Standards In Health Care
Dr Gladstone D’Costa
The law is very clear on many issues of healthcare. The “Indian Medical Council Act, 1956” (and all its subsequent amendments) as well as the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, specifically prohibit anyone from practicing allopathic medicine unless qualified to do so. Supreme Court judgments (Aswhin Patel v/s Poonam Verma; and Mukhtiar Chand v/s State of Punjab) prohibit a person qualified in one system of medicine from practicing any system other than that which he is qualified in. In Professor Thakur v/s Hans Charitable Trust, 2007, the National Consumer Rights Commission stated that “we feel it is high time that hospital authorities realize that the practice of employing non-medical practitioners such as doctors specialized in Unani system and who do not possess the required skill and competence to give allopathic treatment and to let an emergency patient be treated in their hands is gross negligence”. With the provisions of the Clinical Establishments Act coming into force in one state after another, the issue of homeopaths employed as RMOs in allopathic hospitals assumes increasing significance.
In spite of the National Commission ruling, the argument is presented that “we declare that our RMOs are homeopaths and in any case, they do not administer any treatment, but merely act as monitors of the patient’s condition, and relay this information to the consultant in charge, who is an allopath, and who ultimately assumes total responsibility for the patient.” This argument , apart from presenting an ethical façade to a grossly unethical act, does not factor in the definition of “treatment” which is “the provision of specific physical, mental, social interventions and therapies which halt, control or reverse processes that cause, aggravate or complicate malfunctions or dysfunctions” (http://www.oregonlaws.org/glossary/definition/treatment). In other words by virtue of the very fact that the RMO (who is a homeopath) is present and a contributing member of the team treating the patient includes him in the overall sphere of responsibility for the patient outcome, and thereby holds the hospital accountable.
A further twist to the convoluted scenario emerges in a recent paper published in “Health Affairs” by Jishnu Das, a senior economist at the World Bank, in Washington, D.C., and a visiting fellow at the Centre for Policy Research, New Delhi, India and others. This paper seeks to analyze the quality of health care in rural and urban India. It is unique in so far as it attempts to provide systematic and scientific evidence of the quality of health care a patient receives when he or she enters a clinic. While earlier studies have audited prescriptions written by doctors in India and documented patient-doctor interactions, this is India’s first study to use “standardised” patients which, the researchers say, has in recent years emerged as a “gold standard” to assess quality of medical care.” “Standardised patients are people who are carefully trained to portray a medical condition so realistically that they are not detected by a clinician,” said Diana Tabak, associate director of the Standardised Patients Programme at the University of Toronto.
Patients were recruited and trained to present with typical complaints of one of three common conditions; unstable angina, asthma, and a child who is not present but is reported to have a picture of dysentery. These were selected as they are a cross section of common complaints of high incidence in low income settings. The type of symptoms selected represent conditions that have established protocols with clear triage, management, and treatment checklists developed by the government’s National Rural Health Mission. The patients are trained for 150 hours so that when they present the doctor with their symptoms, the diagnosis would be obvious and as uncomplicated as possible. There were 926 clinical interactions with 305 health care providers in both rural and urban settings.
The results of the study were alarming. “We found low overall levels of medical training among health care providers; in rural Madhya Pradesh, for example, 67 percent of health care providers who were sampled reported no medical qualifications at all. What’s more, we found only small differences between trained and untrained doctors in such areas as adherence to clinical checklists. Correct diagnoses were rare, incorrect treatments were widely prescribed, and adherence to clinical checklists was higher in private than in public clinics. Our results suggest an urgent need to measure the quality of health care services systematically and to improve the quality of medical education and continuing education programs, among other policy changes”.
It appears that merely making distinctions between quacks and qualified practitioners, or campaigns against those guilty of cross practice is not going to solve the problem of quality health care in India on a national scale. Whilst there are pockets of excellence, there is a lot of ground that needs to be covered both in the planning as well as the execution of standardised health care.