Technology and family physicians

Reemerging and reaffirming importance of Primary Practice

Silver line in Dark Cloud of Corona Pandemic:

Reemerging and reaffirming importance of Primary Practice.

On the eve of doctor’s day a thought came to my mind about how the basis of delivery healthcare delivery has changed over a period of time.

Before the current pandemic, the society and unfortunately major stake holders and policy makers have just forgotten or overlook the importance of primary care in the country.

We family physicians firmly believe that primary care or family physicians are backbone and most important pillar of any healthcare system, anywhere in the world, but all miserably failed to accept it and have move forward and this fast life and unfortunately paying price for it.

Robust primary care in needed at all times, may it be current pandemic or ever emerging threat of lifestyle diseases.

Let’s have a look what primary care has done in these unprecedented times for across the world.

The main weapons or strategy  to counter current pandemic and manage it are:

1.    Change in behavior of public: most important, the specialty which connected to grass root can do it the best.

2.    Mass public education: via clinics and social media and people still believe what there doctors say….

3.    Early diagnosis: first contact point

4.    Community tracing: good knowledge of social background of patients and community

5.    Early referral in cases where it is needed: identifying danger sings early

6.    Effective follow up of confirmed cases after acute phase is over: post discharge care: answering never ending questions

7.    Home quarantined patients care: customized guidance depending upon patient profile,follow up of vital signs

8.    Psychological counselling: dispel the myths and remove anxiety,panic

And much more, which could do it effectively or better to say already, done it? Of course the answer is loud and clear.

You will be surprised to know that many patients were diagnosed (because family physicians could identify high risk patients as they have strong index of suspicion and community connect and of course they are updated) in just first visit and that too in just 100Rs (most of the family physicians are under paid for the class of service that they provide-but that is not the topic today, some other time): single consultation.

Can you imagine such an affordable care that country like India needed the most?

There are some very milder cases that can be easily managed on out patient basis and treating at home and yet too economical.

This pandemic has 2 main challenges

1. Economic burden on society: because most of the businesses are affected badly, so need affordable care and this will be needed for may be long time.

2. We do not want people to roam around: so need easily accessible healthcare in their nearby.

Both this challenges can be easily met with robust and efficient primary care.

The intent of this article is to show torchlight to the society and planners to re look at the way they deal with primary care.Need is to plan and promote it properly and secondly I wanted to thank you to my family physician colleagues, any where in the system, government or private to keep up the good work that they are doing now and always.

Let’s take a pledge and make a society, where everyone has a family doctor, making healthcare the way it should be: Good quality, easy to access and yet affordable.

Thanks you.

Dr.Pragnesh Vachharajani

Family physician, Ahmedabad

Joint Secretary, federation of family physicians of India

Secretary, Gujarat state family physicians` forum

Past president, IMA, Ahmedabad.

(Views expressed here are personal)

Preparing clinic or office practice in this current pandemic

Crosspathy is not allowed.Kerala Ayurveda Paramparya Vaidya Forum Vs. State of Kerala and Others

From the SupremeCourt Judgement dated 13/04/2018,on the SLP of 'Parambarya Vaidyas'....Landmark Judgement...

"In our country, the qualified practitioners are much less
than the required number. Earlier, there were very few
Institutions imparting teaching and training to the Doctors,
Vaidyas and Hakimis but the situation has changed and there
are quite a good number of Institutions imparting education in
indigenous medicines. Even after 70 years of independence,
the persons having little knowledge or having no recognized or
approved qualification are practicing medicine and playing
24
with the lives of thousands and millions of people. The right
to practice any profession or to carry on any occupation, trade
or business is no doubt a fundamental right guaranteed under
the Constitution. But that right is subject to any law relating
to the professional or technical qualification necessary for
practicing any profession or carrying on any occupation or
trade or business. The regulatory measures on the exercise of
this right both with regard to the standard of professional
qualifications and professional conduct have been applied
keeping in view not only the right of the medical practitioners
but also the right to life and proper health care of persons who
need medical care and treatment".

For complete judgement and other details,please find link below.

http://www.supremecourtofindia.nic.in/supremecourt/2003/10091/10091_2003_Judgement_13-Apr-2018.pdf

http://www.advocatekhoj.com/library/judgments/announcement.php?WID=9976

Courtasy: IMA emills and advocate khoj

Living Will

Supreme Court allows ‘living will’

Dr KK Aggarwal, Recipient of Padma Shri

In a landmark judgement delivered today, the Supreme Court of India has allowed an individual to draft a living will specifying that they not be put on life support if they slip into an incurable coma.

The order was passed by a five judge Constitutional bench comprising Chief Justice of India (CJI) Dipak Misra and Justices AK Sikri, AM Khanwilkar, DY Chandrachud and Ashok Bhushan, which said “Human beings have the right to die with dignity.” 
Though the judges gave four separate opinions, all of them were unanimous that a 'Living Will' should be allowed, because an individual should not be allowed to continue suffering in a vegetative state when they don't wish to continue living, and know fully well that they will not revive. The Apex Court has set forth strict guidelines on how to execute the mandate of the living will.

Four terminologies need to be understood in context of this judgement: Advanced directive, living will, health care proxy and DNR.

Advance directive: This is a legal document made when the person is alive and still in possession of decisional capacity about how treatment decisions should be made on her or his behalf if they are no longer able to make decisions for themselves or lose the capacity to make such decisions. Advanced directives are acted upon only when the patient has lost the ability to make decisions for himself. They can be revoked orally or in writing by the patient at any time (so long as he or she has maintained decisional capacity).
Advanced directive is a Durable Power of Attorney for Health Care (DPAHC or Health Care Proxy) and living will.

Living will: A living will is a document that summarizes a person’s preferences for future medical care including specific interventions such as cardiopulmonary resuscitation (CPR), ventilatory support, or enteral feeding. It is a document in which patients give clear instructions about treatment to be administered or state their wishes for end-of-life medical care, when they are no longer able to communicate their decisions. A living will takes effect when the person is terminally ill without chance of recovery, and outlines the desire to withhold heroic measures.
Health care proxy: A health care proxy is a person identified by the patient who will take decision with regard to treatment on his/her behalf in case he/she is incapacitated. Simply put, it can be likened to giving “power of attorney” but for medical decisions.

DNR or Do not resuscitate: This document applies specifically to cardiopulmonary arrest and not to the current health status, even when the patient becomes progressively more ill. It indicates whether the patient wishes for all efforts to be made to revive him by CPR and to be put on lifesaving ventilator.

The American Heart Association recommends that all patients in cardiac arrest should be resuscitated unless they have a valid DNR order, or in cases where resuscitation is physiologically futile (signs of irreversible death).

A series of workshops and guidelines have discussed end of life choices. It was also discussed at ‘End of Life Care’ CMAAO meeting in Tokyo, Japan in September 2017. Active euthanasia was given a big ‘no’ at this meeting, while with regard to withdrawal of ventilation, two options were suggested: either do not put the patient on ventilator or remove the ventilator.
In its Position Statement on End of Life Care and Advance Care Planning, the American Medical Association (AMA) advocates that advance care planning become part of routine clinical practice so that patients’ wishes and preferences for health care, particularly end of life care, are known and met. AMA further says, “The planning process respects the patient’s right to take an active role in their health care, in an environment of shared decision-making between the patient and doctor. It may involve family members, religious advisors, friends and other people the patient feels should be involved.” However, “an advance directive never takes precedence over the contemporaneous wishes of a patient who has decision-making capacity.”
Advance care planning is also considered a routine part of a person's health care in Australia, which allows competent patients the right to make their own decisions involving the withholding and/or withdrawal of life-sustaining treatment

However, the complete judgment needs to be read to fully understand its implications in practice.

In its judgement in Aruna Shanbaug case, the Supreme Court had permitted passive euthanasia for a patient in permanent vegetative state, provided it had the approval of the High Court.
“Hence, even if a decision is taken by the near relatives or doctors or next friend to withdraw life support, such a decision requires approval from the High Court concerned as laid down in Airedale's case (supra). In our opinion, this is even more necessary in our country as we cannot rule out the possibility of mischief being done by relatives or others for inheriting the property of the patient.”

“132. In our opinion, in the case of an incompetent person who is unable to take a decision whether to withdraw life support or not, it is the Court alone, as parens patriae, which ultimately must take this decision, though, no doubt, the views of the near relatives, next friend and doctors must be given due weight.”

The judgement of the Supreme Court does not answer the question as to who will take the decision to withdraw or remove the ventilator if there is no living will.

The current practice ( though not legal) is that all legal heirs sign a document for DNR or withdrawal.

MCI Ethics 6.7 Euthanasia: Practicing euthanasia shall constitute unethical conduct. However on specific occasion, the question of withdrawing supporting devices to sustain cardio-pulmonary function even after brain death, shall be decided only by a team of doctors and not merely by the treating physician alone. A team of doctors shall declare withdrawal of support system. Such team shall consist of the doctor in charge of the patient, Chief Medical Officer / Medical Officer in charge of the hospital and a doctor nominated by the in-charge of the hospital from the hospital staff or in accordance with the provisions of the Transplantation of Human Organ Act, 1994. 

Message courtesy-IMA

{Published for information purpose only)

National medical bill-courtesy IMA Google group

Straight from the heart: 41 NMC Bill 2017

Dr KK Aggarwal

National President

From SOURCES: National Medical Commission Bill, 2017

Functions

a.    Replaces the Medical Council 1956 Act.
b.    Enables a forward movement in the area of medical education reform.
c.    Moves towards outcome based regulation of medical education rather than process oriented regulation.
d.    Ensures proper separation of functions within the regulator by having autonomous boards.
e.    Creates accountable & transparent procedures for maintaining standards in Medical Education.
f.      create a forward-looking approach towards ensuring sufficient health workforce in India.

Aim


The Bill provides for a medical education system that ensures availability of adequate and high quality medical professionals; that encourages medical professionals to adopt latest medical research in their work and to contribute to research; that has an objective periodic assessment of medical institutions and facilitates maintenance of a medical register for India and enforces high ethical standards in all aspects of medical services; that is flexible to adapt to changing needs and has an effective grievance redressal mechanism and for matters connected therewith or incidental thereto.

Benefits

• End of heavy handed regulatory control over medical education institutions and a shift towards outcome based monitoring.

• Introduction of a national licentiate examination. This will be the first time such a provision is being introduced in any field of higher education in the country, as was the introduction of NEET and common counselling earlier.

• Opening up the medical education sector will lead to significant addition in the number of UG and PG seats and substantial new investment in this infrastructure sector.

• Better coordination with AYUSH systems of treatment.

• Regulation of up to 40% seats in medical colleges to enable all meritorious students to have access to medical seats irrespective of their financial status.

FUNCTIONS

(a) lay down policies for maintaining a high quality and high standards in medical education and make necessary regulations in this behalf;

(b) lay down policies for regulating medical institutions, medical researches and medical professionals and make necessary regulations in this behalf;

(c) assess the requirements in health care, including human resources for health and health care infrastructure and develop a road map for meeting such requirements;

(d) promote, co-ordinate and frame guidelines and lay down policies by making necessary regulations for the proper functioning of the Commission, the Autonomous Boards and the State Medical Councils;

(e) ensure coordination among the Autonomous Boards;

(f) take such measures, as may be necessary, to ensure compliance by the State Medical Councils of the guidelines framed and regulations made under this Act for their effective functioning under this Act;

(g) exercise appellate jurisdiction with respect to the decisions of the  Autonomous Boards, except that of the EMR Board;

(h) lay down policies and codes to ensure observance of professional ethics in medical profession and to promote ethical conduct during the provision of care by medical practitioners;

(i) frame guidelines for determination of fees in respect of such proportion of seats, not exceeding forty per cent., in the private medical institutions and deemed universities which are governed under the provisions of this Act ;

(j) exercise such other powers and perform such other duties as may be prescribed.

Structure:


·        25-member commission (NMC) will include Chairman, Member Secretary.

·         12 ex-officio members: 4 Presidents of Boards, DGHS, DG (ICMR), Dir (AIIMS, New Delhi), Nominee of Ministry, nominees of PGI Chandigarh, JIPMER Puducherry, TMCH Mumbai and NEIGRIHMS Shillong.

·         11-part time members: 3 members from management, economy, law, consumer rights, health research, science and technology; 3 members from the Medical Advisory Council; 5 elected medical persons.

·         At least 16 and up to 22 of the 25 members of NMC would be medical professionals.

·         All selected members would be finalised by a search committee chaired by Cabinet Secretary.



Medical Advisory Council

The Central Government shall constitute an advisory body to be known as the Medical Advisory Council as a platform for States/UTs.

Constitution: 64 members body.

1 member from each State+7 members nominated by MHA to represent UTs.

Members to be VCs of State Health University/University having maximum medical colleges.

All members of NMC.

Chairman UGC, Director (NAAC), 4 members from Directors of IIT, IIM, IISc.

Functions:

(1)  The Council shall be the primary platform through which the States and Union territories may put forth their views and concerns before the Commission and help in shaping the overall agenda, policy and action relating to medical education and training.
(2) The Council shall advise the Commission on measures to determine and maintain, and to coordinate maintenance of, the minimum standards in all matters relating to medical education, training and research.
(3) The Council shall advise the Commission on measures to enhance equitable access to medical education.

AUTONOMOUS BOARDS under the Commission

The Central Government shall, by notification, constitute the following autonomous Boards, under the overall supervision of the Commission, to perform the functions assigned to such Boards under this Act.

(a) the Under- Graduate Medical Education Board (UGME Board);
(b) the Post-Graduate Medical Education Board (PGME Board);
(c) the Medical Assessment and Rating Board (MAR Board); and
(d) the Ethics and Medical Registration Board (EMR Board).

FUNCTIONS of the UGME Board

(a) Prescribe standards for UG medical education;
(b) Grant recognition to new UG medical courses;

FUNCTIONS of the PGME Board

(a) Prescribe standards for PG medical education;
(b) Grant recognition to new PG medical courses;

FUNCTIONS of the MAR Board

(a) Determine the procedure for assessing and rating the medical institutions for their compliance with the standards laid down by the UGME Board or the PGME Board, as the case may be, in accordance with the regulations made under this Act;

(b) Grant permission for establishment of a new medical institution in accordance with the provisions of section 28;

(c) Carry out inspections of medical institutions for assessing and rating such institutions in accordance with the regulations made under this Act

(d) Conduct, or where it deems necessary, empanel independent rating agencies to conduct, assess and rate all medical institutions, within such period of their opening, and every year thereafter, at such time, and in such manner, as may be specified by regulations;

(e)  Make available on its website or in public domain the assessment and ratings of medical institutions at regular intervals in accordance with the regulations made under this Act;

(f) Take such measure, including imposition of monetary penalty, against a medical institution for failure to maintain the minimum essential standards specified by the UGME Board or the PGME Board, as the case may be, in accordance with the regulations made under this Act.


FUNCTIONS of EMR Board

a) Maintain a National Register of all licensed medical practitioners in accordance with the provisions of section 31;

b) Regulate professional conduct and promote medical ethics in accordance with the regulations made under this Act.
c) Develop mechanisms to have continuous interaction with State Medical Councils to effectively promote and regulate the conduct of medical profession;
d) Exercise appellate jurisdiction with respect to the actions taken by a State Medical Council under section 30.

Comparison of some selected features

Body

MCI: Primarily elected body with State/Central nominees.

NMC: Hybrid structure with primacy for selected members.  A few non-medical members.

Permission

MCI: Application to Central Government and permission by Central Government on recommendation of NMC: Application and permission by Medical Assessment and Rating Board (MARB).

UG Courses:
MCI: Permission needed for Establishment / Renewal / Recognition / Increase of intake.
NMC: Permission needed only for Establishment and Recognition. No annual renewal needed.
Automatic increase of seats allowed.

PG

MCI: Separate permission for PG courses after UG recognition.
NMC: College can start PG courses on its own.

Penalty for not meeting requirements:
MCI: No renewal permission. No admission.
NMC: Monetary penalty – up to 10 times the annual tuition fee.

Fee

MCI: No power to prescribe fees.
NMC: To frame guidelines for determination of fees for up to 40% seats in private colleges / Deemed Universities.

Hitcon 2018