The Practice of Double Dipping

Mushtaq shares his perspective on the raging debate about government salaried doctors in Kashmir who pursue private practice on the side

(Dr. Syed Mushtaq Ahmad, 61, was born in Seer Hamdan, Anantnag. He went to Higher Secondary School in Anantnag, before finishing his higher secondary education from the Government Degree College, Anantnag. He received his medical degree (M.B.B.S.) from the Government Medical College (GMC) Srinagar, and subsequently earned M.S. (Anatomy) from the GMC, and Ph.D. in Nuclear Medicine from the Sher-i-Kashmir Institute of Medical Sciences (SKIMS). He complete diplomas related to radiation medicine from the Bhabha Atomic Research Centre (BARC), Mumbai. He rose through the ranks as a faculty member in the SKIMS, and at retirement held the position of Professor and the Head of Nuclear Medicine in SKIMS. Presently, he serves as a senior consultant and head of the nuclear medicine at the Capital Medical Research Centre in Srinagar.)

SKIMS: Eaten Away by the Bug of Private Practice

The Sheri-Kashmir Institute of Medical Sciences (SKIMS) is the outcome of a cherished dream of great visionary like Sheikh Muhammad Abdullah. It is the fruit of love and labour of some great professionals like Dr. Ali Muhammad Jan and others.
Are we losing it to commercialism of healthcare?

SKIMS, as the name implies has been conceived as a tertiary health care medical institution with an objective of providing patient care of high standard, as well as to create high quality medical professionals for the state and country. To achieve this goal SKIMS was linked to AIIMS, New Delhi and PGI Chandigarh for purpose of rules and regulations governing SKIMS doctors to promote the academic caliber and maintain the standards of curriculum and research. To further this cause SKIMS was given a status of deemed university by legislature, to enable it to award degrees in the field of medical and related health sciences ( undergraduate, post graduate, postdoctoral and medical technology courses). The job specification of the faculty of all such medical institutions is three fold viz , i) To deliver specialty and super specialty patient care, ii) To impart high standard teaching and training to undergraduates, post graduates, post doctoral and technical students , and iii) To develop a high quality research in the field of medicine and allied specialties.

Any professional choosing to serve in an academic institute of this nature very well aware of the status of the institution and the nature of services he/she is supposed to provide.

PRIVATE PRACTICE

The impression that Non-practicing allowance ( NPA) is given to the faculty is the only reason why they should not indulge in private practice is false and misplaced. It is the status /position of a particular medical institution which determines whether doctors are allowed /banned for private practice, while as NPA is only an incentive. This status is granted on the basis of the very basic functional concept of the institution. As per SKIMS is concerned following facts are to noted.

1) The governing body (GB) of SKIMS in its 5th meeting held in the year 1979 approved that “All the posts of the institute shall be non-plasticizing and the scale of the pay for each category shall be inclusive of non-practicing allowance”. There is no choice of private practice irrespective of drawing NPA.
2) Subsequently, sanction was accorded to the grant of performance allowance to consultants and resident staff of the institute vide govt; order no. 19-IMS of 1981 Dated 31-01-1981.
3) Vide SRO No :358 dated 1st Dec. 1988, SKIMS faculty members (pay) rules of 1988 provided non-practicing allowance (NPA) for faculty members of SKIMS in lieu of performance allowance ,at revised rates.
4) Thereafter under and in term of SRO 378 of SKIMS, faculty members ( revised pay ) rules 2000 were promulgated. As per rule 8 of rules 2000, it was instructed that “ It shall be ensured by the institute that doctors of the institute don’t take up any kind of private practice.” In addition, NPA rates were revised to 25% of basic pay .
5)Vide a cabinet decision No 171/45 dated 4th oct 2000 and the govt; order no. 195-F of 2000 dt. 18th oct. 2000., it was ordered that the doctors and the paramedical staff of SKIMS shall; not indulge in any kind of private practice.
6) The criminal law ( amendment) ordinance no II of 2001 dated 10th july2001 was followed by the criminal law ( amendment) act, no. XXVI of 2002 dated 23rd April 2002, passed by an unanimous vote of J&K legislature. The act provided amendment of provision of 5(1-a) and 5(2-b) of prevention of corruption act , Sam vat 2006.It provided that any medical and paramedical staff of SKIMS shall be deemed to have committed the offence of criminal misconduct if he/ she resorts to private practice in any form or manner. It also provided that whosoever, abets or aids in commission of this criminal misconduct or allows his premises or nursing home to be used for private practice shall be punishable with imprisonment of up to 3 years and shall also be liable to a fine of up to Rs 10,000.
7) Vide SRO 283 dated 23rd September 2009 issued for implementation of 6th pay commission recommendations to faculty of SKIMS, it was clearly instructed in rule 7 that “ It shall be ensured by the institute that doctors of the institute do not take up any kind of private practice.
8) In every appointment / promotion order of any faculty member , it is clearly mentioned that appointee /promotee is banned to indulge in any kind of private practice. At the time of joining, an affidavit is submitted, stating that the appointee will not indulge in private practice in any form.
9) It is obligatory on part of every faculty members to certify every month that he/ she is not indulging in any kind of private practice.
10) From time to time , SKIMS faculty members have been reminded through circulars from administration that they should refrain from doing any kind of private practice.
11) Most recently, Hon’ble Chief Minister of J&K, who also is the chairman of the Governing Body of SKIMS, many a times publicly advised the faculty of SKIMS to desist from indulging in private practice which is a criminal misconduct.

INCENTIVES GIVEN TO SKIMS FACULTY

I. Superannuation: Age of superannuation for the faculty was fixed as 60 years as compared to the super-annuation age of other doctors and other Govt; employees i.e.55 years which was later raised to 58 years.
II. Pay Scales of SKIMS doctors were always linked to the pay scales at AIIMS and PGI which were always much higher than their counterparts in medical colleges. Right from the year 1979, the SKIMS doctors would draw their salary, DA/ ADA on the same rates as where in vogue at AIIMS and PGI. Accordingly, subsequent pay revisions of 1983, 1988, 2000 and 2009 were implemented for the faculty of SKIMS , in line with the pay revisions at AIIMS and PGI faculty. A senior professor at SKIMS draws a gross monthly salary of around one lac and twenty thousand rupees.
III. NPA: The incentive was given to the consultants and resident staff since 1981 in the form of performance allowance and then non-practicing allowance. The present rate of NPA is 25% of the basic pay. SKIMS is the only medical institute in the country, where non-medical faculty members are given NPA. This has been done to ensure that even the non medicos don’t indulge in any kind of private practice such as in the form of labs etc.
IV. Clinical Research Allowance (CRA) at a fixed rate of Rs-2500 is paid to every faculty member.
V. Other allowances like HRA or fully furnished residential accommodation.
VI. Re-imbursement of telephone bills and transport facility at nominal charges.
VII. Paid conferences: Every faculty member is allowed to attend two academic conferences anywhere in the country and one international conference (anywhere in the world) once in two years with re-imbursement of registration fee, air fare and DA.
VIII. Sabbatical leave/ Ex India Leave: Every faculty member is entitled to one years leave (Ex- India leave) for monetary benefits, after putting in 5 years of service at SKIMS. Invariably, the overstay period getting regularized.
IX. Academic leave: SKIMS is the only medical institute in the country where a faculty member undergoes postdoctoral courses like DM; MCh. and Phd; while they continue to draw all the benefits of being faculty member. In past many doctors were sponsored for such courses outside the state.
X. Re-designation of posts: The faculty positions of lecturer, assistant professor, associate professor and professors were re-designated as assistant professor, associate professor, additional professor and professor respectively, in line with the nomenclature at AIIMS and PGI. This gives the benefit of early qualification as examiners and as experts to other institutions.
XI. Assessment Merit Promotion Scheme(AMPS): In line with policy at AIIMS and PGI, the faculty of SKIMS is entitled for promotion through AMPS. This benefit is exclusively for SKIMS faculty. This scheme provides that an assistant professor (entry post) gets promoted to associate professor; an associate professor gets promoted to additional professor after putting in 4 years of service in each position. Same way, an additional professor gets promoted to professor post after putting in 7 years on the post. These promotions are not subject to the availability of vacancies at these levels. This prevents stagnation at one position and ensures time bound promotion to higher positions even in absence of vacancies.

SPECIAL STATUS OF SKIMS

1) SKIMS is a semi-autonomous Govt; department with its own high powered Governing Body (GB), Standing Academic Committee(SAC), Apical Selection Committee (ASC), Senior Selection Committee(SSC), Junior Selection Committee(JSC), Purchase Committee(PC) and Standing Finance Committee(SFC).
2) The Chief Minister of J&K is the chairman of the SKIMS governing body (GB); Chief Secretary as chairman of ASC; Financial Commissioner as chairman of SFC and Director SKIMS as chairman of the SSC and JSC.
3) The Director of the institute is designated as Ex-Officio Secretary to Govt; of J&K for matters related to SKIMS and Joint Director as Ex-Officio Additional Secretary to Govt; of J&K for matters related to SKIMS.
4) All policy matters are looked after by GB;while as SAC looks after academic policies; ASC looks after appointment /promotion of faculty; SSC and JSC looks after appointment / promotion of Gazetted and non-Gezetted staff; Purchase Committee looks after purchases and SFC looks into financial matters.
5) Unlike other medical colleges, all the decisions regarding institute matters are taken by these committees. This makes SKIMS free from the shackles of PSC;SSRB; and other institutional authorities, so that it should deliver on all fronts without any hassles.
6) SKIMS was declared as a teaching institute vide Govt; order no:112-ME of 1978 Dated 13/ 03/ 1978 and has the status of a deemed university by an act of legislature of J&K so that it can award degrees in medical and allied specialties. It has its own Registrar, Controller examinations, Deputy Registrars and other related staff.
7) Summer & Winter Breaks :Faculty is entitled to 2weeks summer and 4weeks winter vacations.
8) Pay scales of the resident staff are also higher than their counterparts in other medical colleges.
9) Pay scale and promotional avenues of the paramedical staff are also higher at SKIMS.

EFFECTS:

1) Bad name to whole fraternity:

Despite certain shortcomings, it is a fact that Doctors of SKIMS have been rendering invaluable service to the sick, particularly during disturbances in the state. Amongst the SKIMS doctors, it is only a group who are involved in this unlawful activity. It is this group of doctors who are bringing disrepute to whole fraternity and are as impediment to overcome the shortcomings as well as an obstacle to bring required improvement in the work culture of the institute. These are the people who have always exploited every situation for their petty gains. If this menace is not stopped, the dream of raising the status of tertiary patient care, teaching /research somewhere near to that of AIIMS and PGI will remain distant dream.

2) Patient Care:

Patient care is one of the greatest causality. Official working hours at SKIMS are 10am to 4pm which otherwise are lower as compared to working hours at sister institutions of country. Private practice makes these hours even fewer because it invariably results in late arrival to and early departure from the hospital. If a doctor entertains a huge number of patients both morning and evening at his private clinic, with his tired mind what justice he can deliver to patients at hospital.

3) Teaching & Research:

Probably the most hazardous effect in the long term is in the field of teaching and research. The basic concept of creating an institution like SKIMS is imparting teaching / Training to young doctors in various specialties and undertake research in medical and allied sciences which form the back bone of day to day growth of a well knit health care delivery system . When a teacher can spare only few hours, every day in a medical institution, the results are there for every body to see. A glaring example in this regard is very low attendance of faculty and resident staff in every Saturday morning clinical meetings (academic meets) at SKIMS auditorium.

4) Misuse of Hospital Resources:

What sort of healthcare a super specialist like Cardio vascular surgeon, Neurosurgeon, Plastic surgeon, Urologist, Radiotherapist, Pediatric surgeon, Neo-natologist etc. deliver at a shop or so called private clinic or nursing home. Net result is that these patients ultimately land in the institute and minimize the chances of any procedure of an already listed patient who has no resources to attend a private clinic. One can imagine how this opens doors for many more irregularities and corruption. In fact , private practice of many of these doctors is hospital dependent. The facilities provided at SKIMS by tax payers money are being misused by these people to further their income through illegal practice.

5) Growth of hospitals in Private Sector :

The private practice by specialists and super specialists of Govt; institutions has become the biggest obstacle in the growth of standard medical facilities in private sector. The Govt; institutions like AIIMS and PGI are feeding grounds of specialists for private hospitals. With the result world class private hospitals have come up in the country. A specialist doctor after serving in these Govt; medical institutions for number of years moves out to private sector, rather than indulging in illegal private practice. This way the doctor contributes in the Govt; sector and also earns according to his capability. He also paves way for his juniors to grow in Government sector institutions. However, a group of SKIMS doctors consciously indulge in an act which has been declared as criminal misconduct and at the same time occupy seats of respectability in the institute. It is high time that such elements choose between legal and illegal and if they have trust in their ability they should go for full time private practice.

6) Generation of Black Money:

Private practice being illegal, so even if some private practitioner wants to declare his income, he can not do it, resulting in generation of huge amounts of black money. The disastrous effects of black money are well known such as benami properties and extravagant customs, eating into roots of our society.

TRUTH SHOULD PREVAIL

The issue of private practice has been settled once for all, right at the time of inception of this institute and the same policy decision has been upheld from time to time till date. No argument can defend something un defendable. The only issue remaining is the implementation of the genuine ban on illegal private practice , by a group of law breakers. It is worthwhile to mention here that in none of the sister institutions like AIIMS, PIGMER, SGPGI the private practice is allowed and the doctors working in these institutions follow the law in letter and spirit.

1.) An argument on the basis of alleged victimization of SKIMS doctors is being floated, as if they are unaware of the service rules and regulations. Fact of the matter is that every doctor right at the time of applying for recruitment/ promotion in SKIMS knows that private practice is not allowed, as the same is reflected in the advertisement notice itself, as well as in the appointment /promotion order of every appointee .There being no confusion on this account, anybody irrespective of his /her position has to face the consequences of breaking the law and can not allege victimization. Respect can not be demanded but has to be commanded.
2.) Another argument in favour of private practice is that SKIMS doctors are working on meager emoluments. However, the truth is that they are the best paid lot in the public sector of J&K state. These doctors have every right to argue that they are worth more & can always discuss the issue with state administration, but they cannot indulge in illegal private practice as they have joined the institute by choice and after being aware of the rules and regulations. All these doctors also know that they had to use all means to get an entry into the faculty of SKIMS and that the competition for these posts is getting tougher.
3.) An attempt is being to create an impression, as if these doctors are forced to work at SKIMS. The fact remains that a doctor can quit his job at any time or opt for voluntary retirement. A doctor has to make a choice between academic career at the institute or a medical practice career in private sector. There are plenty of examples when doctors like Prof. S.Z. Ahmad, Prof.M .S. Khuroo. Prof. Nazir A. Wani etc. left the lucrative private practice to have an academic position at SKIMS and resumed their private medical practice only after their superannuation. There are also examples of young faculty members like Dr. Shabir Iqbal who after serving in SKIMS for number of years opted out for going into full time private practice. Such professionals are commanding enormous respect in the society.
4.) Another argument to justify the private practice is the lack of medical facilities in the periphery and the lack of equipment in the Govt; hospitals in Srinagar city, is totally misplaced and irrelevant. How can a private practitioner , providing medical consultation in a private clinic, help in overcoming these so called difficulties.
5.) Another argument made is that due to rush in OPD at SKIMS, the specialists have to see more number of patients than is allowed under rules, hence they are entitled to provide paid consultations to patients in private clinics. If the number of patients to be seen by a consultant is restricted under rules, how can a practitioner justify to see much higher number of patients in private clinic. Providing consultation to 50-100 patients in a matter of 2-3 hours, whether in a hospital OPD or private clinic is not justified. A specialist can always insist that he can / will see only 20-25 patients each day in OPD, so that patients can undergo proper medical examination. However, a sufficient number of specialists have to attend OPD each day. Let us take an example of specialists of medicine department at SKIMS, where we have 10 specialists. If every day 5-6 specialists attend morning OPD each day, about 200 patients will receive specialist consultation which will be in addition to the patients who will receive specialist consultation from senior residents & senior post graduate trainees. This is true about other specialisties also. With this arrangement all the patients will return satisfied from the OPD.
6.) Another argument put forward is that by providing consultation in private clinics, a great service is being rendered to the society & that a patient has a chance to have consultation of specialists of his choice. In broader sense it is true but why provide this service through illegal practice & why not become a full time private practitioner and be available to these patients for more number of hours every day in private clinics. This will go a long way in the development of standard medical facilities in the private sector.
7.) Another argument put forward is the corruption in other fields. There is no doubt that illegal activities and corruption are rampant in our society but two wrongs can not make a right. If one has made a choice to be a member of a highly respected profession of medicine, he cannot equate/ compare himself with corrupt professionals.

SOLUTION

1) One time decision to equate SKIMS doctors to doctors working at AIIMS & PGI as far as rules regulations and perks are concerned and whenever any change occurs at these institutions it should automatically apply at SKIMS.
2) Isolate the group of private practitioners and implement the ban on the private practice.
3) Any attempt to degrade this institution to the level of a district hospital should be foiled by all possible means.