 2050 is stipulated to be nearly 50 per cent

• Rural-Urban mind-set needed abolished though

• Rural will be replaced by next two decades by slum dwellers.

Fallacies in Indian Medical Teachings

• We adopted British Model initially and

• Eulogized US Model (AIIMS like institutes)

• Could not provide minimal teaching materials to students and allowed mushrooming of Institutes

Fallacies in Health delivery Systems

• India adopted USSR Model of Health centres manned by doctors meant for hospitals

• Spent minimal on health sector – only one per cent ( plus 3 on education) compared to some 30 per cent on education and health in many countries even poorer than India.

• NMO, IMA, etc. demanded at least 10 per cent on health.

• The blank space was taken over by private sector –some 5 per cent GDP on health by them

• Private sectors in health 'corporatised' the hospitals for affluent

• Pharmaceuticals took advantage of that

• always rising share indices of such hospitals and pharmaceuticals

• Health Insurance Models copied on west cannot work well in Indian scenario which would have collapsed health services in this worldwide recession had foreign insurance companies were allowed.

• 'Medical Tourism' will drop and not needed for these are increasing cost of health delivery in home too.

• Consumer Protection Act (CPA) made an unholy nexus with lawyers which need repealed to make health services cheaper.

Indigenous systems

• Separate Councils were established but most of such doctors use 'allopathic drugs'

• People and policy makers have faith on those for being 'Indian' in some cases

• Practitioners and Pathys are different was not understood

• Scientific advancement of such pathys were obstructed by its practitioners which was a loss to science

Amalgamation of Pathys

• Were advocated and tried but were not on scientific tools but whims and hence failed

• It is required no doubt but how ?

My Suggested Model of Medical Education

• It is comprehensive and fits well to Indian requirement of villages/slums to super-specialty centres

• Provides a scientific base for the consideration of all Pathys

• Takes almost equal time to present system but lays emphasis on different segments

• Abolishes different councils to one Health Council.

• Can be followed by any developing country (Including SAARC Nations)

STAGE I: LMP in Medical Schools

• PMT on competitive basis after +2 examination, should find a way to test aptitude for medical service.

• PMT only on the basis of physics, chemistry and biology can find better future scientists in those streams not doctors

• A medico should have aptitude for a good doctor, teacher, counselor and administrator and empathy for humankind.

• Ways for it should be found out apart from a minimum marks in physics, chemistry, biology.

• LMP Mandatory for all pathys

• 3 years duration + 6 months rural posting

• Emphasis on primary anatomy, physiology and common diseases, and a bit of teaching on the indigenous herbs, yoga's etc.; National Health programmes; some administrative skills

• Should be able for primary care and prompt referral.

LMPs will our basic doctors

• LMPs will be our basic doctors, not MBBS,etc. who likes to stay in towns after prolonged study which not only makes their mentality town-oriented but also it is difficult to provide adequate infrastructure for their proper working in remote health centres.

• LMPs will Man Health centres, PHCs.

• LMPs will also be able to compete with quacks/ paramedical staff which now-a-days deliver every short of health care illegally

• LMPs should also be attached to local schools for delivering one weekly lecture on Health (and Health should be a mandatory paper in +10 school stage) where such doctors can also be made teachers on roll permanently too equivalent to any Graduate Teacher.

STAGE II: MBBS,BAMS,BHMS

• After 2nd competitive examination, admission to medical colleges of any Pathy.

• All India allocation of seats through CBSE have not yielded desired results and needs review.

• 2 years + one year internship in Medical Colleges

• Lay emphasis on secondary care (not much specialized)

• Courses will be modulated to the understanding of the basics of diseases

• Will man referral centres and casualty in any hospital.

STAGE III: RESIDENCY

• Specialist Certificate Residency= PG Diploma of present day

• 2 years at medical schools and colleges + one year district hospital posting

• Examinations at the end may not be mandatory.

• Will be able to handle all sorts of cases which do not require super skills at any hospital setting or consultant practice.

STAGE IV: PG Course, MS, MD, etc.

• After 3rd competitive examination; All India allocation of seats have not yielded desired results and needs review.

• Admission for PG Degree for 2 years course

• Will be able to teach students; enthuse them for research after getting degree as well as to handle patients.

• The emphasis of this course will be for making better teachers and scientists not doctors of secondary care which can well be taken by Certified specialist Residents of STAGE III

• The Pre-and Para-Medical subjects teaching for LMP and Graduate courses be opened to any PG of the related branch e.g. a surgeon can teach anatomy and a physician physiology/ biochemistry/ pathology/PSM/FMT, maybe with a month's orientation course sponsored by the employers to remove malpractice by such teachers who are at present maybe best called 'INSPECTION TEACHERS' on COLLEGE ROLL.

• The number of medical colleges for PG teaching be limited and should produce teachers only.

• The admission test for admission in such institutes should include a method to check the aspirants' ability to teach.

• such posts may be made 'non- private practicing,' though well-compensated as in vogue in many central Institutes.

Indigenous systems in PG only?

• P.G. departments in Ayurveda, Homeo, etc. should also be in such P.G. colleges for better cohesion in research on inter-disciplinary basis.

• In fact, alternatively, only PG teaching after MBBS in such Pathys may work wonder, considering Heinemann, Robert, Kent,etc. were trained doctors who chose to develop Homeopathy

• And except 'Tridosh theory,' the concept of drugs and surgery of Aayurveda is not different from Modern Medicine

STAGE V: Super-specialty courses

• After 4th Competitive examination admission to such centres

• For a 3 year course of DM/M Ch/PhD

• Should be able to perform World Class medical consultation/surgery/research

Comparative duration in years

• Stage Course Proposed Present

• I LMP 3.5 -

• II MBBS,etc. 3 5.5

• III Specialist Res. 2+1* 2

• IV MD/MS 2 3

• V DM/MCh/PhD 3 3

Total 14.5 13.5

*Is in fact, in full service, hence, the duration is equal

Of such Model is 14.5 years for a super-specialist to come out. One year more than at present but that is in full service while in Residency, and hence, equal duration.
6.5 years for a graduate (MBBS, BHMS etc.)- (one year more than at present but can practice after 3.5 years)
Will be compensated if selected for PG course which will be of 2 years only.
11.5 years for a post-graduate degree (MD/MS)- one year more than at present
14.5 years for Super-specialty –)- one year more than at present

Institutions

• For each stage of courses will be different.

• No two courses should be taught in one institution to give emphasis on the specified area of medical education and also to avoid bias in selecting students.

• An accreditation committee should visit all existing teaching (as well non-teaching corporate hospitals)

• Should categorize them which fits in which stage and no compromise on minimum facilities be done.

• Institutions should have sudden inspection

• Inspectors should also visit without information to authorities and submit reports

• Institutions should be demoted or closed down if not equipped and may be converted to only treating not teaching hospitals

• Even hospitals need accreditation for minimum facilities failing which they should be reprimanded and closed down

• Every district should have a medical school (all district hospitals need up-gradation for it) to which should be attached to training schools for paramedical staff as well which are needed more.

• In every state there should be population based number of medical colleges where Stage II and III may be taught.

• And in State/region there should be one or more super- specialty centre to provide teaching for STAGE IV which should again be allocated as per population profile of the area/Sate.

Contents of curriculum

• Should be specifically formulated For every stage with a practical orientation to train students taking up any case suited to his/her caliber rather than uselessly filling mind with all information hardly needed for practice, e.g. brain's fine details of anatomy can be understood by returning to anatomy hall by a DM (Neurology) student rather than a first year MBBS.

• Integrated teaching module be developed for any topic from e.g. from embryology of heart to congenital heart disease can be taught to MBBS/MD student by different set of teachers at a time.

• Inter-disciplinary several new courses need at PG level e.g. PG in General Practice, Medical Ethics, Genetic/Molecular Medicine, Medical Journalism, Bio-Medical Statistics, Calamity Medicine (I proposed first after 1984 Koshi floods), etc.

Medium of Instruction

• Teaching only in English has made British and American (and Australian) Health services stronger at the cost of poor Indian taxpayers' money

• Teaching and examination should be in Indian languages (Osmania Medical College, Hyderabad had teaching in Urdu in pre-independence era)-

• Aayurvigyan Shabdavali of the Standing Committee of GOI need updating for technical terms (based on Sanskrit they should be common for all Indian languages)

• It may be started gradually from Stage I/II.

RESEARCH

• Clinical trials and research in India has made Indians 'guinea pigs.'

• We must recognize our research talents and promote them in the areas of our needs primarily as well as to pure research through national laboratories, ICMR, IITs, IISc, IISER, etc. with which PG Medical Colleges should be linked.

Books, journals, libraries

• Indian Medical authors in different languages be promoted by a Central Authority under Medical Council of India

• All medical libraries be inter-linked and should be freely accessible to PG medical students, teachers and research scholars

• Medical Journalism should be given equivalence of teaching experience.

I.M.S.

• Indian Medical Service (IMS) be reestablished as per pre-Independence days to man as head of PG and Post-PG teaching and treating hospitals as well as from health directorates to secretary level in States, UTs and Union.

Councils, Universities, Grants Commission, Ministry

• All human health related councils-Medical, Dental, Indigenous, Pharmacy, Physiotherapy, Nursing, etc. will be merged to one HEALTH Council.

• There should be one Health UNIVERSITY in each State.

• Similarly Directorate and Ministry of Medical Education having different tiers as specified above.

• Health Grants Commission on the above line.

• Drugs should be de-linked from Ministry of Petrochemicals and attached to Health

• Ministry of Family Welfare detached from Health and attached to Child and other Welfare.

• Health budget be raised to minimum 10 per cent of GDP. Expenditure on Health is an investment not an expenditure.

• Medical education is a life long process.

• Registration renewal is controversial however, CME accreditation counted 5 yearly (cost provided by the employer) should be made compulsory.

Dr. Dhanakar Thakur

Chief Medical Consultant (Med), Ispat Hospital, MECON, Ranchi

• MBBS (1978), MD (Gen.Med.)1985, DCH(1987)- All From DMC

• Editor, Aayurvigya Pragati ( A medical journal of NMO) since 1992

• Editor, New Trends in Medicine (API,1999)

• Editor, Industrial Psychiatry Journal, 2000

• Ass. Editor, Progress in Clinical Neurosciences (NSI,1985 and 1986)

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