In 2013, 56 doctors from Mumbai’s government hospitals were reported to have tuberculosis, leading to two deaths. This vulnerability to infections is not only Mumbai’s matter but the condition prevails in government hospitals all across the country. And resident doctors are the most suffered and the most ignored!
“Resident doctors are the backbone of Indian medical system,” advocates Dr Santosh Wakchaure, president, Central MARD (Maharashtra Association of Resident Doctors), which represents 14 government medical colleges of central Mumbai.
“Yet no proper space for them to sit, no proper hostel facilities, no proper food or say even salaries!” says Dr Narendra Saini, honorary secretary general, Indian Medical Association (IMA). “They do 24 hours duty and constantly remain in touch with patients. If the patient is not getting a proper treatment or drugs or investigation, they are the ones who bear all the burnt. If they are always at the forefront, bearing the violence of attendants of patients then why are they not provided a proper facility or security at the hospital?”
Dr Saini further says, “They have no guarantee of job. After doing more than eight years of medical studies, they still work as ad hoc. Their services as resident doctors are terminated after three years.”
Resident doctors are the doctors practising at hospitals as part of their post-graduation studies. After three years of their services, they have to give exams after passing which they get their medical certification to continue practice. Every now and then, there has been some news of strikes by resident doctors demanding better facilities and security. What is it that leads them to call on strike?
Abysmal Doctor-Patient Ratio
In government hospitals, resident doctors are less in numbers when compared to patients admitted on everyday basis. “In public hospitals, it’s the resident doctors who work 24X7. Senior consultant doctors are only supposed to monitor resident doctors whether everything is going right or they change the prescriptions if necessary. The major workload is divided among resident doctors,” explains a former junior resident doctor, who had served his term in the Emergency Services at Lok Nayak Hospital, New Delhi. He recalls his experience, “I had worked in the emergency department of the government hospital. There used to be about 500 to 700 patients admitting every day. Only three to four doctors were sharing duties at a time, which means they divide the responsibilities among themselves. It used to get really difficult to handle 100 to 200 patients at a time. In case of an emergency, when a patient’s health is collapsing the staff needs to cooperate and work fast but resident doctors don’t get the support of the nursing staff or those who are permanently employed in the hospital. They do not care about patients. In government hospitals, the one who is responsible for the patients is a resident doctor only, since he is studying on the job and his degree always remains on the radar of danger. From this learning phase, if anything goes wrong, he can be disqualified at any moment. The reason why resident doctors are always on their toes.”
“I woke up at 6 o’clock in the morning, did my duty for the whole day and night. It’s been 48 hours and I have not been able to get to sleep yet,” says Dr Balwinder Singh, senior resident doctor and president of Resident Doctors Association (RDA), Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi. The long hours of work at a stretch adds to the frustration. It leads to emotional stress. “After 18 to 19 hours of work at a stretch, it is natural for a human to start losing his/her temper,” a former junior resident doctor adds.
Since resident doctors are studying on the job, they couldn’t find time to study for their exams and look after their health and family. “Due to high work load in medical colleges, a resident doctor doesn’t find time to go for a research work. His time flies away looking after patients as we can’t say no to patients neither we find time to study after our duty hours,” says Dr Mohit Bakshi, a resident doctor at Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University (IMS-BHU).
“While we work, we are still students. We have to give exams after completion of our residency tenure. On the contrary, we are not provided enough time for the preparations of the exams. We are not even granted leaves,” says Dr Santosh Wakchaure, president, Central MARD.
Uncovering Secure Zone!
Resident doctors are manhandled a many times by the attendants of patients that have been the cases in recent past, which proves vulnerable security arrangements at the public hospital premises. “We have to prioritize the patients according to the seriousness of the injury or disease. But all patients’ relatives drag us to their ones at a time, which becomes really stressful for us to handle. If a patient dies because the doctor was busy checking other patient, their relatives blame us for it and often start fighting then and there. And if a doctor is hit, strikes have to happen. There is no security for doctors in government hospitals that anyone can hit a doctor, who is on the job!” explains a former junior resident doctor.
Resident doctors also have to do the night duties. “No security! When patients’ attendance is at large, they hit the doctors. It is happening all over India. Since there is only one doctor, everyone asks him/her to see their patient first. We have a protocol that we first see the one who is more serious in his/her condition. Some patients say that we have come first, so first see us and when we cannot, they get aggressive. In case of emergency, we check the serious patient first whose life is at risk,” says Dr Balwinder Singh of Safdarjung Hospital. “There are also no street lights in the premises of the hospital and things are stolen from our places,” he further adds.
There is no CCTV camera, no security camera and no fire alarm! “We have complained a lot for security, but neither fine nor anything has been imposed on them yet,” complains Dr Balwinder Singh. Similar is the case in Sir Sundar Lal Hospital of BHU. “Many a times, we have faced security issues. Every two or three months, some security incidents happen here. When we strike, they promise us at the time but they are never implemented,” says Dr Mohit Bakshi.
Stipend Delayed or Less Pay
“I still have not got my salary of March,” whines Dr Mohit Bakshi. Late salaries and less pay have been the misery of many resident doctors across all the government hospitals across the country.
The Resident Doctors’ Association of Safdarjung Hospital held a strike last year for the timely payment of their salaries. “Initially salaries were not used to be paid on time to resident doctors. Because of this strike, it’s regulated now,” says Dr Balwinder Singh. “I think it happened because academics don’t send our attendance in time and accounts department takes time to process 1000 students. Since we have held a protest, our pay has started coming on time,” he adds.
At the moment, Delhi offers good stipend in comparison to other states in India. “The reason why I went to Delhi from Mumbai for residency was stipend is good there. As a junior resident, I was earning 64K (Rs 64,000) per month. While in Mumbai, a resident doctor gets only 29K (Rs 29,000) in hand per month. Delhi is under central government and they have made a good stipend mandatory,” says a former resident doctor.
“With long working hours, there is no personal life left for a resident doctor, professional life is dead too with no money,” Dr Balwinder Singh shows his concern. He further adds, “In Delhi, a junior resident gets around 60K (Rs 60,000) and a senior resident gets around 79-80K (Rs 79,000-80,000) while in other states, it is very less which is about 12K to 19K (Rs 12,000-19,000). This is the reason why doctors prefer working in Delhi. All states’ resident doctors flood to Delhi.”
When doctors reach their residency period, they are at the age of 28 to 30 years, when most of them get married or have a family responsibility to look after. Dr Santosh Wakchaure elucidates, “There should be a proper stipend for resident doctors. Why can’t Maharashtra government give good stipend? Besides less pay, our salaries are also delayed.” Dr Wakchaure also advocates the allotment of scholarships to the students in need.
Poor Conditions of Accommodation
As per the rule, government hospitals provide hostels to the resident doctors. “Hostels are paid and the cost is deducted from a doctor’s salary. My hospital pays Rs 8,500 for HRA and if I choose to stay in hostel, they will deduct HRA from my salary. Since hostel conditions are not good, I chose to stay in a rented room,” says a former resident doctor. He also has an experience of staying in a Pune’s hospital’s hostel. “The rooms were very small. A few were shared among doctors and a few were given out on single basis. In shared rooms, six doctors lived together. Mess served unhygienic food. No one looked after those rooms, which resulted in shabbiness. Toilets were also not maintained and they stank all the time.”
“Whatever hostels exist in New Delhi are insufficient. There are about 1000 resident doctors in Safdarjung Hospital and only 88 rooms to accommodate them. The rooms are in the same condition as they used to be back in 1956. In one room, about three to four resident doctors live while some choose to rent the room outside the hospital premises that gets costly to pockets,” says Dr Balwinder Singh. “Initially, there was no drinking water facility for doctors, but after the strike we have made our administration install ROs,” he further adds.
“We are living in a pathetic conditions where you can’t even stand for 15 minutes. We are not even provided things that are necessary for the survival of a human being with no proper sanitations or ventilations. In our hospital two seniors have got tuberculosis,” informs Dr Mohit Bakshi of Sir Sunderlal Hospital.
Why Problems Exist!
According to a report in the Indian Journal of Medical Research in 2013, the fast expansion of medical colleges has resulted in the shortage of medical teachers estimated to be currently 40 per cent. Also, as per the report India plans to open some 200 medical colleges in the next 10 years to meet the projected shortage of 600,000 doctors. “In comparison to India’s population, medical colleges are less. The reason may be that the Indian government grants less funds to the health sector,” says a former junior resident doctor. He further adds, “Russian government allots 7 per cent of its annual budget to health and in India, the maximum budget that is allotted to health has been 3-3.5 per cent. We have such a huge population that this budget falls short. In such less amount, the medical college has to cover everyone’s salary, infrastructure funds etc and according to available funds the number of members per department is decided otherwise they won’t have salary to pay. Corruption also plays a role here.”
Other aspect of it leads to drop in productivity. The central and state governments have built more medical colleges and increased the number of resident doctors in a hospital, but they have not scaled the infrastructure or say operation theatres, which leads to no productivity. “For example, initially there used to be 10 resident doctors but now they have been increased to a number of 30 and operation theatres are the same. How many doctors can work in the single operation theatre at a time? Hence, no output,” says senior resident Dr Balwinder Singh.
Dr Mohit Bakshi, a resident doctor at BHU, asserts, “There is no patient care facility available to resident doctors, the reason why patient faces problem and then they trouble us and say that we don’t work properly. When poor patients come, they have to pay because there are no arrangements from government and when they can’t bear the expenses, they show anger to us.”
“Only 0.9 per cent of GDP is allotted to health sector. Even that budget is not properly audited. What happens to the allotted funds? Why in a hospital a CT scanner or some other machine go out of order in just six months’ time and then there are no repairs done for those things? Why the same company supplies the same machine to a private institution or practitioner and they still continue to run? Has anybody taken notes of those things? How much budget has been utilised properly or not?” asks Dr Saini.
The Truth behind Strikes
“Our strikes convey wrong messages that doctors don’t work,” Dr Mohit Bakshi expresses his concern. Whenever you hear news of resident doctors’ strike, many may think that the doctors are moving away from their responsibilities, but they ignore the plight of doctors they live in because of which they call the strikes. Every medical college has its own resident doctors union. They discuss their problems with the appointed head of the hospital or medical college and if the problem exists at the state level, they approach the health minister. “Around a year back, MARD held a strike demanding an increase in the pay scale, as resident doctors are not paid well in Maharashtra. They wrote a letter to the health minister about the strike that they wouldn’t call off the strike unless their stipend is increased. As a result, resident doctors got a very nominal hike of about three to four thousand rupees, and a few strikers had to back out because their respective medical colleges threatened to cancel their degrees and were asked to attend the colleges. And eventually, the strike was dissolved,” explains a former junior resident doctor.
Not all strikes are called at the state level. “That depends on the nature of demands. If it is only at the administration level, we send a letter first to the medical superintendent of our hospital. If they do not do anything, we warn them of going on a mass leave,” says Dr Balwinder Singh. However during the strike period, resident doctors make sure that the emergency services are not closed. “We continue with the emergency services of the hospital. It is just that we don’t go to OPD and our senior doctors replace us in OPD,” says Dr Singh. “We also deal with it morally. When we protest, people ask us why you are doing this as people are suffering. If everything is in place, strikes won’t happen as there will be no need for it,” he further adds.
Yet No Reforms! Why?
“Every solution exists only for a month or two and then it all falls back to square one,” says Dr Mohit Bakshi.
Why government has not done anything yet? “Because they do not care. One of our professors told us that if you do not work under stress, then how you will learn. For them, stress is good. They do not know the actual condition of the hospital or even if they are aware they are neglecting. Because of negligence, the patients are at stake more than doctors. If a doctor takes longer time to see a patient, then how will he look after other patients who are waiting to be seen,” asks a former junior resident doctor.
Resident doctors believe that funds are granted to hospitals but the hospital administration does not find it worth investing them on the facilities for resident doctors. “Because they know that resident doctors are not their permanent employees and stay only for three years. Since they are students practising in hospitals, no one raises their voice. They let things be as it is,” explains Dr Balwinder Singh.
Dr Narendra Saini of IMA claims that governments don’t listen to them whenever IMA’s representatives guide them of the things needed to be done.
“When resident doctors go on strike, certain steps are immediately taken at the point of time and since there are no budgets allotted for that, the facilities are withdrawn after a certain period of time, falling back into the previous pattern. There are very few places where doctors have gone on strike and changes have remained for a longer period of time,” says Dr Saini.
What Government Can Do?
“Increase the number of qualified doctors along with the infrastructure facilities,” says a former junior resident doctor. Adding to that, he suggests that a resident doctor should have only 10-20 patients at the maximum in a ward.
Dr Narendra Saini focuses on the following reforms:
1. Provide a proper health budget.
2. All treatments should be in order. Provide good infrastructure facilities in OPDs and hostels.
3. Build a good monitoring mechanism from the duty room, where a resident doctor can look after up to 10 wards at a time.
Dr Saini also emphasises the need for a proper referral system. He says, “Why major public hospitals are burdened with OPD patients for small diagnosis, which can be tackled at the dispensary level? When a patient can get treatment in a hospital or clinic nearby his/her home or hometown, he/she doesn’t need to travel that far. What’s the point of building a hospital or clinic with no proper infrastructure facility?”
Dr Santosh Wakchaure emphasises on regulating working hours for resident doctors as well as increasing the stipend. “Government should settle down the working hours for us. Only when working hours are made comfortable for each resident doctor, the quality of work can be ensured and with this patients will also get benefitted.”
Federation of Resident Doctors Association (FORDA) that includes all government medical colleges of Delhi is soon planning to call a strike demanding to make the stipend of Resident Doctors uniform all over India. “When the pay is universal for all the resident doctors then only they would like to practice in their own state instead of coming to Delhi. This way, patients too can get treatment in their own respective states. Nobody likes to being paid less. Only this way, the influx of patients to Delhi for treatment can be controlled,” says Dr Balwinder Singh, general secretary, FORDA.
This is a fact not to be ignored that every senior doctor consultant has gone through residency period at least once in his life! Then why not bring strong and effective reforms in favour of resident doctors?
Priyanka V Gupta