The Foundation Programme1,2,3 is a 2-year, ubiquitous, vocational curriculum undertaken by newly qualified doctors wishing to proceed onto speciality training in the United Kingdom (UK). Since 2006, Foundation Year Trainees in the UK have been required to complete one clinical audit during their two year programme. We review the practice of audit and doctors’ attitudes to the difficulty in performing audits at a National Health Service (NHS) hospital trust comprising three hospital sites in the South East of England. The Foundation Programme demands that Foundation Year Trainees are able to consider the relevance of clinical audit and describe the audit cycle with regard to developing patient care, clinical governance and risk management. They are expected to undertake a clinical audit and recognize how it relates to the improving clinical standards and addressing clinical governance1. Clinical audit can be defined as the processof reviewing the delivery of care to identify deficiencies sothat they may be remedied4. Whilst it was initially used in assessing medicalpractice against local standards, audit ‘has evolved conceptuallyas a mechanism through which evidence-based guidelines can beintroduced into routine clinical practice’5. Apart from fulfilling the requirements of the syllabus, reasons for audit include professional education and the opportunity to improve patient care6. Barriers to audit might include: disagreement amongst professionals as to what constitutes a good audit5;organisational impediments; and a lack of resouces6. This study therefore sets out to investigate the level of audit activity in a hospital trust in South East England amongst all Foundation Year Trainees. Importantly it will also assess doctors’ attitudes and views towards the audit process and perceived or actual barriers to their completion. METHOD Questionnaires were sent to all Foundation Year 1 (F1s = 63 in total) and Foundation Year 2 (F2s = 56 in total) Trainees in the trust (119 doctors). The study group involved trainees in the Foundation Programme from 31st July 2007 to 30th July 2008. Doctors who had been transferred out of the trust were not included in the study. There were no doctors who had transferred into the trust and were in the Foundation Programme. A study representative at each of the 3 hospital sites was tasked to distribute the questionnaires. Trainees were asked to complete the questionnaires in an informal setting and to return them directly to the site representative. The study environment was variable, and questionnaires were distributed and completed on the wards or at group teaching sessions. Participants were given the choice of completing and submitting their form immediately, or submitting it at a later date. Data collection was commenced 11 months after the trainees had commenced employment in the trust and concluded after 2 weeks. This was invoked as many trainees were clearing annual-leave requirements towards the end of their hospital posting, and the consensus that very few audits would be officially completed at that stage of training in the summer. Questions were drawn from previous studies to the barriers to audit in our Trust. In the first section of the questionnaire, participants were asked about: “the number of all audits attempted or applied for”; “the number of new audits attempted or applied for”; “the number of audits completed and presented so far”; and “the number of audits started but never completed”. The second part of the questionnaire assessed subjective opinions on barriers to completing audits. Participants were asked to rate the following 5 statements on a comparative scale of 1-5 (1 being “strongly disagree” and 5 being “strongly agree”): “The audit department is helpful in approving audits”; “senior staff are helpful in involving me in audits”; “I can complete audits within official working hours”; “most audit opportunities are in my area of interest”; “most audit opportunities are of clinical value”. Results were collated and tabulated and presented at local meetings where feedback was received. RESULTS Ninety-two out of a possible 119 (77.3%) Foundation Year Trainees completed the questionnaire (57/63 - F1s, 35/56 - F2s). There were 106 total attempts at audit for the F1 trainees and 65 total attempts for the F2s. Most trainees had attempted 1 or 2 audits in their respective year (42 F1s at 73.7% and 23 F2s at 65.7%). 5 F1s (8.8%) and 3 F2s (8.6%) had neither attempted nor applied for any audits. Ten F1s (17.5%) and 9 F2s (25.7%) had attempted more than 2 audits (Table 1). Table 1: Number of audits attempted by trainees
Number of all audits applied for or attempted
F1s
F2s
Number
Percentage (%)
Number
Percentage (%)
0
5
8.8
3
8.6
1
21
36.8
17
48.6
2
21
36.8
6
17.1
3
3
5.3
3
8.6
4
2
3.5
5
14.3
5
4
7.0
0
0
6
1
1.8
0
0
7
0
0
1
2.8
Total
57
100
35
100
The results for the total number of completed audits (i.e. an audit that included data collection, analysis and formal presentation to the respective department) are summarized in Table 2. For F1s, 32 out of a total 106 attempted audits were completed (30.2%), this percentage rising for F2s (38/65; 58.5%). Thirty-three (57.9%) F1s and 10 F2s (28.6%) failed to complete any audit, with a number able to complete one audit presentation in the year: 18 F1s (31.6%) and 16 F2s (45.7%). Table 2: Number of audits completed by trainees
Number of completed audits
F1s
F2s
Number
Percentage (%)
Number
Percentage (%)
0
33
57. 9
10
28.6
1
18
31.6
16
45.7
2
5
8.8
6
17.1
3
0
0
2
5.7
4
1
1.7
1
2.9
Total
57
100
35
100
With respect to new and original audits attempted by trainees, this was achieved by 66.7% of F1s and 74.3% of F2s (Table 3). There was no formal data on the number of audit loops being closed. Table 3: Number of new audits designed by trainees
Number of new audits attempted or applied for
F1s
F2
Number
Percentage (%)
Number
Percentage (%)
0
19
33.3
9
25.7
1
25
43.9
19
54.3
2
9
15.8
3
8.6
3
1
1.75
2
5.7
4
1
1.75
2
5.7
5
2
3.5
0
0
Total
57
100
35
100
With regard to barriers to completion of audits (Table 4), results were notably equivocal for “helpfulness of the audit department and senior staff” (both averaging 3.1 on the comparative scale of 1-5), and “the clinical value of the audits available” (mean score 3.2). The mean score for “completing audits within official hours” was 2.1 with a similar trend observed in “the audits available in an area of interest” (mean score 2.6). Table 4: Trainees’ experiences with audit
Statement
Score¶
Total responses
1
2
3
4
5
Audit department is helpful
Percentage %
9.1
12.5
44.3
22.7
11.4
100
Numbers
8
11
39
20
10
88
Mean score
0.1
0.3
1.3
0.9
0.6
3.1
Senior staff are helpful
Percentage %
15.4
20.9
23.1
22.0
18.7
100
Numbers
14
19
21
20
17
91
Mean score
0.2
0.4
0.7
0.9
0.9
3.1
Audit completed in working hours
Percentage %
46.2
22.0
16.5
8.8
6.6
100
Numbers
42
20
15
8
6
91
Mean score
0.5
0.4
0.5
0.4
0.3
2.1
Audits in the area of interest
Percentage %
18.7
30.8
25.3
17.6
7.7
100
Numbers
17
28
23
16
7
91
Mean score
0.2
0.6
0.8
0.7
0.4
2.7
Audits have clinical value
Percentage %
7.7
18.7
30.8
34.1
8.8
100
Numbers
7
17
28
31
8
91
Mean score
0.1
0.4
0.9
1.4
0.4
3.2
¶Key: 1= strongly disagree; 2=disagree; 3 = equivocal; 4 = agree; 5 = strongly agreeNB: Some forms were incomplete, and therefore responses may not add up to 92. CONCLUSIONS Although audit is well established to be beneficial in improving clinical practice7, this study suggests that trainees under-perform against the curriculum of the Foundation Programme. Historically, the level of audit activity amongst doctors has been low; for example, McCarthy (1997) demonstrated that whilst doctors see the conceptual value of audit, approximately one-third only had presented their data at a pertinent audit meeting8. These results have been replicated in numerous other studies9,10,11. We believe that this data-set is the first available for junior trainees who have undertaken the Foundation Programme curriculum, with a good response rate of 77.3%, and incorporates the contractual pressures invoked by a European Working Time Directive (EWTD)-compliant Rota12,13. While the results show that the majority of respondents (>90%) had attempted an audit, most significantly the majority of audits that were started were not completed. A large percentage of F1s (57.9%) and F2s (28.6%) failed to complete an audit at all. Similar numbers have been reported, even among senior pediatric trainees at registrar level, where one study demonstrated that whilst audit activity was above 90%, only 16% had completed the audit cycle14. One possible explanation is that many trainees appear to have a sub-optimal comprehension about audit and its process. Our consensus was that some trainees attempted audits that were too large or unmanageable, or even of insufficient quality, in striving to achieve a peer publication from their work. When realized that the publication value is poor, or that the audit design is flawed, many trainees lose interest and fail to complete. Another concept highlighted by this study is confusion over the definition of a “completed audit”. For consideration of completion of an audit, a trainee has to demonstrate both the ability to collect the data and present it to among his peers in a formal meeting. This generally amounts to completion of 5 out of the 6 stages of the audit loop15. Surgical morbidity and mortality presentations had been considered audit by some trainees, as they were termed by the trust as a “surgical audit”. However, the overall clinical consensus is that they are not audit but formative educational meetings because no systemic local or national standards were employed for comparison. This poor understanding of audit has been well described previously16. Potential barriers to the completion of audit include some of the issues raised in this study. In this sample, doctors were equivocal about whether the barrier was the audit department or lack of senior support. This reflected the variability of experience as well as the lack of teaching of the purpose and methods of audit in the undergraduate curriculum. They were also equivocal about the clinical value of audits they had completed. By comparison, a study in Leeds showed that less than half of the 232 respondents were aware of subsequent change in clinical practice and 27% felt it was “a waste of time”7. However this study did not focus on the junior doctor in the beginnings of their postgraduate training. Trainees felt that an additional barrier to audit completion included difficulty in completing audits within their working hours. All Foundation Year Trainees in the trust were working to a EWTD-compliant Rota during the year, where trainees did not exceed 48 hours a week of on-site hospital clinical duties. Trainees also found it difficult to undertake audits in their area of clinical interest. Although part of the reason is circumstantial - the Foundation Year Programme mandates that trainees rotate around various core specialties - this may also reflect a lack of understanding of what the audit cycle actually incorporates, and how it is not formal research in itself15. Approval of audit studies was also thought to be problematic because such meetings only took place monthly with a pre-determined agenda, and consequently, this meant that approval might take several months to obtain for trainees who would actually be based in the trust for no more than 12 months in 3 different specialty departments. There were a number of limitations of the study, one being the small sample size. Secondly, in asking trainees to rate each of the six statements from 1 to 5, trainees who did not complete audits tended to score 3 (neither agree or disagree), and as the results above show, they represented a considerable proportion. A larger sample size and a semantic differential scale (rating responses between 1 and 7) might have been more discerning. The fact that some trainees may have included “audits” which on reflection did not meet the criteria for inclusion was not only interesting but may also have distorted results. Finally, audits that involved joint effort among trainees, but were presented only by one of them in the absence of the others were still regarded by some trainees to be “completed and presented” by all of them. This study has highlighted a number of issues which need to be addressed for clinical audits to be successfully completed during the Foundation Programme. The authors believe that poor completion rates are most probably the result of poor understanding of audit. Potential solutions include teaching medical students concepts of audit; giving structured teaching early in the Foundation Programme; instituting regular audit meetings; incorporating audit as part of contracted working hours; defining audit more clearly among trainees and clinical staff and encouraging more cooperation and integrative liaison with the audit department to process audit proposals quickly and efficiently. Additionally, doctors’ contractual pay-bandings should reflect any out-of-hours work undertaken on audits that improve clinical governance for their Trusts. However, in spite of all these considerations, we speculate that because trainees are only in each post for no more than 4 months during their foundation years, and with the restriction of working hours, the expectation of foundation year trainees to have undertaken and properly understood an audit cycle, implemented change and closed the audit loop is unrealistic. It would be more helpful to the trusts and trainees for audits to be part of the specialty training programme onwards, where trainees stay in a department for a longer time even as they move from one team to another. Further studies might consider in detail the difficulties in each step of the audit cycle15 and explore: Foundation Trainees’ use of the audit department; guidance from senior members of staff; and perceived benefits in clinical practice. Ultimately, audits must implement change17 and all truly successful clinical audits should aid in some way to achieving our fundamental goal in medicine; that being the best clinical practice and best quality of care.
Good Medical Practice describes the professional behaviour expected of doctors and advocates that it should be taught as well as assessed. GMC’s Good Medical Practice specifies the standards of team working, communication skills, accessibility and trustworthiness in relation to professional behaviour1. Ramsden2 stated that: “the students will learn what they think they will be assessed on, not what is in the curriculum, or even on what has been 'covered in class'.” Hence, if the intended learning objectives are to improve professional behaviour and team working in a trainee doctor, then a tool that assesses these characteristics along with providing suggestions for improvement is critical. Multisource Feedback (MSF) is a formative assessment tool that was designed to assess professional behaviour and attitudes, with the aim of continually improving an individual’s team working. Team Assessment of Behaviour (TAB) is an assessment tool for MSF (Appendix 1), and is one of the 2 assessment tools used to assess professional behaviour of foundation doctors in training in the UK, the other being the Mini-Peer Assessment Tool (mini-PAT)3. Our aims for this article were to evaluate whether the format of TAB allowed the MSF process to occur as originally intended, along with looking at possible barriers that may have to be overcome to make it an effective tool. A literature review was carried to appraise the present evidence regarding TAB as an assessment tool and only studies which had relevance to MSF/TAB were included in the study. As TAB is a relatively new tool, there were very few papers’ exploring this is depth which was a major limitation. Hence in the barriers section, we have discussed the possible obstacles to the whole MSF process rather than just TAB. Background The concept of MSF was originally developed by industrial organisations and has been used in postgraduate medicine in USA for assessment of professional behaviour since the 1990’s4,5. Ramsey6 suggested that it is feasible to obtain assessments from professional associates of practicing physicians in areas such as clinical skills, humanistic qualities, and communication skills. TAB was developed by educationalists and senior doctors at the West Midlands deanery7,8,and has undergone extensive field testing among 171 trainees, with analysis of received feedback from 1378 assessments across four different hospitals in the West Midlands. It is currently being used in the West Midlands Deanery for the multisource feedback of foundation programme trainees. Process of TAB The primary aim of TAB as an assessment tool is to identify trainees whose professional behaviour does not meet GMC requirements for good medical practice, so that appropriate action may be taken and also to compliment those trainees who receive good reports. For TAB, up to 10-15 multi-disciplinary colleagues of a doctor assess his/her workplace behaviour. It assesses four domains of professional behaviour: professional relationship with patients, verbal communications, team-working and accessibility. It is the initiative of the trainee to distribute at least 15 TAB forms to peers of their own choice and a minimum of 10 completed forms are required to be returned. The raters should include at least three other doctors including a consultant supervisor and at least five allied healthcare professionals. It’s the responsibility of the educational supervisor to collate and summarise these forms, identifying perceived weaknesses, offering them feedback and directed learning objectives to address any issues. Critique of TAB:1. Validity and reliability of TAB:Validity is a demonstration that a particular instrument can in fact measure what it purports to measure9. TAB portrays face as well as content validity as it assesses areas identified by the GMC1 for good professional behaviour. It is shown to be capable of identifying problem behaviour in trainees, which was the primary aim of the tool7. This tool appears to have good construct validity as it is testing trainee’s behaviour in real life situations. It is difficult to define the predictive validity of any tool, more so in a formative assessment tool. The developers of TAB have not tested for concurrent validity. The concurrent validity for TAB could have been tested by using another MSF tool in addition to TAB for some participants during the field-testing for reliability and validity of the tool. A reliable instrument for a piece of research will yield similar data from similar respondents over a period of time9. Whitehouse7 demonstrated in the pilot study that TAB had intra-observer reliability and inter-observer variability. For inter-observer variability, the Royal College of Psychiatrists compiled a map of assessment programmes against good medical practice domains and considered it appropriate for assessing four domains: good clinical care, working with colleagues, probity, and health11. 2. RatersRamsey et al5 concluded that, with MSF, 10-11 responses per physician were necessary to achieve a generalisablity coefficient of 0.70. Wood et al11 concluded that eight raters were sufficient for a representative score in their study on Obstetrics & Gynaecology trainees in the UK. Obviously more raters would lead to better coefficient and more generalisable results. TAB presently advocates at least ten raters to achieve reliable results.3. Feasibility TAB has four domains and a three point rating scale which are relatively easy to understand and complete. There is no training required for raters and usually takes less than five minutes per assessment per assessor. The paper-based system demanded considerable administrative resources, and therefore a web-based TAB assessment form was successfully piloted in the West Midlands8.4. Trainer & trainee’s evaluation of the processThe evaluation of TAB as an assessment tool was done by Whitehouse et al8 as a part of their field assessment of TAB. The assessors and trainers found the process practical, valuable and fair. 76% of the trainees who responded to the questionnaire felt that it was a useful addition to the assessment of the SHO’s. The educational supervisors had mixed views, with 77% of them finding out nothing new about the trainees. 5. Scoring systemInstead of a Likert scale, the TAB employs broad boxes which offer the rater a choice of giving specific feedback under each domain. This is more helpful to a summariser/assessor than mini-PAT, where a scoring scale is not substantiated by relevant feedback. This assessment tool does not assess clinical performance and one could argue that there could have been more than four domains in order to include other areas of performance, such as clinical skills. However having just four domains can reduce the impact of the halo effect. The halo effect12 can be defined as a rater making an overall judgement of the trainee and scoring the whole form accordingly rather than considering each domain separately. This could be a potential advantage of TAB over mini-PAT where there is no opportunity to provide specific feedback in individual domains, but rather utilises an overall action plan, which may lead to concentrating single element deficiencies while masking other shortcomings. 6. Patient OutcomesThe MSF process in itself doesn’t bear direct consequences on patients’ management, but can help the doctor improve his professionalism, which is critical element of good medical practice1. An improvement in a doctor’s behaviour secondary to the appraisal-feedback process can indirectly improve and contribute to patient management and satisfaction. Potential barriers: 1.Choice of rater:The trainee has the choice of raters, except for the supervising consultant, who must be involved in the process. This is a potential area of difficulty, as the trainee might pick individuals who are more sympathetic to their cause, or who cannot comment much on their interpersonal behaviour, thus leading to skewed results. Kuzmits13 showed that both rater and those being rated needed to be trained to make the rating and feedback process more effective, but this is not felt necessary for TAB. There is also a potential conflict between being a trainer and assessor, and this conflict might lead to clouding of judgement14, which can be addressed by having different assessors and trainers, but considering the service pressures in the NHS, this may not always be possible. 2. Feedback:The value of the MSF process can be limited by the quality of feedback provided to the trainee at the end of the process and depends on the relationship of the trainee and the supervisor15. Evidence shows that non-specific feedback does little to change performance16. Whitehouse8 concluded in their initial study that TAB was able to produce descriptive feedback that was more specific and helpful than existing MSF tools. Assessors completing TAB may not give specific comments or feedback although they are instructed to give some details especially if they chose the rating of “some concern” or “major concern”. Bret and Atwater17 have shown that negative feedback can discourage individuals, and they can even react in anger. Feedback about performance must be descriptive and specific if it is to be helpful to trainees18. Hence it is the responsibility of the supervisor to give feedback which is relevant and helpful, along with creating an action plan with the trainee to address any perceived deficiencies. It must also be stressed that good performers need to be complimented, and encouraged to continue to do so. 3. Training the raters and the supervisor:The raters also need to be educated in the process otherwise they may not give reliable views about the trainee13,19. From the rater’s point of view, it would be beneficial if they were to give specific comment, in order that more relevant feedback can be provided. Most importantly, the educational supervisors who provide the feedback to the trainee can make a difference in constructing agreed learning objectives, and not demoralise the trainee with negative feedback. Kaplan20 also noted that negative feedback can demotivate individuals. Giving face to face negative feedback can be a daunting task and supervisors, if not trained in giving negative feedback may dislike doing it, and so not give properly constructed feedback. The provision of training, however, has time as well as cost implications. Conclusions TAB continues to be part of the national foundation programme curriculum and, used correctly, can serve its purposes both as a screening tool and also for the trainees to use the feedback provided to improve their interpersonal behaviour when needed. Evaluation and quality assurance of this assessment tool should be an ongoing process. More field work in relation to assessment of behaviour in relation to TAB is needed. Patient feedback could be included in TAB which can make it a more reliable tool for assessing a doctor’s behaviour.Further qualitative studies to explore the views and experiences of trainees can help to understand the barriers and attempt to improve the usefulness of the process for the trainees. There are several potential barriers which can subvert the process of MSF by using TAB, and these need to be addressed to make the assessment process more effective and efficient. KEY POINTS
MSF is designed to assess professional behaviour and attitudes
TAB along with Mini-PAT and other tools map MSF principles
The supervisor assumes a key role in giving constructive feedback without demotivating the trainee
Relevant training while giving feedback is critical to the success of MSF
Patient’s involvement in the MSF process could make it more robust.
The huge disease burden and vast health inequalities and given that one in six person in the world is an Indian on the one hand, and the country’s recent economic rise and its intellectual capital in-country and also overseas on the other hand, has created the Indian conundrum for global health challenges. India is now both: the problem – as it contributes to the challenges, and the solution – if it can mobilise its resources. This short paper will expand on the theme and especially explore how the Indian Diaspora in the UK can help to ensure good health and affordable health care to the needy.
The problem: Global health challenges
The World Health Organisation (WHO) has established the ten facts on the global disease burden (Table) (1) and its 2008 report: Primary Care: Now More than Ever (2) has identified the five global challenges in ensuring health care (Box).
TABLE : FACTS ON THE GLOBAL BURDEN OF DISEASE (Source: www.who.int)
1. Around 10 million children under the age of one year die each year
2. Cardiovascular diseases are the leading cause of death worldwide
3. HIV/AIDS is the leading cause of adult deaths in Africa
4. Population ageing is contributing to rise in cancer and heart disease
5. Lung cancer is most common cause of deaths from cancer in the world
6. Complications of pregnancy account for 15% of deaths in women of reproductive age worldwide
7. Mental disorders such as depression are among the leading causes of disability worldwide
8. Hearing loss, vision problems and mental disorders are the most common causes of disability worldwide
9. Road traffic injuries are projected to rise from the ninth leading cause of death worldwide in 2004 to fifth in 2030
10. Under-nutrition is the underlying cause of death for at least 30% of children under five years of age
BOX: FIVE COMMON SHORTCOMINGS OF HEALTH-CARE DELIVERY (Source: WHO Report 2008)
1. Inverse care. People with the most means – whose needs for health care are often less – consume the most care, whereas those with the least means and greatest health problems consume the least. Public spending on health services most often benefits the rich more than the poor in high- and low income countries alike.
2. Impoverishing care. Wherever people lack social protection and payment for care is largely out-of-pocket at the point of service, they can be confronted with catastrophic expenses.Over 100 million people annually fall into poverty because they have to pay for health care.
3. Fragmented and fragmenting care. The excessive specialization of health-care providers and the narrow focus of many disease control programmes discourage a holistic approach to the individuals and the families they deal with and do not appreciate the need for continuity in care. Health services for poor and marginalized groups are often highly fragmented and severely under-resourced, while development aid often adds to the fragmentation.
4. Unsafe care. Poor system design that is unable to ensure safety and hygiene standards leads to high rates of hospital-acquired infections, along with medication errors and other avoidable adverse effects that are an underestimated cause of death and ill-health.
5. Misdirected care. Resource allocation clusters around curative services at great cost, neglecting the potential of primary prevention and health promotion to prevent up to 70% of the disease burden. At the same time, the health sector lacks the expertise to mitigate the adverse effects on health from other sectors and make the most of what these other sectors can contribute to health.
As would be expected the situation in India confirms these facts and challenges. There is a lot of health information for India in the public domain (1,3) although the nature and detail could be improved. Like in many other developing countries the life expectancy has increased and although improved health has led to further economic welfare in India, the country is currently experiencing the triple whammy of the disease burden due to communicable (CD) and non-communicable (NCD) diseases and injuries. Communicable diseases account for about 38% of the disease burden – not only are the ‘traditional’ CDs like malaria rife, the country has seen a big increase in new infections like HIV/AIDS. NCDs including diabetes, heart disease and cancers account for 53% percent of all deaths in the age group 30-59 years in 2005. It is projected that by 2015, 59% of the total deaths in India would be due to NCDs. With 47% of men and 15% of women being regular consumers, tobacco remains the single biggest preventable risk factor. Whilst the developed world is seeing a reduction in deaths due to road traffic accidents, these injuries are projects to rise by nearly 150% in SE Asia region including India. This health picture is compounded by the lower human development, largely due to poverty – a situation that has not been addressed despite recent economic successes, as bemoaned by Amartya Sen (4):
“Yet even a hundred Bangalores and Hyderabads will not on their own solve India’s tenacious poverty and deep seated inequality. The very poor in India get a small- and basically indirect- share of the cake that information technology and related developments generate. The removal of poverty, particularly of existing poverty, calls for more participatory growth on a wide basis, which is not easy to achieve across the barriers of illiteracy, ill-health, uncompleted land reforms and other sources of severe societal inequality. The process of economic advancement cannot be divorced from the cultivation and enhancement of social opportunities over a broad front. “
India’s health sector is diverse and includes not just modern medicine but also a range of traditional systems like Homeopathy, Ayurveda and Unani. The overall governmental expenditure on health has been rather low (0.9% of GDP, whilst the total expenditure is about 5%), with 75% of it being borne by patients and, over 90% of the latter being out of pocket due to a lack of organized insurance. Being sick has meant being bankrupt for a substantial number of rural poor Indians. There is a burgeoning private sector that is driving the specialist end of the provision, with rather poor and often outdated primary care services. The cost of health care keeps going up with little or no assurance that services are appropriate or safe, and the regulatory mechanisms are few. The bottom line in India is that good health happens by chance and good quality health care is a privilege and not a right.
The solution: Add value to planned developments in India
Although it may not seem like it, there is a comprehensive plan to develop national health policy and address some of the fundamental challenges, the following are some of the highlights stated by the Government (1,5):
1. “Commitment of the Government to increase public health share to at least 2% of GDP
2. Efforts to develop regulatory frameworks and options for alternative financing mechanisms including insurance
3. National Rural Health Mission and Reproductive & Child Health Programme. Integrated Management of Newborn and Childhood Illnesses (IMNCI) pre-service and home-based newborn care activities initiated. Multi-skilling of health providers for Emergency Medical Obstetric Care. Introduction of Accredited Social Health Activists (ASHAs). Increased attention to women’s health in national Schemes
4.Increased commitment to health system strengthening, use of capacities in other sectors, and effective partnerships. Enhanced nursing profile and increasing nursing autonomy in practice.
5.Public health education, job descriptions and career paths under review; expanding efforts for multi-disciplinary and multi-sectoral approaches; establishment of the Public Health Foundation.
6.Ongoing capacity building to deal with international agreements and strengthening of the World Trade Organization (WTO) cell in the Union Ministry of Health.
7.Increased commitment and investments, and significant progress in the control and/or elimination of communicable diseases like yaws, leprosy, tuberculosis and several vaccine preventable diseases.”
Overall, there is action at all levels: national, state, institutional and individual and across the range of necessary issues: policy, regulation, resourcing, provision and capacity building by both, public and private sectors. The two key questions for the Indian Diaspora, however, are:
Can we help accelerate these developments?
How can we ensure that these become sustainable?
There is no denying that many individuals from the UK have been, and continue to be, involved in various efforts back in India; be it fundraising, community development, school education or direct clinical provision. In addition, there are various organisations like BIDA, IMA and BAPIO who have potentially the infrastructure albeit their focus has largely been on activities within the UK. The UK Government has recognised its responsibility in supporting international efforts as part of the recent Health is Global Strategy (6), and this provides another timely opportunity. From both, philanthropic and business angles, it makes sense to create a robust Indo: UK collaboration around health and education given common heritage and needs and opportunities on both sides. In addition to working on discrete areas like patient safety (7) or public health capacity building (8) an important first step would be to create a mechanism for regular dialogue in order to identify and progress priority projects of mutual interest.
Conclusions
India has come a long way since its independence and given its size and complexity continues to have ongoing challenges (9, 10,11). It is essential to recognise that health is not a consumptive sector, but by creating healthy people, free from illnesses, can be a productive sector. The basic message of this paper is that being a physician in India in the 21st century is both, a privilege – given the ancient history and traditions and recent economic successes, and a responsibility- given that despite being the world’s largest democracy and an economic superpower there are vast health inequalities and lack of safe, affordable basic health care to a large proportion of the citizens in India.
At the time of writing this paper, there is intense debate about the NHS in the American press triggered by President Obama’s attempts to reform US health care. No doubt whilst things could be better in the NHS, there is still a lot that the world, both developed and developing nations, can learn from the NHS (12, 13) . Indeed best practices, regardless of whether they come from US, UK or anywhere else could, and should, be adapted to support ongoing efforts in India.
Introduction.
This legislation is based on rules established by case law about how to work with people who lack capacity (either on a temporary or permanent basis).
The Act provides a definition of capacity, a functional test for capacity (see Box 1) and a checklist for Best Interest decision making which are under pinned by five key principles (See box 2). The Act is supported by a Code of Practice.
The Act, which applies to all adults aged 16 years or over (with some exceptions), provides a clear definition of incapacity, and for deciding if a person lacks capacity in respect of a particular matter.
“A person lacks capacity in relation to a decision or proposed intervention if, at the material time, he is unable to make a decision for himself in relation to the matter or proposed intervention because of an impairment of, or a disturbance in the functioning of the mind or brain. It does not matter whether the impairment or disturbance is permanent or temporary.” (S2 (1) and (2) MCA 2005.
Box 1. Testing Capacity
The responsibility for testing capacity rests with the person who wishes to make a decision on behalf of someone who lacks capacity.
The functional test of capacity:
Does the person have an impairment or disturbance in the functioning of his mind or brain?
Does the impairment or disturbance make the person unable to
A person is unable to take a decision for himself/herself if he/she is unable to:
Understand the information relevant to that decision;
Retain that information long enough to reach a decision;
Use or weigh that information as part of the process of making the decision; or
Communicate his decision (whether by talking, using sign language, visual aids or any other means).
Box 2. Principles (based on section 1 MCA 2005)
Best interests always.
Less restrictive care provision option.
Encourage individual to make own decisions.
Eccentric decisions are OK.
Presume capacity always.
It is important to note that the decision is always ‘time specific’ and ‘issue specific’. It is also a test applied both to people with temporary or fluctuating capacity (such as people experiencing mental ill-health) and those whose decision making ability is permanently impaired (such as people with a learning disability)
The Act starts from the presumption that those we work with do have capacity, and requires staff to involve them as much as possible in their own treatment and care including when there is evidence that they lack capacity in a particular matter.
The Act also introduces a statutory right to advocacy for those lacking capacity and “unbefriended” through the Independent Mental Capacity Advocacy Service (IMCA), Lasting Powers of Attorney for health and welfare and property and finance and two new criminal offences, i.e. “the wilful neglect or ill treatment of a person lacking capacity” (S 44 MCA 2005.)
The MCA will also apply when someone is detained under the Mental Health Act 1983. For example if the person lacks capacity to consent to treatment for a physical health issue rather than treatment related to mental disorder.
The Act has introduced safeguards for medical practitioners when working with advanced decisions made by people in advance for how they wish to be treated when or if they lose capacity in the future.
Best Interests Check List.
The best interests checklist represents the issues that decision makers must consider when decisions or interventions are made on behalf of someone who lacks capacity, if the decisions (and the decision maker) are to be protected by the MCA
The checklist items include that the decision maker:-
· Must not make their judgement based merely on the person’s age, appearance, condition (or diagnosis);
· Must take into account whether the person is likely to regain capacity with regard to the decision in hand, and whether the decision can wait;
· Must as far as reasonably practicable, ‘permit and encourage’ the person to communicate, including by acting to improve his or her ability to communicate (for example, by using an advocate);
· Must not, where the decision relates to life sustaining treatment, be motivated by a desire to bring about the relevant person’s death;
· Must so far as is possible consider the person’s past wishes and any preferences (particularly when written down) stated by him or her when they had capacity;
· Must take account of the beliefs and values that would have been likely to influence the person’s decision had they had capacity;
· Must, if practical and appropriate, consult anyone previously named by the patient as someone who should be consulted, any carers, anyone who has a relevant lasting power of attorney – a ‘donee’ (remembering that there are two kinds of LPA – (i) personal welfare, and (ii) property and affairs), and any appointed court deputy about their views concerning what would be in the person’s best interests. Protection from liability offered by Section 5 of the Mental Capacity Act
The MCA provides legal protection for people who need to intervene in the lives of people who lack capacity so that they are able to make a decision on that person’s behalf, or provide the care the person needs, as long as they have a reasonable belief that the person lacks capacity to make the particular decision and they are working in the person’s best interests.
Generally, however, protection is available as long as:-
· Reasonable steps have been taken to gain permission from the person concerned;
· The decision maker is reasonably sure the person lacks the capacity to make a particular decision;
· The decision maker is working in their best interests, and before making the intervention you have considered whether there is a “less restrictive’ option than the one proposed, and only ruled it out because it is less effective than the one you are now taking;
· Restraint if needed, is a proportionate response to the risk of harm if no action is taken;
· The action doesn’t amount to a deprivation of liberty, or conflict with an advance decision made by the person, their LPA or a Deputy;
· The decision maker is spending money to buy goods or pay for services that are in the person’s best interests and appropriate authority has been sought.
In a medical context, this could be helpful on a day-to-day basis, or to deal with an emergency situation where the Mental Health Act does not apply as illustrated in the example, taken form the Code of Practice, in box 3 below.
Box 3.
Example:You are called for advice by a local GP. She is with a patient in her home and the ambulance service is in attendance. The patient is dehydrated, and has a suspected UTI (urinary tract infection). The patient has become angry and belligerent at the idea that she needs admission to hospital and is refusing to go. She says that the doctor is in league with her neighbours and they intend to defraud her of her savings the moment she is out of the house. The ambulance staff refuse to intervene because they say it would contravene the woman’s human rights. The GP is considering asking for a Mental Health Act assessment. She says that, because of the advanced age and presentation of the patient, it is too risky to leave her at home. She confirms that she feels the woman lacks the capacity to take the decision about whether or not hospital admission is necessary because of the acute confusional state brought on by the dehydration and UTI.
You are able to advise the GP and the ambulance staff that, in this situation, the Mental Health Act may not be needed as their intervention would be covered by the Mental Capacity Act. The ambulance staff will be covered by sections 5 and 6 of the MCA, as long as their use of force in taking the woman to A&E is proportionate to the risks that staying at home poses to her. They need to be convinced themselves (as the professionals undertaking the act) that the actions would be in her ‘best interests’. The ambulance staff return to talk to the woman, and coax her to sit on their ‘lifting chair’. They are then able to wrap her securely in a blanket, with straps around her, so that they are able to carry her safely to the waiting ambulance despite her vocal protests.
Limitations to Section 5 by Section 6 Mental Capacity Act 2005.
It is important to recognise that section 5 of the Act does not offer practitioners total freedom from liability in providing care or treatment.
· Life-changing events: decisions about life-changing events, such as changes in residence and serious medical treatment will only be covered under Section 5 if the decision makers firstly consult all appropriate parties, and secondly consider whether there is a less restrictive way in which the care needed can be given. If there are no families or friends that professionals can consult in these specific circumstances, or if the decision maker deems the family member or friends “inappropriate", an Independent Mental Capacity Advocate (IMCA) must be instructed to support and represent the person whilst their best interests are being determined.
· The use of force, and depriving people of their Liberty: doctors and other professionals will continue to be protected by the law where, in an urgent situation, it is necessary to restrain or restrict a person who lacks capacity in order to protect them from harm. The force used must be proportionate to the risks involved. However, this protection has a ‘time limit’. Where restraint is needed on an ongoing basis (and restraint can mean the use of medication, or making a decision or making it known to a patient that they would be prevented from leaving) professionals involved won’t necessarily be protected by the MCA – this is where the Deprivation of Liberty Safeguards become important. Safeguards for patients: making decisions in advance Advance decisions to refuse medical treatment
People can now make advanced decisions to refuse treatment, provided that the decisions were made when the person had the capacity to make them.
To make a valid advance decision, a person must:
· Be 18 years or older
· Have capacity to make the specific decision
· Make a decision that is applicable (i.e. specific to the care and treatment they want to refuse and the circumstances in which it will be refused )
The decision doesn’t need to be in writing, unless it relates to life sustaining treatment – in which case it must be in writing, and witnessed.
An advanced decision becomes valid and applicable when all of the conditions described within it are present.
If Doctors are not informed about the existence of an advanced decision then they are expected to treat someone with that person’s bet interests in mind.
Lasting Powers of Attorney and Deputies from the Court of Protection
The MCA allows people to make arrangements for others to make decisions on their behalf when or if they lack capacity.
Lasting Powers of Attorney (LPAs) – The Act allows a person to appoint an attorney to act on their behalf if they should lose capacity in the future. The Act also allows people to empower an attorney to make health and welfare decisions, as well as financial & property decisions (a LPA for finance and property can be used whilst a person still has capacity, if the donee gives specific instruction). Before it can be used a LPA must be registered with the Office of the Public Guardian (see below).
Court appointed deputies – The Act provides for a system of court appointed deputies to replace the previous system of receivership in the “old” Court of Protection. Deputies will be able to be appointed to take decisions on welfare, healthcare and financial matters as authorised by the new Court of Protection (see below) but will not be able to refuse consent to life-sustaining treatment. They will only be appointed if the Court cannot make a one-off decision to resolve the issues.
A Court of Protection – The new Court has jurisdiction relating to the whole Act. It has its own procedures and nominated judges. It is able to make declarations, decisions and orders affecting people who lack capacity and make decisions for (or appoint deputies to make decisions on behalf of) people lacking capacity. It deals with decisions concerning both property and affairs, as well as health and welfare decisions.
A new Public Guardian – The Public Guardian has several duties under the Act and will be supported in carrying these out by an Office of the Public Guardian (OPG). The Public Guardian and his staff will be the registering authority for LPAs and deputies. They will supervise deputies appointed by the Court and provide information to help the Court make decisions. The OPG runs threes registers for Lasting Powers of Attorney, Enduring Powers of Attorney and Deputies; this information is available to members of the public. The OPG will also work together with other agencies, such as the police and social services, to respond to any concerns raised about the way in which an attorney or deputy is operating.
Independent Mental Capacity Advocate (IMCA) – An IMCA is someone instructed to support a person who lacks capacity but has no one to speak for him or her, such as family or friends , or if family or friends are present but considered “inappropriate” to assist in the process. IMCAs must be involved where decisions are being made about serious medical treatment or a change in the person’s accommodation where it is provided, or arranged, by the National Health Service or a local authority, and may be involved in abuse cases. The IMCA makes representations about the person’s wishes, feelings, beliefs and values, at the same time as bringing to the attention of the decision-maker all factors that are relevant to the decision. The IMCA can challenge the decision-maker on behalf of the person lacking capacity if necessary; challenges can be made via the Court of Protection or Judicial Review process. However, it is still up to the decision maker to consider what they believe is in the person’s best interests.
Key Concepts for doctors:
Lack of capacity in one area can’t be assumed to mean lack of capacity in another – and patients should be as involved as possible in all decisions made about their treatment.
Where it is proposed that a person move permanently into residential or nursing care, or serious medical treatment is proposed for someone who lacks capacity, the person’s relatives must be consulted about what they believe the person’s views about this would be, and whether the move or treatment would be in their best interest. If there are no relatives, an IMCA must be consulted.
The MCA s5 protects staff from liability as long as they have a reasonable belief that a person lacks capacity, and any force used in an urgent situation is proportionate to the risks that would fall to that person if they were not restrained. Where care needs to be provided in such a restricted way that it amounts to a ‘derivation of liberty’, this needs to be authorised. From April 09, the Deprivation of Liberty Safeguards may provide the authority needed to detain someone that is unable to consent to care or treatment being provided in a registered care home or hospital setting. (The Deprivation of Liberty Safeguards are the Government’s response to the European Court of Human Rights’ requirement that the so called “Bournewood Gap” be dealt with in British Law.)
Where staff become aware that a patient has made an advance decision refusing a particular treatment, that refusal has the same force as if the patient where making it contemporaneously, i.e. the medical treatment could not be given unless the doctor concerned was happy either that the patient did not have capacity when the decision was made, or that they did not intend the decision to have effect in the current circumstances.
Conclusion.
Anecdotally, medical practitioners appear to have been slow to make use of the powers and safeguards provided by the MCA. Relatively small numbers of referrals have been made to the IMCA services nationally to support those people that lack capacity and are “unbefriended” in the decision making processes around serious medical treatment. Only 671 eligible referrals were received by IMCA services in England and Wales in 2007/2008. (First Annual Report of the IMCA Service, July 2008). Could it be that an assumption is being made that the IMCA service may be seen more of a hindrance than a help, rather than a safeguard for the patient, in providing care and treatment?
The Act requires professionals to “presume capacity” rather than incapacity, for most professionals this is a challenge that we often fail to meet. It is easier to work with a presumption of incapacity and to act in that person’s best interest rather than take the time to “evidence” their capacity in relation to a variety of decisions that may need to be made.
The Act’s two new criminal offences have resulted in a small number of prosecutions to date. These prosecutions have tended to be brought against staff providing care in care homes or domiciliary settings rather than in hospital or other medial settings. Does this mean that staff working in hospitals or medical settings provide better care?
Healthcare organisations are a fertile breeding ground for interpersonal conflict and the development of dysfunctional relationships. The supervisory relationship between trainer and trainee is a particular area of concern for junior doctors. Aside from a problem trainee, such conflict can arise from a difficult supervisor, poor communication, personality clashes and power inequalities. This article will come from a trainee’s perspective in emphasising how these factors relate to the difficult supervisor. Recommendations are made for organisations and individuals on how the causes and consequences of this problem can be addressed .
The nature of working relationships
“Like a successful personal relationship, both sides must be able to acknowledge their goals, the obstacles they perceive in achieving their goals, and must be willing to compromise …” 1
Working relationships, like personal relationships, are embedded in a complex and diverse world with people of different personalities, backgrounds, motives and desires. Getting on with our fellow humans is a fundamental part of living and a challenge in our working lives. Garelick and Fagin (2004) have explored this area and have identified what facilitates a good working relationship (figure 1):
Figure 1: Factors that encourage good working relationships 2
Clarity about the organisation’s tasks and objectives
Clarity about the authority structure, with clear lines of accountability
The presence of a common goal or objectives
The opportunity to participate and contribute
The ability to trust and compromise
The possibility of setting aside inessential differences
Respect for alternative viewpoints
Protection of the weakest member of the team
Good leadership
A balance between individual aspirations and corporate needs
Sharing similar life experiences or cultural background
Dysfunctional Working Relationships
“Differences of perspectives … lead to interpersonal conflict that spirals into dysfunctional relationships” 3
Interpersonal conflict is a “dynamic process that occurs between interdependent parties as they experience negative emotional reactions to perceived disagreement and interference with the attainment of their goals” 4. Interpersonal work conflict can impact in terms of satisfaction, well-being, work disability, and mental health outcomes such as psychiatric morbidity, depression, fatigue and psychological distress 4. Factors that can play a role in conflict include perceived disagreements about tasks, ambiguities in role definition, or if the responsibilities are unclear 4.
One of the central issues inherent in workplace disputes is irrational behaviour on the part of one (or both) of the employees when the facts get confused with their highly charged feelings 5. In an attempt to avoid conflict the other individual may be uncomfortable about raising the issue, feel intimidated by someone with greater authority or power, or suspect a personal agenda, but does not want to sound argumentative. This can result in an emotionally charged situation with layer upon layer of faulty assumptions building up to a proverbial house of cards and the development of entrenched beliefs 3. Therefore what started as a misunderstanding can lead to a dysfunctional relationship3, which can result in multiple problems impacting on the organisation and the individuals involved. Specific consequences include complaints of bullying and racism against the trainer, labelling of the trainee as a doctor in difficulty, or the trainer developing a reputation as a “difficult supervisor”.
Causes of trainer-trainee conflict in medicine
In the field of medicine, particularly given the hierarchical structure of the profession, the potential for conflict is accentuated. Trainees tend to rotate around jobs, and educational supervisors, every 6-12 months. Trainees and trainers are expected to adapt to working with each other with differences in personality, styles of working, and expectations. It is therefore inevitable that difficulties will develop.The fundamental causes of the conflict between trainer and trainee in healthcare are:
1. The problem trainee
The problem junior doctor is a well-established area of concern 6. This type of doctor may be inflexible, clinically incompetent, arrogant, have poor time keeping or organisational skills, refuse to do what is asked, exhibit poor communication skills, lack enthusiasm, lack educational objectives, or have a difficult personality. Despite the “doctor in difficulty” being regarded as a “problem trainee” the dysfunctional relationship between trainer and trainee in medicine is usually a product of both parties.
2. The difficult supervisor
The most important factor in determining trainee satisfaction has been shown to be the quality of supervision provided by the consultant trainer 7. However the difficult supervisor, often a consultant, is an issue that is underreported. The problem consultant comes in various guises shown in figure 2:
Figure 2: The problem consultant 2
Authoritarian and bullying
Controlling
Indecisive and disorganised
Burnt-out
A consultant who is never there
A consultant biding time to retirement
The flirtatious consultant
Poor teacher and communicator
Generally a problem consultant would have, over the years, established a reputation as a difficult person to work with, usually confirmed by their peers and trainees. Unfortunately this aspect of their personality is ignored when they complain about a new trainee. Therefore the consultant is never identified as a difficult supervisor. Knowledge of what constitutes a bad supervisor should be accompanied by what is a good supervisor. In the field of psychology the notion of a good supervisor applies to any supervisory relationship (figure 3).
Figure 3: Good supervisor 8
Straddling the potentially conflicting roles of mentor and evaluator
Providing impartial and thorough evaluation within contexts that respect supervisee’s integrity
Having expertise
Being trustworthy
Modelling respect of differences in values, expectations and experiences
Tolerant of mistakes and facilitating trainees progress
Providing direct and clear feedback to trainees
Open to feedback about their own style of working
3. Communication problems
A supervisor should possess good communication skills in the form of: active listening, demonstrating understanding, using open questions, building areas of agreement and being open. As a good communicator the supervisor should refrain from stating unreasonable expectations, views, or opinions. They should avoid offering incentives / warning of consequences or revealing feelings. In the workplace, in times of pressure, dysfunctional communication is instrumental in trainer-trainee conflict.
These communication problems are prominent in the area of feedback 9. Feedback is a key role of the supervisor 10. Feedback should be honest, relevant, objective, specific, timely, and planned 9. It should be based on accurate information rather than hearsay and focused on behaviour and performance rather than personality and attitude. It should be constructive, conducted in private, descriptive rather than evaluative, and designed to avoid personalising and blaming 9. Feedback should not be given on things the trainee cannot change e.g. personality.
Should the trainee feel offended by feedback at any point then it may be that the supervisor has a hidden agenda or is a bully. A delay in feedback impedes efficient working so the giving and receiving of feedback should also be a balanced ongoing process in order to boost morale and motivation, leading to greater effectiveness and job satisfaction 9. If the supervisor has a good relationship with the trainee then constant feedback should be given about his/her performance: the final report should never be a surprise 11.
4. Personality clashes
Conflict may also reveal itself in personality differences between trainee and trainer. Personality characteristics of the latter that can significantly affect an otherwise healthy relationship include a trainer who is preoccupied with details, order, organisation and schedule. Such trainers may be seen as perfectionist, pedantic, rigid and stubborn, and often insist that others submit to their way of doing things, according to their own self-proclaimed high standards.
Personality clashes may arise from poor communication or underlying factors including racism, sexism, religion, or jealousy and envy interfering with the relationship on both sides 12. The crucial question to ask is whether the trainer-trainee conflict is a result of a difficult trainee, or whether it arises when a trainee does not fit the supervisor’s scheme of things.11
5. Power differential
The trainer/supervisor also has an evaluative function in relation to the trainee and therefore the potential for abuse and trainee vulnerability in respect of the supervisor, is clear 8. The dependence of trainees on trainers for references creates a “potential power imbalance and in some cases may lead to intentional or unintentional harm to the trainee” 13. This harm may be identified in the trainer’s assessment of the trainee when completing the end-of-post evaluation. The trainer taking a proactive approach in writing complaints and sending emails to sabotage a trainees’ career may also demonstrate abuse of power.
Equally an overpowering consultant may, consciously or unconsciously, take advantage of the situation by going on a fault-finding mission. This can become part of a self-fulfilling prophecy. If the trainee is perceived to be poorly performing the supervisor may feel under more pressure and become hostile towards the trainee, without addressing the main problem 12. The result is that the supervisor engages in “continuous criticism and academic humiliation” 12 which causes the trainee to feel more useless and helpless. This can lead to the trainee becoming a scapegoat in an already dysfunctional team12.
Another consequence of the power imbalance is that it causes a state of confusion for trainees who want things to change but will often tolerate the problem and endure it to avoid jeopardising their career prospects. The trainee may feel powerless and fearful about addressing the current problem and choose to be silent on the matter, rather than risk an unpleasant situation 12. Unfortunately such passive behaviour may result in the problem escalating and the trainer may, unconsciously and unwittingly, bully the trainee 8.
How to deal with trainer-trainee conflict?
“Conflicts are really a house of cards ... you can bring them down by getting to the bottom and getting to the facts” 3 .
Dealing with trainer-trainee conflict involves good emotional intelligence, self-awareness (being self aware and taking an honest look at oneself), self-regulation (ability to control emotions), empathy (ability to identify and understand the wants, needs and viewpoints of others), being well-motivated, and having good social skills 14. In other words, successful conflict resolution relies on first understanding ourselves, being aware of our personality, our prejudices, why we like some people and not others, and recognising that certain things will annoy us and not others 11.
From a trainee’s perspective conflict with the supervisor should be addressed at an early stage to prevent escalation of the problem 12. This should include self-appraisal, thinking about the root of the problem in a factual and non-personal way, and informal discussion with a discreet colleague to gain another perspective. Trainees should find out how their predecessor got on in the post. Finally, problems should be freely discussed with the supervisor. However, there may be supervisors with whom it is difficult to have a discussion; therefore the trainee must involve others to deal with the issues which escalate or remain unresolved. If the supervisor is considered the source of the problems there are steps to take to ensure the power of the supervisor is not misused against trainees (figure 4):
Figure 4: Steps to deal with a difficult supervisor 13
College / speciality tutors and clinical tutors / programme directors have an obligation to act as the trainee’s advocate
Where tutors and programme directors fail to act appropriately, a direct approach by the trainee to the local postgraduate dean or relevant college may be indicated
The local trainees’ committee, trade union, and its officers / representatives may also be helpful in acting as the trainee’s advocate in appropriate circumstances
Deanery contact monitoring and training programmes’ approval visits, involving the College and conducted on behalf of the Postgraduate Medical Education and Training Board, also afford opportunity to raise concerns about supervisors
If trainees consider their health affected by the stress of working with a difficult supervisor they should seek help from their occupational health department or postgraduate dean, who may offer confidential services and helpful advice for the assessment of mental health problems affecting doctors
Trainees may be reluctant to take the steps described in figure 4. The power differential between trainer and trainee, as well as acting as an antecedent to the conflict, is a perpetuating factor that ensures nothing is done about it. The difficult supervisor may be underreported for the same reasons seen with workplace bullying, namely, fear of making matters worse, belief that nothing will be done, concerns regarding confidentiality, fear of victimisation, and concerns about being labelled as a troublemaker 15. Ultimately it is the fear of the consequences that deters trainees from speaking out, though it is worth remembering that Franklin D Roosevelt stated in his first inaugural speech, “the only thing we have to fear is fear itself”.
What can healthcare organisations do about supervisory conflict?
Organisations must be proactive in identifying and dealing with problems between trainers and trainees, who in turn ought to be aware of their responsibilities. Organisations may be tempted to sweep problems under the carpet but there are recommendations on how they can address the causes of trainer-trainee conflict (figure 5):
Figure 5: Steps for organisations to tackle the causes of trainer-trainee conflict
Cause
Solution
Problem trainee
Training of supervisors in not only how to identify the problem junior, but how to constructively manage the problem at the outset. Adopting a positive, non-judgemental and non-confrontational approach, and having a problem-solving mindset are essential
Difficult supervisor
Training of supervisors regarding their roles as a educational and clinical supervisor
Training of supervisors in sensitive areas of diversity and equality, and self-reflection, with the support of college tutors and programme directors
360 degree feedback carried out frequently and acted upon promptly during the supervisor’s appraisal
Communication Problems
Communication skills training
Constructive feedback training
Personality Clashes
Training of supervisor and trainee in conflict resolution since there may be personality differences between the two, rather then an individual doctor in difficulty.
Power differential
Power imbalance of feedback can be countered if feedback from each trainee becomes part of appraisal and revalidation for consultants
Colleges should collect anonymous feedback about educational and clinical supervisors from trainees and review their future role as supervisor
Complaints of bullying and racism should be dealt with promptly and effectively by the organisation.
Paice (2002) describes an excellent mentor as someone who “will always inspire, teach by example, and excite admiration and emulation” 16. Mentoring can be beneficial in facilitating the development of the trainee but “faculty mentoring should be avoided’’ 17. In other words mentoring of doctors should not be carried out by the trainee’s educational supervisor or line manager, nor should they be involved in their assessment or appraisal, to avoid blurring the distinction between the roles 17. A good mentor should :
Motivate
Empower and encourage
Nurture self-confidence
Teach by example
Offer wise counsel
Raise the performance bar
However, the authors argue that these are the qualities that should be part of being a good supervisor 17.
Conclusion
“Differences in power and status, and dependence on references, places juniors in invidious positions when they experience problems in their relationships with trainers” 2
The relationship between trainer and trainee should reflect the same warmth and nurturing as in a parent-child relationship. There is a parallel with both types of relationship in that there is an imbalance of power that interacts with poor communication and personality conflicts. In medicine although the problem junior doctor is frequently highlighted it must be remembered that the trainer-trainee conflict may reflect a difficult supervisor. The supervisor needs to achieve a healthy relationship that is sensitive to the needs of the trainee, void of any of their preconceived beliefs and prejudices, and act as a role model in making a good doctor and achieving their full potential 16. Interpersonal conflict can nevertheless develop and escalate to the extent that the trainee may suffer in silence. Healthcare organisations can be more proactive in penetrating the causes of the dysfunctional working relationship. Trainees should be fearless in turning to existing support in face of a difficult supervisor.
KEY POINTS:
Professional working relationships are a major challenge in healthcare
Interpersonal conflicts can lead to a dysfunctional working relationship
Issues include problem trainees, poor communication, and personality clashes
Power inequalities and the difficult supervisor need to be addressed
Trainer-trainee conflict can be resolved with steps taken by the individual
Organisations must address the causes of dysfunctional working relationships
Trainees need to overcome their own fears when tackling conflict
Contact: Mrs. Kelly Westlake Tel: 011-44-29-2068-2131 Email: westlakekm@cf.ac.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Surgery
June 15-17, 2009 United Kingdom / Cardiff
BASIC SKILLS IN HAND SURGERY
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HOW TO PRACTICE EVIDENCE-BASED HEALTH CARE
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June 18-19, 2009 United Kingdom / Liverpool
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3RD SYMPOSIUM ON ACETABULAR RECONSTRUCTION
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Orthopedics / Surgery
June 19, 2009 United Kingdom / London
ROAD TRAFFIC FATALITIES, PASSENGERS, PEDESTRIANS, PATHOLOGISTS & POLICE
Contact: Conference Department, Royal College of Pathologists Tel: 011-44-20-7451-6715 Email: meetings@rcpath.org Website: www.rcpath.org
Pathology
June 19, 2009 United Kingdom / London
MANAGEMENT OF COMMON PROBLEMS IN OLDER PEOPLE
Contact: Joyce Achampong, Senior Regional Events Co-ordinator, Royal Society of Medicine Tel: 011-44-20-7290-2980 Fax: 011-44-20-7290-2989 Email: joyce.achampong@rsm.ac.uk Website: www.rsm.ac.uk/academ/condiary.php
Family Medicine / General Medicine / Internal Medicine
June 19, 2009 United Kingdom / York
UK THALASSAEMIA SOCIETY CONFERENCE
Contact: UK Thalassaemia Society Tel: 011-44-20-8882-0011 Fax: 011-44-20-8882-8618 Email: office@ukts.org Website: www.rsm.ac.uk/academ/condiary.php
Hematology
June 20, 2009 United Kingdom / Wilmslow
2009 ANNUAL MEETING OF BRITISH ASSOCIATION OF UROLOGICAL SURGEONS (BAUS)
Contact: BAUS Tel: 011-44-20-7869-6950 Fax: 011-44-20-7404-5048 Email: admin@baus.org.uk Website: baus.meeting.org.uk
Surgery / Urology
June 22-25, 2009 United Kingdom / Glasgow
GASTROENTEROLOGY FOR THE PCP BRITISH ISLES/NORWEGIAN FJORDS CRUISE
Contact: Continuing Education, Inc. Tel: 800-422-0711 (US) or 727-526-1571 Email: contactus@continuingeducation.net Website: www.continuingeducation.net
Family Medicine / Internal Medicine
June 22-July 04, 2009 United Kingdom / Harwich
BASIC PRACTICAL SKILLS IN OBSTETRICS & GYNAECOLOGY
Contact: Conference Office, Royal College of Obstetricians & Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings
Obstetrics/Gynecology
June 22-24, 2009 United Kingdom / London
BYPASS, BALLOON PUMPS & CIRCULATORY SUPPORT
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: cardiothoracics@rcseng.ac.uk Website: www.rcseng.ac.uk
Surgery
June 22, 2009 United Kingdom / London
WORKSHOP IN PELVIC SURGERY
Contact: TMB Marketing and Communications, Conference Desk Tel: 011-44-1306-877-000 Fax: 011-44-1306-877-777 Email: info@wips-intl.com Website: www.wips-intl.com
Obstetrics/Gynecology
June 22-26, 2009 United Kingdom / London
SPECIALTY SKILLS IN VASCULAR SURGERY
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: vascular@rcseng.ac.uk Website: www.rcseng.ac.uk
Surgery
June 22-23, 2009 United Kingdom / London
5TH INTERNATIONAL CONFERENCE ON CHILDREN'S BONE HEALTH
Contact: Clare Moloney, Oxford International Tel: 011-44-1865-511-550 Fax: 011-44-1865-511-570 Email: clare.moloney@oxfordint.co.uk Website: www.iccbh5.org
Endocrinology / Orthopedics / Pediatrics
June 23-26, 2009 United Kingdom / Cambridge
9TH ANNUAL INTERNATIONAL ASSOCIATION OF FORENSIC MENTAL HEALTH SERVICES (IAFMHS)
Contact: IAFMHS Tel: 604-924-5026 Fax: 604-924-5027 Email: tmoropito@iafmhs.org Website: www.iafmhs.org
Psychiatry
June 24-26, 2009 United Kingdom / Edinburgh
ADVANCED SKILLS IN VASCULAR SURGERY
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: vascular@rcseng.ac.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Surgery
June 24-26, 2009 United Kingdom / London
INTERMEDIATE THORACIC SURGERY
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: Cardiothoracics@rcseng.ac.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Surgery
June 24-25, 2009 United Kingdom / London
ASSOCIATION OF BREAST SURGERY AT BASO TRAINEES MEETING 2009
Contact: Krysia Cruickshank Tel: 011-44-141-211-6248 Email: krysia.cruickshank@northglasgow.scot.nhs.uk Website: www.baso.org
Oncology / Surgery
June 25-26, 2009 United Kingdom / Glasgow
RECENT ADVANCES IN MEDICINE
Contact: Sue Dent, University Hospital of North Tees Tel: 011-44-164-262-4791 Fax: 011-44-164-226-4918 Email: sue.dent@nth.nhs.uk Website: www.rcpe.ac.uk
Family Medicine / General Medicine / Internal Medicine
June 26, 2009 United Kingdom / Stockton-on-Tees
SYSTEMATIC TRAINING IN ACUTE ILLNESS RECOGNITION & TREATMENT FOR SURGERY
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6311 Email: ccrisp@rcseng.ac.uk Website: www.rcseng.ac.uk
Surgery
June 27, 2009 United Kingdom / London
13TH CONFERENCE OF NATIONAL OSTEOPOROSIS SOCIETY
Contact: Sarah Phillips or Kelly Hall, Events Dep’t., National Osteoporosis Society Tel: 011-44-1761-473-106 or 011-44-1761-473-123 Fax: 011-44-1761-471-104 Email: s.phillips@nos.org.uk or k.hall@nos.org.uk Website: www.nos.org.uk
Other Specialties
June 29-July 01, 2009 United Kingdom / Manchester
2009 ANNUAL MEETING OF BRITISH SOCIETY FOR ALLERGY & CLINICAL IMMUNOLOGY (BSACI)
Contact: BSACI Tel: 011-44-207-340-9614 Email: info@bsaci.org Website: www.bsaci.org
Immunology/Allergy
June 29-July 01, 2009 United Kingdom / Nottingham
PATHOLOGICAL SOCIETY OF GREAT BRITAIN & IRELAND SUMMER MEETING 2009
Contact: Pathological Society of Great Britain & Ireland Tel: 011-44-20-7976-1260 Fax: 011-44-20-7930-2981 Email: admin@pathsoc.org Website: www.pathsoc.org
Pathology
June 30-July 03, 2009 United Kingdom / Cardiff
UPDATE IN MANAGEMENT OF DETRUSOR OVERACTIVITY
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: urology@rcseng.ac.uk Website: www.rcseng.ac.uk
Surgery / Urology
June 30, 2009 United Kingdom / London
CARDIOTHORACICS FOR SURGICAL ASSISTANTS
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: Cardiothoracics@rcseng.ac.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Surgery
June 30, 2009 United Kingdom / London
RECONSTRUCTIVE TECHNIQUES IN UROLOGY
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: urology@rcseng.ac.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Surgery / Urology
June 30, 2009 United Kingdom / London
CARE HOME MEDICINE
Contact: Meetings & Events Office, Royal College of Physicians of Edinburgh Tel: 011-44-20-7034-4900 Email: conferences@rcplondon.ac.uk Website: www.rcplondon.ac.uk/event
General Medicine / Geriatrics / Other Specialties / Pain Management
June 30, 2009 United Kingdom / London
SOUTH ASIA DAY: JOINT RCOG/AICC RCOG/SAFOG MEETING
Contact: Royal College of Obstetricians & Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/events
Obstetrics/Gynecology
July 03, 2009 United Kingdom / London
CANCER IN WOMEN BALTIC SEA CRUISE
Contact: Continuing Education, Inc. Tel: 800-422-0711 (US) or 727-526-1571 Email: available through web page Website: www.continuingeducation.net
Family Medicine / Internal Medicine / Obstetrics/Gynecology
July 04-16, 2009 United Kingdom / Harwich
6TH INTERNATIONAL ASSOCIATION FOR BIOLOGICALS SYMPOSIUM ON ADVANCES IN TRANSFUSION SAFETY
Contact: Department of Haematology, Cambridge Institute for Medical Research Tel: 011-44-122-354-8044 Email: jpa1000@cam.ac.uk Website: www.iabs.org
Hematology / Other Specialties
July 06-07, 2009 United Kingdom / Cambridge
4TH NATIONAL AUTISM TODAY
Contact: Mark Allen Group Tel: 011-44-20-7501-6762 Fax: 011-44-20-7733-8174 Email: conferences@markallengroup.co.uk Website: www.mahealthcareevents.co.uk
Family Medicine / General Medicine / Neurology / Pediatrics / Psychiatry
July 06-07, 2009 United Kingdom / London
MRCOG PART 1 REVISION COURSE
Contact: Royal College of Obstetricians & Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/events
Obstetrics/Gynecology
July 06-10, 2009 United Kingdom / London
CURRENT CONCEPTS IN EXTERNAL FIXATION IN TRAUMA
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6337 Email: orthopaedics@rcseng.ac.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Orthopedics / Surgery
July 06, 2009 United Kingdom / London
WORKSHOP ON THE MOLECULAR PHARMACOLOGY & THERAPEUTICS OF BONE DISEASE
Contact: National Association for the Relief of Paget's Disease Tel: 011-44-161-799-4646 Fax: 011-44-161-799-6511 Email: director@paget.org.uk Website: www.paget.org.uk
Endocrinology / Other Specialties
July 06-09, 2009 United Kingdom / Oxford
89TH ANNUAL MEETING OF BRITISH ASSOCIATION OF DERMATOLOGISTS
Contact: Conference & Events Services, British Association of Dermatologists Tel: 011-44-20-7391-6358 Fax: 011-44-20-7388-0487 Email: conference@bad.org.uk Website: www.bad.org.uk
Dermatology
July 07-10, 2009 United Kingdom / Glasgow
13TH BRITISH ACADEMIC CONFERENCE IN OTOLARYNGOLOGY AND ENT EXPO
Contact: ENT UK Tel: 011-44-20-7404-8373 Fax: 011-44-20-7420-4200 Email: conferences@entuk.org Website: www.bacouk.org
Otolaryngology
July 08-10, 2009 United Kingdom / Liverpool
HANDS ON GYNAECOLOGICAL ENDOSCOPY SKILLS WORKSHOP
Contact: Therese Eleftheriou, Course Secretary Tel: 011-44-20-7795-0500 ext. 33863 Fax: 011-44-20-7431-1321 Email: courses@gynendo.com Website: www.gynendo.com/dates.htm
Obstetrics/Gynecology / Surgery
July 08-10, 2009 United Kingdom / London
INTERNATIONAL SYMPOSIUM ON PAGET’S DISEASE
Contact: National Association for the Relief of Paget's Disease Tel: 011-44-161-799-4646 Fax: 011-44-161-799-6511 Email: director@paget.org.uk Website: www.paget.org.uk
Endocrinology / Other Specialties
July 08-09, 2009 United Kingdom / Oxford
11TH NATIONAL CONFERENCE: THE DIABETES EPIDEMIC
Contact: Mark Allen Group Tel: 011-44-20-7501-6762 Fax: 011-44-20-7733-8174 Email: conferences@markallengroup.co.uk Website: www.mahealthcareevents.co.uk
Endocrinology
July 13-14, 2009 United Kingdom / London
DEFINITIVE SURGICAL TRAUMA SKILLS FOR THE GENERAL SURGEON
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6336 Email: trauma@rcseng.ac.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Surgery
July 14-15, 2009 United Kingdom / London
3RD NATIONAL CRITICAL CARE SYMPOSIA
Contact: Mark Allen Group Tel: 011-44-20-7501-6762 Fax: 011-44-20-7733-8174 Email: conferences@markallengroup.co.uk Website: www.mahealthcareevents.co.uk
Internal Medicine
July 15-17, 2009 United Kingdom / London
BRITAIN PACIFIC MEDICAL AND LEGAL CONFERENCE
Contact: Lorenzo Boccalbella Tel: 011-61-07-3254-3331 Fax: 011-61-07-3254-3332 Email: info@educationcpe.com Website: www.conferences21.com
Legal/Ethics
July 17-24, 2009 United Kingdom / Oxford
BRITAIN PACIFIC MEDICAL & LEGAL CONFERENCE
Contact: Continuing Professional Education Pty Ltd. Tel: 011-61-7-3254-3331 Fax: 011-61-7-3254-3332 Email: info@conferences21.com Website: www.conferences21.com
Legal/Ethics
July 17-24, 2009 United Kingdom / Stratford-upon-Avon
BASIC SCIENCE: CELL SIGNALLING AND THE GUT
Contact: United European Gastroenterology Federation Secretariat Tel: 011-43-1-997-1639 Fax: 011-43-1-997-1639 ext. 10 Email: office@uegf.org Website: www.uegf.org
Gastroenterology
July 19-21, 2009 United Kingdom / Cambridge
MRCOG PART 2 REVISION COURSE
Contact: Royal College of Obstetricians & Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/events
Obstetrics/Gynecology
July 20-22, 2009 United Kingdom / London
FRCS (PLAST) AESTHETIC STUDY DAY
Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6336 Email: aesthetic@rcseng.ac.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Plastic Surgery
July 21, 2009 United Kingdom / London
2009 BRITISH ASSOCIATION FOR PSYCHOPHARMACOLOGY (BAP) SUMMER MEETING
Contact: Lynne Harmer, BAP Tel: 011-44-1223-358-421 Email: lynne@bap.org.uk Website: www.bap.org.uk
Clinical Pharmacology / Psychiatry
July 26-29, 2009 United Kingdom / Oxford
BASIC PRACTICAL SKILLS IN OBSTETRICS & GYNAECOLOGY
Contact: Royal College of Obstetricians & Gynecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/events
Obstetrics/Gynecology
July 27-29, 2009 United Kingdom / London
CORE SKILLS IN LAPAROSCOPIC SURGERY
Contact: Julie Bradley Tel: 011-44-121-424-1488 Email: julie.bradley@heartofengland.nhs.uk Website: www.rcseng.ac.uk/education/courses/course_list.html
Surgery
August 19-21, 2009 United Kingdom / Birmingham
11TH NATIONAL CONFERENCE: PARKINSONS DISEASE
Contact: Mark Allen Group Tel: 011-44-20-7501-6762 Fax: 011-44-20-7733-8174 Email: conferences@markallengroup.co.uk Website: www.mahealthcareevents.co.uk
Neurology
August 25, 2009 United Kingdom / London
The Civil Rights Act 1964 remains of the greatest achievements in United States (US) history. It had implications internationally, making racial discrimination illegal, but its effectiveness in the employment domain remains contestable 2. The worldwide existence of workplace racism has attracted controversy and this is drawn out by psychiatry’s attempt to understand the nature of the problem 3. Discrimination at work, based on a person’s race, comes in different guises and can have negative consequences on both individuals and organisations 1. Despite legislation to protect individuals substantial progress needs to be made to eradicate the problem.
What is racism?
The concepts of “race”, “ethnicity” and “racism” are explained in figure 1.
Figure 1: Definition of race, ethnicity and racism 4, 5
Race
The group a person belongs to as a result of a mix of physical features, ancestry, and geographical origins, as identified by others or, increasingly, as self-identified. The importance of social factors in the creation and perpetuation of racial categories has led to a broadening of the concept to include social and political heritage, making its usage similar to ethnicity. Race and ethnicity are increasingly used synonymously.
Ethnicity
The group you belong to as a result of a mix of cultural factors that include language, diet, religion, ancestry, and race.
Racism
A belief that some races or ethnic groups are superior to others, used to devise and justify actions that create inequality between racial groups.
Racism is a social process associated with “overt and covert forceful establishment and maintenance of power by one social group over another” 3.
Racism can be seen as a misuse of power and, even today, power relations are signified by subtle cultural rules that perpetuate racial inequality 6.
What are the origins of racism?
That some races are superior to others has origins from the 19th century 5. The history of racism has stimulated considerable debate in understanding racism.
Racism may have origins in experiences derived from, what is known in analytical psychology as, the collective and personal unconscious. The personal unconscious arises from the lifetime experiences of the individual. This is distinct from the “collective unconscious” which psychiatrist Carl Jung described to represent a form of the unconscious common to mankind as a whole and originating in the inherited structure of the brain 7. This contains inherited primitive cultural and racial elements. Both the personal and collective unconscious, made from our individual and ancestral experiences respectively, may account for the manifestation of racism in society today.
In recent times the experience of overt racial bigotry and prejudice is seldom seen 8. Nevertheless discrimination against members of a social group may persist because it is so deeply entrenched within society, by the personal and collective unconscious, that it becomes the automatic response even when no conscious intent is present 9. “Everyday discrimination” is the discreet, pervasive discriminatory acts experienced by stigmatised groups on a daily basis 10, and highlights the modern perspective that racism is subtle.
The subtlety of racism
“Like a virus that has mutated, racism has evolved into a new form that is difficult to recognise and harder to combat” 8
As blatant forms of racism become extinguished, particularly in the current climate of political correctness, unconscious racial biases in subtle forms, known as ambivalent or modern racism 10, are appearing. This has been referred to as aversive racism occurring in people who possess strong egalitarian values, and who believe they are not prejudiced, but have negative racial feelings and beliefs that they are unaware of 8. These feelings and beliefs are rooted in the normal psychological processes of social categorisation, satisfaction of basic needs for power and control, and socio-cultural influences 8. The ambivalence involving positive and negative feelings creates a psychological tension that leads to an inconsistent pattern in their behaviour 8.
The cumulative effects of unpredictable and seemingly trivial behaviour such as avoidance of ethnic minorities, closed and unfriendly verbal and non verbal communication, and failure to provide assistance, is more damaging 10. Apparently harmless interactions, including racist assumptions and questioning about where somebody is from, also convey messages about marginality and not belonging 11. This subtle racism may contribute to the racism perceived by minority groups in higher status professions and organisations.
Does racism exist in healthcare organisations?
“American Medical Association apologizes for racism in medicine” (10th July 2008) 12.
This admission by the American Medical Association, of racial discriminatory practices against African-American physicians, reflects the recognition of racism in other western countries.
In the United Kingdom (UK) racism has been revealed in public institutions such as the metropolitan police 13 and widely reported in the nursing profession 14,15 within the National Health Service (NHS). Trevor Phillips, chairman of the Equality and Human Rights Commission, referred to the “snowy peaks of the NHS” 16 with a large number of ethnic minorities at the base. Less than 10% of senior managers and 1% of chief executives are from ethnic minority background 17. There is a “glass ceiling” 18 preventing promotion and black and minority ethnic (BME) managers feel they have to work twice as hard and have twice as many qualifications to succeed 19.
Since 2000, after a survey commissioned by Department of Health (DOH) reported that half of front-line NHS BME staff had been victims of racial harassment in the previous 12 months 20, reports of racism in healthcare have increased. In 2001 a Kings Fund report, “Racism in Medicine” 21, generated powerful debate after finding that bullying and discrimination were a daily fact of life for black and Asian doctors. Then in 2003 a British Medical Association (BMA) survey revealed that in ethnic minority doctors, who form nearly one third of the NHS workforce 22, more than 80 per cent believed that their ethnicity had a negative effect on their career advancement 23. In 2004 the Royal College of Psychiatrists accepted that racism existed in the NHS and in their own institution 24.
How does racism manifest itself in medicine?
“Discrimination can appear to be hidden when it is institutionalised, although it is not usually hidden from the person who is subjected to it” 3
Institutional racism is “the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture and ethnic origin” 13. Health disparities among patients have been widely linked to racially biased discriminatory health practices 25, 26, 27 but how do structures, processes, and values within an organisation discriminate against those working in the medical profession?
There is considerable evidence to indicate that discriminatory practices against doctors evolved from medical school. For instance racial discrimination has operated at the time when students applied to study medicine 19, 28, through short-listing based on whether applications had Asian or English names 29, 30, and with downgrading of non-English names by computer 31. Discrimination has also been reported during medical school in the US and Canada 11. UK ethnic minority medical students also perform poorly in examinations compared to white students 32, 33 although the lack of evidence of explicit discrimination may suggest the involvement of more subtle communication styles and cultural differences 33.
If the problems at medical school are accountable by racial organisational processes it is not surprising that discriminatory practices persist after qualification (figure 2)
Figure 2: How BME doctors may experience racism 17, 19, 34, 35, 36
Bullying and harassment
More likely to experience bullying and harassment.
Recruitment and career advancement
More likely to be over-represented in junior grades. Reduced promotion and career advancement also seen in relation to academic careers. Underrepresented in senior leadership positions.
Disciplinary hearings
Over-represented at disciplinary hearings with nearly a third of complaints coming form other health professionals.
Disciplinary action and dismissals
Six times more likely to be disciplined e.g. in 2006 two thirds of the 54 doctors struck off in UK had trained outside UK.
Reward systems
Disadvantaged in the allocation of discretionary grants and NHS distinction awards.
What are the consequences of racism in healthcare?
“Racial discrimination damages both those discriminated against and those doing the discriminating” 37
The cost of workplace racism is that it acts as a chronic and acute stressor on the individual with a range of consequences (figure 3):
Figure 3: Consequences of racism on an individual 1, 10, 38, 39
Psychological
Poor well-being. Loss of confidence. Humiliation. Low morale. Gives a sense of thwarted aspirations.
Physiological
Increase blood pressure. Physical illness.
Behavioural
Bad work performance. Require time off work.
“Racial fatigue” characterises the potential emotional and psychological sequelae of feeling isolated in a work environment in which race regularly influences behaviour but is consistently ignored and nobody wants to discuss it (“racial silence”) 40. Racism may be underreported for the same reasons seen with workplace bullying: fear of making matters worse, belief that nothing will be done, concerns regarding confidentiality, fear of victimisation, and concern about being labelled as a troublemaker 41. In addition the individual may fear being regarded as having a “chip on one’s shoulder”.
Organisations may also suffer with disharmony at work, high sickness levels, and resignation 1. In medicine this results in the “double loss” of a speciality losing highly motivated people and gaining those where enthusiasm may be low 19. In addition victims of racial discrimination in healthcare may pursue legal action. In 2003 a surgeon won over £600,000 42 after being denied entry to the specialist registrar. Another surgeon successfully sued the BMA for more than £800,000 for racial discrimination after it failed to support his own claim against the DOH 43. In another case a UK trust paid £2.5m, including legal costs, for wrongful dismissal of a consultant obstetrician who was investigating discrimination 44.
What can be done if you are experiencing racism at work?
In the UK there is protection by legislation. It is unlawful to discriminate against anyone on racial grounds. The Race Relation Act 1976 defined three types of discrimination (direct, indirect, and victimisation) 1, 45,. Following this was the setting up of the Commission for Racial Equality (CRE) in the UK to tackle racism and promote racial equality 45. The Race Relations Act 1976 has now been superseded by the Race Relations (amendment) Act 2000 46 that requires public bodies to eliminate discrimination, promote equal opportunities, and ensure good race relations. However legal processes are stressful and there are some steps you can take before pursuing this route (figure 4).
Figure 4: Steps to take if you are a victim of racial discrimination 1
Talk to colleagues and friends who may have suffered a similar problem because it helps to share a problem and trying to cope on your own can be particularly stressful.
Keep a diary of events of who said what, when, circumstances and any witnesses – this will give a vital record of the nature of the racism.
Find out whether your employer has specific rules about racism at work or a grievance procedure you can use to raise a problem.
If you are in a union contact them to assist you with talking to management or approaching the perpetrator.
In the UK the Commission for Racial Equality is a national body that can help victims of racial discrimination.
Your local Citizens Advice Bureau or Law Centre may be able to help.
You may want to talk to a private law firm that specialises in discrimination issues.
Recommendations and Conclusion
“The law may be just but its implementation is another matter” 47
Despite legislation and procedures, to address racism at work, healthcare organisations are slow in introducing and supporting the policies for race equality 18. Suits come to legal action, not for a lack of policy, but because of not being enforced 48. Practice is not synonymous with policy 19. Reinforcement of policies depends on the degree to which upper management understands discrimination and harassment 48. Although implementation of policies could be successful in combating overt racism this is not so for the covert form.
The covert form of racism, as in institutional racism where organisational processes are “unwittingly” enacted 13, suggests that racism is inevitable. Even people with strong motivations to avoid it are subject to automatic cognitive activation of stereotypes, which can unconsciously influence behaviour, making diversity training courses and non-discrimination policies relatively ineffective 10. Attending to, and encouraging the reporting of, the “softer” aspects of racism may be the key to establishing a true “positively diverse climate” 10. New forms of racism require new approaches (Figure 5):
Figure 5: The STEEP model to approaching subtle racism in organisations 8
Structured Support
Visibly supported by senior management.
Training and Education
Educate people about subtle bias and training to recognise it.
Experience
Frequent and constructive interracial contact to decrease bias, enhance group cohesion, and increase productivity.
Personal Commitment
Individuals must be committed to recognise and combat subtle racism.
The most important part of the solution is education. Teaching on racism should be incorporated into the undergraduate and postgraduate curriculum 19. However of greater significance is recognising our own personal prejudices, at an early stage, so that prejudices we all harbour are challenged within ourselves.
“The hardest attitude to change is the one you don’t know you have” 8
KEY POINTS – RACISM:
Is associated with power and superiority
Has evolved from an overt to a covert form
Is commonplace in healthcare organizations
Is manifested at each stage of a doctors career
Has implications for individuals and organizations
Can be partly dealt with through policies and legislation
Requires a new approach to eradicate the problem
Useful UK online resources
http://www.oneworkplace.co.uk - “One Workplace Equal Rights” aims to tackle racism and promote equal opportunities in the workplace.
http://homepage.ntlworld.com/rajen/RacialEquality - Race Equality Ltd provides phone advice about racism in the medical establishment.
http://www.bidaonline.org.uk - The British International Doctors Association protects and promotes the interests of Ethnic Minority Doctors and Dentists working in the UK.
http://www.equalityhumanrights.com - A new commission working to eliminate discrimination, reduce inequality, protect human rights and build good relations.
COMPETING INTERESTS None Declared AUTHOR DETAILS MINAL MISTRY, BSc, BM, MRCPsych, MSc, Hampshire Partnership NHS Trust, United Kingdom JAVED LATOO, MBBS, DPM, MRCPsych, North East London NHS Foundation Trust, United Kingdom CORRESPONDENCE: Dr MINAL MISTRY, Hampshire Partnership NHS Trust, Melbury Lodge, Winchester, United Kingdom Email: minalmistry@yahoo.co.uk
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15. Staines R. Is racism a problem in nursing? Nurs Times. 2006; 102(10): 12-13.
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Photographic Documentation Of Open Fractures: A Survey Of Current Practice And Proposed Recommendations. R Ahmad, SKM Annamalai ,SMY Ahmed, SA Joseph And M Bould
The ‘Lost’ Mirena: What Investigations Are Required ? An Intraperitoneal Levonorgestrel-Releasing Intrauterine System Following Uterine Perforation: Case Report Shambhu S And Pappas M
An Unusual Presentation Of Left Ventricular Free Wall Rupture Following A Silent Myocardial Infarction Andrew Peter Vanezis, Rehan Quadery, Mohammad Wasil And Mohammed Azher
Mal-Distribution Of Medical Manpower Resultant Decay Of The Indian Medical Education System: Existing Problems And Possible Solutions Vallyamma P, Deshpande SR And Gayathree L
CAMBRIDGE CONFERENCE ON BREAST CANCER IMAGING March 23-24, 2009 Contact: Hampton Medical Conferences, Secretariat Tel: 011-44-20-8979-8300 Fax: 011-44-20-8979-6700 Email: hmc@hamptonmedical.com Website: www.cambridgeconferencebci.ukevents.org Radiology/Imaging, United Kingdom / Cambridge
2009 ANNUAL MEETING OF THE BRITISH SOCIETY OF GASTROENTEROLOGY March 23-26, 2009 Contact: British Society of Gastroenterology Tel: 011-44-207-387-3534 Fax: 011-44-207-487-3734 Email: bsg@mailbox.ulcc.ac.uk Website: www.bsg.org.uk/meet_calendar/calendar.htm Gastroenterology United Kingdom / Glasgow
BASIC PRACTICAL SKILLS IN OBSTETRICS & GYNAECOLOGY March 23-25, 2009 Contact: Conference Office, Royal College of Obstetricians and Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings Obstetrics/Gynecology United Kingdom / London
OESOPHAGO-GASTRIC CANCER SURGERY March 23-25, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6328 Email: general@rcseg.ac.uk Website: www.rcseng.ac.uk Oncology / Surgery United Kingdom / London
SPECIALTY SKILLS IN BREAST DISEASE MANAGEMENT (ADVANCED) March 23-26, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: breast@rcseng.ac.uk Website: www.rcseng.ac.uk Plastic Surgery / Surgery United Kingdom / London
CHILD HEALTH PROMOTION & SURVEILLANCE March 23-25, 2009 Contact: Symposium Office, Imperial College of London Tel: 011-44-20-7594-2150 Fax: 011-44-20-7594-2155 Email: sympreg@imperial.ac.uk Website: www.prossl.com/symposiassl/events.asp Pediatrics United Kingdom / London
2009 EUROPEAN ASSOCIATION FOR THE STUDY OF DIABETES (EASD) ROBERT TURNER CLINICAL RESEARCH COURSE March 23-27, 2009 Contact: EASD Secretariat Tel: 011-49-211-758-4690 Fax: 011-49-211-758-46929 Email: secretariat@easd.org Website: www.easd.org Endocrinology United Kingdom / Oxford
ROYAL COLLEGE OF PHYSICIANS - RESPIRATORY FAILURE March 24, 2009 Contact: Royal College of Physicians Tel: 011-44-20-7935-1174 Email: conferences@rcplondon.ac.uk Website: www.rcplondon.ac.uk/event Respirology, United Kingdom / London
5TH ANNUAL BRITISH COSMETIC DERMATOLOGY GROUP COURSE March 26-27, 2009 Contact: Rebecca Bennett Email: Rebecca_L_Bennett@btopenworld.com Website: www.bad.org.uk Dermatology United Kingdom / London
IDENTIFYING T CELL SUBSET PHENOTYPE AND FUNCTION IN PARASITE INFECTIONS. March 27, 2009 Contact: EuroSciCon Email: enquiries@euroscicon.com Website: www.euroscicon.com Infectious Disease / Other Specialties United Kingdom / Welwyn Garden City United Kingdom / London
ANNUAL SCIENTIFIC MEETING OF BRITISH SOCIETY FOR INVESTIGATIVE DERMATOLOGY (BSID March 30-April 01, 2009 Contact: Dr. Graham Ogg, BSID Chairman Tel: 011-44-1865-222-334 Fax: 011-44-1865-222-502 Email: graham.ogg@ndm.ox.ac.uk Website: www.bsid.org.uk Dermatology United Kingdom / Cirencester
164TH MEETING OF THE SOCIETY FOR GENERAL MICROBIOLOGY March 30-April 03, 2009 Contact: Josiane Dunn, Meetings Administrator Tel: 011-44-118-988-1805 Fax: 011-44-118-988-5656 Email: meetings@sgm.ac.uk Website: www.sgm.ac.uk/meetings Hematology / Infectious Disease / Other Specialties United Kingdom / Harrogate
2009 ANNUAL MEETING OF THE BRITISH PAIN SOCIETY March 31-April 03, 2009 . Contact: The British Pain Society Tel: 011-44-207-269-7840 Fax: 011-44-207-831-0859 Email: info@britishpainsociety.org Website: www.britishpainsociety.org Pain Management United Kingdom / London
9TH LONDON INTERNATIONAL EATING DISORDERS CONFERENCE March 31-April 02, 2009 Contact: MA Healthcare Events Tel: 011-44-20-7501-6762 Fax: 011-44-20-7733-8174 Website: www.mahealthcareevents.co.uk Family Medicine / General Medicine / Pediatrics / Psychiatry United Kingdom / London
ROYAL COLLEGE OF PHYSICIANS - ACUTE MEDICINE April 01, 2009 Contact: Royal College of Physicians Tel: 011-44-20-7935-1174 Email: conferences@rcplondon.ac.uk Website: www.rcplondon.ac.uk/event General Medicine / Internal Medicine United Kingdom / London
UROLOGICAL ANATOMY FOR SURGERY April 03, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: urology@rcseng.ac.uk Website: www.rcseng.ac.uk Surgery / Urology United Kingdom / London
UK RADIATION ONCOLOGY CONFERENCE (UKRO) April 06-08, 2009 Contact: UKRO Secretariat Tel: 011-44-1904-610-821 Fax: 011-44-1904-612-279 Email: ukro@ipem.ac.ukWebsite: www.ukro.org.uk Oncology / Radiology/Imaging United Kingdom / Cardiff
OTOLARYNGOLOGY FOR GENERAL PRACTITIONERS April 07, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6336 Email: ent@rcseng.ac.uk Website: www.rcsengac.uk General Medicine United Kingdom / London
EUROPEAN PSYCHIATRIC ASSOCIATION SECTION OF NEUROIMAGING 5TH ANNUAL MEETING: GENES, BRAIN, BEHAVIOUR April 09-10, 2009 Contact: Institute of Psychiatry, King's College London Tel: 011-44-20-7836-5454 Email: epaneuroimaging2009@iop.kcl.ac.uk Website: www.iop.kcl.ac.uk Psychiatry United Kingdom / Edinburgh
BASIC PRACTICAL SKILLS IN OBSTETRICS & GYNAECOLOGY April 15-17, 2009 Contact: Conference Office, Royal College of Obstetricians and Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings Obstetrics/Gynecology United Kingdom / London
PROMPT (PRACTICAL OBSTETRICS MULTI-PROFESSIONAL TRAINING) COURSE: TRAINING THE TRAINERS April 16, 2009 Contact: Conference Office, Royal College of Obstetricians and Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings Obstetrics/Gynecology United Kingdom / London
DRAWING FOR SURGEONS April 16-17, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6337 Email: drawingforsurgeons@rcseng.ac.uk Website: www.rcseng.ac.uk Surgery United Kingdom / London
PROMPT (PRACTICAL OBSTETRICS MULTI-PROFESSIONAL TRAINING) COURSE: TRAINING THE TRAINERS April 17, 2009 Contact: Conference Office, Royal College of Obstetricians and Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings Obstetrics/Gynecology United Kingdom / London
2009 ANNUAL MEETING OF THE RENAL ASSOCIATION April 20-24, 2009 Contact: The British Pain Society Tel: 011-44-207-269-7840 Fax: 011-44-207-831-0859 Email: info@britishpainsociety.org Website: www.britishpainsociety.org Nephrology United Kingdom / Liverpool
3RD NATIONAL CONFERENCE: TREATING SCHIZOPHRENIA April 27-28, 2009 Contact: MA Healthcare Events Tel: 011-44-20-7501-6762 Fax: 011-44-20-7733-8174 Website: www.mahealthcareevents.co.uk Psychiatry United Kingdom / London
RHEUMATOLOGY 2009 April 28-May 01, 2009 Contact: Louis Bellintani, Education and Events Officer Tel: 011-44-20-7842-0913 Fax: 011-44-20-7842-0914 Email: conferences@rheumatology.org.uk Website: www.bsrconference.org.uk Rheumatology United Kingdom / Glasgow
OPERATIVE SKILLS IN NEUROSURGERY April 28-30, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6336 Email: neurosurgery@rcseng.ac.uk Website: www.rcseng.ac.uk Neurology / Surgery United Kingdom / London
2009 PATIENT SAFETY CONGRESS April 30-May 01, 2009 Contact: Customer Service Team Tel: 011-44-207-554-5800 Email: psc2009@emap.com Website: www.patientsafetycongress.co.uk Other Specialties United Kingdom / Birmingham
ROYAL COLLEGE OF PHYSICIANS - DEVICE THERAPY FOR HEART FAILURE April 30, 2009 Contact: Royal College of Physicians Tel: 011-44-20-7935-1174 Email: conferences@rcplondon.ac.uk Website: www.rcplondon.ac.uk/event Cardiology United Kingdom / London
RISK MANAGEMENT AND MEDICO-LEGAL ISSUES IN WOMEN'S HEALTH May 06-07, 2009 Contact: Conference Office, Royal College of Obstetricians and Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings Legal/Ethics / Obstetrics/Gynecology United Kingdom / London
SPECIALTY SKILLS IN ONCOPLASTIC & BREAST RECONSTRUCTION SURGERY (ST 5-7) May 06-07, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6332 Email: breast@rcseng.ac.uk Website: www.rcseng.ac.uk Plastic Surgery / Surgery United Kingdom / London
ROYAL COLLEGE OF PHYSICIANS - NEUROLOGY ON ACUTE TAKE May 07, 2009 Contact: Royal College of Physicians Tel: 011-44-20-7935-1174 Email: conferences@rcplondon.ac.uk Website: www.rcplondon.ac.uk/event Neurology United Kingdom / London
THEORETICAL ATSM COURSE IN LAPAROSCOPY SURGERY May 08, 2009 Contact: Conference Office, Royal College of Obstetricians and Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings Obstetrics/Gynecology United Kingdom / London
URODYNAMICS ATSM COURSE May 11-12, 2009 Contact: Conference Office, Royal College of Obstetricians and Gynaecologists Tel: 011-44-20-7772- 6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetingsObstetrics/Gynecology / Urology United Kingdom / London
EMERGENCY SKILLS IN MAXILLOFACIAL SURGERY May 11-12, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6340 Email: maxfac@rcseng.ac.uk Website: www.rcseng.ac.uk Emergency Medicine / Surgery United Kingdom / London
OPERATIVE SKILLS IN EAR, NOSE & THROAT SURGERY May 13-14, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6336 Email: ent@rcseng.ac.uk Website: www.rcseng.ac.uk Otolaryngology / Surgery United Kingdom / London
GP REFRESHER COURSE May 13-15, 2009 Contact: Symposium Office, Imperial College London Tel: 011-44-20-7594-2150 Fax: 011-44-20-7594-2155 Email: sympreg@imperial.ac.uk Website: www.prossl.com/symposiassl/events.asp Family Medicine / General Medicine United Kingdom / London
BIOLOGICAL & PHARMACOLOGICAL ASPECTS OF PERINATAL PSYCHIATRY May 14, 2009 Contact: Institute of Psychiatry, King's College London Tel: 011-44-20-7836-5454 Email: available through website Website: www.iop.kcl.ac.uk Psychiatry United Kingdom / London
ROYAL COLLEGE OF PHYSICIANS - ACUTE AND GENERAL MEDICINE FOR THE PHYSICIAN May 20-21, 2009 Contact: Royal College of Physicians Tel: 011-44-20-7935-1174 Email: conferences@rcplondon.ac.uk Website: www.rcplondon.ac.uk/event General Medicine United Kingdom / Birmingham
OBSTETRIC ANAESTHESIA 2009 May 20-22, 2009 . Contact: Meeting Secretariat Tel: 011-44-2-087-411-311 Fax: 011-44-2-087-410-611 Website: www.oaa-anaes.ac.uk Anesthesiology / Obstetrics/Gynecology United Kingdom / Jersey
FORENSIC GYNAECOLOGY May 21-22, 2009 Contact: Conference Office, Royal College of Obstetricians and Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings Legal/Ethics / Obstetrics/Gynecology United Kingdom / London
INFECTIOUS DISEASES: ADULT ISSUES IN THE OUTPATIENT AND INPATIENT SETTING LONDON TO IRELAND CRUISE May 24-29, 2009 Contact: MCE Conferences Tel: 888-533-9031 Fax: 858-777-5588 Email: info@mceconferences.com Website: www.mceconferences.com Family Medicine / Internal Medicine United Kingdom / London
BASIC PRACTICAL SKILLS IN OBSTETRICS & GYNAECOLOGY May 26-28, 2009 Contact: Conference Office, Royal College of Obstetricians & Gynaecologists Tel: 011-44-20-7772-6245 Fax: 011-44-20-7772-6388 Email: conference@rcog.org.uk Website: www.rcog.org.uk/meetings Obstetrics/Gynecology United Kingdom / London
ENDOSCOPIC SUTURING TECHNIQUES May 27-28, 2009 Contact: Royal College of Surgeons of England Tel: 011-44-20-7869-6337 Email: MIS@rcseng.ac.uk Website: www.rcseng.ac.uk Surgery United Kingdom / London
CURRENT ISSUES IN SEXUAL HEALTH May 28-29, 2009 Contact: Mark Allen Group Tel: 011-44-20-7501-6762 Fax: 011-44-20-7733-8174 Email: conferences@markallengroup.co.uk Website: www.mahealthcareevents.co.uk Infectious Disease United Kingdom / London
PROGRESS IN STEM CELL BIOLOGY May 29, 2009 . Contact: EuroSciCon Email: enquiries@euroscicon.com Website: www.euroscicon.com Biochemistry / Hematology United Kingdom / Welwyn Garden City
Indian medical education system has seen rapid growth in the last two decades. From a miniscule number, private medical colleges have grown to account for more than half of the 270 medical colleges in 2008 and consequently, India has the highest number of medical educators in the world. This unregulated unequal growth brings two issues to focus: the failing quality of medical education and implementing effective solutions to address an artificial faulty shortage due to doctor mal-distribution. The menace posed by the growing merchandisation of medical education has to be warded off and efforts should be made to ensure maintenance of standards and check the unplanned growth of substandard medical colleges and substandard education norms in universities or their constituent medical colleges. There is a strong case for a review of the entire system of medical education and examinations in the country. Some solutions like increasing retirement ages of MD faculty to 70 years, sharing of faculty, increasing MD seats, allowing clinical MDs to teach paraclinical and preclinical subjects or temporary merger of specialities have been proposed to address the faculty shortage instead of relying on inadequately qualified MSc non-medical faculty.
Keywords: Qualified Medical teacher, India, medical colleges, faculty shortage, Medical Council of India (MCI).Abbreviations DCI=Dental Council of India. MSc=Master of Science
Establishing a medical college is not similar to establishing a science or Arts College and apart from a huge capital requires a huge number of qualified, competent, MCI compliant manpower to produce quality doctors.1,4,7 Having established a Medical College, maintaining the standards of education to world acceptable levels with a vision to serve poor Indian masses has been a concern of the Indian planning committees. Also, the good name a college attains is due to the accomplishments of its faculty and alumni. In that regard, proper emphasis on the quality of medical education ,inspite of the recent rapid proliferation of private medical colleges, has rightly been the working domain of Medical Councils all over the country and has consumed energies of Medical Council of India over the last forty years. 1, 4, 7,10,12
The Medical Council of India (MCI), the regulatory and advisory body on medical education, approves medical curricula and permits medical school existence and allows for recognition of medical degrees issued by various universities. The accreditation process for medical schools focuses largely on the infrastructure and human resources required and little on the process and quality of education or outcomes.15 The implementation of the recommendations of MCI regarding recognition or de-recognition of a medical college is governed by the Ministry of Health and Family Welfare, whilst individual universities also have variable sets of regulations for their affiliated medical schools. As a result, there is no uniformity in the standard of medical education across the country. At the time of independence there were just 19 medical schools with an output of 1200 doctors.10 In 1965, there were 86 medical colleges in India with only a few private colleges7 The college total increased to 112 by 1980(at a rate of 30%), to 143 in next decade (rate of growth of 28%) and since 1990 over past 18 years the number has increased to 271, an increase of ~90% compared with the figure in 1990.7 Today, there are 271 medical colleges out of which about 31,000 medical graduates pass out every year and private sector medical colleges have grown to account for more than half of all medical education institutions in India 13
Evidently, medical education system seems to have had an unregulated growth over the last two decades. It has been pointed out that even the prestigious colleges window dress faculty lists or put up names of non-existing academic members in their staff list. 5 Most medical college permissions were gifts given out as largesse or patronage to political heavyweights from health ministry.1,14 Very few have had adequate space, laboratories or hospitals as per MCI norms. They were and remain ill- equipped and inadequately staffed.10 This unregulated rapid growth in enrolment of medical students and poorly implemented regulations relating to admissions, faculty strength and infrastructure in medical colleges adversely impacts quality of training in Indias medical institutions.
Many reputed physicians and surgeons, professors, directors and deans working in new private medical colleges fabricate and falsify records like even birth records and lie to the MCI and the courts in order to get their medical college of questionable standards approved or recognized. Illegal money is involved in the business of getting new private medical colleges approved or recognized by the MCI and the health ministry. The decay of medical colleges reflects the general trend in this country .4,5 Corruption and bribery have made permanent inroads into medical education since past few decades in health universities or entrance examinations. Even clerks in the universities leak question papers and manipulate marks. 1 Perhaps the worst kind of gross unethical practice in academic medicine happens around the time of inspection by the Medical Council of India (MCI) post 1998-2000, in new private medical colleges. In emergency-like frenzied two day shows, busloads of patients are mobilized to fill up empty wards, carloads of doctors are paraded before the inspectors, and even instruments are hired or shifted between colleges, during the period of MCI inspections.4
Privatization in general has been known to increase the gap between rich and poor, amounting to encouraging survival of the richest which cannot be a acceptable goal of any civil society.8 And, the policy of excessive privatization of medical care delivery system has undermined health services and further limited the access of the underprivileged.3,8
Privately, many managements agree that it is very difficult to get faculty and that it is even more difficult to retain them in the wake of continuous offers or lure from newly established medical colleges. Certain medical college locations in smaller cities or semi-urban areas do not have facilities, ambience, or charm of big cities hence attracting teachers or other qualified staff to such medical colleges has been difficult, and various inducements have been applied. Such colleges have been surviving council inspections by window dressing or luring faculty with money. In certain new colleges which are literally brick fresh, bereft of hostel or quarters or other amenities the teachers delay even more to move or settle down themselves. At times doubts are established whether an impossible set of conditions and heavy financial burden is imposed on Medical college managements, by the MCI just to make management fail MCI inspections, but at the same time, some stringent MCI regulations have helped faculty of Medical colleges by ensuring job availability.
Doubling of medical colleges over last 15 years has improved the number of medical practitioners in India, but will the mere increased numbers mean a higher quality health care delivery system is debatable. Most management fail to fulfill the excellent set of norms stipulated by Medical Council of India. It is worthwhile, in national interest to note that, we have been loosing medically qualified post graduates to Western countries since till recently Medical College teaching jobs were low paid and did not give that richness or respect attained by private practitioners. After the Karnataka Government & Pondicherry scales new implementation in 2007, with a heavy Non Practicing allowance teaching profession has gained respectability vis--vis elite in society like software engineers. Similar uniform pay scale implementation is need of the hour, all over the country to prevent medical teacher mass migrations.
Nearly 27000 teachers are required as per Ananthakrishnans calculations 7 to fill the faculty positions in 270 medical colleges purely for the purpose of teaching MBBS.He ignores the existence of ~300 Diplomate National Board hospitals across India and requirement of faculty for DNB courses. He also ignores MCI recognized institutions exist in other countries like China, Nepal, Malaysia, Netherlands and have been training MBBS doctors of Indian origin. All these institutions have been drawing medical teachers to satisfy MCI or DNB stipulations for accreditation. Hence we have to account loosing faculty to such Institutions. Also his manpower calculations are only for colleges purely teaching MBBS and ignore multiple course Colleges like KMC Mangalore, Manipal which harbor 90 MSc students per year per department and ignores existence of PhD students which evidently will require more teachers. He also ignores the net strain on the same faculty who are simultaneously teaching BPT, MPT, etc in allied institutions. A great academic strain on medical college teachers ,exists,which has never been accounted by MCI nor by Dr Ananthakrishnan.So, on the whole, it means that a great qualified medical teacher shortage exists in India. Either it is due to the excessive number of courses imposed on the same faculty or maybe it is inefficient use of existing qualified medical teachers for non teaching purposes.
Contrary to the opinion of Health ministry, eminent educationists Sood & Adkoli point out that the doctor: population ratio has already exceeded that required by the country and there is mal-distribution of their services. They feel that the menace posed by the growing merchandisation of medical education has to be warded off and efforts should be made to ensure maintenance of standards and check the unplanned growth of substandard medical colleges and substandard education norms in universities or their constituent medical colleges. This mal-distribution of medical manpower is the centered on biased political will and seat purchasing power in the community. With the correction of medical manpower maldisditribution medical standards will harmonize throughout India.11,12
Indeed, given the sharp increase in the number of medical colleges and the doubling of enrolment capacity after1980s it is difficult to imagine that enough trained full-time faculty exist to adequately staff the newly created colleges or DNB Hospitals and maintain reasonable teacher-student ratios.9 Dr Ananthakrishnan proposes to allow MSc from Non Medical Universities to teach Medicine. 7 It will be gross medical impropriety to allow such injustice to be allowed by Medical council of India which is supposed to uphold medical education standards across India. What glory does it give Indian medical education system to have a bunch of unqualified non medical doctor MSc teachers seeking to run coaching medical classes a la science tuition centers we fail to see. What is the necessity to increase number of medical college, or medical college seats, in inadequacy of appropriate medical teachers? Is it possible to permit inadequately trained staff to run these colleges, and will the output reflect quality abroad? Emphasis here is not on excellent university results, these MSc teachers, produce by mere mugging up of unconnected facts or figures or excellent power point teaching but what MBBS educated teachers can produce by moulding young doctor student minds by bringing in relevant clinical experience.
Some Solutions
Today, India has the highest number of medical colleges in the world and consequently the highest number of medical teachers. Yet, shortage of medical faculty and lack of medically oriented teaching by appropriately trained MD faculty have tarnished Indian medical glory. The unprecedented institutional growth has created a national quality challenge for medical education and has resulted in varying standards across medical graduates. There is a national need for well-trained faculty who will help improve programs to produce quality graduates. 5,14 Annual student intake is said to be a critical factor in assessing the requirement for teachers as per Ananthakrishnan,7 and should dictate the employment. A punitive MCI, DNB Board and vigilant state medical councils can act synergistically to decrease medical student intake in Medical Institutions where teachers are not ready to go or do not exist. MCI and DNB Board also need to do more for its medical teachers- give them more respect, recognition, arrange for their pensions, gratuity, relieving orders or get involved in pay scale recommendations as no entity exists till date to safeguard medical teacher interests. Measures are required to ensure private medical colleges proper regulation by the medical council. Further, Indian Health ministry has been known to interfere in the functioning of MCI, DCI and DNB Boards, override MCI, DCI and supreme courts decisions and this is undesirable.12,14,15
Increasing the retirement age of MD teachers up to 70 years will harness hard earned medical experience of senior professors to guide preparation of efficient faculty and will reemploy retired teachers . This will also lead to discipline enforcement, more projects, PhDs and papers of relevance. Else, MCI can think of sharing of medical faculty among medical colleges, or dental colleges, and ensure less burdened teaching schedules. Implementing integrated medical education system-will help, as has been experimented in -KMC Manipal, Sri Ramachandra Medical College. Present paramedical system is a confused network of PhDs who have not enriched Medical education system, a proof of which can be the absence of a single Nobel laureate or international repute medical scientist or of the glory of IISc departments, in 270 odd medical colleges across India, even Manipal, or AIIMS in spite of having the system for 50 years. Merging of homogenous specialities like merging of biochemistry with physiology or pathology, microbiology with pathology, or creation of a discipline of laboratory medicine merging pathology, microbiology and biochemistry has been suggested in yahoo groups like mdbiochemists. Merging of homogenous specialities decreases the requirement of professors in biochemistry and microbiology by providing MCI norm requirements of professors from pathology. Also merging of Anatomy with Surgery will be worthwhile and achieve similar objective of providing deficient staff from Surgery department, who happen to be plenty. It is said to bring about some integrated medical education also. This cure is supposed to provide a broad based intermingling for net objective of efficient medical teaching by qualified professors, peers in interrelated departments. We would further extend their argument in suggesting that the proposed speciality merger need not be complete and final but a temporary arrangement for next 20 years.
Acute shortage of medical teachers needs to be filled. Appropriate solution exists within medical education system itself and help can come from recruitment of medical brethren from clinical sciences to fulfill non clinical department norms, as has been happening successfully ,silently ,without MCI approval ,in Tamilnadu and Andhra pradesh government medical colleges. A whole lot of MD or MS or DNB doctors are ready to serve as Medical teachers, but colleges have never used their teachership as MCI does not permit this. Many such part-time consultants who are practicing in community could deliver excellent teaching assignments and help tide over the so called artificial medical teaching crisis.MCIs generosity to allow MDs of homogenous specialties to teach in Pre or Para clinical sciences for a honoraria, rewards system will effectively ,in a short time solve inadequate improper medical staffing problems forever. Number of seats available in various post-graduate medical courses is approximately 11,005 annually which is one third of MBBS graduates coming out every year. Nearly a third of these seats are diplomas and a diplomate cannot be considered for even a junior lecturer post like an MSc graduate, but will be considered for post of Tutor, the lowest cadre of medical teachership. Thus all DCP (Diploma in Clinical Pathology) and DFM (Diploma in Forensic Medicine) loose out Lecturership to their MD colleagues. Increasing the number of MD seats in Para clinical and preclinical sciences and replacing existing Diploma seats with corresponding MD seats is a just approach and should be the right approach for MCI to follow, since in contrast to before 1960s,in present days no postgraduate seat goes vacant-it means there are no shortage of MD aspirants as wrongly assumed by Dr Ananthakrishnan7 .MCI also has to think of giving Junior lecturership posts to MBBS graduates who have been serving as tutors for more than 3 years in any department .
Continuing medical education
Thus there is a strong case for a review of the entire system of medical education and examinations in India. The American style of giving credits for demonstrable good performance throughout the years can be introduced. It will, of course, be necessary to ensure objective evidence of such assessment and performance.1,8 The Indian Health ministry has realized that efficient medically qualified teachers are in the best position to mould young physician minds hence, Indian National Knowledge Commission (NKC-2008) proposes raising average standards and creating centers of medical excellence, revised medical accreditation; methods of attracting and retaining talented medical faculty members and devising measures to ignite, promote and sustain the research tradition in medical colleges and teaching hospitals.
Medical teacher incentivisation8, i.e increments, promotions, paid study leaves will also attract good teachers to stable institutions. In order to recruit good and gifted medical teachers, it is necessary to provide them with regular attractive salaries, amenities and retirement benefits which are realistic and at least on par with the earnings of those in practice.2 Emigration of high quality physicians who could potentially serve as medical teachers in local Medical colleges may lead to further declines in the quality of medical graduates produced. To address regional inequities for medical training and related availability of doctors, firstly, it may be useful to set up adequately staffed medical research and training institutions in economically backward areas. Secondly, the government could subsidize the medical education of individuals living in backward areas, perhaps by combining such a subsidy with a bond to serve in the backward areas for a limited number of years. Implementing this bond system will be in the control of the health ministry.
For existing medical teachers, high standards of teaching are to be maintained and improved upon with constant seminars and workshops. Teaching aids, computers, medical CDs, DVDs, medical e-books, Internet facilities and availability of the latest journals and literature on the subject should be provided in every medical college or diploma national board certified hospital.2At the post graduate level, it is the duty of the senior teacher to train the young doctor so that he learns to perform according to accepted international standards.2 As a long- term policy, no new medical colleges must be permitted in prosperous states, unless they demonstrate an MCI compliant infrastructure and facilities better than those in existing institutions. A revitalized Medical Council of India must be the only agency permitted to recognize such colleges and health ministry need not have any role.1 Since advent of the MCI it has been noted that Indian health ministry can not only ignore a negative rating by Medical Council of India, but also openly defy the Supreme Court.12
India needs also a MCI controlled and Supreme Court monitored screening system of students admitted to medical colleges under the discretionary management quota so that merit remains the paramount criterion. This requires common entrance examinations to assess student performance across colleges, publicly accessible information on admission standards practiced by colleges, including transparent nondiscriminatory ranking by performance, and enforcement of sanctions on colleges violating norms. A useful first step is the government policy of maintaining a accessible list of recognized colleges, but obviously much more needs to be done to implement ways to increase the supply of MD teaching personnel .Indian policy makers need to think proactively about developing a cadre of doctors focused more on medical education and research. Lastly, the Indian Medical Association, Association of Medical Biochemists of India, All India MD/MS Doctors Association, and other national medical and dental professional bodies must play a greater role to foster true medical and dental education and prevent governmental and political interference.1,12,14
COMPETING INTERESTS
None Declared
AUTHOR DETAILS
DR P VALLYAMMA MD, Professor & Head of Biochemistry, Periyaram Medical College, Kerala, India
DR SRINIVAS R DESHPANDE MD, Associate Professor in Biochemistry, Melmarvathur Adiparashakti Institute of Medical Sciences, Tamilnadu, India.
DR GAYATHREE L, MD, Assistant Professor in Microbiology, Hassan Institute of Medical Sciences, Hassan, Karnataka, India
CORRESPONDENCE: Dr P Vallyamma MD, Professor & Head of Biochemistry, Periyaram Medical College, Periyaram, Kannur Dt, Kerala, India
Email: aimdda@yahoo.com
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BJMP June 2009 Volume 2 Number 2
BJMP June 2009 Volume 2 Number 2
Full Issue Booklet (All Articles)
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Full Booklet
Editorial
Obesity and Pulmonary Hypertension. What’s the Link?
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Review Articles
Breast cancer and therapeutic deployment of growth factor receptor
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Oral Bisphosphonates and the Risk for Osteonecrosis of the Jaw
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Ventilator Associated Pneumonia – an Overview
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Uncovering the face of racism in the workplace
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Original Articles
Laporoscopic Fundoplication: Not a simple wrap
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Comparative Evaluation of Four Hepatitis B vaccines Available in Pakistan: Reactogenecity and Immunogenecity
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Mental illness and comorbid insomnia: a cross- sectional study of a population of psychiatric in-patients
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Demographic, socio-economic and psychological determinants of HIV treatment: A community out-patient experience
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Case Reports
Blocked percutaneous endoscopic gastrostomy tube - an unusual cause
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Omental herniaton through umbilicus following lower segment caesarean section in a post caesarean pregnancy
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View Point
The right to consent: Is it absolute?
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Medicine in Pictures
Pictorial essay: central venous catheters on chest radiographs
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Miscellaneous
Upcoming Medical Meetings/Conferences
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