Doctor, test thyself

The Union Health Minister’s proposal for re-registration of doctors every five years has stirred a hornet’s nest. Vibha Sharma talks to members of the medical fraternity to gauge how this will impact healthcare services.

HEALTH Minister Anbumani Ramadoss has his way, every five years Indian doctors will have to appear for a test to check their knowledge for re-validation and re-registration of their practising licence. At least, doctors in government jobs will have take the exam to prove they are fit to practice.

In the face of a rather contradictory and divided opinion amongst doctors, especially private practitioners and their national-level body, the Indian Medical Association(IMA), only time will tell whether the proposal would actually get implemented , and especially made applicable for doctors in the private sector.

But several senior doctors say that a regular check to verify and test skills and a doctor’s claim to practise medicine is a must.

Patients protesting in front of a hospital in Ludhiana
Patients protesting in front of a hospital in Ludhiana

The Health Minister, who is an MBBS himself, says he is ready to take the exam, adding that while the country should have a solid primary health system, Indian doctors need to be conversant with the latest in the field.

To begin with, Dr Ramadoss envisages a five yearly re-registration and re-validation for government doctors, after a Continuing Medical Education (CME) programme, somewhat on the lines of a similar procedure followed in the US, where even very senior doctors have to go through the procedure for licence renewal every five years.

The Head of PGI’s Endocrinology Department, Dr Anil Bhansali, says medical science is under constant evolution with newer trends and practices emerging every day. "Doctors should definitely undergo revalidation. And why only doctors, all professions, including civil services, need to follow this as a rule. In medicine, it is more important as human lives are involved. Those with medical colleges and teaching institutions have an edge over doctors doing private practice as they have better means of keeping abreast. But there should be a check on doctors in private practice. What is even more absurd is the way doctors in state government services are promoted without any examinations."

The government and the MCI, says Dr Bhansali, should organise reorientation programmes followed by an examination. "And based on the result, a doctor’s licence to practice should be renewed. Attending CMEs is not enough as many times they are organised more for commercial interests than anything else."

Promotion should never be without a test determining the efficiency and skill of the doctor, agrees an Army Medical Corps doctor.

The IMA, however, is vehemently opposed to the proposal, calling it an impractical idea as its implementation will require a lot of money which can instead be spent to strengthen the country’s primary health system.

"There is no need for re-validation or re-registration of qualified doctors," says IMA president Vinay Aggarwal.

"A doctor’s life is spent in getting registrations and licences. Re-registration will mean more harassment for doctors and additional money-making avenues for officials, " he says, recommending a compulsory number of CME hours every five years in the form of books, lectures and refresher courses.

"But in the absence of a formal procedure, most Indian doctors are not able to keep pace with latest developments and their knowledge gets outdated fast, especially when medical science is moving on a fast track and there are breakthroughs every other day," says Dr Ramadoss.

The PGI Director, Prof K.K. Talwar, agrees that updating of knowledge is important, but adds that re-examinations for private practitioners may not be a logical solution.

Giving an alternate solution, he says, "The MCI can organise a rational, structured update programme on the basis of CMEs and ensure compulsory participation. Medical colleges can also take the responsibility of updating their graduates periodically with an evaluation at the end."

No check now

In the complete absence of a track-keeping exercise, either by the Medical Council of India (MCI) or its state-level subsidiary units or the government, thousands of doctors continue to practise and prescribe whichever way it suits them.

There have been instances when doctors have been found engaged in other business, even property dealing. "Why is the MCI carrying their burden," questions an Army Medical Corps (AMC) doctor.

In India, once an MBBS, always a doctor, and no questions asked thereafter. Except for Dr Sushil K. Gupta, a Delhi-based doctor and now a practising lawyer, there have been no other instances when a doctor in the Indian medical history has voluntarily asked for his name to be struck off from the Indian Medical Register (IMR). At least the MCI officials do not recall any such instance in the past.

Dr Gupta joined civil services 10 years ago and resigned from the CBI last year. He asked the MCI to remove his name from the IMR, a decision he took after a lot of contemplation. "I wanted to practise law. But the thought of reverting back to practising medicine never occurred as too many advancements had taken place in the field since I last practised in 1994. In any profession, you should know the latest. As a doctor, I should be able to tell my patient everything, explain all possibilities and options. It is the moral responsibility of a doctor to be free and fair with patients," he says.

Besides this voluntary erasure, the MCI has suspended several doctors from the IMR, which has the names of more than 6.5 lakh doctors. These doctors, however, have been suspended only for a period of two to three months, or maximum a year. After this mild reprimand, mostly given for cases of negligence, the doctor gets back to practising medicine. No re-examination, no questions asked.

In any case , considering our vast population, the number of negligence cases registered against doctors are few when compared to western countries. While doctors in the US are facing a severe predicament because of a large number of frivolous lawsuits for financial compensation, Indian doctors hardly ever face litigation.

While ignorance about healthcare is prevalent in a majority of the population, to bring justice to the errant doctor is beyond the means of even the most affluent and educated people. A vast number of the most glaring cases go unnoticed to all.

Doctors know they would hardly ever face any medical negligence case in the protective environment offered to them, which is against the common man

"It is difficult to prove a negligence case as one. Doctors are in a position to produce any number of expert medical evidences, affidavits and witnesses," says Supreme Court lawyer Daya Krishnan.

MCI view

MCI officials agree there is no provision in the Council Act, which governs the methodology by which a medical graduate’s name is borne in the IMR, to make the registration time-bound. "Even after suspension, the Act doesn’t have any such provision. Once a medical graduate is borne on the IMR, he can practise anywhere in India, life long. Some state councils may have some different clauses in their respective Acts, where the process of revalidation or re-registration has been included on the basis of CME hours. But most of these councils are fairly recent in constitution and till now there has been no case when the time limit of the registration of a doctor has expired. So far as time-bound re-registration based on an examination is concerned, neither the MCI or state medical councils have any such provisions," says the MCI official.

A couple of years back, the MCI had sent a proposal for a re-registration programme . After Dr P.C. Kesavankutty Nayar took over as president of the council, the MCI again recommended a re-validation programme based on credit points earned on the number of CME hours attended. "The proposal was sent to the government an year back," says Dr Kesavankutty Nayar.

Varying prescription

Experts say revalidation is serious business and should be there for all profession, whether medicine, law and engineering.

Consider this—A recent study of prescription habits in the heart of Mumbai city found 110 doctors giving 95 different prescriptions to patients suffering with tuberculosis.

"This is the case of a disease where prescription and treatment guidelines are standardised and clearly laid down. If this is happening in the heart of the commercial capital of the country, what would be the fate of poor patients in rural areas of the country?" questions Dr D. Bannerji, Professor Emeritus, JNU, who has written extensively on commercialisation of medical education in India.

Indians make the best doctors, especially those working in high-pressure research and referral institutions in the country. Considering the conditions, workload and pressures under they work, their claim and competence to practice medicine is undoubted .

They are the ones who are largely up to date in knowledge practices and latest advances in the field, However, of more than 6 lakh doctors practising in India, the number of such doctors who are associated with institutions like the PGI and AIIMS is less than 10 per cent. There are 122 government and 107 private colleges in the country, out of which 18,000 graduates pass out every year.

Of them, two-third are from the government colleges and the rest from private medical colleges. "Which makes the number of doctors who may not be fit to practise a rather large figure," says Dr Bannerji.

Many times doctors do not even have adequate knowledge to inform patients the consequences of the treatment or surgery, which often backfires in the form of cases of negligence, says Dr Gupta.

Dean, Maulana Azad Medical College, and President of the Delhi Medical Council, A.K. Aggarwal, says doctors need to learn how to communicate better with their patients. "In a doctor-patient relationship, communication is very important. Doctors should be able to explain modalities and possibilities of complexities. Negligence is not a wilful act, but it can be avoided if good communication exists."

More than re-validation, let’s teach our doctors the real meaning of medical ethics, says the Director, Women, Health and Development of Rational Drug Policy, Voluntary Health Association of India, Dr Mira Shiva.

"In India, 80 per cent of doctors are looking after 20 per cent of the population. This is a sad scenario because for most of these 80 per cent medicos, money-making is the sole criteria," she adds.

Root cause

While Dr Bannerji blames commercialisation of medical education for being the root cause of all problems, there is no doubt that a lack of uniformity has resulted in variant practising habits.

"A large number of private medical colleges are churning out mediocre and even worse-than-mediocre doctors every year. Healthcare is big business. More than 6,000 doctors graduate from private medical colleges. Youngsters who are not even capable of competing in entrance examinations have became doctors, thanks to their papa’s money. The entire medical education system of the country has to be brought under the scanner. Indian doctors were automatically recognised worldwide, even by the General Medical Council of Great Britain. Now they have to sit for an examination, before practising," adds Dr Bannerji.

Raising the standard of medical education is more important, he says, adding that at times doctors not even fit to become lecturers are appointed professors in private colleges.

More than this, doctors from these institutions should never be absorbed in government services without examinations, says the AMC doctor, quoting the incidence when the Army had invited applications for the posts of 20 dental surgeons two years back. than 2200 applications were received and after a test all selected candidates were from reputed medical colleges. None of those from private medical colleges could clear it."

"Our medical education is largely bookish, with not much emphasis on obtaining practical or good communication skills. Later, this gap only but widens," says Dr Shiva.

Even the Health Minister says that all is not well with the medical education in the country and it needs to be modernised and updated.

"Seventy per cent of what is taught in medical colleges is not put to use when a doctor actually starts practising. Quite a bit of what I learnt as a student was not put to practical use when I started practising. Our medical education should be in sync with the modern system and technology so that Indian doctors are in a position to compete with the rest of the world," says Dr Ramadoss.

Over-commercialistion has resulted in gross malpractice of hi-tech facilities, indulging in wrong diagnosis and over-prescription. At times, vitamins are prescribed irrationally to patients, thanks to the lure of foreign trips and gifts doled out by pharmaceutical companies and medical representatives.

"There is an unethical use of life-saving drugs due to a nexus between doctors and chemists. Doctors in private nursing homes conduct Caesareans sections, even when normal deliveries are possible. MRIs and CT scans are recommended even when not required by doctors trained by the government with our, taxpayers’, money.

A large number of doctors posted in rural areas prefer to stay on leave rather than work in the backwaters. While an arrangement is their between them that half of them will work on one day and the other half the next day, effort is always on to get a posting out.

"Isn’t it absurd that even these doctors will get promoted and on time, and without any examination," questions Dr Bhansali.

"Ask these doctors whether they know what the National Health Policy says.

Most of them do not even know that a national list of essential drugs exists. At times, doctors do not know even have adequate knowledge about drugs they are prescribing. Drugs are prescribed on the basis of public relations exercise by glib-talking medical representatives, who dole out gifts and freebees. There have been cases when doctors have been found to be using drugs for pregnancy detection that may have a catastrophic effects on the foetus," says Dr Shiva.

The Delhi Medical Council says the uniformity can be brought about by re-registration linked with specific number of CME hours, says DMC secretary S.K. Khattri.

"Updating knowledge is very important and re-registration after every five years is also very important, for which CME, as a time-tested mechanism the worldover, is the best mechanism along with on-line updating, reading journals, hands-on experience, supervised training also being a part. The DMC is in the process of conceptualising 70-odd CME centres in Delhi," says Dr Khattri.

But Dr Bhansali does not agree. "There has to be a test, a check on whether after the CME, doctors have actually been re-oriented or not. Many times the CME is sponsored by large pharmaceutical companies for purely commercial reasons," says Dr Bhansali.

Anbumani Ramadoss In the absence of a formal procedure, most Indian doctors are not able to keep pace with latest developments and their knowledge gets outdated fast. Medical science is moving on a fast track and there are breakthroughs every other day.

Anbumani Ramadoss, Union Health Minister

K.K Talwar On the basis of CME, the MCI can organise a rational, structured update programme and ensure compulsory participation. Medical colleges can also take the responsibility of updating their graduates periodically and have an evaluation at the end.

K.K Talwar, Director, PGI

Vinay Aggarwal There is no need for re-validation or re-registration of qualified doctors. A doctor’s life is spent in getting registrations and licences. Re-registration will mean more harassment for doctors and additional money-making avenues for officials.

Vinay Aggarwal, President, IMA

Anil Bhansali Why only doctors, all professions, including the civil services, need to follow this as a rule. In medicine, updating is more important since human lives are involved. Why should doctors in state services be promoted without any examinations?

Anil Bhansali, Head, Endocrinology, PGI

S.K. Khatri Updating knowledge and re-registration every five years is very important. Along with CME, a time-tested mechanism the world over, doctors can also go in for on-line updating, medical journals and supervised training.

S.K. Khatri, Secretary, DMC