By Sandagomi Heenpella –
While the whole country is eager to uncover the truth about the 4000 illegal “sterilization” procedures supposedly done by a Senior House Officer attached to the Gynecology and Obstetrics Unit of Teaching Hospital Kurunegala, the allegations alone raises much more sinister issues which may very well be critical to the very existence of the noble profession.
Dr Shafi Siyabdeen
Along with the allegation of doing thousands of illegal “sterilization” procedures during Caesarian Section of Sinhala Buddhist women many salient issues have surfaced.
1. How many Caesarian Sections (LSCS) can a Senior House Officer (SHO) such as the alleged doctor do, per day and during his entire career?
2. Can a SHO do a Caesarian Section without supervision?
3. Whose responsibility is it to ensure that the patient is treated safely and adequately?
4. What are the mechanisms in place to ensure patient safety and prevention of malpractice?
Patient care at government hospitals is guided by circulars and guidelines issued by the Ministry of Health and various other professional bodies such as the College of Gynecologists and Obstetricians.
One such important circular concerned with the practice of Senior House Officers (SHOs) is the circular dated 5th October 1993 issued by the then Secretary to the Ministry of Health, Dr Joe Fernando.
According to the circular, SHOs are expected to assist the Consultant (specialist) in surgeries and procedures. It is the responsibility of the Consultant to train the SHO to perform minor and intermediate surgeries under supervision. Once the Consultant is satisfied with the training, the SHO is allowed to perform a minor or intermediate surgery while the Consultant is physically present in the theatre. Only when the Consultant is fully confident of the competency of the SHO, he could allow the SHO to do a minor or intermediate surgery when he is not in the theatre. However, the Consultant must be present physically in the hospital during the time the SHO is performing a minor or an intermediate surgery.
According to the standing regulations, all patients with complications must be personally operated on by the Consultants and not left to the SHO under any circumstances.
It must be noted that in Obstetric practice any Caesarian section other than a simple uncomplicated pregnancy of a primi (first pregnancy) mother is considered as a major surgery.
If the above circular is in effect (there are no subsequent circulars on the subject) and practiced strictly, it is clear that the volume of surgeries performed throughout the country in Base Hospitals, District General Hospitals and Teaching Hospitals would be very much less. The bulk of the surgeries done at hospitals other than teaching hospitals, where post graduate qualified medical doctors (Registrars) are not available, is done by the SHOs.
If one is to be guided strictly by the circular it is apparent that SHOs cannot do such surgeries alone and certainly not when the consultant is not physically present at the hospital (not quarters). However, in reality, many well experienced SHOs cover-up for the lack of registrars and complete heavy theater lists and perform difficult surgeries. It is not the skill or the experience but the qualification on paper that hinders them from being “qualified” to do such surgeries.
What are the reason for this discrepancy between the regulation and the practice?
1. The number of Registrars are very much less and the facilities to train Registrars is the limiting factor in attaching them to hospitals other than Teaching Hospitals.
2. However, the lack of a system where those medical doctors who have experience of working under consultants for years and gained skills and knowledge on a particular specialty, to be confirmed as “Unit Registrars” caused this vacuum between the Consultant and the SHO.
3. There have been many requests made to the Ministry of Health to establish an intermediate carder where experienced and skilled doctors are placed between consultants and SHOs so that they can take the responsibility of undertaking surgical and other procedures safely and effectively.
4. Another deficit in the medical establishment which warrants mention is the rate in producing specialist and the carder position for them to serve. It is a popular secret that due to lack of vacancies young Consultants who qualify today may never get a chance to serve in a Teaching Hospital till the end of their career.
5. The rate of producing has been limited by many factors including the fact that there is only one institute in post graduate training for the whole country. There is no greater example to elaborate the plight of Specialists’ care in the country other than observing the current pass rate of in Gynecology and Obstetrics post graduate training. There are 51 trainees (Registrars) who are planning to sit for the part 2 examination next month. Out of them 37 are 1st attempters. The rest is second time and the third time attempters.
6. While the health care system is yearning for more specialists and qualified doctors, the Post graduate Institute of Medicine (PGIM) and the Ministry of Health seems not interested in addressing the problem.
The result of such inactivity is the failure of the system giving rise to malpractice and unethical practice. While there are many hospitals including the main hospitals which need more consultants to fulfill the demand, carder vacancies are not created due to dubious reasons? As a result, the Consultant is unable to supervise the juniors adequately. While the circular letter says otherwise, it is only the SHOs who are there to look after the patients and do surgeries at many places while the consultant is at private practice.
The circular:
My No. MAD 43/93
Office of the Director General of Health Services,
385,”Suwasiripaya”,
Deans Road,
Colombo 10,
th
5 Oct.1993.
To: All Directors of Teaching Hospitals,
Medical Superintendents of Provincial Hospitals,
District Medical Officers of Base Hospitals.
The Role of Senior House Officers (without Postgraduate Qualifications) Appointed to Surgical, Gynaecological and Obstetrics Units in Teaching, Provincial and Base Hospitals.
These appointments have been made with the sole objective of providing better quality patients care in the respective units.
Since these SHOO have no Postgraduate qualifications in the Specialty, the responsibility of providing adequate training to them rests with the Consultants of the units.
The Senior House Officers are expected to assist the respective Consultants in the units in providing efficient and effective care to the patients. The SHOO shall assist the Consultants in the ward rounds, at Specialist Clinics and in the Operating Theatre. Patients operated must be constantly monitored by the SHOO till the patient is out of danger. They shall guide the Intern Medical Officers and be on call to the Units and promptly respond to such calls either from Intern Medical Officer or from the wards. SHOO shall carryout these duties under the direction and supervision of the consultants in-charge of the Units.
Surgical/Obstetric/Gynaecological Operations performed by SHOO
a) Before SHOO are permitted to operate, the competency and capability of the officers have to be determined and assessed carefully by Consultants of the Units.
b) Once the Consultants are satisfied with the competence of the officers they may be permitted to operate provided the Consultants are physically present in the Operating theatre, readily available for any eventuality.
c) Once the SHOO have proved their competence, they may be allowed to undertake minor/intermediate, Surgical/Obstetric/Gynaecological Operations, provided the Consultants of the Units are available physically in the hospital who could be summoned immediately in case of emergency.(Here the hospital does not denote the quarters)
d) All patients with complications must be personally operated on by the Consultants and not left to the SHOO under any circumstances.
e) In Base Hospitals where only a single Consultant is available, SHOO shall not undertake Surgical/Obstetric/Gynaecological Operations while the consultant is on leave, except in very exceptional circumstances where surgical intervention is called for, to save the life of a patient. In such situations, the Consultant who is acting for the Unit (who may be a Surgeon or Obstetrician) depending on the situation must be consulted. In these instances, the DMO should be kept informed.
f) Under no circumstances should a Consultant proceeding on leave either for short or long periods, issue instructions and give blanket cover to the SHOO to operate on patients in the absence of the Consultant. The Consultant acting on his/her behalf would decide on the course of action in regard to any patient.
g) In all instances, the sole responsibility for patients admitted to Units rests with the Consultants of the Units. SHOO should not be substituted for Consultants.
h) In all situations, absolute safety and welfare of the patients is paramount. It is the sacred duty of all Consultants, SHOO, Interns, to provide the best possible care and treatment to the patients.
All directors of Teaching Hospitals, Medical Superintendents of Provincial Hospitals, and District Medical Officers of Base Hospitals, are kindly requested to bring the contents of this Circular to the notice of all Consultants as well as SHOO. They would do well to get the concerned officers to note the contents of this Circular.
Dr.Joe Fernando
Secretary,
Ministry of Health & Women’s Affairs
Cc. Provincial Directors of Health Services/Dep. Prov. Directors of Health Services.
charuni / May 30, 2019
Forwarded as received
VOG. Dr. Siraj and another Muslim woman doctor of Peradeniya teaching hospital performed same surgery by clamping the fallopian tubes during C-section surgeries for over six thousand Sinhalese women (mid 2000 onwards) in Peradeniya area. The nurses Dhammika and Euginee were assisting the surgeries and when they asked why this procedure was done by these Muslim doctors, the doctors said it was to reduce bleeding. After some time, when these mothers wanted to have more babies they did not conceive and they came back to the hospital to complain about it. The investigations found out that the fallopian tubes have been damaged due to clamping done during the previous C- section surgeries. The mothers with their husbands wanted to take legal action but the hospital authorities did not want to proceed, Dr. Kapila Gunawardena was the head of the Peradeniya hospital at that time and since he was retiring after a few months, he did not want to get involved. The nurses were willing to testify against these 2 Muslim doctors. Dr. Siraj immediately got a transfer to Ashrof Memorial hospital in Kalmunai and the woman doctor just disappeared. Please, if anyone can bring this out and taken necessary action against these Muslim doctors please do.
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Sarrij / June 2, 2019
C.
Sounds like “hogwash”.
The figures are astounding; your imagination running riot? Get real!
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chiv / May 30, 2019
Let it be clear before I comment. If this doctor is found guilty in a single unethical procedure then he should be punished.Now let me get to facts. Any procedure has to be explained to patient and family in their native language not foreign/English following which pt gives informed consent by signing the necessary legal form. A FAMILY member and a staff (junior doctor or nurse) will attest as witness and then the relevant surgeon will have to sign prior to any procedure. Now any doctor or medical student hearing this case will be asking how can this be possible??? To perform so many for so long without being complained. How long does it take for a mom who has been unethically deceived a child to complain (do not give political excuses because numbers have crossed hundreds).We also need to remember previous antics of Ganasara and the rumors of sterile pills and sweets which our immoral public eagerly exploited. A question to ask . See the report of defence sec who told PSC of some planning taking place in Kurunegala to cause more trouble. Ganasara is just in time released to take up his favorite theme. Kurunegala has already experienced a dry run of riots. Most of the complainants supporting staff and the doctor in question are from the same district.Now where is GMOA and SLMC in this whole picture. They are usually up in arms for foreign matters, trade pacts, anti India stand but not to be seen when a colleague of them is involved. After reading this just thing who is against foreign doctors providing services, and SAITAM when health services are inadequate. If they allowed they will not be able to do private practice while work hours.
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Taraki / May 30, 2019
‘Let it be clear before I comment. If this doctor is found guilty in a single unethical procedure then he should be punished’
Chiv don’t you know that this never happens in Sri Lanka? When did you last hear of a Doctor being struck off? Everything is settled by deals (cash preferably in used notes) and favours or is simply ignored. Its not just the politicians who are corrupt.
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edwin rodrigo / June 2, 2019
Taraki, a good investigator does not stop at the most popular and hence most obvious explanation. He looks for the not so obvious. That is how Sherlock Holmes mad a name and that is how I am going to do it. So how about these:
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1) They are going to one child mothers who are being mobilized by promises of financial rewards.
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2) In SL we know that if an unmarried woman gets pregnant and the culprit flees, the parents look for a man for quick marriage. They are not bothered to find out whether the guy is fertile or not. Once married and a quick child comes, the guy enjoys fame in the village as a ‘stud bull’ who is effective,
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3) All the fallopian cases were done at verbal request of the mother or husband on a person to person basis.
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4) The mother is already having an extra marital affair and does not want a child who obviously looks like the next door neighbor.
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5) They really could not afford another child.
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6) Like Edwin Rodrigo they are suffering from Baby Phobia.
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The possibilities are unlimited. So don’t think that Dr Shafi is like Dr. Josef Mengele of Hitler’s time.
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CondemnedLizaPriceless / May 30, 2019
@RETARDED Reginald SATAN Perera,
Wish a janitor would have plugged your mother’s anus with a toilet plunger preventing her from shitting you into this world. What a racist pig. Your services will soon be needed again in Kurunegala when the duty calls of your Carlton masters.
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Ahmad Nadvi / May 30, 2019
Dear all!
Muslims of Sri Lanka are very nasty people. You cannot go to our eatery where we put a medicine making males impotents and females losing child bearing capacity. If you go to our doctors they make you suffers with the same effect of the above medication. If you buy from our garment shops the clothes got sort of itching effect and in long run you lose your beautiful skin and eventually it causes death. If you travel by our Tuk Tuk or private hire vehicle you’ll get kind of bottom and pack pain and within a short period you’ll die. If you go to our international school we have bomb making and throat slitting courses. If you go to our homes and eat anything definitely it’ll make you convert to our religion. If you open our book you may feel your’re reading from Mahawamsa or Geetha or Bible but actually it is from our dangerous book, you know what I refer to, and you become inhuman. So what you’re going to do, apart from setting on fire and looting our properties, kill all of us? But there is a problem. The Mahawamsa, Geetha and Bible all teach “ahimsa” and you cannot behave like us Muslims. Human and subhuman cannot live together. Thus my suggestion to you all is peacefully leave the country and seek asylum where “ahimsa” is preached and practised..
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Nathan / May 31, 2019
Shehan you have to learn more before commenting. You are not correct here. Besides you cant compare US or UK or Australia to poor SL. In SL patients are treated like cattle and have you seen how many sleep on the ground under a bed with IV drip running. That is SL and that is exactly what we achieved after 70 years of non existent independence. In developed countries patients are humans and there is some value for human life unlike in SL. Haven’t you seen murdered bodies of minorities being eaten by dogs and crows. Havent you seen the number of bodies floating down rivers in south in 88 period? In SL human life is so cheap and cheaper than animals of course. We are a bunch of barbarians and we just dont care who you are. Luckily you ran away to the US but now worst of all trying to compare US to SL? Just imagine the patriotism of Gotta for throwing away his US citizenship for the sake of his country.
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Nathan / May 31, 2019
Let the rumours and racism aside it is time for a thorough inquiry into these allegations as they are of utmost importance. It is illegal and unethical besides dangerous racism. If that is true then we have no doubt that there is a very serious and a dangerous trend already crept into the country and obviously Islam and Muslims are a serious threat to SL. But before jumping at that all depends on an effective, fool proof, fair inquiry conducted by people who have to be neutral and well informed. We as a nation never short of lies, rumours and allegations. From top to bottom is the same. It is also totally unfair for accusing Muslims of this most heinous crime based on mere rumour or perhaps jealousy. It has to be proved beyond doubt. The canines like Weeramonkey or others are of no use and they must simply keep away form this. Theros too to keep away. Let the professionals to do it. Even having an independent foreign expert is not unreasonable. We as a nation have lost faith at each other. We dont trust our own people. This is all we achieved through independence. So let us be sensible and logical and go ahead with a thorough, fair investigation before pointing fingers at each other. Let me also emphasise that it appears as if Muslims of SL seem to be having some long term agenda but that mere speculation does not mean anything unless it is proved objectively. But who is responsible for this chaos is another important question.
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chiv / May 31, 2019
Charuni, please do not forward such messages which are nothing but rumor mongering.No one can keep doing such procedures, of this nature for even , one or two years leave alone from 2000 and thousand of it. Just ask any doctor including final year medical students for a honest opinion and forward that to others. Not the rumors created by racist,trouble makers and other low lives. No mother who have been intentionally deceived will let it happen to others. Other than hospital there are SLMC, GOMA, Health Ministry, media including news paper,social media ,police, courts,activist, then you had thugs like Ganasara, years and years of MR rule and still not one single case was exposed??? This procedure can be easily proved beyond doubts. How come rumors like imaginary sterile pill and sweets spread like wildfire in hours where as 4000 tubal ligations , not one was known to public. Please do not make us laughable when we already are.
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chiv / May 31, 2019
Taraki, dont forget the Russian qualified doctor who had sex with prostitute, was hobnobbing with
Lankawe politicians. He is scot free, passing numbers to politicians to contact when in Singapore. Why blame Doctors only. The whole country SUCKS.
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Ranjan / June 1, 2019
First of all where is the GMOA and his lackeys in this saga. They have been carrying placards protesting on things which really did not concern them or their members. Only for political reasons rather than medical reasons. while they are doing these nefarious trade union activities for political patronage, there members have been caught carrying out unethical sterilisations of women right under their noses. These blaggards should be kicked out from their profession and the
GMOA brought to account for their members and they should be exposed to the general public. Totally independent inquiry should be set up chaired by a distinctive judge or an ex Justice from the Supreme court. How come they did not follow the normal practice like in other countries in these matters. These allegations should be investigated and the truth found out.
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Nathan / June 2, 2019
When illiterate Buddhist clergy and street side morons and some crooked professionals make critical decisions then what else we can expect. It is Only here the morons fast for the removal of people elected by the people without any reason or justification except rumour, gossip and racism. What do these morons know. If so then why the parliament. All because we have stupid, crooked leaders misleading the country. There is emergency and why can’t they chase these fasting rascals. Racism too has its limit. This has become unimaginable. It is simply barbaric and primitive. There is a GMOA that wants ministers removed for nothing. Where are these bunch of trouble makers and why can’t they come out and talk about the plight of medical profession in SL. Let Gamarala to send out a circular that Sinhala patients Sinhala dostharays, dhemalu patients dhemalu dostharayas and Muslim patients Muslim dosthararays. When the country is burning these buggers are debating about what to wear, what design, even the circular may specify the colour and design of the panties. It is a good idea to have a separate ministry to check on underwears and whether there are any dhamma chakra or ganey deiyo printed on the panties. Do we have any direction at all. Is this a country. Circulars sent out then withdrawn. But one thing, the clergy fasting is good for the guys because all are fat and overfed and fasting is the only way to control their body and thinking ability. They have too much energy and too little to do.
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