Service delivery in peril due to private practice, syndication

Greater involvement of doctors in private practice, syndication of employees and overcrowding of patients have put service delivery in Dhaka Medical College Hospital (DMCH) in dire-straits, hospital insiders said.  
Besides, engagement of a large number of honorary doctors in the healthcare services and alleged negligence of duties, especially by senior nurses are also responsible for the prevailing poor state of medicare services in the country's largest public hospital, they observed.
Sources at the hospital said the government-appointed doctors, whose number is much lower than the growing number of patients, have a strong affiliation with private hospitals and clinics and they, in many cases, go for private practice by shifting the responsibility of treatment to the honorary doctors.
Seeking anonymity, an associate professor at the DMCH, said many of their colleagues go for private practice after finishing their jobs at the hospital.
He termed the syndication and domination of Class-3 and Class-4 employees' association as a major hindrance to smooth functioning of the hospital, saying that leaders of the association in many cases are involved in unethical practices like taking kickbacks from the attendants of patients.
"We can do nothing against them as the association is too much powerful. The employees go for strike whenever we raise voice against them," he said.   
During a visit to the DMCH on Wednesday last, this correspondent found a Class-4 employee demanding Tk 300 from a relative of a patient for carrying the patient's trolley to Ward Number-113.
He, however, hurriedly fled the place after realising the presence of a journalist.
When contacted, office-bearers of the employees' association at the hospital refused to make any comment over demand of unethical charges.    
The DMCH authorities highly depend on honorary doctors for ensuring better treatment for the growing number of patients. But a large number of the volunteer physicians are also on the run to find some spaces for private practice, leaving the public medicare system at a stake.
As many as 929 honorary physicians have been put on duties at the hospital but their job status is not well defined in the hospital organogram. On the other hand, the number of government-appointed doctors and interns is 312 and 67 respectively.
However, the DMCH authorities like other public hospitals allow doctors, who want to work voluntarily, to cope with the growing number of patients at the hospital.    
Physicians said the post-graduate medical students under the courses like Fellow of College of Physicians and Surgeons (FCPS) and Master of Surgery (MS)/Doctor of Medicine (MD) programmes need to acquire in-service experience for four years before taking part in the final examination.
"They (post-graduate students) and some other doctors who haven't found jobs yet have shown their willingness to work voluntarily. And they are normally called honorary doctors," said Dr. Mohammad Hedayet Ali Khan, Registrar of the Burn and Plastic Surgery Department of the DMCH.     
Another government-appointed doctor of the hospital said the hospital authority normally allows the volunteer doctors to be involved in private practice on Friday when the pressure of patients is comparatively low, considering earnings for their survival.
"But a large number of them remains busy mostly in private practice by using the brand name of the DMCH and such a tendency often pushes the hospital administration to serious trouble to cope with the growing number of patients," he said.
He also added that the honorary doctors mostly spend night hours in private practice. "After passing a whole night at private clinics and hospitals, it becomes very tough for any doctor to do justice to his/her job on the following morning without any break," he added.    
Both current and former interns of the DMCH who work with the post-graduate trainees said the hospital authority needs their services because of its limited manpower.
But the hospital management should be more cautious in selecting honorary doctors as there are some such physicians whose behaviour with the patients and attendants is not up to the mark.
Talking about the selection process of the honorary doctors, DMCH Deputy Director Dr. Md. Musfiqur Rahman said they seek applications from the volunteer doctors twice a year (January and July) through advertisement in the dailies.         
Then, the applicants go through a test of viva voce by the professors with others of the departments concerned before getting an opportunity to practise here. The selected honorary doctors also receive a joining paper from the hospital authorities for their volunteer services.
"And we treat the honorary doctors keeping in mind the issue of honorary jobs and their status in the organogram," he said, adding that they allow such a high number of volunteer doctors to cope with the growing pressure of patients here.
When his attention was drawn to the issue of private practice, he said that they need earnings to maintain their families.
"We came to know, a very few honorary doctors concentrate on private practice by remaining absent in the hospital. But they will have to fulfill the gap before getting our nod," he said.
Talking to the FE, physicians, who work voluntarily at the DMCH, turned down the claim of duty negligence, saying that the healthcare services at the hospital would be at stake without contribution of the honorary doctors.
Dr. Ali Hasan, who worked voluntarily at the DMCH but currently working at a private medical college, said he, like other honorary doctors, had struggled much during his training days in the absence of any source of earning.
"Many of my colleagues went for private practices at night and in some cases in the evening whenever they had time to do so," he said.
Dr. Shushil, who did his MD training at the DMCH nearly four years ago, said the honorary doctors mostly give top priority to private clinics located in districts adjacent to Dhaka where their demand is comparatively high.
"The volunteer doctors used to receive Tk 2500 by spending 24 hours at a private healthcare centre and each of them normally gets the chance of earning four to five times more a month," he said.
"How can we survive in the highly expensive city if we're not allowed to work outside? That doesn't mean that we do not give enough time for training purpose. After all, we need training clearance from the hospital," said Dr. Sajib, an honorary doctor at the DMCH.     
They also called upon the authorities concerned for introducing special allowances to stop the run of the honorary doctors for private practice and ensure their decent living.
They, however, mentioned that most of the senior nurses at the hospital normally show less enthusiasm in doing their jobs and in most cases they shift their responsibility to their juniors, which is another impediment to the medicare services.