Saturday, April 23, 2005
20-city survey of hospitals and medical colleges
Exclusive 20-city survey of hospitals and medical colleges
India’s health care sector is growing astoundingly fast. India has become a hot medical destination for patients in the middle east, Africa and even the west. And word is spreading that Indian hospitals can provide world class care at competitive rates.
But which of these are world class? All India Institute of Medical Sciences, Delhi, topped our list of 10 best hospitals last year (‘Best hospitals’, Jan. 18). This year, we again commissioned TNS for a follow-up. TNS spoke to 663 general practitioners and 1,013 specialists in 20 cities for the ranking. A hospital entered the roll of honour if at least 10 per cent of the doctors in any speciality rated it as one of the top five. Thus, 22 qualified and the top 10 were chosen on the basis of the proportion of doctors who considered the hospital among the top 5. AIIMS retains its No. 1 position followed by Apollo Hospitals, Chennai; PGIMER, Chandigarh; and CMC, Vellore. Sankara Nethralaya, Chennai, and JIPMER, Pondicherry, have entered the elite club for the first time.
Since the standard of medical education has a direct bearing on health care, we also surveyed India’s medical colleges. For this, TNS spoke to 409 MBBS aspirants. A medical college qualified to be one of the best in the country if it was rated among the top 3 by at least 10 per cent of the general practitioners or students in a city. Like last year, we discuss treatments available for specialities, too. Though we examine in detail only three—trauma care, ophthalmology and prosthetics—we list the best hospitals for 12 specialities.
Many Indians today get good care, but many more—70 per cent of the population—still do not have access to the best. Even as we pat ourselves for all the achievements, let us not lose sight of this stark reality. As Mumbai cardiologist Dr B.K. Goyal says, the primary objective should be to make top class medicare available to the common man.
By Kavita Bajeli-Datt
Prabha, 34, (left) can pass off as yet another plucky working woman as she zooms past on her Kinetic Honda. But what makes her different is that she lost her right leg at 18. And the confidence she exudes is the result of the advances in prosthetics that have given ample freedom of movement to many like her.
Prabha’s right leg, which was turned upwards to the pelvic bone, was amputated after treatments including surgery failed to correct the birth defect. Though she got an artificial leg fitted, she gave it up when she fell on the road three times while crossing and the limb came off. "There was no lock in it," said Prabha. "I felt embarrassed. I decided never to use them and to continue to use crutches. I was really scared."
So she walked on crutches till five years ago when she joined the Indian Spinal Injuries Centre in Vasant Kunj, Delhi, to train physically disabled people in clay modelling and making soft toys. Prabha, who comes to the centre on alternate days, decided to get an artificial limb when she saw people like her at the centre benefit from new prosthetics.
"We have made rapid strides in prosthetic technology," said Dr B.D. Athani, director of All India Institute of Physical Medicine and Rehabilitation in Mumbai, which was the first of its kind in southeast Asia when it was set up in 1955. Dr Dharmendra Kumar of Delhi’s Pt Deendayal Upadhyaya Institute for the Physically Handicapped agrees. "The technology and materials used in India have been rapidly changing in the last few years," he said. "Advanced plastics with increased durability and strength and improved cosmetic appearance have started replacing wood. This has brought down the cost and the weight of the artificial limb, and the time required to fabricate a prosthesis has gone down."
There was a time when artificial limbs were made only in wood. Before Jaipur Foot, there was the British-founded Army Limb Centre in Pune, but the wooden limbs made there were heavy. There was a long waiting list for the limbs, said Prabha Lalji, director of Santokba Durlabhji Memorial Hospital (SDMH) in Jaipur.
Support systems: A patient with spinal injuries at the Indian Spinal Injuries Centre
Jaipur Foot made of wood, rubber and steel proved to be a turning point in Indian prosthetics. Though the Solid Ankle Cushion Heel foot was available then, it was not as flexible as the Jaipur foot that Dr P.K. Sethi first brought out in 1965. "It did not allow the mobility needed to use an Indian toilet and walk on uneven terrain," said Dr Anil Jain, consultant at SDMH. "These were not water-proof so the user had to wear shoes and this didn’t allow the person to go to a temple, mosque and gurdwara. These were not durable, so required frequent replacements and were not easily available. All these drawbacks often forced the user to reject the artificial limbs and revert to crutches. The Jaipur Foot is a culture specific innovation and an answer to all these problems."
Over 1 million Jaipur Foot, which now costs around Rs 400, have been fitted in people from even countries like Afghanistan, Bangladesh and Vietnam. The SDMH’s rehabilitation centre has all the facilities for fitting artificial limbs and low weight thermoplastic calipers in paralysis patients. "Since 1965 the Jaipur Foot has undergone some changes," said Sethi, who trains technicians from across the country and around the world. "It has a new design and is of better quality now. But the major change has been that its wooden forefoot has been replaced by micro-cellular rubber."
New-age prosthetics are lightweight and often incorporate complex electronic and pneumatic mechanisms. "Newer materials have emerged, endoskeletal fitting assemblies have taken the place of conventional wooden structures," said Athani. While prosthetics made of material made in India cost between Rs 400 to Rs 7,000 depending on the body part it replaces, those made of imported materials cost up to Rs 1 lakh. The artificial limb and the procedure of getting it fixed cost Prabha Rs 12,000.
"Imported materials are quite expensive and beyond the reach of poor people," said Kumar. "We are always looking for locally available materials which are strong, durable and are within the reach of Indians." The government is covering the vast amputee population living below poverty line, said Athani, through a scheme of assistance to disabled persons for aids and appliances where the prostheses are given free of cost.
It took 15 days for Prabha to adjust to her new limb and another 15 with the physiotherapist for gait training. Though she uses a walking stick for balance, she is glad that her exoskeletal SACH foot has a lock to keep it in place. Exoskeletal prosthetics have a firm exterior and are cheaper than endoskeletal devices that are soft on the exterior too, said Kaushal Kishore, Prabha’s prosthetist.
Prosthetists are in great demand what with the high accident rates and increasing amputee population. There are degree courses in prosthetics and now the Spinal Injuries Centre is planning to start a postgraduate course. Major H.P.S. Ahluwalia, chairman of the centre, said experts from the west would take classes. Ahluwalia, who is also chairman of the Rehabilitation Council of India, a statutory body of ministry of social justice and empowerment, said the degree would improve the standards in prosthetics.
Said Athani: "With the amputee population on the rise on account of diseases like diabetes, peripheral vascular diseases, and vehicular accidents this [prosthetics] is emerging as one of the important areas. A lot of research needs to be done to improve the technology."
India was slightly behind the west in terms of quality of materials and technology, said Kumar. "Indian scientists and professionals are on the way to developing electronically/electrically controlled upper limb prosthesis from locally available materials which will be much cheaper," he said. "The demand for strong and lightweight components in aerospace and marine industries has produced a variety of new materials that possess mechanical properties which are suitable in making prostheses."
Prabha’s mother, Kamla, is happy for her daughter. "I am proud of her. She teaches others and drives her scooter so well," she said. "She has gained that inner strength." Said Prabha, who has been riding a scooter for three years now: "I have a new confidence that was lacking earlier."
| What’s new The components of the modern prosthesis are socket, elbow joint unit, forearm sheath with wrist unit, terminal device, harness and the control cable system. Conventional above-knee prostheses had a conical socket, thigh piece, knee joint, shin piece, ankle joint and a wooden foot. This was suspended by a pelvic band or by a shoulder strap. As the fitting of the socket to the stump became more and more accurate, the suspension devices have become less elaborate. |
Ophthalmology: Sankara Nethralaya has many firsts to its credit
By Kavitha Muralidharan
Shanthi Srikanth (Left) of Chennai began losing her vision in 1998. Doctors at Sankara Nethralaya, who found that she had uveitis (inflammation in the eye between the retina and the cornea), put her on steroids because nothing else worked. Though her eyes responded well to steroids, she soon developed glaucoma and had to undergo surgery. As her vision improved, doctors brought down the dosage. "There were two things in getting treated at Nethralaya," says Shanthi, 42. Employed in a private firm, she goes to Nethralaya for regular check-ups. "One is the talent of the doctors. The other is their ability to make quick decisions."
With 60 patients on the waiting list and a record 25 vitreoretinal surgeries (for diseases involving the vitreous humour and retina) every day, the 72 ophthalmologists at the hospital including its founder-director Dr S.S. Badrinath perhaps cannot afford to delay decisions. With facilities like ocular pathology, microbiology, genetics and molecular biology labs, surgery of retinopathy of prematurity (disease of the retina affecting prematurely born babies), ultrasound biomicroscope, summit excimer laser for refractive corneal surgery, GDx nerve fibre analyser and automated DNA sequencer, the hospital attracts foreign patients, too.
Nethralaya—fifth best hospital in the TNS survey—has many firsts to its credit. The hospital was the first in India to introduce YAG laser in 1982, and photo refractive keratectomy in 1993, followed by LASIK. It was the first to study the role of the eye in AIDS in India and the first Indian eye hospital to get ISO 9002 certification.
Today, the hospital has 12 ophthalmology departments. "Even our allied departments like genetics, molecular biology and microbiology focus on eye care," says Dr Lingam Gopal, ophthalmologist and president of Vision Research Foundation of Nethralaya. "That is why Sankara Nethralaya has been able to provide the best in eye care."
Research, another strong point of Nethralaya, complements care. For instance, ever since its researchers discovered the link between congenital cataract and the incidence of German measles during pregnancy, the hospital, says Badrinath, has been telling women to vaccinate against the disease before pregnancy.
All research is scrutinised by three committees before it reaches the public. "We have an in-house committee which approves our research," says Gopal. "The research then goes to a research subcommittee, also called internal review board, for further approval. Then we send it to the ethics subcommittee with a retired judge and social worker among its members who can reject the research if they find it unethical."
Nethralaya, which will soon have branches in Dehradun and Mauritius, started teleophthalmology in 2002. A fully-equipped mobile van goes to rural areas where villagers use the satellite-abled facility to interact with doctors at the hospital. "We go to a village for two days and in the evening give talks on eye transplantation and donations, creating awareness," says V. Murali, teleophthalmology in-charge. In fact, the hospital, which gets around 1,000 eyes and performs around 500 transplants a year, has two medical workers only to talk to people about eye donations.
Telemedicine for the villagers is for free. So is treatment for poor patients at the hospital. "Our doctors never look at the purse of a patient because they do not get cuts," says G. Sivaraman, patients relation officer. "For them a poor patient is as important as any other patient. We do not take more money from foreigners."
Man of vision: Dr S.S. Badrinath
Patients like Shanthi are touched by the hospital’s concern for them. So are its 1,000-odd employees. "This is more than a hospital and we are more like a family," says Sivaraman, who has been working at Nethralaya for 15 years. "I have got offers where I could get three times the salary I get from Nethralaya. But for me, this is more than a job. It is a mission."
Not surprising, for it was in answer to a call from the Kanchi Mutt to work for a mission rather than money that Badrinath gave up his plans to move to the US and set up Nethralaya in 1978. "We do not say we will never have failures," he says. "When we have some, it is our human touch which makes the patient understand and accept it, which makes them realise that there are things beyond our control. The human element is an essential part of medicine." Perhaps, it is this realisation that sets Sankara Nethralaya apart.
What’s new Implanting 2.5-5 gm of gold—sorry, you can’t show it off—in the eyelids to get rid of that stare (mostly in people with problems of the thyroid). The dense yellow metal brings the eyelid down. Ultrafast laser that makes clean, high-precision surgical cuts in the human cornea—the first step in the popular LASIK vision correction surgery. |
By Quaied Najmi
There was celebration in the lower middle-class Chauhan household in Chembur, Mumbai, when its first child was born to Jyoti and Sanjay on March 2. But gloom set in a few days later as the baby girl began vomiting and had difficulty breathing. When her condition did not improve with a local doctor’s treatment, they took her to King Edward Memorial (KEM) Hospital’s new emergency medical services department at Parel.
Working with a sense of urgency: A newborn gets emergency care at KEM
After examination, she was moved to the paediatric ICU where she was put on a ventilator. Within minutes a specialist diagnosed the baby’s condition to be the result of a congenital heart defect. "It could require surgery, but that will be decided only after further tests," said Dr Sanjay Mehta, chief of emergency medicine.
Even as the doctors were examining the baby, Philomena Lopez, 55, was rushed in with dropping blood pressure. Since it was too low to be recorded, doctors carried out an emergency procedure of inserting a Central Venous Pressure Line into her heart to record blood pressure. Dr Rajeev Satoskar, associate professor of surgery at G.S. Medical College (attached to the hospital), said that the emergency department got around six cases a day that required the use of CVPL.
Emergency cases like Philomena and baby Chauhan constitute 10 per cent of the 15 lakh patients who come to the hospital’s out-patient department every year. "For us, tackling emergencies, big or small, is a routine matter," said Dr Nilima Kshirsagar, dean of the hospital run by the Brihanmumbai Municipal Corporation. In the TNS survey for specialities KEM stands sixth in trauma care.
With advances in emergency care, the casualty has starting giving way to modern emergency rooms that stock the latest in life-saving facilities. An emergency room gets a variety of cases—cardiac and kidney patients, paediatric cases, food and gas poisoning and accident victims. KEM’s emergency gets even victims of hooch tragedies, riots and bomb blasts. "Anything can happen any time in a huge city like Mumbai and we are prepared for it, 24x7, 365 days, and a disaster management plan is inbuilt in our emergency facility," said Mehta. "Everything works with clockwork precision, there are express procedures to be followed by all. During emergencies, doctors will even pull stretchers or do other menial tasks. No ego hassles."
Things are not too different in the emergency room of Amrita Institute of Medical Sciences, which is ranked the best in Kochi in the TNS city-wise survey of hospitals. "We have a code blue team [consisting of a surgeon, anaesthetist, cardiologist and technician] that responds within two minutes [of an emergency call]," said Dr Geo Gills, head of emergency department at AIMS. "We have all kinds of modern equipment like monitors, central lines for oxygen and air, paediatric warmers and defibrillators."
"The emergency department at KEM has treatment facilities and equipment [comparable to the best], although there have been no significant advances in this sector in the past one year or so," said Dr B.K. Goyal, cardiologist and dean of Bombay Hospital, Mumbai.
"Even private hospitals are trying to catch up; for instance, Bombay Hospital is the only private hospital in India with 110 ICU beds dealing with all kinds of emergency cases."
KEM's Rs 3.2 crore emergency service, equipped with around 70 doctors, works 24x7, 365 days.
The equipment in KEM’s emergency service, which has 30 beds, are exclusively for emergencies. With around 70 doctors, including specialists, the Rs 3.2 crore emergency department is prepared to carry out any surgery, any time. Mehta said that every day the hospital got at least two heart patients who required the streptokinase injection to dissolve a clot in the artery. A police post in the department ensures that the legal and medical formalities can proceed simultaneously in accident cases.
According to Dr V.J. Lahiri, head of the orthopaedic department, the advantage is that all essential services are available in the same area. Speciality doctors come to the patient rather than the patient going to different departments. Said Gills: "An ideal emergency room should have support from different departments like neurology, anaesthesia and gastro, which we have at AIMS."
Many hospitals now offer training to physicians in emergency and trauma care. KEM’s emergency attracts foreign doctors—around 150 every year—who come to study the department and its functioning. In addition, hundreds of local doctors attend three-month-long refresher courses to upgrade their knowledge and for hands-on experience.
KEM is now planning to uplink its facilities with other government hospitals in Maharashtra and offer telemedicine services in collaboration with the Indian Space Research Organisation. On the cards is a poisoning and toxicology centre.
What about flying ambulances? "That’s still far away," said Kshirsagar. "We must first consolidate ourselves at the ground level before we think of helicopter ambulances."
Trauma care: World class emergency rooms give new hope
| What’s new |
By Dr Sumit Ghoshal
Two years ago, the Administrative Staff College of India conducted a prescription audit among doctors at several government hospitals in Maharashtra. It was carried out in the OPDs, which meant that most of the 212 doctors concerned had five to seven years experience after graduation. The findings were as follows.
Details like dosage, strength of the drug and number of days for which it is to be taken were mentioned in just 40 per cent of prescriptions for tablets. In the case of injections, this dropped to 20 per cent. Proper follow-up advice was given in just 18 per cent of cases.
Correct prescription writing skills form the basis of medical practice, and it is quite natural to assume that a qualified MBBS doctor has these skills ingrained in him during his years of study. This is an indicator of the malaise that has affected the medical education in India. According to the Medical Council of India, there are 233 medical colleges in the country, but almost all the new ones that opened in the past five years or so are private. A vast majority of these are nothing but teaching shops, designed to enable their owners to rake in the moolah as fast as they can.
There are a few honourable exceptions: the Manipal Group in Karnataka; Sree Chitra Tirunal Institute for Medical Sciences & Technology in Kerala, Sri Ramachandra Medical Institute in Chennai and some others. But the fact that these are exceptions only proves the rule.
According to a media report, the Karnataka government has decided to start six medical colleges in district hospitals that do not even have proper buildings for the purpose! While the Bidar district administration is struggling to find land to build upon, the foundation stone for Shimoga’s college has been removed. The foundation stones for Bidar and Raichur colleges would be laid in April while the academic session is scheduled to commence after three more months!
Let us come to Gujarat. In Vadodara Medical College, plans to introduce at least seven super specialties—cardiology, urology, burns and plastic surgery, CT surgery, neurosurgery, neurology and nephrology—are in limbo because suitable teachers cannot be found. Of 21 sanctioned posts for professors, associate professors and assistant professors in various super specialties created by the government, only 10 have been filled.
Great reputation: AIIMS, Delhi
"Most PG students are at the mercy of part-time and honorary teachers. This hampers expansion and upgradation of the institute and affects the quality of education," says a senior teacher at the medical college.
Many consider 2003 as annus horribilis with regard to medical college admissions. It actually began the previous year with a spate of litigations. In October 2002 the apex court ruled that the earlier system of 85 per cent merit-based admissions and 15 per cent management quota was to be discontinued and college managements could decide how they wanted to allot seats. Since the ‘management’ quota was the golden goose, this verdict set off a series of wrangles between private medical colleges and the state governments. These continued and admissions were delayed indefinitely.
"The court cases are bound to happen every year," says Dr Sudhakar Sane, a senior professor of surgery in Mumbai. The 2004 round of litigations is still going on. Now the parents associations have gone to court over the fee structure, and the teaching schedule has gone haywire. The Maharashtra Common Entrance Test will take place next month, and the next spate of petitions is expected soon after the results are out!
But there is a more fundamental question that parents and students must ask themselves. Why does someone want to become a doctor? Is it to practise medicine? To get rich in the shortest possible time? To enhance one’s ‘value’ in the ‘marriage market’? Or perhaps to just increase one’s ‘family prestige’ in the community? Ask a sufficient number of people and you will hear all these reasons. And this gives the politicians and money bags the opportunity to exploit the situation.
It seems that for a large segment of the populace, the medical profession is no longer an attractive option, not just in India but also in the UK and the US. People entering the medical profession in several western countries are not of ‘high calibre’ according to a Swedish executive of GE Medical Systems.
The Association of Medical Consultants in Mumbai conducted an informal survey among its 4,000-odd members a few years ago and discovered that a considerable number of them did not want their children to follow them into the medical profession! With that, I rest my case.
Dr Sumit Ghoshal is a doctor-turned-medical writer, working with a PR firm in Mumbai.
Medical education: Colleges become teaching shops for owners to make a fast buck
Guest column
By Dr Umesh D. Parashar
Coming from a family of doctors, I was determined from a very young age to follow the same career. As both my elder brothers had studied medicine at AIIMS, there was pressure on me to become one of the 35 candidates who succeed in the entrance examination attempted by more than 20,000 applicants. I studied diligently and was thrilled to see my name in the list of selected candidates in 1989.
Right from the start, I could see why AIIMS had such a great reputation. Our professors were selected from the best and the brightest in the country and, despite the responsibility of providing clinical care to a large number of patients, devoting time to train students was high priority for them. The small size of each batch allowed all of us to receive personal attention and we always had ample access to training resources, including a high-class medical library with a huge collection of medical textbooks and journals. The quality of clinical bedside teaching was excellent and because AIIMS is a tertiary referral hospital, we saw patients with both common medical conditions and unusual pathologic manifestations. What truly attests to the quality of AIIMS education is the fact that even in the US many medical residency programmes gladly accept AIIMS graduates primarily because of their positive experience with previous graduates from the institute.
While the quality of teaching and availability of resources at AIIMS were excellent, what elevated the training experience was the interaction with other students. All of us were motivated and strived hard to excel. Most of us stayed in the hostels on the campus, which allowed us to bond.
While we all worked hard, we also played hard. Our annual medical festival, PULSE, attracted large crowds of students from medical colleges across the country and often they were surprised to see these ‘studious AIIMSONIANS’ having such a good time!
Despite its high quality, certain aspects of medical training at AIIMS can be improved, particularly based on my experience in the US. For example, the curriculum can better integrate pre-clinical and clinical training. Also, examination of medical students should focus more on assessment of clinical implications, patient evaluation and clinical management skills rather than on textbook knowledge.
On the whole, however, I have many fond memories of my medical school training and feel that it was a world-class experience. I am proud to be an AIIMSONIAN.
The writer is lead medical epidemiologist, SARS Task Force, Centers for Disease Control and Prevention, Atlanta, US.
