Letter from Chennai

RECENT ADVANCES IN MEDICAL ETHICS
Let no one say that we of Tamil Nadu have no concern with medical ethics. We update our codes regularly. We had a code of ethics published in 1998, but we move with the times, and now we have a fresh code published in 2003. I did not see the need for a new code at first, but after reading it I must admit that the new code is a document well worth possessing. It does not have great literary merit, but it certainly brings us up to date.
     The new code begins (Chapter 1.1. A) with the declaration: ‘Each applicant at the time of making an application for registration shall also certify that he/she had read and agreed to abide by the same.’ This puts the responsibility clearly on the doctors. We cannot now claim ignorance of the code in any of our actions.
     An important new exhortation is that ‘Physicians should try continuously to improve medical knowledge and skills’ (1.2.1) and ‘should participate in professional meetings as part of Continuing Medical Education Programmes, for at least 30 hours every five years. The compliance of this requirement shall be informed regularly to Tamil Nadu Medical Council’ (1.2.3).
     Another new injunction is ‘Every physician shall maintain the medical records pertaining to his/her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the Tamil Nadu Medical Council and attached as Appendix 3’ (1.3.1).
     We also need to maintain a register giving full details of all certificates issued. We should always enter the identification marks of the patient, and enter the signature of the patient on the certificate. Our medical registration number must be entered on the certificate. A form is provided in Appendix 2. We should prescribe drugs by generic name. Helpful advice is given telling us that we should be familiar with the various Acts, Rules and Regulations that are in force, and we are cautioned that legislation and court decisions may also influence medical ethics. We are reminded that termination of pregnancy in case of a normal female foetus is professional misconduct, and that it renders us liable to criminal proceedings.
     We are now told that we should ‘expose, to the appropriate authority without fear or favour, incompetent or corrupt, unprofessional, dishonest or unethical conduct on the part of members of the profession’ (1.7). We have tended to stick together in the past, and rarely does a doctor let down a member of his profession. However, now that we have entered a rat race, will this give us an opportunity to harass rivals? Or will we hesitate to cast aspersions? As Jesus said, ‘He that is without sin among you, let him first cast a stone at her.’
     These and other recent advances apart, most of the provisions from the past codes remain. We had them before, but what good did it do us? We advertise, take cutbacks and commissions, give false certificates, cosy-up to the pharmaceutical industry, and no action has ever been taken against any of us. Will not this code also atrophy with disuse?
     Perhaps I am wrong. Item 1.1.2 tells us ‘The prime object of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration.’
     The Gemini Film Circuit, we are informed by the Tamil Nadu Indian Medical Association (IMA) Newsletter, is producing a film called Vasoolraja, MBBS. Having sworn to follow item 1.1.2, it is clear that we are honourable and noble persons, and would never do anything mean of the sort implied by the title of this film. Item 1.1.1 inspires us: ‘A physician shall uphold the dignity and honour of his profession.’ The President of the state IMA engaged a lawyer who sent a notice to the producer and director to change the title of the film and delete the screening of scenes that affect the ‘profession of doctors and their dignity in a court of law, in such event, you will be jointly and severally held liable for all costs and expenses incidental thereto [sic].’ Undeterred, the producers have held a preview and plan an August release. Perhaps we need to retain a sense of humour.

THE ODYSSEY OF THE ASPIRANT FOR A MEDICAL COLLEGE SEAT
I am glad I entered medical college in less complicated times. Hardly a day has passed in recent weeks without medical admissions being in the front pages of the newspapers. I am not sure I understand just what is going on or what is likely to happen, but let me try to give you a gist of my impressions.
     Some years ago, the Government of Tamil Nadu decreed that a candidate who had passed the Higher Secondary School Certificate (HSC) examination but had poor marks could make a second attempt at the examination in the hope of doing better. One notification about medical entrance reads: ‘In the case of candidates who have successfully completed all the subjects of the HSC (Academic) or any other equivalent examination, the marks in the first regular appearance or the marks obtained by them in the first improvement, whichever is higher, shall be considered.’ Further, in the prospectus for admission to the MB,BS, it was stated that, when all other qualifications are equal, preference would be given to the person who is older. One concerned candidate approached the High Court saying that this automatically gave an advantage to improvement candidates who would necessarily be a year older than the regular candidates, and was therefore discriminatory. No less than 23% of the applicants this year are improvement candidates. A single judge decreed that students who had taken improvement examinations should not be allocated seats as it would delay the admission procedure of students who had passed the qualifying examination held in March 2004. The Director of Medical Education proceeded to hold what is called ‘counselling’ for the regular candidates, which is actually the allotment of available seats in the different colleges to candidates who are called in the order of merit. A group of improvement candidates staged a rasta roko outside the office of the Director of Medical Education, apparently with some success. They stopped the traffic for nearly an hour. Two students, who had taken the improvement examination, filed a petition with the Division Bench, urging it to reconsider the issue. The judges who heard their plea suspended the single judge order and posted the case for further hearing. The selection committee interviewed (counselled) the improvement candidates according to their standing in the order of merit, noted their choices, but did not allot the seats, as they had to wait for the court to take a decision.
     Is your head spinning? The Advocate General, appearing on behalf of the government, said that of 945 medical seats, 493 were allotted to regular candidates and 452 to improvement candidates. Consider the odds. Just under a quarter of the candidates have nearly half the seats reserved for them. If I were a regular candidate this year, I would feel aggrieved too. That is where we stand now. The ball is in the High Court. What will the learned judges say? This is one occasion when I would not like to be in their shoes. I cannot wait for the final decision as I have a deadline to meet, and the editor is breathing down my neck. You must watch this space for the verdict in my next letter.
     That is not all. Writs and appeals are still pending against some ambiguous questions in the common entrance test, and against a government order permitting the managements of private colleges to retain 50% of the seats under their control, whereas Karnataka permits only 25%. Spare a thought for the thousands of candidates who are in limbo, unaware of whether they will get their seats or not. I have a word of advice for them. Redirect your application to law colleges. Lawyers have a bright future.

A LEVEL PLAYING FIELD?
There is much, much more going on with medical colleges. I cannot cover it all, but there is one thing I must tell you about. What I have pointed out earlier is common knowledge. Government-run medical colleges do not have adequate staff. Whenever the Medical Council of India (MCI) comes calling, the government transfers teachers in hundreds to man the posts for the inspection and they go back home the day after. I wondered whether the MCI inspectors would read the newspapers or not. Apparently they do. This time they asked each teacher to show proof of residence in the city in which the college was located and hardly any of them could. Further, the MCI made a surprise inspection of the Coimbatore Medical College, not giving the government a fair chance to transfer teachers there in time. ‘The MCI has been detestable,’ an unnamed senior government official is quoted to have said. Anyway, the MCI refused to recognize 3 medical colleges, and 53 postgraduate degree and diploma courses in a number of institutions, though the government has been conducting these for some years.
     What is to be done? The Central Health Minister is from Tamil Nadu, so everyone expects him to do something about it. Our former Chief Minister said the government should be taken to task, but the students should not be penalized for the sins of the administrators. It is good of him to say so. However, the situation was just the same when he ran the government. The answer is simple, but no one in the government seems to think so. The MCI has been entrusted with the task of ensuring that every Indian medical graduate is well educated. It is sad that, for reasons other than medicine, there have been instances of it failing in its duty. Right now, it is making amends for all those past failings and the government should cooperate and correct its own faults, not ask for exemptions.

ANNUAL CONVOCATION OF THE TAMIL NADU
DR M.G.R. MEDICAL UNIVERSITY
The last convocation I attended in Chennai (formerly Madras) was in 1962, when I took my MD degree from the University of Madras. A couple of thousand youngsters had gathered to take their degrees and the atmosphere was riotous. The convocation address has necessarily to be of some gravity, offering sage advice to people as they leave the cloisters of academe and enter the real world. Great orators are not easy to come by and hardly anyone was interested. A buzz of conversation ran round the hall, growing louder every minute and by the time the Chancellor declared the convocation closed, the noise resembled that in the Chennai Central Station.
     A few days ago, I had occasion to attend a convocation in Chennai again, after a gap of 42 years. Most of the time we old fogies speak of the good old days and how things have deter-iorated. This was one occasion on which we could not say that. There were close to 2000 people packed in the hall, but they were dignified and silent and heard Dr G. Lakshmipathy deliver his convocation address with attention and respect. Kudos to the authorities! The proceedings were punctual to the minute, not just starting on time but ending on the dot too. University faculty and staff went through a dress rehearsal the night before the meeting. College students, known to be a bit boisterous, were seated in the front rows. It is always easier to make mischief from the back benches. One major improvement in the academic robes was that the headgear has been abandoned. It was always difficult to keep the mortar board on, and an occasional loss of a high academic’s top gear raised mirth among the bored graduates of years gone by. The robes themselves add dignity to the occasion and have been retained. The university has indeed improved on tradition.

WOULD YOU BELIEVE IT?
The day after I despatched this letter, the High Court of Madras passed an interim order restraining the Censor Board from granting certification to Vasoolraja, MBBS. The plea was made by Dr K. R. Balasubramaniam, President of the Tamil Nadu Medical Council. Has he no more momentous matters to attend to? I await the final order with interest, but whatever happened to freedom of speech? How can there be any objection to anyone poking fun at a fictitious doctor? I for one would be most disappointed if the Court rules in favour of the Tamil Nadu Medical Council.

Postscript from the High Court
The judges have spoken. On Monday, 2 August 2004, they ordered revaluation of 5 out of the 22 disputed questions, and asked the admission authorities to work out a fresh marks list. They accepted the principle of improvement, so improvement candidates can still use their best marks, but they are not given any weightage for greater age against the first attempt candidates. If two first attempt people obtain equal marks, or if two improvement candidates score the same, the elder will get the seat (respect the aged, says the Court), However, if the tie is between an improvement candidate and a regular candidate, age will not apply (respect the aged, but with reservations).
So now the admissions committee can get back to work. However, there is always the Supreme Court for disgruntled candidates.