Straight from the Heart: Will the powers-that-be sit up and take notice?

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The Union Cabinet recently rendered another blow to the medical profession with the approval of the draft National Medical Commission Bill, 2017. The NMC will “cripple” the democratic functioning of the medical profession by making it completely answerable to the bureaucracy.

It is time that the powers-that-be took urgent notice of this crisis and acted accordingly. The medical profession is currently facing the darkest hour. Not only are patients slowly losing faith in doctors and the profession as such, but are also becoming violent against doctors with the slightest provocation. This bill is only an addition to these existing woes and will exacerbate the situation for the medical fraternity and the students of medicine.

The structure of the NMC

The federal character of MCI is not found in the NMC. All the state governments have representation in MCI. Only five states in rotation will have representation in NMC as a result of which it will take two decades for a state to re-enter NMC. The Cabinet has cleared NMC Bill with a 25-member commission appointed by the central government. Of these members, 20 will be appointed by the search committee chaired by cabinet Secretary. Nomination will be done for 12 ex-officio and 6 part-time members. Three of these will be from disciplines such as management, law, medical ethics, health research, consumer or patient rights advocacy, science and technology, and economics. Only five will be elected by the registered medical practitioners from amongst themselves from such regional constituencies.

In effect, it would resemble a situation where the whole parliament is getting dissolved in favor of 25 nominated ministers by the President of India with only five elected members of parliament, one from each zone of the country with no powers to be re-elected.

The chairperson, secretary, and members shall hold office for a term not exceeding four years and shall not be eligible for any extension or reappointment and will retire by age 70. This will lead to a possible backdoor entry of bureaucrats after retirement.

In the MEDICAL ADVISORY COUNCIL, the Chairperson of the Commission shall be the ex-officio Chairperson of the Council and hence will have no autonomy. Every member of the Commission shall also be the ex-officio members of the Council. Each Board shall be an autonomous body and shall consist of a President and two Members, all nominated by the search committee. The commission will be more of an appellant body for aggrieved decision of an Autonomous Board within sixty days.

The four autonomous boards

The bill provides for the constitution of four autonomous boards entrusted with conducting undergraduate and postgraduate education, assessment and accreditation of medical institutions and registration of practitioners under the NMC.

UGME and PGME boards The UGME Board will grant recognition to a medical qualification at the undergraduate level and PGME Board shall grant recognition to the medical qualification at the postgraduate and super-specialty levels. Both boards may seek directions from, the Commission, as necessary. Any recommendations for UG and PG courses shall be made by the three-member committee under the control of the central government.

MAR board This Board shall grant permission for establishment of a new medical institution, carry out inspections of medical institutions for assessing and rating. It can also hire and authorize any other third-party agency or persons for carrying out inspections of medical institutions and for assessing and rating them, as required. It also has the power to impose monetary penalty (first time, second time, and third time in ascending order) against a medical institution for failure to maintain the minimum essential standards specified by the UGME Board or the PGME Board. All the three monetary penalties imposed shall not be less than one-half, and not more than ten times, the total amount charged. Such variation of 50% to 10 times will be the root cause of future corruption. It can also be used as a political action to favor or destroy someone. It will also become necessary to seek prior permission of the MAR Board to establish a new medical college.

EMR board This board shall maintain a National Register and regulate professional conduct and promote medical ethics. The EMR Board or State Medical Council shall also give an opportunity of hearing to the medical practitioner or professional concerned before taking any action, including imposition of any monetary penalty against such person. There will also be a separate National Register for licensed AYUSH practitioner who qualifies the bridge course (Homeopathy or a practitioner of Indian medicine).

Plight of medical students

It has been proposed to conduct UG-NEET in English or other languages with common counselling. There will also be a uniform National Licentiate Examination operational within three years with no PG NEET and with common counselling. This makes it seem like there will be one common licentiate exam. The addition of another exam indicates the height of insensitivity to the plight of medical students who even otherwise undergo a long and tortuous academic career replete with highly competitive exams.

The NMC allows private medical colleges to charge at free will nullifying whatever solace NEET brought. The government can fix fee for only 40% of the seats in private medical colleges. No medical college will survive if there is state central dispute in the fee structure. Up to 40% will give a wide margin for corruption.

Determining who is a qualified medical professional

As per the bill, any person who qualifies the National Licentiate Examination shall have his name and qualifications enrolled in the National Register or a State Register, as the case may be (prospective). Foreign medical graduates shall also have to qualify the National Licentiate Examination only. The Commission, however, may permit a medical professional to perform surgery or practice medicine without qualifying the National Licentiate Examination, in such circumstances and for such period as may be specified by regulations. It also indicates that a foreign citizen who is enrolled in his country as a medical practitioner in accordance with the law regulating the registration of medical practitioners in that country may be permitted temporary registration in India for such period and in such manner as may be specified by regulations. Any person who contravenes any of the provisions of this section shall be punished with fine which shall not be less than one lakh rupees, but which may extend to five lakh rupees. The Central Government can approve the grants of such sums of money as it may think fit.  This will be credited to a fund called the “National Medical Commission Fund” which shall form part of the public account of India.

The course structure

One a year, there will be a joint sitting of the Commission, the Central Council of Homoeopathy and the Central Council of Indian Medicine. This will decide on the approval of specific educational modules or programs that may be introduced in the UG and PG courses across medical systems. This discussion will also entail developing bridges across the various systems of medicine and promote medical pluralism.

Handing over power to administrators

The central government has the power to dissolve the commission if it has persistently defaulted in complying with any direction issued by them. The central government may, by notification, supersede the commission for such period, not exceeding six months, as may be specified in the notification. Anywhere else in the world, the medical profession is bestowed with reasonable autonomy with patient care and safety as the main benefits of such autonomy. Regulators need to have autonomy and be independent of the administrators. The NMC will be a regulator appointed by the administrators under their direct control.

In conclusion

It is not the first time that the government has made such a move. In 2005, the then Union health minister, Dr Anbumani Ramadoss, tried unsuccessfully to bring about a legislation to dissolve the MCI and set up another council under the control of the Health Ministry, which was rejected. That scenario is repeating itself today, with the difference that the union cabinet has given its approval to the draft NMC. The Parliament has a larger role to play in protecting the interest of the medical profession of the country. It is time to act.

Dr KK Aggarwal

National President IMA, Padma Shri Awardee

The Indian Medical Association announces bold steps aimed at restoring faith in doctors and the medical profession

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Proposes certain self-regulatory procedures for doctors and hospitals to adopt

New Delhi, 11 December 2017: The Indian Medical Association (IMA), the largest voluntary organization of Doctors of Modern Scientific Medicine today announced certain self-regulation procedures for hospitals and doctors. This comes in light of the recent incidents involving the lives of a pair of twins, and a 7-year-old girl. The doctor-patient trust in the country, which was already experiencing a downward spiral, has deteriorated further. Doctors, hospitals, the health industry, patients, media, and politicians all are unhappy. Doctors do not have the intent to be the cause for public unrest or loss of public trust. At the same time patients must understand that to err is human and one incident does not mean that there will be more such cases in future as well.

Trust is the foundation of a doctor and patient relationship. The medical profession is undergoing certain changes. While violence against doctors is on the rise and they are being held accountable, at times, for deeds not committed, it is also true that there is some introspection needed on the part of doctors and hospitals, failing which this trust may take a long time to reestablish. Today, the private sector looks after 80% of the patients that too with highest quality. In the absence of state subsidy private sector providing quality care  invariably will come at a cost which is still at fraction of a cost compared to that in advanced countries.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “We represent the collective consciousness of the largest medical association of modern doctors of the country, the IMA. A profession, which has been considered as second to none, & it will remain noble is today, being looked at with suspicion. However, the medical profession is the noblest profession. It is disheartening to see the erosion in trust and we want to make it more transparent. IMA is and will continue to work towards improving doctor-patient relationship. IMA is committed to practicing with humility and pledges to reform the existing system. We will also take the opportunity to say here that the doctor to patient ratio in India is skewed due to which doctors are under a lot of stress. Doctors are also human beings and not healing angels. Once treatment is administered, the recuperation of a patient depends upon physical and organic factors. It is unacceptable and absurd to victimize the medical practitioner if the patient does not respond to treatment.”

All doctors shall practice with compassion and follow IMA ALERT policy (Acknowledge, Listen in detail, Explain, Review and Thank you). The IMA has also announced formation of an IMA Medical Redressal Commission at the state level (in each state) to engage in social, financial, and quality audits of health care (Suo moto or on demand). The commission will have a public man, an IMA office bearer, one former state medical council representative, and two subject experts. The commission shall consider every grievance in a time bound manner. An appeal to the state commission will be heard by the “Head-quarters IMA Medical Redressal Commission” which will have the powers to take suo moto cases also. The headquarters shall also suggest reforms in healthcare on periodic basis.

Adding further, Dr Aggarwal, said, “What happened was most unfortunate. However, not all doctors are wrong, and the public must have faith in them. Such errors happen by accident and not intentionally. Having said this, it is also time for the medical profession to introspect and come out with self-regulation procedures. We are often blamed for prescribing costly drugs. From today onwards, all doctors in the country shall choose affordable drugs. We also appeal to the government to come out with an urgent ordinance for one drug-one company-one price policy. Doctors should actively participate in ensuring that no hospital sells any item priced higher than the MRP. No service charges should be added to procure drugs from outside. MRP shall not be dictated by the purchaser.”

The other points announced by IMA are as follows.

  • IMA recommends that all doctors should prescribe preferably NLEM drugs.
  • All doctors shall promote Janaushidhi Kendras.
  • We appeal to the government to classify all disposables under both NLEM and non-NLEM categories and cap the price of essential ones. Till then all medical establishments should sell the disposables at procurement prize after adding a predefined fixed margin.
  • Hospitals and doctors are often blamed of overcharging and over investigations. Billing should be transparent, and all special investigations should be well informed & explained.
  • Every doctor should ensure that it becomes mandatory on the part of the hospital administrator to give options at the time of admission to choose cost-effective treatment room and treatment (single room, sharing room, and general-ward) and explain the difference in total bill estimates.
  • All doctors should ensure that hospital estimates at the time of admission are near to actual.
  • The treating doctor must explain the chances of death and unexpected complications and resultant financial implication at the time of admission.
  • Once doctors take charge of a patient, the patient should not be neglected. They should look after the patient till discharge.
  • Emergency care is the responsibility of the state government and the government should subsidize the costs of all emergencies in private sector & create a mechanism for reimbursement.
  • Every medical prescription must include counseling on the cost of drugs and investigations.
  • IMA has zero tolerance to doctors indulging in female feticide.
  • IMA has zero tolerance to cuts and commissions. Medical establishment should revisit their referral fee system. Billing paid to doctors should be transparent and reflected in the bill.
  • No hospital can force their consultants to work on targets. Contractual agreements should be in such way in which of both parties that is consultant and the hospital is equally protected. All hospitals should consider not charging service charges from the consultants.
  • Choice of drugs and devices rests with the doctors based on the affordability of the patient and not on the profitability.
  • All hospitals must comply to the commitment towards EWS, BPL, and poor patients without any discrimination.
  • All patient complaints should be addressed in a timely manner through an internal redressal mechanism with a chairman from outside the hospital.
  • All medical establishments must ensure that their business ethics comply with the MCI ETHICS.
  • IMA LAMA policy is being developed as there are no clear guidelines at present.
  • Every dead body needs to be treated with respect and dignity.
  • All charitable hospitals should do their free work as assigned.
  • All needy patients must be routed through the social worker of the establishment and guided and directed to the appropriate place.
  • At least one more equally experienced but unrelated surgeon should be involved in the consent form during elective LSCS.
  • The patient has a right to get medical records within 72 hours of request. Acknowledge their request.
  • The patient has the right to go for a second opinion from an appropriately qualified medical doctor. The primary doctors have should not  get offended.
  • A hospital has no right to stop life-saving investigations or treatment for non-payment of bills if the patient is still admitted in the hospital. The government should make a mechanism for the reimbursement for the above for poor patients.
  • Ensure for us all are equal. BPL, APL, EWS, rich, or poor all should get the same attention and treatment.
  • IMA policy: With no National Guidelines on viability of fetus issue ,it is being looked upon by IMA, FOGSI, IAP and NNF.
  • We are not against any regulations and accountability, but we should all ask for a single window accountability at the state level. The state medical council should be proactive and take timely decisions. We should also ensure a single window registration.
  • We must ensure that our establishment has a transgender policy.
  • All government hospitals should be upgraded and have facilities like those in the private hospitals. All public, private or charitable hospitals should have quality accreditation.
  • No doctors should issue false certificates.

“All the above will & should be implemented with immediate effect”, said Dr Ravi Wankhedkar, National President Elect IMA, in his message.

The above have approval from most stakeholders. A copy of this is being sent to the Health Secretary, Govt of India and Health Minister, Govt of Delhi. Both President and Registrar, Delhi Medical Council, are requested to help in circulating this message to all doctors in Delhi.

We are thankful to the society for raising the issues and will request them to work with the medical fraternity to make IMAs project “Cure in India” a success.

Straight from the Heart: International IMA Activities Report 2017

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The Indian Medical Association IMA actively participates in World Medical Association WMA Confederation of Medical Associations in Asia and Oceania CMAAO Commonwealth Medical Association CMA and World Organization of Family Doctors WONCA meetings. Internationally WMA deals with all policies related to health education and regulations related to all the countries in a broad base. Policies with regard to the above issues in Asia and Oceania regions are broadly dealt by CMAAO and that in Commonwealth countries are dealt with by CMA. Of late many have criticized why IMA should participate in such meetings. Here is a brief note International interactions play a major role in deciding most National or International policies. World Medical Association WMA with the help of 112 National Medical Associations periodically develops concurrence statements concurrence declarations and resolutions on subjects of common interest. Such Statements Declarations and Resolutions are revised based on the current day requirements. There are two types of Revisions Minor revision which can be made any time and major revision which can be made after 10 years of a Declaration Statement . All member countries NMAs can raise their national issues even including work conditions of their Resident Doctors like their duty hours etc. through the International bodies. When these International bodies raise an issue even if it relates to individual countries or segments all member countries follow up such matters with the relevant related authorities in those country ies Segment s creating a huge impact on the early resolution of the issue. IMA led two major revisions polices on behalf of WMA both of which were passed in the last WMA General Assembly held in October 2017 at Chicago. o WMA STATEMENT ON HIV AIDS AND THE MEDICAL PROFESSION Adopted by the 57th WMA General Assembly Pilanesberg South Africa October 2006 and amended by the 68th WMA General Assembly Chicago United States October 2017 o WMA RESOLUTION ON TUBERCULOSIS Adopted by the 57th WMA General Assembly Pilanesberg South Africa October 2006 and revised by the68th WMA General Assembly Chicago United States October 2017 IMA is leading the revisions to third WMA policy on assisted reproductive technologies which is likely to get passed in 2018 WMA is in the process of revising the under mentioned policy in their ensuing meeting The following Declaration of Geneva now called The Physicians Pledge has been amended by WMA. Dr KK Aggarwal and Dr A Marthanda Pillai were members of the Working Group on behalf of IMA. As a member of the medical profession I SOLEMNLY PLEDGE to dedicate my life to the service of humanity THE HEALTH AND WELL BEING OF MY PATIENT will be my first consideration I WILL RESPECT the autonomy and dignity of my patient I WILL MAINTAIN the utmost respect for human life I WILL NOT PERMIT considerations of age disease or disability creed ethnic origin gender nationality political affiliation race sexual orientation social standing or any other factor to intervene between my duty and my patient I WILL RESPECT the secrets that are confided in me even after the patient has died I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice I WILL FOSTER the honour and noble traditions of the medical profession I WILL GIVE to my teachers colleagues and students the respect and gratitude that is their due I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare I WILL ATTEND TO my own health well being and abilities in order to provide care of the highest standard I WILL NOT USE my medical knowledge to violate human rights and civil liberties even under threat I MAKE THESE PROMISES solemnly freely and upon my honor Adopted by the 2nd General Assembly of the World Medical Association Geneva Switzerland September 1948 and amended by the 22nd World Medical Assembly Sydney Australia August 1968 and the 35th World Medical Assembly Venice Italy October 1983 and the 46th WMA General Assembly Stockholm Sweden September 1994 and editorially revised by the 170th WMA Council Session Divonne les Bains France May 2005 and the 173rd WMA Council Session Divonne les Bains France May 2006 and amended by the 68th WMA General Assembly Chicago United States October 2017 IMA also organized attended various international conferences as follows o Annual Scientific Meeting of Chinese Medical Association Nanjing China 14 15 January 2016 o International Summit on Air Pollution Health Advisories New Delhi March 10 2017 o 12th World Conference on Bioethics Medical Ethics Health Law Cyprus March 19 24 2017 o 206th World Medical Association WMA Council Meeting Zambia April 15 22 2017 o International Congress of Indian College of Interventional Cardiology Dubai May 4 7 2017 o 10th Geneva Conference on Person Centered Medicine Geneva May 7 10 2017 o Annual Meeting of Swedish Medical Association Sweden May 29 31 2017 o Annual Meeting of the American Medical Association Chicago June 10 14 2017 o BMA Annual Representative Meeting Bournemouth June 25 29 2017 o 32nd CMAAO General Assembly Tokyo September 13 15 2017 o WMA General Assembly Chicago October 11 14 2017 o European End of Life Issues Vatican November 2017 IMA now has direct one to one association and communication with other Medical Associations of the world. IMA has entered into a Memorandum of Understanding for Developing Strategic Cooperation Partnership with the Chinese Medical Association International collaborations o BMA Chair always attends the NATCON of IMA o Presidents of all National Medical Associations are invited in NATCON. o IMA is affiliated to BMA o Nepal Medical Association is affiliated to IMA. o IMA donated drugs worth Rs. 45 Lakh to Nepal Medical Association during the flood disaster in 2015. o Dr A Marthanda Pillai Past National President and Dr KK Aggarwal National President IMA addressed a press conference in Nepal during their visit to Nepal during flood disaster in 2015. o Dr Ketan Desai Past National President IMA served the highest post of WMA as its President during the year 2016 17. o Dr V C Pillai Past National President IMA served as President CMAAO during the year 1992 93. o Dr Vinay Aggarwal Past National President IMA served as President CMAAO during the year 2013. o Dr KK Aggarwal Hony Secretary General IMA served as Vice President CMAAO during the year 2015 16 o Dr KK Aggarwal National President IMA is serving as 1st Vice President CMAAO during the year 2016 17 o Dr KK Aggarwal National President IMA will take over as President Elect CMAAO for the years 2018 19 o Dr. S Arulrhaj Past National President served as President CMA o Dr K Vijaya Kumar Past National President served as Vice President CMA o Dr Ajay Kumar Past National President IMA is serving as Council Member WMA o Many Past National Presidents of IMA Dr Vinay Aggarwal Dr Ajay Kumar Dr A Marthanda Pillai Dr KK Aggarwal National President IMA and Dr RN Tandon Hony. Secretary General IMA have served have been serving on various Committees of WMA CMAAO o An international conference on Person Centered Medicine will be held in November 2018 at New Delhi o IMA will be hosting 2019 CMAAO meeting in September 2019 o WMA raised and supported the Dilli Chalo movement of IMA IMA is an integral part of global medical associations and should continue to lead the world in the field of medicine.

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