The Tamil Nadu Medical Council Awards

A news item that the Tamil Nadu Medical Council (TNMC) gave some awards to doctors caught my eye the other day, and I was astonished. There were five categories of awards: (i) The best teacher from government teaching institutions under the Director of Medical Education; (ii) The best doctor from non-teaching government institutions under the Director of Medical Services and the Director of Public Health; (iii) The best doctor among private practitioners; (iv) The best doctor among private practitioners in non-corporation areas; (v) The best doctor from primary health centres or among private practitioners in non-corporation, non-municipal areas. I was clearly out of date. Apparently these awards were instituted in 2014, and I had missed the fact during the previous two years.

I carefully read through the Medical Council of India Act of 1933, the renewed Act of 1956, the Indian Medical Council Amendment Act of 2012, the Indian Medical Council (Amendment) Bill of 2013 and the Tamil Nadu Medical Council Act of 1914 and beyond. The duties of the medical council, as specified in these documents, are to lay down standards of undergraduate and postgraduate medical education in the country, to accredit medical colleges to enrol students and educate them, to inspect examinations, to maintain a register of appropriately educated medical practitioners, to recognize medical qualifications obtained from other countries, to prescribe a code of medical ethics that we are to follow, and to make sure all of us follow that code.

The TNMC (then the Madras Medical Council) was established in 1914 by the Madras Medical Registration Act of 1914, with additions and amendments made at various times through the years. Its website says, ′It does all the works of the Medical Council of India except the medical education. It maintains the registry of doctors practising in the state. Apart from the registry of doctors, the Tamil Nadu Medical Council acts as the disciplinary body for all doctors of modern medicine and imparts, monitors adherence to medical ethics by the medical fraternity. It acts on alleged medical negligence. It awards credit points for continuing medical education (CME) and insists that all doctors to regularly update their medical knowledge. The Tamil Nadu Medical Council has passed a resolution to make credit points compulsory and start mandatory re-registration every 5 years from 2017.′

Nowhere in the details of the duties of the TNMC could I find a responsibility to search for and find the best doctor in the state in any category. In fact, as I reported in these columns in 2003, ^[1] the TNMC threatened to take action against doctors who were judged by a television channel to be the best in their fields. The president of the TNMC at that time said, ′Even taking part in such surveys amounts to indirect advertisement. This is a clear violation of medical ethics and we would like to put an end to this once and for all. We fear that this will lead to various undesirable practices.′

Now why would the TNMC give priority to something that is clearly not part of its duties, over its other weighty responsibilities, especially when its sometime president has himself expressed the fear of undesirable consequences? Is it really possible to find the best doctor in any category from among the thousands of doctors registered in the state? Mysterious are the ways of the TNMC.

However, I am delighted to find that the TNMC is moving with the times in other ways, and has introduced a system of obtaining credits and re-establishing our qualifications to remain on the medical register. I would like to record my appreciation.

The Milk Of Human Kindness

We were all horrified to see a photograph in our newspapers the other day of a young man throwing a puppy off the roof of a two-storey building, and to read the accompanying report that he had done this and a friend of his had recorded the deed on his smart phone and circulated the picture. The poor victim was later found alive but with a fractured hind leg, and is being treated for the injury.

The worst part of this story is that the boy who threw the dog off the roof, and his accomplice who recorded this sin for posterity, are both medical students. They were identified after the video was circulated, and were arrested and released on bail. A case has been registered against them, and the college has suspended them.

Another recent story that made the headlines was that of a young woman from a neighbouring state who was ragged at a nursing college. She was forced to drink toilet cleaner. That is not merely humiliating, but could be a health hazard, and it is fortunate that she is alive to make the complaint against her seniors.

Students may take to medicine as a career in the hope that they will become rich. They may be scientifically attracted to the subject because they savour the challenge of curing difficult patients, or may desire fame by reaching great heights in the medical sciences. Girls and some men take to nursing because it is on the whole a safe profession, with abundant employment opportunities and some security. Whatever the motives, they should have a touch of human kindness. They should feel some sympathy for their suffering subjects, even if they are not deeply moved by the plight of their patients. No one who has a streak of cruelty in him or her should be allowed to enter this field. Inflicting suffering on a harmless and helpless dog, or an equally harmless and helpless junior medical or nursing student, shows that the person is psychologically unsuited to the healing profession, and should be kept out of it. I do not know whether it is possible to reliably detect any such trait in an applicant for medical or nursing studies, but any demonstration of such inhuman cruelty should lead to expulsion from the college.

No Ounce Of Prevention

The old Andhra Pradesh and its successors-Telangana and the truncated Andhra Pradesh-Karnataka and Tamil Nadu have all committed themselves to a policy of providing free dialysis for people with end-stage renal disease who are below the poverty line. This is a popular promise, and none of these governments have made public how they propose to implement this scheme, though commonsense dictates that it is manifestly impossible. A report from Chittoor in the Hindu, datelined 30 July 2016, states that 3000 patients are on the waiting lists of various hospitals that are unable to take them because there are inadequate facilities for dialysis.

To make matters worse, the Central Government has also jumped on this bandwagon. The finance minister has made provision of funds for dialysis in the budget for 2016-17. His figures suggest an expenditure of 2000 per dialysis. A patient needs three dialyses per week to keep in good health. He could stay alive and reasonably well on two dialyses a week, and most of the existing government support for dialysis covers only eight dialyses a month, i.e. 96 dialyses a year. The finance minister′s estimate is that 2.2 lakh patients enter end-stage renal disease every year. My own estimate, based on the experience of the Kidney Help Trust, is many times that figure, but let us stick with these numbers. If we cover all, as the minister proposes, we would spend 96x2000x220 000 or 4224 crore in the first year. These patients will continue on dialysis for several years. Ten years should be a minimum period of survival on dialysis, which means that, at the end of 10 years, we will be spending 42 240 crore per year on dialysis alone. The budget for the social sector including education and healthcare in 2016-17 is 151 581 crore. I do not know what will be the share of healthcare in this amount, but it looks as though dialysis alone will take the lion′s share of health expenditure within a few years. If so much is spent on dialysis alone, many other schemes will remain unfunded. In fact, as is happening today, only a lucky few of those with renal failure will benefit. On what basis will we decide who lives and who dies?

In our present financial condition, India, and its constituent states, cannot afford to treat all patients with end-stage renal disease, or even a major proportion of them. The prime aim of every government, at the Centre or in the states, is to get itself re-elected, so it is perhaps understandable that all of them make these empty promises. Should not a responsible opposition question the government on how it proposes to finance these proposals? While empty words are spoken about tackling non-communicable diseases, no concrete measures have been taken up. Diabetes and hypertension are directly responsible for around 50% of all chronic renal disease, and hypertension accelerates the decline in renal function in all other renal diseases. The early detection and effective treatment of these conditions, on a domiciliary basis, are feasible at an infinitely lower cost, well within our present budgetary constraints. ^[2] Sadly, irrespective of the party in power, populism trumps practical policies.

Kerala Shows The Way

The Government of Kerala has decided to induce motorcyclists to protect themselves by wearing crash helmets. From 31 July 2016, petrol will not be sold to them if they are not wearing helmets. The scheme has been implemented in major cities and seems to be working now. How long will the resolution last?