Health care always has a some political overtones , and this threads concerns a detailed article by a senior doctor of North America who at one time was also probably leaning to ANP of KPK and he has made some very pertinent points about how our hospitals work .
They are worth a reading and the very fact that “The News” published it in two parts means how serious he was at being heard fully .The whole article is pasted below the dotted line.
It has some solid points and I felt that in view of immensity of problem it needs a larger readership.
The suggestions put forward by the doctor essentially mean that “Professor Centric “ culture be replaced and USA style attending physician concept be introduced . A good local example of which is Shifa international where most senior physicians hardly have a dedicated good office and patients from different specialties are admitted to the same ward . Unlike present system where beds for each specialty is different and some times remain unoccupied whereas other units on take day are full and people are forced to bring beds from home.
The learned doctor has good points but what he is proposing has problems . As a matter of fact Dr.Arshad Rehan who has North American connections might not know that in 2000 AD , as a result of similar wish of certain Pakistani doctors in North America who wanted to offer some form of services to larger Hospitals and may be some control too , was a submission and proposal fashioned into a ten year gradual control of these via programme of Boards running hospital . These were handed to then President and principal secretary in APNNA meeting and never got proper well reasoned reply but it was found impracticable .
Dr.Arshad Rehan takes a dim view of Mushroom growth of labs around Hospitals and also criticizes senior teachers and the huge manpower accompanying professors in ward round of which we all know .
The lodgers of suggestions of year 2000 and Dr.Arshad Rehan is not aware , that it is not just a matter of egotism , no patient acknowledges a doctor as genuine in his heart unless he has a office of his own , some beds to admit on and some followers on round to pay homage too. The crowd is the only way to make everyone come on time on some days atleast.
It is not just the senior doctors , to whom this arrangement appeals , but the senior civil servants of other departments frown upon private style hospitals and want this system to stay . This system provides VIP centre like at PIMS for senior civil servants.Doctors will is a small fry , the senior civil servants want to benefit from jobs for their relatives , they wants shares in procurements etc.
The ward for one speciality has advantage that it is easy to round , during night some house officer or medical officer sleeping in side room can be woken by nurse or patient attendent. The doctor in attendance belongs to the field. In comparison in Shifa international where same system as supported by the writer , the night doctor often is not wellversed in case as he has to attend all type of fields as patients are not speciality wise . Result is not good .
The USA system is a high cost system , a battery of tests which in Pakistan costs 15000 would cost may be ten times as much in USA . In Pakistan medical specialist is the only one who offers his fifteen minutes for Rs 1500/- , He may be triply qualified from Abroad with 20 years experience while a lawyer would not talk unless 40000/- is paid in advance for nothing in comparison, while lawyer is locally qualified and most often a LLB from third floor law colleges .
The best option is not to chase Government owned institutions any longer for reforms . Best is reserve atleast 20% Budget of each major government funded hospital for hiring private GPs and Medical specialists , labs and small nursing homes in the catchment area of each hospital and contracting them to provide services free of cost or subsidized at government expense . This will reduce Rush in government hospitals and help finance medical profession . Doctors with no physical space and offices and no beds earmarked is a non starter for Pakistan . This will also force doctors to travel from ward to ward for long periods of time finding patients of his firm .
The worthy doctor should instead open a good free cardiac hospital as stenting so commonly needed is too expensive for poor persons and every second person is a smoker .
May be Imran khan is for whom he has gone to such trouble . Imran khan has good platform for experimenting with everything .
One last thing that outsiders should be aware of is that many people like government institution to pass some periods where it is neither fully under provincial government control nor fully autonomous , they use this period to do illegal things under autonomy and then revert back to government attached department . In PIMS there was strike three days back and all senior workers with substantial pension rights or other rights want no university , they want PIMS to be hospital again , after all there is no justification for shaheed Bhutto university , he was a hanged for murder man , with murderers confessing they murdered on whose behest .
Imran better stay away from reforming and concentrate on hiring private GP and acute hospital care at no or little cost to patient and funded by the state ,by cutting budgets of these big state hospitals , I do not think that Pakistani state can ever fund more that first two days of ICU care and free hired GP care for poor and very young or very old .
But our hospitals definitely need reform and learned doctor’s observations and suggestions need a good read and attention .
----------------------------------------------------------------------------------------------------------------------------------------
Dr .Arshad Rehan article
Text of the Above link below :
As expected, the Khyber Pakhtunkhwa Medical Teaching Institutions Reforms Act 2015 has generated resistance from various vested interests. This was to be expected. The legislation proposes changes in the way government hospitals are run, with the formation of a board of governors (BoG) for each Medical Teaching Institute (MTI). It also seeks to ask the senior physicians to choose between being civil servants or to employees of the institute itself.
The existing ‘civil servants’ and ‘employees of the MTI’ are given the option of either doing institution-based private practice (IBP) or outside private medical practices. Future employees, however, will only have the option of IBP. While the legislation is not ideal, it definitely is a step in the right direction. The implementation will now, however, test the resolve on the part of the political leadership of the province.
In this article I write to explain what the reality of the health care system is and address some of these issues in context of Pakhtunkhwa. I look at the problems afflicting the medical care, administration & teaching at the Medical Teaching Institutions in Pakhtunkhwa in particular and make some recommendations.
The present system in our tertiary care hospitals is broken. In fact, there is no system at all. What we have is a hodgepodge of arbitrary rules and regulations resulting from ignorance on the part of the government and bureaucracy and convenience of the physicians and ancillary staff with almost total disregard for efficiency and patient care.
This system was adopted from the old English and German systems of the 19th & early 20th centuries. It has since long become redundant in most of the developed world, even in India – as well as in quality private hospitals within Pakistan.
The present system in our tertiary care hospitals could aptly be termed ‘professor-centric’ rather than ‘patient-centric’. The universe of the hospitals is centred around the professors. The head of the unit is considered the god of everything within his ‘unit’ – with little or no accountability at all. A particular ‘unit’ or ‘ward’ is, for all practical purposes, the personal fiefdom of the professor. As one junior doctor remarked, the only thing lacking is separate flags or coat of arms.
There is a terrible waste of human resources within this system. There are four post-graduate qualified consultants within one unit: the professor, the associate professor, the assistant professor and the senior registrar. Instead of delivering independent patient care, the latter three, equally qualified by all means, work under the supervision of the professor who also presides over 20-30 trainee medical officers (TMOs) and some 10-20 house officers (HOs).
There is no bed-management system in place. Let us take the example of a typical medical unit. It has about 45 patient beds. It takes turns with on-call or emergency days. This creates a situation where if ‘Medical A’ is on-call, the 45 beds fill in very quickly. Now extra beds, in some cases brought by the attendants of the patients, are arranged even in the corridors to accommodate new admissions. This places more burden on resources such as toilets, ventilation, air-conditioning etc and creates an unsafe atmosphere for patient care. When even these ‘special beds’ get filled, new intake is refused citing bed unavailability.
At the same time however, the units that are not on-call, will have a number of beds available but no patients can be accommodated there as they are the domain of other professors. A survey conducted at the Khyber Teaching Hospital in Peshawar in the recent past revealed that the overall bed occupancy rate was only about 70 percent at any given time. This means that in a 1000-bed hospital, approximately 300 beds are empty while many deserving and critically ill patients are refused admission on account of this artificial bed ‘shortage’.
It is a rather unique phenomenon that there have to be strictly dedicated units or ‘beds’ for allied specialties such as endocrinology, nephrology, gastroenterology, ophthalmology and ENT etc. This again is because of the false but convenient notion that to employee a consultant (a professor), he or she has to head a physical space. This is one of the hindrances in the way of hiring more manpower, including many desperately needed sub-specialties.
The public, for example, may be surprised to know that none of our so-called tertiary care hospitals have any properly trained infectious disease specialists who can deal with conditions like complicated tuberculosis and other complex infections.
This corrupt and outdated system prevents efficiency and has developed a remarkable illusion of being overburdened. True that there are other variables as well but the hospitals will be overburdened if an efficient mechanism for patient care is not in place. The on-call unit will certainly look busy when it has patients lying in the corridors while in reality the next-door unit has 20 beds lying empty.
Working hours at our hospitals must be the most lenient anywhere in the world. The official hours are from 8:00am to 2:30pm but even these are not adhered to. A typical day for most professors at hospitals dawns at around 10:00am and ends at noon. During these two hours, patient care and teaching responsibilities are somehow miraculously handled. In some of the units, the professor and the associate or assistant professor have a mutual understanding where one would not show up at all for a week or so and then it is the other’s turn to take this unofficial vacation.
The OPD or outpatient clinics are the most neglected. Their hours of working are dismal. Most units start their OPD at around 10:00am and close shop by noon or at most 1:00pm. How can you then not get a mad rush at the OPD, when the patients are to be crammed within this two or three-hour window? Even with these abysmal hours, the senior staff seldom shows up at the OPD themselves. I was told that a certain professor of ophthalmology at one of the Peshawar hospitals has not graced the OPD with his presence for the last four or so years. This certainly is not unique.
The Operation Theatre (OT) also schedules cases from 7 or 8:00am to only noon or 1:00pm. Most of the staff then calls it a day with only skeleton staff left to deal with emergencies. We hear time and again that the OT is overburdened. Well it may not be overburdened anymore and two patients might not need to be operated upon in the same room at the same time – violating all codes of privacy and ethics – if the OT would schedule cases every working day from 7:00 am to 5:00 pm.
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
The writer is former president of the Association of Pakistani Cardiologists of North America (APCNA).
Source
They are worth a reading and the very fact that “The News” published it in two parts means how serious he was at being heard fully .The whole article is pasted below the dotted line.
It has some solid points and I felt that in view of immensity of problem it needs a larger readership.
The suggestions put forward by the doctor essentially mean that “Professor Centric “ culture be replaced and USA style attending physician concept be introduced . A good local example of which is Shifa international where most senior physicians hardly have a dedicated good office and patients from different specialties are admitted to the same ward . Unlike present system where beds for each specialty is different and some times remain unoccupied whereas other units on take day are full and people are forced to bring beds from home.
The learned doctor has good points but what he is proposing has problems . As a matter of fact Dr.Arshad Rehan who has North American connections might not know that in 2000 AD , as a result of similar wish of certain Pakistani doctors in North America who wanted to offer some form of services to larger Hospitals and may be some control too , was a submission and proposal fashioned into a ten year gradual control of these via programme of Boards running hospital . These were handed to then President and principal secretary in APNNA meeting and never got proper well reasoned reply but it was found impracticable .
Dr.Arshad Rehan takes a dim view of Mushroom growth of labs around Hospitals and also criticizes senior teachers and the huge manpower accompanying professors in ward round of which we all know .
The lodgers of suggestions of year 2000 and Dr.Arshad Rehan is not aware , that it is not just a matter of egotism , no patient acknowledges a doctor as genuine in his heart unless he has a office of his own , some beds to admit on and some followers on round to pay homage too. The crowd is the only way to make everyone come on time on some days atleast.
It is not just the senior doctors , to whom this arrangement appeals , but the senior civil servants of other departments frown upon private style hospitals and want this system to stay . This system provides VIP centre like at PIMS for senior civil servants.Doctors will is a small fry , the senior civil servants want to benefit from jobs for their relatives , they wants shares in procurements etc.
The ward for one speciality has advantage that it is easy to round , during night some house officer or medical officer sleeping in side room can be woken by nurse or patient attendent. The doctor in attendance belongs to the field. In comparison in Shifa international where same system as supported by the writer , the night doctor often is not wellversed in case as he has to attend all type of fields as patients are not speciality wise . Result is not good .
The USA system is a high cost system , a battery of tests which in Pakistan costs 15000 would cost may be ten times as much in USA . In Pakistan medical specialist is the only one who offers his fifteen minutes for Rs 1500/- , He may be triply qualified from Abroad with 20 years experience while a lawyer would not talk unless 40000/- is paid in advance for nothing in comparison, while lawyer is locally qualified and most often a LLB from third floor law colleges .
The best option is not to chase Government owned institutions any longer for reforms . Best is reserve atleast 20% Budget of each major government funded hospital for hiring private GPs and Medical specialists , labs and small nursing homes in the catchment area of each hospital and contracting them to provide services free of cost or subsidized at government expense . This will reduce Rush in government hospitals and help finance medical profession . Doctors with no physical space and offices and no beds earmarked is a non starter for Pakistan . This will also force doctors to travel from ward to ward for long periods of time finding patients of his firm .
The worthy doctor should instead open a good free cardiac hospital as stenting so commonly needed is too expensive for poor persons and every second person is a smoker .
May be Imran khan is for whom he has gone to such trouble . Imran khan has good platform for experimenting with everything .
One last thing that outsiders should be aware of is that many people like government institution to pass some periods where it is neither fully under provincial government control nor fully autonomous , they use this period to do illegal things under autonomy and then revert back to government attached department . In PIMS there was strike three days back and all senior workers with substantial pension rights or other rights want no university , they want PIMS to be hospital again , after all there is no justification for shaheed Bhutto university , he was a hanged for murder man , with murderers confessing they murdered on whose behest .
Imran better stay away from reforming and concentrate on hiring private GP and acute hospital care at no or little cost to patient and funded by the state ,by cutting budgets of these big state hospitals , I do not think that Pakistani state can ever fund more that first two days of ICU care and free hired GP care for poor and very young or very old .
But our hospitals definitely need reform and learned doctor’s observations and suggestions need a good read and attention .
----------------------------------------------------------------------------------------------------------------------------------------
Dr .Arshad Rehan article
Text of the Above link below :
As expected, the Khyber Pakhtunkhwa Medical Teaching Institutions Reforms Act 2015 has generated resistance from various vested interests. This was to be expected. The legislation proposes changes in the way government hospitals are run, with the formation of a board of governors (BoG) for each Medical Teaching Institute (MTI). It also seeks to ask the senior physicians to choose between being civil servants or to employees of the institute itself.
The existing ‘civil servants’ and ‘employees of the MTI’ are given the option of either doing institution-based private practice (IBP) or outside private medical practices. Future employees, however, will only have the option of IBP. While the legislation is not ideal, it definitely is a step in the right direction. The implementation will now, however, test the resolve on the part of the political leadership of the province.
In this article I write to explain what the reality of the health care system is and address some of these issues in context of Pakhtunkhwa. I look at the problems afflicting the medical care, administration & teaching at the Medical Teaching Institutions in Pakhtunkhwa in particular and make some recommendations.
The present system in our tertiary care hospitals is broken. In fact, there is no system at all. What we have is a hodgepodge of arbitrary rules and regulations resulting from ignorance on the part of the government and bureaucracy and convenience of the physicians and ancillary staff with almost total disregard for efficiency and patient care.
This system was adopted from the old English and German systems of the 19th & early 20th centuries. It has since long become redundant in most of the developed world, even in India – as well as in quality private hospitals within Pakistan.
The present system in our tertiary care hospitals could aptly be termed ‘professor-centric’ rather than ‘patient-centric’. The universe of the hospitals is centred around the professors. The head of the unit is considered the god of everything within his ‘unit’ – with little or no accountability at all. A particular ‘unit’ or ‘ward’ is, for all practical purposes, the personal fiefdom of the professor. As one junior doctor remarked, the only thing lacking is separate flags or coat of arms.
There is a terrible waste of human resources within this system. There are four post-graduate qualified consultants within one unit: the professor, the associate professor, the assistant professor and the senior registrar. Instead of delivering independent patient care, the latter three, equally qualified by all means, work under the supervision of the professor who also presides over 20-30 trainee medical officers (TMOs) and some 10-20 house officers (HOs).
There is no bed-management system in place. Let us take the example of a typical medical unit. It has about 45 patient beds. It takes turns with on-call or emergency days. This creates a situation where if ‘Medical A’ is on-call, the 45 beds fill in very quickly. Now extra beds, in some cases brought by the attendants of the patients, are arranged even in the corridors to accommodate new admissions. This places more burden on resources such as toilets, ventilation, air-conditioning etc and creates an unsafe atmosphere for patient care. When even these ‘special beds’ get filled, new intake is refused citing bed unavailability.
At the same time however, the units that are not on-call, will have a number of beds available but no patients can be accommodated there as they are the domain of other professors. A survey conducted at the Khyber Teaching Hospital in Peshawar in the recent past revealed that the overall bed occupancy rate was only about 70 percent at any given time. This means that in a 1000-bed hospital, approximately 300 beds are empty while many deserving and critically ill patients are refused admission on account of this artificial bed ‘shortage’.
It is a rather unique phenomenon that there have to be strictly dedicated units or ‘beds’ for allied specialties such as endocrinology, nephrology, gastroenterology, ophthalmology and ENT etc. This again is because of the false but convenient notion that to employee a consultant (a professor), he or she has to head a physical space. This is one of the hindrances in the way of hiring more manpower, including many desperately needed sub-specialties.
The public, for example, may be surprised to know that none of our so-called tertiary care hospitals have any properly trained infectious disease specialists who can deal with conditions like complicated tuberculosis and other complex infections.
This corrupt and outdated system prevents efficiency and has developed a remarkable illusion of being overburdened. True that there are other variables as well but the hospitals will be overburdened if an efficient mechanism for patient care is not in place. The on-call unit will certainly look busy when it has patients lying in the corridors while in reality the next-door unit has 20 beds lying empty.
Working hours at our hospitals must be the most lenient anywhere in the world. The official hours are from 8:00am to 2:30pm but even these are not adhered to. A typical day for most professors at hospitals dawns at around 10:00am and ends at noon. During these two hours, patient care and teaching responsibilities are somehow miraculously handled. In some of the units, the professor and the associate or assistant professor have a mutual understanding where one would not show up at all for a week or so and then it is the other’s turn to take this unofficial vacation.
The OPD or outpatient clinics are the most neglected. Their hours of working are dismal. Most units start their OPD at around 10:00am and close shop by noon or at most 1:00pm. How can you then not get a mad rush at the OPD, when the patients are to be crammed within this two or three-hour window? Even with these abysmal hours, the senior staff seldom shows up at the OPD themselves. I was told that a certain professor of ophthalmology at one of the Peshawar hospitals has not graced the OPD with his presence for the last four or so years. This certainly is not unique.
The Operation Theatre (OT) also schedules cases from 7 or 8:00am to only noon or 1:00pm. Most of the staff then calls it a day with only skeleton staff left to deal with emergencies. We hear time and again that the OT is overburdened. Well it may not be overburdened anymore and two patients might not need to be operated upon in the same room at the same time – violating all codes of privacy and ethics – if the OT would schedule cases every working day from 7:00 am to 5:00 pm.
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
The writer is former president of the Association of Pakistani Cardiologists of North America (APCNA).
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