Health Watch

‘Doctor watch’ - is he any good?

Continued from May 27

Dr. Kasun Ratnayake, Dr. Samanthi Athukorale and Dr. Thishan Nallaperuma (United Kingdom)

The transfer system of consultants has defects as the ministry follows solely a seniority based system. They follow a ‘marking system’ and add marks counting from the day one that he/she completed the MBBS rather than considering their total performances as well.

Ministry offers marks commencing from the year MBBS was obtained till to date (2 marks for preliminary grade and 2 marks for grade 2.) Another 3 marks is given taking into consideration the year the postgraduate degree was obtained up to the date he/she is eligible to work as a board-certified consultant (after foreign training). Finally add the said two types of marks and announce the rank. According to this scheme, if you got through the exam with great difficulties sitting for the MD or MS (Doctor of Medicine or Surgery) Part 1 exam for 4 times and again MD Part 2 for 5 times but still you could go to a TH easily, more than a scholar (who gets through exams very well) could, regardless of your skills. There are many Consultants of this nature serving right now in the key hospitals.

Conversely the talented doctors who got though all the exams at their very first attempt plus performed well in the Universities obtaining classes with gold medals are completely ignored. This bad system further encourages the brain-drain and to stay them lethargically without following further exams such as MRCP (Royal College Exams, UK).

The people who got through further exams are badly ignored. In any profession there are brilliant people who have performed very well compared to their colleagues but the health ministry didn’t understand this difference and how to utilize them. In a cricket team also top-notch batsmen are placed in the top in the batting order regardless of their seniority to gain the best outcome.

The doctors who got through the exams after sitting many times cannot perform during their overseas training. Hence they will comeback to Sri Lanka (SL) as soon as possible. In contrast to them, the skilled people are offered permanent jobs in foreign countries identifying their skills. We met a lot of doctors of this nature who decided to stay in UK and Australia saying “If we come back to SL we cannot use our skills aptly due to prevailing seniority base system.” Likewise this poor system has created an avenue for brain-drain. If the Ministry wants, they could do a survey and see.

Apart from that, this is a very serious issue financially because government spends money from primary education till the completion of postgraduate degree and further they offer two years paid study leave in order to get overseas training either paying monthly allowance or allowing them to find paid jobs.

In UK, qualified consultants can apply when a Consultant position is vacant in NHS (National Health Service) hospital. Subsequently they will conduct a series of interviews and select the most suitable person. Sometimes relatively senior person would become unsuccessful if a less senior person could show better performances.

This situation instigates all consultants to continue their education and update their CVs every 3 months with their CPD activities. Our doctors require preparing CVs when they plan to go for foreign training only and MBBS holders never have CVs.

How to overcome this issue

Considering aforesaid real and pathetic side of the health sector, it is self explanatory that we should remedy the same without any further delay. Being followers of western traditions of medicine we cannot see any valid reason as to why we should ignore their high standard of practice.

Suggestions

1. Provide directives by the Minister to the local doctor’s official body, SLMC (Sri Lanka Medical Council) like Health Secretary of UK instructed their body (GMC) ;

a. Appoint a panel of expertise – This should include few members from the Ministry, PGIM (Post Graduate Institute of Medicine) and SLMC in order to prepare a ‘revalidation program’ for each level of doctors following the UK system targeting the commencement year 2016 (ideally by 2015).

b. CPD system - Prepare a CPD system including proper ‘Marking Scheme’ illustrating the minimum level of marks to be achieved mandatorily by a doctor each year.

The SLMC shall publish in their website regarding the authorized events, conferences, workshops etc to be participated by non-Consultants and Consultants in two separate lists and number of marks could be earned against each event.

Non Consultants – As per above.

Consultants – The activities such as Clinical Audits should be carried out from their capacity also shall integrate with their CPD marking scheme.

c. New Transfer Scheme - All categories of doctors shall receive new transfer scheme combined with new marking system instead of present seniority based scheme. This shall include offering additional FIX marks for their performance in the MBBS such as classes, gold medullas etc and for their further studies and exams.

Non Consultants – Some doctors have got through MD/MS part 1 but they couldn’t pass the Part 2 in order to be a consultant, however the knowledge gathered in addition to MBBS would be still valid to offer 0.5 marks at least.

Consultants – They should be given fix marks in the transfer equation for Postgraduate degree (better than now) and for further studies i.e. MRCP (RCP or RCS exams), MSc, Diplomas, Researches etc, as well.

(Above said mechanism will help promote self-motivation of doctors to do further studies and consequently it will lead automatically to upgrade the standard of the health sector)

NOTE: Strengthening the SLMC like GMC is another mandatory requirement.

2. Initially this system may start in the level of consultants hence transfer system to the THs should be kept temporarily on hold till year 2014. However as a privilege existing consultants serving in the end-stations (THs and 2nd layer General Hospitals) can continue their services till the retirement. As and when they retire, vacancies shall be filled temporarily until the new appointments are made under the new system in 2014.

3. Easiest step- Providing right place for right people (brilliant people) in the transfer list would be the easiest action that the ministry can take with less effort.

I.e. Restructuring the existing making scheme for consultants’ transfers: - allocate at least 4 marks for MD (or MS) for each year from the year of qualifying instead of present mark 3. Consequently skilled people (who got through exams on time...etc) could obtain a better place in the list than now.

NOTE- If Ministry delays in implementing above 2 and 3 (easy steps), the existing damage will continue.

4. Apply the suggestion mentioned in above 1 and 2 for next layer of doctors gradually after implementing for consultants.

If the Health Minister can identify the said lapses and implement a new system to remedy the gaps it will be very reasonable for patients and also for the talented and postgraduate qualified doctors who are disappointed right now. All doctors should be offered a mandatory target to achieve each year and the ministry can offer financial incentive schemes for additional performances apart from better place in the transfer list.

A safer childhood through lactation management

Exclusive breastfeeding during the first six months yields numerous and definite benefits to both mother and the baby. “The first milk that is secreted, commonly referred to as the ‘golden elixir’ is a thick yellow liquid called colostrum. It is secreted in small quantities but has tremendous benefits to the newborn baby.

It is rich in nutrients and antibodies including white blood cells, immunoglobulins, carbohydrate, fats, Docosahexaenoic acid (DHA), arachidonic acid (AA) and protein in correct proportions.

The composition of the milk changes as the baby grows in line with the infants requirements. No formula can ever match this,” said Prof. Asvini D Fernando - immediate past President of the Sri Lanka College of Paediatricians at a recent seminar jointly organized by Sri Lanka College of Paediatricians and Unilever (manufacturers of Pears baby range.)

Benefits of breastfeeding

Apart from this both the mother and the baby reap a multitude of other advantages from breastfeeding. Breastfeeding assists the uterus return to its pre-pregnant state faster and reduces the risk of ovarian cancer and pre-menopausal breast cancer in the mother.

It promotes bonding between the mother and the baby, lowers the risk of gastro-intestinal (gut) illness, allergies, asthma, diabetes, obesity, some childhood cancers, respiratory tract (chest) infections, urinary tract infections and SIDS (Sudden infant death syndrome) in the child.

Challenges

Given the mutual benefits, breastfeeding should come naturally to any mother. However, certain mothers face various challenges in establishing breastfeeding and maintaining it. Speaking from her experience in handling such situations during the last 35 years Dr. Kalyani Guruge stated, “Some mothers find it difficult to initiate and establish breastfeeding. One of the important reasons is ‘postpartum blues’ which can be very mild and go unnoticed or sometimes severe. During this phase the mother’s confidence of looking after the baby can be low and they may feel their breast milk production is not adequate for the baby. The guidance and support given at this crucial time by the hospital and community medical staff as well as the parents, spouse, relatives and friends are extremely important.

Unfortunately some mothers are advised by the immediate family and friends or even by the medical professionals to start on formula milk which becomes a difficult practice to reverse once established.

Today, families tend to be nuclear and new mothers lack the support of the extended family on a day to day basis. This poses yet another challenge since these mothers have to juggle taking care of the new born baby and housework which can lead to using formula. With proper guidance and support this situation can be avoided. The Lactation Management centres facilitate such support and guidance,” stated Dr. Kalyani Guruge.

Overcoming challenges

“Mothers need support to establish breastfeeding and then to continue doing so without setbacks. Some hospitals have already established Lactation Management centres and are providing a very good service. The Sri Lanka College of Paediatricians last year decided to initiate Lactation Management centres (LMCs) in hospitals that did not have such centres and upgrade existing LMCs where necessary in collaboration with the Family Health Bureau of the Ministry of Health. This was to ensure that mothers have access to guidance on breast feeding at all times throughout the country. This decision was a result of a workshop held in collaboration with the World Health Organization (WHO), which identified childhood malnutrition as a challenge that Sri Lanka still faces.

The idea developed around the theme ‘Developing pathways to a safer childhood’, which was the theme of Sri Lanka College of Paediatricians strategic approach for the year 2011/2012. Unilever’s Pears came forward to support us in this initiative” elaborated Prof. Asvini Fernando.

A practical approach

Thus far, Unilever’s Pears has extended its support towards establishing two Lactation Management Centres; one at the Homagama Base Hospital and the other at the Karawanella Base Hospital.

“Mothers can visit the Lactation Management centres from 8am in the morning to 5pm in the evening for guidance, psychological support as well as for practical advice on issues pertaining to breastfeeding. Our services are available to all mothers who need guidance. Any mother who requires our services can visit the centre for guidance, even if they delivered the baby at a private hospital.

Paediatricians and nurses at these Lactation Management centres supported by Pears will guide mothers in their need and ensure personalized care for each mother and baby. We have designed the interior of the LMCs in such a way to enable mothers to spend as much time as they prefer at the centre. That way the mothers receive the best possible care and advice,” said Dr. Rasika Gunapala, Consultant Paediatrician Homagama Hospital.

The centres will be open from 8 am till 12noon during weekends and Public holidays as well while those who cannot visit the centres may call the hotline for advice. In an attempt to maximize the effectiveness the LMCs are located near maternity wards at the hospitals and the interior of the centres are adorned with posters with useful breastfeeding information.