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IMPROVING HEALTHCARE: A Resident point of view
6/19/2019 12:24:21 AM


This issue of safety of doctors has become a national issue post the West Bengal incidence. While safety of doctors is a must and has to be ensured at all costs, also we have to consider the plight of the poor patient who belongs to the lowest strata of society and comes to a tertiary care center after being referred from the best healthcare facility available in his/her vicinity.
Healthcare is not just the responsibility of the medical residents. It is the joint responsibility of residents, senior doctors, hospital administration, civil administrators of health ministry in state/centre and our legislators.
Recent comments by chief minister of West Bengal after the incident of attack on an intern in a hospital in her state, " Several policemen also die on duty, but they never say they will go on a strike because of that."
This comment is really silly and not expected from a Chief minister. The two professions have no comparisons. Only thing common between the two is both the ordinary security personnel and junior doctors are on the front line. But the profession of the former involves combat at times with the goons/enemies and they are given proper training for it. Doctors are healers and junior doctors who are on front line are trained to deliver healthcare to the patients in need. The legitimization of violence against doctors that has happened in last few years is sad and this has to change.
This article will enlist possible solutions so that best healthcare delivery is ensured to common masses.
Before I suggest possible reforms which can be brought, the reader should understand the cadre of hospital.
Intern : Completed 4 and a half years of mbbs ----> now doing 1 year obligatory internship in a hospital before he is awarded mbbs. An intern's role in hospital is to give relevant investigations to the patient, patient monitoring and learning procedures and techniques under guidance of residents and senior doctors.
Resident: Pg course is 3 years in duration. Accordingly we have residents ---> pgy1, pgy2 and pgy3. They specialize in one particular branch; say medicine. Residents are the backbone of any hospital. They are the most numerous in number and they run the hospital 24*7.
Rest of the hierarchy nomenclature is irrelevant to this blog and the reader.
We have to understand that doctors in India are overburdened. A medicine or pediatrics resident on average gives 10-12 duties of 36 hours in a month. The state of residents of other branches is not so good too. These hectic duties surely affect the performance of the service providers. It brings in the residents psychological changes too. Also, this is not all that juniors doctors have to face. Interns have to concomitantly prepare during their 1 year internship for NEET PG exam to get high ranks (which ensures them the branch of there choice in post graduation ). The PG residents have to attend a lot many conferences, journal clubs, presentations and also prepare there thesis while giving hectic duties i mentioned above ( easily crossing 100 hours in a week ).
In the United States, the Accreditation Council for Graduate Medical Education (ACGME) regulates residents' duty hours. In September 2010, the ACGME released new standards which came into effect in July 2011 (after they found there residents are overburdened), include the a maximum of 80 duty hours per week (averaged over 4 weeks)
These guidelines were brought to decrease error rates. Although the trainees working under the current work rules spent fewer hours at the hospital, they were not sleeping more on average than residents did prior to the rule change, and their risk of depression remained the same as it was among the doctors working prior to 2011.
How could fewer hours lead to more errors? For one, interns reported that while they weren't working as many hours, they were still expected to accomplish the same amount that previous classes had, so they had less time to complete their duties. According to the researchers, this may be leading to work compression, and that can increase the risk of errors or mistakes if residents don't have as much time to make and recheck patient-care decisions. In addition, the pressure may be even greater for residents in many hospitals where the new restrictions on hours were not accompanied by funding to hire new staff to balance the workload.
There should be periodic audits ( by auditing body; structure explained below ) in all hospitals to determine the need of actual number of post graduates; if fixed working hour times for post graduates have to be followed. Annually, considering the patient load in respective hospitals, demand for seats of postgraduates should be increased or decreased by the auditors involved in the process. At the same time, hospital administration should make sure that all prerequisites set for granting post graduate seats are meant, so that the hospital gets permission from central regulators to increase post graduate seats as per demand to match patient load effectively.
Conclusion from 1 and 2: There should be further comparative studies to determine adequate working hours for the residents. But one thing is for sure, currently medical residents in india are overburdened by there duty hours and hence are not able to maintain work-life balance. Even if at >80 hours/week, residents are able to deliver same level of health care as < 80 hours/week, still a resident is entitled to a life outside hospital and should be treated at par with other professions in work hour times. Instead of overburdening one resident, work should be divided properly by employing adequate number of residents.
Now we have got adequate number of residents with good working hours who are able to deliver there best and maintain work life balance. Still there can be instances, when the residents can face the wrath of angry attendants. Some of the things which can be done are:
a) Decreasing the attendant load in hospital ( possible solutions )
Only 1 attendant can accompany a patient in emergency/OPD. If the patient is very sick, not more than 2 attendants will be allowed
In wards, we see lots of relatives coming to visit the sick patient in recovery. There should be a mechanism to ensure that if any more than 2 attendants come to visit, they would be charged a fixed amount say 500/- rupees and that would go to revenue of government hospital and the same amount received would be cut from patient's total medical bill in case of private hospital
Less attendant load will help residents to deliver more time to the patient. At the same time, less number of attendants in the hospital decreases the chance of doctors being assaulted.
b) Effective number of security personnel available at all high patient load points in hospital round the clock
c) CCTVs should be present at all possible places in the hospital
d) Written undertaking should be taken from the attendants that they in any case would not get involved in any form of violence against any hospital staff. If they do so, they will have to face legal action ( outlined below ).
Now our adequate number of residents who work fixed number of hours ( decided after many comparative studies what are ideal duty hours ) have been provided with effective security to rightfully deliver there services ( hypothetically in this blog above ).
But there has to be an effective timely audit mechanism to assess the performance of this system. Ideally, it should be undertaken by a committee which must include postgraduate residents too as its members. There should be government civil servants and prominent citizens of the city/town (where the hospital is located) in the auditing committee to assess the efficiency of health care delivery, adequacy of residents available, if shortage of residents felt: ensuring steps have been undertaken by hospital administration to match the prerequisites set by national body overlooking allotment of postgraduate seats. The actions of the auditing committee will obviously come under RTI act so that average citizen should know how proactively the auditing body is working to lessen the deficiencies. The selection of the members of the auditing committee should be democratic and should involve voting that includes voting by all the healthcare staff of the hospital. The auditing committee can also be given additional powers of being a grievance cell for hospital staff which includes work place harassment, crime against women etc. Sufficient powers should be given to the body so that a healthy work environment is made for residents to work and incidences of corruption by anyone in hospital top to bottom are settled in the hospital only. If anyone has issue with the decision of the this proposed body, the courts are always there.
Point 3 which requires protection of the residents definitely needs a sound backing of law so that those who takes law in there own hands are effectively dealt with. Thankfully, Health minister of India has shown positivism in this regard. Any incidence of violence against the doctors on duty should be made a non bailable offense.
The central as well as state government should make sure that civil servants working in there respective ministries ought to have a fixed percentage of doctors. How can a Sociology graduate's opinion ( qualified IAS ) be more relevant that a DM Nephrology with 10 years of experience in hospital and who knows the hospital working from inside.
Lateral entry should be promoted further to ensure experts are able to frame effective health policies
India spends a little over 1 % of GDP on health, far below Singapore ( 2.2 % ), which has the lowest public spending amongst countries with significant universal health coverage service. PM of India has said in one of his speeches that he aims to increase current spending to 2.5 % by 2025. Schemes of central government like Ayushman Bharat are laudable and show good intent. But, there is a lot of margin still left in terms of implementation of the schemes actually on ground. All the solutions mentioned from 1-5 need money. So, effective funding is crucial.
Similarly, states can increase their spending on health in state budget. Instead of opposing each other's schemes for political factors, both center and state should come together and keep healthcare out of the politics. In this way, in a developing country like India, we will be able to maximize the impact of limited resources we have in terms of GDP expenditure on health.
So basically,
Adequate funding ----> Adequate infrastructure ----> Adequate number of residents working adequately with fixed duty hours -----> Adequate security and backing of legislation to make work environment safe ----> Periodic audits to ensure all is well with the preceding steps at hospital level -----> Adequate Healthcare
Definitely a happy resident will offer the best to his patients and the patients will be satisfied too if the above ideas are implemented in letter and spirit.
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