DNB now equivalent to MD/MS/MCh/DM degrees

The Diplomate of National Board (DNB) degrees have finally been equated with MD/MS and DM/M.Ch for teaching jobs. The DNB degrees in broad specialities will be completely equivalent to the MD/MS degree; and the DNB degree in super-specialities will be equivalent to the DM/M.Ch degree.The latest notification from the Government of India can be downloaded from here.

The Union Ministry of Health and Family Welfare (MoHFW) and the Medical Council of India (MCI) were earlier in a standoff. The MCI guidelines were formulated by the Post-graduate Medical Education Committee (the PG Committee) constituted under Section 20 of the Indian Medical Council Act, 1956. It was on the basis of the recommendation made by the PG Committee in 1993 that the Government stipulated in October 1994 that for teaching appointments in broad specialities, a DNB degree holder was required to have at least one year’s experience as tutor/ registrar/ demonstrator, or an equivalent post, in a recognised undergraduate medical college. Similarly, for teaching posts in super specialities, a DNB awardee was required to undergo two years’ training in a recognised medical college with recognised post-graduate degree course in the concerned speciality. The Health Ministry had said that its Diplomate of National Board degrees will be treated on a par with the MD/MS and DM/M.Ch degrees awarded by Indian medical institutions for the purpose of all appointments including teaching posts in medical institutions.

Every year, there are about 25,000 medical graduates of whom 9,000 obtain MCI-approved post-graduate degrees and about 3,000 qualify with DNB degrees. But employment opportunities in medical institutions were significantly limited for DNB degree holders because of the MCI guidelines. There was also scope for at least doubling the number and also institute national programmes in areas where there is shortage of faculty. But the MCI directives prevented many institutions from offering their facilities for training DNB students.

While the Indian Medical Council Act only mandates the MCI to prescribe under-graduate courses and degrees, as well as approve the corresponding institutions offering them, it has only advisory and recommendatory powers as regards post-graduate courses and degrees. However, according to the NBE, the MCI had in recent years begun to impose guidelines for post-graduate education as well. These guidelines, as formulated by the PG Committee, rendered a whole cadre of DNB-qualified post-graduate medical students ineligible for teaching posts in medical institutions. This assumed authority, the NBE contended, went beyond the provisions of the Indian Medical Council Act.

The requirement of additional experience was reasonable earlier because DNB students did not do any dissertation for their degrees. But now since DNB students also have to do dissertations, there is no rationale any longer for insisting on additional teaching experience. Moreover, all over the world the paradigm of medical education has advanced and today it is integrated with clinical science.

In 2003, the MCI enumerated specific reasons why it could not accept the equivalence of DNB degrees with MD/MS and DM/M.Ch degrees. However, both the Government and the NBE find no merit in the MCI’s arguments and have rejected them. In August 2004, and again in September 2005, the MoHFW notified that institutions conducting MCI-approved post-graduate courses were also permitted to run DNB courses. However, in November 2005, the MCI unilaterally instructed all medical institutions to refrain from this practice without seeking the Government’s consent as required.

The National Board of Examinations (NBE) was established in 1975 with the aim of elevating standards of post-graduate medical examinations and ensuring uniformity across the country. The NBE became an independent autonomous body under the MoHFW in 1982. The Board has a system of accreditation of hospitals and institutions having adequate trained manpower and infrastructure for training students towards post-graduate and post-doctoral degrees of the Board.

Entry to the DNB programme is through a very stringent qualifying Central Entrance Test and an institutional-level speciality-specific aptitude evaluation. Qualifying for the degree is through an extremely rigorous evaluation both in theory and clinical knowledge in which the pass percentage is only about 30-35 per cent.

Medical experts say that, by enabling the large number of NBE-qualified post-graduate medical students to enter the country’s mainstream health care system, this move would help offset to a great extent the shortage of teachers in medical institutions that could arise as a result of the envisaged expansion. In fact, this shortage is in some sense artificial because the guidelines of the Medical Council of India (MCI) rendered a whole cadre of qualified doctors ineligible for teaching posts.

Google Health: Facebook for Healthcare?

Google is letting patients share electronic medical records with loved ones or care providers who may be needed to help in emergencies. Google Health has quietly launched an application for secure sharing of your online medical records:

The Google solution, introduced without fanfare, solves many confidentiality issues by putting the patient in control of medical record sharing. Call it “Facebook for Healthcare”. You invite those who you believe should see your medical information and you can disinvite them at anytime.

The decision to let people selectively allow others to glimpse medical profiles results from feedback it has gotten since Google Health medical records service was launched in May 2008.

“One issue we hear regularly is that people want help coordinating their care and the care of loved ones,” Google product manager Sameer Samat said in a message posted at the California firm’s website. “They want the ability to share their medical records and personal health information with trusted family members, friends, and doctors in their care network.”

Google Health now has a “share this profile” feature that permits chosen people to view, but not alter, online medical records.

Privacy advocates worry that online medical information is vulnerable to tampering or snooping, possibly from insurance companies or employers out to reduce liabilities by shunning those with health issues. Google said it built a secure computer platform separate from its search system to host medical records as part of an emphasis on keeping health information protected.

Google vice president of search product and user experience Marissa Mayer said at the launch of Health that it was built with “our highest level of security.”

Google Health has links to pharmacies, clinics and diagnostic labs. The service is free and enables people to have electronic copies of information such as prescriptions, lab test results, hospital stays, and medical conditions stored on Google computers. People can link heart monitors to Google Health so vital statistics can be fed to a heart attack assessment services online. A “virtual pillbox” will also automatically send alerts to people’s mobile telephones, reminding them when it is time to take medicines.

We really do seem to be moving into an era where patients control their own health data, order their own diagnostic tests (e.g. direct-to-consumer genetic tests), and increasingly make their own decisions about their healthcare. Whether this will actually result in better health outcomes remains to be seen; but there is no question that it will seriously disrupt the traditional medical model.

Dirty needles: A sore point

A mutant strain of hepatitis B has now killed more than 70 people in Gujarat in what is now becoming one of India’s biggest medical scandals. The outbreak has been traced to used and dirty hypodermic needles which should have been incinerated but instead were simply washed, repackaged and sold back into the medical industry for reuse.

Within the past week, police have discovered a staggering 75 tonnes of neatly packaged waste – including needles, paediatric droppers and syringes – waiting to be resold to private medical clinics. Police describe the waste scandal as a “serious organised crime racket”. Authorities admit they have no idea how many thousands of dirty needles may already be in use in medical clinics across the state – they say that they are unlikely to find them all.

There is no law forcing the 13,000 private medical practitioners across Gujarat to reveal where they bought their equipment. Police said many were “refusing to co-operate and admit if they bought these dangerous tools or not”.

So far the list of those supplying needles has included pharmaceutical companies, individual doctors and a state hospital. At that hospital, dangerous medical waste that had been left out for incineration was collected by cleaners and porters and then sold on to gangs who traded in it. “Everyone got their cut,” said a police spokesman.

In 2004 a study was conducted at 84 centres by the IndiaCLEN (International Clinical Epidemiology Network) to estimate the burden and safety of injection use in India.Interviews were carried out with over 24,021 households and 3,562 health facilities across India. 17,844 injection processes and 24,030 client-provider interactions were observed.

The study found that nearly 62.9% of injections were unsafe. Nearly one-third of administered injections carried the risk of spreading blood-borne viruses and nearly 44.8% of health facilities didn’t have proper injection disposal

According to World Health Organisation estimates, there are an estimated 30,000 HIV infections and over 21,000,000 Hepatitis B infections every year due to unsafe injections. However, Dr Narendra Arora, executive director of INCLEN (International Clinical Epidemiology Network) which had conducted the 2004 study chose to differ.

“There is a great need to improve the quality of our injections and the way they are administered, but a lot has been done since the study. The government has introduced auto-disposable syringes in all immunisation programmes, which are much safer than the glass syringes used earlier,” Dr Arora said. Experts agreed that only 17% of injections come under the immunisation programme, the rest are given for curative purposes, a sector that isn’t as well regulated. “We have also set up 20 model injection centres across the country for training medical professionals on how to give injections in a safe manner,” said Dr Arora.

The state of biomedical waste management is a joke in this country. Doctors can no longer feign ignorance for what is clearly an act of omission. Coupled with rampant unawareness of the need for disposable syringes and needles, the conniving black market only serves to promote these death godowns. Clearly in these dire times, lots more needs to be done.

Two more AIIMS like medical institutes, five colleges to be upgraded

The Indian government sanctioned Rs.16.46 billion ($340 million) for setting up two more premier referral institutes on the lines of the prestigious All India Institute of Medical Sciences (AIIMS) here.

In 2005, the government sanctioned five similar institutes at Bhopal (Madhya Pradesh), Bhubaneswar (Orissa), Jodhpur (Rajasthan), Patna (Bihar), Raipur (Chhattisgarh) and Rishikesh (Uttarakhand).

The new referral institutes, to be established at a cost of Rs.8.23 billion each, will be located at Raiganj in West Bengal’s North Dinajpur district and at a site to be chosen by the Uttar Pradesh government. Each institution will have a 960-bedded hospital, with 500 beds for the medial college hospital and 300 beds for its speciality and super speciality departments. This apart, 100 beds will be set aside for the ICU and accident trauma department, 30 beds for physical medicine & rehabilitation departments and 30 beds for the AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy) departments. The medical college will annually take in 100 undergraduate students, besides running postgraduate and doctoral courses in various disciplines.

The cabinet also sanctioned Rs.7.50 billion for upgrading five existing government medical colleges. The five government medical colleges being upgraded are located at Aligarh (Uttar Pradesh), Amritsar (Punjab), Madurai (Tamil Nadu), Nagpur (Maharashtra) and Tanda (Himachal Pradesh). Each college will be upgraded at a cost of Rs.1.50 billion, with the central government providing Rs.1.25 billion and the state government providing the balance Rs.250 million. In the case of the Aligarh college, which is part of the Aligarh Muslim University, the human resource development ministry will provide the Rs.250 million.

Doctors for rural areas: Where will they descend from?

Responding collectively to the excellent comments from Rakesh, Ramji, Chetna and Shruti in the previous post.

I agree that it requires more than fortitude to serve in an area devoid of basic amenities. It is easier said than done. Bureaucrats are the most convenient whipping boys. And that angst is reflected in Dr Ramji’s comment that the MCI office should be shifted to rural India!

Meenakshi Gautham’s article that Rakesh posted, gives an excellent insight into the pathetic working conditions that doctors often face.

Socially, a rural posting can be excruciatingly isolating and working conditions quite challenging for someone who has spent long years acquiring knowledge and skills in an urban medical institution. In the words of a medical intern: “Doctors are extremely reluctant to be posted at PHCs for it is literally a professional dead end. There is a fear of sophisticated skills becoming rusty. Also a fear of an academic fade-out due to absence of the stimulating atmosphere that one finds in city hospitals and urban practice.”

Other sore points are the unsatisfactory working conditions, lack of adequate staff and equipment and primitive living quarters. A young female medic said about her heroic attempt to live out a rural posting: “I decided to live in the doctor’s quarters and went to check it out. It was impossible to live in! The place was in total disrepair, there was no electricity and the toilet was quite a distance away from the house.” The trip cost her her job and the public sector lost a precious woman doctor.

I live in Sevagram, which is by all means a rural area. But the fact remains that I have all basic facilities which are available for subsistence. And most of all, I am not intellectually isolated. I have people of my own wavelength, with whom I can interact. If it weren’t for my job satisfaction, which stems from availability of infrastructure and a progressive looking management, I wouldn’t have stayed on here. Imagine a young doctor, just out of medical school, posted to a PHC– where there is nothing intellectually stimulating. One sees suffering and is frustrated with one’s inability to change things. There is certainly no job satisfaction and no incentive to stay on.

In a thought provoking article, my friend and senior colleague Dr SP Kalantri says:

Doctors who feel aggrieved at being forced to serve in rural areas are unlikely to fulfil their obligations to the people there. Making the rural healthcare system work and getting enough doctors to do that is one of the several challenges that the (health) minister faces today. But this will have to be based on an understanding of the forces that have created the present system of medical education and practice, forces that are antithetical to ethical practice. Major changes are needed before we can speak realistically of promoting socially conscious behaviour in the medical profession.

The solution perhaps lies in thinking out of the box. Is it time to promote a separate cadre of health professionals who will serve the rural populace? It remains a fact that in majority of cases, a basic doctor with no specialization or even a trained health worker will suffice. Specialists are required in 10% of cases and tertiary care in 1-2%. Do we need to therefore focus our energies elsewhere? Or will efforts to put up proper infrastructure lead to expected consequences of doctors choosing to serve in rural areas? Medical education needs to be made relevant to our context. The more we veer towards specialists, the more our primary health care will suffer. I wonder if it will be fashionable yet again to be a basic doctor. And maybe we can erase the stigma of being a ‘plain MBBS’ some day.

Eight medical colleges in Maharashtra do not have permanent Deans

Of the 14 government-run medical colleges across Maharashtra, eight are without permanent deans.

After B M Sabnis retired from Grant Medical College in Mumbai, the institute did not have anyone to take over the post. Same is the case with the government-run medical colleges at Pune, Solapur, Nanded, Miraj and Kolhapur, while deans of two institutes at Akola and Ambajogai have sought voluntary retirement.

A senior medical education department official added that a proposal on the appointment of new deans has been gathering dust in chief minister’s office.

“The proposal was sent to Chavan’s office in the first week of December, but so far he has not cleared it. Once the file is cleared, we will immediately issue the orders,” he said.

Another former dean complained that medical education was last on the priority list of the government.

“There were hundreds of vacancies in all medical colleges across the state. It swung into action only after some of the prestigious institutes were shut down following mass exodus of teachers in the wake of specific directives of the Bombay high court,” he said.

We now have headless institutions, which obviously will slumber on, directionless. Whither justice!

Rural posting for doctors: Compulsory?

The Health Ministry and the Medical Council of India (MCI) are at loggerheads again.

Health Minister Anbumani Ramadoss had said on Wednesday:

The government had decided to make one-year combined rural posting mandatory for doctors seeking post-graduation from the next academic session.

Now the MCI says that compulsory rural posting of doctors was “not feasible” as it would lengthen the medical education course and disturb specialization schedules. MCI Chairman, Ketan Desai went on to say:

“MCI has already taken sufficient steps to increase the strength of medical practitioners in rural areas. Of the 130 medical colleges opened since 1997, 101 are in rural areas. It is mandatory for all new colleges to have a minimum 25 acres of land, which is not possible in urban areas such as Delhi and Mumbai.”

The health ministry wants doctors stationed at primary health centres, community health centres (at sub-district level) and district headquarters for four months each during rural postings. For this, they will get a monthly stipend of Rs 10,000. MCI’s argument is that doctors in rural postings do not get to hone their skills due to lack of infrastructure.

The fact remains that attempts to compel doctors to serve in rural areas have failed miserably. They are trained in tertiary care centres and then expected to perform in areas which barely have electricity and water. It is a state of disillusion as the young doctors are frustrated with their ‘learned helplessness’. If the infrastructure is improved, working conditions are satisfactory and the incentives (monetary and job satisfaction) exists, doctors will willingly serve these areas. To expect novices just out of college to completely shoulder the burden of the nation’s top priority is ridiculous.

As for MCI’s claim of opening medical colleges in rural areas, it is a sham. For the private owners have long since, converted the noble profession into a business. How many students who have been forced to pay through their nose for their education would choose to serve in rural areas, instead of logically ‘recovering’ their investment as soon as possible.