Tuesday, 30 May 2017

Straight from the heart: Enough is Enough

Straight from the heart: Enough is Enough Dear Colleague, Past National Presidents, Past Honorary Secretary Generals, Teachers and Friends Greetings from the Indian Medical Association (IMA), the collective consciousness of all doctors in India At present, we are directly connected to 3 lakh doctors and indirectly to more than 12 lakh doctors through Federation of Medical Associations (FOMA). And, via the World Medical Association (WMA), we connect to 112 countries. IMA has declared the “Dilli Chalo” movement on 6th June to bring to the attention of the Nation the plight of the medical profession, which is being strangulated from all directions and facing its worst period. Doctors are being denied justice even within the frame work of the constitution of India. How come everybody, including the government, is silently watching the rising incidents of violence against doctors? We become doctors to serve and not to harm the community. We are not against accountability, but no one can be allowed to take law in their hands. Violence against healthcare professionals is becoming more and more frequent in India. Often, there is an attempt to soften the resultant outcry by blaming the medical profession itself as being the cause of provocation. On many occasions, fraud on doctors is perceived as fraud by doctors. To prevent this, every healthcare facility should identify areas prone to high-risk violence in their establishment, which should be manned by adequate number of experienced doctors, voice activated CCTV cameras and adequate security. A well-structured and effective Grievances Redressal mechanism should be established at each clinical establishment (both for patients or their relatives and for the healthcare providers). A timely and transparent root cause analysis of every case of violence should be done and entered in a centralized IMA registry. Every establishment must have a policy to handle any situation of violence. We also must not forget that the patient and or their relatives at that moment are victims of acute stress and are likely to misbehave. Aggression will only fuel more aggression. Not losing temper at any cost in any situation should be a part of the emergency protocol. In any such situation, the first on call health reporter and/or the investigating officer are the most important. One should not avoid them. No news can be published or reported without the version of both the parties and that is the law. Never disclose patient details to the media, while giving your side of the defence. This may be a professional misconduct in lieu of violation of patient privacy. All health care personnel, who have been victims of violence must be adequately compensated, financially and also with regard to medical treatment. It is our luck that the Hon’ble acting Chief Justice of Delhi Smt. Geeta Mittal, in a suo moto order on violence against public hospitals dated 3.05.2017, has made IMA as a party in the case. Directly or through the court, we want the Ministry of Health and Family Welfare, Government of India to urgently and promptly implement MCI suggested amendments to make soft skill communications a compulsory part of UG and PG curriculum. Also, based on the inter-ministerial committee recommendations, the Central Government should urgently enact ‘uniform central act against violence’ along the lines of that enacted in 19 states and make violence against doctors a non-bailable offense punishable with up to 14 years imprisonment on the lines of abatement of a murder because violence against doctor may cause death of other unattended patients. Should we compromise on this issue? We want a central law against violence. Why are we suddenly being tried as criminals? Recently, doctors are being tried under criminal law for medical negligence. To establish criminal liability, it is first important to ascertain the presence of mens rea or intent to harm. Or that the doctor had the ‘knowledge’ that the treatment could harm but did not take the necessary informed consent. IPC 304 cannot be applicable on us on these grounds. Under IPC section 88, no harm is an offence if done in good faith, then why are criminal complaints filed against us? Why are we still booked under section 304? In criminal negligence cases, intent to harm has been replaced by gross negligence and we are booked under 304A. Gross negligence itself is not defined in IPC. As per MCI Code of Ethics regulation 8.6, “professional incompetence shall be judged by peer group as per guidelines prescribed by Medical Council of India”, but these guidelines are non-existent till today. Also, as per the Supreme Court Judgment in Jacob Mathew vs State of Punjab, no FIR can be filed against the doctor till a preliminary enquiry reveals a prima facia case of professional negligence. Every doctor is innocent till he or she is convicted. Media should not be allowed to report any doctor’s name till he/she is convicted of negligence. But today the first thing media does is to disclose the name of the doctor, even before even an FIR has been lodged. Is disclosing the name of the doctor before conviction not defamation? Criminal law punishes only affirmative harm but in medical negligence, failure to act in a prudent manner is also a crime. It should not be forgotten that medicine, especially emergency medicine, is inherently risky. Adverse outcomes or mistakes do not necessarily mean that care was negligent or that health care providers are criminally at fault. In emergency, triage becomes difficult with the present work load. In the event of a disaster, we are required to devote minimum time to dead patients (black code); immediate attention to serious patients (red code), semi attention to less serious patients (yellow code, can wait for one hour) and least preference to minor injury cases (green code, can wait for three hours). However, doctors are often abused by VIPs with minor injuries. IPC Sections 304 A (death due to negligence), 336 (act endangering life or personal safety of others), 337 (causing hurt by act of endangering life) and 338 (causing grievous hurt by act of endangering life) are being frequently applied against medical practitioners. Don’t you agree that criminal prosecution against doctors should be an exception and not a routine? Criminal penal provisions are also provided under MTP Act, PCPNDT Act, POCSO Act, HIV-AIDS Act, West Bengal Clinical Establishment Regulatory Commission Act etc. In many of these, a doctor can be prosecuted for non-professional violations like not wearing an apron, not wearing a name plate etc. Are we criminals? Do we deserve this? Doctors often take calculated risks, when treating their patients. Death does not automatically mean negligence. That error of judgment, difference of opinion, mere deviation from standard line of treatment are not negligence, is the settled law. Than why implicate us, till the matter has been decided by the court? In many of its judgments, the Supreme Court has said that judges are not experts and to decide a medical negligence, expert opinions are required. Then why does the media decide a case of medical negligence against us simply on the basis of allegations by the patient or their relatives. Even this is a settled law that when two experts differ, the benefit of doubt goes to the doctor. A doctor should not be judged by the expert’s level of competence. A doctor is only required to possess an average degree of skill, knowledge and expertise and not the maximum degree. Should we allow our doctors to indulge in loose talk in media or speak against their own colleagues? To re-emphasize, the law makers, experts and the police must consider section 88 of IPC, which saves medical professionals from criminal liability when the act is done in good faith, to be read with section 304 A. The West Bengal Clinical Establishment Regulatory Commission Act has used the word ‘shall’ for imprisonment of up to three years for any violation of the act. Don’t you think it is criminal on the part of the government to provide this criminal provision? What do we want? We want de-criminalization of clinical practice. Should doctors be made to face the limitations of the government? It is the constitutional duty of the governmental to provide free drugs and investigations for primary care and emergent care. The very fact that 80% of the health care services are handled by private sector means that either the services of the government are not up to the mark or they do not have enough infrastructure. The private sector does the job of the government. We are told to provide free services to government clinics on the 9th of every month for antenatal care. We are told to abide by national health programs, but are we given our due? Why is there no parity in pay scales for service doctors? Why is the uniform 7th Pay Commission not applicable to them? Why are our doctors continuing with ad hoc jobs for years together? Why is there no equal work for equal pay policy? Why is there no uniform age for retirement? Why are doctors paid differently in different states? Why are doctors posted in villages/rural areas not paid higher and income tax free salaries than the urban postings? Is this not exploitation? There is already a shortage of doctors, establishment and beds. We need twice the number of doctors, three times the number of nurses and four times the number of paramedics in the society. Than why so many exams for medical students, so many registrations for opening a new medical establishment and so many windows for accountability? Why can’t we have single window registration and single window accountability? Why is an MBBS graduate, who has gone through 36 examinations in 3 dimensions to get his degree, is being asked to sit for another 3-hour MCQ paper to obtain his license to practice under NEXT? Why can’t the government conduct a common final MBBS exam? Why force another exam ‘NEXT’, after getting an MBBS degree? Do we want NEXT? We are professionals and not businessmen. We have qualified one of the most difficult exams. Over 10 lakh students appear to secure admission to one of 50,000 seats. Once we are responsible professionals, then we are entitled to our professional autonomy, the autonomy to choose patients, drugs, brands, investigations and the line of treatment. We know and understand that we need to be rational, but we cannot be dictated to. When the government has allowed one company to market a generic drug under three name (generic-generic, trade generic and branded-generic) and also at differential prices, then why punish and defame doctors? In India, most drugs are generic and to choose the company is our right. Government should come out with ‘One Generic name, One Price, One company’ policy. I don’t want to be blamed for choosing a specific lab, pharmacy, diagnostic centre or a hospital. Can’t I refer patients to them on merit? Am I not entitled to take decision for the benefit of the patient and to choose a low radiation vs high radiation CT scan; 1.5 vs 3 TESLA MRI scan, ELISA vs Spot test? Why can’t I choose a drug from a particular pharma company as long as I am rational in choosing my drug? Is the company not doing the job of the MCI or the DCGI? Are they not updating my knowledge both in theory and skills? Why take away the prescription rights of doctors and give it to unqualified chemists? Why is the government allowing pharmacies to be run by outsourced non-professional chemists? It’s not the doctor’s job to search for the cheapest brands. It’s like the government saying that we will allow drugs to be sold at variable prices, but you should not write the costlier ones. In other words, we will give licenses to five star restaurants, but you are not allowed to go to the five star restaurants. The right to choose the brand or the company name lies with the doctor as it is he/she who owns the legal responsibility of the case. If the brand is chosen by the chemist, who will be responsible if the patient dies during treatment. Say no to NMC Why do we need a government? Why not a Supreme Court Monitoring Committee or twenty nominated members to run the government? If not, then why attempt to have an autocratic, bureaucratic, undemocratic, non-representative, 20-member nominated body including 8 non-medical persons to oversee medical education, ethics and practice by abolishing a democratically elected federally-represented 168 members Medical Council of India. If the Govt thinks that the IMC Act needs amendments, then that should be the option taken by the government. We also need to have a uniform and fair NEET exam. How can we allow different sets of papers for the same exam? Even if the exams are in different languages, the questions should be the same. Why finish AYUSH¬¬¬¬¬¬¬? By allowing and promoting AYUSH to practice modern medicine, are we not finishing the very existence of AYUSH in the country? Now and then it is said that AYUSH should be allowed to prescribe OTC drugs Are we saying that AYUSH doctors cannot treat even minor ailments? Scheduled drugs should only be allowed to be written by MBBS or BDS doctors. Anti quackery The floodgates of modern medicine practice are being thrown open to quacks and no action is taken against them. No unqualified person should be allowed to prefix ‘Dr’ before their name. Medicine in the hand of quacks is like handing over a razor to a monkey. Capping of compensation When the medical profession is considered noble and doctors provide subsidy in the consultation to all patients, than why are compensations awarded in crores basing it on the patient’s income? The formula 70-age of injury x annual income + 30% - 1/3 is not the right formula. Compensation has to take into consideration age of the patient and disease severity along with workman compensation formula. Instead of amending CPA now, the West Bengal Clinical Establishment Regulatory commission has provided one more avenue for compensation to patients. Do we deserve this? Empowerment of MBBS doctors Today most MBBS doctors are facing problems and they need to be empowered. We need to think of a three tier system of referral. More than 25000 additional PG seats in Family Medicine are needed. All GPs should be in retainership under government programs. IMA in policy making Why are professional decisions about the medical profession taken without taking the medical profession into confidence? Why can’t IMA be a part of every policy making committee of the government. Why can’t IMA be allotted a room at Nirman Bhawan? Inter-Ministerial Decisions An Inter-ministerial committee was formed more than two years back. It has still not delivered its results. The ministries involved are Health, Consumer, Law and Home. Other ministries are now raising objections on most of the demands. Why should clerical errors be a crime under PCPNDT Act? Why should CEA be not consumer-friendly? Why should there not be a central act against violence? Why should we be liable for crores for only hundreds of fee charged? Etc, etc. There is no end to the injustice heaped on the medical profession. Let us not compromise on our demands • Criminal prosecution of medical negligence and clerical errors is not acceptable. • Capping the compensation in CPA on doctors. • Professional autonomy in treatment and prescriptions. • Stringent central act against violence. • Amendments in PC PNDT, Central CEA, West Bengal CEA Acts. • No unscientific mixing of systems of medicine. • Empower MBBS graduates. • One drug - One company - One price. • Implement recommendations of the inter-ministerial committee in six weeks. • Single window accountability. • Single window registration of doctors and medical establishments. • No to NMC: Amend IMC Act to maintain professional autonomy. • Uniform final MBBS exam instead of 'NEXT'. • Uniform service conditions for doctors and faculty. • Same work - Same pay - Pay parity - No to adhocism. • Fair conduction of NEET exam. • IMA member in every government health committee. • Central anti-quackery law. • Reimbursement of emergency services for private sector. • 25000 family medicine PG seats. • Aided hospitals and retainership in general practice. • Health budget of 5% of GDP for universal health coverage. Dr KK Aggarwal National President IMA & HCFI

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