“Dear Dr Aggarwal (President, Indian Medical Association)
I am a practicing surgeon and a long-standing member of the Indian Medical Association. Over the last few weeks I have received multiple messages from you to participate in today’s protest events termed the “Dilli Chalo” and the “Pen Down” campaign against what you call “atrocities” faced by the medical profession. Whilst many of the issues you highlight do affect me in my work, I am writing this open letter to explain why I have consciously decided not to participate in today’s campaign. By doing so I also hope to stimulate discussion amongst your members.”
Everybody has a right to differ. And, addressing such issues is very important. Critics are the best friends of the IMA.
But any reservations concerning the profession should be discussed under any appropriate IMA Platforms like local, state or national IMA meetings or through their representatives in the Central Working Committee or the Central Council of the IMA and not on any open fora. They can also be addressed directly to the national president. It is for this reason, that I have not put this letter in public domain but it is via IMA that I am answering your concerns.
“Physical violence against doctors needs condemnation. I have very early in my career been roughed up in the casualty of one of Mumbai’s teaching hospitals when a Member of Legislative Assembly was brought in shot dead. I have written publicly on this issue to state that whilst the problem is genuine the solution of offering security and protection is superfluous and symbolic.”
I agree with you in this aspect. There are two aspects to this. First, we need to understand that there has been a paradigm shift in the recent years. This is the Internet age and the expectations of the patients are changing and their expectations from doctors are much more from what they were earlier. The medical fraternity is not ready for this change because this change has happened too fast. We do not want to subject ourselves to any questioning; this is the way we have been taught that the doctor uses his skills and acumen to choose the best necessary intervention to treat the patient and informs the patient of the same.
But the patient of today is no longer satisfied with just this. He wants answers to everything. He has answers literally at his finger tips because almost everyone has a smart phone today. He wants to be a part of the decision making. We have to acknowledge that health care has changed from being ‘paternalistic’ to ‘patient-centric’.
The widening gap between doctors and patients needs to be bridged and the way to do this is by simple and well-informed communication. In its vision 2015 document, the Medical Council of India (MCI) had recommended early integration of communication skills training into medical curriculum, both at the undergraduate and post graduate levels. This needs to be urgently and promptly implemented by the Health Ministry. Soft skills should be compulsory part of our medical education.
But, having said this, protection for doctors is necessary and is not an unreasonable demand. Doctors often manage serious patients, especially in the emergency ward and ICUs. Any physical or mental abuse may disturb the doctor and in turn may adversely impact the care of serious patients.
In critical areas and emergency areas, provisions must be made to protect the doctors so that doctors can work with a free mind without the fear of criminal prosecution. Such provisions are in place for say, a public servant or police or for a judge or for a pilot, so why not for the doctor?
We believe in accountability, but no one can be allowed to take the law in their hands. There are appropriate fora for the aggrieved patients or their family members to file a complaint against the doctor.
“I work in a large public hospital in Mumbai where my own resident doctors recently faced the ire of relatives because seriously injured accident victims have to be ferried to other CT scan facilities because the hospital’s CT machine closes down at 4 pm for lack of staff. Public anger is often misdirected against junior doctors when the problem is of huge deficits in basic emergency care, which are visible to patients’ families.”
Health is a state subject and it is the constitutional duty of the government to provide healthcare to all. But the govt. looks after the healthcare needs of only about 20% of the population. The remaining 80%, who do not get beds in the govt sector end up in the private sector. Doctors, in both govt and private sectors, are overworked and there is a huge load of patients, which is unlikely to change as the Finance Minister recommends that a doctor is required to spend only 4 minutes with each patient. This is totally impractical.
As in the Uphaar Cinema tragedy, where the owners were held responsible for the mishap, the owner of the hospital or the establishment and the Chief Secy or the Health Secy of the govt should be held responsible for the lack of infrastructure.
“Way back in 1986 as young doctors in Mumbai’s KEM Hospital, we led a protest hunger strike demanding that the emergency medical ward be improved. Our protest was supported across the board by hospital workers and nurse unions, public organisations, political parties and, of course, the medical profession including the IMA. Three newspapers wrote editorials congratulating us on taking up an issue in the interests of our patients. It would be interesting for you to know that some of us were served termination notices on the charge of leaking sensitive information to the press. This termination was later overturned by the Mumbai High Court which observed that we had actually acted in public interest.”
Since I have taken over in the last two and half years, all our protests have been pro-community oriented. To provide affordable health care, a doctor needs to be happy and today my doctor is not happy. He is not working in a congenial atmosphere. He is under stress. Therefore, charity begins at home. We need to look after not only the public interest but also the interests of the doctor.
IMA does not believe in strike. IMA believes in Satyagraha. The Dilli Chalo movement on the 6th of June was not a strike but a Satyagraha. We even put out Ads in 6 newspapers in Delhi. We are continuing a dialogue with the govt. We have met with the Chief Minister of West Bengal and the Health Minister of Delhi. We have also met the Health Secy, DGHS and the Health Minister on many occasions in this regard. We always look for a peaceful and amicable solution but some degree of protest needs to be made, in order to make ourselves heard so that our demands register with the Govt and also the public.
“In 1984, as a young intern I participated in the leadership of a strike in Maharashtra to protest the opening of the state’s first private capitation medical college. Amongst the many events during the strike, I particularly remember a massive march on the streets of Mumbai where students, resident doctors, senior teachers and even members of the public including trade unions, student organisations and political parties participated. And yes, we also marched hand in hand with the then IMA state leadership. I refer to these incidents to point out that historically young doctors in India and even the IMA has a tradition of participating in issues of larger interest beyond the narrow confines of professional demands. Unfortunately, I cannot say that of today’s IMA. For that matter I would suggest that you have become extremely sectarian, sometimes even at the cost of the interest of patients.”
Presently IMA is working on the concept of IMA 1 voice. When it comes to the profession, there are no groups, there is no politics. More than a lakh of doctors were connected in the Satyagraha on that day, which is an unmatched record in the history of IMA. Here, I would like to share with you some figures.
- 11,788 members of the association were present physically at Delhi IG stadium
- 43,767 members of the association signed their digital attendance
- 75,000 members were reached through eMedinewS, a daily news letter
- 67, 000 members were reached through eMedinexus, a virtual medical platform
- WhatsApp video appeal opened by 172,564 members
- Voice SMSs sent to 180,000 members. 32,456 members answered the call and 8,634 members signed their pledge.
- Online petitions signed by 63,457 members of the association.
- Total views in IMA Website Dilli Chalo 37,745 members
These numbers tell us that this movement was non-sectarian, beyond politics or any factions.
I have never been involved in IMA politics. I always liked to get everybody involved and work alongside me. The very fact that over one lakh participated in the Satyagraha means that this was not just an involvement of people but involvement of the pain and misery of the doctor fraternity who wanted to project themselves under one roof and under my leadership.
“For example, last year I was a part of a committee formed by the state in Maharashtra to formulate a local draft of the Clinical Establishments Act. One of the terms of reference of the committee was to “rationalise” fee structure. Some of us thought that this was a good opportunity to come out with broad guidelines on charges and improve transparency in the billing process in big hospitals. In my view this is one of the single biggest trust deficits today between our profession and the people. The IMA representatives in the committee opposed us tooth and nail, and with other medical associations scuttled this provision from the final draft of the bill. This in my view was also due to the fact that your leadership in many states is essentially from nursing home owners whose financial interests seem to determine your stands.”
We are drafting a central model Clinical Establishments Act. You can send your suggestions to us. We will welcome them. As far as charges are concerned, the Health Ministry has agreed that all charges have to be in consultation with IMA. The charges have to be reasonable, but the seniority and experience of different people have to be maintained. The MCI also mandates that consultation fee and other charges have to be transparent.
IMA has now opened a Costing Dept to guide formulation of charges under various heads. If you volunteer your services to this, we would be happy to take your services.
“I would also like to remind you of a letter I wrote to you in February 2016. This was in the context of the incident at Jawaharlal University where a group of students were charged with sedition. You and your colleague had written a letter to the Home Minister of India on the letterhead of the IMA congratulating him for the action they had taken against the JNU students and warning medical students not to participate in such activities. I wrote to you asking whether this was a view of the entire IMA and whether the issue had been discussed before the letter was issued. I still have not heard from you though you acknowledged receipt of the letter.”
No such letter has been officially issued by the IMA. And one letter, which was being debated by IMA, was leaked by somebody, because the IMA decided not to release the said letter. It was not the IMA stand.
“Whilst you showed instant concern over the events in JNU, the IMA has been silent over several issues related to public health problems in the country. Whereas you include the demand for a fair conduction of the NEET exam, the association has never openly attacked the very idea of private capitation medical colleges and deemed universities controlled by powerful politicians that have played havoc with India’s medical education system. In my view, your letter to the Home Minister was nothing but an attempt to curry favour with the new power centre.”
NEET is because of IMA. NEET has taken care of all private capitation fee, and it is because of the efforts of the IMA that NEET has happened and the system has got cleaned up.
IMA is also for 25,000 PG seats for Family Medicine. We believe that GPs are the backbone of medical practice as they are the first point of contact for the patient. IMA wants a proposal for family doctors so that cheaper and affordable healthcare can be delivered to the people.
“There are indeed many serious issues involving working conditions of medical professionals in India. Whether it is the pathetic working conditions of resident doctors, the pressure faced by doctors in large private hospitals for reaching “targets”, the browbeating of honest doctors by threats of transfers in the public sector, the IMA does not have any substantial record of taking up these issues. On the other hand your demands like stopping “unscientific mixing” of various systems of medicine are hypocritical given the fact that many of your members employ doctors trained in alternative systems of medicine as resident doctors. Or are lay people to understand that you make an exception to your stand when you get cheap labour?”
Improving the working conditions of doctors is of great concern to us. We are essentially fighting for the parity of service conditions and improvement in infrastructure for all residents and the faculty.
Doctors in large private hospitals do face pressure to reach certain “targets”. But, IMA has already passed a resolution that targets, in both private and govt sector, shall not be accepted. IMA has also come out with a policy that they will remove the member from the primary membership if any member is found to indulge in unethical practices, cuts and commissions. If any member is found guilty of sex determination, the Association would also terminate his/her membership.
If cases of threats of transfers are reported and brought to the notice of IMA, then IMA can take action. IMA has been taking up such issues on priority.
Our stand is that Ayush should be promoted along with all respective systems of medicine. If they wish to work with each other jointly, it is fine. But, if they are going to interfere in each other’s pathy, the respective pathy will never grow. If the message to the public is that Ayurveda wants to prescribe, for example, Crocin, the perception is that there is no treatment for fever in Ayurveda, which I don’t agree with. I am a strong advocate for Ayush and believe that they should be respected and encouraged in their own respective fields of medicine.
Employing doctors trained in alternative systems of medicine as resident doctors is not the policy of IMA. This has been clearly stated by IMA. Also, there are many state medical council decisions where doctors have been punished for employing Ayush doctors.
“Finally, I wish to suggest to you that whilst you articulate the narrow problems of allopathic doctors through such protests, you are not likely to reach far without the support of a section of public sentiment. When, in the spirit of medical associations across the world, including the IMA of yesteryear, which have a glorious history of defending the interests of patients as they defend their own, you decide to hold a march for affordable and accessible health care, you can count on me to be there.”
We are for the public, we were for the public and we shall always be for the public. In the next couple of months, IMA will come out with a series of public awareness events in the interests of the society. The doctor-patient relationship is a sacred one that cannot be disputed.
In my presidential address when I took office, I had said that there is now a paradigm shift in the thinking of IMA from a professional approach to a community approach. We have shifted to what “IMA Should Do” from “IMA can do”. IMA is now community friendly and we are now doing a lot of community-friendly work.
You can contact me via email any time. My email address is firstname.lastname@example.org.
I hope for and look forward to your participation in all endeavors of IMA.