What lies beneath
Resident doctors of JJ Hospital on an indefinite strike have been dealing with several major issues, including a lack of surgical hands-on experience, academic and research activities, everyday unpleasant and obscene language directed towards resident doctors, and much more, at Byculla, in Mumbai, India, on Thursday, June 01, 2023. (Photo by Bhushan Koyande/HT Photo) (HT PHOTO)
When a few weeks ago there was news that resident doctors from JJ Hospitals’s ophthalmology department had collectively complained against their current and ex head for harassment and lack of training it initially sounded like an intradepartmental fracas. But when this moved towards full-fledged strike action by all resident doctors, first from JJ and then across the state, it was obvious there was something much deeper taking place
Sanjay Nagral
June 01, 2023, Hindustan Times
Mumbai’s JJ Hospital and Grant Medical College manages to stay in the news. As one of India’s earliest medical colleges of modern medicine, it has plenty of history going for it. But it is also the setting for periodic newsy items. For example, when high profile prisoners are taken for medical examination and treatment. It is rumoured that the Dean of JJ has to spend a lot of time in Mantralaya. Whether this is true or not, as the flagship institution of the Maharashtra government, it is certainly a victim of political attention and meddling which sometimes bursts out into the open. Proximity to power is a double-edged sword.
Resident doctors of JJ Hospital on an indefinite strike have been dealing with several major issues, including a lack of surgical hands-on experience, academic and research activities, everyday unpleasant and obscene language directed towards resident doctors, and much more, at Byculla, in Mumbai, India, on Thursday, June 01, 2023. (Photo by Bhushan Koyande/HT Photo) (HT PHOTO)
When a few weeks ago there was news that resident doctors from its ophthalmology department had collectively complained against their current and ex head for harassment and lack of training it initially sounded like an intradepartmental fracas. But when this moved towards full-fledged strike action by all resident doctors, first from JJ and then across the state, it was obvious there was something much deeper taking place. Resident doctors in India typically strike for a better pay. But this a different demand. For the removal of a departmental head, who is politically connected, for abuse of power. Who was allegedly denying surgical training to residents for his own ambition of setting world records for the number of cataract procedures. The protest was also against his son who allegedly frequented operation theatres and performed surgery without being on the staff. In other words, the strike was against a style of functioning which was arbitrary, top down and denied training to trainees.
Resident doctors are simultaneously postgraduate students who work in hospitals both for training as well as a degree. The quid pro quo is work in return for training. Along with nurses, they are the main workforce. They are the lowest in the medical hierarchy. They stay on the campus and essentially run the minute-to-minute show. At night, they look after patients while the seniors are sleeping. Given the many shortages and fault lines of public healthcare, residents are often asked to perform tasks that are not really their job. Running from one department to another collecting reports is one such task. The workload often involves sleepless days and nights. Add to this the massive number of patients especially in public institutions. A large number of resident doctors have been victims of violence against health care workers in India. Because it is they who are often breaking bad news on the frontlines. All this has been romanticized and normalized as a rite of passage essential to good training.
The hierarchical ecosystem that pervades medical training can be intimidating. In a traditionally top-down approach, all work, especially hard labour is handed down to the juniormost trainee. Weapons of reprisal like the threat of being denied leave, not signing the mandatory thesis to being failed in exams are freely used to instil fear. This is facilitated by a feudal atmosphere, which in its everyday form involves juniors addressing a colleague one year older as ‘sir’ or ‘madam’. Even the British would be embarrassed. The outbursts like the current one in JJ are often an expression of long-standing pent-up repression.
The stir in JJ also foregrounds another challenging issue. That the postgraduates were not even allowed to perform simple cataract surgery unlike their counterparts in other hospitals. It’s true that a junior surgeon can only train by actually performing an operation. But how does one ensure safety of the patient? The obvious answer is that the senior guides the junior through the procedure. Currently this is done with a certain informality and lack of standardisation. In India, public hospitals allow surgical trainees to operate more. Uncomfortable as it may sound but, in a sense, the poor are used for training. They are unlikely to complain about a junior trainee operating on them. On the other hand in private hospitals, now increasingly involved in postgraduate training, there is less scope for ‘hands on’ training. After all these are private patients who are paying. If all this sounds gross and crude, that’s because it is.
Countries across the globe have recognised the challenge of resident training and working. Working hours for junior doctors were restricted long ago by national mandates. This was essentially a recognition of the fact that overworked junior doctors presented a threat to patient safety. Junior doctors now also can formally report their seniors and the quality of training to regulatory authorities. They are unionised and negotiate training and working conditions. Training programs have a component of feedback from trainees as a prerequisite for recognition. Supervision by seniors is mandated. Anonymous whistle-blower mechanisms have been established to promote reporting of inappropriate behaviour. Healthcare in India, otherwise quick to adopt global trends in technology, has ignored such changes.
As a resident doctor in Mumbai’s KEM Hospital in the late 1980s, I was in the leadership of the Maharashtra Association of Resident Doctors. We led struggles for better training, working and living conditions. We also intervened in many cases of harassment by seniors. I remember a sense of solidarity amongst our members, which transgressed many a social divide, and was also in some ways a coping mechanism. Much has changed since then. Careerism has reached a new high with everyone left to fend for themselves. With young trainees increasingly being away from their hometowns and families, the sense of isolation is strong.
The training and well-being of resident doctors actually impacts the quality of doctors that a country’s citizens will face. Like many other issues in healthcare it’s hence a matter of public concern. The next time you are in a hospital with an emergency, it is a resident doctor who is likely to be the first to see you and decide your fate. And if we are hit once again by a pandemic like Covid it is resident doctors who will be donning PPEs and risking their lives. Since they have not been coopted by the system, they often reveal the truth.