OPINIONS

In response to ‘A year as a doctor’s apprentice’

Saturday, December 7, 2013

by Dr Kiran Kumbhar

Out of thousands of things taught at school, there is one which is powerfully embedded in my head. While doing a letter-writing exercise, we were asked to write a letter to the city municipal authorities complaining about the increasing amount of garbage being thrown on streets. After checking our notebooks the teacher lauded our efforts, but said she was disappointed with one aspect. All of us had been quite enthusiastic in complaining and describing the concerned problem to our heart’s content, but ‘not one had suggested a solution’. What she said then should actually be one of the most universal rules of human conduct: You get the right to complain about a problem in the society only when you can also offer a solution to it, however small it may be.

Dr Kiran Sambhaji Kumbhar

A few days back we saw a piece in this magazine describing the ‘malpractices’ that go on in a government hospital. The title ‘A Year as a Doctor’s Apprentice’ belied the content; expecting a tidy narration of the wonderfully tumultuous and bittersweet journey of a medical internship, one was disappointingly treated to a monotonous tirade of complaints and accusations. Exposing the generic deficiencies in a system is commendable, but specifically pointing to a single hospital and narrating only one side of a mind-blowingly complex social problem is abominable and a disservice to the general reader. The problems described in the article are blanket issues, spanning most hospitals (both government and private), in India as well as many other countries. No balanced discussion of the issues featured in the said article, and no attempt was made to investigate the possible reasons behind their existence. Society is quick to pounce on such ‘juicy’ stuff, and that is exactly what happened. Hundreds of positive articles about doctors and hospitals must have appeared in this magazine before, but they were never noticed outside; the said article, however, was enthusiastically covered in a national news website. Thus, as has happened most of the times with this country’s doctors, only the flip side of the story reached the layman. The saddest part here was that a doctor facilitated it with both hands.

The paramount lacuna in that piece is the presence of hyperbole ad nauseam, which sends out a completely inaccurate message. ‘Nobody wants a patient admitted in their own ward’. Painting the entire creed of resident doctors with the colour of just a handful among them is indigestible. ‘Pregnant women are beaten like anything’. That is a statement more disdainful than the supposed act. I have studied and worked for over six years at the hospital where this ‘third degree torture’ allegedly happens, and I proclaim that it is a tremendously laughable overstatement. While describing his internship, the writer says ‘For one whole year you have to suffer both physically and mentally’. There’s only a tiny problem there: ‘I suffered’ should have been in place of ‘you’. Almost two hundred doctors do their internship at that and at other government hospitals every year, and for most of them it is a wonderful, enriching and enlightening experience. What shocked me the most was, although the writer claims to have been at the hospital for a full year, I didn’t come across any mention of the ‘malpractice’ and ‘physically and mentally disturbing’ events of patients’ relatives manhandling and beating up doctors and other hospital staff. Or of patients themselves offering bribes to everybody from the ward-servant to the medical officer to get their ‘unethical’ work done. Unwittingly or on purpose, the author gives credence to the general attitude of the society and politicians that the sufferings and inconveniences of Indian doctors are absolutely insignificant, and that their only job is to act as scapegoats whenever any health related issue goes public.

When people talk about the widespread corruption in politics, one common argument is that politicians come from the society itself, and since most people are always greedy and selfish, that is naturally reflected in the political class. It is a fair argument, and it applies to doctors too — though fortunately to a much lesser degree. The issues raised in the article are too complex to be tackled in small write-ups. But for the sake of discussion, let’s consider the ‘batting’ and ‘increased workload’ aspects. This is not as simplistic as it looks. It happens (SOMETIMES, and through SOME doctors) consequent to an amalgamation of a few to many of several unique facets of the Indian health system: a gargantuan population to be served, an impotent decision-making political class prone to trivializing public health, corrupt government systems, the extremely laborious residency schedule of doctors, woefully inadequate number of doctors and nurses, too less hospitals, far too less facilities in the too less hospitals, and even among those, awfully too less ‘functioning’ facilities. If the matter was as simple as saying ‘A government hospital is not expected to show such a behaviour towards the poor; wasn’t it bloody built for the poor?’ the issues would have been successfully tackled and ended decades ago.

The American author Mark Twain once profoundly said: ‘There is no sadder sight than a young pessimist.’ It is indeed distressing when young torchbearers of a profession do not devote at least as much thought and energy to solving the problems in their professions as they give to blabbering about them. A world with millions of people around is never going to be perfect or right. But we should surely try to create at least small pockets of perfection and virtuousness so that the cumulative balance of thoughts and deeds of all people never tilts to the wrong side. In fact in the very hospital referred to in the said article, there are countless examples of such resplendent halos of morality, ethics and compassion which have, despite corruption and administrative apathy, kept the hospital sublimely illuminated all the time. We find resident doctors who are favourites among patients, kind of their rockstars: whenever the patient sees her or him entering the ward, they instantly feel fifty per cent better. There are professors in that hospital who are legends in themselves: with a wealth of experience and phenomenal medical knowledge they make it sure that despite all the deficiencies of the government setup, patient diagnosis and treatment are as impeccable as anywhere in the world. As with schools and courts and other institutes, there sure are several ills in our hospitals. Most young doctors and interns keep ranting about them, but once their courses are finished, hardly anyone displays any willingness to get back into the system and try to improve it. A very relevant quote comes to one’s mind: All of us are experts at practicing virtue at a distance.

It’s a plain fact that without sweeping, nationwide political reforms, it will be impossible to get rid of most of the problems with the health system, or for that matter with all government systems including education, judiciary, agriculture et al. However, young doctors, especially the querulous ones, still do have a lot of options to make significant contributions if they wish so. We have very few ethical and efficient doctors in the decision-making processes of health systems. Young doctors can assume the posts of medical officers at primary health centres and district hospitals. They can work hard and climb the organizational ladder to become a Taluka MO or even a District Health Officer/ Medical Superintendent. These posts will give them a lot of leverage in making positive impacts. Doctors can even study public health and get into government/international agencies responsible for the drafting and issuing of practice guidelines. They can earn a PG degree and assume a teaching post at a government hospital instead of setting up a private clinic: that way they can contribute more constructively in getting rid of the ills they witnessed during their internships and residencies.

There is so much to be done and so many avenues of going ahead and making an impact. But for that a better, more positive mentality is a sine qua non: first in the general public so that they acknowledge the intricacies of health systems and rather than just breathing down the necks of ‘sitting duck’ doctors, they demand proactive attention to health issues from their chosen political representatives; and secondly among medical personnel so that instead of getting bogged down by the stinking, diabetic foot of their own parent health system, they go ahead and nurse it, clean it, cure it as best as they can.

Dr Kiran Kumbhar
MBBS (2010)
Sassoon Hospital, Pune

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16 Comments »

Comment by Vikram Jaisal
2013-12-07 10:54:08

It is easy for someone sitting in a comfortable AC chamber of a multinational giant’s Mumbai office to judge and patronize about the raw experience of a hurt optimist. I didn’t know there was an excuse for not serving one’s duty. Won’t be surprised if the company employees don’t visit this “resident”!
All that apart, virginity is strong in this one…

 
Comment by Kiran Kumbhar
2013-12-07 11:51:10

Immature remarks Mr Jaiswal. Stay away from people’s personal lives and concentrate on the issues. I have worked for three years at various hospitals in different capacities, and my present job is part of my wide attempts to understand and experience first hand the various facets of a medical education. And for anyone who questions about my credentials, I have been accepted into a renowned international university for the course of Masters in Public Health, and I am going to use that knowledge to help heal the system as best as I can. The health systems will always stay my area of active work.

 
Comment by Kiran Kumbhar
2013-12-07 12:03:41

I have a sincere request for the magazine editors. Unfortunately, remarks which are completely off the topic have been issued against both Dr Patel and me. So it would be better if such comments and found and deleted, so that we get better, constructive discussions about the main problems, about the content of the articles.

 
Comment by Abey
2013-12-08 02:08:35

You are trying to trivialize the emotions that a young doctor has expressed. You seem to suggest that if we do not have a solution for the problem we should keep quiet. That decorum must be maintained and atrocities should be dealt with on a systemic level.

Specific examples are a good way to focus the attention. And highlighting specific behavior patterns are illuminating. This focuses the light on harsh truths.

The harsh truth that Varun Patel’s article shows is that the medical community are largely callous about their responsibility to patient care and hospital hygenie. Private hospitals are only marginally better of course. There is nothing new in what Varun says. We all know it. His experience has brought it to focus that is all.

The other truth that Varun Patel’s article highlights is that there are doctors who are sincere, committed, and who have not succumbed to the callousness. Your suggestion about climbing the organizational ladder sounds good on paper but ground realities destroys any hope for the heroic souls who would attempt tackling the system.

To fix a system a framework should exist that protects and encourages honest sincere committed doctors, without such a system any kind of heroics will fall flat on its face and you will have the usual ladder climbers who are more focused on the seat than the patient.

And till we have such a system articles like Varun’s should be lauded and encouraged. If nothing else it will at least hopefully shame the medical community into bringing into central focus the one thing every doctor should care about: the patient.

It is abominable that patients are turned away, doctors get a cut from the chemist, and there is no disservice to the reader since the reader already knows the nightmare most government hospitals are.

 
Comment by Rajiv
2013-12-08 02:11:00

Ever since the advent of modern medicine in India, the doctors in public funded or charitable hospitals, small private clinics and to some extent even in private hospitals have toiled hard. As a class they have done the best under the circumstances to provide an acceptable level of health care within a resource constrained environment. When the demand supply gap crosses a threshold – a not so uncommon occurrence in busy public hospitals, keeping one’s head above the water may seem like a perpetual struggle. We are all familiar with the ingenuity applied by the residents and consultants at times of crisis due to erratic supplies of essential items and drugs, equipment failure, unanticipated staff shortage or unexpected mini-epidemics. But the legendary abilities of Indian doctors sometimes fall woefully short and they (or the health care system) fails the hapless patient. And the hapless patient may not necessarily be poor – anyone could be at the receiving end of the health care inadequacies. While at the macro level the health planners and funders are supposed to have their own monitoring mechanisms which should trigger corrective actions and infusion of as much resources as available, at the micro level the residents, consultants and hospital administrators are supposed to find ways to keep systems streamlined and working.
An average Indian doctor still works very hard, struggles to find time for self and family, is not super rich and still commands genuine respect by the society at large. However there have been rotten apples – and keeping with the general trends of morality and ethics in the society, they have been increasing with each passing decade. Though unfair, people at the bottom rung of any profession such as medical interns have always been at the receiving end from all quarters including their seniors, paramedical staff and sometimes even the patients. But their zeal to learn, become competent and to do good helps them to keep their morale even when others think they are nobody. It will be hard to miss a devoted and enthusiastic intern. More often than not they will make great doctors whether they get a post graduation of their choice or even if they do not get a PG. Medicine is one of the toughest as well as the most satisfying profession. A degree of despondency among the young medical interns in the harsh realities of the developing countries is understandable but not acceptable as they have made a conscious and voluntary decision to study and practice medicine in India. They have to be the engine of change to bring about improvements within the existing resources and leverage greater resource allocation to health care. But anyone who has joined medicine without knowing the reality of the country or expecting it to magically change while they are doing their MBBS will certainly come in for a rude shock.

 
Comment by Gautama
2013-12-08 03:25:54

Just to add to Rajiv’s comment about demand and supply in the Indian public healthcare system, the hospital in question is a tertiary referral centre. In other words, it was in theory meant to handle the more complex of medical cases. However, since we have a primary health set-up that is inadequate, the burden of managing the entire spectrum of cases (for those who cannot afford private care) falls on the large (in terms of number of beds) but relatively poorly funded government hospitals. Given the severe resource crunch in which they work, I firmly believe that the staff at government run hospitals across India do a stellar job that would be difficult to match elsewhere in the world under identical circumstances. In the mad rush that Indian medical students seem to have got themselves into of going from MBBS to an MS/MD to MCh/DM or their equivalents (either within India or outside, preferably in the most clinical of super-specialties), no one really finds the time to see anything positive in India, to appreciate what is right. It is very, very easy to blame specific entities for things that appear wrong. No one finds the time either to take a more macro, systems-based view of the problems plaguing our nation’s healthcare. To truly understand and fix these problems, doctors actually need to train in policy making, in sociology, in economics, and in biometrics. Such cross-disciplinary training has happened very successfully in most developed countries — and doctors with such training have been instrumental in getting the life expectancies of entire populations in these countries to where they are. Contrary to what one may assume, historically, incentives for such training have not been provided in the developed world — a lot of the motivation that doctors have had to study these subjects simply comes from patriotism. It comes from a far more philosophical perspective of the role that a doctor should play in society. But I wonder which intern nowadays is willing to take that career plunge that sets aside the stethoscope and the white coat?

“Jo bhi wrong-va hai usay,
Set right-va karo ji,
Naahi loosiye ji hope,
Thoda fight-va karo ji…”

~ Moora, Gangs of Wasseypur 2

 
Comment by Kiran Kumbhar
2013-12-08 20:05:52

Rajiv Sir and Gautama Sir.. Thank u very much for ur comments. They added still more constructive dimensions to the issue, and even I learned a thing or two from you.

 
Comment by Rajiv
2013-12-08 22:48:32

To practice medicine – even if one is constrained to provide piecemeal solutions,one has to have a holistic perspective. To deliver life saving cutting edge medical treatments we do need Super specialists in tertiary care centres, but they are no good without first becoming a good specialist and specialists are no good without first becoming good doctors. In our obsession with blaming everything on the general lack of resources we loose sight on the equally pressing need for reforms in medical education and training and in putting emphasis on prevention.

 
2013-12-09 11:02:52

Hi Dr. Kiran,

This was a wonderfully written and thought out article.

However, it seems to me that it was thought of only in the context of Dr. Varun’s post.

Let me offer you a background of where and what I have done before I continue.

I did my MBBS in a very small village town called Loni, Pravaranagar. I did my internship through there
with the first 3 months at Shirdi wherein I contracted a disease that paralysed me for a year and I then continued my internship on a walker and crutches at Sir J.J. Hospital and its various posts. I did a one year stint at the PHC at Palghar.

I worked as a surgical resident at Rajawadi General Hospital (BMC run) for three years

There is so much truth in both your articles that it’s easy to miss the bigger picture.

I have seen ‘batting’ and unfortunately or fortunately been at the receiving end of it as well. I’ve admitted patients who were clearly required to be admitted in the medical ward only because they wouldn’t just to have them transferred to another unit the next day.

We’ve had patients admitted in our ward who came to the casualty the night before but were not admitted because the other unit was exceptional at batting them away just to come another day

I’ve taken transfers to my ward till my fellow residents and interns begged me to stop saying our ward is always full.

There was just one answer to them all. The more you see the more you will learn and the more you will earn! For some strange reason, this chant seemed to calm them down everytime.

For the part about patients sitting out of the casualty I’ve seen that too. Maggots, Diabetic Foot, Gangrene…I’ve seen them all turned away by the CMO when I wasn’t on duty only to be told to mind my unit’s business on my non call days.

I’ve seen people come from across the country to meet and talk to my Unit Head just for 5 minutes because he was open to alternative medicine. I’ve seen that 67 year old Unit Head ready to come to the hospital from half way across town just to consult on a patient that we weren’t sure about.

I’ve seen patient’s relatives beating up my colleagues when the patient died. TWICE in my unit with different colleagues. Over a period of 3 years. With nothing done about it both times in spite of police complaints and strikes.

I’ve participated in parallel OPD’s when the strike was on with almost all residents in attendance.

When you talk about corruption, I know people taking kick backs even now, after being established private practitioners, and I know people who flat out refused when we were doing our internship for free!

I have been made to stay up 56 hours caring for a patient as an Intern when my resident and registrar had to study for their exams. They were extremely good seniors and I did it because I wanted to not because I had to. But, there was a question in my mind, was this what I bargained for? Is this what I want to do?

Climbing up the ladder. In our day and age, working hard at PHC’s and government posts to try and reach the level of the Superintendent is not only a far fetched dream, but is also much like the elections of today. There is no separating politics and climbing the organizational ladder. I say this from past experience wherein my Associate Professor stayed and A.P. for seven years because he was told the only way to get promoted to Professor was to leave his city and go work someplace else.

The other issue is money and I hear many morale battles saying medicine is not about money. I would ask you to come back to this post about 8-10 years down to road when you are married and have kids and still have to depend on your family to cover expenses. People in the developed world take up positions in their respective government institutions because they are well provided for.

Not matter how much this stings, it is about the money.
Would you not give up an opportunity at private practice if you are well compensated for your time at a government hospital.

Lastly lets agree that there are always two sides to a coin and there are enough good doctors to overshadow the bad but all Dr. Varun’s post has done is highlight a side. At this stage of his life, it will look all bad. We tend to glorify the ugly because that’s what gets people’s attention and I suspect that’s all he intended.

Only if someone highlights the issues will there even be a discussion for improvement. I’m glad that you have provided the flip side to show that there are indeed good things about the profession. But let’s not kid ourselves. There’s just too much to go and it will take immense efforts from all of us to improve this.

A simple thing that I have started in my private practice is to prescribe drugs with their generic names written alongside brand names. The choice is then on the patient!

Let’s work together to change the system.

P.S. Why go abroad to get a degree in MPH. Stay on in India and change the system from here!

P.P.S. I will be putting this response up on my blog at http://blog.drmulchandani.com along with a link to this article as well as Dr. Varun’s article!

 
Comment by Vik
2013-12-09 22:19:02

At a time when young men in their twenties and thirties living in an environment where money is all. Politics is no more about policy-making or about governance. Politics is commerce. One might think that morality would restrain people from corruption. One can go on and on to nail every single segment of society. One can summon innumerable examples not only from India but also from the most advanced nations of the world to prove that institutions have crumbled and systems are collapsing because of human greed and corruption. Socialism, capitalism, democracy and communism have all collapsed at the altar of corruption. Technology has led to the growth of wealth. The lure of wealth has made mankind greedy. Greed has destroyed all sense of honour. All this has made the world flat.

The revolution to rescue mankind from the doom towards which it unthinkingly hurtles can erupt from any corner. The crisis is moral. It has to be demonstrated to people that happiness does not depend on the acquisition of increasing wealth. It has to be demonstrated that wealth cannot be measured by the quantum of money. It can only be measured by the quantum of satisfied needs.

India awaits a moral revolution. Will it come? If so, from where? For a moral revolution Dr Varuns Patels experiences has become a level playing field not just for Doctors but also the patients.

Calling it foolish is an Irony and utter ignorance.

 
Comment by G again
2013-12-09 22:53:02

@Dheeraj – As to why go abroad for the MPH? Well, looking at the present scenario, those with elite foreign training (and a conscience) in economics or epidemiology seem to be far better placed a lot earlier in their careers to influence national policy in economics and health for the good of India. (for example, google the work being undertaken by Prabhat Jha (Toronto/Oxford) and Raghuram Rajan (Chicago/MIT)). Of course, wouldn’t advocate going abroad with the intention to settle abroad.

 
Comment by Kiran Kumbhar
2013-12-09 23:34:44

@G again, @Dheeraj
G again, u said it rite. Eg, Sushila Nayar, former Union Health Minister, did MBBS from Lady Hardinge and MPH from an American university. Drs. Rani Bang and Abhay Bang, who are doing stellar public health work in Maharashtra, too did their MPH from the US. Gandhi spent many of his formative years abroad. Its always good to expand our horizons.

 
Comment by Vik
2013-12-09 23:43:10

@Dr Dheeraj,

In this era of globalization the requirement of International exposure to the students during the period of their study is being increasingly felt. When a student goes for higher education or applies for job, he or his interviewer uses the quality parameters of higher education and compares the colleges and universities. The purpose is to guage his international exposure that can be achieved only by the education of global quality standards. Needs and expectations of the society are changing very fast and the quality of higher education needs to be sustained at the desired level.

NBA has been facilitating improvement of quality and relevance of technical and professional education in the country to bring it at par with international standards. Only certain Universities and their affiliated colleges follow and implement guidelines as they can afford. Today we see an enormous increase in the numbers of colleges, universities and students. Its result comes out due to the decline in the quality of higher education. Numbers of colleges, universities are increasing day by day but quality in higher education is deteriorating as they neither follow guidelines of UGC – NBA nor AICTE – NAAC. Only a few universities / deemed universities, autonomous colleges and institutions of higher learning like IIT, IIMS, and ALLM etc have strict implementation of quality guidelines.

The need of the hour is to have universities tie up with international institutes to stimulate the learning process for an excellent human resource output strictly following the quality parameters set by UGC and AICTE.

 
Comment by Avinash Deo
2013-12-11 11:18:27

I felt that Dr Patel’s article was about TRP which he has got. I am sure at least one critical patient was sent home cured by Sassoon hospital during the one year Dr Patel was there. I wonder why this does not find a mention in Dr. Patel’s article. Media has made us into a vouyeristic sensationalization loving pessimistic society where the good things make little impact. Had Dr. Patel written only about the good things at Sassoon Hospital no one would have bothered to read the article.

We erroneously believe that we have eradicated bonded labour. The medical resident doctor is bonded labour with a very low morale. Where he/she stays is a pigsty and where he/she eats is from a trashcan. If a crook knifed by another and succumbs in a public hospital the resident is the target for thrashing. I would have appreciated Dr. Patel had also written about the working hours, stresses, pay and living conditions of resident doctors. I wonder why he did not notice the poor living and working conditions. Hospitals will shutdown without residents. I would have appreciated if Dr. Patel had at least mentioned the number of residents who contracted multi-drug resistant tuberculosis and are going thru the misery of second line anti-tuberculous therapy.

To all who have suggested the need to get committed young doctors for healthcare I only have to say that the commitment depends on the morale of the medical staff. In a society that weight everything in terms of money, morale of a person who is paid so little and treated so shabbily as a medical resident, will be low. You need to talk to these young doctors to understand the king of uncertainties they face in life at an age where there peers from other professions are getting a host of company paid benefits. If the society cannot address their concerns it will be hypoctitic to expect them to reciprocate concern and follow the Hippocrates’ oath.

 
Comment by Avinash Deo
2013-12-11 11:20:22

The last paragraph should read ” …..You need to talk to these young doctors to understand the kind of uncertainties they face in life at an age where there peers from other professions are getting a host of company paid benefits,”

 
Comment by Kiran Kumbhar
2013-12-11 23:46:22

Avinash Deo. Bang on! U hav touched on an aspect wch I did not include in my rebuttal. Cz of course my aim was only to point out the glaring, awful deficiencies in the relevant article and to give some glimpses of how it could have been written and presented better. Sadly, d damage had already been done: the TOI had, in its usual excitement of crucifying govt residents, given it wonderful mileage. Still, it was necessary to register protest, to display the ‘context’ of the sensationalized incidents and to show ppl and young doctors alike that there r better ways to address d issues than pointing fingers at resident doctors in general.

 
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