Saturday, 21 May 2016

Spiritual Healing

Spiritual Healing 
A guest blog by Dr Amudha Anand, Singapore

This topic is very abstract and need to be experienced to understand. Being an initiated and practicing spiritual healer I will try to share relevant information in a simple manner.

Health is defined by World Health Organisation as a state of complete physical, mental and social well being and not merely an absence of disease. Science of healing is helping an individual restore his health through the cosmic energy (paramatma) that activates its extension (the jeevatama) that resides in every individual.

Different systems of healing act through different existential sheaths of our lives (phenomena called koshas). Current western medical systems acts through annamaya kosha or physical body. Pranayama  and pranic healing systems work through pranamaya kosha; this would be the vital force or energy that pervades the physical body. Manomaya kosha based healing is understanding and using one’s mind to heal (this is not just psychology, for instance religion and spirituality uses manomaya kosha for healing; some say that homeopathy is the better understanding of the mind after which is thought to enable healing through homeopathy). Vigynanamaya kosha is the sheath of intellect that we have, understanding and using this phenomenon is the basis of vignyanamaya healing; some say Ayurveda uses vignyanamaya principles. Most spiritual healing happens through anandamaya kosha; anandamaya is a state of inherent eternal bliss, a disturbance of this can and will affect all the koshas and hence the whole person. Healing with knowledge of the annamaya kosha heals the spirit – that would be the meaning of spiritual healing.

Being a human with an open mind is the only requirement to be a healer or be healed. I had hypertension longstanding vertigo and irritable bowel syndrome all of which got cured by spiritual healing after a two day chakra cleansing course by a great spiritual master.

One of the most useful methods used in spiritual healing is clearing the chakras.

There are seven chakras in our body

Each of these chakras have specific functions; their blockages have specific adverse effects and cleansing them has specific positive effects – a full detailing of these are beyond the scope of this short write up. As a mini illustration, the Sahasrara or crown chakra flowers when we live in gratitude. Getting to that point is a journey with defined pathways. But the effect of reaching that point is a life that is lived in gratitude, living in gratitude for all that we possess shifts your consciousness to higher plane.

(There are many references and links available, this is just one easy one to become aware of the chakras and their relevance in healing )

The innate intelligent energy that resides within us which is called Kundalini energy gets activated by cleansing the chakras. The full activation of the Kundalini is when it rises from the Muladhara (base) to the Sahasrara (at the crown of our head) and results in oneness with the absolute eternal. Regular practice of yoga, pranayama and dhyana can activate this energy when done over many years. Same can be awakened by a spiritual master in a word, touch or glance. This healing from a master happens for a short while but we can continue to remain healed by following the above mentioned practices on a regular basis.

A healthy satvic diet (yogic, stable, pure, clean, moderate diet) helps in acceleration of healing process making our body a good conductor to receive such energy.

The very first experience of this inner energy spreading within self gives one intense bliss the memory of which keeps one go deeper into seeking. The first sign is well being for oneself which when pursued with essential Vedic practices and initiation leads to healing of self and those around.

Somewhere along this path one is able to experience the vast difference between maya (illusion) and the TRUTH. As you go deeper into the pursuit of truth healing happens as a continuous process and our mind that was constantly looking for pleasures outside turns inward. The journey inward gives us the realization of the supreme purpose of human birth. 

All diseases, mishappenings, trauma and unhappiness is deemed to be the play of the macrocosm (paramatma), for the microcosm (jeevatma) to unite with its higher self. Once the being identifies with source and pursues techniques to be in constant communion with the source, major barriers that is knowledge, maya and ego melts unfolding higher powers in the form of siddhis and then we know that spiritual healing is one small yet important effect in this journey.

This science was thought to be part of each being in ancient times which was maintained by the culture of the day nourished by systems such as the gurukul. Now the same knowledge is being renamed, repackaged and taught to us in modified and edited versions.

We should aim to tap into the benefit of these ancient systems by tapping into the positive aspects of transcendent knowledge based spiritual practices; these are not the rituals of religion which are different from spiritual practices. This when acquired under guidance of authentic Guru will lead us from darkness to light, bondage to freedom and sickness to health.

I am not against any system of medicine. Whichever system is necessary and suitable for any given disease condition must be used to cure our illnesses; however when we aim for a certain kind of complete cure that goes above and beyond any presenting illness in question, in my personal view, it would only be possible by dealing with our person (body, mind and spirit) holistically that promotes healing from within.

May your health and healing include the healing of your spirit.

Dr Amudha Anand
Paediatrician, Singapore

(with editorial assistance by M Hemadri)


Note by M HEMADRI – Success in Healthcare, which is the name and the purpose of this blog recognizes that there are many modes by which success can be achieved in healthcare – Spiritual Healing by the vedic method is one of the ancient and profound methods. Amudha’s short writing is a welcome addition to this blogsite; my sincerest thanks to her.


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Friday, 15 April 2016

Honoring the Mothers of Gynecology

Honouring the Mothers of Gynecology

This blog was written after hearing Shankar Vendantam’s excellent podcast from the NPR Hidden Brain series on the mothers of gynecology.

The history of healthcare, the history of the noble profession, doctors, nurses, scientists and others has an underbelly of unethicality and double standards. This is often justified by the rationale that the practices were compatible with the ‘standards of the time’. That is one of the fundamental issues, the wrong question is whether it was compatible with the standards of the time, a possibly right question would be whether it was compatible with some of the eternal principles of medical practice. We will find again and again that actions of many of our predecessors in modern healthcare were not compatible with eternal ethical principles of healthcare.

An infamous example of an individual was the American physician J Marion Sims, who acquired black women slaves for the purpose of experimental surgery to resolve vesico-vaginal fistula. He operated on them without anaesthesia when anaesthesia was available and he operated on white women with the same condition only when he had completed his experimental surgery on black slave women after his technique was perfected on these black women. Who were these black women? It seems there were 14 of them; we do not even know their names except three of them. Anarcha, Betsy and Lucy.

In the NPR podcast historian Vanessa Gamble alludes to some potential motives. The women with vesico-vaginal (abnormal connections between urinary bladder and vagina) and recto-vaginal (abnormal connections between rectum and vagina) fistulas that happened after traumatic childbirth, meant that these enslaved women could not work for their ‘masters’ and could not reproduce creating more enslaved people to benefit their ‘owners’. So, it seems that it might not have simply been the desire to progress the frontiers of surgical science that was the primary motivator for Sims to have acted unethically. The view that he might have acted unethically is not just from retrospection, he was challenged about it even within his time.

Vanessa Gamble and Bettina Judd (a poet) talk in the NPR podcast about how these women whose life, living and bodies were used without consent could be recognised; there is some talk on statues along with the one that exists for Sims. Recognising and honouring these women is not tokenism, it is a fundamental for progress of humanity. Statues will act as symbols but they will have the constraints of geography and history whereas Sims will continue to have universality.

The mothers of gynecology should have universality (while Sims would become a lesser part of history). With that in mind I propose the following:

1)      Anarcha should be referred to as the mother of gynecology.

2)      The vaginal speculum currently known as Sims and its variants should from now be known as the Betsy speculum

3)      The surgical procedure to repair vesico-vaginal fistula should be called the Lucy’s repair.

While these three are important, it is also important to stop referring to Sims as the father of gynecology.

These suggestions stem from the principle where an immoral or unethical person is disassociated from any glory that is derived from the outcome of such person’s activity. The new world demands a new kind of approach, the sins, crimes and injustices of the past will remain – the benefits from those should not. The ignominy suffered by these women must be honoured by making them the main story; Sims of course needs a place on the page which he will have as an incidental footnote in the history of gynecology. Success in Healthcare demands these actions, we cannot allow healthcare to fail by not giving the mothers of gynecology their rightful place.

Organisations and persons working for equality and justice should lobby the gynaecological profession to adopt these changes so that they become the norm.


PS: I started writing a blog called ‘What are the nasties in healthcare we may regret in the future?’ and intended to use the mothers of gynecology as an example. Once I started writing it I realised that it will be yet another injustice if the mothers of gynecology did not have their own place in these blog pages.


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Saturday, 9 April 2016

A View of the NHS from the private sector health care

A View of the NHS from the private sector health care - A Personal Perspective:
Joe Karthikappallil

Whenever there are more than one solution to solve one problem  its safe to assume that  none works satisfactorily .

Healthcare for all free at the point of delivery is a commendable dogma which has made the UK a privileged population.  The staff including doctors who are appointed to the NHS enjoy reliable employment with a decent pension provision and great  perks with no pressure, obligation, or motivation to a  target orientated work ethic or to eliminate the waiting list of patients - apart from their goodwill.  

My experiences in the NHS are limited to ophthalmology and it would be reasonable to limit my comments to this speciality. Others may be able to comment on their speciality.  Lengthy waiting lists in Ophthalmology in the 90s and 00   were the result of a healthcare monopoly. Lack of competition and assured employment caused the incumbent surgeons to become inefficient. The result, lack of essential healthcare for the needy. 

Monopoly kills competition and stifles viable alternatives. Lack of competition causes creeping inefficiencies. Choice is important to maintain efficiency and keep costs down. Capitalistic market forces are not ideal but it delivers results. Private healthcare had to be roped in to reduce the massive waiting times in a fully funded NHS. How this could be achieved was a lesson that the NHS needed to learn.

The private sector quickly realised that efficient use of surgeons who are an expensive and scarce resource is key – something the NHS has still not taken any notice of. Five days a week and sometimes more - surgeons were utilised to perform surgical operations.

All other activity involved in the patient pathway could be serviced by staff who were trained e.g. preoperative assessment, biometry preparing the patient for operation, consenting and all postoperative care. This was a concept which the NHS was resistant to. Doctors were involved in organising all the above activity.

It was customary for all cataract surgeries to be performed under GA in the NHS whereas surgeons elsewhere were performing the same surgeries under topical anaesthesia. Compared to an average NHS list of 4 to 5 patient who required inpatient care due to GA, the private sector could treat 25 cataracts without anaesthesia cover as outpatient procedure. These efficiencies were lacking in the NHS due to the lack of competition.

A huge outcry was raised by the incumbent surgeons pointing out safety and cherry picking of patients. But evidence based medicine and audit of the outcomes paid put to these baseless allegations.  Kicking and screaming, efficiency in the NHS was improved.

Today the constant threat of funding following the patient compels the NHS to find efficiencies and failing surgeons and departments are shut or amalgamated.

The NHS is a monolith as far as procurement is concerned. Huge efficiency can be achieved if standardisation of use of capex products. In Ophthalmology departments the number of high tech equipments purchased and serviced runs in to billions of pounds.

The private sector buys standard equipments in large orders and thus drive prices down form suppliers. For instance the lenses and surgical instruments used in cataract surgeries, eye drops used can be standardised and prices can be a fraction of the current price if all orders are generated centrally. Similarly servicing charges for equipments are enormous and could be mitigated by  a dedicated NHS team of service engineers  - the private sectors do this currently.

These are just a few ways efficiencies of scale can be achieved. To the trained eye the NHS seems to be riddled with inefficiencies and in this age of technology, where there is a will, a way can easily be found. This is a relentless everyday process of discovering and upgrading efficiency.

In various other fields of British life, partnership between the private sector and the public sector is acceptable. The famous nuclear deterrent of the cold war was built on private public partnership.
There are build and operate private and public enterprise in constructing  hospitals  but not  healthcare delivery systems.

Not long ago NICE came along with recommendations regarding laser vision correction that made a mockery of available evidence base. All it achieved was a loss of credibility and a diminished its status as an institute of excellence. To lay out clear guidelines to the effect that although there is clear evidence to suggest that laser vision correction for myopia and hyperopia which is safe and effective there is no case for this to be available on the NHS would have been an elegant  stance to take. 

Such procedures  are performed and the public who have done their research are availing of such services but the animosity that this generates between the  surgeon community each trying to  undermine the other is unbecoming of an  erudite community of health professionals.

Aneurin Bevan in 1946 conceived and dedicated to the nation the NHS on the premise that services were provided free at the point of use. Advances in technology, extension of life expectancy, changes in the nation’s demographics and the longest recession in living memory are some of the forces testing the resolve of the British Isles - it is a challenge if such a health service or any health service conceived on the premise of free delivery at the point of care can endure any longer.

The people of the nation, if not the politicians are determined, that the NHS, the envy of the rest of the world shall endure. Take care of the pennies the pound will take care of itself. You shall find efficiency or efficiency shall be thrust upon you. A strong resolve alone is not sufficient to ensure that this generation and many generations to come shall continue to benefit from the high ideals of our fore-fathers.

Author of this post:
Joe Karthikappallil, FRCS Ophthal, is a consultant ophthalmologist in the private sector working in the northwest of England. The views expressed are his personal views and does not represent the views of any organisation, individual, associates, businesses, etc. 

I thank Joe for his contribution to this blogsite. 


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Saturday, 13 February 2016

Should a UK postgraduate medical qualification be awarded to someone who has not worked in the UK?

UK medical postgraduate qualifications can be obtained outside UK(1,2) without any work experience in UK. This is common knowledge among the medical profession around the world. This also a rather unique system since most postgraduate medical degrees and diplomas offered by institutions in many other countries require a period of training within their own countries. We were curious to know if the members of the public were aware of the ways by which UK postgraduate medical qualifications could be obtained and if it made any difference to their choice of a doctor to treat them.

A PubMed search did not reveal any such study about the public perception of doctor’s qualifications and its impact on consumer/patient’s decision making.

Our objective was to find out:
1)  If the public knew that UK postgraduate medical qualifications could be obtained outside UK
2)  If the public knew that UK postgraduate medical qualifications could be obtained without any work experience in the UK
3)  If the public knew that UK postgraduate medical qualifications could be obtained outside UK and without any UK work experience would it make any difference in their choice of a doctor if they needed medical care.

150 members of public in Kuwait from a similar social class and educational background were given questionnaires in either English or in Arabic. Questions were designed in sequence as per the objectives defined.

We found:
53% were not aware of the terminology of UK qualifications such as FRCS/MRCP etc
75% were aware that doctors with UK qualifications were practising in their city
72% would prefer to see a doctor with UK qualifications if they had a choice
50% thought that a doctor with a UK qualification would have a higher level of knowledge
45% thought that a doctor with UK qualification would have higher skills
85% said that if they were consulting a doctor holding UK qualifications they expected to benefit from the doctors UK experience
54% expected a doctor holding a UK medical qualification to have worked in the UK
67% did not know that a UK postgraduate medical qualification can be obtained without ever working in the UK
79% said that if they were seeing a doctor with UK qualification and they had the choice they would prefer to see one who has UK experience as well
84% said that if they had a major problem that needs a specialist consultation they would prefer to see a UK qualified doctor who also has UK work experience.


About half the respondents were not aware of the terminology of UK postgraduate medical qualifications, but three fourths knew that doctors with such qualifications were practicing in their city. The majority also said that they preferred to see a doctor who held UK postgraduate qualifications. Therefore we feel that it is in the interest of the medical fraternity in the UK to promote an increased awareness of the terminology of the UK medical postgraduate qualifications so as to enable patients to make a better informed choice in selecting a specialist medical practitioner.

However, half of our respondents did not expect a doctor holding UK postgraduate medical qualifications to have a higher level of knowledge or skills. But, interestingly we note that a majority would like to consult a doctor with UK qualifications. This suggests that there must be other intangible factors at work, perhaps ‘trust’, ‘glamour’, an ability to induce patient confidence and so forth which are inherent or implied.

An overwhelming majority said that when they consulted a doctor holding UK qualifications they expected to benefit from that doctor’s UK work experience. Two thirds of the patients did not know that a UK postgraduate medical qualification could be obtained without UK work experience. This suggests that patient’s expectations could be let down due to a lack of information and awareness of the way in which such qualifications are awarded. Perhaps, more seriously it is possible to speculate that some patients have the mistaken impression that doctors who hold UK qualifications have worked in the UK when that is not actually the factual situation.

An overwhelming majority of our respondents said that if they had a problem that needed specialist consultation they would prefer to see a doctor who had UK postgraduate medical qualification and UK work experience. We infer that lack of information prevents patients from making the choice that they would like to make. Our respondents were all from a more or less similar social background of an educated and middle class nature. It may be possible to assume that in the general population or in a population segment with lesser education, the awareness of such matters is likely to be much less while the expectations may be similar and hence prevents them even more from making a proper informed choice; sometimes, possibly a wrong choice.

In summary, our survey shows that in Kuwait some patients thought that when they consulted a doctor with UK postgraduate qualifications the doctor also had UK experience. Many patients did not know that UK postgraduate medical qualifications could be obtained without ever setting foot in the UK. Patients preferred to consult a doctor who has a UK qualification and UK experience. We conclude, that some of the patient’s expectations are not being met due to the way in which the award of UK postgraduate medical qualifications are made. We also feel that some patients could be misleading themselves into thinking that when they consult a doctor holding UK qualifications the doctor also had UK work experience when in actual fact that may not necessarily be the case.

One of our recommendations would be that UK postgraduate medical qualifications be awarded only to persons with UK work experience. Alternatively separate nomenclature could be used to indicate that the UK qualification was obtained without UK experience and/or training; the Royal College of Surgeons of Edinburgh has already started some movement towards such a practise by the award of SMRCS,(3) etc. Perhaps doctors holding UK qualifications could be obliged to divulge their training information as a part of enhanced ethical disclosure, say in their reception or waiting areas of their office. The institutions awarding such qualifications could have information campaigns that inform the patient hence empowering them with the ability to make an informed choice.

The Americans do not seem to confer their clinical postgraduate qualifications to doctors who have not actually worked in the USA.

The survey was conducted in the year 2000, we are not aware if there have been any changes in the public perceptions and understanding on this matter since.


Note: The above material is extracted from the following poster presentation:
A postgraduate medical qualification from the UK. What does it mean to the public in Kuwait? M. Hemadri and M. Purva. Hull York Medical School First Research Conference, Hull. 11th February 2004.


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Sunday, 3 January 2016

Is the NHS Pension Scheme fragile?

Is the NHS Pension Scheme fragile?


This is from NHS BSA FAQs '

Where do the contributions go to?

The NHS Pension Scheme, is an unfunded occupational scheme backed by the Exchequer, which is open to all NHS employees and employees of other approved organisations. Pension contributions for individual scheme members are collected by NHS Employers and are forwarded to NHS Pensions Other income is also received, for example from people transferring from other pension schemes in the form of a cash equivalent transfer that buys a service credit in the NHS scheme.

The income is used to offset the payments that the scheme makes to pensioners or people leaving the Scheme.

Details of income received from 1995/96 to 2009/10 is available here.

Employers and employees pay contributions based on a percentage of pensionable pay. Every four years the Government Actuary conducts a full actuarial review and recommends contribution rates in their Valuation report to the Secretary of State for Health. This is based on the use of a ‘notional fund’ as if all income from the start of the NHS Pension Scheme had been invested. As a result the Scheme is unfunded as there is no actual asset for a ‘pension fund’ on the balance sheet of the pension scheme.

At each valuation any deficit or surplus in the notional fund may result in a recommendation to adjust the level of contributions from the estimated future cash flows of the pension scheme.'

‘‘……… there is no straight link between the pension contributions paid in and the pension paid out.’’


So the NHS employees pay into a pension scheme that has no real money held in it, no asset, no pension fund. This income into the NHS pension scheme is paid out as NHS pension to past/retired eligible employees. Every four years the current employees of the NHS contribution into the scheme is adjusted and set so that the needs of the NHS pensioners can be met.

If you had a new financial entrepreneur offering you such a scheme, you would not pay a penny into it. In terms of the mechanics of how the scheme works it is like a Ponzi. The two differences between a true Ponzi and this one is that the NHS pension is ‘backed by the treasury’ and the primary intention is not to defraud using a fraudulent investment.

Wikipedia states

A Ponzi scheme is a fraudulent investment operation where the operator, an individual or organization, pays returns to its investors from new capital paid to the operators by new investors, rather than from profit earned by the operator.

Ponzi schemes sometimes commence operations as legitimate investment vehicles, such as hedge funds. For example, a hedge fund can degenerate into a Ponzi scheme if it unexpectedly loses money (or simply fails to legitimately earn the returns promised and/or thought to be expected)………

Promoters also try to minimize withdrawals by offering new plans to investors, often where money is frozen for a longer period of time, ……………………….

Further commentary

The NHS pension scheme is thought to be ‘gold plated’ which in common understanding means it is secure and provides higher returns than other pensions. It services its commitment by the current contribution of its payers. It has no corpus, no fund, no asset. The pension scheme has already changed rules by delaying access to pension for some.

If the NHS is privatised or if less people worked for the NHS then their contributions could rise (according to the four yearly actuarial valuation) and if very few people are employed by the NHS directly then the NHS pension will fail to legitimately bring in revenue to service its commitment to pensioners.

In effect, paying into the NHS pension could be like paying National Insurance. National Insurance it is not actually insurance with defined benefits claimed against contracted criteria, it is additional tax with benefits decided by government policy. Similarly, the NHS pension, since there is no asset or fund, it becomes dependent on the country’s economy and government policy. There has been significant opposition to the NHS pension changes, yet because it is government policy defined, the government uses its authority to make the changes to cope with what is very fragile.

It is a worry but….
The biggest reassurance is that the NHS pension is backed by the treasury which means as a strong western economy NHS staff pensions are safe.

The concerns are loaded towards/against younger NHS employees. Many are worried about the sustainability of public sector pensions, the CBI in UK talks about a £1trillion pension black hole.

It is best to think of reform of the NHS pension by creating a ring fenced fund which is then backed by the treasury. That will be a sign of mature strong financial management which reduces the vulnerability of the NHS pension. With an aging population, with NHS being the largest employer in UK we are talking about a lot of old people who are or will be ex-NHS, any measure to make their support structures stronger will be worth its while.


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Saturday, 21 November 2015

Standardised Management Conversation

The Book

I have written a mini-ebook called Standardised ManagementConversation (SMC) which I think is essential for healthcare directors, managers and senior clinicians. The SMC is a model which is to be used when various healthcare managers talk to those who report to them. It will also be useful for non-healthcare professionals and managers as the fundamental principles are more or less the same.

Since the conversation is standardised in the model, it makes conversation between people predictable and stable with no surprises. The model is based on sound principles, years of observations and practical experience. It draws on conventional management, clinical ‘lean’ management and some lateral thinking.

It is a small booklet. It is priced at £0.99 for UK and $0.99 for USA (equivalent prices for other countries) published in the ebook format via Amazon available at this link

The Cause

I will be donating all the money that I get from the first year (November 2015 to December 2016) sales of this mini-ebook to a charity called Udavum Karangal in India (  ) for the purpose of sponsoring an orphan child all the way through childhood till the child finishes education and leaves the orphanage. This scheme costs about $1000 or £600 which is actually a great value for money to see a child through childhood and education, thus providing a solid foundation for a stable adult life. I like long term thinking and long term benefits, that is why I have chosen this charity. I have personal experience of sponsoring children through this scheme. I have no other relationship with this charity, they do not know that I am doing this.

So here we go, if you are a director or manager in any field or have aspirations to become one in the future, especially if you are in healthcare, if you are a clinician with an interest in management, buy the mini-ebook SMC - Standardised Management Conversation. If you like it and use it and you are successful it is a win for you as a reader of SMC booklet, it is a success for me as an author and it is a success for a child till he/she becomes an adult. Well, if you do not like it, your £0.99 is pure charity.

It is a win-win-win whichever way you look at it. You may perhaps now want to make a guess on the gist of the content of the SMC mini-ebook.

Thank you for your support.


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PS: As a new author, new to e-publishing, if there are issues with it kindly provide me feedback so that I can improve on it.

Friday, 30 October 2015

Evolution of professionalism and ethical medical practice in UK and some lessons for India

Indian background: personal view of my experience in India

The issue of ethicality for me, as for many doctors in India, started before joining medical college. In my time and until today, the issue of admission to higher education by merit as judged purely by school final examinations and entrance tests versus the need for social justice to correct the vestigial effects of historical wrongs remains a highly volatile, emotionally-charged ethical dilemma. Once we joined medical college, we saw that the professionalism was often tainted by the general corruption and laissez-fare attitude of which it is often accused.

We overcame these issues due to four main factors:

a) We were really passionate about being doctors;

b) the subjects were really tough, so there was not much time to think about anything else;

c) some highly ethical, professional teachers had a disproportionately positive impact on our thoughts; and

d) most of us were only passive players in any unethical and unprofessional behaviour (at that time, that made it okay).

My own brief period of post-graduate training in India was a mixed experience - for me because of where I worked, my training was directly related to my effort, with the occasional heartache when some VIP’s son (it was usually the son) forcefully robbed me of my opportunity. Many of my colleagues completed their post-graduate training with limited skills; some of them could afford (the time, money and connections) to gain it in the real world after they finished their training and become better doctors; the normal reality of life engulfed the rest and they entered a self- perpetuating cycle of talent deficit. In the years as a young doctor in India, and then later as an experienced surgeon who practised in India for a brief period, I saw repeated examples of unsupported doctors driven to displaying unprofessional and unethical behaviour which were adversely affecting the patient’s clinical care amidst a few individual islands and beacons of high moral behaviour. To avoid being misunderstood or misquoted, let me make it very clear - my view is that the doctors in India want to deliver the highest quality of clinical care and they want to apply ethical methods. The social construct and systems often try to push them away from ethicality; some doctors manage admirably to resist this.

Broad UK contextual principles

The UK is indeed a very ethical and professional atmosphere for doctors. Generally, expressed behaviours are a function of societal standards and expectations. The UK has a high degree of expression of the whole spectrum of the domains of human action - a high level of personal free choice which is tempered with a high level of societal ethics; and a high level of legal control should the personal free action cross ethical boundaries. To phrase it differently, people can do what they want, they do that with consideration for the rest of the society and when they cross boundaries there are laws and rules in abundance which are generally enforced effectively. This was not achieved easily.

Broad context for doctors

There are broader factors that act as the foundation for professionalism and ethicality. As soon as we begin working in the UK, we realise that the bulk of healthcare is delivered by the government through the NHS (though there is increasing privatisation at this time).We learn that the rich and poor can get the same access and treatment, which is more or less of the same standard, across the country. Healthcare has no relationship with the ability to pay – it is free at the point of care. An overwhelming majority of doctors are employed by the NHS on national contracts and there is no difference in pay, and thus earnings, for doctors from various specialties working in any part of the country. Private care exists for people with money or private health insurance; but it is usually to jump any queues and get some frills but the care quality is in substance the same. The system generally removes any financial or professional reasons that might trigger unprofessional or unethical behaviour.

Specific context for doctors

Doctors are held to higher standards of behaviour; these are regularly reviewed and set out in the UK regulator’s (General Medical Council’s) Good Medical Practice guide. Doctors’ annual appraisals are related closely to the domains defined in the GMC’s GMP guide. There is a specific area in annual appraisals titled ‘probity’ which is taken very seriously. Further, a doctor’s personal health problems have to be declared and their impact on effective functioning assessed. The GMC’s GMP is applicable not just within a doctors’ professional and clinical domains it is applicable to behaviour standards in a doctor’s personal life as well. If a UK doctor’s drunken behaviour during private holidays affected any member of the public the GMC wants to know about it and will investigate it to see if there were any patterns that might impinge on patient care. If a doctor attends a court of law on a completely private matter such as speeding on the road or a financial irregularity the GMC wants to know about it and is likely to sanction in parallel for any major convictions in court. A registered doctor is expected to have a higher standard of behaviour compared to the average member of the public and when it slips the regulator will not hesitate to act against that doctor. The GMC even has guidance on how doctors should interact in the social media even when doctors interact with social media on non-clinical matters. Voluntary compliance is the norm. Breaches are quite a few but these are resolved through either local or social pressure. A word from the senior, a call from the medical director or a well meaning assertive/aggressive warning from people in the social media is usually enough for doctors to pull back and fall in line. Doctors have to reflect on their developmental Continuing Medical Education/Continuing Professional Development (CME/CPD) activity, doctors have to reflect on the complaints they face. Currently, doctors are required to have regular 360 degree feedback administered by an independent party, funded usually by their employers - this feedback is obtained from randomly chosen colleagues including other doctors of various grades, nurses, managers and others. If this feedback shows a need for improvement that has to be undertaken. The UK regulator has recently introduced revalidation for doctors where annual appraisals form the core element of the decision to revalidate a doctor every five years and allow them to practise. All the above descriptions form a part of the appraisal revalidation process.

The evolution of current practices

This is an interesting exercise in conducting large scale change. It was a slow, incremental multi-channel process that took many years and many stages. CME/CPD requirements were defined by the Royal Colleges in the early 1990s. Clinical audits were introduced in a big way in the early 1990s, 360 degree appraisals were introduced as a part of progression for trainees in the early 2000s; reflective practice was introduced in medical schools in the early 2000s. Cross pollination of these practices between specialties and grades were encouraged. Formal annual appraisals were introduced with it being mandatory for trainees. Soon annual appraisals became an essential part of senior doctors’ career job planning and career progress with many elements already having been brought together. Now all these have been pulled together into a comprehensive appraisal-revalidation system which is mandatory.

In the late 1990s, the Bristol enquiry into paediatric cardiac surgery deaths on how a department’s poor performance went unrecognised over a period of time; in the early 2000s, the Shipman enquiry on how a doctor could escape any official scrutiny over many years of criminality; and currently the Francis report on how a whole local system focused on the wrong things causing patient harm without being challenged by clinicians were major national external stressors that have pushed the medical profession to re-focus on the patient and start taking responsibility.

Some counter points

Is the NHS system perfect? Certainly not. Will it catch the bad doctors? Probably not. The scientific evidence for many of these methods is arguable. Many doctors opposed it actively all along and resist it passively even now. Some use it as a purely tick box exercise so that they will have a licence to practise their jobs. No one can be sure if these improve clinical quality for the patient.

What it does seem to have done is to increase the professionalism and ethicality of doctors. When anyone suspects a breach of professionalism and ethicality by doctors anyone is entitled to report the doctor to the GMC. The GMC does a full investigation only for a small number of the cases reported to them. During the investigations the GMC looks for reflection, maintenance of clinical skills, and development of insight. If the GMC is satisfied with these then it decides on minimum sanctions or on no sanctions at all. If it is not satisfied, the sanctions can be very severe, including erasure. The GMC, backed by the law, is a powerful force for doctors to seek a higher degree of professionalism and ethicality.

In practice, a large number of doctors who are international medical graduates (IMG) and who are from black and minority ethnic (BME) origins believe the system may be broadly very fair for the UK local graduates, but for IMGs and BME doctors there is evidence of a higher rate of reporting to the GMC and a perception of a higher chance of sanctions and a higher severity of sanctions. This is seen by many IMG and BME doctors as somewhat defeating the otherwise worthy ideals that in general work well. It is not as though there are no other sub-radar ethical problems: defensive practice, higher levels of service utilisation with its implications of unnecessary interventions, racial divisions (in jobs, exams, pay grades, bonuses) and others.

Transferable lessons

The principles underpinning UK medical practice are universal and hence transferable. The core principles are:

a) expecting a higher standard of behaviour from doctors in the practice of their profession and in their personal lives;

b) having a strong, progressive regulator backed by law; and

c) encouraging and supporting doctors at every opportunity to be ethical and professional, but with the clear

d) understanding that any breaches will involve facing the full impact of regulatory and legal enforcement without fear or favour.

The practice of these principles is not easily transferable since the context and environment is very different in India.

As very junior surgical trainees in India we used to ask patients to buy a variety of drugs, sutures and allied implements for their care - we would also make a judgement on the economic capacity of the patient, and on that basis ask them to buy a certain amount more than what would actually be needed for their care, sometimes upto double their actual requirement. We then used to store this in our individual cupboards and use the surplus for the care for other patients. Sometimes, we told the patients that this is what we were doing, sometimes we did not – either deliberately or simply due to lack of time. Essentially all of us were running our own individual small scale charity process. We saw this as completely ethical, moral and professional. We were saving lives, we were curing patients.

In the UK, this will be misrepresentation, lying, theft, financial misdemeanour, etc, all of which obviously are offences with the potential to end careers.

In India unnecessary investigations could have a financial motive (essentially fraud), in the UK it is mostly simply a matter of high utilisation (hence an issue of lack of operational standards). In India, talking to the next of kin of ill patients is normal accepted practice; in the UK, speaking to the next of kin without specific consent is sanctionable under the Data Protection Act and is a clear breach of right of privacy.

Creating an Indian system

A two-channelled approach may be needed in India. The first channel is to enable a higher standard of positive behaviours from doctors.

My personal suggestion is for doctors to create and maintain their own personal-professional portfolios. These portfolios could be reviewed by either employers or peers (individuals or professional bodies) every two years; and voluntarily submitted to the state medical councils every four years. In return these doctors could get the status of updated/enhanced registrations. Over a period of time, the medical councils and professional bodies can work together to make the portfolio very robust (perhaps in 20 years’ time the whole process can include a 5 yearly voluntary written knowledge test). A higher degree of respect, recognition and remuneration for doctors who have updated/enhanced registration could be an incentive to encourage the uptake.

The second channel would be to reduce the incidence and severity of negative behaviours in doctors. Pro-active, transparent, supportive intervention by the relevant professional society and the state medical council will be crucial. However, when those interventions fail a strict regulatory and legal approach will be needed.

A time defined, long term, incremental protocol, with specific measures that must be achieved, should be mandated with implementation commencing urgently.

I am hoping that these words make meaning and help thought in creating workable recommendations to enhance the ethics and professionalism of doctors in India. This will be essential for the future of the doctor-patient relationship and to enhance the reputation of doctors in/from India.


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This was originally written at the request of Prof Rajan Madhok as a part of background documentation for a conference in Kolkata in January 2014
The Global Indian Doctor: Workshop on promoting professionalism and ethics

The article was republished in Sushrutha (Volume 7 Issue 3), BAPIO's magazine published on the occasion of their annual conference 2015.