Physicians, heal thyself

Part - II
The teaching of medical students and post-graduate trainees takes a terrible hit in the current circumstances. We all learn from our teachers and the same culture is carried forward when the trainees themselves qualify and are appointed on one of the senior posts.
The ward rounds are a spectacle worth watching. There are more people on a ward round than those at attendance at a club level cricket match. Imagine the three senior staff, led by the unit head, followed by a procession of 20-30 TMOs, 10-20 HOs and then the nurses and paramedical staff. It looks as if an army of 40-50 people has invaded the patient’s space. How one can accomplish patient care and medical teaching in these two hours with this procession in tow is beyond comprehension.
The pathology and imaging departments paint an even worse picture. These should be the main producers for the hospitals in monetary terms. Despite an abundance of staff on payroll, these services, particularly pathology, for all practical purposes are almost non-existent. You see a mushroom growth of private labs around government teaching hospitals but would fail to see any in the vicinity of the big private hospitals. This is because big private hospitals conduct all pathology investigation in-house. Government-run hospital pathologists all have their private labs and various not-so-underhand deals are in place with them so almost negligible testing is done within the hospitals.
There is no system of Quality Assurance (QA) or Peer Review in place. As a result, there is no accountability and people literally get away with murder. There is no fair or unbiased system of reviewing unexpected deaths or complications occurring within the hospital. There are no reliable data on the mortality or morbidity rates within the hospital. It is a shame that hospitals are allowed to operate in this manner.
It is suggested that the present professor-centric model be dispensed with henceforth. It is incompatible with 21st century medical care and teaching and only serves vested interests. In the rest of the world, the titles of professor, associate and assistant professor are academic and/or honorary. These titles are not related to patient care in the literal sense. Those with requisite post-graduate qualifications and training all qualify as consultants or attending physicians who can lead patient care teams independently.
The existing human resources should be utilised to the fullest extent. Instead of qualified doctors acting subservient to one senior doctor, smaller efficient ‘teams’ should be developed. Each team could comprise a consulting/attending physician, a few TMOs, HOs and medical students. This way 20 teams each could be developed even from the existing resources of the general medical and surgical units.
The teams should participate on a monthly rotation schedule. These could be assigned various rotations such as the inpatient day shifts, OPD, afternoon/night shifts and consult services to other specialties. It should be mandatory for everyone, including the consultant/attending, to adhere to the work hours – say from 8:00am to 4:00pm. The OPD should run for full eight hours a day and the Operating Room for at least the same number of hours. Continuity of care should be ensured inpatient and in the OPD. Each TMO/HO/consultant should have one particular full or half day of the week assigned to the OPD where they see their own patients; independently for consultants and under supervision for HOs/TMOs.
A bed management system should be put in place, which efficiently places patients all over the hospital according to well-laid guidelines without geographical limitations. The admitting/consulting teams should then follow their patients wherever their physical location might be. The only separate, dedicated units/beds should be for specialties such as OBGYN and paediatrics. Even there, the arbitrary sub-division should be abolished and a numerically smaller but efficient team system be put in place. A pager/beeper system should be installed to ensure prompt availability during regular work hours or when on-call.
The allied specialties and sub-specialties should be developed primarily in the role of outpatient care teams and in a predominantly consulting rather than admitting role. This will lead to greater interaction among various specialties leading to better patient care and teaching.
The practice of getting patients to get pathology testing or imaging done from private facilities should be prohibited and any such instance should prompt thorough review and accountability. The government should ensure that labs and imaging facilities are well-equipped. This would require an initial capital investment but will bring in great dividends for these institutions, eventually making them financially independent and viable. It should be ensured that all pathology and imaging services are conducted within the hospital itself. Even send-outs should be through the hospital lab in arrangement with reputable labs such as those at the Aga Khan or Shaukat Khanum hospitals.
A robust QA process should be put in place to review unexpected mortalities and morbidities. Referrals to the QA should be encouraged without fear of reprisal, retaliation or intimidation.
The teaching of medical students and post-graduate trainees should be improved. Regular, dedicated teaching conferences should be a daily feature where the presence of trainees and faculty should be ensured. Once again, the post-graduate trainees and medical students should rotate on smaller, efficient teams that will enhance their professional growth.
As explained in the beginning, the Khyber Pakhtunkhwa Medical Teaching Institutions Reforms Act 2015 is not an ideal piece of legislation but a bold and commendable step in the right direction. The BoG in at least one of the MTI has already started implementing some of the changes suggested above. It is hoped that the government will not cave in to the entrenched vested interests and continue with its reform plans. In case of a medical emergency, everyone, including the high andmighty, have to come knocking at the doors of these hospitals and a better system will be to the benefit of everyone.
My recommendation for an amendment to the Healthcare Act would be to have one system instead of the dichotomy that it proposes. If doctors adhere to their duties, working at least eight hours a day, participating in a shift-based rotation, they should be free to do whatever they desire with their free time. They can then choose between outside private practice vs institution-based practice, as they please and should not be forced into IBP only. The only precondition should be that they fulfil their duties as employees of the hospitals to the fullest and not for a mere 2-3 hours a day.
The government should ensure that hospitals are properly equipped and that doctors who work hard are properly rewarded in terms of financial remuneration and other facilities. A culture should be established where hard work is rewarded – and rewarded well.
It should be understood that we all choose our careers ourselves and that government service and the role of a medical teacher is not a right but a choice. There are many excellent senior doctors in the government sector who work really hard even in the present system. I am sure they will welcome the new steps being undertaken. If some, however, feel that they are unable to adhere to the rules and regulations for one reason or another they should look at other avenues.
One thing is for sure: the current status quo has failed to deliver over the years and it must not be allowed to carry on any further.
Concluded
The writer is former president of the Association of Pakistani Cardiologists of North America (APCNA).