Sunday, 3 December 2017

Doctors in India: Villains or Victims?

"We have not lost faith, but we have transferred it from God to medical profession"
- George Bernard Shaw

The doctors community in India, both in public and private sectors, is in a state of unrest. Every few days there is news about brutal attacks on doctors and these are justified by patients’ family and friends as attributable to alleged medical negligence. Thanks to social media, copycat attacks are becoming frequent. The members of the medical fraternity very actively exchange news/ideas, devise strategies to overcome the problem, go on transient strikes, get assurances from the powers that be that concrete steps would be taken to contain such attacks; only for the cycle to restart after a short period. In a study that was conducted by IMA a few years ago three fourths of the doctors surveyed said that they were physically attacked at least once. In a study published in the national medical journal of India last year, not only significant number of doctors are getting attacked but it is also grossly under reported. The trend is getting worse.

Doctors were considered Gods at one time, when did the doctors become demons? From being the rakshak why did they become raakhshas in the public perception.
"Vaidhyaraja namasthubhyam, Yamaraja sahodara!! Yamasthu harathi praanaan, vaidhyah praanaan dhanaanicha!!"
(Meaning: Salute you doctor, brother of Yama, for Yama takes away only our lives, you take away our lives and wealth too) Sanskrit subhashitha.

The problem started when the health care started shifting from public sphere to private. Up to early 1980s patients were get treated in the private sector but when they had major ailments depended on government and teaching hospitals for their treatment. With the advent of corporate hospitals who were capable of providing care for an extended range major ailments, health care cost escalated and high end health care became inaccessible to a majority of people in India. In the absence of national health insurance scheme many citizens make out of pocket payment (OOP) which pushes 32 to 39 million people every year into Catastrophic Health Expenditure (CHE), which is defined as health expenditure which threatens a family's basic standard of living. The situation is only getting worse by the fact that the government's expenditure on health is just at 1% of GDP. (MOHFW2009).

Doctors who work in private hospitals in India know very well that one of the important triggers for irrational behaviour by patient and families is financial issues, especially when the patient outcome is not favourable. The potential for catastrophic health expenditure could cause psychological havoc.

"The huge gap between the rich and the poor, globally and within nations is not only morally wrong, it is also a source of practical problems"
Dalai Lama.

A patient who is at the risk of eliminating his/her financial resources to obtain healthcare, does not realise medical science has its limitations, every illness cannot be cured and there will be an outcome which is unacceptable in some cases. Good counselling of the exact nature of the problem and probable or definite poor outcome including mortality can mitigate this misunderstanding to some extent. Most of the doctors in India have realised the importance of this only in the recent years. As we are battling out issues like large volumes of patients, limited resources and poor infrastructure in almost all public sector providers and most of the private hospitals; effective communication and empathy could be one of the ways to keep situation under control at least partially and temporarily.

"To effectively communicate, we must realise that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others"
Tony Robbins

Even as we doctors condemn unacceptable behaviour by patients and their relatives, can we absolve ourselves of wrong doings? Doctors say that there are some irregularities by a few individuals and a few hospitals and that should not be reason enough to portray the entire community adversely. True, that should not be the case but is it only a few individuals or hospitals? If we believe so, then we may need a reality check. Have we not heard of hospitals expecting their consultants to work to a target? Are we not aware of conversion rates, referral fees, unnecessary laboratory investigations by doctors and cross referrals, indicated or not?

"I am dying from treatment of too many physicians"
- Alexander the great.

This commercialisation and greed has become worse by the entry of unscrupulous businessmen, liquor barons and politicians into the ‘business’ of medical colleges and hospital ownership. Some/many, with their clout seem to flout every rule, manage accreditation yet unable to provide infrastructure or sufficient human resources.

"I have always tried to avoid politics because most politicians I know are quite dirty in terms of human dignity, ethics and morals"
- Steven Seagal

The reality is, when an idealistic young doctor comes to practice with noble intentions he/she is caught in this web of helplessness because of the lack of the right conditions needed practice his/her profession. This is highlighted by Dr Arun Garde, from Pune, in his book in Marathi "Voices of conscience from the medical profession".

"Every truth has two sides; it is as well to look at both before we commit ourselves to either"
- Aesop

So who are the one who get attacked and is physical attack of doctors justified?

The ones who are attacked are residents, doctors who are on duty in high risk areas, especially in government  hospitals, charitable trust hospitals, small nursing homes and occasionally resident doctors on duty in bigger corporate hospitals though the vicarious responsibility of treating these patients rest with the consultants. The corporate hospital owners or senior consultants who are in many ways responsible for the impression (or truth) that hospitals are primarily profit seeking places, never get attacked. Like every battle, it is only the foot soldiers who get attacked. By doing this the patients further alienate the residents who are already overworked, under suboptimal working conditions which results in worsening of already acrimonious situations.

"Soldiers win battles, generals get credit for them."
Napoleon Bonaparte.
(In this case they get attacked!!)

Are patients justified in attacking the doctors, whatever the grievance? If money is an issue, why do such attacks take place in government hospitals where treatment is free? While there may be many reasons, here is mine. We are living in a society which is becoming increasingly uncivil and aggressive. There are many people who throw shoes and slippers at politicians; vandalise houses of cricketers when there is something as trivial as defeat in cricket match. So when a major tragedy like a loss of life of a dear one happens they indulge in violence. Further, many of them come to a government hospital after exhausting their financial resources they have, this results in their desperate but bad behaviour.

The health benefit schemes introduced by some of the state governments have benefited the private hospitals and insurance companies; that government money could have been better used to improve the infrastructure in major hospitals. In a recent survey by the citizen engagement platform more than 40% of the participants said that they don't trust the private hospitals but 80% visited private hospitals when there was an illness in the family.

"There are far too many silent sufferers.
Not because they don't yearn to reach out but because they have tried and found no one who cares"
- Richelle E Goodrich

The media do not play a constructive role. The police choose to stay away because they believe it is natural for the patients to be distressed and use that as a justification. In some cases the hospitals and doctors don't help their own cause by criticising the treatment given at another facility either because they are not thoughtful enough or they think it will help in their own defence, thereby indulging in medical jousting. The already vitiated atmosphere is made worse by this, making an irate mob, violent.

"We are all connected, when one arm or foot is poisoned the whole body is infected"
Suzy Kassem.

We doctors often become defensive or even play the victim and say we sacrifice everything to continue as a doctor. Every profession in this competitive world has its own difficulties. Because we deal with human lives we seem to run the additional risk of getting attacked immediately by a crowd which gets provoked when things happen contrary to their expectations. However, we can demand stringent laws and better security in the work place. This is more easily said than done.

"Doctors are only doing KRIYA, that is earning their livelihood through this profession, not doing KARMA, that is doing charity for betterment of mankind"
Dr Pankaj Chaturvedi, quoting Bhagavath Gita

The educated people rarely resort to this kind of physical violence against doctors. I know of instances where frank negligence on the part of  doctors resulted  in mortality and morbidity. I know how a middle aged executive became disabled because of inordinate delay and inappropriate treatment; an elderly surgeon who succumbed to negligent care following a surgery and another elderly gentleman never recovered from an easily treatable problem because it was identified late. All these hospitals are well equipped, high end hospitals and what happened there was definite provable negligence. The families of these patients because of their education and politeness did not indulge in unruly behaviour despite spending huge amounts of money for treatment.

"Human behavior flows from three main sources, desire, emotion and knowledge"
- Plato.

Is it not an option to go to the consumer forum? According to a study, cases in the consumer forum has gone up by 400% in the last decade, the inordinate delay to get justice in Indian legal system adds to the frustration. Recently there was consumer forum ruling which was pronounced in 2017 for a case filed in 1998. More over the economically underprivileged ones are left with very little to fight a legal battle after they have spent their money in treatment, so they resort to their version of instant justice.

"Do not expect justice where might is right"
- Plato.

We are not Gods and cannot save all patients, we live at a time and age where practice of defensive medicine is almost a norm. We have not been able to address our issues of poor patient doctor ratio, infrastructure, abysmal working condition and inappropriate financial compensations.

Too many questions. Too few answers. The way forward.

We need a mechanism where we can make the patients our partners and communicate our difficulties to them. We have to spread awareness among public the factual and realistic capabilities and limitations of today's medical science.  We ought to stop advertising treatment modalities which may not be of benefit. We have to stop advertising treatment which could be inaccessible to many.

The doctor - patient trust and relationship is at its lowest point. Is the only way ‘up’?

While we demand a civil behaviour from our patients, it is important for us to do some soul searching and take that extra step and walk that extra mile to restore the trust and confidence of patients in doctors, medical profession and hospitals.
This in no way is a justification of violence against doctors. Every challenge is an opportunity and this is an opportunity for doctors for course correction where appropriate. The argument is advocatus diaboli.

"As doctors we generally don't tell outright lies. We don't speak the truth fully."
Dr.Allan Hamilton.

Are the patients ready for it? More importantly are we doctors ready for it?

Dr Usha
Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)


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Monday, 5 June 2017

Why current healthcare will be obsolete and what we need to do about this

The writing is on the wall.

The last few decades have seen 2 groups of people: One group that is “dying longer”, yes some might call it living long but not healthy. As a physician I call it dying longer. These are folks who are disabled, obese or emaciated and depressed or demented, with multiple medical issues spending a quarter of their life in the medical system, and the last decade of life in a long term care facility. Everyone knows someone in the family that is taking a multiple medications and is still sick and needing care. 

The other group has people whose symptoms similar to their sick family members but want to resist going down the same path of chronic illness with multiple medications. Since the traditional system seems to offer nothing beyond a pill for every ill these folks are seeking alternative healing pathways.

Why are they not using the constantly advancing medical system? It is because medical system is making advances in leaps and bounds on diagnoses and management of diseases with AI (artificial intelligence) however what they are failing to see is people do not want to have the next best treatment or the greatest new drug. They simply want to be and feel well with no medications and have complete resolution of their symptoms.

Here comes the total disconnect: A system that is creating newer tests and drugs and a clientele that is interested in partnership and cure and not a patriarchal dispensing of drugs.

This has created a new group of “healers” who have taken to the social media and the web with personal experience of healing themselves as the only qualification needed to become an “alternative health care provider”.

How did this shift happen? Why did this shift happen?
The shift was slow and steady and now it has exploded (reaching that critical mass). Everywhere you turn there are several online courses to help you finding healing opportunities. Courses that help you heal your thyroid. Courses and providers who help you heal your metabolism and your gut. Businessmen, actors, activists, who have created apps and tests to address your true weight gain issues, hormone issues, autoimmune issues and the list is endless. Not only are they providing what the public is looking for they are also creating this distrust in the current medical system.

As with everything else that starts off with a noble cause like climate change, like animal rights, like alternative energy, seeking great health is a valid cause, but is now being monetized by everyone. And when people are desperate they will find themselves spending a lot of money and taking a lot of ill-advised treatment till they find the right solution or they actually harm themselves in the process, and become skeptical of the whole system.

The shift happened because the medical system is behind in times. It is not held to other service
industry standards where the clients’ voice is heard.
Clients I do not believe want a cable TV in their hospital room. They do not want their powdered
scrambled eggs on a platter, for breakfast. They simply want to feel well. They want results not another surgery or pill for their ill. They are tired of being tired and sick. They are tired of taking another medication or adding another supplement to their

On the other hand today’s medical world is considered a great place to stay employed for a long
time. It costs 16 to 19 % of our GDP and yet the outcomes are a growing list of chronic medical
conditions with rising costs and insurance premiums with no end in sight. Our development is trying to put the care into the hands of the patients using apps, artificial intelligence and the growing field of telemedicine where we are educating people that their care is a click away. We are educating people to look for sickness and quick relief of symptoms when they are seeking permanent wellness.

So how do we sort through this dynamic shift?

The medical schooling needs to change. We need to embrace the need to understand how and why the body shows symptoms not simply identify and suppress this instantaneously with a drug that can only potentially cause another problem.

Hospital profitability needs to change. When a hospitals’ profit is tied to full beds (healthy people
do not occupy hospital beds) we will be promoting illness not wellness. Hospitals should be fewer and most of the hospitals should become healing sanctuaries where people are admitted initially for acute care they need and then transferred to the sanctuary part, where they address the root cause of illness. Here, they should educate and engage the patient in change in life style addressing stressors and the outcome being getting the body back to health.
This would be the best of both worlds where the provider is educated in the art of true healing and the study of the science of disease.

The medical industry is riddled with contradiction. We are trying to “cut medical costs” by getting mid-level providers to provide early detection and not true prevention( primary care), we are trying to emasculate the image of a physician by making them data collectors and with increasing regulations, in the name of efficiency(standard guidelines and EMR). We also promote the newer drugs and more expensive testing and surgeries. The medical associations
are living off the support of “Big Pharma” that thrives off of illness.

So what do we really want? What business are we truly in and who is our ideal client?

This should be our food for thought.
Nisha Chellam M.D. ABIHM 
Internal Medicine

Find out more about Dr N Chellam's work at this website 


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Saturday, 27 May 2017

Ebbinghaus Illusion : Philosophical and Human Factors thoughts

The Orange Circles, both of them are exactly the same size. However, at a quick glance, it is very obvious that one looks bigger than the other.

Philosophical questions

The first question is which orange circle would you like to be? Small fish in a big pond or big fish in a small pond? Why? If you are the fish, do you realise that the fish is the same irrespective of the pond. Are you living in hope? Are you living in false hope? Do you think the big pond means that you have a great opportunity etc? The size of the pond does not allow the fish to become bigger or smaller.  Is it a protection mechanism that you are using? Small fish in a big pond, are you trying to hide to protect yourself? Are you trying to be insignificant? Do you fear that you might be attacked by predators? Big fish in a small pond, are you the predator? Are you trying to show off and dominate? If you are, what impact is that having on your eco-system?

Political questions

If you are surrounded by ‘small’ people it may make you seem/feel big and if you are surrounded by ‘big’ people it may make you seem/feel small – would you be aware of that? How comfortable would you be with that? What would upset you? How can you use it to your advantage?

Human Factors perspective

What goes on around you can distort your perception. We also know that our perception is our reality. We face adverse effects for ourselves and create adverse effects for others by distorted reality.

Let us say you are selecting someone for a job or a promotion and you faced this distortion and always picked what you thought was a bigger orange circle, you would be causing chaos and confusion. Let us say both the orange circles are urgent medical conditions and you constantly chose the ‘larger’ one you would continuously disadvantage one particular group of patients.

Similarly, when gearing up for tasks, you could be under prepared or over prepared depending on how you perceive. You could then face surprises, nasty surprises that could harm. It is this kind of illusion that results in over estimating our strengths and underestimating our weaknesses.

It is okay for poets to talk about the moon being larger and closer or smaller and farther but when it comes to operations of any kind but especially in healthcare - Measurement and objectivity are important, they become even more important in complex situations.


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Saturday, 25 March 2017

Busting Myths in Healthcare Management

Busting myths in healthcare management
A dozen at a time

Myth 1

Quality can be measured

(But, Quality Improvement can be measured)

Myth 2

Publications and guidelines (national) are a good source of evidence (for QI)

(Often published evidence is invalid, not robust enough or gets outdated soon. Guidelines are rarely tried in their totality before being recommended)

Myth 3

Increasing Quality Increases Cost

(Improving Quality Decreases Cost)

Myth 4

Improving Quality Improves Safety
Often No

(Improving Quality Improves Quality, Improving Safety Improves Safety. According to definitions they are two different things.)

Myth 5

Management by Objectives/Targets are good (for QI)

(Targets especially mandatory ones are prone to scamming)

Myth 6

Above Average is a Good Indicator of Quality

(Averages are flawed. Averages are not real)

Myth 7

A high percentages of good things and a low percentages of bad things are good indicators of quality improvement
May be but not really

(Percentages could be misleading. Percentages are not real numbers)

Myth 8

Culture Can Be Changed

(Processes can be changed and that may change culture)

Myth 9

All Directors in the Board of Directors are Leaders

(Leaders are follower defined not position defined)

Myth 10

Management Principles are the same for Healthcare as in any other field

(The frontline in healthcare is unique and very different)

Myth 11

Errors can be eliminated (in healthcare)

(Errors can be reduced but cannot be eliminated. But harm can be eliminated.)

Myth 12

Human Factors is about Changing Behaviour

(Human Factors is about changing Design)

 You can learn more about these from many sources (eg. University of Hull or enquire about a bespoke course )


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Sunday, 1 January 2017

Medical Education Reforms in India - Too Little Too Late?

Medical education reforms in India - Too little too late?

India is the second most populous country in the world with a population of 1.3 billion. The numbers are an issue, however, the diversity of our population is an important consideration as well.  This diversity is reflected in almost every aspect of our culture and policy including education; this often is worthy of celebration. However, when it comes to healthcare, this diversity results in fragmentation. Without a unified approach we cannot improve our performance in public health, which lags far behind other countries on nearly every health and human development indices.
Therefore, the need of the hour, is a robust system of medical education, which improves the quality of doctors it produces.

When we discuss health education we need to look at three important aspects:
a) the selection of students,
b) their training and
c) their evaluation when they complete the course. 

Till this year we had problems beginning in the very first step, the selection of students. In a country with multiple certification boards of school education and varying standards, we obviously did not have a single system of entrance examination. This meant every state conducted its own entrance examination. To add to the complexity some of the private medical colleges indulge in malpractices helping students slip through the cracks of such a fragmented system.  One of the most apparent manifestations of such malpractice was the concept of “capitation fee”. A student who had obtained a seat in one such medical college last year stated under anonymity that he “booked” his seat in advance and entrance test was a mere formality. The admission tests conducted by state funded colleges are not free from malpractices either. In the newly formed state of Telengana, the admission test was conducted thrice possibly because of similar issues in 2016, putting the students through a lot of inconvenience and extreme uncertainty.

The National Eligibility cum Entrance Test (NEET) was introduced in 2012/2013 for entry into postgraduate and graduate courses. With the NEET it is mandatory that a student should have a minimum qualifying mark to be in the merit list, which is applicable even to private medical colleges as they also come under NEET unlike earlier times when there were no such criteria. For political reasons some of the states and the private medical colleges appealed against it in the apex court. The court ultimately quashed the exam, calling it illegal. This verdict was unfortunately pronounced after students appeared for the test and exams had to be conducted again by the respective states for admission.

Again after three years it could be reintroduced for graduate entrance in 2016. This year too, plagued by confusions it was conducted twice. Later because of lack of clarity the states were given the option of accepting or rejecting the test. This resulted in windfall for private colleges which increased the fee steeply because parents of children who would have let them repeat the test in the normal course next year, if unsuccessful in the first attempt, crammed for the seats paying hefty donations.

From this academic year we are going to have NEET on regular basis for graduate, postgraduate and specialty courses. This would at least curb manipulations in the conduct of the test because it is an online test. This also ensures the students get a qualifying mark to be in the merit list.
Dealing a double blow to  merit is the system of reservations which being  primarily caste based instead of income based, results in quality medical education being put even further out of reach of meritorious but economically backward students. Even with NEET, this system of caste based reservation has not been done away with.

Moving past the testing process, we find issues with testing methodology too. We still persist with methods which tests only memorized knowledge and not the student’s analytical skill. Likewise ,there is a gap in testing the student’s aptitude. There is no method at the time of admission to check if a given student has what it takes to become a doctor. The Charaka Samhitha, an ancient medical treatise which dates back to 2nd century BC candidly describes the attribute of a medical student. It states: ”The ideal medical student should be of  mild disposition, noble by nature, never mean in his acts, free from pride, strong of memory, liberal minded, devoted to truth, likes solitude, of thoughtful disposition, free from anger, of excellent character, compassionate, one fond of study, devoted to both theory and practice, and seeks the good of all creatures”. No one could have put down more succinctly what is required of a medical student. Not paying heed to these words of wisdom over the years has resulted in generations of doctors who are poorly informed and unprofessional.

The problems, unfortunately, do not end with selection process and continue into training. There has been no major change in the curriculum, which continues to encourage rote learning. It is not formulated according to requirements of the population which the doctor under training would be catering to, but focuses on a learning a lot of theory. Such a curriculum fails to inspire students, whose studies are getting so diluted that they would choose to read study guides instead of text books. None of these augur well for the training of good doctors. This issue was addressed in the Vision 2015 document, which was drafted by a Board of Governors who took over from the MCI. The blueprint, which covered both graduate and postgraduate education, detailed an entry level exam which is common, a curriculum which has both horizontal and vertical integration where the students are trained in basic sciences, lab sciences and clinical sciences from first year onwards and a nationwide common exit level exam before the degree is awarded. The whole process is yet to be effectively implemented though the document was drafted in 2013.

The infrastructure in government funded colleges leaves a lot to be desired, due to the inadequate budget allotment to health and education. A mere 4.05% of the GDP is spent on health, which funds government hospitals which are supposed to be training the medical graduates. Even what is allocated is not fully spent, due to the leakage of funds at all levels. Added to this is the shortage of faculty who, because of better remuneration choose to work in private hospitals. The private institutions also do not spend their revenue on upgrading the infrastructure after their approval and do not most often have required staff.

Realising the need for the long awaited reforms in medical education, a three member committee of the NITI Aayog drafted the National Medical Commission Bill 2016 which would replace the Indian Medical Act, 1956.This in itself is a topic for discussion. The draft bill, aimed at bringing about a complete reformation has flaws which require immediate correction. The most important one is the issue of fee capping in private colleges, which is not clearly spelt out, which means deserving students inspite of a good rank in NEET, may not have access to most of the seats due to non affordability.

The next major feature of the bill which may be self defeating the purpose of improving the quality is the proposal of allowing “for profit” medical colleges. Though the rationale for this may be the need for increasing the number of colleges to meet the demand, this would once again bring in the private players whose intention of starting a college would be commerce. We have now 426 colleges, nearly half of which are private. One proposal that frequently comes up to overcome this problem is to upgrade large district headquarters hospitals to teaching hospitals.

If we need to have a medical education system that would be comparable to the rest of the world, we need to pay attention to student selection which should be purely merit based, infrastructure, training and their evaluation. This is the only way to produce doctors who would be able to face the unique challenge s faced by the society and health care industry.

Dr Usha
Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)


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Wednesday, 7 September 2016

A Discriminating View of the Doctors' Staffing Crisis in the NHS

We are going through extraordinary times for the NHS, especially so for doctors. From my perspective, this reflects the effect of not getting it right for everyone from the beginning.

The NHS as a care delivery model is fantastic. Tax funded, free at the point of care delivery, delivered at more or less the same standard across the country. It is so special, no doubt about the model/pathway.

The issue comes when it comes to staffing that delivery model. There was simply no staff at any time to deliver this model. So quite simply, as was always done in British history, the UK looked abroad for resources (the detriment to other countries by this policy is till today ignored by the UK). For healthcare the crucial frontline resource - the doctors were simply imported, poached, stolen (you can choose whichever word you want depending on the perspective) from abroad. India being a country which has medical education delivered in English following a British system of medicine was a natural target. For ages, even till today many IMGs end up as GPs in inner city and deprived areas. But it is the hospital medical hierarchy where the glaring disparity hits you.

There was always a surplus of registrar and senior registrar posts compared to the consultant posts (there was a permanent pyramid). Now that may be a problem in itself leaving people without opportunities. What happened from the mid 1970s onward, the demographics of the pyramid shifted. In the registrar and senior registrar grades there were mixed ethnicity with plenty of IMGs but very few of the IMGs went on to become consultants. The locals were in line for progression to a consultant post barring unforeseen circumstances and the IMGs were to remain permanently as registrars and senior registrars barring unforeseen circumstances, till they retired or died. These were later called staff grades and associate specialists. Name change and plenty of warm talk but the intention and roles remained the same. 

In the late 1980s and early 1990s I have heard numerous that local graduates holding registrar and senior registrar posts stated openly, loudly and clearly that they will put up with difficult conditions and low pay because it is only for a relatively short time before they became consultants. Meaning, that locals will progress on to higher pay and the IMGs will remain on the lower pay. This suited a brilliant care delivery model to be delivered at a low cost using a rubbish discriminatory unjust medical staffing model.

Of course, this strategy would have worked except that more consultants were needed and there were not enough local candidates. By late 1990s early 2000s the system woke up to this and created more medical school places and in my view with the hope that this local - IMG differential would continue. Where it went wrong primarily is that they underestimated the impact of women entering medical school, like most men, most women are excellent doctors but firstly they also want a good lifestyle (in contrast to men who in my view were often married to their careers) and more importantly physiology demands that many women choose to have children. So workforce planning went for a six; more IMGs were needed and the flood gates were opened in the early and mid 2000s. 

You see, now, suddenly, the pay for doctors is thought of as high, suddenly evening and weekends are no longer want to be considered as premium pay time. When medicine was overwhelmingly a white, male profession with IMG men manning the lower ranks these were not issues, doctors pay was relatively high compatible with their education and contribution, weekends were precious. The demographics change to equal number of women and a large number of IMGs and the values change.

The next wrong calculation comes from the fact if UK thinks they can import their way out of this mess. I don't know about other countries but many Indian young doctors are very wary of coming to UK; the training opportunities have increased in India, the economic opportunities have increased in India and lifestyle is improving in India - the exchange rate alone is no longer attractive.

To me it seems that the establishment does not want medicine to be an elite profession as it was when it was white male dominated. This makes it distinctively unattractive. There was always discrimination, there still is; the difference now is that there is FOI, there is corporate social responsibility and transparency. In the past we knew IMGs failed exams but we did not know the numbers, we always accepted that we did not reach the necessary standard, we were expected not to reach the standard, we were brought up being told that we could not reach the standard. None of that bullshit anymore. We know the numbers which are spread immediately all around the world by email, whatsapp, fb and twitter. We are asking questions; does the Indian IMG paeds reg trained in UK and taking the exam in UK have a higher failure rate in the UK version of MRCPaed than the Indian paed trainee who takes the exam in India never having worked a day here? Does the MRCGP International AKT MCQ have a longer time to answer their question than MRCGP UK which puts IMGs at risk of failing a 'purely knowledge exam'? We suspect an adverse use of linguistic bias. We know that Scottish, Irish etc need a grade c in English equivalent to IELTS 6.5 but IMGs need an English standard much higher, yet found fault with their language. We know the students in England do not need English A levels to get into med school. The standard for IELTS for IMGs was not set by administering to a group of local FY2s, it was actually set by an equivalent of a large focus group sitting around a table and deciding what was an acceptable standard; what a marvelous way of standard setting (accompanied by truck loads of stats on why that kind of standard setting was valid, the whole lot I found dubious, okay, to put it politely, it was very highly subjective)

The senior doctors including senior IMG doctors seem to have a distinct mentality that is not quite in sync with the younger doctors and their aspirations. The true cost of discrimination against women, discrimination against IMGs is now biting back.

A fabulous care delivery model designed six decades ago by the local population for the local population in UK did not consider the career prospects of IMGs and did not care that women were not part of the game for a long time are now completely flummoxed when IMGs are waking up and women are demanding a different kind of atmosphere. 

I wait to see if the lessons from past atrocities will be learned, I wait to see if because of the change in demographics medicine will be deliberately made into a lesser profession. I am not optimistic about the people becoming just. Why am I not optimistic? Let us look at the current routes into UK for IMGs - the MTI and the PLAB.

The whole MTI premise is based on getting people into UK to fill in rotas. It would be very difficult to provide any proper training in two or three years; especially when MTI doctors are not deanery numbered trainees for whom there is still to some extent funding for training. When I look around, I find that most new entrants into UK are in rota fodder posts and not in any proper training posts. I am not sure if there are large number of MTI doctors who are undergoing specialised training  (say for instance in pancreatic transplants), I suspect most of them are at SHO and junior registrar levels.

Let us say that a doctor goes back to India after MTI and applies for a job in a corporate hospital in competition with a CCT holder - who will get the job? Let us say an MTI completed doctor applies for a job anywhere else in the world (middle east, australia, etc) what kind of a job will (s)he get on the basis of MTI? Has anyone asked these questions? My personal feeling is that in most of the cases a typical MTI doctor after the completion of the time and leaves UK as per the rules is unlikely to be a strong candidate for any job anywhere in the world (I am sure there will be exceptions to this assumption).

So what is the use of MTI posts? 

The next is PLAB route doctors who more often than not spend years in a variety of non-training posts. My advice to young doctors who come to UK after PLAB process is 'take a formal training post or do not take a post at all in the UK'.

If still doctors from India want to come to UK via MTI or accept a non-training post via PLAB then the only logical reason for that would be to use UK as a temporary staging post to analyse and access opportunities in the rest of the world eg prep for USMLE etc.

UK should stop looking at IMGs as rota fodder. The system should change to provide every doctor who enters UK only formal training posts with the intention of making them a consultant or a GP; there may be some who eventually choose not to practice as a consultant and take up a senior non-consultant post, that would be a matter of personal choice and not a systematic denial of opportunity. This means at junior levels there are only training posts. Well, will this ever happen, I wish it would but I am pretty certain it won't. The system is designed for and habituated to exploitation of the IMGs; that system is unlikely to shock itself by changing even when it faces its own existential crisis.

So unless there is a technological solution there is going to be an ugly muddle impasse in the NHS for a long time to come.


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Friday, 19 August 2016

Seven Day NHS from a 2006 perspective

The seven day NHS debate has been raging for a while now. People die over the weekend, people do not die over the weekend, weekend should become normal time, there are no staff, there is no money; the arguments are plenty.

Interestingly in 2006 I looked at this issue from a flexible working, work-life balance, ‘flexible weekend’ perspective. I did a sample survey of a small number of people and then qualitative interviews of an even smaller number of people.

The quest was to find out if NHS employees had the ability to choose your own two days off in lieu of the traditional Saturday-Sunday weekend off would they go for it?

My own personal view at that time was that employees would love the flexibility and really go for it. That was my mental construct, assumption, bias at that time; though I tried my best for my views not to interfere with my study. Once the study was done, I realised my assumptions were completely wrong.

The findings were fascinating:          

More than 70% felt there would not be enough staff to enable the system to run a routine 7 day NHS service

56% did not prefer to have the ability to choose their own two day weekly break (they would rather stick with the standard Sat-Sun)

66% felt that choosing their own 2 day weekly break/off days (in contrast to the traditional Saturday-Sunday weekly break/off days) will not improve their work-life balance.

61% felt that once this ‘choice’ of being able to choose their own weekly two day off was introduced they may be forced to take specific days off which may not really be of their choice

My views now

These findings from a good representative cross section but small number of NHS employees with a good rate of response to a questionnaire and from a selected representative employees personally interviewed in detail for qualitative analysis.

Firstly, it almost prophetic, that normal NHS employees even in 2006 felt that we would not have enough staff to run a seven day NHS. Those were the days staff numbers were growing and money was not tight; yet they felt that way. It seems even more true now.

Next, the importance of family and social life was based on having the weekly break on days common with family and community. Hence the ‘choice’ of the ability to choose one’s own days off in the week turns out not be a choice at all since it does not suit families and community.

The most alarming was the degree of distrust of the system and the managers – the employees felt that what was offered as a choice now could morph into something that they might be forced to do down the line.

We can see all these magnified big time in the junior doctors’ dispute – shortage of doctors, importance of a family/community oriented work-life balance and huge distrust of the system.

I paste some extracts of the study below to give you a bit more of the flavour.

It seems that the normal employee and the powers that be hold contradictory views. In that context if employees feel forced to do disliked activity engagement falls and unhappiness will rise - that cannot be good for patients. If the forced changes remain in place for long, new employees may know no different in the context of their employment but it will have severe impact on families and community - is that a price worth paying?


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READ ON......................................................


‘If it changes week to week, it would help us to get things done during ‘week’ days’

Leisure ‘facilities will be available on two full days and will be less busy’

Will choose Fri and Sat as alternate days off

‘I like having Saturday Sunday off. Husband works 5 days a week. Son at school. Sat-sun only time apart from annual leave that we have quality time as a family’ I will choose Sat-Sun as my preferred days.

‘I would like days off in the week during school holidays to spend more time with son and to cut down on child care expense’

‘It will help me with child care’
‘Friday prayer’
Will choose Thu/Fri.

‘My husband and daughter get week-ends off, so I would like to be at home with them’ I will deliberately choose Sat-Sun.

‘My husband is off work on sat and Sunday, (if I chose this scheme) I would be working when my family is at home’.

‘Working part time I have the flexibility of having two days off in one week as well as being off at weekends. It really makes no difference to me what two days I have off in the week’.

I like to have sat sun at home. My daughter is at an age where I do need to care for her. I do understand the reasons, as when she was younger I worked nights to accommodate her school hours.

To reduce stress I would like to break up my working days. Choose Tuesday and Friday off


‘Other family and friends have their weekends on Sat/sun’

‘Will lose contact with my kids’

‘My activities involve other people up and down the country and everybody may not be free on the same day’

‘Working on Saturday-Sunday can be mentally taxing’
‘Can’t coordinate with friends and family’s off days’

My husband and daughter are not at home Monday to Friday’.

‘My job would not be suitable for me not being here on two days during Mon-Fri. Patients would be unaware of my being here on Sat/Sun and would expect me to be available Mon/Fri’


A large number (20/23, 87%) of respondents worked weekends. This could superficially suggest they were in favour of flexible working or extended working practises. However, the weekends in almost all cases are mandatory contractual conditions being part of the job rather than due to an active choice by the respondent. There are nearly no opting out clauses from weekend work in many circumstances except perhaps on grounds of ill health.

Weekend working which is contractual was not seen by the employees as a form of flexible working practise. They did not mark it as a flexi-practise anywhere in their responses of their awareness and use of flexi-work. In the above contexts, working weekends as a mandatory part of the job could perhaps be construed as an ‘inflexible working practise’

Concerns about flexible working

It emerges that one of the main reasons for being wary about the choice of the concept of this study is that the employees may be forced to ‘take specific alternative days instead of Saturday/Sunday’. This is how it currently works with weekend work by ‘rota’ for doctors and by ‘self-rostering’ for nurses. The opt outs from such rotas are either rare or non-existent. Logically there is a fear that this choice will become an obligation or an enforced choice rather than a true choice with no benefits in return.

In the free hand responses the main theme that emerges is the family. The family was the reason why most respondents would not want any other days other than Saturday/Sunday as their weekly break lest it disturb their current family arrangements. In fact one illuminating response was that the Saturday/Sunday break was a positive ‘preferred choice’ due to the current established social more of mandatory weekly holidays so that the quality of cherished family experience is retained.


Some managers saw immense advantages to their particular family situation. However it could be argued to what extent would or should an organisation match with the employee’s family situation which by logical extension, as seen in the study, to the employee’s spouse’s arrangements. It can be understood how this can cause complex administrative difficulties.

The staff and the managers in this study gave similar reasons of family, work, difficulty in organisation and ability to provide a seven day service as affecting their choice of accepting or rejecting the proposed model, but came to different conclusions with the staff unwilling to accept a personalised weekly off-days and the managers seeming keen about it. The inference here is that the same scheme that suits the manager’s families seems not to suit the staff’s families. Hence suiting individual families seems an issue of primacy.


One manager said, ‘I don’t think a common weekly day off for everyone is that important’.

That statement contradicts the view of the Keep Sunday Special (2006) lobby arguments. The KSS feels that social capital is lost and engaging in community activity is affected by not having a common weekly day off. They quote USDAW poll where 92% of shop workers do not want an extension of the present working and NOP 2005 consumer poll where nearly nine out of ten people said that it is important for family stability and community life to have a common weekly day off. However the facts are that Sunday shopping is present and growing. The availability of online shopping and 24/7 weekday shopping and the argument to treat retail equal with other businesses such as restaurants and hotels makes an argument to treat Sunday different a weak one. Leisure is now commercialised and commodified and could be considered an industry. Hence, the question of communal leisure has to be weighed against individual choice. The difficulty is in understanding whether individual choice is truly available or is constantly overridden by organisational needs.

This debate emerges in this study as well in the form of staff being wary of being forced to opt for a ‘choice’ that they do not prefer and with the managers being enthusiastic about the study subject whether organisational priority would hijack individual choice.

Perhaps the average employees experience and perceptions have been shaped by the origin and difficulties faced by the ‘work-life balance issue’ with women having had to go part time, difficulty in returning to full-time work, gender based pay differences, the economic pressures on employees especially on women and single income families, increasing stress, decreasing satisfaction and the employer profitability orientation of the general debate. This could have played a part on our respondents being wary of new initiatives on ‘work-life balance’.

The evidence suggests that larger organisations offer flexible working practises including a wider range of the modes of flexi-work. Our institution being an NHS Trust hospital therefore fits in the profile of a large organisation and the proposed extension could be offered to increase the range of flex-work programmes.

The findings in this study is compatible with the evidence in the literature that shows that managerial, highly educated and high-income workers are more likely to take up flexible working since it is thought that they are more likely to benefit from organisational changes (Nisar). However in this study we also find that doctors as a group though fit into the profile who according to the literature are likely to embrace flexible working rejected the concept. This could be due to the specific situation of doctors whose terms and conditions are in general nationally agreed and set. Further since they already working shifts, weekends, on-calls etc they feel any further expansion of flexi-work as proposed could be manipulated to impinge on working styles, training and personal time.

There is a history of compensation for adverse working conditions. Weekend working is hence compensated with premium rates. The proposal under question offers choice but the findings could be interpreted as the loss of the opportunity to earn premium rates in the guise of offering an increased choice.

It has been argued that flexi-work arrangements are one of the many strategies such as flat hierarchies, horizontal networking, multilevel skills, team and employee involvement in operational decision making, to implement a decentralised organisation. But the evidence of this in practise is very limited (Nisar). It could therefore be surmised that in the absence of a package to effect truly decentralised organisation, the offer of flexi-work or its extensions may not have much takers.

In Senge’s view: “the fundamental flaw in most innovators’ strategies is that they focus on their innovation . . . rather than understanding how the larger culture will react to their efforts.”


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