Should medical students resort to a strike?

Should medical students resort to a strike?
Thomas George at http://www.issuesinmedicalethics.org/082mi059.html
Indian Journal of Medical Ethics Apr-Jun2000-8(2)

The medical students, resident interns and post-graduate students of Tamilnadu were on strike from February 17 till March 4. Although there were 16 grievances, the two main demands were an increase in the stipend and a law to prevent the setting up of any more private medical colleges in the state. On February 25, the government offered an increase in the stipend but refused to give an assurance on the private medical college issue. The strike continued and five students went on a “fast until death”. The students demanded an audience with the chief minister, but he demanded that they first call off the strike. The opposition leader raised the matter in the legislative assembly. Finally the chief minister agreed to meet the students on March 4.

The government agreed to raise the stipend from Rs. 2,250 to Rs. 3,027 for the resident interns. For post-graduates, the amount would go from Rs. 2,500 to Rs. 4,400 for first year postgraduates, Rs.4,641 for the second year and Rs.4,883 for the third year. Those doing super-specialty courses would get Rs. 5,366. The government also agreed to a 10 per cent annual increase of the stipend to prevent future strikes on this score.

During the course of the strike it became clear that the students were extremely concerned about the possibility of new private medical colleges in Tamilnadu. This was because in the recent past one had been started in Salem. This college had obtained permission from the Medical Council of India and the central government, despite being refused permission by the state government. It had approached the Supreme Court and won a directive to the state government to accord permission. The students were informed that this entire drama had become possible due to an amendment to the Medical Council Act in 1993, which vested the power to sanction new colleges with the MCI.

They had obtained a legal opinion to the effect that if the state passed a law to prevent the setting up of any more medical colleges in the private sector,it would override any law of the Central Government, since education is on the concurrent list. The students were apprehensive that this point was not being brought to the attention of the chief minister and hence their insistence on meeting him.

Other than the Christian Medical College, there are three private medical colleges in Tamilnadu. All of them were opened during the governance of the late MGR. Two of them have got deemed university status and admit students after collecting exorbitant capitation fees. They conduct bogus entrance examinations to give a façade of fairness to the selection process, but it is an open secret that one has to pay a capitation fee if one wants to get seat.

This is not to suggest that the DMK has been correct in their approach to medical education. During their several stints in power, they completely corrupted the selection process and a large number of undeserving students got not only medical seats, but also post- graduate seats. Subsequently, many of them were appointed to faculty positions. Knowledge of the kind of people they have put into the teaching medical colleges is perhaps one of the reasons that politicians now hardly ever go to a state government institution for medical treatment. MGRwent to the USA for a renal transplant. Even his early treatment in Chennai was not at the so- called “premier” institution, the Madras Medical College, but at a private hospital. It was during the governance of MGR that an entrance examination was introduced for entry to the medical colleges. This was probably more a response to the number of writ petitions that went against the state government every year in the matter of medical admissions and the strictures of the court, rather than any desire for fair play.

The question arises: Should medical students resort to a strike, however just their demands? This has been debated many times. Some concerned people believe that doctors should not go on strike, although they agree that many of the grievances are genuine and that governments are unresponsive (1,2). It is amazing that in the two references given, one written in 1992 and the other in 1999, i.e. a full seven years later, the grievances of doctors remain similar.

This suggests that policy-makers do not care, and can be forced to respond only by an extreme act like a strike. It is true that the poor suffer the most when there is a strike in a public hospital. But this is equally true when, for example, transport employees go on strike. The fundamental problem is that the state is not sensitive to the needs of the poor. This is seen in so many ways, like the meagre allocations for education, while handing out tax cuts to the already filthy rich. Expecting doctors alone to always be ready to sacrifice is neither meaningful nor healthy. Society has to be structured in such a way that rewards are allotted in a just manner. Doctors, who put in a lot of hard work, as most interns do, certainly deserve better working conditions. Until they get them as part of their rights, such strikes are likely to recur. They are a symptom of a deep malaise in our society, of which one manifestation is that a few undeserving but powerful people grab much more than their share of the fruits of development, while the vast majority are left to scrounge for the remaining crumbs.

References:

1.Ashtekar A, Mankad D: MARD strike: our reservations. (Letter). Issues in Medical Ethics 2000; 8: 2.
2. Pandya S: Letter from Bombay. National Medical Journal of India 1992; 5: 44-45

Should doctors strike work?

Should doctors strike work? by Yash Lokhandwala at Indian Journal of Medical Ethics
Apr-Jun1996-4(2) http://www.issuesinmedicalethics.org/042ed047.html

Strike is a legitimate form of collective protest in a democracy. At the same time, the guiding principle of medicine is the alleviation of suffering. Thus the issue of whether doctors should ever strike work is contentious. Some have preached from an ivory tower and advocated against this form of protest (1) . Opinions have been expressed that the suffering caused by a strike of doctors violates the ‘raison d’etre’ of the medical profession.

Of course one cannot deny that patient care suffers during a strike by doctors. The scale of harm caused depends upon the role played by doctors in that particular health set- up, the type of cases under treatment, and, of course, the duration of the strike.

Issues prompting strike
It is important to analyse the issues at stake which prompt a strike if one is to make a ‘cost- benefit’ assessment. For if a strike, in the long run, is to result in better health for a large section of the people, the inconvenience caused to a few during the strike may be justifiable.

Let us consider a scenario where the medical profession is forced to become a passive or active accomplice of a tyrannical political system as when doctors are forced to participate in state torture of revolutionaries. Doctors may be made to examine the victims before torture, help decide the best means and degree of torture appropriate for each victim (2). In extreme cases, they may even be asked to participate in the torture process itself. The role played by senior German doctors in the torture and experimentation of Jews and communists in Nazi Germany is well documented. Even today, in some South American, African and Asian countries, when doctors were ordered to play such a role by the state against its political opponents, several doctors refused, at much personal risk. Individually, these doctors were hounded and persecuted

In other countries such as Pakistan the medical associations protested and even went on strike to highlight the issue. Obviously such a strike would be supported by all right- thinking people. Thus to say that it is unethical for doctors to strike work as a blanket statement is completely unrealistic.

Let us now consider a less extreme instance. In 1984, as a member of the Maharashtra Association of Resident Doctors (MARD), I was a participant in a month- long strike against the proposed setting- up of private capitation- fee medical colleges in Maharashtra. We held that these colleges would serve as a backdoor route of entry for the academically less- deserving rich into the medical profession. This would lead to rampant commercialisation of medicine by half- baked doctors sprouting forth from these colleges, out to recover their lakhs of rupees of investment at the expense of an unsuspecting public. Pleas in 1983- 84 by many, including MARD, to government and university authorities to refrain from permitting (and encouraging) private medical colleges (charging exorbitant fees) to start, fell on deaf ears. We had then pleaded that, if we really needed more doctors, more public medical colleges be started.

Each of these proposed private medical college trusts enjoyed strong political patronage. The colleges were to be used to enrich their patrons and enhance their political power. It is not surprising that MARD’s pleas were brushed aside. Left with no other option, MARD declared a strike, which unfortunately failed in preventing the setting up of these commercial colleges. The strike did succeed in getting guidelines established for maintaining academic standards in these colleges and also for reserving a portion of the seats for meritorious poor students. Over the years these guidelines were side-tracked and many more tinpot medical colleges have sprung up. Today, 12 years down the road, we are experiencing the disastrous consequences of this shameful policy. Poorly trained ‘doctors’ emerge from these colleges, their first objective being the recovery of hundreds of thousands of rupees that their parents have spent in educating them. Now these same armchair philosophers who lament the present morass, criticise efforts such as a strike (even if this is the only possibly effective means) to prevent a foreseen Greek tragedy.

MARD strike justified
Finally let us consider the most mundane, yet commonest reason for a doctors’ strike. Yes, I’m referring to strikes for economic demands, brought into focus by the recent MARD strike of resident doctors in public hospitals for pay rise and better living conditions. One need not go into the miserable conditions that resident doctors work under, since these have been repeatedly described in the lay press. Suffice it to say that their living and working conditions, coupled with a meagre salary, made it impossible for them to work efficiently and to live with dignity. Directly or indirectly, sooner or later, such oppressive working conditions are bound to result in suboptimal work quality and output. Numerous representations over the years to the authorities for provision of decent accommodation and realistic salaries have gone unheeded. Except for 1989, the state Government has never increased the salaries of resident doctors without a strike action by MARD.

If the recent predictable MARD strike had not occurred, the situation would have kept deteriorating towards a total system failure, i. e. a foreseeable breakdown of efficient patient care due to the inability of resident doctors to function properly. In fact, we frequently read about the shortage of faculty members in public hospitals due to poor salaries . It may not be alarmist to say that a breakdown of public health services is imminent. Yet our preachers from the pulpit would say, ‘Let things collapse but do not strike work. ’

References
1. Pandya SK: Letter from Bombay. Strikes in hospitals. British Medical Journal 1988; 297: 1278.
2. Jesani A: Supreme court judgement violates medical ethics. Medical Ethics 1995; 3: 38.
3. Amnesty International Report, 1986.
4. Jain K: Medical colleges face faculty shortage. Times of India 3 March 1996 page 7. 48

Yash Lokhandwala ,Member, Executive Committee, Maharashtra Medical Council, Member, Central Advisory Board of Education (New Delhi), Ex-member, Medical Council of India

Trends in public health

Read this old post written in 2000 at http://www.issuesinmedicalethics.org/081ed003.html by Arun Bal

It is still very relevant, even today

Resident doctors of public hospitals in Mahaharashtra were on strike again, demanding parity in their stipend with other states. This was their sixth strike in two decades. The usual pattern is that the strike is carried forward for two to three weeks and then withdrawn in the face of government coercion. The government does little to prevent such strikes, or to hold any meaningful discussion with the agitators once they begin. This is primarily because the people affected by the strike are poor and unorganised, and cannot put much pressure on the government. Also, the public’s health is a low priority for all political parties.

Resident doctors make up the backbone of public hospitals affiliated to teaching hospitals, and the government‘s assertion that the strike did not affect services in these hospitals is completely false. Resident doctors are post- graduate medical students who work as resident doctors as a part of their post- graduation. Keen on completing their post- graduate studies, they are usually up-to- date on recent developments in their subject. They are responsible for the efficient work culture and relatively high quality patient care in these hospitals — a contrast to district hospitals with facilities similar to teaching hospitals but with full- time doctors who are government employees.

Demands justified
There is a big gap in the stipend paid by the government of Maharashtra and that paid by other states. The government expects resident doctors to work 24 hours a day without the protection of any service rules because they are students. At the same time, it charges them hefty teaching fees for post- graduate courses.

The government also argues that resident doctors in Bombay are working in the best hospitals in the country, and will go on to earn lakhs in their private practices based on the experience they receive at these hospitals. This ‘good will’ justifies the low stipend that they receive. The government’s contribution towards this ‘good will’ is zero.

Resident doctors in Maharashtra work and live in abysmal conditions which are bound to affect patient care adversely. In times of medical crisis, they must depend on archaic communication systems. Discharge cards are still hand written, though computerising the record system would save significant time for patient care. Essentially, the government has always looked upon resident doctors as cheap labour for its public teaching hospitals.

In short, the demands of resident doctors in Maharashtra were justified.

Why the strikes fail
However, resident doctors have failed to garner public support for any of their strikes in the last 25 years. The reasons: the inherent weakness of the Maharashtra Association of Resident Doctors (MARD) as an organisation whose members and leadership change every three years, and the lack of social awareness about the critical role that resident doctors play in public teaching hospitals. The government has always exploited these facts to break the strike.

Both MARD and the medical profession at large have failed to create public awareness about the importance of resident doctors for public teaching hospitals. The medical profession’s general lack of political awareness contributes significantly to the current situation. The main demand in residents’ strikes has always been monetary. Instead, the focus of any negotiation should be the poor working conditions which affect patient care.

Any strike by health professionals which deprives people of basic care is unethical. MARD should have allied with other medical and social organisations to lobby the government, negotiate and arrive at an amicable solution. They should also have focused on the trends in health care responsible for the situation today.

Trends in public health
Investment in the care of seriously- ill patients as a percentage of investment in public health has been decreasing over the years, particularly after the World Bank / IMF’s structural adjustment programme pushed for privatisation of the public health system. The Maharshtra government’s recent Rs 771 crore loan from the World Bank to modernise the district and sub-district level health- care system is conditional on starting user fees and increasing the involvement of the private sector in the public health system. The government has already announced that private doctors will be hired on contract to improve the functioning of public hospitals. It is surrendering public hospitals to private medical colleges which don't have a hospital of their own, in order that these understaffed institutions run by politicians meet the Medical Council of India’s requirements. Finally, the entry of private health insurance companies is likely to reduce the importance of public teaching hospitals.

While these trends are not directly related to the resident doctors’ strike, the government is likely to use the strike as a excuse to take privatisation one step further. Its move to reduce the importance of resident doctors by reducing the seats for open category post- graduate registration, reserving some for full- time government doctors, will, in the long run, adversely affect patient care in public hospitals. Neither MARD nor other professional organisations in the state have taken note of this fact.
National standardisation of stipends to post- graduate students and resident doctors is unlikely unless the medical profession realises the political and social implications of health care privatisation and joins hands with like minded organisations to create public awareness on the issue. Such public protest — with the support of professional organisations — forced the British government to abandon similar plans in some National Health Service hospitals.

The recent resident doctors’ strike in Maharashtra is a symptom of a crumbling public health system. The medical profession’s ignorance of this fact will only help the government break the strikes.

--------------------------------------------------------------------------------

Arun Bal,Flat 6, Mallika, Makranth Housing Society, SVS Marg, Mahim, Mumbai 400016

Illegal working hours of junior doctors throughout the country

TO,

THE NATIONAL HUMAN RIGHT COMMISION
NEW DELHI


Sub: Illegal working hours of junior doctors throughout the country
And routine (!)Death of patients due to this forced negligence.

Sir,


This is to bring in to your notice the illegal and unhealthy working hours of junior doctors in the Government hospitals and teaching institutes throughout the country and the adverse effect it has on the safety of poor patients. Today in all other sector where continuous round the clock duty are required i.e. Telecommunication, Railways, Airlines, Travel, Forces etc., the norms of 48 hours/week or less and shifts and night duty norms are followed (compensatory off are given, if stretched any time beyond recommended limit). It is unfortunate, as well as inconsistent with their own principles, that the organizations most vitally concerned with the health of the community should in many cases show such DISREGARD for the health of their own employees. The issue of long working hours in medical and health services is particularly important, not only because the staff/doctor has not only to provide care, mostly on a round the clock basis, but also because THEIR WORK INVOLVES A HIGH LEVEL OF RESPONSIBILITY FOR THE HEALTH AND WELL-BEING, AND SOMETIMES THE SURVIVAL OF PATIENTS.

As per the directives of the Honourable Supreme Court in its judgment dated,25.9.87, in writ petition No. 348-352 of 1985, all the State Governments, Medical Institutions and Universities are required to amend their rules and regulations to introduce a uniform residency scheme by 1993.

THE HONOURABLE SUPREME COURT IN ITS ORDER STATED

“A uniform practice has to be evolved so that the discipline would be introduced. We
accordingly allow the present arrangement to continue for a period of five years
I.e. upto 1992 inclusive. For admission beginning from 1993 there would be only one
pattern. All Universities and institutions shall take timely steps to bring about
such amendments as may be necessary to bring statutes, regulations, and rules
obtaining in their respective institutions in accord with this direction before the end of
1991 so that there may be no scope for raising of any dispute in regard to the matter.
The uniform pattern has to be implemented for 1993. It is proper that one uniform system is brought into vogue throughout the country.”

In this connection Ministry of Health & Family Welfare, Govt. of India has sent directive to all states & U.T. administrations vide letter No. S-11014/3/91/ME (P) dated 05 June, 1992. Unfortunately many States in India refused to obey that orders till date.

Ministry of health and family welfare, Government of India sent consolidated instructions to all states and UT administration vide letter number S-11014/3/91 ME(P) regarding implementation of Uniform Central Residency Scheme after the directives of the Supreme Court in its judgment dt. 25.9.87 in writ petition No. 348-352 of 1985,
The instruction No.13 of this letter ‘Hours of Work', it is mentioned that
"Continuous active duty for resident doctors will not normally exceed 12 hours per day. Subject to exigencies of work the resident doctors will be allowed one weekly holiday by rotation. The resident doctors will also require to be on call duty not exceeding 12 hours at a time. The junior Residents should ordinarily work for 48 hours per week and not more than 12 hours at a stretch subject to the condition that the working hours will be flexible as may be decided by the Medical Superintendents concerned keeping in view the workload and availability of doctors for clinical work."
As we see, here total weekly hours of work (48 hrs/week) as well as the maximum hours in single stretch (12 hours) are clearly defined. Of course the authorities may remind us the flexibility given in above instruction. However we would like to state the following.
a) Any flexibility given by law or constitution should only be used as a special measure and must not be used as ROUTINE. Today Medical colleges in India are forcing Junior doctors to work continuous 24 Hrs (!) and this is being practised routinely for last many years.
b) That flexibility is given for 'Working hours' & not for hours of work that is, while authorities are free to post any doctor in day or night or in holidays, they must stick to the norms of "hours of work" that is Maximum 48 hours in a week and 12 hours Finally even if the total no. of doctors posted (when all posts are filled) are not able to cope with work load under normal working-hours-limit then the no. of post must be increased. In no case junior doctors to be forced to work more than what is permitted by law and various recommendations. in a single stretch.

The International Labour Organization, Geneva (India being the member of the same) as early as in 1962 in its recommendation No.116 concerning Reduction of hours of work in its General principle No. 4 states as
PRINCIPLE 4: Normal hours of works should be progressively reduced, when appropriate with a view to attaining the social standard indicated in the Preamble of this recommendation without reduction in the wages of the workers as at the time hours of work are reduced.
PRINCIPLE 6 states as - Where normal weekly hours of work are EITHER FORTY EIGHT OR LESS, MEASURES FOR THE PROGRESSIVE REDUCTION OF HOURS OF WORK in accordance with paragraph-4 should be worked out and implemented in a manner suited to the particular national circumstances and the conditions in EACH sector of economic activity.
Further in Determination of Hours of works 12(1) it states: The calculation of normal hours of work as on average over a period longer than one week should be permitted when special conditions in certain branches of activity or technical needs justify it.
Recently ILO in its Night Work Recommendation 1990 (No. 178) states that "the normal hours of work of night workers should generally be less on average than those of workers performing the same work to the same requirements by day."
Considering that today in India in 5 days week most of the office workers perform a 42-43 hours/week and the maximum limit is set as 48 hours/week for all including the health sector, the total hours of work of doctor (especially Junior doctors , interns) per week must be less than this (i.e. 48 hours/week) as they perform most (all) of the night duties.
Further in this recommendation it is clearly stated that IN NO CASE should two consecutive full time shifts be performed, except in cases of FORCE MAJEURE (The allowed hours of shift in a single stretch is MAXIMUM 12 hours) & In No case further extension of this limit (12 hours) should be done. Presently, we Junior doctors are forced to work continuous 24 Hours (!) in a single stretch. In many departments weekly hours (Normal average) are 65-80 hrs/week & it crosses even 100(!)Hrs/week.
Further it states that at least 11 hours of rest period should be granted between two shifts (One must remember, shift are of Maximum 12 hours) as far as possible.

Presently Resident doctors (Post graduate students in Medical colleges) in India are forced to work 85-105 hrs/week in most of the clinical departments without the protection of any service rules because they are students. This is done under the instruction of the Head of the Departments concerned. Junior doctors pursuing their post graduation course, whose final assessment are in hands of these authorities, i.e. HODs. There fore no one normally risks their career. This way exploitation of this floating population of junior doctors goes on and on the other hand patients suffer routinely and many times even die due to this forced negligence. While stretching duty hours our learned authorities simply forget the PROVEN FACT that errors and accidents increases sharply (An exponential graph) in mental and physical work, when duty hours are stretched beyond 10-12 hours continuous duty.

As the graph of errors and accidents increases steeply this 100% increase (24 hrs continuous duty in place of 12 hours maximum limit) in duty hours is sufficiently enough to do BLUNDERS AND ENDANGER human life.

"A doctor at his 20th-24th hour of continuous duty in Emergency ward, if not able to provide proper care to the patient for whom even a single minute can prove life saving or Fatal. This way if patients suffer than who will be HELD RESPONSIBLE, the Doctor on duty or the HOD or DME or the Govt.?”
Because doctor is performing unofficial extended hours, and he/she has the reason to state that doctor was not in his/her proper mental and physical condition due to chronic sleep deprivation and exhaustion. In fact this extended hour coincides with the mid night and early morning time, when all those patients who come to casualty irrespective of there diagnosis, feel that if they will delay till morning it may be harmful/fatal to them and most of the times indeed these emergencies are life threatening. With great hope in mid night when they visit hospital for proper care, they find a drowsy, tired, exhausted doctor, who is not even able to examine properly. The general impression becomes that doctor has neglected him, where as patient hardly knows doctor’s real condition. After all patients do deserve the proper and efficient care, especially when there is no scarcity of doctors and this duty regime is artificially motivated. The finding of Justice Ranganath Mishra, former National Human Rights Commission, about delay and negligence in treatment of accident victims, are actually related with this illegal duty hour practice. Under growing public demands for health quality services the question which involves life of human beings, cannot be left unanswered.

After approximately eighteen hours of work Doctors have got the equivalent psychomotor dysfunction as having a blood alcohol level of .05. So not only at .05 you're not allowed to drive but at the equivalent level of psychomotor dysfunction you're allowed to look after patients. And by the time you've worked for twenty-four hours you've got the equivalent of having a blood-alcohol level of .1 and that's just ridiculous.

In most of the countries there is a limitation on extra hours, the average over month or quarterly it must be with in norms, which varies 40 to 48 hours per week in different countries. In most of the states in India no duty hour’s norm exists. Most hospital authorities do not even bother how many hours a junior doctor has worked, and so it increases up to inhumane levels as high as 103 hours in a week.

One should also note that a number of countries have enacted duty hours regulations for doctors. In Denmark, Norway and Sweden, residents work only 37-45 hours per week. In Netherlands, residents’ duty hours are limited to 48 hrs per week. France has a 35 hour per week limit.

The unexpected death of Libby Zion, 18 yr old daughter of an attorney and writer for the New York Times, at New York hospital in 1984, led to series of investigation that resulted in profound changes in residency duty hours in USA.

In similar situation in London in December 1990 a junior doctor obtained a preliminary judgement from the court of Appeal on a claim for damages against Bloomsbury Health Authority. The court said that health authorities could not lawfully require junior doctors to work for so many hours that there was a foreseeable risk of injury to their health. The Vice-Chancellor, Sir Nicolas Browne-Wilkinson, said: “In any sphere of employment other than that of junior doctors, an obligation to work up to 88 hours in any one week would be rightly regarded as oppressive and intolerable." The doctor had served a writ on the health authority in March 1989 after working a 112-hour week which included a 49-hour shift over a weekend. He felt that his health had suffered so much that he resigned from his job at University College Hospital, London, and gave up medicine for a time.

Great public and media attention was drawn in September 1990 when two doctors in the neonatal pediatrics unit of the Southern General Hospital, Glasgow, were threatened with dismissal for refusing to carry on working 115 hours a week. After two sessions working the 115-hour week, the doctors said that chronic sleep deprivation was severely impairing their medical judgment and putting the lives of new-born babies at risk. In the same month a hospital patient in Middles borough died after a tired doctor gave her the wrong injection. The doctor had been on duty for 30 hours with just three hours interrupted sleep when she gave the fatal injection.

The comments of the acting coroner in the inquest into the death of a New Zealand woman, the innocent party in a car crash, reinforce the importance of addressing the issue of fatigue. The patient survived the accident, but died following a mishap while in hospital. A significant issue for the coroner was the extent to which the fatigue of one of her doctors may have played a part in her demise. The coroner remarked that there was a growing level of concern, both nationally and internationally, over the hours of work of doctors in hospitals, and suggested that the medical professional bodies address the issue of extended periods of work.

Hope in India, justice will not get delayed until some VIP will die. Negligence and irritative behaviour (due to chronic sleep deprivation) of doctors in government hospitals are known to every one and the death due to such forced negligence are nothing but routine (!) death of hospitals.

With great hope, that commission will look in to the matter and take necessary steps to end this violation of human rights of both patients and junior doctors.



March 5th 2006


Ref.
1. Honorable Supreme Court in its judgment dated, 25.9.87, in writ petition No. 348-352 of 1985
2. Letter No. S-11014/3/91/ME (P) dated 05 June, 1992.
3. Letter No. S-11014/25/89- ME(P).
4. Letter No. S-11014/39/80-ME(P)
5. Conclusion from general report (Latest), Standing technical committee for Health & Medical Services, ILO, Geneva.
6. ILO`s recommendation No. 178, 116.
7. Swan, N. Juniors' Hours: International Overview. BMJ 1990; 301: 830-832.
8. Olson LG, Ambrogetti A. Working harder -- working dangerously. Fatigue and performance in hospitals. Med J Aust 1998; 168: 614-616.
9. Williamson A. The effects of workload and long hours of work on medical officers. Sydney: National Institute of Occupational Health and Safety (WorkSafe Australia ), 1995.
10. Nocera A, Khursandi DS. Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? Med J Aust 1998; 168: 616-618.
11. Fein EB. Flouting law, hospitals overwork novice doctors. New York Times, 14 December 1997; 1.
12. Holmes G. Hospital medical officers: hours of work and workloads, A strategic approach to occupational health and safety. Canberra: Australian Medical Association, 1995.
13. Department of Transport. Investigation into the Kings Cross Underground Fire. London: HMSO, 1998.
14. Coroner's Court. In the matter of the death of Patricia Margaret Ross. Rotorua, New Zealand : 15-17 October 1997; 18-20.
15. Permanent Working Group of European Junior Hospital Doctors. Working conditions for doctors in training. Conference Proceedings, Executive Summary. Brussels: European Union Publications Office, December 1995.
16. European Union. Directive on Working Time, 93/104. Brussels: European Union Publications Office, 1993.
17. NHS Management Executive. Hours of work of doctors in training: guidance on regional task forces.London: Department of Health; 1991.
18. Neurosurgery 54:925-933,2004 Resident duty hours in American Neurosurgery.

1999 Maharashtra PG Strike

EXCERPT FROM PRESS RELEASE DURING RESIDENT DOCTOR'S STRIKE IN 1999, INDICATING WAFT SUPPORT .

NOVEMBER 25: The state government today issued an order empowering deans of all government medical colleges to recruit specialist doctors on a contract basis to counter the resident doctors' strike. Required on an urgent basis are: neurosurgeons, nephrologists and cardiologists among others. In lieu, the government has agreed to pay these superspecialists Rs 500 for every eight hours of work.
The government's announcement comes a day after a resolution passed on Wednesday by The Welfare Association of Full-Time Teachers at Nair Hospital suggested that they might eventually call upon the authorities to close down the hospital as they were finding it difficult to cope. In view of the strike, which entered its fourth day today, teachers have been manning emergency services in the city's municipal and government hositals.
T C Benjamin, secretary, state Medical Education and Drugs Department, told Express Newsline, that the move to hire doctors on contract was to ensure that superspeciality servicescould function smoothly. In the same breath, he added that health services in the city had not been really affected by the strike. A copy of this order has also been sent to Municipal Commissioner K Nalinakshan who could if he wished implement it in civic hospitals. In addition, the government has also requested the Ministry of Defence to dispatch reinforcements from the army medical corps.

Asked whether he saw any anamoly on spending on hiring these doctors rather than paying the residents more, Benjamin said that while the latter would incur an additional expenditure of Rs 25 crore per year, the sum spent on hiring doctors on contract was relatively meagre. ``How much would paying each doctor Rs 500 entail,'' he asked. ``Anyway, social considerations are our utmost priority?''

In a climbdown from the earlier position, Dr V L Deshpande, State Director for Medical Education and Research, said the authorities have even offered a hike of 45 per cent to the resident doctors as opposed to the 20 per centoffer earlier and have agreed on a salary of Rs 7,000 for a junior resident. ``It should be remembered that resident doctors are students and cannot be given the salary of a government employee,'' he pointed out.

But the residents are in no mood to relent. At a morcha at Azad Maidan today, they stressed that nothing short of central pay parity will do, even if continuing the agitation meant rustication.

Addressing a gathering of about 400 resident doctors, the MARD organising secretary, Dr Rajas Deshpande, claimed the authorities were trying to misinform the public that the hospitals are running smoothly. ``The deans are doing so for the love of their chair,'' he said, adding that they had thus betrayed their own resident doctors and no longer commanded their respect. He also said that the government had implemented the Fifth Pay Commission scales for medical teachers to prevent them from going on strike. ``The timing is not a coincidence,'' he added.

Patients continued to be a casualty of thisconflict. Outpatients departments of most hospitals were virtually empty and only emergency cases were admitted to the wards. A senior doctor from St George's Hospital admitted that even though they have been told to maintain services, the fact was that there was a complete collapse of patient care.

And if the government is not feeling the pinch of the resident doctors' strike, it is the teachers working in public hospitals who have been affected. WAFT president Dr Asha Pai Dhungat told Express Newsline that while AMOs from peripheral dispensaries were putting in a lot of work, ``They cannot handle situations where immediate treatment is required.. But they are sincere and hard-working.'' In its Wednesday resolution, WAFT has also said, ``Due to the large volume of emergency cases that we have to deal with in the absence of resident doctors, our best may not be enough to prevent patient morbidity and mortality. Medico-legal problems could thus arise for which we would not be responsible in anymanner.''

Copyright © 1999 Indian Express Newspapers (Bombay) Ltd.

All PGs are Equal - Supreme Court

PETITIONER:
DR. DINESH KUMAR & ORS. A
Vs.

RESPONDENT:
MOTILAL NEHRU MEDICAL COLLEGE, ALLAHABAD & ORS.

DATE OF JUDGMENT25/09/1987

BENCH:
MISRA RANGNATH
BENCH:
MISRA RANGNATH
DUTT, M.M. (J)
ACT:
Professional Colleges-Medical Colleges-Admission to
Post Graduate Courses-Structuring of courses-Common pattern
and uniform system-Necessity for-Holding of all India
examination for reserved seats-Directions by Court. C
JUDGMENT:
ORIGINAL JURISDICTION: Civil Misc. Petition No. 7667 of
1987.
In
Writ Petition Nos. 348-352 of 1985.
(Under Article 32 of the Constitution of India).
Madan Lokur for the Petitioners.
G. Viswanatha Iyer, P.K. Pillai, M.K.D. Namboodary for
the State of Kerala

B.R. Aggarwala, and Ms. S. Manchanda for Medical
Council of India.
D.N. Devedi, R.P. Srivastava, Mrs. Halida Khatun and
Ms. A. Subhashini for the Union of India.


The following order of the Court was delivered

Three aspects of the matter require consideration of
this Court apart from the question of finalising the
schedule relating to holding of the selection examination
and those are: (1) structuring the Post Graduate courses (2)
the question of diploma being a qualification for n
admission in Post Graduate course as prevailing in the State
of Tamil Nadu and (3) Provision in regard to super
specialities like MD and other higher degrees.

A uniform practice has to be evolved so that the
discipline would be introduced.
We accordingly allow the
present arrangement to continue for a period of five years
i.e. upto 1992 inclusive. For admission beginning from 1993
there would be only one pattern

All Universities and institutions
shall take timely steps to bring about such amendments as
may be necessary to bring statutes, regulations, and rules
obtaining in their respective institutions in accord with
this direction before the end of 199 1 so that there may be
no scope for raising of any dispute in regard to the matter.
The uniform pattern has to be implemented for 1993.

It is proper that one uniform system is brought into
vogue throughout the country. The justification for such a
course has been appropriately emphasised both in the main
judgment as also in the intermediate order made by us and
there is no necessity to reiterate the reasoning now


All directions necessary for the Post Graduate courses
are now complete. We direct the Union of India, the Medical
Council of India, H
356
the State Governments, Universities, Medical Institutions
and all other authorities that may be involved in
implementation of the scheme to give full effect to the
orders and direction made by this Court in the proper spirit
so that the scheme may become operative as directed. We make
it clear that no application for any modification of matters
already covered by our order henceforth shall ordinarily be
entertained.
A copy of this order shall be communicated forthwith
to the Chief Secretary of every State and Union Territory
for compliance. A copy of it be also sent to the Director
General, All India Radio and Doordarshan for appropriate
publicity of the order in general interest.
N.P.V.
357

Stipend for Post Graduates

As per the directives of the Honourable Supreme Court in its judgement dated,25.9.87, in writ petition No. 348-352 of 1985, all the State Governments, Medical Institutions and Universities are required to amend their rules and regulations to introduce a uniform residency scheme by 1993.
In this connection Ministry of Health & Family Welfare, Govt. of India has sent directive to all states & U.T. administrations vide letter No. S-11014/3/91/ME (P) dated 05 June, 1992.
The Medical council of India has also stated that “all candidates joining post graduate training programme must work as full time residents during the whole period of their training programme. The post graduate students shall be paid adequate remuneration irrespective of the status of the institution whether Government/Private/Autonomous”.

Court prefers entrance rather than Exit

From Chennai Online http://www.chennaionline.com and The Hindu http://www.hindu.com

High Court quashes Tamil Nadu Government's new admission policy

By A.Subramani

Chennai, Feb. 17: The Madras High Court on Monday struck down the Tamil Nadu Government's new admission policy for professional courses, and alsodirected the Government to commence the process for conducting commonentrance test for the coming academic year.

The First Bench comprising Chief Justice A.P. Shah and Justice PrabhaSridevan, passing orders on a batch of writ petitions, filed both in favourof and against the new policy dispensing with the CET for State Board students alone, said the State did not have legislative competence to pass the impugned legislation. The Bench said it also violated the fundamental right to equality as enshrined in the Constitution.

It sought to distinguish State Board students from non-State board candidates, and that while the former was exempted from writing the "burdensome" CET the latter was expected to write their qualifying examination and then sit for the CET. It was a twin burden as the CET was designed on the basis of the syllabus of the State Board students, it pointed out.

The State lacked legal competence to come out with the impugned Act as regulating procedure and laying down guidelines for admission to professional courses was a field occupied by the Centre, the Bench said, adding that such matters were clearly governed by the Medical Council and All India Council for Technical Education Regulations, it reiterated.

The Tamil Nadu Government also failed to furnish the scientific data based on which it came to the conclusion that dispensing with the CET would result in improving the academic prospects of students from rural areas, the Bench said.

It also pointed out that the available statistical data proved that the CBSE and ICSE students never stood between the rural students and their chances to obtain admission in professional courses. The legislation must have addressed the real issue of the urban matriculate versus the rural matriculate within the State Board stream, it said, and added that the legislation would only result in enabling the urban matriculate to steal a march over their rural counterparts.

When the State Advocate-General pleaded for a leave of the court to prefer a Special Leave Petition in the Supreme Court, the Bench rejected the plea and instead directed the Government to start the process for holding the CET in Tamil Nadu without any further delay.

The Madras High Court today struck down the Tamil Nadu government legislation abolishing Common Entrance Test (CET) for admissions to professional courses for state board students.

A Division Bench comprising Chief Justice A P Shah and Justice Prabha Sridevan held that the state government had no powers to enact the legislation abolishing CET for state board students and that the Act was void and unenforceable.

Allowing a batch of petitions from students challenging the Act, the Chief Justice, who dictated the order on behalf of the Bench, held the Act had no nexus to the objects to be achieved by the recent 93rd Constitutional amendment.

The Bench observed that under the recent amendment, Article 15(5) of the Constitution empowered the state governments to bring forward laws for the benefit of socially and educationally weaker sections.

Holding that the state Legislature was not competent to bring out the Act, the Bench said it also violated the principle of equality enshrined under Article 14 of the Constitution.

The impugned legislation, the Bench said, was against the regulations of the Medical Council of India (MCI) and All-India Council for Technical Education (AICTE).

"It is difficult to accept the state government stand that if the CET was abolished it would help rural students," the Bench said.

The court directed the state to commence the process for holding the CET in accordance with the MCI and AICTE regulations for the academic year 2006-07 for students of all educational boards.

The Bench had on February 24 reserved orders for today after hearing arguments by petitioners' counsel and advocates representing the state government, including Supreme Court lawyer Mukul Rohtagi and state Advocate General N R Chandran.

The impugned Tamil Nadu Regulation of Admission to Professional Courses Act, 2006 was passed by the state Assembly on January 27.

The petitioners contended that the Act violated the fundamental right of equality as guaranteed under the Constitution by proposing different examinations and valuations for different boards for admissions to the same professional courses.

The Act, while exempting students of state board curriculum from taking entrance examinations for admission to professional courses in the state, had made CET mandatory for students from other boards.

The state government had abolished the common entrance test last year itself through an executive order, but it was struck down by the High Court. (Our Correspondent)

Validity of Service Quota

CASE NO.:
Appeal (civil) 7256 of 1999
Appeal (civil) 7259 of 1999
Appeal (civil) 7260 of 1999
Appeal (civil) 7263 of 1999

PETITIONER:
PRE-P.G. MEDICAL SANGARSH COMMITTEE & ANR.

Vs.

RESPONDENT:
DR. BAJRANG SONI & ORS. ...

DATE OF JUDGMENT: 14/08/2001

BENCH:
Doraiswamy Raju, S.R.Babu

JUDGMENT:
Raju, J.

These appeals involve a challenge to the powers as well as the right of the State Government to provide for reservation of seats for admission to Post Graduate Medical Courses for in-service candidates and the reasonableness or otherwise of the extent upto which such reservations could be made. Before the learned Single Judge, challenge was made to the decision of the Government/University fixing 33% to be the qualifying marks for in-service candidates to render them eligible for admission to the Post-Graduate courses. The second ground of challenge was to the decision of the Government to increase the reservation of seats for admission into Post-Graduate courses for in-service candidates from 25% to 50% out of the remaining 75% of the seats after excluding 25% of the seats reserved for central quota.

The learned Single Judge by his order dated 22.2.1998 repelled the challenge based on the first ground and held that the State, which is authorized to regulate the admissions to Post-Graduate Courses of Medicine by prescribing minimum qualifying marks in the entrance examination therefor, is entitled, as in this case, to fix a minimum of 33% for the in-service candidates, and that this could not be said to be illegal. So far as the second ground of challenge was concerned, it met with the acceptance of the learned Single Judge, who came to the conclusion that there was no justification made by placing materials on record for directing such an increase in the matter of reservation from 25% to 50% and the same was liable to be set aside as excessive, while maintaining, at the same time, the earlier prescribed reservation upto 25%.

Aggrieved, the State of Rajasthan as well as some of the in-service candidates filed appeals before a Division Bench and the Division Bench by its judgment dated 13.7.1999 set aside the order of the learned Single Judge in so far as he interfered with the increase in the percentage of reservation made for in-service candidates from 25% to 50% on the ground that not only the State had such powers to prescribe, on such matters as a matter of policy, but the learned Single Judge, who sustained such powers to inhere in the State, could not have interfered with the policy-decision of the State Government necessitating such increase from 25% to 50% for in-service candidates for admission to Post-Graduate courses in the Medical Colleges of the State, particularly when the policy-decision was based on reasons which had nexus to the objects sought to be achieved. In the light of the above, the Division Bench thought it unnecessary to examine further whether the increase of seats from 25% to 50% for in-service candidates pertains to the area of reservation or fixing the source of admission. The appeals were accepted and allowed.

Hence, the above appeals by the petitioners before the learned Single Judge and others permitted to file appeal by this Court. Heard learned counsel on either side.

The very question was considered by this Court in a decision reported in State of Tamil Nadu vs T. Dhilipkumar & Ors. (1995(5) SCALE 208) and it was held as follows :-

"4. In so far as the additional mark awarded to in-service candidates serving in rural areas is concerned, the judgment of this Court in Dr.Dinesh Kumar & Ors vs Motilal Nehru Medical College, (1986(3) SCR 345) is the answer to the argument that in-service
candidates serving in rural areas will, after acquisition of post-graduate degrees, return to rural areas. The observations in this behalf have been cited by the High Court and in our view, rightly.
..............................................................
6. In our view, the High Court was right in the view that it took, that no reservation beyond fifty per cent is ordinarily contemplated and this percentage is what the High Court allowed. In striking down the additional mark for in-service candidates serving in rural areas, the High Court followed the decision of this Court."

In Ajay Kumar Singh And Others vs State of Bihar And Others (1994(4) SCC 401), this Court held that the Indian Medical Council Act, 1956 did not empower the Council to regulate or prescribe qualifications or conditions for admission to Post-Graduate courses and that regulation and admission to such Medical courses is not only incidental but an integral part of the power of the States, which establish and maintain such institutions out of public funds and the State could always regulate the admission policy while adhering to the standards determined by the Medical Council. The learned Judges, who delved into the matter at length, also highlighted the vital fact that mere academic performance is no guarantee of efficiency in practice in the field of medicine and consequently, it is wrong to presume that a doctor with good academic record is bound to prove a better doctor in practice. In yet another decision reported in K.Duraisamy and Anr. etc. etc. vs The State of Tamil Nadu and Ors. [2001(2) SCC 538 = JT 2001(2) SC 48], though rendered in the context of working out the reservations and the manner stipulated therefor, by the Government, the very question about the power of the Government also came up for consideration and one of us (Raju, J.), speaking for the Bench, while applying the earlier decision in 1995(5) SCALE 208 (supra), observed as follows :-

"8. That the Government possesses the right and authority to decide from what sources the admissions in Educational Institutions or to particular disciplines and courses therein have to be made and that too in what proportion, is well established and by now a proposition well settled, too. It has been the consistent and authoritatively settled view of this Court that at the super-speciality level in particular and even at the Postgraduate level reservations of the kind known as 'protective discrimination' in favour of those considered to be backward should be avoided as being not permissible. Reservation, even if it be claimed to be so in this case, for and in favour of in-service candidates, cannot be equated or treated at par with communal reservations envisaged under Articles 15(4) or 16(4) and extended the special mechanics of their implementation to ensure such reservations to be the minimum by not counting those selected in open competition on the basis of their own merit as against the quota reserved on communal considerations
.

9. Properly speaking, in these cases, we are concerned with the allocation of seats for admission in the form of a quota amongst in- service candidates, on the one hand, and non-service or private candidates on the other and the method or manner of working out in practice the allocation of seats among the members of the respective category. Could the State Government have legitimately made a provision allocating 50% of seats exclusively in favour of in-service candidates and keep open the avenue for competition for them in respect of the remaining 50% along with others denying a fair contest in relation to a substantial or sizeable number of other candidates, who are not in service and who fall under the category of non-service candidates, will itself be open to serious doubt. One such attempt seems to have been put in issue before the Madras High Court which held that reservation in favour of in-service candidates for the academic year 1992-93 should be confined to 50% and awarding of two additional marks, instead of one additional mark for each completed year of service in primary health centers, was unconstitutional and when the matter was brought to this Court, in the decision reported in State of Tamil Nadu vs T. Dhilipkumar & Ors. [1995 (5) Scale 67] the decision of the High Court has been upheld. This Court also further observed that the Government should appoint a highly qualified committee to determine from year to year what, in fact, should be the percentage-wise reservation required for in-service candidates, having regard to the then prevailing situation and that the percentage of fifty percent shall, if found appropriate, be reduced."

It is permissible for the Government to fix such a source or classification of candidates from which selection for admission to the Post-graduate Colleges in the State had to be made for yet another genuine, relevant and reasonable cause and purpose, which has, in
our view, sufficient nexus to the larger goal of equalization of educational opportunities and to sufficiently prefer the doctors serving in the various Hospitals run and maintained from out of public funds by the Government or Government departments, in the absence of which there would be serious dearth of qualified post-graduate doctors and experts to meet the requirements of such Hospitals run by the State and State Departments, the only avenue open for treatment of the large body of ordinary common man, all over the
State. This larger public interest, unlike reservations envisaged for SC/ST with a different and laudable purpose to assist educationally backward classes, is a distinct and vitally important public purpose in itself absolutely necessitated in the best of public interest. The decision reported in Dr. Narayan Sharma And Another, etc. vs Dr.Pankaj Kr. Lehkar And Others, etc. (2000(1) SCC 44) is not directly on the point with which we are concerned in this case. Similarly, the observations made and dicta laid down in what is known as Mandal's case reported in Indra Sawhney vs Union of India And Others (1992 Supp. (3) SCC 217) also has no relevance or application to the case on hand.

The learned counsel for the appellants, who filed the appeals with the permission of the Court, also sought to challenge the conclusion arrived at by the learned Single Judge in repelling the challenge made to the reduction of the minimum cut-off marks for
selection of the in-service candidates from 50% to 33%. Apart from the tenability of the objection taken by Shri Sushil Kumar Jain, learned counsel appearing for the private candidate-respondents, that if there was no challenge made of this reasoning before the Division Bench of the High Court it is not permissible to take such a stand in this Court, we are also of the view, on the merits of the claim itself, that there is no substance in the same. It is not in controversy that during the academic years in question, there was no stipulation by the Medical Council of India of any minimum eligibility marks to be secured in the entrance examination for admission to post-graduate courses. Though it is said that in 2000 such a stipulation has been made, for the obvious reason that during the years under our consideration there is no such stipulation, the challenge in this regard does not merit our consideration or acceptance, leave alone the question as to the efficacy or binding nature of the said stipulation, which we do not propose to adjudicate upon in these cases. That apart, as rightly pointed out in one of the judgments of this Court noticed above, mere theoretical excellence or merit alone is no sufficient indicia of the qualitative merits of the candidates in the field of actual practice and application. The doctors, who are in-service candidates in various medical institutions run and maintained by the Government or Government Departments, have wide area and horizon of exposure on the practical side and they may not have the required extra time to keep themselves afresh on the theoretical side like an open candidate who may have sufficient time at his disposal to plod through books. The in-service candidates in contrast to the fresh or open candidates have to spend much of their time on attending and treating the patients in the Hospitals they serve gaining excellence on the practical side and, in our view, they would constitute a distinct class by themselves to be given a special treatment and no grievance can be made out on the ground that the minimum eligibility marks for their selection in respect of seats earmarked for them should also be the same as that of the fresh or open candidates. We could see no discrimination or arbitrariness involved in the special provision made to meet a just and appropriate need in public interest.


For all the reasons stated above, these appeals fail and shall stand dismissed. No costs.

[ S.

Fate of Contract Medical Consultants

From http://www.tnhealth.org/webboard/messageDetail.asp?MessageId=9088

Subject : RE: counselling;;;;;; doubts
MessageDate : 1/21/2006 10:42:15 AM
Posted By : tnhealth.org
Email : feedback@tnhealth.org
Message : Dear Asstsurgeon,

Appointment of contract Medical Consultants is purely on temporary basis and their services are liable to be terminated at the time of selection of TNPSC candidates.

For tnhealth.org

***---REPLIED TO MESSAGE BELOW---***
sir i had been selected for the current tnpsc interveiw.there are rumors that the posts filled up by contract doctors will not be shown in the vacancy list during counselling for the selected candidates and only those who work at the present station as contract doctors are eligible to take the same places in the tnpsc counselling.kindly clarify in this regard.

AlPG 2nd Councelling SC WP(Civil) No.157/2005 2006 01 12

ITEM NO.1 COURT NO.3 SECTION X
S U P R E M E C O U R T O F I N D I A
RECORD OF PROCEEDINGS

WRIT PETITION (CIVIL) NO(s). 157 OF 2005

AMIT GUPTA & ORS. Petitioner(s)
VERSUS
U.O.I. & ANR. Respondent(s)

(With appln(s) for stay)
(FOR FINAL DISPOSAL)

Date: 12/01/2006 This Petition was called on for hearing today.

CORAM :
HON'BLE MR. JUSTICE K.G. BALAKRISHNAN
HON'BLE MR. JUSTICE R.V. RAVEENDRAN

For Petitioner(s) Ms.Indu Malhotra, Adv.
Mr.Vikas Mehta,Adv.
Mr.Vikram Mehta, adv.

For Respondent(s)UOI Mr.Gopal Subramaniam, ASG
Ms.Sandhya Goswami, Adv.
Mrs.Sushma Suri, Adv.

For MCI Mr.Mariarputham, Adv.
Mr. Maninder Singh,Adv.
Ms.P.M.SIngh, Adv.
Mr.Sunil Fernades, Adv.
Mr.Saurabh Mishra, Adv.

Mr.Dhruv Mehta, Adv.
For M/S K.L. Mehta & Co. ,Advs

UPON hearing counsel the Court made the following
O R D E R

Heard both sides.

Learned counsel for the petitioners, by an interim measure prays that there should be a second counselling for the seats to be filled up in the All India Quota for Post-graduation (both Medical
and Dental) education. Formerly, there was no second counselling for filling up the seats for the All
India Quota. An affidavit dated 5.1.2006 has been filed by the Asst.Director, Directorate General of
Health Sciences pursuant to the order passed by this Court on 30.09.2005. A time schedule has been
attached to this affidavit whereby counselling for admission to the Post-graduate courses would be done
for the All India Quota and the State quota. Counsel for the petitioners submits that the second
counselling for allotment of seats for the All India quota should be done after the first counselling of the
State quota is over. However, learned Addl.Solicitor General appearing on behalf of Union of India
and also learned counsel for the Medical Council of India submit that this would upset the whole
schedule as there would be delay in the matter of admission and the seats which were not filled up in the
All India Quota could not be filled up in the State quota. We make it clear that in the All India Quota
of 50% the authorities shall try to fill up 50% of the seats allotted in the All India Quota.
As an interim measure, the schedule given in the affidavit shall be followed for this year
(2006-07) and this is without prejudice to the contentions raised by the parties on either side. The
learned Addl. Solicitor General makes a submission that the second counselling for the All India quota
also is not finally decided by the Union of India. However, there is a request from the student
community that this should be done as an interim measure and the schedule given in the affidavit shall
be followed for this year (2006-07) and the Medical Council of India shall make sufficient publication of
the schedule and all the colleges involved in the admission of both All India quota and the State quota
shall be informed of this revised schedule well in advance. The schedule may be notified by the Medical
Council of India in the official Gazette and other print/electronic media.
After the admissions are over, the Union of India shall file an affidavit indicating the
number of seats filled up in the All India Quota as well as in the State quota for the Post-graduate
students.

Post in the first week of May, 2006.

(G.V.Ramana) (Veera Verma)
Court Master Court Master

200 Posts in CEmONC on contract basis

They are appointing these doctors to the GH and upgraded PHCs.

And the newspaper article does not mean "appointment of 200 doctors"

The news release is "creation of 200 posts" which is always going to be filled on contract basis like this http://www.tn.gov.in/gorders/hfw-e-197-2004.htm

Now this merits some discussion.

Imagine there are 50 posts of doctors in a district. There were vacancies in some posts - few in districts like Chennai and Madurai and a lot of vacancies in districts like Nilgris and Perambalur.

Now the government appoints temporary doctors over there, on contract basis, (As per G.O No 197, H& FW Dept, dated 07.06.2004, Annexure IV paras 4, 5 and 6 where doctors are appointed on Contract Basis) with a condition that the contract shall initially be for six months from the date of appointment or till the regular candidates appointed through the TNPSC join duty at that place

1. The Appointee shall not be entitled for any preferential claim whatsoever for regular appointment in Government service at a future date.
2. The Appointee shall not be entitled to any probationary or other rights.
3. The services of the Appointee are liable to be terminated at any time during the contract period without any notice.

http://www.nellaimedicos.com/blog/doctorsandlaw/2005/06/contract-medical-consultants-and.html

So this is a very good order (at least in theory). let me explain. Vacancies continue to arise in govt posting due to

1. Retirement
2. Creation of medical colleges , creation of departments
3. Few of our people "absconding" - either going abroad or settling down in a private practise - I think we have to blame our people for this.

But the TNPSC exam is conducted on a yearly basis. (some times once every 4 years). SO there are vacancies. The district collector and JD are given powers to appoint a temporary doctor so that the public do not suffer. Subham

But there are deeper meaning to it. If there is a vacancy, the govt can appoint a new doctor from the waiting list of previous TNPSC. So what the GO actually leads to is a situation where the govt pays Rs 8000 for the contract doctor, where as it has to pay Rs 15000 for a regular appointee.

In fact the appointment of contract doctors is for the sole reason of saving money. Any other reason (like administrative delay etc) can be easily solved with paper work.

When a regular doctor wishes to come to that place, the contract doctor can be asked to go home or move to another vacancy nearby

But now what has happened is CREATION OF POSTS. In short, these posts will be ALWAYS filled by doctors on contract basis only.

So why has it happened.

The reason is simple. There are many government medical colleges that have been started in the past few years. Thoothukudi, kanyakumari, Vellore, Theni etc. ANd that means you have to create posts in that college. As Dr.Asha has pointed out, such a post (in a teaching institution) cannot be on contract basis. So the government has decided to divert the Salary hitherto given to the staff (regular) in PHCs and GH and has decided to fill the post in GH and PHC on contract basis.

In short, you are getting (new) medical colleges (tertiary institutions) with regular staff while the (old) GH and PHC have contract staff. Some twenty years ago (when MCI was not so strict), they would have easily started a medical college with temporary staff.

And coming to the present order, that is of course a welcome step. When there is a CEmONC within 50 kilometres of any village in Tamil Nadu that is going to benefit the rural public.

In any government setup, It is a normal phenomenon to start something on a temporary basis and then move to permanent basis. So far everything is well and good. (That is appointment of doctors on temporary basis)

But what has now happened is the entire posts are temporary - that means there will always a contract doctor and not a regular doctor on that posts

So you have the following scenario

1. No CEmONC (Read Hospital)
2. CEmONC (Hospital) with temporary doctors at temporary posts
3. CEmONC (Hospital) with temporary doctors at regular posts
4. CEmONC (Hospital)with regular doctors at regular posts

Though 4 is the ideal scenario, you will agree that 2 is better than 1.

In the past the situation will proceed from 1 to 3 to 4
Now it has come from 1 to 2 and will NOT proceed.

And let me come to a user poll

What will you prefer

60 hospitals with temporary doctors
or
30 hosptials with permanent doctors.

Look it at a broader perspective... This question has two answers, one from a doctor point of view and another from a public point of view...

AlPG 2nd Councelling SC WP(Civil) No.157/2005 2005 12 06

ITEM NO.4 COURT NO.3 SECTION X




S U P R E M E C O U R T O F I N D I A

RECORD OF PROCEEDINGS




WRIT PETITION (CIVIL) NO(s). 157 OF 2005




AMIT GUPTA & ORS. Petitioner(s)


VERSUS


U.O.I. & ANR. Respondent(s)


(With appln(s) for stay)

(FOR FINAL DISPOSAL)




Date: 06/12/2005 This Petition was called on for hearing today.




CORAM :

HON'BLE MR. JUSTICE K.G. BALAKRISHNAN

HON'BLE MR. JUSTICE G.P. MATHUR

HON'BLE MR. JUSTICE R.V. RAVEENDRAN





For Petitioner(s) Ms.Indu Malhotra, Adv.


Mr.Vikas Mehta,Adv.




For Respondent(s) Mr.Mohan Parasaran,A.S.G.

Ms.Sandhya Goswami, Adv.

For Ms. Sushma Suri ,Adv


Mr. Maninder Singh,Adv.




M/S K.L. Mehta & Co. ,Advs





UPON hearing counsel the Court made the following

O R D E R





List this matter in the 2nd week of January, 2006.



(G.V.Ramana) (Anand Singh)

Court Master Court Master

MAMS/MNAMS/Dip. N.B equal to MD/MS

No. V. 11025/6/94-MER (UG)
Government of India
Ministry of Health & Family Welfare
New Delhi, the 3.10.1994

To,

Health Secretaries of all States/U.T. Govts.

Sub: NBE qualifications awarded by the National Board of Examination Equivalance of

Sir,

I am directed to say that Medical qualification awarded by the National Board of Examinations are included in the First Schedule to the Indian Medical Council Act, 1956 and are considered at par with Post graduate Medical qualifications of the Indian Universities. However, it has been brought to our notice that employing organizations are not recognizing these degrees at par with MD/MS degrees of other Universities. As the National Board of Examinations, and autonomous body directly under the control of the central government, is keeping high standards of Medical examinations and it is requested that all concerned may please be instructed to give due importance to NBE qualifications and treat them at par with MD/MS of Indian Universities for all posts, including teaching posts.

The Medical Council of India while considering the question of equivalence of MAMS/MNAMS/Dip. N.B. qualification awarded by the National Board of Examination with M.D./M.S. and D.M./Mch. qualifications granted by Universities/Medical Institutions, has adopted the following recommendation, which was circulated to all the authorities concerned by the Council on 6.12.93 for–information and necessary guidance.

It is recommended that for teaching appointments in the broad specialities the holder of Diplomate NBE should have at least one year teaching experience as tutor/Registrar/Demonstrator or equivalent post in a recognized Medical College imparting undergraduate teaching and training for appointment as Lecturer. Regarding the candidates holding Diplomate NBE in Super Specialities, the training shall be for two years in a recognized Medical College having recognized postgraduate medical degree in the concerned speciality for appointment as Lecturer.

It is requested that the above may please be brought to the notice of all recruiting agencies under control for information and compliance.

Yours faithfully,
Sd/-
(Alok Perti)
Director (ME)

About Court Case in Karnataka

PG Aspirants: Fight for our righte - Merit Vs Might: "Post Graduate Aspirants Group: Karnataka State Junior Doctors' Association (KSJDA)

Other GO (Govt Orders) for CL (Casual Leave)

See Casual Leave as per FR (Fundamental Rules) for more information

1. Casual leave (CL) should not be combined with E.L.(Earned Leave) or U.E.L. (Unearned Leave)
2. Advance Application of CL need not contain the purpose for which the CL is required - G.O. Ms No 1410 P & AR dated 02.12.1977
3. Application for leave (or extension of leave) should be given either before availing the leave or at the time of joining duty - G.O. Ms No 1410 P & AR dated 02.12.1977
4. Employees irrespective of the office hours are eligible for 12 days CL - Govt Lr. No 109257- A/85 P & AR dated 31.12.1983
5. When CL is not available at the credit, they may take EL for short spells by sending advance intimation - Ruling (3) under FR 67
6. Contigent employees are also eligible for C.L if they have completed 30 days of duty - G.O. Ms No 1180 P & AR dated 15.12.1986


See Casual Leave as per FR (Fundamental Rules) for more information

Casual Leave as per FR (Fundamental Rules)

See
Other GO (Govt Orders) for CL (Casual Leave) for more information

ANNEXURE VII.
Executive Instructions regarding Casual Leave.
[See ruling (3) under Rule 85 of the Fundamental Rules of the Tamil Nadu Government
- Appendix I - Section VII.]
ORDINARY CASUAL LEAVE.
1. Casual leave is not provided for in the Fundamental Rules and is a concession to enable
Government servants in special circumstances to be absent from duty for short periods without such
absence being treated as leave under the Fundamental Rules or the Tamil Nadu Leave Rules, 1933.
2. No Government servant may, in any case, be absent on casual leave for more than @twelve
days in the course of one calendar year. Casual leave may be combined with compensatory leave,
Sundays, or other authorized holidays provided that the resulting period of absence from duty does
not exceed ten days. The fact that a maximum has been fixed for the amount of casual leave which
may be taken within a year, does not mean that an officer is entitled to take the full amount of casual
leave as a matter of course. †If the eleventh and subsequent days are incidentally declared as
holidays on account of natural calamities, death of national leaders, bandhs, strikes, a change in the
date of the festival as per the announcements made by religious heads during religious occasions,
etc., a Government servant who is on casual leave or compensatory leave may avail himself of those
days also eventhough the period of absence exceeds ten days.
@[G.O. Ms. No. 704, P. & A.R. (FR 3), Dept., dt 8-7-1985, w.e.f. 1-6-1985.]
†[G.O. Ms. No. 309, P. & A.R. (DO II) Dept., dt. 16-8-1993.]
Note (1).—In the case of Government servants appointed under emergency provision and who are
likely to be ousted at any time, their eligibility for casual leave shall be calculated with reference to the
period actually spent on duty and shall be Proportionately limited. As a working principle, they may be
granted two days casual leave for every two months service and such leave may be combined with
holidays subject to the maximum prescribed in the above instructions.
(G.O. Ms. No. 1122, Finance, dated 26th November 1959.)
Note (2).—Casual leave may be granted for half-a-day at a time on application. In such cases, the
half-a-day period should be either three hours from the commencement or before the closure of office
hours.
(G.O. Ms. No. 907, Finance, dated 21st July 1970.)
3. Heads of departments should intimate their intension or taking casual leave to Government in
the department concerned.
4. A register of casual leave taken should be maintained in every office.
5. Omitted.
6. Omitted.
[G.O. Ms. No. 802, P. & A.R. (FR. 3), Dept., dt. 14-8-85.]

See
Other GO (Govt Orders) for CL (Casual Leave) for more information

St John’s Medical College to fill up mgmt seats

From http://deccanherald.com/deccanherald/nov112005/state19185220051110.asp
St John’s Medical College to fill up mgmt seats : by DH News Service Bangalore:

The Karnataka High Court on Thursday declared that Bangalore-based St John’s Medical College is free to fill up all the seats in the post-graduate medical courses under the management quota. This order, however, would be effective from the next academy year.

Meanwhile, the court granted relief to the students admitted to the college under the Government quota during the academic years 2004-05 and 2005-06 by not disturbing their admissions.

A division bench comprising Justice B Padmaraj and Justice V Jagannathan delivered the verdict on the petitions filed by the students and the college management.

Government quota : Students, admitted under the Government quota had questioned denial of admission by the college. On the other hand, the college, claiming autonomous status on being a minority institution, had questioned government’s power to allot students.

More students : By virtue of this judgement, the college, which has been permitted by the Medical Council of India to admit only 56 students for both the PG degree and diploma courses in an academic year, will have to accommodate 82 students. Both the MCI and the Rajiv Gandhi University of Health Sciences have to approve these admissions.

The college, contending that it had the right to fill up all the seats, had admitted 56 students during last two academic years. On the contrary, the Government had refused the contention of the college and had allotted 26 students in each academic year under its quota.

No power : While relaying upon the recent verdicts of the Apex Court, the division bench held that the Government can not force the college, which is a minority autonomous institution, to surrender 50 per cent of its seats to the Government’s seat sharing and reservation policies. “Forcing the institution for government quota in the form of any Act or the Rules or the regulations by the Medical Council of India would be violative of Article 30 of the Constitution”, the court held.

However, the bench said that the admissions already made under the Government quota can not be disturbed at this stage. The Court approved the admission of all 82 students saying that all of them were meritorious, selected as per the norms and admitted by virtue of various interim orders passed by the High Court and the Supreme Court. The Court also directed the college to allow all the students, who are pursuing various courses, to complete their courses.

College warned : Meanwhile, the division bench warned the college to be careful in future and always respect the law. The bench made this observation while dismissing a contempt of court petition filed by some of the students against Principal of the college for denying admissions to them despite interim orders of the court.

Ethical dilemmas.

Ethical dilemmas.

From Journal of Post Graduate Medicine
www.jpgmonline.com

Pandya SK
Department of Neurosurgery, Seth GS Medical College, Parel, Bombay.

Correspondence Address:
Department of Neurosurgery, Seth GS Medical College, Parel, Bombay.



How to cite this article:
Pandya SK. Ethical dilemmas. J Postgrad Med 1997;43:1-3


How to cite this URL:
Pandya SK. Ethical dilemmas. J Postgrad Med [serial online] 1997 [cited 2005 Nov 9];43:1-3. Available from: http://www.jpgmonline.com/article.asp?issn=0022-3859;year=1997;volume=43;issue=1;spage=1;epage=3;aulast=Pandya




:: Introduction Top

Dilemma: difficulty, impasse, perplexity, predicament, quandary.
All medical doctors face situations from time to time, where the proper course of action is not clear. We are tempted, then, to paraphase Hamlet: “To do, or not to do - that is the question ...”

Take the case of a patient with confirmed malignant cancer of the breast whose chest x-ray film shows a rounded metastatic deposit. She now presents with a history of a recent focal epileptic fit but without any neurological abnormality on examination. Computerised tomographic scan shows what is most probably a metastasis in the left parietal lobe over the motor strip. Are we justified in advising excision of the tumour, knowing that it might leave her hemiplegic and when her general prognosis as regards long-term survival is grim?
Under such circumstances, how do we arrive at a decision? What do we navigate by?

:: Guiding principles Top

Four fundamental ethical principles have received universal acceptance by medical professionals:
* non-maleficence - ‘primum, non nocere’: first of all, do no harm
* beneficence - whatever we do must be for the benefit of the patient;
* respect for autonomy - the patient has an absolute right to make decisions concerning his own well-being, on any test or therapy proposed for him and on measures for resuscitation, prolonged maintenance on a ventilator and other such events.
In order to make such decisions, the patient - and family - need to be adequately informed on the pros and cons of each step. It is the communication of such details, in a manner that is clearly understood, that forms the basis of informed consent.
Justice as with reference to fair distribution of scarce resources; respect for the rights of the patient and family in the context of the rights of society at large; the use of the least expensive means in investigation and therapy; and respect for morally acceptable laws. It also implies the overcoming of personal prejudices - as against homosexuals or chronic alcoholics.
Thoughtful application of these principles to specific instances often helps resolve dilemmas.

:: Some common ethical dilemmas Top

Let us take examples from either end of the spectrum of life.
The treatment of infertility:
In a country where untold numbers of orphaned or discarded infants and children languish in unfeeling institutions where they are denied the attentions of parents and the company of siblings, is it fair for us to embark on such expensive techniques as in vitro fertilization?
On the other hand we have the plea of the barren wife who is willing to sacrifice almost everything to achieve the status of mother.
Possible resolution of dilemma:
Since it is the mother who comes to the doctor seeking treatment and since she has the right to decide on what should be done to and for her, the position of the orphaned children should not be allowed to intrude on the management of her problem.
Abortion:
Those in favour point to the legal sanction afforded to the termination of the life of the unborn foetus. Some have gone so far as to say that this is a welcome means for controlling our mushrooming population. Others have used it to get rid of female foetuses in their quest for the male child.
Many, however, remain troubled. Is this law morally acceptable? Are we ever justified in snuffing out life?
Possible resolution of dilemma:
This will depend on the beliefs and values cherished by the individual doctor. The doctor who holds life, as a sacred boon granted to an individual must refuse to perform or advice an abortion except in the specific instance where continuation of pregnancy may kill the mother. (Here, the operative principle is that the life of the mother is of greater concern than the life of the unborn foetus.)
Must we always strive to keep every baby alive, irrespective of costs?
Take two examples:
A premature newborn weighing 600 grams. Left to itself, it will perish. We can make extraordinary attempts to help it survive. In the process we may lead to a situation where the family is saddled with a severely handicapped individual with poor mental abilities.
A baby is born with meningomyelocele, paraplegia, incontinence of urine and severe hydrocephalus. A light applied to the head shows brilliant transillumination of the intracranial contents suggesting a paper-thin brain. It is possible to repair the skin over the exposed and damaged spinal cord and insert a shunt to drain the accumulated cerebrospinal fluid into the peritoneum. Survival is now assured but the family will bear the burden of looking after a mindless person who unknowingly passes urine and stools reflexly and will never understand, appreciate or communicate.
Possible resolution of dilemma:
The doctor must place the pros and cons of treatment in either instance before the parents. The doctor sympathetic to the social milieu in which the family exists and of the precarious economic circumstances of a particular family will emphasize the liabilities to the parents should treatment be preferred. I have, at times, gone a step further and told the parents that were the child in question mine, I would have decided against treatment.
If it is decided not to treat, should the patient’s life be terminated by a fatal dose of a drug? Some advocate stopping all feeds and supplying only water to take away thirst. The logic offered is that by this means we are not taking away life but allowing nature to take its own course. Is starvation to death not more cruel than instant death?
Possible resolution of dilemma:
Here, as often is the case with ethical dilemmas, the individual doctor’s conscience must dictate the course of action. Such a decision, however, must take into account the fact that the law of the land does not permit any doctor to kill the patient by any act of commission.
Admission to an intensive care unit:
The intensive care unit is already full of seriously ill patients, each of whom needs the special attention afforded in it. A fresh patient is brought to the clinic who also needs this specialized care. There is no other nearby centre that can take him. What is to be done?
Do we continue to treat existing patients and place this patient in a room or ward without special facilities for monitoring and treatment and, in the process, lose this patient? Do we shift the ‘least seriously ill patient’ out of the unit to make way for the new arrival and, in doing so, jeopardize the life of someone who may be on the way to recovery?
What if the new arrival is a ‘V.I.P.’?
A similar dilemma is posed when one has to select which of two patients is to be provided the only available ventilator.
Possible resolution of dilemma:
A new patient presenting to a clinic or hospital has not yet established the doctor-patient relationship with the consultant. Existing patients in the intensive care unit are already under his treatment and he is responsible for their welfare. His primary concern, then, must be for patients already in the unit. If, however, there if definite evidence that one of them can, without any risk, moved out of the intensive care unit to the half-way house of the semi-intensive care ward, such a transfer can be affected so as to take in the new patient.
Demand for euthanasia by a terminally ill patient in unremitting agony:
A patient with widespread cancer is in severe agony, which persists despite use of the maximal therapeutic doses of powerful drugs such as morphine. He begs to be relieved of pain and asks for the use of much larger doses, knowing that such doses will be fatal. Should one oblige?
Possible resolution of dilemma:
Here, as often is the case with ethical dilemmas, the individual doctor’s conscience must dictate the course of action. Such a decision, however, must take into account the fact that the law of the land does not permit any doctor to kill the patient by any act of commission.
Shutting off the ventilator:
The law, as it stands, does not allow one to take a brain-dead patient off the ventilator unless this patient is a donor of an organ such as the heart. What about the patient who is not suitable to offer an organ but whose relatives can no more afford the cost of an intensive care unit?
Should we insist on following the letter of the law so that we are not subject to prosecution under the Consumer Protection Act or the Indian Penal Code?
Possible resolution of dilemma:
The law, in this instance, is faulty. It is illogical to permit removal of the heart, lungs, kidneys, pancreas and other organs for transplantation into another patient and not allow switching off the ventilator. Senior lawyers consulted by us inform us that judges would, in all probability, rule in favour of the doctor, provided the procedure for the diagnosis of brain death before switching off the ventilator was foolproof.

:: Some personal guidelines Top

I have found the following additional guidelines useful. I pass them on for your consideration.
* The golden rule: Do unto others, as you would have others to do unto you. I have often found it helpful to ask myself, “Were I the patient, what course of action would I have wished the doctor to follow?”
* The patient comes first. The raison d’etre of our profession is the patient. We are here to serve him. The sick patient, often in physical pain and always in mental distress, deserves our fullest attention and calls for the best qualities of our mind and heart. His interests and decisions must prevail above all else except when the patient is non compos mentis. In the latter instance, the decisions of his family must prevail.
* The poor patient deserves special consideration He has nowhere else to go. He does not possess the means to command or demand. In our milieu he is often reduced to seeking help with bowed head and hands folded together. And he is ill. Medically malpractice against this group is particularly abhorrent.
* Ensure that your decisions and actions are scientific, humane, effective and in the best interests of the patient and his family. Record them. Once this is done, you need fear no individual, administrator or tribunal.

Ayurveda Drugs - Danger to Life - Poison which kills

The flip side of Ayurveda.

Thatte UM, Rege NN, Phatak SD, Dahanukar SA
Dept. of Pharmacology, Seth GS Medical College & KEM Hospital, Parel, Bombay, Maharashtra.

From Journal of Post Graduate Medicine
www.jpgmonline.com

Correspondence Address:
Dept. of Pharmacology, Seth GS Medical College & KEM Hospital, Parel, Bombay, Maharashtra.



How to cite this article:
Thatte UM, Rege NN, Phatak SD, Dahanukar SA. The flip side of Ayurveda. J Postgrad Med 1993;39:179-82,182a


How to cite this URL:
Thatte UM, Rege NN, Phatak SD, Dahanukar SA. The flip side of Ayurveda. J Postgrad Med [serial online] 1993 [cited 2005 Nov 9];39:179-82,182a. Available from: http://www.jpgmonline.com/article.asp?issn=0022-3859;year=1993;volume=39;issue=4;spage=179;epage=82,182a;aulast=Thatte



"A 62 year old male patient was brought to the casualty in an unconscious state. A detailed history from relatives revealed that he was a known diabetic whose hyperglycemia was well controlled with insulin and glibenclamide. Five days earlier he had started an ayurvedic drug for psoriasis. He developed giddiness following ingestion of the drug, but ignored it. Subsequently, he became unconscious. He was diagnosed to be in hypoglycemic coma to which he ultimately succumbed."
While investigating the causes for such sudden hypoglycemia, the attending physician would naturally question, "Could the ayurvedic drug be responsible for the hypoglycemia?". This case was referred to the Adverse Reactions (Ayurvedic drugs) Monitoring Cell of the Ayurveda Research Centre of King Edward Memorial Hospital. On scanning available ayurvedic literature, no reference could be found describing metabolic actions of any of the constituents of this medication. Subsequent animal studies revealed, however, that in occasional mice a significant hypoglycemia occurred, reiterating the fact that the adverse interaction in the patient could have been due to the inadvertent co-administration of the ayurvedic agent and powerful hypoglycemic agents.
This case dramatically illustrates the sequel of self-administering 'ayurvedie' drugs and emphasises the fact that there is indeed a flip side to Ayurveda. We present in this brief article, the other side of Ayurveda.
A question that will arise at the outset is why read about adverse effects of ayurvedic drugs (let alone their uses or benefits) if we do not practice Ayurveda? The answer to this question is simple: over 80% of our population takes ayurvedic medicines - either self-prescribed or through a ‘Vaidya’. These same patients expect to be treated by our medicines while simultaneously taking ayurvedic medicines often leading to interactions of the type described above.
Another point to note is that a large number of herbal preparations are in the market under the label 1 ayurvedic Drugs'. Due to aggressive salesmanship and over-the-counter (OTC) availability, these drugs are prescribed by doctors and consumed by patients widely.
Hence, it is obvious, that at least in our country, we have to be aware of salient beneficial and adverse effects of commonly used ayurvedic drugs as much as of allopathic agents.
Ayurvedic drugs that one is likely to encounter in practice can be discussed under two broad categories: a) the traditional formulations including for example kadhas (decoctions), arishthas (decoctions containing alcohol) or gutis (pills) and b) the so called ayurvedic formulations which are a combination of different herbal extracts (sometimes aqueous, sometimes alcoholic). These plants are prescribed individually or together for a particular condition in ayurvedic texts. However, their fixed dose combination, as marketed, may not be mentioned therein. These herbal medicines are prescribed for a wide variety of non-specific conditions like improving vitality, anti-stress effects, boosting immunity and increasing appetite or memory!
Since, in this article we are discussing adverse reactions, we shall for the moment assume efficacy of these herbal preparations. It is an old adage of pharmacology that teaches us that if a drug is effective it is most likely to produce a side effect [1].
In fact, standard text-books of Ayurveda mention that ayurvedic drugs, if improperly used can be toxic. Charaka[2] states in the Sutrasthana of the Charaka Sarnhita - "A potent poison also becomes the best drug on proper administration. On the contrary, even the best drug becomes a potent poison if used badly".
Ayurvedic texts classify toxic plants (See http://www.jpgmonline.com/viewimage.asp?img=jpgm_1993_39_4_179_598_1.jpg) into different categories depending on the part of the plant that is toxic. Subsequent research has revealed the exact chemical nature of the toxic alkaloid validating the knowledge laid down in ayurvedic texts.



In fact, in Ayurveda, there is a separate science which deals with toxicological aspects and is known as Vishagarvajrodhika tantra' (toxicology)[3].
There are enough grounds to conjecture that some knowledge regarding toxicity of plants was obtained through observation of behaviour of insects and animals towards these plants. Plants, which were never infested with insects, were considered dangerous: these were later shown to contain repellants like anthraquinone, naphthalene or nimbidine. Plants like vinca or nerium from which animals steer clear have later been shown to contain toxic materials. Aconitum does not allow any other plant in its vicinity! An interesting feature about ancient ayurvedic physicians worth noting, and perhaps emulating, is their ability to improvise on information they had, using whatever facilities were at hand. Thus, for example, when the physicians discovered that a particular plant was visciously toxic and perhaps fatal, they evolved ways by which the toxic components could be destroyed and converted them not only to safe but further therapeutically useful entities! The story of Aconitum heterophyllum is illustrative in this respect. The roots of this plant are considered toxic (they contain an alkaloid aconitine) and following ingestion of roots, the toxicity manifests in the form of tingling numbness of mouth and throat, abdominal pain, loss of muscle power, visual and auditory disturbances and finally clonic convulsions [4]. However, aconite forms an important constituent of ayurvedic formulations. The aconite used in the formulations is not a crude agent but one, which is processed. This processing involves boiling of roots with 2 parts of cow's urine (7 hours per day) for 2 consecutive days. The roots are then thoroughly washed with water and boiled with 2 parts of cow's milk for the same duration. These are washed again with lukewarm water, cut into pieces, dried and ground. It has been shown that aconite becomes safe only after this elaborate process and all the steps are 6 essential for complete detoxification[6],[7].
Besides toxicology, ayurvedic pharmacology describes in some detail the side effects that can occur with different therapeutically useful drugs. Further, it also describes ways (which also include manufacturing techniques) to minimise these side effects. Just like we, for example, would advise that NSAIDs should not be taken on an empty stomach, Ayurveda gives instructions regarding time of drug administration, the relationship with food, type of food which should be avoided/permitted with the drug etc. The do's and don'ts are clearly enunciated. For example, amalki (amla, Emblica officinalis) should be avoided at bedtime to prevent harmful effects on teeth [8]. Chyavanprash contains large quantities of Amla - one wonders whether the package insert with any Chyavanprash mentions this precaution! Similarly, pippali (Piper longum) used in asthma should be avoided in patients with peptic ulcer disease and should be consumed with milk [9].
Tribhuvankirti is a combination of several plants which is very commonly used to treat a "cold in the head" and fever. There are clear instructions in Ayurveda that because it contains aconite [Table - 1] it should be used cautiously. When used, it should be taken with tulsi (holy basil) juice, ginger juice or honey[8].
Guggul is derived from the resin of Commiphora mukul [11] and is used in a variety of diseases including hypercholestrolemia (in fact gugglulip has been introduced into the market for this condition) and arthritis[12]. Ayurveda specifies that guggul should be used cautiously in patients with peptic ulcer disease. While on guggul therapy the patient is advised to avoid sour food, alcohol and heavy exercise[13],[14].
The subject of teratogenecity also figures in Ayurveda. Thus, certain plants like Terminalia hebula (harda) are to be avoided in pregnancy. This is a constituent of a large number of OTC preparations. It is a powerful purgative and is supposed to stimulate GI motility and would therefore be contraindicated in pregnancy[15]! This fact is not sufficiently publicised.
Apart from plants, Ayurveda also includes metals in its formulary. Thus, several preparations containing metals like mercury, lead and copper are available readily in the market on OTC basis. These metals have to be deligently processed before they are suitable for human consumption and there is again a long list of do's and don'ts regarding their use. Unfortunately, there are no quality control methods to standardise such metal containing drugs and to find out whether processing of metal is done appropriately so as to render it nontoxic. This thus increases the probability of toxic effects.
The case history of a 70-year-old male patient referred to the ADR monitoring cell illustrates the relevance of being aware of these. This patient was taking a 'herbo-mineral' preparation 'Mahayograj Guggul' in the dose of 4 tablets three times a day, for the complaints of joint pains for well over two years. He got relief from the arthritis but developed symptoms of lead poisioning including severe anaemia with classic basophilic stippling of the RBCs. The case was referred to the ADR cell with the query whether Mahayograj Guggul could lead to this problem. As this preparation contains lead, our centre adviced immediate withdrawal of the preparation.
This particular preparation is prescribed for rheumatoid arthritis in ayurvedic texts[13] and contains several plants and metals as shown in http://www.jpgmonline.com/viewimage.asp?img=jpgm_1993_39_4_179_598_2.jpg .





Ayurvedic textbooks recommend a special pharmaceutical process to detoxify the metals. The lead in this preparation has to be processed by first heating over a fire till it glows. It should then be cooled by dipping into a mixture of sesame oil, buttermilk, cow's urine and a decoction of three plants, viz. amia (E.officinalis), beheda (T. bellerica) and harda (T. chebula). After repeating this procedure thrice, the lead is heated the fourth time following which it is dipped into a churna (powder) made of the rind of tamarind and Piper longum. This lead is then mixed with arsenic sulphide and wrapped in a betel leaf and warmed in a crucible to a fixed temperature. This process is repeated thirty times before nagabhasma or processed lead is ready for use[16]. In addition, in the doses that this patient was taking the drug he would have consumed a phenomenal 414 mg lead per day for more than 2 years leading to lead toxicity. There are two points to note in this case. Firstly, Ayurveda definitely reconimends Mahayogiraj Guggul for rheumatoid arthritis but has cautioned about duration of therapy, which was overlooked. Secondly, as there are no quality control procedures in existence, there is rio way to know whether the lead in this formulation had been processed in the complex way it should have been.
This brings us to the second group of the 'herbal' formulations marketed under the label 'Ayurvedic'. All doctors are aware that such preparations are available, many may be prescribing them and some will come across patients self-medicating themselves with these drugs. What exactly are these drugs and what do we know about them? Most doctors prescribe these agents, in spite of lack of sufficient clinical studies (using the randomised controlled clinical trial model) proving their efficacy in comparison to allopathic drugs, in the utopian misconception that "never mind if they are ineffective, they will be safe!"
What adverse effects can occur with such formulations? The most glaring are possible drug interactions with the usually co-administered allopathic drugs. Several plants have been shown to alter bio-availability of allopathic drugs[17].
Similarly when used in combination with allopathic drugs they may alter their pharmacodynamics. The example in the diabetic patient described earlier is illustrative. Further, such herbal preparations may produce toxicity, often unexpectedly, per se.
A very herbal remedy is the need to conduct safety studies on them. Protagonists for this believe that with the changing ecological environment, use of pesticides, new manufacturing techniques, modern formulations and combinations of herbs not prescribed in ayurvedic texts, the need for looking at ayurvedic herbal drugs as new drug entities cannot be ignored. This is being seriously considered by the office of the Drugs Controller of India and an amendment to the laws governing manufacture and sale of ayurvedic drugs is on the anvil.
Opponents feel however that herbal remedies are natural remedies and are beyond conventional toxicity studies. Further developmental costs would be formidable.
Is there a via media? Perhaps incorporation of any or all of the methods summarised in [Table:3] would optimise use of ayurvedic drugs.
The Adverse Drug Reaction monitoring cell for Ayurvedic Drugs has been set up at the Ayurveda Research Centre of King Edward Memorial Hospital, Mumbai with several aims. Alongwith documenting anecdotal case reports suggestive of adverse effects to ayurvedic drugs, (please see ADR reporting card) we also, where necessary conduct studies in animals to confirm or rule out the cause and effect relation between the drugs and side effects reported. Further we give information related to ayurvedic drugs.
In conclusion we can reiterate that in view of the fact that we are
a) not using ayurvedic drugs only in the form as described in standard texts,
b) making over-the-counter formulations without much heed to the need for individualisation,
c) giving ayurvedic drugs in combination with allopathic agents which have a narrow therapeutic margin,
d) using raw plant material that is possibly polluted by environmental and ecological devastation,
e) not having good quality control methodologies,
We must beware. We must not wait for a thalidomide- like tragedy in Ayurveda to shake us out of our complacence that ayurvedic drugs are safe!

:: References Top

1. Melmon KL, Morrelli HE. Drug Reactions. In: Clinical Pharmacology. Basic Principles in Therapeutics, 2nd ed. New York: Macrinillan Publ Co; 1978, pp 968. Back to cited text no. 1
2. Samhita C. Sutrasthanam In: Sharma PV, editor. Charak Samhita Varanasi: Chaukhamba Orientalia; 985; 1:126. Back to cited text no. 2
3. Dahanulkar SA, Thatte UM. Historical survey of the evolution of Ayurveda. In: Ayurveda Revisited. Mumbai: Popular Prakashana; 1989; 10-27. Back to cited text no. 3
4. Franklin CA, In: Modi's Medical Junspiudence and Toxicology, 21st ed. Mumbai: NM Tripathi Pvt. Ltd; 1988, pp 279. Back to cited text no. 4
5. Sastri A. In: Sri Vagbhatacharya’s Rasaratna Samuchchaya, 6th ed. Varansi: Chawkhamba Sanskrit Series office; 1978, pp 590. Back to cited text no. 5
6. Sen SP, Khosla RL. Effect of Sodhana on the toxicity of aconite (vatsnava). Current Med Pract 1968; 12:694. Back to cited text no. 6
7. Thorat S, Dahanulkar SA. Can we dispense with ayurvedic Somskaras? J Postgrad Med 1991; 37:157-159. Back to cited text no. 7
8. Gogate VM. Emblica officinalis. In: Drvyaguna Vigyan. 1st ed. Pune: Continental Prakashan; 1962, pp 350. Back to cited text no. 8
9. Swami B. Tribhuvankirti. In: Rasadarpan - part 1, 3rd ed. Patiyala: Swami Publication; 985, pp 393. Back to cited text no. 9
10. Sukh Dev. A modern look at an age old ayurvedic drug gugguiu. Science Age 5:13-18. Back to cited text no. 10
11. Satyavati GV. Gum guggul (Commiphora mukul) - the success story of an ancient insight leading to a modern discovery. Ind J Med Res 1988; 87:327-335. Back to cited text no. 11
12. Gogate VM. In: ayurvedic Materia Medica. Pune: Continental Prakashan; 1981, pp 289-290. Back to cited text no. 12
13. In: Bhavaprakash Nighantu Karpooradi vargu. Varanasi: Chaulkhamba Sanskrit Samsthan; 1969, pp 205. Back to cited text no. 13
14. Gogate VM. Terminalia chebula. In: Dravyaguna Vigyan, 1st ed. Pune: Continental Prakashan; 1982, pp 436 Back to cited text no. 14
15. Gune G. In: Ayurvediya Aushadhi Gunadharma Shastra, Siddhaushadhi, part IV, 2nd ed. Ahmadnagar: Mohan Mandir; 1934; 8-9. Back to cited text no. 15
16. Dahanulkar SA, Kapadia AB, Karandikar SM. Influence of trikatu on rifampicin bioavailability. Indian Drugs 1982; 271-273. Back to cited text no. 16
17. Back to cited text no. 17