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.
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.
My No. MAD 43/93
Office of the Director General of Health Services,
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.
Ministry of Health & Women’s Affairs
Cc. Provincial Directors of Health Services/Dep. Prov. Directors of Health Services.